Large Lumbar Disc Herniation Research Articles

Percutaneous Endoscopic Lumbar Discectomy Using a Double-Cannula Guide Tube for Large Lumbar Disc Herniation.

ObjectiveTo compare the effect of percutaneous endoscopic lumbar discectomy (PELD) using a double‐cannula guide tube (DGT), traditional PELD, and open lumbar discectomy (OLD) to treat large lumbar disc herniations (LLDHs).MethodsSeventy patients who presented with LLDH without cauda equina syndrome and were treated with surgery in our hospital from October 2015 to October 2017 were included. The detailed index included the visual analog scale (VAS) for back and radicular leg pain and the Oswestry Disability Index (ODI) in the immediate preoperative period and at the final follow‐up. The operation time, radiation exposure time, surgical satisfaction rate, and modified MacNab criteria score were also recorded.ResultsThe leg and back pain of the patients in these groups improved significantly in the postoperative period. No significant differences were observed in leg pain improvement between the other two groups; however, patients in the PELD group (with or without DGT) presented with significantly higher improvement in back pain than the OLD group (t = 9.965, p < 0.001). The final ODI scores were 12.1 ± 4.9, 11.2 ± 2.9, and 16.4 ± 3.6 in the PELD, PELD‐DGT, and OLD groups, respectively. Patients in the PELD and PELD‐DGT groups presented with significantly lower postoperative ODI scores than those in the OLD group (t = 20.834, p < 0.001). The mean postoperative hospital stays were significantly shorter in the PELD group and PELD with DGT group than in the OLD group (t = 46.688, p < 0.001). The mean operation time was significantly shorter in the PELD‐DGT group than those in the PELD group (t = 25.281, p = 0.001). No perioperative complications were observed in either group. Based on the modified MacNab criteria, excellent and good outcomes were achieved in 20 out of 21 patients (95.2%) in the PELD group, 23 out of 24 patients (95.8%) in the PELD‐DGT group, and 22 out of 25 patients (88.0%) in the OLD group. The rates of excellent and good outcomes were higher in the PELD and PELD‐DGT groups than in the OLD group, but there were no significant differences (χ 2 = 1.454, p = 0.835).ConclusionsPELD using DGT is a safe and effective option for LLDH and features advantages such as improvements in back pain, a lower hospitalization cost than OLD, a shorter operation time, and less fluoroscopy than traditional PELD.

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.

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.

What every spine surgeon should know about transforaminal lumbar interbody fusion surgery for herniated discs.

The aim of this study is to report our experiences on managing large lumbar disc herniations with several symptoms by surgery with transforaminal lumbar interbody fusion (TLIF) and to shed light for spine surgeons about TLIF surgery. We retrospectively evaluated our database of patients with various lumbar spine pathologies who underwent TLIF surgery from 2014 to 2017. We separated 18 patients who had been operated on for extruded disc herniation, which causes severe pain and radicular symptoms. The pain was quantified by visual analog scores (VAS). The disability status were pre-operatively and post-operatively evaluated by the Oswestry Disability Index (ODI). We evaluated the patients for at least two years. Interbody fusion was detected by routine radiographs at six, 12, and 24months after surgery. An ODI outcomes analysis demonstrated a statistically significant improvement in the six and 24-month mean scores compared with the pre-operative scores on the same scales. Patients' mobility improved significantly after surgery, as indicated by the decrease in the Oswestry Disability Index from 72 to 23 over twoyears (p < 0.001). Pain rapidly decreased in all patients and continued to decrease at the time of the latest follow-up. The mean pre-operative VAS scores for pain was 8.8; it had improved to 2.4 after surgery (p < 0.05). Within the follow-up period of twoyears, the ascertained mean VAS declined from 8.8 to 1.4 (p < 0.001). The average disc space height at the herniated levels was fairly well maintained. No patient had evidence of implant failure. Interbody fusion was graded as definitely solid in 100% of cases twoyears post-operatively. One patient displayed a superficial wound infection. Following appropriate debridement and antibiotics, the wound healed without sequelae. No major complications were observed, including permanent neurological deficit, pulmonary embolism, peri-operative cardiac event, or death. The findings of our study and those in the literature showed that primary herniated disc patients with radicular and chronic low back pain, degenerative changes, bi-radicular symptoms, and instability are required to have fusion after a discectomy. Being a heavy-duty worker is also a criterion for fusion surgery. TLIF is performed by a unilateral approach preserving the interlaminar surface on the contralateral side, which can be used as a site for additional fusion. As an effective results TLIF procedure should be chosen for fusion surgery.

