Paramedian Disc Research Articles

Surgical Treatment of Far Lateral Lumbar Disc Herniation: Outcomes of the Safe and Simple Midline Approach.

ObjectiveSurgery for far lateral lumbar disc herniation (FLLDH) hernias is different than surgery for median and paramedian disc hernias. Our study offers a minimally invasive surgical technic for far lateral disc herniations.MethodsThe results of the midline surgical approach in 18 patients diagnosed with FLLDH were evaluated retrospectively.ResultsA total of 18 patients (7 females, 11 males), with a mean age of 57.9±9.4 years (range: 35-71 years), were included in the analyses. Three patients (16.7%) had lesions at the left L3-L4 level, six patients (33.3%) on the left L4-L5 level, five patients (27.8%) on the right L3-L4 level, and four patients (22.2%) on the right L4-L5 level. All patients had low back and leg pain. These complaints completely regressed after surgery.ConclusionThis study presents a review of a consecutive series of patients who underwent minimally invasive surgery for FLLDH using a midline approach.

Far lateral lumbar disc herniation part 1: Imaging, neurophysiology and clinical features.

Far lateral lumbar disc herniations (FLLDH) represent a separate category of disc pathology which includes both intraforaminal and extraforaminal lumbar disc herniations, that are characterized by a peculiar clinical presentation, diagnostic and treatment modalities as compared to the more frequent median and paramedian disc hernias. Surgical treatment often represents the only effective weapon for the cure of this disease and over the years different approaches have been developed that can reach the region of the foramen or external to it, with different degrees of invasiveness. The diagnosis is more demanding and still underestimated as it requires a more detailed knowledge in the spine anatomy and dedicated radiological studies. Computerized tomography and in particular magnetic resonance imaging are the appropriate tools for the diagnosis of FLLDH. Despite the widespread use of these diagnostic tests, many cases of FLLDH are overlooked due to insufficiently detailed radiological examinations or due to the execution of exams not focused to the foraminal or the extraforaminal region. Neurophysiological studies represent a valid aid in the diagnostic classification of this pathology and in some cases they can facilitate the differential diagnosis with other types of radiculopathies. In the present study, a comprehensive review of the clinical presentation, epidemiology, radiological study and the neurophysiological aspects is presented.

A rare case of L5-S1 right severe foraminal stenosis and paramedian disc herniation result in foot drop of right lower extremity: A case report

Objective: the authors presented a extremely rare case of severe foraminal stenosis combined with huge lateral lumbar disc herniation 
 Case presentation: The authors presented a 74 – year old, male with type II chronic diabetes, had severe pain of the dermatomal distribution of L5, S1 nerve roots, and foot-drop of the right lower limb. When we evaluated the patient’s MRI, the huge paramedian disc herniation of the right L5-S1 level was seen and the right L5-S1 laminotomy and discetomy were planned for the treatment of the patient. However, the clinical symptoms were not completely correlated with that MRI findings so that, we re-checked the MRI, particularly at the lumbosacral region, and the right severe foraminal stenosis of L5-S1 level was found. The patient underwent surgery with facetectomy, transforaminal interbody fusion, and pedicle screw fixation. After the operation, the patient has quickly reduced radiating pain of the right lower extremity, although the foot-drop was not improved. Because of the huge lateral lumbar disc herniation impression, that could affect the assessing the patient’s injury correctly, leaded consequences of a missing diagnosis of foraminal stenosis and inadequate surgery method.
 Conclusion: It is essential to detail examination of the clinical manifestations and thorough assessment of MRI for evaluation of the correlation between the physical examination and MRI findings before making the decision of surgical method.

MRI predictors of revision surgery after primary lumbar discectomy

The prognostic significance of preoperative MRI findings in patients undergoing discectomy is incompletely understood. Identifying the radiological predictors of revision surgery on pre-operative MRI can guide management decisions and potentially prevent multiple surgeries. We included 181 patients who underwent primary lumbar discectomy between 2010 and 2014. All patients were contacted via a short telephone interview to determine if they had revision surgery within 5 years of their index surgery. Preoperative MRI of the lumbosacral spine was evaluated for various radiological factors including type of disc herniation, anatomical location of herniation, direction of herniation, degree of disc degeneration, end plate changes and presence of listhesis. Other potential confounders including age, gender, smoking status and index level of surgery were also recorded. Multivariate model of all radiological predictors and confounders were developed and a step-wise approach was used to remove insignificant variables in order to develop final significant multivariate model. P value of <0.05 was considered statistically significant. Patients with retrolisthesis were found to be 2.7 times more likely than the patients without listhesis to require revision surgery (p = 0.019). Patients with foraminal disc herniation were 3.45 times more likely than the patients with paramedian disc herniation to require revision surgery (p = 0.026). Other MRI predictors failed to achieve statistical significance. Based on the data presented patients with retrolisthesis and/or foraminal disc herniation should be counselled on the relatively higher risk of revision surgery when proceeding with discectomy, or alternative options should be considered.

