Foraminal Lumbar Disc Herniation Research Articles

Access Pain During Transforaminal Endoscopic Lumbar Discectomy for Foraminal or Extraforaminal Disc Herniation.

Transforaminal endoscopic lumbar discectomy (TELD) under local anesthesia is a promising minimally invasive surgical option for intractable lumbar disc herniation (LDH). However, our understanding of access pain prediction during foraminal pathological procedures is limited. To our knowledge, no predictive rules for access pain have been established during TELD for foraminal or extraforaminal LDH. This study, with its potential for predicting access pain during TELD and discussing strategies for pain prevention and management, could significantly benefit the field of endoscopic spine surgery. This observational study included 73 consecutive patients who underwent TELD for foraminal or extraforaminal LDH between January 2017 and December 2022. Preoperative clinical and radiographic factors affecting significant access pain and the impact of access pain on clinical outcomes were evaluated. The rate of significant access pain was 13.70% (10 of 73 patients). Extraforaminal LDH tended to cause more severe pain than did foraminal LDH during TELD under local anesthesia (p < 0.05). Although the degree of access pain was not related to global clinical outcomes, increased pain was strongly associated with prolonged operative time and length of hospital stay (p < 0.05). TELD could be an effective surgical option for foraminal or extraforaminal LDH under local anesthesia. More access pain might develop during TELD for extraforaminal LDH. The extraforaminal component of LDH could narrow the safe working zone. Significant access pain might prolong the duration of surgery and hospitalization. Thus, a specialized technique is required for the clinical success of TELD.

Recurrence of lumbar disk herniation after microdiscectomy: a two-center retrospective analysis of 1214 cases and identification of risk factors.

To present the incidence of recurrent lumbar disc herniation (RLDH) and to identify radiological and patient-related risk factors that lead to recurrence after lumbar disc herniation (LDH) treatment with microdiscectomy. Between January 2013 and December 2021, 1214 patients who had undergone microdiscectomy for LDH were included in this retrospective study. Patients were divided into two groups, the recurrent group and the non-recurrent group, and their demographic, clinical and radiologic characteristics were recorded. The association between the variables and RLDH was assessed by univariate and multivariable logistic regression analyses. Mean ages were similar in the recurrent (51.48 ± 13.63) and non-recurrent(50.38 ± 14.53) groups (p=0.232). Males represented 59.6% of the recurrent group and 49.8% of the non-recurrent group (p=0.002). Multivariable logistic regression revealed that being a male (p=0.009), diabetes mellitus (p=0.038), smoking (p<0.001), grade 4&5 disc degeneration (p<0.001), and having protruded (p=0.002), extruded LDH (p<0.001), paracentral (p=0.008) and foraminal LDH (p=0.008) were independently associated with recurrence. To reduce RLDH frequency and need for revision surgery, modifiable risk factors should be minimized before and after the initial surgery. Also, in patients with unmodifiable risk factors, patients should be clearly informed about the risk for recurrence and possible alternative treatment methods should be considered.

Recurrent or junctional lumbar foraminal herniated disc in patients operated with trans pars microscopic approach

This is a retrospective monocentric study. The aim of this study is to analyze the incidence of recurrent or junctional lumbar foraminal herniated disc, in patients treated with trans pars microsurgical approach. Foraminal lumbar disc herniation represents a challenging pathology for the spinal surgeon. The appropriate surgical approach still represents a matter of debate. Several open and minimally-invasive techniques have been developed, in order to allow a proper tissue exposure and preserving the vertebral stability. The trans pars approach has already been described as a possible alternative, allowing excellent exposure of the herniated fragment with minimum bone removal. While few studies have analyzed the very low rate of post-operative instability, no articles deal with the incidence of post-operative herniated disc recurrence or junctional disc herniation in patients treated with this technique. We enrolled 160 patients operated at our institution. A univariate and multivariate analysis of possible factors influencing outcome (age, sex, level and BMI) was performed. Outcome variables were recurrent or junctional herniated disc. At the end, 135 patients were analyzed. Of the 135 patients, six presented recurrent herniated disc (4.4%) and other three developed a junctional herniation (2.2%). The occurrence of junctional herniated disc or recurrent herniated disc was not influenced by the analyzed variables, both at univariate and at multivariate analyses. The trans pars approach presents a low rate of recurrence and junctional herniation. Age, sex, level, and BMI do not influence the recurrence rate, both at same level and at junctional level.