Spontaneous regression of extruded lumbar disc herniation: case report and its pathogenesis

Abstract Lumbar disc herniation is a common disease that present with back pain and radicular pain. The most efficient method for the treatment of lumbar disc herniation is still controversial. Spontaneous regression of lumbar disc herniation has been recognized with the advancement of radiological diagnostic tools and can explain the reason of spontaneous relief of symptoms without treatment. The proposed hypothesis are; dehydration, retraction of the disc herniation in the annulus fibrosus, enzymatic catabolism and phagocytosis. In this study we present a case with large lumbar disc herniation regressing by itself and the potential mechanisms of disc regression have been discussed.

A retrospective study of epidural and intravenous steroids after percutaneous endoscopic lumbar discectomy for large lumbar disc herniation

ObjectiveTo assess the early curative effect of epidural or intravenous administration of steroids during a percutaneous endoscopic lumbar discectomy (PELD). Methods28 consecutive patients who underwent PELD due to large lumbar disc herniation between November 2014 and January 2016 were followed up for 6 months. These patients were divided into two groups according to the treatment they received after PELD. 14 patients (Group A) were treated by PELD and epidural steroids, while the other 14 patients (Group B) were treated by PELD and intravenous steroids. We evaluated the effectiveness by the preoperative and postoperative visual analogue scale (VAS) scores for back and leg pain, and the postoperative Oswestry disability index (ODI) at 3 weeks after surgery via the clinical charts and telephone interview. Postoperative hospital stay and time return to work were investigated as well. ResultsThere is a significant decrease in VAS (back, leg), ODI, and time return to work (p < 0.05). For VAS (back), Group A showed a significant decrease compared with Group B at 1 day and 1 week after surgery (p = 0.011, p = 0.017). As for VAS (leg), Group A showed a significant decrease compared with Group B at 1 day, 1 week, 3 weeks, and 3 months follow-up examinations (p = 0.002, p = 0.006, p < 0.001, p < 0.001). For ODI, Group A showed a notable decrease compared with Group B (p < 0.001). The postoperative hospital stay in two groups was not statistically different (p = 0.636). But the time return to work in Group A was significantly shorter than that in Group B (p = 0.023). ConclusionPatients who underwent PELD with epidural steroid administration for large lumbar disc herniation showed favorable curative effect compared with those who underwent PELD with intravenous steroid administration.

Spontaneous resolution of a large lumbar disc herniation

Joint Bone Spine - In Press.Proof corrected by the author Available online since mercredi 9 novembre 2016

Transforaminal lumbar interbody fusion using one diagonal fusion cage with unilateral pedicle screw fixation for treatment of massive lumbar disc herniation.

