Sequestrated Disc Herniation Research Articles

EXPERIENCE OF RESORPTION OF LUMBAR SPINE HERNIAS

Background. In most cases, the reduction in pain and clinical manifestations is associated with a decrease in the size of the hernia or its resorption, which is the natural process of reduction or complete disappearance of the hernia without the need for surgical intervention. Currently, there are several intensive physical therapy methods that influence the process of hernia resorption, making conservative treatment preferable. Materials and methods. At the «Expert Neuro» clinic, as part of a prospective observational study from 2023 to 2024, 30 patients with a confirmed diagnosis of “herniated intervertebral discs of the lumbar spine” were analyzed based on the results of magnetic resonance imaging. The main group of patients received conservative treatment using modern high-intensity physiotherapy methods, the control group received classical methods of conservative treatment. Results. According to magnetic resonance of the spine, 3 patients developed resorption of a herniated intervertebral disc. In all patients, radiculopathy symptoms improved after 1 month and lower back pain symptoms improved after 2 to 3 months. Conclusion. According to our clinical experience and relevant literature, sequestered disc herniations have a high rate of resorption. Pathophysiological processes of inflammation and regeneration are the main mechanisms of this phenomenon. Conservative management of such patients in the absence of definitive surgical indications should not be underestimated.

The Lasegue test: Defining its specificity and sensitivity based on geometry.

The Lasegue test -also known as the straight leg raise test-, used for diagnostic purposes in cases of lumbar disc herniation can be explained by geometrical rules. This study aimed to describe the relationship between the apical and basal size of the herniated disc and the Lasegue test, and to describe the specificity and sensitivity of the herniated disc as a function of its height, location, and size. The study evaluated cases diagnosed with lumbar disc herniation with available MRI scans and Lasegue test results. The radix length to the foramen was calculated by recording the apical length and the base length of the herniated disc. The level and apical direction of the herniated discs were also recorded to determine the specificity and sensitivity of the test. Data from a total of 865 cases were analyzed. The apical length of the herniated disc was the most critical criterion for determining the Lasegue test. The Lasegue test is most sensitive and specific in lateral herniated discs at the level of L4-5. The specificity and sensitivity are decreased in L3-4, migrated, and sequestered disc herniations. In these cases, false-negative results may occur. Sensitivity decreases in the median and paramedian herniated discs. Compression of the sciatic nerve reduces herniated disc straightness. The Lasegue test is a test that can be defined according to the rules of geometry. Knowing the factors that decrease specificity and sensitivity and cause false positive/negative results will facilitate correct diagnosis.

Functional Outcome after Fenestration and Discectomy in Young Adults Presenting with Unilateral Radiculopathy

Introduction: Lumbar disc herniation is one of the common ailments in young adults. The common levels of L4-L5 and L5-S1 have been chosen for ours. The Evaluation was done based on the level of disc herniation and also with different types of disc herniation such as contained, extruded, or sequestrated disc herniations. The outcomes were evaluated using the Japanese Orthopedic Association (JOA) scoring system. Methods: Thirty-three patients with a single-level disc herniation at L4-L5 or L5-S1 who did not show significant improvement of radiculopathy even after a conservative trial were included in the study. All patients were consented and subjected to surgery-unilateral fenestration and fragment discectomy. Patients were evaluated based on their JOA Scoring which was done preoperatively and postoperatively on day 10 and at 1 month, 3 months, 6 months, and 1 year. The functional outcome in percentage was calculated using the “recovery rate” by the Hirabayashi index. Results: Following fenestration discectomy, the functional outcome of the patient was found to be good. O the 33 patients operated, males n = 20 and females n = 13. According to Hirabayashi's recovery rate, 48% (n = 16) patients were found to have an excellent result with recovery rate of >80%. Good results were seen in 43% (n = 14) with recovery rates ranging between 70% and 80%. About 3% (n = 1) had a fair result with recovery rate of 56% and 6% (n = 2) had poor results with recovery rate < 50% following surgery. Applying the paired t-test, P was calculated and was 0.0001 which is statistically significant. Complications included incidental durotomy, pseudomeningocele, recurrent disc herniation, and spondylodiscitis. Conclusion: Patients who underwent fenestration discectomy for single-level lumbar disc herniation at L4/5 or L5/S1 showed significant functional improvement as per JOA scoring and Hirabyashi's recovery rate. The results were comparable with newer techniques such as micro and endoscopic discectomy.

