Anterior-to-Posterior Migration of a Lumbar Disc Sequestration: Surgical Remarks and Technical Notes about a Tailored Microsurgical Discectomy

Extrusion of disc material within the spinal canal complicates up to 28.6% of lumbar disc herniations. Due to the anatomical “corridors” created by the anterior midline septum and lateral membranes, relocation occurs with an anterior and anterolateral axial topography. Posterior migration is an extremely rare condition and anterior-to-posterior circumferential migration is an even rarer condition. Its radiological feature can be enigmatic and since, in more than 50% of cases, clinical onset is a hyperacute cauda equina syndrome, it may imply a difficult surgical decision in emergency settings. Surgery is the gold standard but when dealing with such huge sequestrations, standard microdiscectomy must be properly modified in order to minimize the risk of surgical trauma or traction on the nerve roots.

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The clinical significance of gadolinium enhancement of lumbar disc herniations and nerve roots on preoperative MRI

Neuroradiology ◽

10.1007/s002340050688 ◽

1998 ◽

Vol 40 (12) ◽

pp. 800-806 ◽

Cited By ~ 18

Author(s):

P. C. A. J. Vroomen ◽

S. J. M. Van Hapert ◽

R. E. H. Van Acker ◽

E. A. M. Beuls ◽

A. G. H. Kessels ◽

...

Keyword(s):

Clinical Significance ◽

Lumbar Disc ◽

Gadolinium Enhancement ◽

Nerve Roots ◽

Disc Herniations

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

10.31487/j.ssg.2020.01.03 ◽

2020 ◽

pp. 1-2

Author(s):

Abdullah Alshammari ◽

Michael Weber ◽

Rodrigo Navarro-Ramirez ◽

Susan Ge

Keyword(s):

Epidural Space ◽

Cauda Equina Syndrome ◽

Lumbar Disc ◽

Cauda Equina ◽

Foot Drop ◽

Low Back ◽

Decompressive Laminectomy ◽

Safe Management ◽

Disc Herniations ◽

Space Case

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.

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Posterior epidural migration of a lumbar disc herniation

Surgical Neurology International ◽

10.25259/sni_67_2019 ◽

2020 ◽

Vol 11 ◽

pp. 4

Author(s):

Meryem Himmiche ◽

Khalid Chakour ◽

Mohammed El Faiz Chaoui ◽

Mohammed Benzagmout

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Cauda Equina Syndrome ◽

Lumbar Disc ◽

Cauda Equina ◽

Low Back ◽

Case Description ◽

Disc Material ◽

Disc Herniations ◽

History Of

Background: Posterior epidural migration of a lumbar disc fragment (PEMLDF) refers to the dorsal migration of disc material around the thecal sac that can lead to radiculopathy and/or cause a cauda equina syndrome. It is rare and the diagnosis is often just established intraoperatively. Case Description: A 50-year-old male with a chronic history of low back pain and psychosis presented with PEMLDF originating at the L4–L5 level. Conclusion: Lumbar disc herniations rarely present as PEMLDF resulting in symptoms varying from radiculopathy to cauda equina syndrome. These should be included among the differential diagnostic considerations for dorsolateral epidural lesions.

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Spontaneous and rapid resolution of a massive lumbar disc herniation

Surgical Neurology International ◽

10.25259/sni_491_2021 ◽

2021 ◽

Vol 12 ◽

pp. 352

Author(s):

Dinesh Naidoo

Keyword(s):

Lumbar Disc Herniation ◽

Disc Herniation ◽

Spontaneous Recovery ◽

Surgical Intervention ◽

Nonoperative Management ◽

Lumbar Disc ◽

Cauda Equina ◽

Neurological Deficits ◽

Lumbar Surgery ◽

Disc Herniations

Background: Most lumbar disc herniations can be successfully treated conservatively. However, massive lumbar disc herniations are often treated surgically to avoid permanent cauda equina syndromes/neurological deficits and potential litigation. Nevertheless, here, we present a 51-year-old female who refused lumbar surgery due to coronavirus disease 2019 (COVID-19) and sustained a full spontaneous recovery without surgical intervention. Case Description: A 51-year-old female presented with a massive lumbar disc herniation at the L5S1 level. Despite refusing surgery for fear of getting COVID-19, she spontaneously neurologically improved without any residual neurological or radiographic sequelae. Conclusion: Although the vast majority of patients with massive lumbar disc herniations are managed surgically, there are rare instances in which nonoperative management may be successful.