Surgery for extraforaminal lumbar disc herniation: a single center comparative observational study

BackgroundSurgery on extraforaminal lumbar disc herniation (ELDH) is a commonly performed procedure. Operating on this type of herniation is known to come with more difficulties than on the frequently seen paramedian lumbar disc herniation (PLDH). However, no comparative data are available on the effectiveness and safety of this operation. We sought out to compare clinical outcomes at 1 year following surgery for ELDH and PLDH.MethodsData were collected through the Norwegian Registry for Spine Surgery (NORspine). The primary outcome measure was change at 1 year in the Oswestry Disability Index (ODI). Secondary outcome measures were quality of life measured with EuroQol 5 dimensions (EQ-5D); and numeric rating scales (NRSs).ResultsData of a total of 1750 patients were evaluated in this study, including 72 ELDH patients (4.1%). One year after surgery, there were no differences in any of the patient reported outcome measurements (PROMs) between the two groups. PLDH and ELDH patients experienced similar changes in ODI (− 30.92 vs. − 34.00, P = 0.325); EQ-5D (0.50 vs. 0.51, P = 0.859); NRS back (− 3.69 vs. − 3.83, P = 0.745); and NRS leg (− 4.69 vs. − 4.46, P = 0.607) after 1 year. The proportion of patients achieving a clinical success (defined as an ODI score of less than 20 points) at 1 year was similar in both groups (61.5% vs. 52.7%, P = 0.204).ConclusionsPatients operated for ELDH reported similar improvement after 1 year compared with patients operated for PLDH.

Complications and limitations of endoscopic spine surgery and percutaneous instrumentation

Endoscopic spine surgery has started replacing conventional microdiscectomy in various centers across the globe. With development in the field of optics and instrumentation, the field of percutaneous endoscopic spine surgery has evolved immensely. With increasing experience, endoscopic spine surgeons have expanded the indications not only to lumbar paramedian disc herniations but also to central disc herniations, high-grade migrated disc herniations, sequestered herniations, thoracic and cervical disc herniations, and more recently, lumbar canal stenosis. With broadening indications, unexpected adverse events are bound to increase. Hence, it is essential for the endoscopic spine surgeons to be aware of the potential hazards and unexpected complications of the procedure so that appropriate care is taken to avoid adverse events as much as possible. In this article, we summarize all the complications of transforaminal endoscopic discectomy reported in the literature. We have classified the complications into intraoperative, immediate postoperative, and late postoperative complications. The senior author has also suggested the tips to avoid these complications and carry out the procedure as safely as possible. As percutaneous instrumentation, particularly, percutaneous pedicular screws, is also becoming common with the development of minimally invasive spine surgery, we have also summarized its complications and limitations. An insight into these complications will help the endoscopic surgeons to take special precautions when performing the procedure.

Coronal magnetic resonance imaging of three-dimensional fast-field echo with water-selective excitation improves the sensitivity and reliability of identification of extraforaminal lumbar disc herniation

ObjectiveThe complete view of the nerve root, including the extraforaminal zone, can be displayed by coronal magnetic resonance imaging (MRI) of three-dimensional (3D) fast-field echo with water-selective excitation (CMRI). However, its sensitivity, specificity, and reliability for the diagnosis of extraforaminal lumbar disc herniation are unclear. We compared the sensitivity, specificity, and reliability of conventional MRI, CMRI, and 3D MRI for the identification of extraforaminal lumbar disc herniation.MethodsThis study involved 140 patients (68 with extraforaminal lumbar disc herniation and 72 with paramedian disc herniation). Their mean age was 44.57 ± 14.59 years. Conventional MRI, CMRI, and 3D MRI of all patients were evaluated by five experts. The reliability, sensitivity, and specificity of the three imaging techniques for identification of extraforaminal lumbar disc herniation were compared using kappa statistics and the chi-squared test.ResultsCMRI showed higher agreement (0.843) than conventional MRI (0.671) and 3D MRI (0.771) for the identification of extraforaminal lumbar disc herniation. CMRI demonstrated higher sensitivity (95.6% vs. 91.2%) than conventional MRI (85.3% vs. 70.6%) and 3D MRI (92.6% vs. 86.7%) regardless of whether performed by junior or senior surgeons.ConclusionsCMRI is helpful for identification of extraforaminal disc herniation by junior and senior orthopedic surgeons.

