Extreme lateral lumbar disc herniation

Introduction of extreme lateral lumbar disc herniation The extreme lateral type (also known as the outermost type) lumbar disc herniation (extreme lateral prolapseoflumbarintervertebraldisc) is a special type of lumbar disc herniation, in which the disc herniation oppresses nerve roots from the same intervertebral space. The disease was first reported by Abdullah in 1974. The incidence rate was inconsistent, accounting for about 1% to 11.7% of the total number of patients with lumbar disc herniation, with an average of about 10%. In the past, there was insufficient understanding of this special disease, so the clinical failure of the lumbar spine surgery was often caused by missed diagnosis and misdiagnosis. With the continuous development of imaging diagnostics, especially CT technology, the clinical summary of extreme lateral lumbar disc herniation has increased year by year, but it is still necessary to write a detailed introduction to attract everyone's attention. basic knowledge The proportion of patients: the incidence rate of people over 30 years old is about 0.004% - 0.005% Susceptible people: no special people Mode of infection: non-infectious Complications: lumbar spondylosis

The cause of extreme lateral lumbar disc herniation

(1) Causes of the disease

A series of clinical symptoms are caused by the degeneration of the lumbar disc and the prominent outer side.

(two) pathogenesis

The lumbosacral nerve root is generally emitted from the cauda equina in the inner and upper part of the corresponding intervertebral foramen. After walking a distance in the spinal canal, it enters the nerve root canal and then passes through the corresponding intervertebral foramen. There is a gap outside the intervertebral foramen. It is called the far lateral space. The front of the gap is the vertebral body and the intervertebral disc, which accounts for 30% to 40% of the transverse diameter of the lumbar vertebrae. The surface has the posterior longitudinal ligament attached, the posterior is the ligamentum flavum, and the lateral side is the intertransverse space. The ligament, the nerve root from the intervertebral foramen, enters the extreme lateral space and traverses behind the intervertebral disc. In this gap, the epidural fat and vein are abundant, and the nerve root and the posterior root ganglion are back. The lateral side is often covered by veins, and the root artery and root vein can be found on the lateral side near the transverse intersegmental ligament. According to anatomical studies, the lumbar pedicle is gradually deflected from the waist 1 to the waist 5 from the lateral part of the vertebral body. At the same time, the transverse process of the pedicle from the pedicle is gradually toward the front, because the lumbar pedicle gradually thickens from top to bottom and gradually slanted outward, the width of the pedicle also increases, according to the previous literature. Record, nerve The intervertebral foramen is transversely moved behind the intervertebral disc, but according to Fournier et al., the nerve roots in the nerve root canal actually travel from the inside to the outside, and the angle is almost vertical. The first to third lumbar nerves are more perpendicular in the nerve root canal, and the travel path outside the intervertebral foramen is located behind the intervertebral disc; and the fifth lumbar nerve is inclined in the nerve root canal. The stroke is longer, and the position outside the intervertebral foramen is just outside the lumbar disc of the 5~1 intervertebral disc. Thus, when the intervertebral disc of the upper lumbar vertebra protrudes out of the intervertebral foramen, the nerve root is far from the posterior aspect. It is not easy to cause oppression; in the lower lumbar nerve roots, the chance of compression is obviously much more, and the presence of the iliac crest reduces the lateral clearance of the lumbar 5~1 pole, which undoubtedly increases the chance of compression of the lumbar 5 nerve root.

According to the location of the prominent nucleus pulposus, the lateral lateral lumbar disc herniation can be further divided into two types, namely intraforaminal prominence and extraforaminal prominence, because the nucleus pulposus protrudes from the annulus fibrosus Later, the nerve roots that will give out the intervertebral foramen are pressed outwards, and the nerve roots have little room for movement due to the limitation of the pedicle and/or the intervertebral foramen ligament, which is easily compressed and causes symptoms, and clinically The most common posterior lateral disc herniation differs in that the compression site is at the intervertebral foramen of the upper intervertebral space or outside the intervertebral foramen, ie the lumbar 3 to 4 intervertebral disc herniation oppresses the lumbar 3 nerve root, waist 45 and lumbar 51 intervertebral disc herniation respectively compress the lumbar 4 and lumbar 5 nerve roots. In addition, the incidence rate in each gap is also different, that is, the lumbar 4~5 protrusion is the most common, followed by the waist 3. 4, waist 5 ~ 1, waist 2 ~ waist 3 and waist 1 ~ 2, which occurs in the waist 3 ~ 4 proportion is relatively high, while the posterior lateral disc herniation occurs mostly in the waist 4 ~ 5 and waist 5 ~ 1, extreme lateral lumbar disc herniation generally does not involve the sacral nerve root.

Extreme lateral lumbar disc herniation prevention

Early detection and early diagnosis are the key to the prevention and treatment of this disease.

Extreme lateral lumbar disc herniation complications Complications lumbar spondylosis

Lumbar spine pain, lumbar bulging

Extreme lateral lumbar disc herniation symptoms Common symptoms Lower extremity radiation pain sensory disorder thigh tingling hip lateral soreness Spinous process tenderness Spinal nerve compression Lumbar spinal canal stenosis Posterior margin spur formation Lumbar spine degeneration overproduction Low back pain

Low back pain and lower extremity radiation pain are the most common clinical symptoms. Because the posterior root ganglia is often squeezed together with the nerve root, the degree of radiation pain in the lower extremities can be quite serious. When the waist 1 ~ waist 3 nerve roots are involved, the hip will be caused. In the groin area and the front side of the thigh, some patients may also have atrophy of the quadriceps.

