Central Lumbar Disc Herniation Research Articles

Prodrome to Seizure in Transforaminal Endoscopic Surgery: A Series of 9 Cases

Objective: Percutaneous transforaminal endoscopic lumbar discectomy (PTELD) is safe and ef- fective. Perioperative or postoperative seizures are a rare complication that can be prevented by promptly identifying prodromal symptoms and signs. This study aimed to identify prodromal symptoms and risk factors of avoidable seizures in patients undergoing PTELD and to quantify irrigation fluid ingression into the epidural space on immediate postoperative magnetic reso- nance imaging (MRI).Methods: This retrospective analysis included patients who underwent PTELD under local anes- thesia from February 2018 to June 2022. Surgical records were reviewed to identify patients who developed prodromal symptoms, and immediate postoperative MRI was evaluated for ra- diological correlations.Results: Nine patients developed prodromal symptoms of neck pain (n = 6), upper dorsal pain (n = 7), headache (n = 2), confusion (n = 2), visual disturbance (n = 1) and hemodynamic alter- ations (n = 4). No patients had seizures. Calcified lumbar disc herniation-associated posterior apophyseal ring fracture, central lumbar disc herniation, obesity, double-level surgery, use of an automated pump, and a large working channel endoscope were associated with an increased fluid flow rate for epidural work and duration of surgery. MRI showed significant epidural fluid collection cranial to the operative level, reaching the thoracolumbar junction, in patients with prodrome, suggesting increased intracranial pressure due to thecal sac compression. Conclusion: Prodromal symptoms should be considered a red flag for avoidable seizures. The duration of surgery and infusion fluid flow rate are controllable risk factors during surgery. Risk factors should be kept in mind. The judicious use of automated pumps and larger channel work- ing endoscopes is recommended.

Clinical results of combined interlaminar and transforaminal endoscopic discectomy for central large disc herniation

ObjectiveThe purpose of this study was to inscribe the combined interlaminar with transforaminal endoscopic discectomy for central large disc herniation and report clinical results. MethodsPatients diagnosed with large central lumbar herniated nucleus pulposus who underwent combined interlaminar and transforaminal endoscopic discectomy between 2015 and 2020 were reviewed. Perioperative data, preoperative and postoperative Oswestry Disability Index (ODI) scores, visual analog scale (VAS) back pain scores, VAS leg pain scores, and complications were evaluated and recorded at 1 week and 3 and 6 months postoperatively and each year thereafter. ResultsThe study revealed 9 cases (22.22% female). The average age of patients was 42.33 ± 19.8 years old (range, 18–83 years old). The levels of surgery were L3-4 in 22.22%, L4-5 in 77.77%. This combined approach has an average operative time of 104.44 ± 22.42 min. The VAS Back and Leg were improved from pre-operative score from 5.0 ± 2.0, 4.42 ± 2.93 to 2.18 ± 1.97 and 2.55 ± 2.84 retrospectively at 1 week. The ODI score was improved pre-operative from 46.85 ± 15.61% to 14.94 ± 19.08% at 3 month follow up. There were 2 cases (22.22%) diagnosed of recurrent disc herniation. No case of epidural hematoma, infection, permanent neurological deterioration, cauda equina syndrome. ConclusionsCombined interlaminar and transforminal endoscopic discectomy is an option for central large lumbar disc herniation.

The Clinical Diagnostic Value of Lumbar Intervertebral Disc Herniation Based on MRI Images.

MRI was used to measure the changes in the angle of the facet joints of the lumbar spine and analyze the relationship between it and the herniated lumbar intervertebral disc. Analysis of the causes of lumbar disc herniation from the anatomy and morphology of the spine provides a basis for the early diagnosis and prevention of lumbar disc herniation. There is a certain correlation between the changes shown in MRI imaging of lumbar disc herniation and the TCM syndromes of lumbar intervertebral disc herniation. There is a correlation between the syndromes of lumbar disc herniation and the direct signs of MRI: pathological type, herniated position, and degree of herniation. Indirect signs with MR, nerve root compression and dural sac compression, are related. The MRI examination results can help syndrome differentiation to improve its accuracy to a certain extent. MRI has high sensitivity for the measurement of the angle of the facet joints of the lumbar spine and can be used to study the correlation between the changes of the facet joint angles and the herniated disc. Facet joint asymmetry is closely related to lateral lumbar disc herniation, which may be one of its pathogenesis factors. The herniated intervertebral disc is mostly on the sagittal side of the facet joint, and the facet joint angle on the side of the herniated disc is more sagittal. The asymmetry of the facet joints is not related to the central lumbar disc herniation, and the angle of the facet joints on both sides of the central lumbar disc herniation is partial sagittal.

