L4 Lumbar Spine

Keywords; L4 Lumbar Spine, chiropractic help, facet arthropathy spondylolysthesis, slipped disc rules.

Any lower back disc protrusion may cause a serious list to port, or starboard, called an antalgia, though not necessarily. It is often worse at L4. We at Chiropractic Help call it the sign of Pisa! And of course accompanied by acute lower lumbar back pain. In Holland it's called spit. In the English speaking world, "lipped disk. In the language of the Two Ronnies; I've just done my back in.

The word antalgia is really two words joined together:

Ant meaning away from.

Algia meaning pain.

Antalgia means thus leaning away from the pain.

It's a reflex spasm of the back to protect the nerve from being pinched when you have a bulging lumbar disc. It's a serious sign, and neglected often progresses to a sciatica; severe pain down the leg. Always assume it will take at least six weeks for the annulus fibrosus to heal because, if you have a relapse, you can expect that it will quickly progress from a Grade one lumbar disc protrusion, to grade two, or three, and even heaven forbid, grade four and a high likelihood of lumbar spinal surgery.

The first grade is known as a lumbar disc protrusion. The rule in health care is the same as in money. Look after the pennies, and the pounds will look after themselves. Care properly for your grade one Lumbar disc protrusion and you won't end up with a grade two; and ultimately grade four. Clinically I like to thing of a grade five. More about that later.

A little warning; these terms, bulge, protrusion, prolapse, extrusion and sequestration tend to be used rather loosely, espectially the first three.

Go on, take a look at lumbar disc protrusion, I'll wait until you're done! Then hit the go back one page arrow at the top of your page, and I'll be waiting, for the rest of your L4 lumbar spine tour, and how to avoid lumbar surgery.

Searching for something specific? Say, slipped disc rules. Just type it in here.

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What is confusing is that antalgias come into two forms: one away from the pain, and one towards the pain - but we call them both antalgias.

  1. Away from: Postero-lateral bulge.
  2. Towards: Postero-medial bulge.

They must both be taken seriously, but what is interesting is that the postero-medial kind responds very quickly to Chiropractic adjustments - but it still takes six weeks to heal. If you ignore this fact, relapse is common frequently progressing to pain and tingling in feet and legs.


L4 Lumbar Spine

Should the bulging disk irritate the nerve, usually the L5 nerve, you will start to feel tingling following a specific pattern. Then the skin becomes hypersensitive, and if you still do nothing the skin, particular on the lower leg stretching over towards the top of the foot and the big toe, will become numb. TINGLING IN FEET AND LEGS ...


Within each spinal nerve, there are in fact two nerves. One bringing information from the limbs for example, and the other innervating the muscles.

The L5 nerve root, the one usually affected by a bulging L4-L5 disc, classically supplies a muscle called the Extensor Hallucis Longus. If it's weak, you will have difficulty raising your great toe off the ground.

Can you do this?


Because the pain often resides quite quickly with Chiropractic help with a medial slipped disk, patients sometimes stop the rehab, thinking the condition was no big deal and your chiropractor has golden hands!, start sitting and bending too quickly, and whoops, a relaps. In my experience, the medial disk is much easier to manage, but in reality, research proves that a greater percentage of medial disks end up in lumbar spinal surgery.

Medicine's approach is to treat a herniated lumbar disk first with anti inflammatory drugs and then, if that doesn't help, with lower back surgery.

However, at chiropractic help, we don't see this as an inflammatory condition, unless it's been neglected for weeks or months. Rather, like a broken arm, the displaced nucleus pulposus should first be reduced, a variety manual techniques are used, and then the joint rehabilitated.

A corset to immobilize the joint for a period, when doing unavoidable activities like bending and sitting, may be useful, but should not be used for long periods.

We are also not in principle against good lower back surgery, and every chiropractor has to refer patients to good surgeons periodically. However, Failed Back Surgery is a daily phenomenon in our clinics, so we are convinced that a course of Chiropractic care should be mandatory before surgery.

More, interesting research shows that if you first consult a chiropractor for a serious low back injury, you are significantly less likely to end up under the knife. Every week, day?, lost before that disc is reduced increases the likelihood of surgery.

So, this is a normal disc. Note the very strong washer than contains the nucleus, and the location of the nerve root just behind the disc, exiting from the  spine via the inter vertebral foramen.  In the third picture down, you'll see how the disc can bulge into the foramen.

Grade 1: This is a disc bulge, where we started this page. A grade 1 protrusion gives no leg pain, but if it threatens the nerve root you'll often start looking like a question mark: the sign of Pisa.

Grade 2: Protrusion. Now the bulge is larger and is certainly affecting the nerve root. The protrusion may be "lateral" as in the graphic below, in which case Pisa leans "away" from the pain.

