herniated lumbar disc.doc

8/20/2019 herniated lumbar disc.DOC

1/15

CASE WRITE-UP: 4

Topic: Lumbar Disc Herniation

BY

Zairul Anuar B Kamarul Bahrin (M.D USM

!


2/15

CASE SUMMARY

"atient#s $ame: %n K.H.

A&e ' Se ' )ace: *+ ,ears ' man ' mala,

-enti/ication $umber: 0*1213415453!0

Date o/ /irst seen at 6rthopeic clinic: !! 7une *11!

The patient 8ho is a tai ri9er 8as re/erre to the orthopeic clinic /or a lo8er

bac;ache /or one ,ear uration. The bac;ache 8as associate 8ith a raiatin& pain an

numbness o/ her ri&ht le&. An oral anal&esic ;iller onl, pro9ie a partial an temporar,

relie/. The le& pain 8as reall, botherin& him as he coul not stan /or a lon&. The

problem starte 8hen he li/te a hea9, bo about a ,ear a&o. There 8as no urinar, '

bo8el problem. He 8as other8ise health,.

A ph,sical eamination in#t sho8 an, remar;able si&n ecept /or the strai&ht

le& raisin& 8hich 8as reuce to about 35 < on his ri&ht le&. He ha an almost normal

ran&e o/ bac; mo9ement. $o ob9ious muscle 8ea;ness an sensor, e/icit 8as etecte

on his lo8er limb.

A plain raio&raph o/ lumbosacral re&ion sho8e a loss o/ normal lumbar

lorosis. There 8as no /racture or ob9ious spinal instabilit,. The hei&ht o/ the isc spaceappeare to be normal.

A presumpti9e ia&nosis o/ an acute lumbar isc prolapse 8as mae. A Ma&netic

)esonance -ma&in& re9eale a ri&ht posterolateral isc herniation 8hich cause a

narro8in& o/ the ri&ht inter9ertebral /oramina bet8een L54S! space.

He 8as a9ise to &o /or a sur&ical inter9ention. He uner8ent an open

iscectom, on !3 September *11!. A bul&e isc 8as remo9e at the le9el o/ L54S!

space 8hich ha been impin&in& on the ner9e root at the posterolateral spinal canal

re&ion. There 8as no earl, postoperati9e complication note. He uner8ent bac;

ph,siotherap, ' rehabilitation pro&ram as outpatient basis.

His bac;ache 8as 9er, much reuce. The sciatica resol9e a/ter t8o months

/ollo8in& the sur&er, an resume his 8or; as usual.

*


3/15

DISCUSSION

The case illustrate abo9e is a common scenario /or patient 8ith acute herniate lumbar

isc

A normal ault isc is compose o/ a central nucleus pulposus an an outer annulus

/ibrosus. The annulus /ibrosus is mae o/ a tou&h /ibrous rin& 8ith i//erent t,pe o/

mesh. =ater mae up +14+5> o/ its content. The remainin& constituents are colla&en an

proteo&l,can. ?olla&en t,pe ! /orms the peripher, (outermost o/ annulus 8hereas

colla&en t,pe * /orms the innermost o/ annulus. There are numerous /ree ner9e enin&s in

the outer la,er o/ annulus /ibrosus an the posterior lon&ituinal li&ament. -n the lumbar

spine the anterior annulus is thic;er an stron&er than posterior annulus. Ho8e9er astron& posterior lon&ituinal li&ament co9ers the 8ea;er posterior annulus. The isc has

no bloo suppl, (a9ascular. -t recei9es its nutrition 9ia a passi9e i//usion throu&h the

en plates an the peripher, annulus. The isc has no healin& potential /ollo8in&

/issurin& @ /ra&mentation. The 8ei&ht bearin& point an the ais o/ rotation /all sli&htl,

posterior to the miline o/ the isc.