Differential Diagnosis Strategy between Lower Extremity Arterial Occlusive Disease and Lumbar Disc Herniation.

Considering the increasingly incidence rate of lower extremity arterial occlusive disease and difficult to distinguish from lumbar disc herniation, it is very necessary to exclude lower extremity arterial occlusive disease resulting in lower limb symptoms from lumbar disc herniation. More importantly, who have a higher risk of combining with lower extremity arterial occlusive disease and misdiagnosed as lumbar disc herniation? Why those patients are easy to be misdiagnosed as lumbar disc herniation? It is worth analyzing and discussing. The risk factors including age, gender, the medical history of high blood pressure, diabetes, smoking and coronary, pulse pressure, lumbar disc herniation segment and type, ankle-brachial index, and straight leg raising test were observed. The Oswestry disability index and the Japanese Orthopedic Association score were collected preoperative, six months after posterior lumbar interbody fusion and six months after vascular interventional treatment to evaluate the symptoms relief and surgical efficacy. There was a statistically significant difference (P < 0.01) in pulse pressure, ankle-brachial index, central disc herniation, and straight leg raising test between two groups. There was a high risk to missed diagnosis of lower extremity arterial occlusive disease and misdiagnosed as lumbar disc herniation when patients are with a mild central lumbar disc herniation, higher pulse pressure, lower ankle-brachial index, and straight leg raising test negative. Therefore, sufficient history-taking and cautious physical examinations contributed to find risk factors and attach importance to such patients and, further, to exclude lower extremity arterial occlusive disease from lumbar disc herniation using lower extremity vascular ultrasound examination.

Evaluation of the effectiveness of transforaminal epidural steroid injection in far lateral lumbar disc herniations.

Far lateral lumbar disc herniations (FLDH) consist approximately 0.7-12% of all lumbar disc herniations. Compared to the more common central and paramedian lumbar disc herniations, they cause more severe and persistent radicular pain due to direct compression of the nerve root and dorsal root ganglion. In patients who do not respond to conservative treatments such as medical treatment and physical therapy, and have not developed neurological deficits, it is difficult to decide on surgical treatment because of the nerve root damage and spinal instability risk due to disruption of facet joint integrity. In this study, we aimed to evaluate the effect of transforaminal epidural steroid injection (TFESI) on the improvement of both pain control and functional capacity in patients with FLDH. A total of 37 patients who had radicular pain caused by far lateral disc herniation which is visible in their lumbar magnetic resonance imaging (MRI) scan, had no neurological deficit and did not respond to conservative treatment, were included the study. TFESI was applied to patients by preganglionic approach. Pre-treatment Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores of the patients were compared with the 3rd week, 3rd month and 6th month scores after the procedure. The mean initial VAS score was 8.63 ± 0.55, while it was 3.84 ± 1.66, 5.09 ± 0.85, 4.56 ± 1.66 at the 3rd week, 3rd month and 6th month controls, respectively. This decrease in the VAS score was found statistically significant (p = 0.001). ODI score with baseline mean value of 52.38 ± 6.84 was found to be 18.56 ± 4.95 at the 3rd week, 37.41 ± 14.1 at the 3rd month and 34.88 ± 14.33 at the 6th month. This downtrend of pa-tient's ODI scores was found statistically significant (p = 0.001). This study has demonstrated that TFESI is an effective method for gaining increased functional capacity and pain control in the treatment of patients who are not suitable for surgical treatment with radicular complaints due to far lateral lumbar disc hernia.