Transforaminal Epidural Steroid Injection in the Treatment of Pain in Foraminal and Paramedian Lumbar Disc Herniations.

To compare the effect of fluoroscopically guided transforaminal epidural steroid injections on radicular pain in foraminal and paramedian lumbar disc herniations. This study included patients who did not benefit from previous medical treatments or are not suitable for surgery. Transforaminal epidural steroid injections for the treatment of foraminal and paramedian lumbar disc herniation were performed in 370 and 1262 patients, respectively. Every group’s preprocedural visual analogue scale (VAS) and 12-week postprocedural VAS scores were recorded, and statistical analysis was performed. The complications noted were also recorded. The preprocedural and postprocedural mean VAS scores for radicular pain in foraminal disc herniation were 67.11 ± 4.28 and 34.78 ± 3.64, respectively. However, the preprocedural and postprocedural mean VAS scores in paramedian disc herniation were 62.16 ± 6.65 and 19.07 ± 4.50, respectively. Statistical analysis of the varying preprocedural and postprocedural VAS scores showed that transforaminal epidural steroid injections were more effective for paramedian disc herniation than for foraminal disc herniation (p < 0.05). Transforaminal epidural steroid injections were more effective for paramedian lumbar disc herniation than for foraminal disc herniation, 12 weeks after the procedure.

Recurrent upper lumbar disc herniation treated via the transforaminal approach using microendoscopy-assisted lumbar discectomy: a case report

BackgroundAlthough microendoscopy-assisted lumbar discectomy for lateral or extraforaminal lumbar disc herniations via the lateral approach has previously been reported, microendoscopy-assisted lumbar discectomy for central or paramedian disc herniations via the lateral approach has not been reported.We report the first case of recurrent upper lumbar disc herniation (L2–L3) treated with microendoscopy-assisted lumbar discectomy via the transforaminal approach. No microendoscopy-assisted lumbar discectomy for recurrent upper lumbar disc herniation via the transforaminal approach has previously been reported. Percutaneous endoscopic lumbar discectomy via the transforaminal approach is very useful as a minimally invasive surgery for disc herniations. We applied percutaneous endoscopic lumbar discectomy via the transforaminal approach, and invented a new microendoscopy-assisted lumbar discectomy via the transforaminal approach.Case presentationA 79-year-old Japanese man was operatively managed for recurrent L2–L3 herniation. An 18 mm skin incision was made approximately 70 mm from the midline to the lateral side to allow a sufficiently angled trajectory to the extraforaminal space. The transforaminal approach was used. The exiting nerve root was identified along its course inferior to the pedicle. The lateral portion of the pars interarticularis and the facet joint was removed using a high-speed drill under the guidance of an endoscope. The tip of the endoscope was set at the lateral side of the dura mater. The dura mater was retracted medially and gently, and the herniated disc fragments were removed safely. All symptoms were relieved postoperatively. Postoperative magnetic resonance imaging demonstrated disappearance of all herniated disc fragments. A postoperative three-dimensional computed tomographic scan demonstrated the complete preservation of the facet joint.ConclusionsThis is the first report of a case of recurrent upper lumbar disc herniation treated with microendoscopy-assisted lumbar discectomy via the transforaminal approach. This procedure allows for the use of a nerve retractor and other instruments to detach adhesions from the dura mater. This procedure has the advantages of clear visualization of the dura mater, exiting nerve root, and traversing nerve root, and diminished risk of nerve injury, and complete preservation of the articular surface of the facet joint.

A Prospective Study of Interbody Fat Graft Application With the Anterior Contralateral Cervical Microdiscectomy to Preserve Segmental Mobility.