Clinical application value of modified Lee grading system to evaluate the degree of foraminal stenosis in patients with intervertebral foraminal lumbar disc herniation

Objective: To investigate the clinical application value of the modified Lee grading system (abbreviated as the modified system) in evaluating the degree of intervertebral foraminal stenosis(IFS) in patients with foraminal lumbar disc herniations(FLDH). Methods: MRI data of 83 patients with FLDH-IFS (34 patients in the operation group and 49 patients in the conservative group) in Yantai Affiliated Hospital of Binzhou Medical University and Yantai Yantaishan Hospital from March 2018 to February 2021 were retrospectively collected. There were 43 males and 40 females, ranged from 34 to 82 years old, with an average of (61±10) years. MRI images of selected patients were independently evaluated and recorded by two radiologists in a blind method, using both the Lee grading system (abbreviated as Lee system) and the modified system, respectively and each method was evaluated twice. The difference between the evaluation level of the two systems, and the agreement of observer assessments of the two systems were compared, and the correlation between the evaluation level of the two grading systems and the clinical treatment modalities was analyzed. Results: The percentage of nongrade 3 (grade 0-2) patients with effective conservative treatment according to the two grading systems was 94.6 % (139/147) and 64.2 % (170/265), respectively. The percentage of grade 3 patients requiring surgical treatment according to the two grading systems was 69.2 % (128/185) and 61.2 % (41/67), respectively. There was a statistically significant difference between the evaluation levels of the modified system and the Lee system (Z=-5.16, P=0.001). In the Lee system, the intra-observer observation consistency Kappa values of the two radiologists were 0.735 and 0.542, respectively, which were highly and moderately consistent; and the inter-observer observation consistency Kappa values were 0.426-0.521, which were moderate consistency. In the modified system, the intra-observer consistency Kappa values of the two radiologists were 0.900 and 0.921, respectively, and the consistency was almost completely consistent; and the inter-observer consistency Kappa values were 0.783-0.861, which were highly consistent or almost completely consistent. Lee system and clinical treatment modalities was correlative (rs=0.39,P<0.001), and modified system and clinical treatment modalities was correlative (rs=0.61,P<0.001). Conclusion: According to FLDH-IFS, the modified system can comprehensively and accurately grade, with high reliability and reproducibility. The evaluation level has a more significant correlation with clinical treatment modalities.

