Overview: extreme lateral (also known as the most lateral ) lumbar disc herniation disorder (extreme lateral prolapse of lumbar intervertebral disc) of lumbar disc herniation is a special type, refers to the oppression of the disc material from the same issue of the intervertebral nerve root level. The disease was first proposed by Abdullah equal first reported in 1974, its incidence is not consistent with each report, which accounts for the total number of patients with lumbar disc herniation 1% to 11.7%, an average of about 10%. In the past for lack of knowledge of this particular disease , it is often due to clinical misdiagnosis caused by failed back surgery. With CT imaging diagnostics, especially the continuous development of technology for extreme lateral lumbar disc herniation concluded increasing year by year, but details still need the author to draw our attention.[Cause]
(B) the pathogenesis
lumbosacral nerve roots within the intervertebral foramen generally above the corresponding cauda equina issued by the , in the spinal canal after walking for some distance into the nerve root canal, then the corresponding intervertebral foramen piercing. There is a gap outside the intervertebral foramen, called extreme lateral gap (far lateral space), the gap in front of the vertebral body and intervertebral disc, lumbar transverse diameter of about 30% to 40%, the surface of the posterior longitudinal ligament attached to the rear of yellow ligament, lateral to the intertransverse ligament. Issued after the nerve root from the intervertebral foramen into the far lateral space in the rear disc crosses. In this space, the epidural fat and veins are very rich, after the nerve root and dorsal root ganglia often covered by the intravenous, go down to the outside near the intertransverse ligament can be found at the root of the root artery and vein. The anatomical study found that the issue of lumbar vertebral pedicle from the site from 1 to L5 lumbar anterolateral bias gradually, while the transverse part of the pedicle is also gradually moving the issue forward. As the pedicle gradually inclined from top to bottom and gradually thickening and lateral pedicle width increases. Based on previous literature records, the nerve root foramen piercing the lateral disc rear Traveling. However, according to Fournier and other observations, the nerve root in the nerve root canal walk on the line is actually from the inside to the outside line to walk under the ramp, the angle almost perpendicular. In comparison, the first 1 to 3 lumbar nerve root in the neural tube is more vertical angle of Traveling, traveling in line outside the intervertebral foramen is located at the rear disc foreign; and 5th lumbar nerve root in the neural tube traveling direction of oblique lines, trips are longer, the intervertebral foramen to go outside the line location right in the lumbar 5 sacral 1 disc on the outside. Thus, when the upper lumbar intervertebral disc prominent outside the intervertebral foramen, the nerve root from its rear far, is not easy to create pressure; the next lumbar nerve root compression is clearly much more opportunity. The presence of sacral wing and the lumbar 5 sacral 1 extreme lateral gap decreases, will increase the L5 nerve root compression opportunities.
prominent nucleus according to the location can be extreme lateral lumbar disc herniation and further divided into two types, namely, within the intervertebral foramen (intraforaminal) highlight the type and outside the intervertebral foramen (extraforaminal) prominent type. As highlighted within the nucleus pulposus from the annulus will be issued after outward at the top of the formation of foraminal nerve root compression, and nerve root as the pedicle, and (or) foraminal ligament, there was little movement restrictions, it is vulnerable to pressure and cause symptoms. And the most common clinical posterolateral disc herniation is different is that the pressure on one part of it is in the intervertebral foramen at the nerve root or intervertebral foramen, but that is 3 to 4 lumbar disc lumbar 3 nerve compression root, lumbar 4 and lumbar 5 5 S1 lumbar disc pressure, respectively, 4 and L5 nerve root. In addition, the gap in the incidence of some of the differences that highlight the waist and 4-5 the most common, followed by 3 to 4 lumbar, lumbar 5 to sacral 1, 2 waist waist waist 3 and 1 to 2, which occurs 3 to 4 in the proportion of the waist is relatively high, then the lateral lumbar disc herniation occurs in the vast majority of 4 to 5 and lumbar 5 sacral 1. extreme lateral lumbar disc herniation is generally not involving the sacral nerve roots.[Sign]
low back pain and sciatica is the most common clinical symptoms. As the dorsal root ganglia and nerve roots often been a while compression, so the extent of sciatica can be very serious. 1 to 3 lumbar spinal nerve root involvement will lead to hip, groin area and front thigh pain. Some patients also appear quadriceps atrophy.