Any surgical procedure aims at protecting mobile segments at the operated level, and the sagittal balance of the columna vertebralis. Interbody fusion has become an often applied technique in anterior cervical discectomy. To indicate that a minimally invasive technique in which we use interbody fat graft placement showed great results and effectiveness, especially in patients who were suffering from cervical paramedian disc herniation. In this study, 432 patients were observed from 2000 to 2013. All these consecutive patients had paramedian disc herniation. The initial 239 patients (group 1) underwent microdiscectomy without graft placement, whereas the remaining 193 patients (group 2) had a microdiscectomy with interbody fat graft insertion. The Neck Disability Index (NDI) and Short Form-36 (SF-36) were used to evaluate clinical outcomes. They were followed up for 5.3 years (range 2-13 years). Spontaneous radiological fusion was noticed in 12% of group 1 patients and none of the group 2 patients. It has been observed that the mean overall cervical curvature (C2-7) angles and segmental lordosis did not change significantly in late follow-up findings. During both early and late follow-ups, all patients indicated a decreasing NDI score, but in late follow-up, an improving SF-36 score. This surgical technique provides good direct decompression and preserves mobility at the treated level, while preventing disc collapse.

Lumbar Disc Herniation Presented with Contralateral Symptoms.

ObjectiveThis study aimed to unravel the putative mechanism underlying the neurologic deficits contralateral to the side with lumbar disc herniation (LDH) and to elucidate the treatment for this condition.MethodsFrom January 2009 to June 2015, 8 patients with LDH with predominantly contralateral neurologic deficits underwent surgical treatment on the side with LDH with or without decompressing the symptomatic side. A retrospective review of charts and radiological records of these 8 patients was performed. The putative mechanisms underlying the associated contralateral neurological deficits, magnetic resonance imaging (MRI), electromyography (EMG), and the adequate surgical approach are discussed here.ResultsMRI revealed a similar laterally skewed paramedian disc herniation, with the apex deviated from the symptomatic side rather than directly compressing the nerve root; this condition may generate a contralateral traction force. EMG revealed radiculopathies in both sides of 6 patients and in the herniated side of 2 patients. Based on EMG findings and the existence of suspicious lateral recess stenosis of the symptomatic side, 6 patients underwent bilateral decompression of nerve roots and 2 were subjected to a microscopic discectomy to treat the asymptomatic disc herniation. No specific conditions such as venous congestion, nerve root anomaly or epidural lipomatosis were observed, which may be considered the putative pathomechanism causing the contralateral neurological deficits. The symptoms resolved significantly after surgery.ConclusionThe traction force generated on the contralateral side and lateral recess stenosis, rather than direct compression, may cause the contralateral neurologic deficits observed in LDH.

Surgical treatment of far lateral lumbar disc herniation: a safe and simple approach.

Lumbar discectomy is one of the most commonly performed neurosurgical procedure. Far lateral disc herniations (FLDH) make up a minor portion of the total discectomy workload for spine surgeons. Due to their lower incidence, as well as their different anatomical positioning compared to the more common para-median disc herniation, the surgical procedures involved in releasing the neural compression caused by FLDHs are often challenging and at times frustrating to most spine surgeons, resulting in suboptimal outcomes for the patient related to the higher risk of spinal instability from facet joint disruption and may even be associated with nerve root injury. We discuss here a safe and simple approach to tackle FLDH.

Case Report: A case report highlighting bilateral EDB wasting as a clinical marker for lumbar canal stenosis.

Herein we discuss a case of a 55 year old male presenting with history suggestive of sciatica on the left leg. Straight leg raising (SLR) test was positive at 45 degrees on the left side. His ankle reflex was absent and the power of extensor hallusus longus (EHL) was 4/5 on the same side. MRI lumbosacral spine revealed left paramedian disc prolapsed on L4/L5 level with spinal canal diameter of 9mm.However since his bilateral extensor digitorm brevis (EDB) werewasted, we suspected associated lumbar canal stenosis and thereby opted for laminectomy and discectomy in this case. Intraoperatively dural wasting, hypertrophied facets and narrow canal were confirmed. Laminectomy, medial facectectomy and discectomy were carried out. The patient recovered uneventfully with resolution of his sciatica-like pain. Bilateral EDB wasting thereby provides a clinical clue to the underlying lumbar canal stenosis and can help in making correct therapeutic decisions.