The isc uner&oes an a&in& process throu&h a series o/ ine9itable chan&es 8hich ma,

be accentuate in preispose ini9iual. The 8ater an proteo&l,can (ne&ati9e char&e

content ecrease. Ho8e9er the colla&en content an a ;eratin sul/ate ' chonroitin sul/ate

ratio increase. The biolo&ical chan&es preisposes to the /ormation o/ intraiscal /issure

an /ra&mentation. This is /ollo8e b, a pro&ressi9e annular isruption. The inner

annular la,er pro&ressi9el, become more super/icial 8hich ultimatel, results in a

complete annular tear. The isc material 8ill then herniate into the spinal canal throu&h

the 8ea; area.

As /issurin& an /ra&mentation ta;e place an isrupts the annulus la,er patient 8ill

eperience an episoic bac;ache o/ten raiatin& to the bac; o/ thi&h. 6nce the isc

material herniate into the canal the intraiscal pressure an the pressure to8ars the

sensiti9e annular are relie9e. T,picall, a sciatic pain replaces the bac; pain.


4/15

There are t8o basic mechanisms 8hich are belie9e to cause lo8er limb pain an

sciatica in a herniate isc.

a. Mechanical e/ormation seconar, to either

i. Tension mechanism. -n ,oun&er patient the spinal ner9e ma, be stretche o9er

the herniate isc or

ii. Compressive mechanism. -n oler patient 8here the ner9e is compresse

bet8een the herniate isc material an the ri&i portion o/ spinal canal ie. lamina

or li&amentum /la9um posteriorl, an the meial borer o/ peicle laterall,.

Both moe o/ mechanism cause ecessi9e pressure to the ner9e ma, irectl,

inure the ner9e impair 9ascular raina&e or initiate the in/lammator, response an lea

to instertitial an periraicular /ibrosis. The ahesion ma, bloc; the ?SC /lo8 ma, be

relate to pain stimulation. 6noa8a et al (*11* stuie ectopic /irin& in an in 9itro

moel o/ the isolate orsal root an clari/ie that the orsal root &an&lion is more

sensiti9e to mechanical compression than the orsal root that the threshol o/ mechanical

response o/ orsal root &an&lion is lo8ere b, h,poia an that ectopic /irin& is inuce

b, some biochemical meiators. $itric oie 8as /oun to is stron&l, su&&este to be

in9ol9e in raiculopath, s,mptoms ie.sciatica.

b. $ucleus pulposus inuce e//ect.

Earious substances ma, lea; /rom the e&enerati9e isc to the aacent ner9e

root causin& chemical raiculitis. The neurotoicit, 9ascular impairment an

in/lammator, mechanism ma, cause the pain. The resultant /ibrosis ma, cause the

persistent pain espite aeFuate ecompression.

Disc bul&e is e/ine as a i//use outpouchin& o/ the annulus /ibrosus ue to an earl,

isc e&eneration an isc space collapse.

3


5/15

A true isc herniation is e/ine as a /ocal outpouchin& o/ isc material seconar, to

anatomic eran&ement limite to a speci/ic circum/erential re&ion o/ the annulus.

Herniate isc can be classi/ie into * broa cate&ories:

!. Base on the herniate isc material relate to posterior annulus an "LL an

continuit, o/ the herniate isc to the remainin& o/ the isc.

a. "rotrue

Herniate isc is co9ere b, an intact annulus but eccentricall, isplace

(a containe t,pe

b. %true (05 > o/ cases

$oncontaine herniate isc material is in continuit, 8ith the isc space but

etenin& completel, into the epiural space throu&h the isrupte annulus.

c. SeFuestrate (less than 5 >

$oncontaine herniate isc not in continuit, 8ith isc space an is a /ree

/ra&ment o/ material in epiural space. $o e/ect can be seen in the annulus.

(%ismont an ?urrier!+2+.

The histolo&ical stu, o/ the ecise herniate lumbar inter9ertebral isc re9eale that

most o/ the herniations o/ a lumbar inter9ertebral isc that occur be/ore the a&e o/ G1

,ears 8ere protrusions o/ the nucleus pulposus. A /e8 cases o/ prolapse anulus /ibrosus

occurre a/ter the a&e o/ G1 ,ears ol. A m,omatous e&eneration o/ the annulus

/ibrosus precee an the o/ orientation o/ /ibers 8as re9erse in the a&ein& isc

(Yasuma et al !++1.