Or it may be medial to the nerve root, in which case Pisa leans "towards" the painful side. Now the Slump test for sciatica will be positive, if it's one of the lower discs. The mid to upper lumbar spine would affect the Femoral nerve with pain in the side and front of the thigh.

Grade 3: Prolapse / aka an extruded disc. Leg pain, but no numbness or weakness.

Grade 4: Leg pain WITH altered sensation in the leg and/or weakness of the muscles associated with that nerve root.

S1 nerve root: difficulty standing on your toes (raising the heel).

L5 nerve root: unable to raise the great toe.

L4 and higher nerve roots: Foot drop if the Tibialis anterior muscle is affected, or weakness at the knee if the Quadriceps muscle is affected.

Grade 5: No, or minimal back pain, but severe leg pain, weakness and sensory change. Because the "sequestered disc" has completely escaped, it produces bizarre sensory changes. Sometimes under the foot, then on the side of the ankle, then perhaps the side of the foot...

The sequestered disc can move down, as in the graphic below, or upwards.


Mr van der D, aged 68 had an attack of "spit" seven years ago. He didn't respond well to drugs or physiotherapy, and it was decided that he should have a lumbar decompression operation. This is the X-rays taken BEFORE the operation.

The L4 lumbar spine op didn't help, so six weeks later he had a second more drastic operation. Look carefully at the L4-L5 disc space. These X-rays were taken immediately after the second op.

Notice the severe loss of the disc space where the nucleus pulposus was extracted in the lumbar decompression of this L4 lumbar spine. He has a flat tyre, and quite soon it's going to be bone on bone, or lumbar stenosis.

The operation relieved his back pain and leg pain, for a time, but set him up for a certain lumbar stenosis: severe narrowing of the foramen where the nerves emerge. Now he has had severe unrelenting pain down the leg for three months. Read more lower down about chiropractic help Lumbar Stenosis.


He's responded well to the first two treatments, but to be quite honest, the future remains uncertain. At least six to eight weeks of treatment, rehab, and a life time of chiropractic care.

Before you go for a lumbar spinal surgery after a L4 lumbar spine protrusion, try everything first. When and if all else fails, including a solid attempt at chiropractic help, then and only then submit to your surgery. Done by an expert, say your prayers, it can be a wonder. But it can also be a disaster. It wasn't cynical chiropractors who coined the phrase, FBS. Failed back surgery.

Just the anaesthetic alone has its dangers. Anaesthetic Alzheimers is a reality for both the older person and small children especially.


Never treat Case files as gospel, but cases like this one often they reveal a gem of truth worth considering... L4 LUMBAR SPINE CASEFILE ...


Small slipped discs are not uncommon and you will recover quickly with chiropractic help, but if you have a severe attack of lower back pain, are standing like Pisa, and especially if you have radiating pain down the leg, then we strongly recommend these slipped disc rules if you want to escape lumbar surgery.

Some of them are controversial. For example, research shows that bed rest alone has little or no value, in fact may make you worse. My unresearched opinion is that, combined with chiropractic help, and active exercises done every half an hour, and getting up every hour for a short walk, that bed rest is very beneficial.


Between every pair of lumbar vertebrae are three joints:

  • One disk joint
  • Two facet joints.

See those facets, right and left? They are the source of much lower lumbar back pain. If they remain chronically fixated then the hyaline cartilage is starved of nutrients and oxygen causing what is known as IMMOBILISATION ARTHRITIS ...


In the figure above, notice the line called 'pars'. This is the site where a fracture can occur, usually in childhood when the cartilage has not yet turned to bone. This can allow L4 to slide forwards on L5 ... but sometimes it occurs because of severe degenerative changes in the facet joints causing Lumbar Facet Arthropathy SPONDYLOLYSTHESIS ...

Personal anecdote. During the first 20-25 years of practice, I would never have tackled a Grade 4 or 5 lumbar disc injury. Then gradually with increasing manipulative and management skills, urged on by patients who would steadfastly refuse surgery, I began to tackle and succeed with some of the very serious lower back injuries.

Then three months ago, I  myself had a very serious L3/L4 disc injury. The disc split into two parts, one extruded into the foramen, and the other sequestered into the spinal canal. Could chiropractic repair such a serious injury, normally considered a surgical emergency? Femoral nerve damage ...

Have A Question about your lower back?

I receive many questions about Chiropractic. It might be help with a spinal condition, but it might also be from a person who can't walk after a hip operation, or some such thing.

I will do that by answering your questions personally, but it will be converted to a Web Page so others can benefit from your questions. Omit your name if you like.

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There is no charge for this service, however if you find my answer useful, you might like to consider purchasing my latest book, Stones in my Clog. Gems, both funny and healthful, from the life and work of a Chiropractor. It's only $2.99. http://www.bernard-preston.com/Stones-in-my-Clog.html

Pose Me A Question! Pretty please, in decent grammar and spelling.