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Posterior epidural migration of herniated lumbar disc fragment

Journal of Neurosurgery Spine ◽

10.3171/2010.11.spine10142 ◽

2011 ◽

Vol 14 (3) ◽

pp. 313-317 ◽

Cited By ~ 28

Author(s):

Ahmet Sengoz ◽

Kadir Kotil ◽

Erol Tasdemiroglu

Keyword(s):

Surgical Treatment ◽

Cauda Equina Syndrome ◽

Lumbar Disc ◽

Cauda Equina ◽

Case Series ◽

Rare Condition ◽

Neurological Deficits ◽

Lumbar Region ◽

Duration Of Symptoms ◽

First Choice

Object Posterior epidural migration of a free disc fragment in the lumbar region is a very rare condition that has only been reported in isolated cases to date. Patients with this condition present with radiculopathy or major neurological deficits. Difficulties in diagnosis and the choice and timing of surgical treatment are important in these cases. In this clinical case series, features of cases with posterior epidural migration of free lumbar disc fragments accompanied by cauda equina syndrome are discussed. Methods Eight cases (0.27%) of posterior epidural migration of disc fragments were detected among 2880 patients surgically treated for lumbar disc herniation between 1995 and 2008. Seven of these patients had cauda equina syndrome. The mean duration of symptoms in the 8 cases was 4.2 days (range 1–10 days). The group included 6 men and 2 women, with a mean age of 48 years (range 34–72 years). The sequestered disc fragments were at the L3–4 level in 6 patients (75%) and the L4–5 level in 2 (25%). Magnetic resonance imaging showed tumor-like ring contrast enhancement around sequestered fragments in 5 patients. The patients' motor, sensory, sexual, and urological functions were evaluated postoperatively, and modified Odom criteria and a visual analog scale were used in the assessment of postoperative outcomes. Results A microsurgical approach was used in all cases. Sequestrectomy with minimal hemilaminotomy and removal of the free segments were performed. The patients were followed up for a mean period of 28.5 months. Three patients (37.5%) had excellent results, 3 (37.5%) had good results, 1 patient (12.5%) had fair results, and only 1 patient had poor results according to the Odom criteria. The main factors affecting the long-term outcomes were the presence of cauda equina syndrome and the time period between onset of symptoms and surgery. Conclusions Patients with posterior migration of a disc fragment present with severe neurological deficits such as cauda equina syndrome. Because the radiological images of disc fragments may mimic those of other more common posterior epidural space–occupying lesions, definite diagnosis of posteriorly located disc fragments is difficult. All of these lesions can be completely removed with hemilaminotomy and sequestrectomy, and early surgical treatment is important as a first choice to prevent severe neurological deficits.

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Caudal Lumbar Disc Herniations Are More Likely to Require Surgery for Symptom Resolution

Global Spine Journal ◽

10.1177/2192568220905849 ◽

2020 ◽

pp. 219256822090584

Author(s):

Anmol Gupta ◽

Shivam Upadhyaya ◽

Caleb M. Yeung ◽

Peter J. Ostergaard ◽

Harold A. Fogel ◽

...