TORAKOLOMBER BİLEŞKE DİSK HERNİASYONLARININ CERRAHİ TEDAVİSİNDE POSTEROLATERAL TRANSKAMBİN YAKLAŞIM

Objective: The optimal surgical approach for treatment of thoracolumbar junction disc herniations (TLJDH) remains controversial. Anterolateral retroperitoneal, anterior transthoracic, posterolateral, lateral and transforaminal endoscopic approaches are used in current surgical treatment of TLJDH. In a posterolateral transcambin approach, a small piece of bone is removed from the pars interarticularis and facet joints, and decompression is achieved by discectomy without causing instability. The transcambin approach has advantages such as discectomy without advanced neural tissue retraction, short recovery time and less postoperative complications. Methods: The eight patients with 3 T12-L1 and 5 L1-2 TLJDH who were operated on using the posterolateral transcambin approach between 2016-2018 in our clinic were presented retrospectively. The study included patients with extruded or sequestrated disc herniation that had far lateral, foraminal, and paramedian extension, and caused cauda equina syndrome, conus medullaris syndrome, and radiculopathy. A skin incision and fascia opening were done from midline. The exiting root was revealed at laterally of pars interarticularis by subperiosteally stripping of paravertebral muscles and the removal of disc fragments were targeted. Results: Three male and five female patients with a mean age of 45.1 (32-66). Mean operation time was 57.8 minutes. Preoperative VAS values were 8.75±0.51 and postoperative VAS values were 1.25±0.65. According to the MacNab classification, 62.5% excellent, 25% good and 12.5% were fair. There was no neurological injury, cerebrospinal fluid (CSF) fistula, pneumothorax, or operation field hematoma.Conclusion: The transcambin approach was found to be useful in terms of a relatively short operation time, low morbidity probability, and less postoperative pain in patients with TLJDH. 

Cauda Equina Syndrome after Sequestered Disc Herniation Migrating to the Dorsal Epidural Space: Case Report and Review of the Literature

Background: Posteriorly migrated epidural disc fragments (PMEDF) presenting with cauda equina syndrome are relatively common. These cases are sometimes inaccurately identified on MRI as; epidural tumors, abscesses, hematomas and or facet cysts. Proper description and identification are key to be able to provide effective and safe management. Currently we are presenting the case of a patient with cauda equina syndrome secondary to a posterior mass compression intraoperatively identified as a PMEDF. Case Description: 45-years-old male presenting with insidious low back pain that progressed to urinary retention and bilateral foot drop. An MRI of the lumbar spine showed a posteriorly located epidural lesion. That appeared to be dependent on a left facet cyst. The patient was treated with a decompressive laminectomy and multiple disc fragments were identified under the ligamentum flavum and over the posterior epidural space. Conclusion: Posterior epidural migration of a lumbar disc fragments (PEMLDF) are not a common presentation of intervertebral disc herniations and their differential diagnosis and treatment might require a different surgical approach; fusion vs decompression. PEMLDFs should be suspected on those patients presenting with sudden cauda equina syndrome and posteriorly located epidural lesions on MRI.

Clinical case: conservative treatment of sequestered disc herniation

The literature has a lot of descriptions of the spontaneous disappearance of herniated discs. This article presents a clinical case of conservative treatment of sequestered disc herniation applying a complex of drug treatment and kinesitherapy. After 5 months a positive trend was observed against the background of conservative treatment. A year later, there was a lack of clinical symptoms and, according to MRI, and positive dynamics in the form of a decrease in the caudal sequestration of L5-S1 to symmetrical circular protrusion (hollow capsule effect). Key Words: sequestered disc herniation, drug treatment, kinesitherapy, MRI.

