Clinical and radiographic characteristics of upper lumbar disc herniation: ten-year microsurgical experience

Far-Lateral Transforaminal Unilateral Biportal Endoscopic Lumbar Discectomy for Upper Lumbar Disc Herniations

OBJECTIVE

The upper lumbar region has distinctive anatomical characteristics that contribute to the challenges of performing discectomy. We introduce far-lateral transforaminal unilateral biportal endoscopic (UBE) lumbar discectomy for central or paracentral disc herniations in the upper lumbar region.

METHODS

We conducted retrospective review of the patients who underwent a far-lateral transforaminal UBE lumbar discectomy at our institution from January 2018 to September 2024. The electronic medical records, operative records, and radiologic images of the patients were reviewed.

RESULTS

A total of 27 patients underwent far-lateral transforaminal UBE lumbar discectomy for central or paracentral disc herniations in the upper lumbar region. The patient had a mean age of 54.0 ± 13.7 years. Operation was performed at the L1-2 level in 3 patients (11.1%), L2-3 in 9 patients (33.3%), and L3-4 in 15 patients (55.6%). The patients were followed-up for a mean of 27.7 ± 19.3 months. The Oswestry Disability Index was significantly decreased from 36.3 ± 6.8 preoperatively to 3.7 ± 3.3 at last follow-up (p < 0.001). The visual analogue scale (VAS) back was significantly decreased from 7.8 ± 0.9 preoperatively to 3.1 ± 0.6 postoperative day 2 (p < 0.001). The VAS leg was significantly decreased from 8.1 ± 0.8 preoperatively to 2.3 ± 0.7 postoperative day 2 (p < 0.001).

CONCLUSION

The far-lateral transforaminal UBE lumbar discectomy would be a viable surgical option for upper lumbar disc herniations.

Percutaneous transforaminal endoscopic discectomy for Upper Lumbar Disc Herniation versus lower lumbar disc herniation: clinical outcomes and technical consideration

BACKGROUND

Upper lumbar disc herniation (ULDH) accounts for 1-10% of all lumbar disc herniations (LDH). This study aimed to evaluate the clinical characteristics and outcomes of patients with ULDH who underwent percutaneous transforaminal endoscopic discectomy (PTED) compared with those with lower LDH.

METHODS

60 patients with ULDH or L4-L5 LDH treated with PTED between May 2016 and October 2021. MacNab criteria, visual analog scale (VAS) of back pain and leg pain, and Japanese Orthopedic Association (JOA) were evaluated before and after surgery.

RESULTS

In the L1-L3 group, 59.1% of the patients had a positive femoral nerve tension test, and 81.8% of the patients had a sensory deficit. Both groups showed significant improvements in VAS scores for low back and leg pain, and JOA scores postoperatively. No significant differences in the degree of improvement were observed between the two groups. The excellent/good rate was 81.8% in the L1-L3 group and 84.2% in the L4-L5 group, showing no significant difference.

CONCLUSION

PTED has comparable efficacy in treating ULDH as it does in treating lower LDH, it is a safe and effective treatment method for ULDH.

