This topic contains 12 replies, has 3 voices, and was last updated by 
Carl Nottoli, DC May 21, 2020 at 2:28 pm.
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Andrew Wengert
I currently have a patient with an L5-S1 annular fissure to the left of midline.
Her first order hx matches up perfectly except symptoms are on her right side.
My question is, Does the side of the damage have to match up with the side of the scleratome’s referral?
Seth Schultz, DC
The sinuvertebral nerve innervates the annulus as a whole to my understanding. If there is damage to the annular fibers that nerve would be stimulated.
What is the sx quality?
Andrew Wengert
Thank you for helping Seth. Dull, achy, deep, tension
Seth Schultz, DC
So now the question would be why the right side? What other pathology could be present to cause the right side to be symptomatic and not the left.
Carl Nottoli, DC
Great problem solving so far!
Andrew, what’s to say the annular tears haven’t also migrated to the right as well? How recent are the images from when you had your consultation?
Can you give the rest of the 7 first order history answers?
Andrew Wengert
63 year old female
Location ant RIGHT hip and into thigh (near perfect match for S1 sclerotome).
Quality: dull achy tension on initial
Now shooting burning
Intensity: currently 7/10
Average 7/10
Worst 8-9/10
Provocative:
Laying down in any position (not mentioned on initial but is now worst provocative
Bending forward
Sitting
Coughing/sneezingPalliative:
Laying on side with pillows between legs (slight lessening of symptoms)
WalkingAll lumbar and hip tests were 100% from a ROM perspective.
With the exception of
QLF: 80% 2.5 inches flat L4-S1
SLPF 4” from floor with reproduced CC
R SLR and SHF mild reproduction of CC at end ROMPalpation: Despite the relatively good function there was 2+ adhesion in both the right and left erectors.
With such good function I was definitely thinking structure so ordered the MRI right off the bat.
FASTMAP 100% STRUCTURE + FUNCTION
MRI 4/29/20:
L5-S1 Bulge with annular fissure left of midline
L4-5 minimal bulge Left facet effusion
L2 small schmorl’s node sup endplatePatient did a 5-6 day steroid pack. 1st 3 days felt almost no pain but since then pain returned. 2 Aleve will take edge off now
Carl Nottoli, DC
Thanks for the information and great job getting the MRI first.
While there is clearly multiple disc issues happening, consider looking for unusual things with unusual presentations. The quality of symptoms may also represent a nerve problem. Now instead of only looking at location as a sclerotome, which peripheral nerve supplies that region? I have included a screen shot for you to cross reference.
If a nerve is entrapped at the psoas for example, it could potentially follow the similar provocatives and the other ones can be explained from the annular tear. The psoas is active with bending, sitting, coughing/sneezing.
I have seen on rare occasions, and discussed in some instructor settings, the possibility of a nerve entrapment along the psoas that doesn’t block KHE. It’s rare.
Let us know what you find.
Seth Schultz, DC
I’m curious Andy, did you palpate local tissue?
Andrew Wengert
Carl thank you for your help with this. That chart is really helpful with this and some of my other cases. I would say it closely matches the anterior femoral cutaneous nerve distribution but would also be the lumboinguinal branch of genitofemoral.
Seth I’m ashamed to say no. At the time it seemed to match up so well with the sclerotome referral, so I didn’t. I will check psoas and the anterior hip next time the patient comes in.
Seth Schultz, DC
Awesome, let us know what you find. Looking forward to it.
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