L4 Lumbar Spine

L4 Lumbar Spine is a troublesome area of the low back.

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 is called spit. In the English-speaking world, "slipped disk.

In the language of the Two Ronnies; I have 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 is a reflex spasm of the back to protect the nerve from being pinched when you have a bulging lumbar disc. It is 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 level two, or three, and even heaven forbid, four and a great likelihood of 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 will not end up with a grade two; and ultimately progressing to grade four. Clinically I like to think of another level, grade five; more about that later.

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

Go on, take a look at lumbar disc protrusion; I will wait until you are 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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The disc anatomy of the L4 lumbar spine.

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.

The PL disc herniation at L4 often causes a sharp antalgia to the opposite side.


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 is one of the first symptoms that drive a patient to seek chiropractic care.

The straight leg raise and the Slump test for sciatica are two standard parts of the chiropractic examination.

L5 dermatome is usually affected by a L4 lumbar disc herniation.


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?

Extending the great toe is sometimes weakened by a L4 lumbar disc prolapse.

Medial hamstring reflex

The medial hamstring reflex is the one most readily tested in this case, for the L5 nerve root.

I have called it the L4 lumbar spine reflex, since that is the vertebra that is most commonly the spoke in the wheel.

This reflex is not commonly tested, but is vital in cases where there is loss of toe extension. The extensor hallucis tendon reflex is not readily elicited.

The medial hamstring tendon also becomes soft and loses its tension. It's best tested with the patient lying supine but can be done both prone and sitting as demonstrated at the link above. 


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.

Normal disc anatomy.

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.

Bulging disc anatomy of the lumbar spine.

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.

Extruded disc anatomy of the lumbar spine.

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.

Sequestrated fragments of the disc in the lumbar spine.


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.

Lateral lumbar spine x-ray before an 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.

Lateral lumbar x-rays of the spine after surgery.

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.
A pars defect between the facets.

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 three 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.

However, do understand that, in the main, I'm going to be directing you, should it be pertinent, to a Chiropractor in your neck of the woods. I'll respond to all reasonable inquiries, but please be specific, and give as much detail as you can.

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.


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