PREVALENCE AND CHARACTERISTICS OF UPPER LUMBAR DISC HERNIATIONS IN OUR PRACTICE: A RETROSPECTIVE ANALYSIS

ABSTRACT Introduction: Upper lumbar disc herniations (ULDH) are considered infrequent injuries (1-11%). They present, most often in older adults, with special clinical features that make diagnosis and therapeutic decision-making difficult. The prevalence, location, and management of these herniations and the medical history of our patients were analyzed. Methods: Sex, age, injury level, previous surgery, and patient treatment data from July 2018 to May 2021 were collected retrospectively. During this period, 179 patients underwent surgery, 33 of whom patients presented ULDH. Results: Thirty-three patients were included in the study (18 male and 15 female). Ages ranged from 39 to 85 years, with a predominance of elderly patients. The levels operated were L1-L2 in seven patients, L2-L3 in ten patients, L3-L4 in fourteen patients, and surgery in two levels (L2-L3, L3-L4) in two patients. In our practice, microdiscectomy is the preferred approach and was performed in all cases, with the addition of fusion in four of the 33 patients. Finally, a history of low lumbar disc herniation (LLDH) surgery was found in 16 patients. Conclusions: In our population, ULDHs are a rare entity with lower prevalence at the higher lumbar levels. They occur more frequently in elderly patients and clinical presentation can vary, which is a challenge for surgeons. In older adults, the development of lumbar kyphosis due to vertebral wedging is considered a risk factor for the development of ULDH. Surgical management by microdiscectomy is considered a technique with good results for this pathology. Level of Evidence III; Retrospective, longitudinal, descriptive, observational study.

The Results of Using a Transforaminal Lumbar Interbody Fusion Cage at the Upper Lumbar Level

Aim

The aim of this study is to apply surgical treatments to upper lumbar disc hernias in order to provide lumbar stability and lumbar lordosis using a transforaminal lumbar interbody fusion (TLIF) cage and to preserve the success rate of surgical results by protecting neural structures without excessive subject tension.

Material and methods

Between 2012 and 2017, 32 patients who had undergone an operation for upper lumbar disc herniation and who had received a transforaminal lumbar interbody fusion cage using a posterior technique were evaluated retrospectively.

Results

The radiological and clinical findings, surgical methods, and results of the patients were evaluated. In our study, 25 (78.1%) of the patients with upper lumbar disc hernias who were evaluated retrospectively were female and seven (21.9%) were male. Their average age was 55.43 years. The average follow-up was 21.75 months. The most common complaints were lower back pain, leg pain, and claudication. In the findings from neurological examinations, a positive result on the femoral stretching test occurred in 30 (93.7%) patients. In the degenerative spinal structure of patients at the L1-2 and L2-3 levels, a transforaminal lumbar interbody fusion was performed via a wide laminectomy with posterior stabilization due to a wide-bottomed disc hernia and stenosis. Only one of the patients with a neurological deficit still had a motor deficit after surgery.

Conclusion

While planning a surgery for upper lumbar disc hernias, the anatomical features of this region and the patients' radiological and neurological findings should be carefully evaluated. If TLIF is performed during upper lumbar region surgery, it may be preferable to perform it using a posterior technique.

Surgical Outcomes for Upper Lumbar Disc Herniations: A Systematic Review and Meta-analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

To conduct a literature review on outcomes of discectomy for upper lumbar disc herniations (ULDH), estimate pooled rates of satisfactory outcomes, compare open laminectomy/microdiscectomy (OLM) versus minimally invasive surgical (MIS) techniques, and compare results of disc herniations at L1-3 versus L3-4.

METHODS

A systematic review of articles reporting outcomes of nonfusion surgical treatment of L1-2, L2-3, and/or L3-4 disc herniations was performed. The inclusion and exclusion of studies was performed according to the latest version of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

RESULTS

A total of 20 articles were included in the quantitative meta-analysis. Pooled proportion of satisfactory outcome (95% CI) was 0.77 (0.70, 0.83) for MIS and 0.82 (0.78, 0.84) for OLM. There was no significant improvement with MIS techniques compared with standard OLM, odds ratio (OR) = 0.86, 95% CI (0.42, 1.74), P = .66. Separating results by levels revealed a trend of higher satisfaction with L3-4 versus L1-3 with OLM surgery, OR = 0.46, 95% CI (0.19, 1.12), P = .08.

CONCLUSION

Our analysis reveals that discectomy for ULDH has an overall success rate of approximately 80% and has not improved with MIS. Discectomy for herniations at L3-4 trends toward better outcomes compared with L1-2 and L2-3, but was not significant.

Surgical outcomes of decompression alone versus transpedicular screw fixation for upper lumbar disc herniation

Background

Surgical outcomes of upper lumbar disc herniations (ULDHs) including T12-L1, L1-L2, and L2-L3 levels are characteristically less favorable and more unpredictable.