Dimensions of intervertebral foramen during different trunk positions in central and Paramedian disc bulge, with kinisiologic H reflex correlation

Dimensions of intervertebral foramen during different trunk positions in central and Paramedian disc bulge, with kinisiologic H reflex correlation

Concomitance of fibromyalgia syndrome and cervical disc herniation.

[Purpose] Fibromyalgia syndrome (FMS) and cervical disc herniation (CDH) are a common diseases commonly encountered in physical therapy clinics. There are also patients who have both of these diseases. In this study we aim to investigated whether FMS is a risk factor for cervical disc herniation and the frequency of their coincident occurrence. [Subjects and Methods] Thirty-five patients having a primary FMS diagnosis according to the American Rheumatism Association criteria are taken into consideration and a control group were the subjects of this study. The two groups were compared with respect to cervical disc hernia using cervical region MRI. [Results] The distribution of disc hernia of 6 fibromyalgia patients who had cervical discopathy was: 16.6% C2–3, 16.6% C5–6, 16.6% C6–7, 33.3% C4–5, C5–6 (two levels in two patients) and 16.6% C4–5, C5–6, C7–1 (three levels in one patient) . The herniation directions were given as: central in 5 levels, right paramedian in 1 level, and left paramedian disc hernia in 1 level. There were 4 cervical disk hernia in the control group. The herniation direction were central in two, right paramedian in one, and left paramedian in one patient. [Conclusion] In this study, the existence of cervical disc herniation in fibromyalgia patients was found to be not different from the normal population.

Concomitant combined degenerative compression of the spinal cord and cauda Equina: A report on three cases

We report on three cases with concomitant combined degenerative compression of the spinal cord and cauda equina which were diagnosed and operated in a single stage. The first case presents left-sided paramedian disc herniations at L1-2 and L4-5 levels, combined with concurrent degenerative spinal stenosis. The second case includes right-sided paramedian disc herniation at Th12-L1 level in combination with severe degenerative lumbar spinal stenosis at L3-4 level. The third case describes advanced degenerative compression at Th7-8 level with concurrent central spinal stenosis at L4-5 level. We have discussed the clinical presentation of concurrent combined symptomatic degenerative compression of the spinal cord and cauda equinа which can deceive the physician and lead to omitted diagnosis of the thoracic compression. In an attempt to avoid misdiagnosis of thoracic degenerative compression, it is necessary to perform thorough neurological examination of the spinal cord motor and sensory functions. In addition, further MRI examination of upper spinal segments is needed, if previous studies of the lumbar spine fail to provide reasonable explanation for the existing neurological symptoms.

The Comparisons of Surgical Outcomes and Clinical Characteristics between the Far Lateral Lumbar Disc Herniations and the Paramedian Lumbar Disc Herniations.

ObjectiveThe purpose of this study is to analyze clinical characteristics and surgical outcomes of the far lateral and the paramedian disc herniations.MethodsThe 88 patients who underwent an operation for lumbar disc herniations were reviewed. Visual analogue scale of leg and back pain, occurrence of sensory dysesthesia and motor deficit before and after operations were used to compare the far lateral with the paramedian disc herniations.ResultsStatistically, the far lateral herniations had more severe radicular leg pain and showed more frequent occurrence of sensory dysesthesia than paramedian herniations before operation (p<0.05). In the far lateral herniation group, preoperatively, 15 patients (75%) had sensory dysesthesia and among them, 4 patients (27%) showed improvement. In the paramedian herniation group, preoperatively, 25 patients (37%) had sensory dysesthesia and among them, 21 patients (84%) showed improvement. The degree of improvement in sensory dysesthesia was statistically higher in paramedian herniation group (p<0.05). In the far lateral herniation group, preoperatively, 11 patients (55%) had motor deficit and among them, 10 patients (91%) showed improvement. In the paramedian herniations, preoperatively, 29 patients (43%) had motor deficit and among them, 25 patients (86%) showed improvement. The degree of improvement in motor deficit was not statistically significant between groups (p>0.05).ConclusionPreoperatively, the far lateral herniations had more severe radicular leg pain and frequent occurrence of sensory dysesthesia. Postoperatively, the sensory dysesthesia was less improved and back pain was more severe in the far lateral herniations.