In some cases, straight leg raising test can be positive. The positive rate of straight leg raising test, various reports vary. broom reported 13 cases, of which 10 cases were positive. Jackson and Glah reported 16 cases, positive straight leg raising test accounted for 8 cases. Epstein and Statistics of the 170 cases of extreme lateral lumbar disc herniation cases, straight leg raising test was positive 94%. Abdullah and other treatment in a group of 138 cases, the straight leg raising test negative 65%, if the remaining 35% of the straight leg raising test was positive in the combined spinal disc, severe spinal stenosis and previous surgery scar left by other factors into account, the negative rate as high as 85% to 90%.
Epstein and other reports, most patients in the standing and walking may induce low back pain and sciatica. Kanogi and Hasue examination of 26 patients, 22 cases of lumbar extension in the time-induced pain. Abdullah, etc. are found, the spine will bend to induce pain in the affected side, and that the signs are more reliable. When the upper lumbar nerve compression, the femoral nerve traction test, mostly positive, but some scholars believe the signs are not specific. In addition, nerve root compression can produce a corresponding movement, sensory disturbances, and hyporeflexia.
based on history and clinical signs and symptoms, common X ray, myelography is not clear diagnosis. clinical diagnosis based on CT, discography, mri examination and laboratory tests before being diagnosed.[Aftertreat]
no relevant information.[Treat]
1. non-surgical treatments such as patients with mild symptoms and no obvious neurological signs, can be used Non-surgical treatment, the main methods include bed rest, brake, physical therapy and drug therapy. However, due to extreme lateral lumbar disc herniation symptoms were more serious, so take the chance of surgical treatment for more. Epstein believes that about 10% of patients by 6 weeks after conservative treatment can lead to satisfactory results. In many non-surgical therapy, absolute bed rest and traction is still the most simple and effective stabilization measures.
2. surgical treatment of far lateral lumbar disc herniation reported various methods of treatment are not consistent, its efficacy is still difficult to compare with each other. It is generally believed, should be based on specific use cases of pathological anatomy of the most safe and effective procedure.
(1) fenestration surgery: posterior midline incision, and on this basis of fenestration in lumbar disc herniation surgery revealed the most common, patients should fully reveal the corresponding lamina and facet joints of all, the removal of the lamina, while the lower edge of the inside should be the edge of the small joints, especially the next facet of the vertebral body on the inside edge and the pedicle be removed on the edge. nerve root in the nerve root canal to the outside from the inside on line to walk under the ramp, it is located up the exposed nerve root canal up to the top of the prominent nucleus, the outside is exposed at the bottom of the nerve root canal or even outside of the prominent outside the intervertebral foramen the nucleus. One lumbar 5 sacral 1 level of nerve root canal stenosis less, spacing is also wider pedicle, it generally makes use of this surgical prominent nucleus to get better exposure. However, due to the prominent nucleus of the intervertebral foramen exposed outside is not ideal, non-rigid to be removed under direct vision (especially when combined nerve root canal stenosis) is likely to cause nerve root injury.
(2) through the isthmus fenestration technique: Department of the fenestration operation is usually implemented on a gap cut the gap on the edge of the lamina and pedicle part of the isthmus, but the small joints still be retained, that is, lumbar nerve root compression in the lumbar 3 to 4 when the gap for treatment, when the L5 nerve root compression space in the back 4 to 5 treatments. The surgical exploration can not be both the central spinal canal and nerve root canal, mouth lesions, only a very simple positioning is very clear lateral prominent.
(3) incision of the intervertebral foramen: When the nerve root entrapment site is not yet clear, it can go in both directions along the nerve root foramen with the nerve cut better reveal the root, due to removal of a large range of small joints, which require both lumbar spine fusion. Therefore, the surgical procedures for lumbar instability is only required to interface via the side of the facet joint line fixation cases.
