Cervical epidural steroid injections for symptomatic disc herniations

OBJECTIVES: Cervical disc herniations are a common cause of radicular pain from nerve root impingement and may necessitate surgical decompression to alleviate symptoms. The use of cervical epidural injections has not been studied in detail. The objective of this retrospective study was to examine the efficacy of cervical epidural steroid injections for the treatment of symptomatic herniated cervical discs. METHODS: Patients with herniated cervical discs without myelopathy that had failed conservative management and were otherwise surgical candidates were offered a trial of cervical epidural injections. The results and benefits of the injections were examined as well as the incidence of proceeding to surgical intervention. RESULTS: Of the 70 treated patients, 44 (63%) had significant relief of their symptoms and did not wish to proceed with surgical treatment. Of the 26 patients who underwent surgical decompression, 92% had successful resolution of their symptoms. The nonsurgical and surgical groups were similar in terms of gender, preinjection symptoms, or number of injections. However, significant differences between the two groups were found with regard to age (P<0.05) and time from initial consultation to initial injection (P<0.05). With an average of 13-month follow-up, 45 (65.3%) patients reported a good/excellent result per Odom criteria. In addition, 53 (75%) would attempt cervical epidural steroid injections again in the future. No complications were noted in our series. CONCLUSIONS: Cervical epidural injections are a reasonable part of the nonoperative treatment of patients with symptomatic cervical disc herniations. The success rates appear to be very similar to prior studies of lumbar epidural injections for symptomatic lumbar disc herniations. It appears that a large percentage of the patients may obtain relief from radicular symptoms and avoid surgery for the follow-up period up to 1 year. In addition, patients older than 50 years and those who received the injections earlier, less than 100 days from diagnosis, seemed to have a more favorable outcome.     

极外侧腰椎间盘突出症的临床分型及手术方式选择

目的 提出极外侧腰椎间盘突出症的新的临床分型,为手术方式的选择提供依据.方法 按照椎间盘突出的位置及其临床症状将极外侧腰椎间盘突出症分为椎管内椎间孔内型(Ⅰ型)、椎间孔内型(Ⅱ型)和椎间孔外型(Ⅲ型).据此对2002年1月至2007年1月收治的38例极外侧椎间盘突出症患者进行临床分型,并结合临床分型选择(1)经横突间椎间盘切除;(2)经椎管部分关节突切除、潜行椎间盘切除;(3)经椎管椎间盘切除+经后路椎体间融合(PLIF)等手术方式.38例患者中男性25例,女性13例;平均58.4岁.其中L_(3～4) 17例、L_ (4～5) 13例、L_5S_1 8例.单纯椎间盘突出23例,合并椎管狭窄15例.所有病例均表现为突出节段出口根受压的症状和体征,其中Ⅰ型中的7例同时伴有下位神经根受压的表现,15例合并椎管狭窄者存在间歇性跛行,21例有明确的腰痛症状.手术前后行根性疼痛VAS评分,术后采用MacNab方法进行临床疗效评定.结果 按照新的临床分型,38例患者中Ⅰ型10例、Ⅱ型19例、Ⅲ型9例.经横突间行椎间盘切除5例,经椎管部分关节突切除、潜行椎间盘切除7例,经椎管椎间盘切除+PLIF 26例.随访时间6个月～4年10个月,平均2年11个月.VAS评分术前平均为7.4分,术后2周为2.7分,末次随访为3.1分.末次随访MacNab评定结果:优20例、良12例、可5例、差1例,优良率为84.2%.并发症:伤口表浅感染1例、减压不满意者1例、脑脊液漏1例.未见内固定断裂、松动等.结论 新的临床分型,对认识极外侧腰椎间盘突出症的病理变化及选择手术方式等具有重要的意义.     

Epidural injections for the treatment of symptomatic lumbar herniated discs

Epidural steroid injections are widely used as part of the conservative care for symptomatic herniated lumbar discs. There are studies showing their effectiveness, and some studies demonstrating no clinical benefits. The purpose of this study was to evaluate the effectiveness of epidural steroid injections for patients with symptomatic lumbar disc herniations who were surgical candidates. Sixty-nine patients were diagnosed with a herniated disc in the lumbar spine and remained symptomatic despite conservative care, and were treated with an epidural injection in an attempt to avoid surgical discectomy. Of the total group of 69 patients (average age = 44.8 years, range 19-77 years, average follow-up = 1.5 years), 53 (77%) had successful resolution or significant decrease of their symptoms and were able to avoid surgery. Only 16 (23%) patients failed to have significant relief of their symptoms and required surgical treatment of their herniated disc. Epidural steroid injections have a reasonable success rate for the alleviation of radicular symptoms from lumbar herniated discs for up to twelve to twenty-seven months. Patients treated with injections may be able to avoid surgical treatment up to this period and perhaps even longer.     