Keyword(s):

Lumbar Disc Herniation ◽

Disc Herniation ◽

Nonoperative Management ◽

Lumbar Disc ◽

Strong Association ◽

Cauda Equina ◽

Radicular Pain ◽

Motor Deficits ◽

Disc Herniations ◽

The Impact

Study Design: Retrospective study. Objectives: We examined the impact that location of a lumbar disc herniation has on the likelihood that a patient will require surgery after at least 6 weeks of nonoperative management. Methods: Using ICD-10 codes M51.26 and M51.27, we identified patients at a single academic institution from 2015 to 2016 who received a diagnosis of primary lumbar radicular pain, had magnetic resonance imaging confirming a lumbar disc herniation, and underwent at least 6 weeks of nonoperative management. Patients experiencing symptoms suggesting cauda equina syndrome or progressive motor deficits were excluded. Results: Five hundred patients met inclusion/exclusion criteria. Twenty-nine (5.8%) had L3-L4 herniations, 245 (49.0%) had L4-L5 herniations, and 226 (45.2%) had L5-S1 herniations. Overall, 451 (90.2%) patients did not undergo surgery within 1 year of diagnosis. Nonsurgical patients had an average herniation size occupying 31.2% of the canal, compared with 31.5% in patients who underwent surgery. While herniation size, age, sex, and race failed to demonstrate a statistical association with the likelihood for surgery, location of disc herniation demonstrated a strong association. L3-L4 and L4-L5 herniations had odds ratios of 0.19 and 0.45, respectively, relative to L5-S1 herniations ( P = .0047). Patients were more than twice as likely to require a surgery on an L5-S1 herniation in comparison with an L4-L5 herniation ( P < .05). L3-L4 herniations rarely required surgery. Conclusions: Patients with caudal lumbar disc herniations were more likely to require surgery after at least 6 weeks of conservative management than those with disc herniations in the mid-lumbar spine.

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Is Open Lumbar Micro- Discectomy Safe at Periphery of Nepal?

Nepal Journal of Neuroscience ◽

10.3126/njn.v13i1.15909 ◽

2016 ◽

Vol 13 (1) ◽

pp. 30-34

Author(s):

Bal K Thapa

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Disc Herniation ◽

Economic Status ◽

Lumbar Disc ◽

Low Back ◽

Indications For Surgery ◽

Nerve Roots ◽

Disc Herniations

Lumbar disc surgery is performed exclusively for disc herniation. Either low back pain, or sciatica or both are common presentations depending upon the levels of compressed nerve roots. Indications for surgery and MRI needs to be carefully judged upon keeping the economic status of our patients into consideration. Open lumbar (micro) discectomy is safe and successful method for lumbar disc herniations at periphery. Results in these hundred thirteen initial cases with minimum follow up of 5 years indicate that this is not only feasible but safe in these 57 males and 56 female patients aged between 12 and 93. Redo surgeries were not that difficult in this series and were safe. There were 18 cases with Multiple and 95 single levels. Of the single levels it gradually increased as the level gradually decreased in terms of the vertebral counts. L3/4: 3 cases, L4/5: 28 cases and L5/S1 : 64 cases . There were 18 cases of more than one level discs. There were 96 (Micro) discectomies, 11 Laminotomies and 6 Laminectomies.Nepal Journal of Neuroscience 13:30-34, 2016

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Intradural lumbar disc herniations at the L1–L2 level: A case study and literature review

Surgical Neurology International ◽

10.25259/sni_108_2020 ◽

2020 ◽

Vol 11 ◽

pp. 67

Author(s):

Giancarlo Ponzo ◽

Massimo Furnari ◽

Giuseppe Emmanuele Umana ◽

Massimiliano Giuffrida ◽

Giovanni Federico Nicoletti ◽

...

Keyword(s):

Lumbar Spine ◽

Literature Review ◽

Current Literature ◽

Lumbar Disc ◽

Cauda Equina ◽

Acute Onset ◽

Case Description ◽

Lumbar Mri ◽

Disc Herniations

Background: Intradural disc herniations (IDHs) are rare occurrences (0.26–0.30%), and most frequently involve the lumbar spine at the L4–L5 level. Here, we present a patient with an L1–L2 IDH and reviewed the current literature. Case Description: A 65-year-old female presented with the acute onset of bilateral paraparesis accompanied by urinary dysfunction. The lumbar MRI showed a mass at the L1–L2 level with caudal migration, accompanied by a positive “hawk-beak” sign. At surgery, consisting of a L1–L2 laminectomy, a large IDH was encountered responsible for marked cauda equina/root compression. Postoperatively, the patient immediately fully recovered. The literature we identified cited just seven similar studies of L1–L2 IDH. Conclusion: In a 65-year-old female, an IDH was anticipated at the L1–L2 level due to the combined MR findings of a large L1–L2 mass with caudal migration and the positive “hawk-beak” sign.