(4) resection of all small joints: When patients with severe nerve root canal stenosis or, even total removal of the small joints, so clearly exposed the entire nerve root and the ganglion. However, this may easily lead to post-operative surgical lumbar instability, so some scholars believe that when the combined implementation of degenerative lumbar spondylolisthesis or facet joint resection of the whole lumbar spine fusion should be the same time. Even a very light degree of postoperative lumbar instability will adversely affect the efficacy of surgery, so when all the small joints were removed, whether the patient is young or old, should undergo lumbar fusion, integration approach can be used in addition to The traditional posterolateral fusion, posterior lumbar interbody fusion and small surgical joint fusion, the gold has been carried out by a single oblique interface fixation popular.
(5) laminoplasty: a line through the arch on one side or both sides of the isthmus en bloc laminectomy, spinal decompression and disc line of resection lamina and then plant it back into place to rebuild the lumbar spine stability. The surgical advantages are numerous, but the key is to pay attention to the plant back to the lamina to be fixed, to prevent accidents.
(6) lateral fenestration: the prominent nucleus in the intervertebral foramen and the lateral (or) possible cases outside the intervertebral foramen lateral fenestration, that is removal of the outer edge of the pedicle isthmus and the lateral edge of the small joints. The surgical advantages that maximize the retention of the integrity of the small joints, decompression should be accompanied by removal of the medial part of the intertransverse ligament and intervertebral foramen is located outside the mouth of the yellow ligament. lateral fenestration and resection of the medial facet joint can also be the fenestration or by surgical isthmus fenestration in combination, to the maximum extent possible to retain a stable structure based on the lumbar nerve root to complete the full reveal. In theory, the advantages of this surgical lot, but in actual operation by the posterior midline incision exposed outside the intervertebral foramen lesions difficult, and poor vision, it will increase the risk of nerve root injury , therefore, should not be used clinically unless the dissected segment combined with tumor, deformity and other lesions.
(7) next to the middle of the incision surgery: for simple extreme lateral disc herniation. surgical incision through the side by the multifidus muscle and the muscles between the longest entry, direct small joints and the intertransverse ligament deep to the very outer space, after careful nerve root retractor can be found outside the nucleus protruding intervertebral foramen. Ensure that the key to successful operation is familiar with local anatomy: the dorsal root ganglia are usually located within the intervertebral foramen, in its remote, before and after the synthesis of lumbar nerve root will be issued immediately after the branch and the anterior branch. Anterior branch of the pedicle close to the ventral posterior lateral tail end of the line and skewed to go through the surface of disc space, posterior branch of the traveling back and dorsal direction of the bias, into the medial branches, muscular branches and lateral branches and penetrate very outer space. The nerve root in the intervertebral foramen piercing the lateral segmental vessels are still accompanied, of which the posterior branch of the lumbar nerve with the lateral branches of segmental arteries accompanying the terminal branches of the most important line of the vein with a lot of variation, often surrounded by venous plexus nerve root formation. Surgery should avoid the structural damage. When a prominent nucleus in the lumbar 5 sacral 1 level, the removal of the iliac wing on the edge will help to reveal. However, some scholars reported in obese patients, revealing more difficult.
(8) micro-surgery and percutaneous discectomy: Darden other side incision by the removal of prominent nucleus under the microscope, that the advantages of this approach view clear and the small risk of nerve root injury. But in recent years that such a high rate of technique and efficacy of harming the poor, is no longer used by everyone. The percutaneous discectomy because it is narrow clinical indications less.
(9) anterior discectomy: some scholars use the abdominal extraperitoneal discectomy, but can not deal with the nerve root under direct vision, and to simultaneously lumbar fusion, it is not widely used.
(10) to retain the small joints of the nucleus posterior decompression and resection of the expansion: The authors found that the vast majority of cases were associated with developmental lumbar spinal stenosis, and constitute the incidence of early onset and easy main anatomical factors, and thus advocate the removal of the nucleus at the same time expanding the spinal canal, the operation should not exceed the small joints, small joints of the associated deformities and root canal stenosis is only part of the medial facet resection may, at this time of the prominent nucleus, either lateral or extreme lateral are easily removed. adhesion of the individual and the dura mater into the dural sac or within the nucleus has also cut the dural sac under direct vision through the removal of such a general surgical patients is still the first choice.