*. Base on the anatomic location o/ the herniate isc alon& the circum/erence o/ the

annulus /ibrosus:

• Anterior : thus no neural compression is epecte or

• "osterior alon& the posterior annulus. The herniate isc can be ?entral (miline

or "osterolaterall, in isc space (the 8ea;est portion o/ posterior annulus is on

either sie o/ miline ue to lac; o/ rein/orcement b, "LL: or laterall,

( /oraminal or etra/oraminal ( /ar lateral ' lateral to the neural /oramen .

5


6/15

?entral isc herniation ma, cause spinal stenosis an narro8 one or both lateral recesses

a//ectin& the /ormin& ner9e root at that le9el ( L5 roots at the L345 isc space as /or

eample .

"osterolateral isc herniation a//ects the /ormin& ner9e root at the le9el o/ herniation ( at

the lateral recess one.

Coraminal or etra/oraminal herniation a//ects the eitin& ner9e root at the le9el neural

/oramen or /ar lateral one respecti9el,. (e.&. L3 root at the L345 le9el.

The conus meularis is sacral en o/ the spinal cor at the le9el o/ L!4* isc space

Belo8 this the lumbar an sacral ner9e roots eten cauall, as the caua eFuina 8ithin

the thecal sac. These lumbar ner9e roots t,picall, /orm an separate /rom the thecal sac

at the isc space le9el abo9e the peicle an tra9els cauall, alon& the meial borer o/

the peicle until it enters the neural /oramen. The le/t an ri&ht spinal ner9e eit belo8

their 9ertebral peicle (L3 spinal ner9e in/erior to the L3 peicle. The lateral borer o/

the /ormin& spinal ner9e is ;no8n as the shouler o/ the ner9e. The acute an&le bet8een

the /orme spinal ner9e an the continuit, o/ thecal sac is ;no8n as ner9e ailla.

The lateral recess one is the re&ion o/ the spinal canal bet8een the lateral borer o/ the

ural sac an a line connectin& the meial borer o/ the peicles. The 9ertebral bo, an

isc /orm the anterior borer an the posterior borer is /orme b, anterior sur/ace o/ the

superior articular process o/ the /acet oint an the lateral epanse o/ the li&amentum

/la9um. The lumbar ner9e root /orms in the lateral recess &enerall, at the le9el o/ isc

space.

The neural /oramen is a space bet8een aacent peicles throu&h 8hich the spinal ner9es

pass se&mentall,. The upper ' cephal hal/ o/ the anterior borer is mae o/ the 9ertebral

bo, an the lo8er ' caual hal/ is mae o/ the inter9ertebral isc. The posterior borer is

the /acet oint mainl, the superior articular process o/ the lo8er 9ertebra.

The s,mpotamatic patient ma, present 8ith:

a. )aiculopath,

G


7/15

Se9ere raiatin& lo8er etremit, pain:

Lo8 lumbar ner9e: pain tra9els posterior in the thi&h @ le& raiatin& in the a

ermatome pattern sole lateral /oot (S! orsal aspect o/ the an;le an /oot (L5.

Upper lumbar ner9e: pain raiates to the anterior thi&h (L* ant ;nee an meial le&

(L 3.

The sciatica is commonl, escribe as abrupt onset o/ sharp or stabbin& pain.

More commonl, constant but ma, 9ar, in a se9erit, 8ith position an acti9it,. The

patient is usuall, more com/ortable stans than sit.

b. List to one sie

Listin& is a8a, /rom the o/ pain in orer to brin& the compresse ner9e root a8a,

/rom the more poasterolateral isc herniation . Listin& to8ar the sie o/ le& pain ma,

inicate meial ner9e compression /rom an aillar, isc herniation.

c. ?aua %Fuina s,nrome. -t is cause b, lar&e central isc herniation at L345 or L43.