Sequestered Disc Herniation in a Dog

Background: Dogs are frequently affected by intervertebral disc degeneration, a structural failure associated with changes accelerated by aging. Disc degeneration may occur in the presence or absence of clinical signs, which are variable and common to other spinal cord diseases and therefore early diagnosis is crucial to a successful outcome. Treatment may be conservative or surgical according to severity of the clinical signs and should be combined with a rehabilitation protocol. Prognosis depends on the location of the spinal cord compression, volume and velocity of the disc material herniation and time between initial clinical signs, definitive diagnosis and therapeutic approach. Case: A nonchondrodystrophic 14-year-old dog with acute clinical manifestation of paraparesis and proprioceptive deficit in hind limbs was submitted to myelography examination. There was contrast column deviation in the T13-L1 region, determining spinal compression, and spondyloses were also noted in several thoracolumbar vertebrae. Hemilaminectomy was performed with complete removal of the compressor fragment. Histological analysis confirmed the presence of fibrocartilaginous material that corresponds to the part of the annulus fibrosus. The kidnap of the fragment was characterized by loss of continuity with the remaining disk. In these cases, magnetic resonance imaging does provides the definitive diagnosis, since neoplasm, arachnoid cysts and abscesses may be remaining differential diagnosis. Therefore, surgical approach followed by histopathological analysis of the obtained material are necessary to confirm the diagnosis.Discussion: The present report differs from most cases of disc herniation because it is a thoracolumbar lesion with an acute manifestation of significant neurological deficit in an elderly dog of non-chondrodystophic breed. Also, material of the free fibrous annulus itself in the medullary canal is not a common histopathological presentation of disc extrusion usually composed by nucleus pulposus. After neurolocalization of the lesion by clinical neurological examination, the radiographic evaluation shall precedes the myelography, since this is contraindicated when there is suspicion of discoespondylitis, fracture, dislocation or vertebral subluxation, which had not yet been discarded. Even if the MRI is performed, in the cases of a sequestered fragment, it still remais differential diagnoses include arachnoid cysts, discoespondylitis, hematomas, abscesses and neoplasms, including metastases, so only surgical approach to obtain material for histopathological analysis may provide definitive diagnosis. According to the histopathological examination, the herniated material had a fibrocartilaginous characteristic: several concentric fibrous blades, composed of collagen and fibrocartilage, thus characterizing the herniated material as a fragment of the fibrous ring. When removed from the vertebral canal, the contents did not show resistance, being withdrawn completely and without continuity with its origin intervertebral disc. The patient's disc herniation could not be classified as a disc protrusion because this affection is described as a projection of the fibrous annulus towards the vertebral canal due to the partial rupture of fibers and mineralization of the nucleus pulposus, without discontinuity of some content. Disc protrusion shows mild and progressive signs, except if there is complete rupture of the fibrous ring as can be seen in the sequestered disc herniation. Although infrequent, elderly animals of non-chondrodisiotic races may show acute signs of neurological deficits. Sequestrated disc herniation may mimic other lesions, requiring a surgical approach to obtain material for histopathological analysis to confirm the diagnosis.

Misdiagnosis of posterior sequestered lumbar disc herniation: report of three cases and review of the literature.

Posterior migration of sequestered disc is an extremely rare event that mimics more common spinal lesions as spinal tumors, making difficult its preoperative diagnosis and appropriate management. We retrospectively reviewed all lumbar disc herniations treated by surgery at our institution from 2006 to 2016 to identify cases with posterior sequestered disc fragments and possible misdiagnosis for other spinal lesions. Complementarily, a literature review of misdiagnosed cases of posterior migrated discs was undertaken. Three posterior sequestered lumbar disc cases (one intradural), were found among the 1153 reviewed surgeries. Two of them, presenting with progressive neurological deficit, were respectively misdiagnosed as pseudotumoral lesion and meningioma/neurogenic tumor on MRI. After intraoperative diagnosis and emergent resection, histology confirmed intervertebral disc tissue. The remaining case had an accurate preoperative diagnosis and after an initial conservative management finally underwent surgery because of refractory pain. Full recovery was achieved months after surgical treatment in all cases. Non-tumoral lesions are the most frequent misdiagnosis of posterior sequestered lumbar disc described in the literature. Early surgical treatment is the standard management due to high incidence of cauda equine syndrome (CES); however, spontaneous regression of posterior sequestered lumbar disc herniations has been recently reported. In conclusion low incidence and similar clinical and radiological features with other more common posterior spinal lesions like hematomas, synovial cyst or abscess turns posterior sequestered disc herniations a diagnosis challenge. Despite high incidence of CES, an initial conservative management should be evaluated in selected patients without neurological deficit and well-controlled pain.