Comparison of 1-year results of single transforaminal epidural steroid injection among patients with different spinal pathologies-related radicular pain.

This study aims to investigate the effectiveness of transforaminal epidural steroid injection (TFESI) in patients with lumbar radicular pain or radiculopathy caused by different spinal pathologies. One hundred and seventy seven patients who underwent single transforaminal epidural steroid injection were included in the study group and divided into 3 subgroups (central spinal stenosis + lateral recess stenosis, foraminal stenosis, lumbar disc herniation) according to existing spinal pathology. Patients' visuel analogue scale (VAS) measures and Oswestry Disability Index (ODI) scores were recorded and the patients who give favourable response to treatment were called respondents and who were not called as non-respondents. Subgroups were compared statistically at the end of 12 months. Sixty patients (33.9%) were considered as respondents and 117 patients (66.1%) were non-respondents in the entire study group. Patients with foraminal stenosis included the vast majority of the respondents and showed better results of pain relief as opposed to patients of other groups at the end of 12 months (P < 0.001). TFESI was an effective treatment modality for pain relief and functional improvement in patients with foraminal stenosis. However, it could not produce the same results in patients with central spinal stenosis and lumbar disc herniations.

Radiographic and clinical outcomes of huge lumbar disc herniations treated by transforaminal endoscopic discectomy

ObjectivesLarge Central disc herniations (occupying more than 50% of canal area) are notorious as they are generally associated with worse outcomes and are technically difficult to manage. Transforaminal endoscopy (TELD) has evolved to become an interesting alternative for lumbar disc herniations. The aim of the paper is to review our technique of transforaminal endoscopy in large central disc herniations and describe the clinical and radiographic results. We also describe an innovative technique of intraoperative epidurography to assess the adequacy of decompression in some cases with severe canal compromise. Patients and methodsWe performed a retrospective analysis of all the patients undergoing TELD from December 2012 to October 2018 for huge central lumbar disc herniations. The procedure was done under local anaesthesia and required a more horizontal approach angle, undercutting of superior articular process and posterior annular release to reach the herniated fragment in the epidural space. In severe cases, a radiopaque dye was introduced via trans-sacral catheter to check the adequacy of decompression. The disc height, lumbar lordosis, segmental lordotic angle on standing radiographs and Canal cross sectional area(CSA) on MRI were evaluated preoperatively and compared with postoperative images at the end of 1 year/final follow-up. The Visual analogue scale(VAS) for Back and Leg pain and Oswestry disability index (ODI), MacNab criteria, return to daily activities, return to work, patient satisfaction rate and recommendation to others were the clinical outcomes evaluated. The percentage of patients achieving the Minimal clinically important difference (MCID) of 3 points for VAS and 12 points for ODI was calculated. ResultsA total of 18 patients, with an average age of 35.1years (range 20–61), were operated. The mean VAS back improved from 5.7(±1.77) to 1(±0.77) and VAS leg improved from 7.3(±1.37) to 1.1(±1.09). The ODI improved from 49.88(±11.42) to 13.88(±7.28) at final follow-up. According to MacNab criteria, 17 patients had excellent and 1 had good outcome at final follow-up. The patient satisfaction rate was 90.5%, with 94% patient recommendation rate. All the patients returned to daily activities and work/modified work within a median of 5 weeks. There was 1 patient who required conversion to open surgery due to incidental dural tear, 1 patient who had a remnant disc required a revision tubular discectomy and 1 patient who had recurrence at 6 weeks and again at 2 years which was treated by repeat TELD. Five patients had impending cauda equina. All the patients achieved the MCID for VAS and ODI within a median period of 6 weeks and 3 months, respectively. The recovery rate was 90.1%. Five patients had grade 4 weakness of great toe/ankle dorsiflexion, one also had ankle flexion weakness preoperatively which improved after surgery. The CSA improved from a preoperative mean of 62.26(±30.3)mm2 to 122.16(±56.5)mm2 postoperatively. The CSA improved to 141.05(±63.86)mm2 at 1 year followup. The average disc height which was 9.71 mm(±2.4) was maintained at follow-up of one year which was 9.21 mm(±2.4). The lumbar lordosis and segmental lordotic angle changed from 27.08°(±15.9) and 2.82°(±5.7) to 35.8°(±8.56) and 4.85°(±4.39) respectively. ConclusionTELD may be considered as an alternative to microdiscectomy or fusion procedures for huge central disc herniations with favourable outcomes. However, sufficient expertise with the procedure is necessary. Intraoperative decompression may be confirmed with intraoperative epidurography. The patient acceptability of the procedure is good and causes minimal disruption of the normal anatomy.