Features of Clinical and Magnetic Resonance Imaging of Lumbar Disc Herniation

A study of 55 patients with lumbar disc herniation who were taken MRI and surgery at hospital E from January 2019 to December 2019. Results: The mean age was 58.96 ± 16.4, the female/male ratio was 1.12/1. People doing heavy work had a higher risk of disc herniation than those doing light work (63.7%). Common symptoms: lumbar pain (100%), sciatica pain, pain with mechanical properties (85.45%), limited spinal movement (90.91%), Lasègue sign (+) (74.55%), bell sign (+) (54.55%); signs of nerve root damage: sensory disturbances 72.73%, movement disorders 50.91%. Clinical lesions were common in L5 (65.45%) and S1 (45.45%) roots. Hernias were common at L4/5 (81.8%) and L5/S1 (70.9%). The degree of hernia was mainly bulge and hernia, accounting for 60% and 52.73%, respectively. 98.18% herniated to the back, central hernia accounted for the highest rate (41.82%). The rate of nerve root compression detected on MR is 90.91%. Evaluation of nerve root damage in clinical and magnetic resonance had high concordance in L5 and S1 roots (98.17% and 100%, respectively). Conclusion: MRI helps in early, accurate diagnosis and treatment orientation of lumbar disc herniation.&#x0D; Keywords: Disc herniation, MRI lumbar spine, lumbar pain. &#x0D; References&#x0D; [1] R. J. Gardocki, A. L. Park, Lower Back Pain and Disorders of Intervertebral Discs, Campbell's Operative Orthopaedics, 12th ed, Elsevier Mosby, 2013:chap 42.[2] N. V. Chuong et al., Research on Lumbar Disc Herniation at Department - Department of Internal Neurology, Hospital 103 - Military Medical Academy, Journal of Military Medicine, Vol. 3, 2015, pp. 5 - 16 (in Vietnamese).[3] S. Lee, J. H. Kang, U. Srikantha et al., Extral Foraminal Compression of the L5 Nerve Root at the Lumbosacral Junction: Clinical Analysis, Decompression Technique, and Outcome, Journal Neurosurgery Spine, Vol. 24, No. 1, 2014, pp. 1-9, https://doi.org/10.3171/2013.12.spine12629.[4] S. Eicker, S. Rhee, H. Steiger et al., Transtubular Microsurgical Approach to Treating Extra Foraminal Lumbar Disc Herniations, Neurosurgery Focus, Vol. 35, No. 2E1, 2013, pp. 1-6, https://doi.org/10.3171/2013.4.focus13126.&#x0D; [5] H. M. Cuong, Research on the Diagnosis and Surgical Treatment of Disc Herniation in the Lumbar Spine and Side Deviation by Bone Window Opening Method, Master's Thesis of Medicine, Hanoi Medical University, 2010&#x0D; (in Vietnamese).[6] J. D. Lurie, T. D. Tosteson, A. N. Tostenson et al., Surgical Versus Non-operative Treatment for Lumbar Disc Herniation: Eight-year Results for the Spine Patient Outcomes Research Trial, Spine, Vol. 39, No. 1, 2014, pp. 3-16, https://dx.doi.org/10.1097%2FBRS.0000000000000088.[7] M. R. Konieczny, R. Jeremia, M. Post et al., Signal Intensity of Lumbar Disc Herniations: Correlation With Age of Herniation for Extrusion, Protrusion, and Sequestration, Int J Spine Surg. Vol. 14, No. 1, 2020, pp. 102–107, https://doi.org/10.14444/7014.[8] M. H. Daghighi, M. Pouriesa, M. Maleki et al., Migration Patterns of Herniated Disc Fragments: a Study on 1,020 Patients with Extruded Lumbar Disc Herniation, Spine Journal, Vol. 14, No. 9, 2014, pp. 1970-1977, https://doi.org/10.1016/j.spinee.2013.11.056.[9] M. Karademir, O. Eser, E. Karavelioglu, Adolescent Lumbar Disc Herniation: Impact, Diagnosis, and Treatment, J. Back Musculoskelet Rehabil, Vol 30, No. 2, 2017, pp. 347-352, https://doi.org/10.3233/bmr-160572.[10] R. G. Menon, M. V. W. Zibetti, M. Pendola et al., Measurement of Three-Dimensional Internal Dynamic Strains in the Intervertebral Disc of the Lumbar Spine with Mechanical Loading and Golden-Angle Radial Sparse Parallel-Magnetic Resonance Imaging, J Magn Reson Imaging, Vol. 54, No. 2, 2021, pp. 486–496, https://doi.org/10.1002/jmri.27591.&#x0D; &#x0D; &#x0D;

Comparação da eficácia dos corticosteroides nos pacientes com hérnia discal extrusa submetidos a bloqueio radicular transforaminal