Spinal manipulation in the treatment of patients with MRI-confirmed lumbar disc herniation and sacroiliac joint hypomobility: a quasi-experimental study

BackgroundTo investigate the effect of lumbar and sacroiliac joint (SIJ) manipulation on pain and functional disability in patients with lumbar disc herniation (LDH) concomitant with SIJ hypomobility.MethodsTwenty patients aged between 20 and 50 years with MRI-confirmed LDH who also had SIJ hypomobility participated in the trial in 2010. Patients who had sequestrated disc herniation were excluded. All patients received five sessions of spinal manipulative therapy (SMT) for the SIJ and lumbar spine during a 2-week period. Back and leg pain intensity and functional disability level were measured with a numerical rating scale (NRS) and the Oswestry Disability Index (ODI) at baseline, immediately after the 5th session, and 1 month after baseline.ResultsA significantly greater mean improvement in back and leg pain was observed in the 5th sessions and 1 month after SMT. Mean changes in ODI in the 5th session and 1 month after treatment also showed significant improvement. The MCIC for NRS and ODI scores in the present study were considered 20 and 6 points, respectively. Therefore, the mentioned improvements were not clinically significant in the 5th session or at 1-month follow-up.ConclusionFive sessions of lumbar and SIJ manipulation can potentially improve pain and functional disability in patients with MRI-confirmed LDH and concomitant SIJ hypomobility.Trial registrationIrct.ir (Identifier: IRCT2017011924149N33), registered 19 February 2017 (retrospectively registered).

A Modified Translaminar Osseous Channel-Assisted Percutaneous Endoscopic Lumbar Discectomy for Highly Migrated and Sequestrated Disc Herniations of the Upper Lumbar: Clinical Outcomes, Surgical Indications, and Technical Considerations

Objective is to describe a safe and effective percutaneous endoscopic approach for removal of highly migrated and sequestrated disc herniations of the upper lumbar spine and to report the results, surgical indications, and technical considerations of the new technique. Eleven patients who had highly migrated and sequestrated disc herniations in the upper lumbar were included in this study. A retrospective study was performed for all patients after translaminar osseous channel-assisted PELD was performed. Radiologic findings were investigated, and pre-and postoperative visual analog scale (VAS) assessments for back and leg pain and Oswestry disability index (ODI) evaluations were performed. Surgical outcomes were evaluated under modified MacNab criteria. All of the patients were followed for more than 1 year. The preoperative and postoperative radiologic findings revealed that the decompression of the herniated nucleus pulposus (HNP) was complete. After surgery, the mean VAS scores for back and leg pain immediately improved from 8.64 (range, 7–10) and 8.00 (range, 6–10) to 2.91 (range, 2–4) and 2.27 (range, 1–3), respectively. The mean preoperative ODI was 65.58 (range, 52.2–86), which decreased to 7.51 (range, 1.8–18) at the 12-month postoperative follow-up. The MacNab scores at the final follow-up included nine excellent, one good, and one fair. The modified translaminar osseous channel-assisted PELD could be a safe and effective option for the treatment of highly migrated and sequestrated disc herniations of the upper lumbar.