A lo8 bac; pain bilateral lo8er etremit, pain sale anesthesia or ,sthesia an motor

8ea;ness in the le& are the usual presentation. The bo8el an blaer incontinence ma,

occur. Such patient reFuires emer&ent ima&in& o/ spinal canal 9ia M)- or ?T m,elo&ram

an emer&ent sur&ical inter9ention. Kostui; et al (!+2G in a retrospecti9e re9ie8 o/

!cases o/ caua eFuina s,nrome seconar, to a central isc lesion ienti/ie t8o

moes o/ presentation. The /irst 8as an acute moe (!1 patients in 8hich there 8ere

abrupt more se9ere s,mptoms an si&ns an a sli&htl, poorer pro&nosis a/ter

ecompression especiall, /or the return o/ blaer /unction. The secon moe o/

presentation (*!patients 8as a &raual onset. All patients ha urinar, retention

preoperati9el,. Blaer /unction 8as the most seriousl, a//ecte /unction preoperati9el,

an remaine so postoperati9el,. The pro&nosis /or return o/ motor /unction 8as &oo

since *0 o/ the ! patients 8ho 8ere operate on re&aine normal motor /unction.

"reoperati9el, all patients ha sciatica. The a9era&e time to sur&ical ecompression a/ter

the patient 8as seen ran&e /rom !.! a,s /or the more acute lesions to . a,s /or the

secon &roup. There 8as no correlation o/ these times 8ith return o/ /unction. There/ore

e9en thou&h earl, sur&er, is recommene ecompression oes not ha9e to be

0


8/15

per/orme in less than si hours i/ reco9er, is to occur as has been su&&este in the

paste that ecompression be one as soon as possible to allo8 maimum reco9er, an

minimie scar /ormation 8hich is ;no8n to be a seFuel o/ prolon&e neural

compression. The pro&nosis /or motor reco9er, 8as the same a/ter the t8o moes o/

clinical presentation (maorit, 8ithin G 8ee;s a/ter sur&er,. Ho8e9er reco9er, o/

blaer /unction tene to be less in the patients 8ith more acute s,mptoms. All but si

o/ thirt, the patients 8ho 8ere operate on reco9ere

sensation completel, 8ithin si months.

The raicular pain 8as most probabl, cause b, ner9e root compression b, the

herniate nucleus pulposus as the le& pain 8as much &reater compare to bac; pain.

Ho8e9er 8hen the le& pain is minimal an the bac; pain is preominant precaution

shoul be ta;en be/ore the conition can be ia&nose as a herniate inter9ertebral isc.

The le& pain 8orsene as the patient#s pro/ession reFuire him to sit an ri9e /or lon&

hours.

As the acute episoes subsie the e&ree o/ spasm iminishes remar;abl,. The

strai&ht le& raise 8as still restricte to about 35 e&ree on the patient#s ri&ht le&. The

speci/ic ner9e root tension si&n is elicite b, slo8l, ele9atin& the a//ecte lo8er

etremit, b, the heel 8ith the ;nee /ull, etene. 6nl, reprouction or 8orsenin& o/

raiatin& pain belo8 the ;nee inicates a positi9e si&n. ShiFin& et al (!+20 reporte that

the istribution o/ pain on SL) allo8e an accurate preiction o/ the location o/ the

lesion in !11 (22.5 per cent o/ the !! patients. A central protrusion tene to cause pain

in the bac; lateral protrusions cause pain in the lo8er etremit, an intermeiate

protrusions cause both (bac;ache an le& pain.