Outcomes of Discectomy in Young Adults With Large Central Lumbar Disc Herniations Presenting With Predominant Leg Pain.

Study Design:Retrospective cohort study.Objectives:Discectomy alone or discectomy with fusion have been 2 polarized options in the management of large lumbar disc herniations presenting with leg-dominant pain in young patients. The objective of the study was to evaluate the outcomes of discectomy in young patients with large central lumbar disc herniation (CLDH) presenting with predominant leg pain.Material and Methods:Young patients (<45 years) presenting with predominant leg pain and MRI confirmed diagnosis of CLDH between April 2007-January 2017 were included in the study. All patients underwent tubular microdiscectomy. Outcomes of surgery were evaluated using visual analogue score (VAS) for leg and back pain, Oswestry Disability Index (ODI), and Macnab’s criteria.Results:Ninety patients fulfilled the inclusion criteria. The mean age of patients was 34.9 years (range 19-45 years). Mean follow-up was 5.09 years (range 2-10 years). The incidence of CLDH in young adults was 30% and incidence among all “operated” lumbar disc herniations was 15.9%. The mean VAS for leg pain improved from 7.48 ± 0.9 to 2.22 ± 0.84 (P < .05) and the mean ODI changed from 60.53 ± 7.84 to 18.33 ± 6.20 (P < .05). Fifty-nine patients (65.6%) reported excellent, 25 patients (27.8%) reported good, 3 patients each (3.3%) as fair and poor outcomes respectively.Conclusion:Discectomy alone for CLDH with predominant leg pain is associated with high success rate and low need for a secondary surgical procedure. Patient selection in terms of leg-dominant pain may be the main attribute for lower incidence of recurrence, postoperative back-pain, and instability needing a secondary procedure. Minimally invasive discectomy may provide an added advantage of preserving normal spinal anatomy, thus minimizing the need for primary spinal fusion in these patients.

Friday, September 28, 2018 3:00 PM–4:00 PM abstracts: optimizing lumbar disc surgery: 215. Patients presenting with a lumbar far-lateral herniated nucleus pulposus can expect similar postoperative outcomes to those presenting with a central or paracentral herniation