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Does surgical decompression alleviate neglected cauda equina syndromes attributed to lumbar disc herniation and/or degenerative canal stenosis?

Surgical Neurology International ◽

10.25259/sni_512_2020 ◽

2020 ◽

Vol 11 ◽

pp. 278

Author(s):

Sulaiman Sath

Keyword(s):

Cauda Equina Syndrome ◽

Lumbar Disc ◽

Cauda Equina ◽

Surgical Decompression ◽

Bladder Function ◽

Disc Disease ◽

Residual Symptoms ◽

Canal Stenosis ◽

Complete Restoration ◽

Disc Herniations

Background: Most studies recommend urgent decompression (e.g., within 48–72 h) of the symptomatic onset of a cauda equina syndrome. As patients in our area typically underwent >3 months delayed surgery for cauda equina syndromes due to disc disease/stenosis, we asked whether surgery was still worthwhile. Methods: This was a retrospective analysis of 12 patients (2012–2018) who underwent delayed surgical decompression for cauda equina syndromes secondary to lumbar disc herniations and/or degenerative lumbar canal stenosis. Results: After a mean postoperative duration of 8.22 months, nine patients experienced the complete restoration of bladder status; two patients required intermittent self-catheterization, while one patient had some residual symptoms (e.g., urgency but able to void with some difficulty). Conclusion: For 12 patients who originally presented with cauda equina syndrome with complete incontinence, nine exhibited delayed full recovery of bladder function with average of 8.22 months postoperatively. We would, therefore, advise that delayed surgical decompression be offered to these patients, irrespective of the preoperative duration of cauda equina syndromes with complete incontinence.

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Transdural approach for calcified central disc herniations of the upper lumbar spine

Journal of Neurosurgery Spine ◽

10.3171/spi-07/09/370 ◽

2007 ◽

Vol 7 (3) ◽

pp. 370-374 ◽

Cited By ~ 15

Author(s):

Jeong-Wook Choi ◽

Jung-Kil Lee ◽

Kyung-Sub Moon ◽

Hyuk Hur ◽

Yeon-Seong Kim ◽

...

Keyword(s):

Lumbar Spine ◽

Disc Herniation ◽

Nerve Root ◽

Lumbar Disc ◽

Cauda Equina ◽

Cerebrospinal Fluid Leakage ◽

Nerve Root Injury ◽

Central Disc ◽

Disc Herniations ◽

Transdural Approach

✓Disc herniations of the upper lumbar spine (L1–2 and L2–3) have a frequency of 1 to 2% of all disc herniations. During posterior discectomy after laminectomy, significant manipulation of the exiting nerve root is unavoidable because of the narrow lamina and the difficulty in mobilizing the nerve root. The authors adopted a transdural approach in patients with calcified central disc herniation at the L1–2 level to reduce the risk of nerve root injury. Four patients suffering from radiating pain together with back pain were treated using the transdural approach. Pre-operative neuroimaging studies revealed severe central disc herniation with calcification at the L1–2 level. After laminectomy or laminotomy, the incised dura mater was tacked, and the cauda equina rootlets were gently retracted. An intentional durotomy was performed over its maximal bulging of the ventral dura. After meticulous dissection of dense adhesions between the disc herniation and the dural sac, adequate decompression with removal of calcified disc fragments and osteophytes was accomplished. Clinical symptoms improved in all patients. Postoperative permanent cerebrospinal fluid leakage and pseudomeningocele were not observed, and no patient had a progressive lumbar deformity at an average follow-up of 53 months. Transient mild motor weakness and sensory change were observed in two patients postoperatively; however, these symptoms resolved completely within 1 week. The posterior transdural approach offers an alternative in central calcified upper lumbar disc herniation when root retraction is dangerous.

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