# A Prospective Clinical and Radiological Study of Symptomatic Upper Lumbar Disc Herniation in the Indian Population

## TL;DR

This study examines how upper lumbar disc herniation varies by spinal level in Indian patients, identifying age and neurological patterns.

## Contribution

The study identifies level-specific clinical and radiological patterns of upper lumbar disc herniation in the Indian population.

## Key findings

- L1-L2 herniations are more common in younger patients and are typically MSU Type 1B.
- L2-L3 and L3-L4 herniations are more common in older patients and are associated with upper motor neuron-like neurological features.
- Neurological symptoms like gait imbalance and bowel/bladder involvement are more frequent at L2-L3 and L3-L4 levels.

## Abstract

Introduction

The upper lumbar spine is anatomically predisposed to neural compression due to a relatively narrow spinal canal, the presence of the conus medullaris and proximal cauda equina, and reduced segmental mobility. This distinct anatomy can lead to a wide range of clinical presentations, from nonspecific polyradiculopathy to cauda equina syndrome. The variability in symptoms and the unique anatomical features often complicate surgical decision-making. The primary objective of this study was to evaluate the association between upper lumbar disc level (L1-L2, L2-L3, L3-L4) and neurological as well as functional presentation. Secondary objectives included correlation with radiological characteristics and demographic variables.

Material and methods

A prospective observational study was conducted at Stavya Spine Hospital and Research Institute over a period of one year. Patients meeting the inclusion criteria underwent a comprehensive clinical evaluation, including a history-taking session, physical examination, and assessment using functional scoring systems, such as the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI). Patients were asked to map their patterns of back and leg pain, and radiological findings were meticulously documented.

Results

Fifty patients were enrolled consecutively, with an overall mean age of 51.26 ± 14.68 years. Patients with L1-L2 disc herniation were younger (mean age 42.13 ± 11.14 years) compared with those with L3-L4 herniation (54.45 ± 12.24 years). Although patients with L1-L2 disc herniation were younger on average compared with those with L3-L4 herniation, the difference in age across disc levels was not statistically significant. Most L1-L2 disc herniations were classified as Michigan State University (MSU) Type 1B, while L2-L3 and L3-L4 herniations were predominantly MSU Type 2B and Type 3B, respectively. Gait imbalance, extensor plantar response, motor weakness, sensory deficits, reflex changes, and bowel or bladder involvement were more commonly observed in patients with L2-L3 and L3-L4 disc herniations.

Conclusion

Upper lumbar disc herniation demonstrates level-specific demographic and clinico-radiological patterns. L1-L2 herniations occur in relatively younger patients and are predominantly MSU Type 1B, whereas L2-L3 and L3-L4 herniations are more common in older individuals and are typically larger, classified as MSU Type 2B and 3B. Disc herniations at L2-L3 and L3-L4 levels more frequently present with upper motor neuron-like (epiconus-related) neurological features, including gait imbalance, extensor plantar response, motor weakness, sensory deficits, reflex changes, and bowel or bladder involvement. Recognition of these level-dependent clinical patterns is essential for accurate diagnosis and timely surgical decision-making in upper lumbar disc herniation.