In some cases, the straight leg raising test can be positive. The positive rate of the straight leg raising test is different. Broom reports 13 cases, of which 10 cases are positive, Jackson and Glah report 16 cases, straight leg Epstein counted 170 cases of extreme lateral lumbar disc herniation, 94% of cases with positive straight leg elevation test, and straight leg raising test of a group of 138 cases treated by Abdullah et al. Negative patients accounted for 65%, if the remaining 35% of the straight leg elevation test positive combined with intraspinal disc herniation, severe spinal stenosis and previous surgical scars and other factors are taken into account, the negative rate is as high as 85% ~ 90%.

Epstein et al reported that most patients induced low back pain and lower extremity radiation pain when standing and walking. Twenty-two of the 26 patients examined by Kanogi and Hasue induced pain during lumbar extension. Abdullah et al found that when the spine was bent toward the affected side, Pain will be induced, and this sign is considered to be more reliable. When the upper lumbar nerve is compressed, the femoral nerve pull test is mostly positive, but some scholars believe that this sign is not specific. In addition, the nerve root can be compressed. Corresponding movements occur, and sensory disturbances and reflexes are diminished.

Cases with congenital developmental lumbar spinal stenosis were not only early onset, but the symptoms were significantly heavier.

Examination of extreme lateral lumbar disc herniation

Skouen et al. performed biochemical measurements of serum and cerebrospinal fluid in 143 patients with lumbar disc herniation. The total protein, albumin, IgG content, cerebrospinal fluid and serum albumin ratio, and the ratio of cerebrospinal fluid to serum albumin IgG were observed with the position of the intervertebral disc. The internal and external gradual increase, the correlation is statistically significant, which is believed to be caused by the leakage of plasma proteins from the nerve roots.

Because the clinical manifestations of this disease are basically the same as the posterior lateral disc herniation in the previous gap, the diagnosis is mainly based on imaging examination. Imaging examination can also help to eliminate other diseases that can cause similar symptoms, such as lateral recess stenosis, peritoneum. Post-hematoma, retroperitoneal tumor, nerve root deformity or tumor.

X-ray film

X-ray plain films are generally considered to have no diagnostic value for extreme lateral disc herniation.

2. Myelography

Because the subarachnoid space terminates in the posterior root ganglia, myelography is difficult to show extreme lateral disc herniation. Therefore, myelography is the same as X-ray film, which is mainly used to exclude other lesions. Therefore, when patients have nerve root compression symptoms When the results of myelography are negative or do not conform to the clinical manifestations, the intervertebral discs in the intervertebral foramen should be highly suspected. Some people advocate angiography, but the clinical application is less.

3. Intervertebral discography

There has been a lot of debate about the diagnostic value of discography. There was a group of 77 cases of discography, the diagnostic accuracy was 92.2%, but the operation was more complicated, so it was not widely used.

4. CT examination

CT examination can clearly show the position and extent of disc herniation. Therefore, with the wide application of this imaging technique in clinical practice, the report of the extreme lateral disc herniation has also increased significantly, showing the disc nucleus with prominent soft tissue density. The dural sac and epidural fat have good contrast, but when the protrusion is located in the intervertebral foramen or outside the intervertebral foramen, the adjacent nerve roots and/or posterior root ganglia are approximately equal in density, possibly It will bring certain difficulties to the diagnosis, even misdiagnosed as a tumor. Furthermore, if the CT examination does not include the underlying layer of the pedicle, it may cause a diagnosis omission. Therefore, a thin layer including the upper and lower pedicles should be used. Scan to avoid omission, if necessary, coronal reconstruction should be performed. CT discography can further improve the accuracy of diagnosis. It can be used as appropriate. Segnarbieux et al believe that when the CT findings are suspected of extremely lateral disc herniation and the diagnosis is difficult to determine, CT discography should be performed. A comparative study of various imaging methods shows that the diagnostic accuracy of myelography is only 12.5%. Intervertebral discography was 37.5%, CT examination and CT myelography were both 50%, and the diagnostic accuracy of CT discography was as high as 93.8%, but Epstein et al believed that CT myelography is better than CT alone. Some scholars have reported that partial intervertebral disc herniation CT examination showed a vacuum phenomenon, that is, there is air in the prominent nucleus pulposus.

5. MRI examination

Multi-planar MRI technique is ideal for the display of intervertebral foramen structures. The boundary between the prominent nucleus pulposus and the nerve root is also more clear than that of the CT examination image. However, the good display of the prominent nucleus pulposus by MRI images often depends on the orientation and plane of the examination. The choice, Grenier et al. MRI examination of 33 cases of 34 disc herniations that had been diagnosed by CT examination showed that 3 lesions were not shown in the sagittal plane, but in the cross section and the 15° to 30° coronal plane. It is shown that the 15°30° coronal image not only shows the most clear display of the herniated disc, but also accurately reflects the nerve root compression. The scholar also found that the larger nerve root and the expanded venous plexus are easy to dissociate. The nucleus pulposus in the intervertebral foramen is confused.

In theory, MRI should be more satisfactory for the location and extent of nerve root compression, but according to the literature, the application of this technique in the diagnosis of extreme lateral disc herniation is far less common than high-resolution CT scans. For example, the MRI sagittal image often does not include the intervertebral foramen, and the scan layer thickness is also higher than the CT scan.

Diagnosis and diagnosis of extreme lateral lumbar disc herniation

According to the medical history and clinical symptoms and signs, ordinary X-ray, myelography can not be clearly diagnosed, the clinical diagnosis is mainly based on CT, discography, MRI and laboratory tests can be diagnosed.

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