突出椎间盘自然吸收现象的回顾性研究

目的研究突出椎间盘自然吸收的现象,为腰椎间盘突出症的非手术或手术治疗选择提供依据。方法对18例发生突出椎间盘自然吸收现象患者的病程、症状、体征及影像学资料进行回顾性分析。结果所有患者均为破碎型突出。18例均获随访,时间6~72(17±15)个月。突出物吸收率:完全消失12例,显著缩小6例。其中1例后纵韧带破裂者遗留少许腰痛,跟腱反射未恢复,但能正常工作及生活;另有1例腰腿痛复发,影像学显示突出间盘缩小后再次大块脱出,后纵韧带破裂;其余患者症状体征完全恢复,腰椎主动活动自如。结论腰椎间盘突出症如果后纵韧带完整,即使突出物巨大,症状重,只要没有马尾综合征或进行性单根神经根麻痹,都可以进行非手术治疗,且预后良好;但椎间盘吸收后在合适的条件下可再次突出。     

A minimally invasive transmuscular approach to far-lateral L5-S1 level disc herniations: a prospective study

BACKGROUND: Among all lumbar disc herniations, L5-S1 far-lateral disc herniations are rare entities. Besides, surgical approach may be difficult because of the very narrow passage at this level. For these 2 reasons, most spine surgeons are not experienced in herniations at this level. According to new microanatomic studies, previous lateral approaches at this level often do not allow access to the neuroforamen without partial or total destruction of the L5-S1 facet joint. To preserve the facet joint, an approach was developed. PURPOSE: To assess the efficacy of a surgical technique that is a minimally invasive intermuscular approach (MIIMA) for decompression of L5-S1 far-lateral level disc herniation (FLLDH). STUDY DESIGN: We present a prospective clinical study analysis of 14 patients with L5-S1 far-lateral disc herniations in a period between 2000 and 2004, treated with microsurgical technique. METHODS: An imaging study revealed consistency with the patient's clinical presentation. In our department, a total of 580 patients underwent discectomy between 2000 and 2004 for lumbar disc herniation. RESULT: Twenty-eight patients had foraminal or extraforaminal herniations (4.8%). Fourteen patients had FLLDH at the L4-L5 level (2.4%), whereas the other 14 were cases of FLLDH at the L5-S1 level (2.4%). One patient had FLLDH at both L5-S1 and L4-L5 levels (7.1%). The mean age of patients was 53.6 years, and the male:female ratio was approximately 5:9. All patients failed to recover after at least 6 weeks of conservative therapy. The mean duration of symptoms until the time of surgery was 7.2 months. Using this MIIMA technique, the authors removed the herniated discs compressing the (L5) nerve roots. Clinical outcome was measured using the visual analog scale. Every patient was discharged within 24 hours. Satisfactory (excellent or good) results were demonstrated in 13 patients (92.9%), because, except for 1 (7.1) permanent dysesthesia case, 4 cases (21.3%) were temporary dysesthesia. Postoperatively all patients reported excellent relief of their sciatic pains, and there were no technique-associated complications. No recurrence was observed during the follow-up period ranging from 10 to 60 months (mean, 29 mo). This is one of the major complications of any approach to a far-lateral disc. CONCLUSIONS: The authors describe a MIIMA for excising herniated discs that is applicable to all types of far-lateral lumbar herniations. Postoperative dysesthesia is the most important complication and may persist as it did in our cases. Consequently, manipulation of the ganglion should be avoided at all costs, if possible. The MIIMA procedure provides a simple alternative for treating lumbar foraminal or lateral exit zone herniated discs in selected cases. This approach is effective, allowing the preservation of the L5-S1 facet joint, saving the facet joint, preventing postoperative instability, and offering a direct view of the L5-S1 neuroforamen.     