Objetivo: Comparar a eficácia de diferentes corticosteroides (dexametasona, betametasona e triancinolona) utilizados na técnica de bloqueio do ramo troncular, por meio da avaliação da melhora do quadro álgico, em pacientes com lombociatalgia. Métodos: 60 pacientes maiores de 18 anos, com queixa de lombociatalgia refratária ao tratamento conservador, diagnosticados com hérnia de disco lombar foraminal extrusa por meio do exame de ressonância magnética, sem critérios de instabilidade vertebral em radiografias dinâmicas da coluna lombar foram divididos em 3 grupos de 20 indivíduos cada. O Grupo 1 recebeu dexametasona, o Grupo 2 betametasona e o Grupo 3 triancinolona. Todos os pacientes responderam à escala visual analógica nos períodos de pré-bloqueio e com 1, 6 e 12 meses após a realização do mesmo para avaliação de dor. Resultados: Foi observado melhora significativa da dor após a realização do bloqueio nos 3 grupos, não havendo diferença estatística entre os fármacos. Conclusão: O bloqueio do ramo troncular é uma técnica eficaz no tratamento das lombociatalgias, contudo, não existe diferença na eficácia dos três fármacos estudados. Sendo assim, a escolha do corticosteroide deve ser feita de forma individualizada, levando-se em conta fatores não avaliados nesse estudo, como disponibilidade, custo e reações adversas.

Translaminar Approach for Treatment of Hidden Zone Foraminal Lumbar Disc Herniations: Surgical Technique and Preoperative Selection of Patients with Long-Term Follow-Up

Lumbar disc herniation is a common degenerative disease of the lumbar spine with a prevalence of 1%-3% in some population studies. In 10% of patients, there is a fragment migrated cranially in Macnab's "hidden zone." In selected cases, this fragment can be removed with a translaminar approach that was described in 1998. We provide a detailed description of the technical advantages and pitfalls of the translaminar approach in a consecutive series of 32 patients treated at our institution. Patients were divided preoperatively and postoperatively into 5 classes based on the Oswestry Disability Index (ODI): class 1, ODI 0%-20% (minimal disability); class 2, 20%-40% (moderate disability); class 3, 40%-60% (severe disability); 60%-80% (crippled); 80%-100% (bedridden or disabling symptoms). Four (12.5%) patients were upgraded 1 ODI class after the operation; 6 (18.7%) patients were upgraded 2 classes, 8 (25%) patients were upgraded 3 classes, and 11 (34.4%) patients were upgraded 4 classes. In 3 (9.4%) patients, ODI class did not change after the operation. After surgery, 7 (21.9%) patients developed mild low back pain. Mean follow-up was 25 months. When performed by dedicated spinal neurosurgeons, the translaminar approach is safe and effective in patients with long-term follow-up. Most patients showed an improvement in ODI. Major pitfalls were related to surgical selection and the narrow working space.

Transpars Microscopic Approach for the Treatment of Purely Foraminal Herniated Lumbar Disc: A Clinical, Radiological, Two-center Study.

This is a prospective two-center study. The aim of this study was to assess the safety and efficacy of treating patients with lumbar foraminal disc herniations via a microscopic transpars approach, with a clinical and radiological follow-up evaluation. Purely foraminal lumbar disc herniations comprise about 5% of all lumbar herniated intervertebral discs. Operative management can be technically difficult, and the optimum surgical treatment remains controversial. From January 2012 to January 2015, 47 patients were prospectively recruited. Patients were followed-up as outpatients at 1 week after discharge, then at 1, 6, and 12 months.A clinical multiparametric evaluation of patients including numeric rating scale (NRS), drugs intake, Macnab criteria, and working days lost was used.Postoperative dynamic x-rays (flexion, extension) were performed in all cases 12 months after surgery. No surgery-related complications occurred.Among the 35 patients who were not retired at the time of the study, 29 patients returned to work and to normal daily activities within 60 days after surgery.Pain evaluation at discharge showed a significant improvement of NRS score, from 8.93 to 1.45 at 12 months. Root palsy significantly improved in all cases already at 1-month follow-up. Drugs intake analysis showed that at 6-month follow-up, no patients used steroids, or opioids, 17 patients used non-steroidal anti-inflammatory drugs when needed, and 29 patients (61.7%) used no drugs for pain relief. No significant variations occurred at 12-month-follow-up.At 12-month follow-up, excellent or good outcome (following Macnab criteria) was achieved in 36 (76.6%) and 8 (17%) patients, respectively.There were no cases of spinal instability at 12-month radiological evaluation.No recurrence occurred at follow-up. Transpars microscopic approach is effective and safe for the treatment of FLDH, but larger studies are needed. 3.