(b) the prognosis
a clear diagnosis, surgery to completely remove the oppression, the prognosis is generally acceptable.
Skouen other of 143 Name of lumbar disc herniation in patients with biochemical measurements in serum and cerebrospinal fluid and found that CSF total protein, albumin, igg levels, cerebrospinal fluid and serum albumin ratio and CSF igg and serum albumin ratio were the location with the disc gradually increased from the inside out , the correlation was statistically significant, that the phenomena of plasma protein leakage from the nerve root caused.
Because the clinical manifestations of this disease with a gap on the rear lateral disc herniation is basically the same, so the diagnosis based on imaging studies. imaging can also help rule out other diseases cause similar symptoms, such as lateral recess stenosis, retroperitoneal hematoma, retroperitoneal tumor, deformity or nerve root tumor and so on.
2. myelography as subarachnoid terminate in the dorsal root ganglia, spinal angiography is difficult to show extreme lateral disc herniation, spinal angiography and therefore X-ray, are primarily used to exclude other lesions. Therefore, when patients there is nerve root compression symptoms of spinal cord imaging results were negative or inconsistent with the clinical manifestations, should be highly suspected intervertebral foramen inside and outside of the disc. It was also advocated imaging of nerve root, but the clinical application of less.
3. discography discography for the diagnosis there has been a lot of controversy. there was a group of 77 cases discography, diagnostic accuracy was 92.2%, but the operation is more complicated, it is not generally application.
4.CT check CT scan can show more clearly the location and extent of the disc, which as of this imaging technique widely used in clinical practice, the reports of extreme lateral disc herniation is also increased significantly. soft tissue density and intervertebral disc prominent dural sac and epidural fat with good contrast, but the prominence is located outside the intervertebral foramen or foraminal, its proximity to the nerve root and (or) dorsal root ganglia with density roughly equal, the diagnosis could have caused some difficulties, even misdiagnosed as cancer. Furthermore, CT examination without including the bottom level of the pedicle may also be lead to missed diagnosis, therefore, should include upper and lower pedicle, including TLC, so as not to miss, where necessary, coronal plane reconstruction. CT discography to further improve the diagnostic accuracy can be selected as appropriate. Segnarbieux so that, when the CT findings and suspected diagnosis of far lateral disc herniation is difficult to determine when they should row CT discography. A variety of imaging methods comparison study showed that spinal cord imaging diagnostic accuracy rate of 12.5% , discography of 37.5%, CT examination and CT myelography are 50%, while the diagnostic accuracy of CT discography is as high as 93.8% rate, but is that Epstein et al, CT myelography is superior to CT scan alone. In addition, Some scholars have reported that some foraminal disc outside CT examination showed the vacuum phenomenon, which highlight the presence of air within the nucleus. 5.MRI check: multi-planar mri techniques for the display of the ideal structure of the intervertebral foramen, prominent nucleus and the boundary between the nerve root is also more specific than CT scan images, mri images of the prominent nucleus, but a good show is often determined by examining the choice of direction and plane. Grenier, etc. on the CT scan has been diagnosed 33 cases of 34 disc with MRI, the results in the sagittal plane in 3 cases lesions have not been shown, in cross section and 15 ° ~ 30 ° coronal plane are shown, including 15 ° ~ 30 ° coronal plane as the disc is not only prominent display of the most clear and accurately reflect the situation of nerve root compression. The scholars also found that the coarser nerve roots and expansion of the venous plexus is easy and free within the nucleus in the intervertebral foramen confusion.
theory, mri of the location and extent of nerve root compression in the display should be more satisfied, but according to the literature, this technology in the diagnosis of far lateral disc herniation in the application of far and high resolution CT scanning in general. The reason may be, mri sagittal image often does not include foraminal matrix, slice thickness is also higher than CT scan.[Diff]
no relevant information.[Disease]
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