"eripheral circulation hip an ;nee oint motion ha9e to be eamine. An abomen

eamination: palpation /ollo8e b, rectal tone an sensation is also important. Thorou&h

ph,sical eamination is important to a9oi missin& other cause o/ bac; pain or

raiculopath,. Amon& the common iseases that can mimic the isc isease inclues

an;,losin& spon,litis multiple m,eloma 9ascular insu//icienc, arthritis o/ the hip

osteoporosis 8ith stress /ractures etraural tumors peripheral neuropath, herpes oster

an piri/ormis s,nrome. The latter i//erential ia&nosis is o/ten o9erloo;e. The

2


9/15

conition is usuall, eri9e /rom a clinical assessment. Durrani an =innie su&&este the

/ollo8in& ia&nostic criteria /or piri/ormis s,nrome:

• i&ital palpation o/ the piri/ormis muscle to reprouce sciatica

• rectal or pel9ic eamination to rule out lateral pel9ic 8all tenerness an

reprouce sciatica

• Creiber& an "ace si&ns

• tonic eternal rotation o/ the a//ecte lo8er etremit,.

• Anesthetic bloc; in the piri/ormis muscle ima&in& eamination aroun the

piri/ormis muscle ( M)- an an electroph,siolo&ical metho usin& H re/le

$a;amura et al (*11* e9aluate the recore action potentials /rom the lumbar spine

a/ter stimulation o/ the peroneal ner9e in patients 8ith piri/ormis s,nrome. Themeasurement 8as use to support the ia&nosis o/ piri/ormis sunrome. Ho8e9er the

obecti9e test nees to be subecte /or /urther clinical trial.

The ia&nosis o/ herniate lumbar isc 8as almost certain b, clinical u&ment. The

raiolo&ical moalities /or the e9aluation o/ lo8 bac; pain inclues a plain raio&raph

m,elo&raph, compute tomo&raph, an ma&netic resonance ima&in& ( Holtas S !++.

Ma&netic resonance ima&in& pro9ies the best ima&in& o/ the isc an neural tissues. A

sa&ittal M) ima&es are use/ul /or assessment o/ neural /oramen an spinal canal. -t is

important to correlate the clinical s,mptoms an si&ns to the /inin& o/ M) ima&e. -t

sho8e a posterolateral isc herniation 8hich cause a narro8in& at the ri&ht

inter9ertebral /oramina bet8een L54S! space. This correlate 8ell 8ith the initial clinical

assessment

Most patients 8ith raiculopath, an ocumente lumbar isc herniation 8ill ha9e a

spontaneous resolution o/ s,mptoms 8ithout inter9ention o9er time in up to +1 > o/

cases. These patients 8ho 8ill reco9er spontaneousl, 8ill o so 8ithin the /irst G4!*

8ee;s. )eports o/ serial ?T an M)- re9ie8s in ocumente lumbar isc herniation ha9e

sho8n a si&ni/icant o9erall ecrease in sie o/ the herniate material o9er time

presumabl, ue to eh,ration o/ the isc /ra&ments an possibl, ue to resolution o/ the

herniation b, an in/lammator, responses (Haro H et al !++G.

+


10/15

The sur&eon shoul be a8are se9eral important accepte concepts 8hen treatin& a patient

8ith lumbar isc herniation (Mc ?ulloch !++G:

• More than +1> o/ patient 8ith clinical si&ns an s,mptoms relate to herniate

isc impro9es 8ith a conser9ati9e treatment.

• 6nl, *43> o/ patients 8ith herniate isc reFuire sur&ical inter9ention.

• A ma&netic resonance ima&in& 8ill re9eal a herniate isc in about *1> o/

as,mptomatic patients a&e less than G1 ,ears ol.

• A sur&ical inter9ention 8ill impro9e the short4term outcomes /or patients 8ith

sciatica (satis/actor, outcome in +1> o/ cases but lon&4term outcome sho8s

little i//erence bet8een those treate sur&icall, an those treate conser9ati9el,.

Thus it is 8orth8hile tr,in& a &oo nonoperative treatment plan /or most patient 8ith

acute lumbar herniate isc. The initial &oal is to control s,mptoms. Most patient respon

to nonsteroial anti4in/lammator, ru&s ($SA-Ds. Be rest ma, be use/ul /or ! to *

a,s but not lon&er. 6nce s,mptoms are controlle start an acti9ation rehabilitation

pro&ram. Such a pro&ram shoul inclue both an aerobic conitionin& component an

trun; muscle stren&thenin&.