Translaminar Microendoscopic Herniotomy for Cranially Migrated Lumbar Disc Herniations Encroaching on the Exiting Nerve Root in the Preforaminal and Foraminal Zones

Study DesignCase series.PurposeThe aim of this study was to describe translaminar microendoscopic herniotomy (TL-MEH) for cranially migrated lumbar disc herniations encroaching on the exiting nerve root in the preforaminal and foraminal zones and to report preliminary results of the procedure.Overview of LiteratureConventional interlaminar approaches for preforaminal and foraminal lumbar disc herniations result in extensive removal of the lamina and facet joint to remove disc fragments safely. More destructive approaches increase the risk of postoperative segmental instability.MethodsTL-MEH is a minimally invasive procedure for herniotomy via the translaminar approach using a microendoscopic technique. TL-MEH was performed in seven patients with a cranially migrated lumbar disc herniation encroaching on the exiting nerve root. The disc fragments were located in the preforaminal zone in four patients, and in the preforaminal and foraminal zones in three.ResultsAll patients experienced immediate relief from symptoms after surgery and satisfactory results at the final follow-up. Surgical complications, such as a dural tear, nerve injury, and surgical site infection, were not investigated.ConclusionsTL-MEH seemed to be an effective and safe alternative minimally invasive surgical option for patients with a cranially migrated lumbar disc herniation encroaching the exiting nerve root in the preforaminal and foraminal zones.

Carbon Dioxide (CO2) Laser-Assisted Microdiscectomy for Extraforaminal Lumbar Disc Herniation at the L5-S1 Level

The purpose of this study was to analyze the surgical outcomes of carbon dioxide (CO(2)) laser-assisted microdiscectomy for extraforaminal lumbar disc herniations (EFLDH) at the L5-S1 level. Microdiscectomy via the lateral transmuscular route is beneficial for treating EFLDH at the L5-S1 level. However, this technique may not effectively remove concomitant foraminal lumbar disc herniation (FLDH), resulting in persistent leg pain and a necessity for revision surgery. CO(2) laser-assisted microdiscectomy could be an effective alternative, as it enables effective decompression of EFLDH as well as of the accompanying FLDH, despite a narrow operative window. Thirty-one consecutive patients with EFLDH at the L5-S1 level who underwent CO(2) laser-assisted microdiscectomy via the lateral transmuscular route were prospectively enrolled. Clinical outcomes were assessed 1 year after surgery by using the visual analogue scale (VAS) scores, Oswestry Disability Index (ODI), and patient's subjective satisfaction rate. Of the 31 patients, 10 were male and 21 were female, with a mean age at surgery of 62.2 years. All patients showed improvement in leg pain immediately after surgery. Transient dysesthesia developed in one patient. Of the 28 patients (90.3%) followed for a 1-year period, the mean VAS for back pain and leg pain, as well as the mean ODI, decreased significantly from 5.2, 8.3, and 60.7% to 2.6, 1.8, and 18.1%, respectively. The mean subjective satisfaction rate was 75.7%. Clinical success was observed in 27 patients (96.4%), and reherniation occurred in one patient (3.6%). No patient underwent reoperation for reherniation or segmental instability. CO(2) laser-assisted microdiscectomy for EFLDH at the L5-S1 level showed satisfactory surgical results at the 1-year follow-up.

