1.

I diagnosed with LBP, first of all the definition of LBP is clinical syndrome with main
symptoms as pain or other discomfort in the low back area and arounds (low back area is
below the last costal margin until the gluteal fold). This patient presented with complaints
of pain that was felt in the right lower back area near the buttocks area. And we suspect
the diagnosis of LBP in this patient with lumbar HNP because, based on the history, as I
explained earlier the patient complains of pain located in the lower back area, then the
character of the pain in HNP is usually sharp pain and accompanied by radiating pain (up
to the tip of the foot). which is commonly referred to as sciatica), based on the patient's
risk factors, there is also a history of frequent lifting of heavy objects by bending over
which can be one of the etiological factors causing mechanical HNP. From the physical
examination we found pain when bending over, a special test to check the sciatic nerve
was positive, and there was a sensory deficit in the right L4 and L5 dermatomes, where in
this result we suspected the affected nerves were at the L4 and L5 root levels, by
Therefore, if the defect is at the L4 root, we suspect a disc herniation between L3 and
about 3 vertebral levels below it.

2. HNP is most common in the L4-L5 and L5-S1 lumbar intervertebral discs. This can be
due to the first being because the posterior longitudinal ligament is getting thinner in the
lumbar vertebral section and in the S1 section, it only covers half of the intervertebral
disc, so that the narrowed ligament results in a lack of protection against the surrounding
nerve tissue. Another factor is the nucleus pulposus is located in the middle to 1/3
posterior of the disc, so the annulus fibrosus is thicker in the anterior and thinner in the
posterior which allows for higher herniation. Other factors besides anatomical causes are
mechanical factors, where the lumbar vertebrae play an important role in bending or
rotational movements, majority of spinal flexion & extension (90%) occurs at the L4-L5 and L5-
S1. The strength and stability factors are due to the : combination of the spine bone and
the pelvis, then there is spinal curvatures (which are 16 times stronger than without the
curva), then the long and short spinal ligaments and the role of surrounding muscles:
abdominal , back extensor, hip flexors, glutei, hamstring

3. For the differential diagnosis in this patient... first I will try to explain based on the
etiology of LBP first, where the etiology of LBP can be caused by mechanical and non-
mechanical. Mechanical LBP is also divided into static mechanics and dynamic
mechanics. So that the differential diagnosis for HNP is in LBP diseases that arise due to
mechanical causes (especially dynamic), it can be in the form of a sprain or strain which
is the most common cause of mechanical LBP, then canal stenosis which we can evaluate
also based on the history and physical examination whether there are signs such as
intermittent claudication or not. Other differential diagnoses, such as spondylolisthesis or
possibly degenerative discs, can then be confirmed by imaging.