Both trun; /leors an etensors shoul be stren&thene. -/ the patient emonstrates &oo

pro&ress he or she can resume /ull acti9ities at approimatel, months a/ter onset

assumin& that there is /ull compliance 8ith an acti9ation pro&ram. "h,sical therap,

shoul be use uiciousl,. The eercises shoul be /itte to the s,mptoms an not /orce

as an absolute &roup o/ acti9ities. "atients 8ith acute bac; an thi&h pain ease b,

passi9e etension o/ the spine in the prone position can bene/it /rom etension eercises

rather than /leion eercises. -mpro9ement in s,mptoms 8ith etension is inicati9e o/ a

&oo pro&nosis 8ith conser9ati9e care. 6n the other han patients 8hose pain isincrease b, passi9e etension ma, be impro9e b, /leion eercises. These eercises

shoul not be /orce in the /ace o/ increase pain. This ma, a9oi /urther isc etrusion.

Malmi9aara et al. compare the e//icac, o/ be rest alone bac; etension eercises an

continuation o/ orinar, acti9ities as tolerate in the treatment o/ acute bac; pain. The,

!1


11/15

conclue that continuation o/ orinar, acti9ities 8ithin the limits permitte b, pain le

to a more rapi reco9er, (Spren&ler!+22.

The epidural a lon!actin steroid "ith an epidural anesthetic in#ection is an

ecellent metho o/ s,mptomatic treatment o/ bac; an le& pain /rom isco&enic isease

an other sources. Most stuies sho8 G1> to 25> short4term success rate that /alls to

1> to 31> lon&4term (G4month &oo result rate. The local e//ect o/ the sterois has

been sho8n to last at least three 8ee;s at a therapeutic le9el. -n a 8ell4controlle stu,

Berman et al /oun that the best results 8ere obtaine in patients 8ith subacute or

chronic le& pain 8ith no prior sur&er,. The, also /oun that the 8orst results 8ere in

patients 8ith motor or re/le abnormalities (!*> to !3> &oo results. Ho8e9er the

proceure is contrainicate in the presence o/ in/ection neurolo&ical isease (such as

multiple sclerosis hemorrha&ic or bleein& isorer caua eFuina s,nrome an a

rapil, pro&ressi9e neural e/icit (Holmes !+0+.

There are a /e8 indications $or surical intervention in patients 8ith lumbar isc

herniation. This inclues patients 8ith a:

•

?aua eFuina s,nrome• "ro&ressi9e motor 8ea;ness

The sur&ical inter9ention is also inicate in selecte patient 8ho has /aile a trial o/

three months o/ nonoperati9e treatment. Some centers consier the persistent o/ pain /or

at least si 8ee;s etenin& belo8 the ;nee as /ailure o/ conser9ati9e treatment. The pain

shoul ha9e been ecrease b, rest anti4in/lammator, meication or e9en epiural

sterois but shoul ha9e recurre to the initial le9els a/ter a minimum o/ G to 2 8ee;s o/

conser9ati9e care (%ismont an ?urrier !+2+.

!!


12/15

The aim o/ sur&er, is:

• To ecompress the neural tissue

• To pro9ie pain relie9e

• To achie9e se&mental spinal stabilit,

• To replicate /unction o/ the natural isc

• To preser9e normal ran&e o/ motion.

An appropriate patient selection is important prior isc sur&er,. The patient 8as alrea,

su//erin& the le& pain /or almost a ,ear. The iscectom, can be one as an electi9e case.

The limited open approach and discectom% &"ith or "ithout a loupe mani$ication'

is an establishe proceure o/ pro9en e//icac,. An aeFuate sur&ical eposure is

necessar,. A small laminotom, 8ith eposure o/ the lamina abo9e an belo8 to the le9el

o/ herniate isc is o/ten aeFuate. Ho8e9er a complete laminectom, ma, be necessar,

in patient 8ith a lar&e herniate isc an 8ho presente 8ith a neurolo&ic e/icit. An

incision is mae in the annulus /ibrosus. The central an lateral part o/ the nucleus

pulposus is remo9e as much as possible. The ner9e root shoul be easil, isplace ! cm

meiall, a/ter the remo9al o/ herniate isc. Shoul the root remain /ie aitional

eploration o/ the /oramina an the 9ertebral canal is necessar,. The use o/ a loupe

ma&ni/ication help to impro9e the 9isualiation an hanlin& o/ the ner9e roots so that

iatro&enic irre9ersible neural inur, can be a9oie (Holmes !+0+.