Microdecompression for Extraforaminal L5-S1 Disc Herniation; The Significance of Concomitant Foraminal Disc Herniation for Postoperative Leg Pain

To analyze the relationship of concomitant foraminal lumbar disc herniation (FLDH) with postoperative leg pain after microdecompression for extraforaminal lumbar disc herniation (EFLDH) at the L5-S1 level. Sixty-five patients who underwent microdecompression for symptomatic EFLDH at the L5-S1 level were enrolled. According to the severity of accompanying FLDH, EFLDH was classified into four categories (Class I : no FLDH; Class II : mild to moderate FLDH confined within a lateral foraminal zone; Class III : severe FLDH extending to a medial foraminal zone; Class IV : Class III with intracanalicular disc herniation). The incidence of postoperative leg pain, dysesthesia, analgesic medication, epidural block, and requirement for revision surgery due to leg pain were evaluated and compared at three months after initial surgery. The incidences of postoperative leg pain and dysesthesia were 36.9% and 26.1%, respectively. Pain medication and epidural block was performed on 40% and 41.5%, respectively. Revision surgery was recommended in six patients (9.2%) due to persistent leg pain. The incidences of leg pain, dysesthesia, and requirement for epidural block were higher in Class III/IV, compared with Class I/II. The incidence of requirement for analgesic medication was significantly higher in Class III/IV, compared with Class I/II (p=0.02, odds ratio=9.82). All patients who required revision surgery due to persistent leg pain were included in Class III/IV. Concomitant FLDH seems related to postoperative residual leg pain after microdecompression for EFLDH at the L5-S1 level.

Clinical Characterizations and Radiologic Findings of Pure Foraminal-Type Cervical Disc Herniation

A retrospective study of 15 cases of pure foraminal type cervical disc herniation (CDH) was performed. The objectives were to describe the clinical characteristics and to assess the radiologic findings. Although foraminal lumbar disc herniation has been reported, pure foraminal-type CDH has not been fully elucidated. It is not only a rare condition but also a difficult one to diagnose. All patients underwent MRI, CT myelography (CTM), and CT discography (CTD). Herniated discs were removed by the posterior approach. Clinical symptoms were evaluated at preoperative and postoperative period. On MRI, 2 cases were positive, 6 cases were suspected, and 7 cases were negative. On CTM, 7 cases were positive and 8 cases were negative; and on CTD, all cases were positive. As to the association between the herniated disc and posterior longitudinal ligament, 12 cases were intraligamentous. The association between the herniated disc and nerve root revealed that 10 discs were at the axillary portion of the nerve root. Pure foraminal-type CDH may be overlooked with conventional MRI or CTM, so CTD should be performed. It provides valuable and additional information in difficult or ambiguous cases such as pure foraminal type.

Tratamento cirúrgico das hérnias discais foraminais pela microdiscectomia artroscópica

A hérnia discal lombar foraminal é extremamente incapacitante em relação à sintomatologia clínica. Nos últimos quarenta anos muitas alternativas foram propostas no tratamento dessa patologia. Vinte pacientes com essa síndrome radicular foram operados, via póstero-lateral, pela técnica da microdiscectomia artroscópica. O acompanhamento foi realizado com questionários de auto-avaliação pré-operatória e pós-operatória sendo obedecidos rigorosamente os critérios de inclusão e exclusão para a indicação cirúrgica. A idade média dos pacientes foi de 43 anos, com variação de 23 a 58 anos. Houve predomínio do sexo feminino (13 pacientes e freqüência percentual de 65%) em relação ao masculino (7 pacientes e freqüência percentual de 35%). Todos os pacientes foram operados de hérnia discal lombar foraminal no nível entre as 4ª e 5ª vértebras lombares. Os resultados clínicos apresentaram um percentual de 75% de sucesso. Não ocorreram nesse estudo complicações, tais como: lesão nervosa motora, vascular ou discite bacteriana.

