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The signs of more severe spinal root compression are impairment of sensation, loss or diminution of tendon re exes, and muscle weakness, as summarized in Table 11-1 Generally, disc herniation compresses the root on one side, at the level just below the herniation (see below) Hypotonia is evident on inspection and palpation of the buttock and calf, and the Achilles tendon tends to be less salient Paresthesias (rarely hyperesthesia or hypoesthesia) are reported by one-third of patients; usually they are felt in the foot, sometimes in the leg Often there is a diminution of pain perception corresponding to the appropriate dermatome; the location of sensory symptoms conforms to the dermatomal supply of the sensory root (Figs 9-1 and 9-3) Muscle weakness occurs, but less frequently In only a few patients is a foot drop (L5 root) or weakness of plantar exion (S1 root) the main feature of disc protrusion, but it is notable that some of these patients will have little associated pain The ankle or knee jerk is usually diminished or lost on the side of the lesion The re ex changes have little relationship to the severity of the pain or sensory loss Furthermore, compression of the fourth or fth lumbar root may occur without any change in the tendon re exes Bilaterality of symptoms and signs is rare, as is sphincteric paralysis, but they may occur with large central protrusions that compress the cauda equina The cerebrospinal uid (CSF) protein is then predictably elevated, usually in the range of 55 to 85 mg/dL, sometimes higher As indicated above, herniations of the intervertebral lumbar discs occur most often between the fth lumbar and rst sacral vertebrae (compressing the S1 root) (Fig 11-4) and between the fourth and fth lumbar vertebrae (compressing the L5 root) It is important, therefore, to recognize the clinical characteristics of root compression at these two sites, as summarized in Table 11-1 Lesions of the fth lumbar root produce pain in the region of the hip and posterolateral thigh (ie, sciatica) and, in more than half such cases, lateral calf (to the external malleolus), dorsal surface of the foot, and the rst or second and third toes Pain is elicited by the straight-leg raising test or one of its variants, and protective nocifensive re exes come into play that limit further elevation of the leg Paresthesias may be felt in the entire territory or only in its distal parts The tenderness is in the lateral gluteal region and near the head of the femur Weakness, if present, involves the extensors of the big toe and of the foot The ankle jerk may be diminished (more often it is normal), but the knee jerk is hardly ever altered Walking on the heels may be more dif cult and uncomfortable than walking on the toes because of weakness of dorsi exion With lesions of the rst sacral root, the pain is felt in the midgluteal region, posterior part of the thigh, posterior region of the calf to the heel, outer plantar surface of the foot, and fourth and fth toes Tenderness is most pronounced over the midgluteal region (in the region of the sacroiliac joint), posterior thigh areas (sciatica), and calf, and the straight-leg raising tests exaggerate or bring this out Paresthesias and sensory loss are mainly in the lower part of the leg and outer toes, and weakness, if present, involves the exor muscles of the foot and toes, abductors of the toes, and hamstring muscles The Achilles re ex is diminished or absent in the majority of cases In fact, loss of the Achilles re ex may be the only objective sign Walking on the toes is more dif cult and uncomfortable than walking on the heels because of weakness of the plantar exors The less frequent lesions of the third and fourth lumbar roots give rise to pain in the anterior part of the thigh and knee and anteromedial part of the leg (fourth lumbar), with corresponding sensory impairment The knee jerk is diminished or abolished L3. how to view pdf file in asp.net using c# We need to follow certain steps to generate PDF from Rotativa tool:
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