L4 is at the level of the iliac crests — a key surface landmark — and the L4 nerve root is responsible for the tibialis anterior and knee extension, making L4 disc pathology a common cause of foot drop.
L4-L5 disc herniation is the second most common lumbar disc herniation site after L5-S1, compressing the L4 nerve root to produce medial leg pain and numbness with tibialis anterior weakness and diminished patella reflex. The iliac crests are at the L4-L5 level on average, making this the standard landmark for lumbar puncture technique. L4-L5 spondylolysis and spondylolisthesis are less common than at L5-S1 but produce identical symptoms.
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