Transforaminal percutaneous endoscopic discectomy in the treatment of far-lateral and foraminal lumbar disc herniations.

Far-lateral (extraforaminal) and foraminal disc herniations comprise up to 11% of all herniated intervertebral discs. Operative management can be technically difficult, and the optimum surgical treatment remains controversial. Accessing these lateral disc herniations endoscopically via a percutaneous transforaminal approach offers several theoretical advantages over the more traditional procedures. The object of this study was to assess the safety and efficacy of treating patients with far-lateral and foraminal disc herniations via a percutaneous transforaminal endoscopic approach. A retrospective analysis was performed of 47 consecutive patients who underwent surgery via this approach. All procedures were performed after induction of a local anesthetic on an outpatient basis. Outcome was measured with Macnab criteria and by determining a patient's return-to-work status. The median follow-up period was 18 months (range 4-51 months). Excellent or good outcome was obtained in 40 (85%) of 47 patients. Of the 38 patients working before the onset of symptoms, 34 (90%) returned to work. Five patients (11%) experienced poor outcomes and subsequently underwent open procedures at the same level. Of the 10 recipients of Workers' Compensation, Macnab criteria indicated a significantly worse outcome (70% excellent or good), but an excellent return-to-work status was maintained (90%). There were no complications. Transforaminal percutaneous endoscopic discectomy is safe and efficacious in the treatment of far-lateral and foraminal disc herniations.

Pars interarticularis fenestration in the treatment of foraminal lumbar disc herniation: a further surgical approach.

A new surgical approach to foraminal disc herniation is proposed. The procedure was performed in 28 patients during a span of 3 years. The herniation was purely foraminal in 18 patients and mainly foraminal with a definite extraforaminal component in the other 10 patients. Surgical treatment was offered only after 6 weeks of therapy with anti-inflammatory drugs and strict bed rest had proved to be ineffective. To unroof the foraminal compartment, an ovoid fenestration (10 x 5 mm) is cut, with its major longitudinal axis at the level of the pars interarticularis, just medially and slightly off-center under the lateral isthmic notch, i.e., below the pedicle projection. This fenestration exposes the foraminal root compressed by the herniated disc, which can be easily removed. Treatment was successful in all patients, with swift remission of pain and only mild postoperative discomfort. All patients resumed their occupations as usual within 10 to 30 days after the operation, according to type of work. Mean follow-up is 24 months (range, 12-36 mo), without any return of pain. We propose pars interarticularis fenestration because it spares, with minimal bone removal, the facet joints and the anatomic continuity of the pars interarticularis, yet properly exposes the foraminal compartment both medially and laterally and thereby permits optimal removal of the disc herniation.

A comparative Analysis of Spondylolysis Repair

This retrospective study compared patient outcome after two surgical techniques for pars interarticularis repair: 1) buck screw fixation and 2) the modified Morscher-designed spondylolysis distraction hook. To determine whether one technique was associated with higher radiographic, clinical, or implant failure. Both techniques have been reported as giving good clinical results. Twenty patients were included in this study. All patients had Type IIA spondylolytic defects with either a Grade 0 or Grade I spondylolisthesis. Nine patients were treated with the Morscher hook implant, and 11 patients were treated with the Buck technique. Radiographic follow-up of the Morscher implants demonstrated loosening in three and breakage in one. Radiographic analysis of the Buck technique demonstrated implant failure in one. Failure of healing occurred in four instances with the Morscher implant compared with two instances with the Buck technique. Clinical outcome was assessed using the modified Prolo score. The mean outcomes were 6.33 in the Morscher group and 6.09 in the Buck group. In these patients, the Morscher implant had a high failure rate. Furthermore, the clinical outcome in this group of patients was poor using either technique.