Background:Large lumbar or lumbosacral (LS) disc herniations usually expand from the paramedian space to the neuroforamen and compress both the transversing (lower) and the exiting (upper) nerve roots, thus leading to bi-radicular symptoms. Bi-radicular involvement is a statistically significant risk factor for poor outcome in patients presenting with far lateral or foraminal disc herniation after facet preserving microdecompression. There is evidence showing that patients suffering from large lumbar disc herniations treated with interbody fusion have significant superior results in comparison with those who received a simple discectomy. We report our experiences on managing large LS disc herniation with bi-radicular symptoms by transforaminal lumbar interbody fusion (TLIF) using one diagonal fusion cage with unilateral pedicle screw/rod fixation.Materials and Methods:Twenty-three patients who suffered from single level lumbar or LS disc herniation with bi-radicular symptoms treated with unilateral decompression and TLIF using one diagonal fusion cage with ipsilateral pedicle screw/rod fixation operated between January 2005 and December 2009, were included in this study. Operation time and blood loss were recorded. The pain and disability status were pre- and postoperatively evaluated by the visual analog score (VAS) and Oswestry Disability Index (ODI). Interbody bony fusion was detected by routine radiographs and computed tomography scan. Adjacent segment degeneration was detected by routine radiographs and magnetic resonance imaging examination. Overall outcomes were categorized according to modified Macnab classification.Results:The patients were followed up for an average of 44.7 months. Pain relief in the VAS and improvement of the ODI were significant after surgery and at final followup. No severe complications occurred during hospital stay. Interbody bony fusion was achieved in every case. No cage retropulsion was observed, while 3 cases experienced cage subsidence. Adjacent segment degeneration occurred at 3 discs cephalic to the fusion segment at followup. No patients underwent revised surgery. Overall outcome was excellent in 5 patients (21.7%), good in 13 (56.5%), fine in 4 (17.5%), and poor in 1 (4.3%).Conclusions:TLIF using one cage with ipsilateral pedicle screw/rod fixation is an effective treatment option for massive lumbar or LS disc herniation with bi-radicular involvement.

Percutaneous Endoscopic Lumbar Discectomy as an Alternative to Open Lumbar Microdiscectomy for Large Lumbar Disc Herniation

Remarkable advancements in endoscopic spinal surgery have led to successful outcomes comparable to those of conventional open surgery. Large lumbar disc herniation (LLDH) is a serious condition, resulting in higher surgical failure when accessing the herniated disc. This study compared the outcomes of LLDH treated with percutaneous endoscopic lumbar discectomy (PELD) and open lumbar microdiscectomy (OLM). Retrospective assessment. This retrospective observational study was conducted from January 2011 to June 2012. Forty-four consecutive patients diagnosed with LLDH without cauda equina syndrome who were scheduled to undergo spinal surgery were included. LLDH was defined as herniated disc fragment occupying > 50% of the spinal canal. Clinical outcomes were evaluated using a visual analogue scale (VAS, 0 - 10), functional status was assessed using the Oswestry Disability Index (ODI, 0 - 100%) at 1, 6, and 24 months postoperatively and surgical satisfaction rate (0 - 100%) at final follow up. Radiological variables were assessed by plain radiography. Forty-three patients were included; 20 and 23 patients underwent PELD and OLM, respectively. Both groups exhibited significant improvements in leg and back pain postoperatively (P < 0.001). Although there was no significant difference in leg pain improvement between the groups, improvement in back pain was significantly higher in the PELD group than in the OLM group (4.9 ± 1.5 vs. 2.5 ± 1.0, P < 0.001). The surgical satisfaction rate of the PELD group was significantly higher than that of the OLM group (91.3% ± 6.5 vs. 84.3% ± 5.2, P < 0.001). Mean operating time, hospital stay, and time until return to work were significantly shorter in the PELD group than in the OLM group (67.8 vs. 136.7 minutes, 1.5 vs. 7.2 days, and 4.2 vs. 8.6 weeks; P < 0.001). Disc height (%) decreased significantly from 23.7 ± 3.3 to 19.1 ± 3.7 after OLM (P < 0.001), but did not change significantly after PELD (23.6 ± 3.2 to 23.4 ± 4.2; P = 0.703). The segmental angle of the operated level increased from 10.3° to 15.4° in the PELD group, which was significantly higher than that in the OLM group (9.6° to 11.6°; P = 0.038). In the OLM group, there was one case of fusion due to instability. In the PELD group, one case required revision surgery and another case experienced recurrence. There were no perioperative complications in either group. The study was retrospective with a small sample size and short follow-up period. PELD can be an effective treatment for LLDH, and it is associated with potential advantages, including a rapid recovery, improvements in back pain, and disc height preservation.