BACKGROUND CONTEXT A far lateral herniated nucleus pulposus (HNP) consists of 7%-12% of all disc herniations. 'Far lateral' is often used to describe a lumbar disc herniation that compresses the exiting nerve root at the same level, lateral to the neural foramen. The far lateral disc herniations have been described to elicit radicular leg pain that is more severe than a central or paracentral lumbar disc herniation due to direct compression of dorsal root ganglion, and are said to have a more acute onset in their clinical symptoms. However, literature does not provide much description of the comparative postoperative outcomes between those presenting with a far lateral HNP and those with a central or paracentral herniation. PURPOSE The goal of this study is to examine the pre- and postoperative outcomes between patients presenting with a central or paracentral versus a far lateral HNP. STUDY DESIGN/SETTING Retrospective cohort series. PATIENT SAMPLE We performed a retrospective cohort analysis of patients who underwent a primary lumbar microdiscectomy between 2009 and 2015 by one of two senior orthopaedic spine surgeons for lumbar spinal stenosis. Patients were excluded from analysis if they had any previous lumbar surgery, an unstable spondylolisthesis, were under 18 years of age at the time of surgery, or had postoperative follow up less than 3 months. Patients were divided into two groups based on the location of the HNP (central or paracentral versus far-lateral). OUTCOME MEASURES Patient reported outcomes were obtained in the form of Oswestry Disability Index (ODI) scores, Visual Analog Scales (VAS) scores for the back and leg, 12-Item Short Form Mental and Physical Survey (SF-12) scores, and the Veterans Rand 12-Item Health Mental and Physical Survey (VR-12) scores. METHODS Baseline patient characteristics were compared using chi-squared analysis and independent sample t-tests for categorical and continuous data, respectively. Bivariate and multivariate regressions were subsequently used to compare clinical outcomes between procedure groups. Multivariate analyses controlled for differences in baseline patient characteristics. RESULTS Overall, 212 consecutive patients who fulfilled our inclusion criteria were assessed. Average follow-up was 24.14 months (range 3–78 months). There were 191 patients who presented with a central or paracentral HNP, while 21 patients presented with a far-lateral HNP. There were no significant differences in the demographic variables between these two groups. Patients with a far lateral disc herniation presented with a trend towards a shorter duration of symptoms prior to surgery (24.5 vs. 31.5 months; p=.052). On multivariate analysis, patients with a far lateral disc herniation presented with significantly lower SF-12 mental (52.14±13.49 vs. 55.1±6.55; p=.034) and physical scores (24.76±7.5 vs. 36.9±11.1; p=.008). Similarly, the far-lateral disc herniation patients also presented with significantly lower VR-12 mental (47.2±12.8 vs. 56.9±7.0; p=.024) and physical scores (25.8±8.7 vs.39.38±11.8; p=.005). However, postoperatively, all patients have similar SF-12 and CR-12 survey scores. The improvement in ODI score was significantly lower in the patients presenting with a far lateral disc herniation (7.8±15.1 vs. 28.3±21.5; p=.002). No significant difference in re-operation rates was found (p=.236). CONCLUSIONS Patients presenting with far lateral disc herniations present with significantly lower SF-12 mental and physical scores as well as lower VR-12 mental and physical scores. However, at approximately 2 years following a lumbar microdecompression surgery, both groups of patients express similar successful outcomes, including SF-12 and VR-12 survey scores. Re-operation rates are similar between the two groups. Despite compression at the site of the dorsal root ganglion and the reported greater difficulty in addressing far lateral disc herniations, patients presenting with these far lateral disc herniations can expect similar outcomes to those patients present with herniations in the central or paracentral region.

Significance and pitfalls of percutaneous endoscopic lumbar discectomy for large central lumbar disc herniation.

Percutaneous endoscopic lumbar discectomy (PELD) is a relatively less invasive treatment for lumbar disc herniation (LDH). The present study focused on the transforaminal approach (TFA) and investigated the significance of PELD via this approach for large central LDH. LDH that did not show cerebrospinal fluid (CSF) on axial T2-weighted magnetic resonance images was defined as large central LDH. PELD via the TFA was performed in 11 patients with large central LDH. Pre- and post-operative statuses were evaluated using the modified Japanese Orthopedic Association (mJOA) and Numerical Rating Scale (NRS) scores. The patients' mean age was 44.1 years; there was single-level involvement, mostly at L4/5 (seven cases). The mean recovery rate of the mJOA score was 48.7%, and mean pre- and post-operative NRS scores were 7.1 and 1.5, respectively. The mean operative time was 38.1 min. Although there were no major complications, the dura was accidentally punctured at the initial operative step for discography in one case. LDH recurred in one case at 5 months after the operation, and the patient was treated by PELD via the TFA on the contralateral side. The TFA for PELD is a safe, minimally invasive, effective treatment for large central LDH. However, the operator should pay attention to malpositioning of the flat and laterally expanded dural sac.

Effects of release and decompression techniques on nerve roots through percutaneous transforaminal endoscopic discectomy on patients with central lumbar disc herniation.