Сervical microdiscectomy: method and surgical strategy

Objective. To implement the interlaminar lateral approach for extraction of herniated discs (HD) in the cervical spine. Materials and methods. During 2012–2015 in Regional psychoneurological hospital 56 patients with cervical HD were operated. There were 22 females, 36 males among them. Disc herniation at the CV–CVI level occurred in 21 cases, CVI–CVII in 20 cases. The main disease signs were cervicalgia, monoradiculopathy. Fifty patients with medial hernia were operated using anterior cervical microscopic discectomy approach to HP extraction and intervertebral cage implantation (PEEK material). Six patients with lateral hernia were operated using posterior interlaminar cervical microdiscectomy. Anterior approach was performed by a standard method using CODMAN retractor, high-speed drill Stryker TPS. The posterior interlaminar approach was performed using paramedian incision 3 cm, intermuscular approach to the posterior lateral mass and arch on the affected side with Medtronic Metrix system followed by interlaminectomy performed by high-speed drill not more than 1 cm that was rather enough for hernia extraction from under nerve root. Results. In all cases we managed to achieve the regression of radicular and cervicalgia syndromes. No complications were fixed during both surgical approaches. There was no difference observed in duration of surgical intervention using both methods, which was about (64±12) min. All patients were verticalized and activated in 3–4 hours after surgery. Conclusion. Cervical microdiscectomy is a standard method for cervical HD surgery. The posterior interlaminar approach is an effective method used for lateral herniations, especially sequestered ones. It promotes the preservation of intervertebral disc and reduction of the total cost of surgery due to no necessity to use the implants-prosthesis. We suppose the posterior cervical microdiscectomy of lateral, sequestered intervertebral disc herniations in cervical spine to become a standard method of treatment.

Spontaneous Resolution of an Extraforaminal Lumbar Disc Herniation; Report of a Case and Review of the Literature

Extraforaminal lumbar disc herniations (ELDHs) are a relatively uncommon cause of lumbar radiculopathy. In the patients suffering this kind of disc herniation, severe intractable radiculopathy due to dorsal root ganglion compression usually leads to surgery. However, although the value of conservative strategy for spontaneous resolution of intracanal lumbar sequestrated disc herniation is a well-known scenario, but it is not verified in extraforaminal disc herniation. Herein, a 53-year-old man with severe left -sided femoral radiculopathy at the vicinity of L3 which was associated with decreased knee jerk is presented. MRI revealed a huge extraforaminal disc herniation at L3-L4 level on the right side. Surgery was recommended, but since the patient was reluctant to undergo surgery, a period of conservative treatment, with transforaminal block, combined with NSAID’s prescription result in dramatic pain amelioration. Control MRI after 3 months showed relative hyperintensity of the corresponding disc. However, MRI at 9- months follow -up where the patient was completely pain free, revealed disappearance of the offending disc. To our knowledge, the scenario of spontaneous resolution of extraforaminal disc herniation has not been reported previously in the literature.

Sequestered lumbar disc herniation mimicking spinal tumor

AbstractThe occurrence of herniated disc simulating diseases in neuroimaging it's an uncommon situation. However, due to changes that occur in sequestered disc fragment, some cases can mimic spinal neoplasms. Thus, we present the case of a female patient, 60 year-old, with left back pain and left leg weakness. Left lower limb presented with strength grade IV, positive 45 degress Lasègue's signal and patellar areflexia. Lumbar spine magnetic resonance imaging (MRI) showed an expansive left centro-lateral lesion at L4-L5 level, hypointense on T1W, hyperintense on T2W, with peripheral contrast uptake, causing compression of the dural sac and L5 nerve root. A hemilaminectomy was performed, with complete excision of the lesion. Histological analisys confirmed discal hernia. Disc herniation is a condition characterized by the displacement of the disc content to the spinal canal, predominantly in the lumbar region, and manifesting as radiculopathy. The fragment sequestration occurs in 30% of the cases and is characterized by loss of continuity with remaining disc. MRI exams generally allow diagnostic confirmation; however, there may be diagnostic confusion with tumors, arachnoid cysts and abscesses. The inflammatory reaction occurred in the disc fragment produces the differences in MRI signal. The fragment is hypointense on T1W, hyperintense on T2W, with peripheral enhancement after contrast. Malignancies and Schwannomas have homogeneous or heterogeneous uptake. The epidural abscess is isointense on T1W and hyperintense on T2W, with homogeneous or peripheral enhancement, similar to discal herniation. Thus, sequestered disc herniation can mimic other space-occupying lesions, being necessary a surgical approach to obtain material for histopathological analysis and diagnostic confirmation.