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Do understand that lower back pain is extremely complex, so I can only give general guidelines. There's no substitute for a careful thorough chiropractic examination.

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Important tip:

It's my considered opinion that most patients who end up in surgery,

  • themselves think the condition too serious for a chiropractor
  • their doctor (or spouse) think the condition too serious
  • expect to be fixed with a few clicks of the back
  • won't take rest and do the exercises faithfully
  • don't think the condition serious enough to slow down or stop, or follow the slipped disc rules mentioned above.


Did you find this page useful? Then perhaps forward it to a suffering friend. Better still, Tweet or Face Book it.

Interesting challenges of the day

1. Mrs B has had one of the nastiest of conditions; vertigo caused by a disturbance in the inner ear. Falling repeatedly and vomiting she consulted her doctor but medication didn't help. After two sessions of the Epley manoeuvres she was 50 percent better. After two weeks she was 75 percent improved; no longer vomiting or falling. She's not enjoying the Brandt Daroff home exercises.

2. Mr S, a 48 year old man, has right low back pain, groin pain and a numb feeling in his lower leg when he sports. For six months he's been off football. He too has two problems; a very treatable lumbar facet syndrome and a very serious blocked artery in the groin; it's called intermittent claudication. Smokers beware.  

3. Mr S looks like the leaning tower of Pisa; he has a slipped disc at L5 making him lean towards the opposite side. It's called the postero lateral disc hernia; we'll fix it, but he has to stop for a week or two. Antalgias are serious so take them seriously. 

4. Mrs V too has two conditions; a chronic low grade sciatica giving her an ache in the right leg, and a threatening Morton's neuroma. She's glad I'm back in Holland; chiropractic fixed it before, and we'll fix it again. 

5. Mrs W is one of the lucky ones, says her doctor. I agree. He says only 40% of patients with lumbar stenosis have a successful operation. We fixed a nasty slipped disc three years ago, but it came back two years later; the surgeon did a fine job but she has a weak ankle now giving her subtalar joint pain; it's routine stuff. 

6. I myself had an acute exacerbation of a femoral nerve lesion last year. One immediate treatment of the new strain by my colleague has fixed the pain in the lower back, but there's some residual numbness in the lower leg; no soaring tomorrow alas.

7. This lady is a 86 year old woman with a 63 scoliosis. Chronic lower back has been her lot in life but she's well pleased with chiropractic and comes for chiropractic help once a month; some conditions you can never cure.

8. She is an 78 year old woman, is doing remarkably well with a bad sciatica. But over 200 pounds she is not losing weight; in fact, gaining despite my suggestions. She's high risk for a stroke. I have referred her to a dietician to crack the whip.

9. A 61 year old man with upper cervical pain yesterday; it's not severe but also not getting better of its own accord. He's afraid it may turn very acute as when I treated him three years ago. Since then it's been fine. 

10. A 64 year old woman has had scheuermanns disease; it's left her with a spinal kyphosis and chronic middorsal pain. She responds well to chiropractic treatment provides she come every six weeks or so for maintenance treatment.

11. Mrs C has been having severe headaches, and taking a lot of analgesics. It's a non complicated upper cervical facet syndrome, and she's doing well.

12. Mrs D, a middle aged woman with hip pain of one year duration, despite other treatment. Xrays reveal an impingement syndrome and early hip arthritis. There's much to be done.

13. Mr D, a 71 year old man, has a severe ache in the shoulder and midback since working above his head. Trapped nerve tests are negative but he has advanced degenerative joints of Luschka; after just two treatments he is 50 percent better. Can we reach 90?

And so the day goes; chiropractors shouldn't be treating the elderly most medical sites state but that's so much bunkum.

Have a problem that's not getting better? Looking for a different slant on your pain? Want to pose a question?

Interesting questions from visitors

CLS writes:

Greetings, Dr B.
You helped me quite some time back with a soothing and professional response which turned out to be exactly correct. I now consult a local chiropractor. You write a superb newsletter, too.

Your own unresolved problem. Pose a question

Knowing that up to 70% of the time the correct diagnosis is made with no examination, no special tests, no xrays, but just from the history, there's a fair chance I can add some insight to your unresolved problem. But at least 30% of the time, I may be quite wrong! Give plenty of detail if you want a sensible reply.

You visited this chiropractic help site no doubt because you have a problem that is not resolving and want to know more about what chiropractors do.

The quickest and most interesting way is to read one of my ebooks of anecdotes. Described by a reader as gems, both funny and healthful, from the life and work of a chiropractor, you'll love them. Priced right at $2.99, though Kindle fiddles the price without telling me.

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