The clinical effects and safety of release and decompression techniques on nerve roots through percutaneous transforaminal endoscopic discectomy (PTED) while treating patients with central lumbar disc herniation (CLDH) were explored. Patient cases of lumbar and leg pain treated in Bethune International Peace Hospital from July 2013 to October 2015 were collected retrospectively. The patients in these cases received imaging examinations such as computed tomography and magnetic resonance imaging. Among these cases, 37 CLDH patients with no other complications were selected for this study. A total of 22 males and 15 females aged 28–54 years, with an average age of 36.8±1.5 years, were the subjects of the study. Their disease course was from 1 month to 3 years, with a median course time of 1.5 years. Visual analogue scale (VAS), Japanese Orthopaedic Association (JOA) scoring and the MacNab method were used to evaluate treatment effects. After permission from patients or their family members, release and decompression techniques of nerve roots were performed through PTED. All patients had successful surgery. Their average surgery time was 41.3 (25.5–57.1) min. A physician followed-up each patient from 0 to 18 months after surgery, with the average follow-up period of 12.1 months. VAS scoring of lower limbs was 7.95±0.82 before surgery and 2.28±0.35, 3 months after surgery. VAS scoring of lower limbs was 2.06±0.58, 1 year after surgery and 2.12±0.23 at the last follow-up appointment. JOA scoring was 12.6±0.72 before surgery and 20.4±1.08, 3 months after surgery. JOA scoring was 21.1±0.82 1 year after surgery and 21.2±0.36 at the last follow-up. Differences are of statistical significance (P<0.05). There were no complications for any of the cases. One patient did not improve after surgery, so a laminectomy and bone grafting internal fixation were performed. Two patients relapsed after surgery and received laminectomy and bone grafting internal fixation. The total percentage of excellent and good rates was 83.5%. In conclusion, release and decompression techniques on nerve roots using PTED while treating CLDH resulted in a safe, effective and less traumatic outcome with fewer complications and quicker pain relief than alternative treatments. Due to the results of this study, the use of these techniques in treating CLDH should be more widely considered.

Full-Videoendoscopic Interlaminar Surgery for the Treatment of Lumbar Disc Herniations—A Series of 50 Cases

The present study aims to describe the results of full-videoendoscopic surgery through the interlaminar route for central lumbar disc herniation in a series of 50 cases in Brazil.This is a retrospective single-center study. With the aim of describing safety, the present study reports the complication and revision rates. The clinical results were collected with the visual analogue scale (VAS) and with the Oswestry Disability Index (ODI) (a questionnaire to evaluate functional disability) at the preoperative visit and at 6 months postsurgery.The average surgical time was 20 minutes (range: 9–40 minutes), and 100% of the procedures were performed in an outpatient setting. The mean VAS scores improved from 9.4 to 1.1 (p &lt; 0.001), and the mean ODI scores decreased from 69 to 9 points in the last follow-up (p &lt; 0.001). There was 1 case (2%) with hernia recurrence, 1 case with intraoperative root injury (2%), and 2 cases (4%) that required lumbar fusion due to a preexisting instability. No infections were observed.The full-videoendoscopic surgery is a modern option for treating lumbar disc herniation. In the present study, we have observed that the use of this technique for the removal of fragments affecting the vertebral canal presented satisfactory clinical results, low complication rates, and that it has demonstrated its feasibility in an outpatient setting without prolonged hospitalization.

Demographical Aspects of Central Large Lumbar Disc Herniation.

The purpose of this study was to investigate the risk factors for the development of the central large disc herniations and to compare the demographic data between central mass prolapse and broad-based central disc herniation. Between 2002 and 2007, 1630 patients underwent surgery and a large disc herniation was the main problem in 59 patients (3.6%). We performed a retrospective analysis of the demographic data of these patients. Magnetic resonance (MR) images were evaluated according to the disc type and level. Variables were evaluated both at baseline and follow-up, with special emphasis on physical job characteristics, sports activities, and MR - based morphologic findings. Central large disc herniation was diagnosed in 59 patients consisting of 41 males and 18 females. The average age was 34.7 years. 36 patients had a central mass prolapse that occupied more than 50% of the spinal canal. Intraoperative observations confirmed that 29 out of 36 central disc prolapse patients (80.5%) had intact posterior longitudinal ligaments. Interestingly, the condition in these 29 patients was found to have a direct relation with age and occupation or other body training sports activities. The size of the large central disc herniation, physical activity, age and gender are major factors in the development of disc herniation.