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.

Spontaneous Regression of Extruded Cervical Disc Herniation in a 26-Year-Old Woman: A Case Report and Review of the Literature

Introduction The spontaneous regression of lumbar disc herniation was increasingly documented in the literatures. However, radiographically demonstrated regression of a cervical disc herniation with myelopathic symptoms was relatively rare, because most cases received early surgical intervention as soon as radiological presentation of serious extrusion in cervical vertebrae. Materials and Methods In this article, one case of spontaneous regression of extruded cervical herniated discs was presented. No history of trauma was reported in a 26-year-old woman, with 1-month history of gradual-onset neck pain and upper back pain, and left arm numbness. Magnetic resonance imaging (MRI) of the cervical spine revealed spine seriously compressed at the cervical C5-C6 levels. The patient denied operation and received conservative rehabilitation treatment. Results The disc regressions were correlated with clinical improvement and documented with follow-up MRI studies 6 months later. Nonsurgical conservative observation may be considered an option for treatment of some extruded cervical disc herniations that are likely to regress for very specific and predictable reasons based on thorough understanding of patient's case history and positive signs. It was necessary to take frequent follow-ups and excluded gradual spine lesion. Conclusion Nonsurgical conservative observation may be considered an option for treatment of some extruded cervical disc herniations that are likely to regress for very specific and predictable reasons based on thorough understanding of patient's case history and positive signs. It was necessary to take frequent follow-ups and excluded gradual spine lesion. Disclosure of Interest None declared References Ito T, Yamada M, Ikuta F, et al. Histologic evidence of absorption of sequestration-type herniated disc. Spine 1996;21(2):230–234 Slavin KV, Raja A, Thornton J, Wagner FC Jr. Spontaneous regression of a large lumbar disc herniation: report of an illustrative case. Surg Neurol 2001;56(5):333-336, discussion 337 Mochida K, Komori H, Okawa A, Muneta T, Haro H, Shinomiya K. Regression of cervical disc herniation observed on magnetic resonance images. Spine 1998;23(9):990-995, discussion 996–997 Saal JS, Saal JA, Yurth EF. Nonoperative management of herniated cervical intervertebral disc with radiculopathy. Spine 1996;21(16):1877–1883

Massive lumbar disc herniation with complete dural sac stenosis

Background:Large lumbar disc herniation (LDH) has been reported to have a greater tendency to resolve in clinical and pathomorphological evolutions. However, various definitions of large LDH have been used without validation, and the clinical symptoms of large LDH have not been fully elucidated. We conducted a retrospective analysis to determine the clinical characteristics and treatment outcome of massive LDH with complete dural sac stenosisMaterials and Methods:We retrospectively reviewed 33 cases of LDH with complete dural sac stenosis on magnetic resonance imaging. Complete dural sac stenosis was defined as no recognizable rootlet and cerebrospinal fluid signal on T2-weighed axial MR images. The clinical outcome parameters included back pain, leg pain, Oswestry disability index (ODI), and neurological dysfunction. The paired t-test and Wilcoxon's signed rank test were used to compare serial changes in back pain, leg pain and neurological dysfunction.Results:Mean duration of followup was 66 months (range 24 - 108 months). There were 24 male and 9 female. The mean age was 37 years (range 20 - 53 years). At presentation, mean visual analogue scales for back pain and leg pain were 75.3 ± 19.1 (range 12 - 100) and 80.2 ± 14.6 (range 0 -100), respectively. Mean ODI was 67.1 ± 18.8 (range 26 - 88). Neurological dysfunction was found in 9 patients (27.3%), and the bowel/bladder dysfunction was found in 2 patients (3.1%). Conservative treatment was performed in 21 patients (63.6%) with satisfactory results. Seven patients underwent decompressive surgery, and 5 underwent posterolateral fusion.Conclusions:A massive LDH with complete dural sac stenosis was found to be associated with severe back and leg pain at presentation, however surgical treatment can be deferred unless significant neurological symptoms occur.