Objectives

This study was conducted to compare the surgical outcomes of decompression alone versus decompression combined with transpedicular screw fixation in treating upper lumbar disc herniation.

Methods

This retrospective cohort study was carried out at Neurosurgery Departments, Tanta University. The study included 46 patients with a symptomatic high lumbar herniated disc at T12-L1, L1-L2, and L2-L3 levels. The enrolled patients were divided into two groups depending on whether they were operated on via decompression and partial medial facetectomy (group 1, 22 patients) or via the previous maneuver plus transpedicular screw fixation (group 2, 24 patients). All patients were medically evaluated immediately after the operation; then, they were followed up at the 3rd and the 6th months following surgery. Patients’ outcomes were assessed by visual analogue score (VAS) and Oswestry Disability Index (ODI) scores.

Results

Median VAS scores in each group revealed significant reduction immediately following surgery and at each of 7 days, 3 months, and 6 months in comparison with the preoperative VAS score (p<0.001). Furthermore, each group showed significant stepwise reduction in the median ODI score at the 3rd and the 6th months postoperative compared to the preoperative ODI score (group 1 = 68.0, 19.0, 15.0; p< 0.001 and group 2 = 66.5, 20.0, 15.0; p< 0.001), with no significant differences between both groups (p> 0.05).

Conclusions

Both standalone decompression and decompression combined with transpedicular screw fixation revealed comparable favorable outcomes in patients with ULDH.

Two-level percutaneous endoscopic lumbar discectomy for highly migrated upper lumbar disc herniation: A case report

BACKGROUND

The technique of percutaneous endoscopic lumbar discectomy (PELD) as a transforaminal approach has been used to treat highly migrated lower lumbar disc herniations. However, due to the different anatomic characteristics of the upper lumbar spine, conventional transforaminal PELD may fail to remove the highly migrated upper lumbar disc nucleus pulposus. Therefore, the purpose of this study was to describe a novel surgical technique, two-level PELD, for the treatment of highly migrated upper lumbar disc herniations and to report its related clinical outcomes.

CASE SUMMARY

A 60-year-old male presented with a complaint of pain at his lower back and right lower limb. The patient received 3 mo of conservative treatments but the symptoms were not alleviated. Physical examination revealed a positive femoral nerve stretch test and a negative straight leg raise test for the right leg, and preoperative visual analog scale (VAS) score for the lower back was 6 points and for the right leg was 8 points. Magnetic resonance imaging (MRI) demonstrated L2-L3 disc herniation on the right side and the herniated nucleus pulposus migrated to the upper margin of L2 vertebral body. According to physical examination and imaging findings, surgery was the primary consideration. Therefore, the patient underwent surgical treatment with two-level PELD. The pain symptom was relieved and the VAS score for back and thigh pain was one point postoperatively. The patient was asymptomatic and follow-up MRI scan 1 year after operation revealed no residual nucleus pulposus.

CONCLUSION

Two-level PELD as a transforaminal approach can be a safe and effective procedure for highly migrated upper lumbar disc herniation.

Relationship between X-ray findings of lumbar spondylosis and knee pain

Background

The aim of this study was to investigate the correlation between radiographic measurement in lumbar spine and clinical information including symptoms or results of functional testing using a baseline data of longitudinal cohort study.

Methods

A total of 314 elderly subjects were recruited from 5 orthopedic clinics or affiliated facilities. Data for the present investigation were collected via an interviewer-administered questionnaire, which included questions on past medical history, drug history, pain area. And also results of functional testing and X-ray imaging of the lumbar spine were collected. Analysis was carried out to determine any correlation between results of X-ray imaging of the lumbar spine and other collected data, and sorted regarding Akaike Information Criterion (AIC). The correlations among these variables and odds ratio were also analyzed.