Nucleus pulposus atherectomy decompression and ozone nucleolysis combine lumbar traction in the treatment of central type lumbar disc herniation

Objective To investigate the clinic technique and effect of treating lumbar disc herniation (LDH) with decompressor and ozone injection combined lumbar traction after surgery.Methods 110 contained LDH patients were randomly divided into two group:decompressor and ozone group,decompressor and ozone combined lumbar traction after surgery group.Under the guidance of CT,fifty-five patients in group A were treated by disc decompression with Decompressor through poster olateral approach,then ozone was injected into the lumbar disc or out side the lumbar disc,and the other fifty-five patients in group B were treated by lumbar traction after surgery that disc decompression and ozone injection same as the group A in once a day and one week of treatment.The theraputic effect was evaluated by comparing VAS,effective rate of therapy before and after treatment.Results The VAS score of two groups at 1,3,7 days between pre-and post-treatment had singificantly different(t =2.159,2.163,2.169,2.167,2.173,2.192,all P ＜0.05).110 case were followed up after 6 and 12 months,The good-excellent rate of therapy in B group 12 months were better than those of A group (x2 =74.23,75.11,all P ＜ 0.05).Conclusion Decompressor combined ozone injection and lumbar traction after surgery is an effective menthod for treatment of the central type mbar disc herniation. Key words: Disc decompressior; Disc decompression; Iumbar disc herniation syndrome; Ozone; Lumbar traction

Atypical presentation of cauda equina syndrome secondary to lumbar disc herniation

The article describes the case of 35 year old female who was admitted to the department with saddle type hypoesthesia, anal incontinence without muscle weakness of lower extremities and sciatica. Central lumbar disc herniation (LDH) was determined on level L5-S1 level and the patient was operated thereafter. In the postoperative period, the patient did not have any muscle weakness of leg but had residual saddle type sensory loss and sphincter dysfunction. This article discusses atypical presentation of cauda equina syndrome (CES) secondary to LDH. Early diagnosis and surgery are important factors for a better prognosis in CES.

Cauda equina syndrome: a review of the current clinical and medico-legal position.

Cauda equina syndrome (CES) is a rare condition with a disproportionately high medico-legal profile. It occurs most frequently following a large central lumbar disc herniation, prolapse or sequestration. Review of the literature indicates that around 50-70% of patients have urinary retention (CES-R) on presentation with 30-50% having an incomplete syndrome (CES-I). The latter group, especially if the history is less than a few days, usually requires emergency MRI to confirm the diagnosis followed by prompt decompression by a suitably experienced surgeon. Every effort should be made to avoid CES-I with its more favourable prognosis becoming CES-R while under medical supervision either before or after admission to hospital. The degree of urgency of early surgery in CES-R is still not in clear focus but it cannot be doubted that earliest decompression removes the mechanical and perhaps chemical factors which are the causes of progressive neurological damage. A full explanation and consent procedure prior to surgery is essential in order to reduce the likelihood of misunderstanding and litigation in the event of a persistent neurological deficit.

Radiological and Clinical Outcome after Simple Discectomy of Central Massive Lumbar Disc Herniation

Study Design: This is a retrospective case control study. Objectives: To analyze our results following simple discectomy of central massive disc herniation focusing on instability for the usefulness of intervertebral fusion. Summary of Literature Review: Lumbar instability is a complication of central massive disc herniation. However, there is limited evidence on the correlation between lumbar instability and loss of disc material. Materials and Methods: A total of 25 patients who had undergone discectomy for a single-level lumbar disc herniation were followed up for two years. The clinical group (group A) included 12 patients that had a compromised canal with greater than 50% of the herniated disc, while the central axis of the herniated disc was less than 20% deviated from the center axis of the spinal canal, as seen on MRI. The control group (group B) had 13 patients that had a compromised canal with less than 50% of the herniated disc while their axis was more than 20% deviated from the center axis of the spinal canal. Clinical and radiologic instability, pain and functional disability were compared between the two groups. Results: No differences was found between the two groups in clinical instability, radiological instability, visual analogue scale (VAS), and the Oswestry disability index (ODI). Conclusions: Central massive disc herniation after discectomy did not show a significant difference in clinical or radiological instability from that of other herniation types.

