Difficulties of Upper lumber disc herniation Management

Momen M. Almamoun 1, Ali R. Hamdan 2

1Department of neurosurgery Faculty of medicine, Sohag University, Egypt

2 Department of neurosurgery Faculty of medicine, South Valley University, Qena, Egypt

 

 

ABSTRACT

Disc herniation at the upper lumber levels (L1-2, L2-3, and L3-4) constitutes approximately 5% of all cases of lumbar disc prolapsed(1,10,12)

Preoperative symptoms  and signs are highly variable. Sensory, motor, and reflexes are potentially misleading in suggesting the level of herniation.(1). Sensitivity and specificity of MRI in the diagnosis of disc herniation ranged from 71: 100% and from 50: 86 % respectively (15) Intraoperative X-ray is needed to localize the level of disc surgery(1)

Study Design:     it is a retrospective clinical study

Objective: This study was conducted to study the unique clinical presentation and the operative outcome of the patients presented with high lumber disc prolapsed.

 Patients & Methods: It's a clinical retrospective study harboring upper lumber disc prolapse that includes surgical management of 17 patients and the effect of surgical management on the outcomes starting from June 2009 to june 2014. Surgery was performed for all patients with failed medical treatment for at least 4 weeks or in case of neurologic deficit, Standard posterior bilateral laminectomy and discectomy was done and 2 patients required facetectomy for foraminal decompression and patient with recurrent disc and that with fracture pars all had transpedicular screw fixation  and cage. All surgeries were done with the image intensifier to localize the level of the disc prolapsed. Results: seventeen patients of upper lumber disc prolapse were included in this study; fourteen patients (82.4%) were males while three patients (17.6%) were females. The age range was 18-63 years. As regard the occupation thirteen patients were hard workers (constructions & farmers), three were house wife and one was official employer.  Back pain was presented in all patients, upper thigh pain was presented in twelve (70.6%) patients, four (23.5%) patients presented with sciatic pain, thirteen (765%) with parathesia, nine (52.9%) with motor weakness and four (23.5%) with sphincteric disturbance. On examination, there were positive Straight Leg Raising (SLR)  test in five (29.4%) patients, femoral stretch in ten (58.8%) patients. Sensory hyposthesia at different dermatomal distribution at different levels was present in all patients. Two (11.8%) patients had complete cauda equine, one (5.9%) patient had right lower limb monoplegia and incomplete cauda equine lesion in three (17.6%) patients. The outcome was assessed based on Odom criteria (Excellent, Good, and Bad). Patients were followed up after 1weak, 2 weeks 1 month and then every 6:12 week for at least 2 years.

  • Conclusion: Herniated discs at the L1–L2 or L2–L3 level are different entities from those at lower levels of the lumbar spine, Preoperative symptoms and signs are highly variable, Early radiologic investigation with MRI is recommended in suspected patients, Intraoperative X-Ray is mandatory to localize the level of disc at surgery, non operative treatment of high level LDP has a less improvement rate than that at L 4-5 – L 5-S1 level and so surgery is indicated earlier, excellent and good outcome ranged from 80%to 93%, and due to anatomically narrow canal at upper lumber spine wide decompression and fixation is  recommended