Foraminal Lumbar Disc Herniation

This study analyzed a series of 83 patients operated on for foraminal lumbar disc herniation. This study sought to develop clinical and radiologic diagnoses, evaluate interlaminar and extra-articular exposures, and evaluate postoperative results. Some authors have reported a specific clinical syndrome, but other reports have indicated the clinical picture is indistinguishable from usual posterolateral disc herniation. Surgical management often has been compared between the interlaminar and extra-articular approaches. Clinical findings were reviewed. All patients were evaluated with computed tomography, but radiologic diagnosis required computed tomographic discography for 26 patients. Interlaminar exposure with partial medial facetectomy was performed in 73 patients and an extra-articular approach was necessary in 10 patients. Postoperative results were evaluated with a 2-year follow-up. Foraminal lumbar disc herniations have a specific clinical picture, particularly severe radicular signs. Precise preoperative radiologic evaluation is essential for successful operative procedure. Postoperative results were good in 76% of the patients. The other patients felt mild residual radicular pain, although no residual root compression was found on postoperative computed tomography. Only 21% of the patients that had a radicular deficit recovered totally. Foraminal lumbar disc herniation involves characteristic clinical features. Radiologic diagnosis requires high-resolution computed tomography, computed tomographic discography, or magnetic resonance imaging. Most foraminal lumbar disc herniations are reached through the interlaminar exposure extended to the upper lamina and medial facet without total facetectomy. An extra-articular approach should be reserved for extra-foraminal herniations.

Disco-Computed Tomography in Extraforaminal and Foraminal Lumbar Disc Herniation

Between January 1990 and February 1992, a total of 301 patients underwent discectomy for lumbar disc herniation; 29 had an extreme lateral herniation, i.e., foraminal or extraforaminal. The intervertebral foramen is a three-dimensional area demarcated primarily by the pedicles; we call it the lateral interpedicular compartment. The extraforaminal zone is the space outside the lateral border of the pedicles. All patients were evaluated by computed tomography (CT), water soluble myelography, postmyelographic CT scanning, or magnetic resonance imaging. Fifteen patients consecutively underwent disco-enhanced CT to adjust a correct diagnosis and to distinguish extraforaminal from foraminal herniation. In 10 cases of extraforaminal herniation, a selective radicular decompression with good-to-excellent clinical results was achieved by an extra-axial lateral decompression of the interpedicular compartment, with preservation of the facet joint. The operative target was the lateral aspect of the pars interarticularis and not the intertransverse space, as previously described. In two cases of both foraminal and extraforaminal herniation, the same technique was used. Fourteen patients with foraminal disc herniation and three patients with both foraminal and extraforaminal herniation underwent a standard intervertebral foraminotomy. An accurate preoperative diagnosis established by disco-CT is crucial in order to select the most suitable surgical approach.

Disco-Computed Tomography in Extraforaminal and Foraminal Lumbar Disc Herniation

BETWEEN JANUARY 1990 and February 1992, a total of 301 patients underwent discectomy for lumbar disc herniation; 29 had an extreme lateral herniation, i.e., foraminal or extraforaminal. The intervertebral foramen is a three-dimensional area demarcated primarily by the pedicles; we call it the lateral interpedicular compartment. The extraforaminal zone is the space outside the lateral border of the pedicles. All patients were evaluated by computed tomography (CT), water soluble myelography, postmyelographic CT scanning, or magnetic resonance imaging. Fifteen patients consecutively underwent disco-enhanced CT to adjust a correct diagnosis and to distinguish extraforaminal from foraminal herniation. In 10 cases of extraforaminal herniation, a selective radicular decompression with good-to-excellent clinical results was achieved by an extra-axial lateral decompression of the interpedicular compartment, with preservation of the facet joint. The operative target was the lateral aspect of the pars interarticularis and not the intertransverse space, as previously described. In two cases of both foraminal and extraforaminal herniation, the same technique was used. Fourteen patients with foraminal disc herniation and three patients with both foraminal and extraforaminal herniation underwent a standard intervertebral foraminotomy. An accurate preoperative diagnosis established by disco-CT is crucial in order to select the most suitable surgical approach.