Microscopic anterior foraminal decompression combined with anterior lumbar interbody fusion

Background contextAnterior lumbar interbody fusion (ALIF) with percutaneous pedicle screw fixation (PPF) provides successful surgical outcomes to isthmic spondylolisthesis patients with indirect decompression through foraminal volume expansion. However, indirect decompression through ALIF followed by PPF may not obtain a successful surgical outcome in patients with isthmic spondylolisthesis accompanied by foraminal stenosis caused by a posterior osteophyte or foraminal sequestrated disc herniation. Thus far, there has been no report of foraminal decompression through anterior direct access in the lumbar spine. PurposeThis study aims to describe the new surgical technique of microscopic anterior foraminal decompression and to analyze the clinical outcomes and radiologic results of the microscopic anterior decompression during ALIF followed by PPF. Study design/SettingWe conducted a multisurgeon, retrospective, clinical series from a single institution. Patient sampleThis study was carried out from March 2007 to July 2010 and included 40 consecutive patients with isthmic spondylolisthesis accompanied by foraminal stenosis caused by posterior osteophyte or foraminal sequestrated disc herniation undergoing microscopic anterior foraminal decompression during ALIF followed by PPF. Outcome measuresThe visual analog scales (VAS) of back and leg pain and the Oswestry disability index were measured preoperatively and at the last follow-up. MethodsPostoperative computed tomography and magnetic resonance imaging measured whether decompression of neural structure had been made and morphometric change of the foramen and the amount of resected bone. Moreover, segmental lordosis, whole lumbar lordosis, disc height, and degree of listhesis were measured through X-ray examination before the operation and at the last follow-up; we also verified whether fusion had been achieved. ResultsSuccessful decompression was confirmed in both patients with foraminal stenosis caused by posterior osteophyte and those with foraminal sequestrated disc herniation. Clinically, compared with before the surgery, the VAS (leg and back) and the Oswestry disability index significantly decreased at the last follow-up (p=.000). With regard to radiology, at the last follow-up all patients had bone fusion on X-ray examination, and an increase in disc height, a reduction in the degree of listhesis, an increase in segmental lordosis, and an increase in whole lumbar lordosis were significant in both groups (p=.000) compared with before the surgery. Foraminal volume, foraminal width, and foraminal height also significantly increased postoperatively compared with before the operation (p=.000). The height, width, and dimension of resected body were 4.61±1.05 mm, 7.92±1.42 mm, 17.15±4.96 mm2, respectively, in patients with foraminal stenosis caused by a posterior osteophyte, and 3.88±0.92 mm, 6.8±1.29 mm, and 13.12±2.25 mm2, respectively, in patients with foraminal sequestrated disc. ConclusionsThe microscopic anterior foraminal approach provides successful foraminal decompression. Combined with ALIF and PPF, this approach shows a good surgical outcome in patients with isthmic spondylolisthesis accompanied by foraminal stenosis caused by a posterior osteophyte or those with foraminal sequestrated disc herniation.

The usefulness of magnetic resonance imaging for sequestered lumbar disc herniation treated with endoscopic surgery