Can Large Cervical and Lumbar Disc Herniations Producing Radiculopathies Be Intentionally and Rapidly Improved?

Can Large Cervical and Lumbar Disc Herniations Producing Radiculopathies Be Intentionally and Rapidly Improved?

Clinical and Radiological Findings of Nerve Root Herniation after Discectomy of Lumbar Disc Herniation

The authors report 2 cases of nerve root herniation after discectomy of a large lumbar disc herniation caused by an unrecognized dural tear. Patients complained of the abrupt onset of radiating pain after lumbar discectomy. Magnetic resonance imaging showed cerebrospinal fluid signal in the disc space and nerve root displacement into the disc space. Symptoms improved after the herniated nerve root was repositioned. Clinical symptoms and suggestive radiologic image findings are important for early diagnosis and treatment.

Treatment of large lumbar disc herniation with percutaneous ozone injectionviathe posterior-lateral route and inner margin of the facet joint

To evaluate the effects of percutaneous ozone injection via the posterior-lateral route and inner margin of the facet joint in the treatment of large lumbar disc herniation. Fifty-eight patients with large lumbar disc herniation were treated with percutaneous injection of ozone via the posterior-lateral route and inner margin of the facet joint under digital subtraction angiography. Second injections were performed 5 d after the initial injection. All patients were followed up for 6-18 mo. A modified Macnab method was used for assessing clinical outcomes after oxygen-ozone therapy. Successful puncture was obtained in all patients. The overall efficacy was 91.4%; the outcome was the excellent in 37 cases (63.8%), good in 16 cases (27.6%) and fair/poor in 5 cases (8.6%) according to the Macnab criteria. No severe complications were found throughout this study. Percutaneous intradiscal ozone injection via the posterior-lateral route and inner margin of the facet joint is effective and safe for treatment of large lumbar disc herniation.

Surgery vs. Epidural Steroids for Lumbar Disc Herniation

When a patient with symptomatic lumbar disc herniation fails to improve after noninvasive management, options include epidural steroid injections and surgery. These two options were compared in a study conducted by a single U.S. orthopedist. The trial included 100 patients with large lumbar disc herniations, …

Síndrome de Ogilvie. Presentación de 3 casos

Lumbar spine surgery represents a common procedure in Neurosurgery. Ogilvie's Syndrome is an infrequent complication of lumbar disc surgery, characterized by acute paralytic ileum as a result of acute colonic dilatation without mechanical obstruction. We present the clinical data, surgical findings and evolution of three patients operated on for large lumbar disc herniation. They presented with unilateral lumbociatic pain related with physical effort and monoradicular deficit. Diagnosis was established by CT scan and all patients were operated on through a standard laminectomy. Abdominal pain, distention and lack of bowels sounds began on the second postoperatory day. This complication was avoided by conservative treatment and parenteral administration of neostigmine. Ogilvie's Syndrome appeared in 3 cases out of more than 1000 patients undergoing lumbar disc surgery and is characterized by acute colonic dilatation including cecal distention. Other lumbar disc surgery complications such as gastrointestinal perforation, urethral injury or intra-abdominal vessels damage were excluded. Conservative treatment including parenteral neostigmine was always sucessful.

Spontaneous regression of a large lumbar disc herniation:: Report of an illustrative case

A case of spontaneous regression of a large herniated disc at the lumbar level is presented. The disc regression correlated with clinical improvement and was documented on serial MRI studies. Although the phenomenon of spontaneous disappearance of decrease in size of herniated disc fragments is well known, the exact mechanism underlying this process remains unclear. This report discusses three possible explanations for disc regression: retraction into the intervertebral space, dehydration/shrinkage, and resorption due to inflammatory reaction.