Microsurer% lum(ar discectom% is essentiall, similar to stanar open iscectom,

apart /rom limite but aeFuate illumination an ma&ni/ication (8ith the use o/

microscope. The proceure is technicall, emanin&. "ostacchini et al (*11*

conucte a prospecti9e stu, in9ol9in& !!G patients 8ith motor e/icits associate 8ith

herniation o/ a lumbar isc that uner8ent microiscectom,. The, 8ere stuie urin&

the /irst si months an at a mean o/ G.3 ,ears a/ter sur&er,. The muscle 8hich most

/reFuentl, ha se9ere or 9er, se9ere 8ea;ness 8as etensor hallucis lon&us /ollo8e in

orer b, triceps surae etensor i&itorum communis tibialis anterior an others. At the

!*


13/15

latest /ollo84up eamination 0G> o/ patients ha complete reco9er, o/ stren&th.

"ersistent 8ea;ness 8as /oun in !G> o/ patients 8ho ha a mil preoperati9e e/icit

an in +> o/ those 8ith se9ere or 9er, se9ere 8ea;ness. Muscle stren&th 8as &rae 3

in all patients 8ith persistent 8ea;ness ecept /or /our 8ith a 9er, se9ere preoperati9e

e/icit a//ectin& the L5 or S! ner9e root. %cluin& this last &roup the e&ree o/ reco9er,

o/ motor /unction 8as in9ersel, relate to the preoperati9e se9erit, an uration o/

muscle 8ea;ness.

Chemonucleol%sis 8ith ch,mopapain inection is another option to shrin; the protrue

isc. An en,me that is use 8ill react 8ith the central nucleus as a primar, substrate

8ithout necessaril, a//ectin& the protrue portion o/ the isc. Ho8e9er the en,matic

reaction is i//icult to stanarie 8ith a set osa&e because o/ 8ie 9arieties in the

composition o/ the substrate amon& patients. The proceure is not so popular because o/

its hi&her /ailure rate. )an et al sho8e impro9ement in onl, GG> o/ the patients usin&

ch,mopapain as compare to 25> to +1> in open iscectom,. -t is contrainicate in

seFuestrate isc patients 8ho are aller&ic to papa,a or its eri9ati9es pre9ious sur&ical

treatment o/ the lumbar spine ()e9el !++.

)ercutaneous *um(ar Discectom% is esi&ne to mechanicall, ecompress a herniate

lumbar isc throu&h a posterolaterall,4inserte cannula. Se9eral technical challen&es /or

the posterolateral enoscopic proceure can be encountere (Yeon& et al*11!:

• A sa/e an e//ecti9e access is limite to a narro8 channel.

• There is no or little 8or;in& space (as compare 8ith the proceure /or ;nee an

shouler oints

• The creation o/ intraiscal 8or;space is neee be/ore intracanal isc /ra&ment

etraction.

• A herniate /ra&ment is accessible onl, 8hen the operatin& instrument is place in

the optimal traector,.

Delamarter et al (!++5 reporte microiscectom, results o/ ecellent &oo an /air in

++> o/ !23 patients. As 8ith microsur&ical iscectom, an chemonucleol,sis it is

contrainicate in patients 8ith a spinal stenosis (%ismont !+2+.

!