Forty two patients with sequestered lumbar intervertebral disc herniation were treated by endoscopic surgery with the mobile Endospine system. The herniations and migration were confirmed on magnetic resonance imaging (MRI). The interlamina fenestration and pars interarticularis fenestration approaches were used for intracanal herniations and far lateral lumbar disc herniations (FLLDH) according to the degree of migration as observed on MRI. Sequestered herniations were exposed and removed completely with the mobile endoscopic system for all patients without neurologic complications or dural tears. Intraoperative findings were compared with preoperative MRI results. Of 24 caudal intracanal herniations, 15 had sequestered nuclei located ventrally beneath the dural theca and the transverse nerve root; 5 were between the transverse nerve root and dural theca (axillary); 4 were dorsally located on the nerve root and dural theca. However, preoperative MRI did not clearly display the sequestered nuclei between the transverse nerve root and dural theca (axillary), or the dorsally migrated disc on the nerve root and dural theca. Of 6 cranial intracanal herniations, 5 had free fragments located beneath the dural theca, and 1 dorsal to the dural sac. Of the 2 dorsal herniations, the migrated nucleus adhered to the dural sac was not found on preoperative MRI; in the other case, dorsal migration of nucleus, annulus and endplate around the dural sac was also not observed on preoperative MRI. Among the 10 FLLDH, preoperative MRI showed cranial migration and foraminal obstruction in all patients, with sequestered disc material at the ventral and medial sides of the exiting nerve root, displacing the exiting nerve root and ganglion cranially and dorsally. During the 12 to 48 month postoperative follow-up period, 26 patients had excellent clinical results and 15 patients had good results (Macnab scale). In conclusion, MRI is important for evaluating sequestered lumbar disc herniation, although it has its limitations. Sequestered herniations can be exposed and removed completely with the mobile endoscopic system.

Surgical Strategies in the Management of Sequestrated Disc Herniations in the Lumbar and Cervical Spines

Orief et al. have reported six cases of sequestrated disc herniation, five in the lumbar spine and one in the cervical spine, which regressed in the follow-up magnetic resonance imaging (MRI) corresponding to neurological improvement. We also experienced the same kind of cases of cervical and lumbar disc herniations in the repeated MRI several months after the initial study. With their thorough review of the literature, they concluded that the possible mechanism of resorption of the sequestrated disc was dehydration and inflammationmediated resorption as a foreign body in the vascular-rich epidural space, which seemed to be quite reasonable. Ahn et al. (1) reported an interesting observation on effect of the transligamentous lumbar disc herniation on their regression and clinical outcome. Of 36 patients with symptomatic lumbar disc herniations that were treated conservatively and followed up by MRI, 25 decreased in size. Ten (56%) of 18 subligamentous herniations, 11 (79%) of 14 transligamentous herniations, and all 4 (100%) of sequestrated herniations were reduced in size. The authors concluded that transligamentous extension of herniated discs through the ruptured ligament was important to its reduction in size than its initial size of the herniated discs. Komori et al. (3) emphasized the importance of contrast-enhanced MRI in conservative treatment of lumbar disc herniations. In all cases of migrated discs, circular enhancement was visualized on contrastenhanced MRI, and 17 (77%) of 22 cases showed gradual thickening of enhanced area and decrease in size of migrated discs. The herniated discs disappeared in nine and markedly decreased in seven, corresponding to their good clinical course of sciatica. They concluded that contrast-enhanced MRI was a useful prognostic parameter.

Immunopathological observation of lumbar disc herniation and discogenic pain

Objective To evaluate and compare the immunopathological changes of lumbar disc herniation and discogenic pain. Methods Seventy-one lumbar disc nucleuses were collected intra-operation,and they were divided into four groups. Group A： 30 cases of disc herniation, Group B： 22 cases of sequestered disc herniation, and the patients in Group A and B received discectomy; Group C： 10 cases of discogenic pain were confirmed by discography, and the painful disc was excised through anterior retroperitoneal approach; Group D： 9 cases of lumbar bust fracture who received anterior subtotal corpectomy and discectomy, and the nearly normal caudal disc was collected as control. The disc nucleuses were processed in the following methods： 1） HE stain and pathological observation; 2） Immunocytochemical test using monoclonal antibodies to CD68 and CD45RO molecule for macrophage and T lymphocytes, respectively. The positive cells were counted and analyzed with statistic method. Results 1） Pathological observation with HE stain： compare to control group, the degeneration of nucleus cell was evident in the other groups. There were obvious infiltration of inflammatory cells and focal neovascularization in group A and especially in Group B.In Group C, only diffuse inflammatory cells was found without neovascularization, but the degeneration of matrix was more severe. 2） Positive rate of CD68 cells： Group B （63.6%）〉Group C （40.0%）〉Group A （26.7%）〉Group D （0%）. There were significant differences among groups （P〈0.05）. 3） Positive rate of CD45RO cells：Group B （59.1%）〉Group A （13.3%）, Group C and D were negative, and the positive cell were found in slice of the same site of positive CD68 cells. The differences between each group were significant （P〈0.05）. Conclusion The nucleus of herniated disc has evident inflammatory and autoimmunity reaction. The nucleus of discogenic pain is infiltrated with diffuse inflammatory cells and some macrophages, without T lymphocyte and neovasularization, so the autoimmunity course is not evident. Key words: Lumbar vertebrae; Intervertebral disk displacement; Low back pain; Immunohistochemistry