Evaluation and treatment of chemonucleolysis failures

Fifty patients underwent chemonucleolysis for the treatment of lumbar disk herniations unresponsive to conservative therapy. In patients treated with chymopapain, unrelieved sciatica was the most common cause of clinical treatment failure. Eight patients (16%) experienced no relief or only a transient reduction in their radicular symptoms following chymopapain injection. All eight patients were clinically reevaluated and underwent repeat neuroradiographic studies. Computed axial tomography and lumbar myelography demonstrated persistent nerve root compromise at the level of the injected disk space. Open diskectomy was performed in all eight cases. Postoperatively, seven patients noted complete resolution of their radicular symptoms; one patient had intermittent low back and leg pain following surgery.     

Combined intra-extracanal approach to lumbosacral disc herniations with bi-radicular involvement. Technical considerations from a surgical series of 15 cases

Large lumbosacral disc herniations effacing both the paramedian and the foraminal area often cause double radicular compression. Surgical management of these lesions may be difficult. A traditional interlaminar approach usually brings into view only the paramedian portion of the intervertebral disc, unless the lateral bone removal is considerably increased. Conversely, the numerous far-lateral approaches proposed for removing foraminal or extraforaminal disc herniations would decompress the exiting nerve root only. Overall, these approaches share the drawback of controlling the neuroforamen on one side alone. A combined intra-extraforaminal exposure is a useful yet rarely reported approach. Over a 3-year period, 15 patients with bi-radicular symptoms due to large disc herniations of the lumbar spine underwent surgery through a combined intra-extracanal approach. A standard medial exposure with an almost complete hemilaminectomy of the upper vertebra was combined with an extraforaminal exposure, achieved by minimal drilling of the inferior facet joint, the lateral border of the pars interarticularis and the inferior margin of the superior transverse process. The herniated discs were removed using key maneuvers made feasible by working simultaneously on both operative windows. In all cases the disc herniation could be completely removed, thus decompressing both nerve roots. Radicular pain was fully relieved without procedure-related morbidity. The intra-extraforaminal exposure was particularly useful in identifying the extraforaminal nerve root early. Early identification was especially advantageous when periradicular scar tissue hid the nerve root from view, as it did in patients who had undergone previous surgery at the same site or had long-standing radicular symptoms. Controlling the foramen on both sides also reduced the risk of leaving residual disc fragments. A curved probe was used to push the disc material outside the foramen. In conclusion, specific surgical maneuvers made feasible by a simultaneous extraspinal and intraspinal exposure allow quick, safe and complete removal of lumbosacral disc herniations with paramedian and foraminal extension.     

The value of spinal computed tomography in diagnosis of herniated lumbar discs

Summary In this study the diagnostic value and topographical accuracy of spinal computed tomography (CT) in the preoperative diagnosis of lumbar disc herniations were tested in 36 patients with surgically proven herniated discs. All patients also underwent metrizamide myelography. CT findings and myelograms were compared and correlated with the surgical observations. Especially in demonstrating exact diagnosis (lateral or more medial protrusion), and in showing the extent of upward or downward displacement of free disc material, CT provides valuable preoperative information. As a non-invasive diagnostic procedure, spinal CT scan may replace lumbar myelography in many patients with radicular lumbar pain.     

Diagnosis and microsurgical approach to far-lateral disc herniation in the lumbar spine

Lumbar-disc herniations that occur beneath or far lateral to the intervertebral facet joint are increasingly recognized as a cause of spinal nerve root compression syndromes at the upper lumbar levels. Failure to diagnose and precisely localize these herniations can lead to unsuccessful surgical exploration or exploration of the incorrect interspace. If these herniations are diagnosed, they often cannot be adequately exposed through the typical midline hemilaminectomy approach. Many authors have advocated a partial or complete unilateral facetectomy to expose these herniations, which can lead to vertebral instability or contribute to continued postoperative back pain. The authors present a series of 25 patients who were diagnosed as having far lateral lumbar disc herniations and underwent paramedian microsurgical lumbar-disc excision. Twelve of these were at the L4-5 level, six at the L5-S1 level, and seven at the L3-4 level. In these cases, myelography is uniformly normal and high-quality magnetic resonance images may not be helpful. High-resolution computerized tomography (CT) appears to be the best study, but even this may be negative unless enhanced by performing CT-discography. Discography with enhanced CT is ideally suited to precisely diagnose and localize these far-lateral herniations. The paramedian muscle splitting microsurgical approach was found to be the most direct and favorable anatomical route to herniations lateral to the neural foramen. With this approach, there is no facet destruction and postoperative pain is minimal. Patients were typically discharged on the 3rd or 4th postoperative day. The clinical and radiographic characteristics of far-lateral lumbar-disc herniations are reviewed and the paramedian microsurgical approach is discussed.     