Results

T12/L1% disc height showed a minimum AIC value with buttock pain (− 4.57) and history of vertebral fracture (− 4.05). The L1/L2, L2/L3, and L3/L4% disc height had a minimal AIC value with knee pain (− 4.11, − 13.3, − 3.15, respectively), and odds ratio of knee pain were 3.5, 3.8, and 2.7, respectively.

Conclusions

Correlation was recognized between the T12/L1% disc height and both buttock pain and previous vertebral fractures, and the L1/L2, L2/L3, and L3/L4% disc height showed a correlation with knee pain. Especially the L2/L3% disc height and knee pain had a strong correlation. It was suggested that these findings may provide additional basis to the concept that lumbar spinal lesion associates with knee pain clinically.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2755-1) contains supplementary material, which is available to authorized users.

Clinical diagnosis of upper lumbar disc herniation: Pain and/or numbness distribution are more useful for appropriate level diagnosis

OBJECTIVE

The purpose of this study is to disclose the characteristic symptoms and signs in L2, L3 and L4 nerve root disturbance.

MATERIALS AND METHODS

Fifty eight patients who underwent lateral herniotomy were analyzed. Breakdowns are 15 patients with L2/3 lateral disc herniation (group A), 20 patients with L3/4 lateral disc herniation (group B), and 23 patients with L4/5 lateral disc herniation (group C). The following items were examined: 1) localization of the subjective pain and numbness, 2) objective neurological findings, including deep tendon reflex, manual muscle strength (MMT), straight leg raising test (SLRT) and femoral nerve stretch test (FNST).

RESULTS

In group A, subjective pain and/or numbness was present in the thigh aspect, proximal to the knee joint in all patients. In group B, 80% of the patients had subjective pain and/or numbness in the medial site of the knee joint. In group C, the subjective pain and/or numbness was localized in various aspects of the lower extremity. Weakness in the iliopsoas, the femoral quadriceps, and the anterior tibial muscle were observed in 60-95%, 27-70%, 0-43% of three groups, respectively. Depression or absence of the patella tendon reflex was present in 27-100% of three groups. SLRT and FNST were positive in 13-87% and 91-95% of three groups.

CONCLUSION

Symptomatic levels of nerve root disturbance in the upper lumbar spine could not be accurately identified by objective neurological findings alone. Pain and/or numbness localized in the thigh area proximal to the knee joint is a specific sign of L2 nerve root disturbance. Either subjective pain or numbness in the medial knee joint aspect is another key sign which strongly suggests L3 nerve root disturbance.

The Comparative Analysis of Clinical Characteristics and Surgical Results between the Upper and Lower Lumbar Disc Herniations

Objective

There are differences in the clinical characteristics and surgical results between upper (L1-2 and L2-3) and lower (L3-4, L4-5, and L5-S1) lumbar disc herniations. We conducted this study to compare the clinical features and surgical outcomes between the two types of lumbar disc herniations.

Methods

We retrospectively reviewed the clinical features of patients who underwent microdiscectomies from 2008 to 2012. We evaluated the clinical characteristics such as age, preoperative autonomic dysfunction, the presence or absence of previous lumbar surgery and fusion required during surgery. Visual Analogue Scale (VAS) scores about back pain and leg pain were evaluated preoperatively and at the final follow-up.

Results

Upper lumbar group (n=15) was significantly older than lower lumbar group (n=148). The incidence of autonomic dysfunction was significantly higher in upper lumbar group. The number of patients with a previous lumbar surgery was significantly greater in upper lumbar group. There was no statistical significance for fusion required during surgery between two groups. Both groups showed a significant decrease in the VAS scores of leg pain. VAS scores of back pain were significantly decreased in lower lumbar group. But this was not seen in upper lumbar group. Both groups showed significant improvement of Oswestry Disability Index score.

Conclusion

Upper lumbar group had different clinical characteristics from those of lower lumbar group and these include older age, a higher incidence of autonomic dysfunctions and a higher incidence of patients with previous lumbar surgery. There were no significant differences in surgical outcomes, except for back pain, between two groups.