Atypical Presentation of Thoracic Disc Herniation: Case Series and Review of the Literature

Modern imaging has revealed that thoracic disc herniation (TDH) has a prevalence of 11–37% in asymptomatic patients. Pain, sensory disturbances, myelopathy, and lower extremity weakness are the most common presenting symptoms, but other atypical extraspinal complaints, such as gastrointestinal or cardiopulmonary discomfort, may be reported. Our objective is to make providers familiar with TDH's atypical symptoms to help avoid potential serious consequences created by a delay in diagnosis. We report the cases of two patients who each presented with atypical extraspinal symptoms secondary to a TDH. One patient presented with a chronic history of nausea, emesis, and chest tightness and MRI showed a large right paramedian disc herniation at T7-8. A second patient reported chronic constipation, buttock and leg burning pain, gait instability, and urinary frequency; an MRI of his thoracic spine demonstrated a central disc herniation at T10-11. TDH can present with vague extraspinal symptoms and unfamiliarity with these symptoms can lead to misdiagnosis with progression of the disease and unnecessary diagnostic tests and medical procedures. Therefore, TDH should be included in the differential diagnosis of patients with negative gastrointestinal, genitourinary, and cardiopulmonary system basic studies.

Foreign body reaction to hydroxyapatite after anterior cervical discectomy with fusion

Dear Editor, The surgical management of cervical disc herniation has greatly evolved over the last century. Shortly after the anterior cervical approach and fusion with a horseshoe bone graft [5], the interbody fusion using autologous iliac bone was described [2], and recent studies have highlighted the morbidity associated with these autografts [3, 8, 9], mainly donor site morbidity and limited supply. Consequently, the use of allograft or synthetic materials for fusion has been increasing. Nevertheless, the fusion rates are similar for the three methods, with synthetic materials averting the pain of autograft bone sourcing and being less expensive than allograft bone use [1, 7]. We are reporting an unexpected complication following the use of phosphocalcic hydroxylapatite after anterior cervical discectomy with fusion. A 68-year-old man with type 2 diabetes mellitus, came to the out–patient clinic of our department complaining of decreased strength on the right limbs. He presented with a right hemiparesis (grade 2) and hemihyposthesia, with ipsilateral gait disturbance; no changes in muscle stretch reflexes were elicited and the Babinsky sign was present on the right side only. The cervical spine MRI revealed right paramedian C4-C5 cervical disc extrusion, with upward and downward migration, and compression of the spine cord. The patient was submitted to surgery: anterior cervical C4-C5 discectomy; fusion with cage filled with autologous bone and hydroxyapatite, and fixation with an anterior plate (over C4 and C5). He recovered motor function, being discharged 48 h later with grade 4 muscle strength and the ability to use the right hand in activities of daily living. However, he was readmitted at 15 days postoperatively with a paraparesis and paraesthesias in both forearms and hands. The MRI showed spinal cord compression at C4-C5 and upward migration of the cage into the C4 vertebral body. He was reoperated and the anterior plate and screws were removed. We did a C4 corpectomy, dissection and excision of epidural tissue and fusion with mesh filled with autologous bone and anterior plate between C3 and C5, with fixed screws over both vertebral bodies. The epidural tissue was sent for microbiology and for histopathology analysis. The patient was treated empirically with a high dose of flucloxacilin for an eventual empyema, and was discharged with partial recovery of autonomous gait with orthosthasis, and no paraesthesies. The microbiological evaluation was negative but neuropathology revealed a foreign body reaction with calcium-positive material surrounded by giant-multinucleated cells (Fig. 1). The patient was followed in the immunoallergy out-patient clinic in order to test hypersensivity to hydroxyapatite, which was negative. At 4 weeks after reoperation, the patient showed a J. P. Lavrador : S. Livraghi Department of Neurosurgery, Hospital de Santa Maria, CHLN, Lisbon, Portugal

Horner Syndrome associated with a Herniated Cervical Disc: A Case Report.

Horner syndrome (HS) occurs when there is interruption of the oculosympathetic pathway. The causes of HS are various, but HS originated from herniated cervical disc is very few. HS attributable to the lesion of the first-order neuron of cervical spinal cord is extremely rare. A 41-year old male was admitted for sudden onset of left ptosis and right side numbness. Neurological examination revealed ptosis, miosis and facial anhidrosis on the left side. MRI and CT scans demonstrated large left paramedian disc herniation with cord compression at the C4-5 level. The herniated disc was removed through anterior approach and his symptoms were improved after the operation.