Translaminäre Fensterung bei nach kaudal sequestriertem lumbalem Bandscheibenvorfall – Technische Mitteilung

Translaminar approaches have been described for lumbar disc herniations which are displaced cranially or laterally into the neuroforamen. This technique provides the advantages of a minimally invasive approach with regard to postoperative instability or partial facet joint resection and avoids a medial arthrectomy. We describe this technique for the first time as an option for a caudally sequestrated disc herniation via a transaxillar sequesterotomy.

A stiff and straight back preoperatively is associated with a good outcome 2 years after lumbar disc surgery

Background and purpose The degree of lumbar lordosis and reduced lumbar mobility are regarded as important clinical features in patients with low back pain, and in lumbar disc herniation A more stiff back preoperatively in a proportion of patients has been shown to be associated with sequestered disc herniation. The main aim of this study was to investigate whether there was any correlation between lumbar lordosis and flexion on the one hand in patients with lumbar disc herniation who were scheduled for surgery, and postoperative pain and disability on the other. Our second aim was to determine the patterns of postoperative improvement in pain, perceived disability, and flexion/lordosis for 2 years after surgery.Methods Pain (VAS), disability (DRI), lumbar flexion and lordosis (Debrunner's kyfometer) were measured pre- and postoperatively in 80 patients who underwent microscopic lumbar disc surgery.Results Patients with preoperative hyperlordosis had more severe pain and more disability postoperatively than patients with hypolordosis. The level of pain did not change much from 2–6 weeks postoperatively until 2 years, while the perceived disability did not reach a steady state until 6 months after surgery.Interpretation Patients with a stiff and flat back have a good prognosis after lumbar disc surgery, and in most cases the pain will reach the 2-year level during the first 2–6 weeks, while the physical restoration measured by the lumbar flexion and lordosis, and the perceived disability, will continue to improve over the first 6 months after surgery.

Dorsally Sequestered Cervical Disc Herniation

A case report of dorsally sequestered cervical disc herniation. To present an unusual case of dorsally sequestered cervical disc herniation and to briefly review the literature on this condition. There have been few reports of migration of cervical disc herniation to the posterior surface of the spinal canal. A 72-year-old man experienced a sudden episode of weakness of both lower extremities after playing golf, which gradually progressed, resulting in inability to walk without aid. Magnetic resonance imaging revealed a well-defined, oval mass lesion on the left dorsal aspect of the spinal canal, which compressed the dural sac at the level of C7. The mass lesion was isointense on T1-weighted images and heterogeneously hyperintense on T2-weighted images, and contrast-enhanced magnetic resonance imaging demonstrated peripheral enhancement of the mass lesion. The patient underwent surgery consisting of decompressive laminoplasty of C6 to C7, partial laminectomy of T1, and removal of the mass lesion. Histologically, the mass lesion was diagnosed as a dorsally sequestered disc herniation. After surgery, the weakness of both lower extremities gradually resolved, and the patient was able to walk without assistance at 2 weeks after surgery. It is important to appropriately differentiate dorsally sequestered disc herniation from other epidural mass lesions such as extradural tumor before operation and essential to perform early and sufficient surgical decompression of the spinal cord to prevent poor postoperative course in cases of acute onset and rapid progression of the paralysis caused by disc herniation.