14/15

Conclusion

The limite open approach an iscectom, 8as an appropriate ecision mae b, the

sur&eon as the ia&nosis 8as con/irme b, a ma&netic resonance ima&e. The o//enin&

herniate isc can be remo9e 8ith certaint,. The sur&ical proceure is relati9el, sa/e as

compare to other techniFues 8ith preictable sur&ical outcome. Ho8e9er both the

sur&eon an the patient must realie that isc sur&er, is not a cure but ma, onl, pro9ie a

s,mptomatic relie/. -t neither stops the patholo&ical processes that allo8e the herniation

to occur nor return the patient the bac; to its pre9ious state. The patient must still practice

a &oo posture an bo, mechanics a/ter sur&er,. Acti9ities that in9ol9es a repetiti9e

benin& t8istin& an li/tin& 8ith the spine in /leion ma, ha9e to be curtaile or

eliminate. Some permanent moi/ication in the patient#s li/e4st,le ma, be necessar, i/ a

prolon&e relie/ is to be epecte.

RE+ERENCES

!. Delamarter R.,. et al. "ercutaneous Lumbar Discectom,. "reoperati9e An

"ostoperati9e Ma&enetic )esonance -ma&in&. J Bone Joint Surg.!++5004A: 5024

523.

*. Eismont +.-. Currier ,. ?urrent concepts re9ie8: Sur&ical mana&ement o/

lumbar inter9ertebral isc isease. J Bone Joint Surg [Am] !+2+0!:!*GG40!.

. /olmes /.E. Rothman R./. TechniFues o/ lumbar laminectom,. Inst Course

Lect !+0+*2:*11.

3. /aro /. Shinomi%a 0. 0omori /. et al. Unre&ulate epression o/

chemo;ines in herniate nucleus. Spine !++G*!:!G30.

!3


15/15

5. -avedan S. Sonnta 1.0 . Lumbar Disc Herniation : Microsur&ical Approach

The ?on&ress o/ $eurolo&ical Sur&eons. Neuroscience. *11*3:!G14!G3.

G. McCulloch -.A. Cocus issue on Lumbar isc herniation:Macro an

microiscectom,. Spine !++G*!:3545G.

0. Na2amura /. Se2i M. 0onishi S. et al. "iri/ormis S,nrome Dia&nose b,

?aua %Fuina Action "otentials: )eport o/ T8o ?ases. Spine.*11*35:0431.

2. 0ostui2 -. ). et al. ?aua %Fuina S,nrome An Lumbar Disc Herniation. J

Bone Joint Surg. !+2GG24A: 2G4+!.

+. Ono3a"a T. Atsuta Y. I2a"a M. et al. $itric 6ie -nuce %ctopic Cirin& in a

Lumbar $er9e )oot =ith ?aua %Fuina ?ompression. Spine.*11**:!G04!0.

!1. )ostacchini +. 4iannicola 4. Cinotti 4. )eco9er, o/ motor e/icits a/ter

microiscectom, /or lumbar isc herniation. J Bone Joint Surg [B].*11*

23:!1314!135.

!!. Revel M et al. Autamate percutaeous iscectom, 9ersus chemonucleol,sis in

treatment o/ sciatica. Spine !++!2:!40.

!*. Shi5in 6. 7uan3hi 8. Dehao +. Si&ni/icance o/ the strai&ht le& raisin& test in

the ia&nosis an clinical e9aluation o/ lo8er lumbar inter9ertebral isc

protrusion. J Bone Joint Surg[A]. !+20G+ : 5!045**.

!. Sprenler D.M. Lumbar iscectom,. -n : Chapman MW e. 6perati9e

6rthopaeicsEol . "hilaelphia: Lippincott!+22: *155.

!3. Yeun A.T. Tsou ).M. "osterolateral %noscopic %cision /or Lumbar Disc

Herniation: Sur&ical TechniFue 6utcome an ?omplications in 10 ?onsecuti9e

?ases. Spine *11! !2:2431.

!5. Yasuma T. 0oh S. O2amura T. Yamauchi. Histolo&ical ?han&es in A&in&

Lumbar -nter9ertebral isc . Their role in protrusion an prolapses. J Bone Joint

Surg[A] !++10*: **14**+.

!5

herniated lumbar disc.doc

Documents