Transdural approach for calcified central disc herniations of the upper lumbar spine

Disc herniations of the upper lumbar spine (L1-2 and L2-3) have a frequency of 1 to 2% of all disc herniations. During posterior discectomy after laminectomy, significant manipulation of the exiting nerve root is unavoidable because of the narrow lamina and the difficulty in mobilizing the nerve root. The authors adopted a transdural approach in patients with calcified central disc herniation at the L1-2 level to reduce the risk of nerve root injury. Four patients suffering from radiating pain together with back pain were treated using the transdural approach. Preoperative neuroimaging studies revealed severe central disc herniation with calcification at the L1-2 level. After laminectomy or laminotomy, the incised dura mater was tacked, and the cauda equina rootlets were gently retracted. An intentional durotomy was performed over its maximal bulging of the ventral dura. After meticulous dissection of dense adhesions between the disc herniation and the dural sac, adequate decompression with removal of calcified disc fragments and osteophytes was accomplished. Clinical symptoms improved in all patients. Postoperative permanent cerebrospinal fluid leakage and pseudomeningocele were not observed, and no patient had a progressive lumbar deformity at an average follow-up of 53 months. Transient mild motor weakness and sensory change were observed in two patients postoperatively; however, these symptoms resolved completely within 1 week. The posterior transdural approach offers an alternative in central calcified upper lumbar disc herniation when root retraction is dangerous.

Cauda equina syndrome in a 32-year-old woman following an L5-S1 central lumbar disc herniation

A 32-year-old woman with a history of chronic low back pain, hypertension, and urinary retention presented to the emergency department with left hip pain radiating to the posterior thigh, medial leg, and foot. Three days after admission, she developed cauda equina syndrome (CES) with decrease in left leg strength and sensation, as well as urinary and rectal incontinence. She was found to have a midline and left paracentral L5–S1 disc herniation on MRI and was taken to the operating room, where an L5–S1 hemilaminectomy and discectomy was performed. Her function improved almost immediately, and continued to improve after discharge from the hospital. In this report, we present a review of the literature on CES and focus on the relation between timing of surgery after the onset of CES and functional outcome.

Central lumbar disc herniation.

A follow-up study which describes the experience of the Department of Neurosurgery in Berne in the treatment of patients with central lumbar disc herniation (CLDH). The anatomical position of lumbar disc herniation, in general, does not seem to affect postoperative outcome. However, according to other studies a subgroup of patients with central lumbar disc herniations appears to have poorer results. The aim of the present study was to assess clinical outcome in a recent cohort of patients, to investigate whether there is a difference in outcome with regard to the surgical approach (unilateral vs bilateral) and to compare the postoperative results between the subcategories of CLDH: central massprolaps (CMP) and central contained disc herniation (CCDH). Between 1990 and 1997, 40 out of 3150 patients operated on for lumbar disc herniation were diagnosed with CLDH (1.2%). The patients were operated on through unilateral or bilateral fenestrations with microdiscectomy. Recent follow-up studies were obtained by standardized questionnaires. The retrospective investigation was performed by an unbiased observer. Long-term follow-up was available for 34 of the 40 patients (85%) at a mean of 3.3 years. Eight patients had an excellent result (24%), 15 patients a good result (44%), 8 patients a fair (24%) and 3 patients had a poor result (9%). Overall, the operation was considered successful in 68% of patients. There was no statistically significant difference in outcome in patients with CMP as compared with those with CCDH (75% versus 64%). There was also no significant difference for better outcome between bilateral as compared with unilateral approaches. Postoperative outcome of central lumbar disc herniation (CLDH) is poorer as compared with other types of lumbar disc herniation. The reason seems to be the anatomical position of the disc herniation with a peculiar derangement of the disc architecture. The surgical approach itself or the subcategories of CLDH appear to have only minor impact on postoperative outcome. Interlaminar fenestrations, in general, are appropriate for removal of the disc fragments.