Thoracic disc herniation mimicking acute lumbar disc disease

STUDY DESIGN: Case report of a 49-year-old woman with a lower thoracic disc herniation mimicking acute lumbosacral radiculopathy. OBJECTIVE: To describe an unusual case of thoracic disc herniation mimicking acute lumbar disc disease. SUMMARY OF BACKGROUND DATA: Symptomatic thoracic disc herniation is rare and its clinical manifestations differ widely from those of cervical and lumbar disc herniations. Midline back pain and signs of spinal cord compression progressing over months or years are the predominant clinical features. Acute and subacute thoracic disc herniation occurs in less than 10% of patients, and isolated root pain is unusual. METHODS: A 49-year-old woman had acute low back pain radiation into the left buttock and the lateral aspect of the left leg and left foot. Magnetic resonance imaging study showed a bulging disc and posterior osteophytes at T11-T12. RESULTS: Surgical removal of the herniated disc and osteophytes rapidly relieved her symptoms and neurologic deficits. A follow-up neurologic examination 3 years later showed normal motor and sensory functions, although low back soreness was noted occasionally. CONCLUSION: A case of thoracic disc herniation mimicking an acute lumbosacral radiculopathy is presented. Compression of the lumbosacral spinal nerve roots at the lower thoracic level after exit from the lumbar enlargement may be the mechanism for this unusual presentation.     

Concomitant sacroiliac joint pain in patients with lumbar disc herniation: case series

Recent studies have shown that not all lumbar disc herniations are symptomatic and that when followed longitudinally, these patients develop back pain independent of the previous imaging study. This is a case report of two patients with radicular symptoms and lumbar disc herniations that underwent diagnostic injections to locate their pain generator. Both patients failed to respond to transforaminal epidural steroid injections. Transforaminal injections can be diagnostically sensitive for radicular pain but not specific. This is a direct result of the spread of medication to other levels in the epidural space, thus affecting multiple levels of innervation. Follow-up with two sacroiliac injections gave significant relief of their pain. They were both treated conservatively for sacroiliac joint pain and did well. One remained pain free after several months and the second remained with minimal pain until she presented again in her 3rd month of pregnancy with return of her pain. The differential diagnosis of lumbar radicular pain is discussed as well as the authors' experience in using diagnostic injections.     

Results of anterior and posterior approaches for removal of cervical spondylosis and herniated discs

Summary The present series (years 1975–1978) consists of 53 operated patients, 42 of whom had spondylosis and 11 cervical disc herniations. Of the patients with spondylosis 17 had also a narrow spinal canal. One disc patient had stenosis of the spinal canal (Table 1). The anterior approach was carried out according to Cloward's procedure and the posterior approaches included operating of the respective root canals and removal of ventral spondylotic masses with a microdrill or Epstein's spoons. The operation route was selected according to medial or lateral situation of the osteophytes or the herniated disc. The criterion of operation was radicular pain, motorweakness or spasticity that persisted despite conservative treatment and when there was evidence of spinal cord compression. Prior to operation all patients were studied by means of myelography and EMG. Of the total 53 patients, 43 recovered completely or considerably, nobody became worse and neurologic deficits did not progress postoperatively. The results were good in 18 of the 23 patients treated by the Cloward procedure and in 25 of the 30 laminectomized patients.All patients with herniated disc recovered completely or considerably while only 32 of the 42 patients with spondylosis recovered (Table III).The complications of each procedure were not serious and only one patient, whose wrong disc interspace was operated on did not recover (Table IV). The follow-up time was rather short for the whole series, being less than two years. Later recurrences may be possible. It is our belief that operation in selected cases is a useful method for relief of symptoms of cervical spondylosis or herniated disc and both anterior and posterior routes are necessary within the armamentarium of a neurosurgeon in order to deal easily and safely with both ventral and lateral spondylotic or herniated disc masses.Presented at the 31. Scandinavian Neurosurgical Society Meeting in Oulu, June 13–16, 1979.     

Percutaneous automated discectomy: a new method for lumbar disc removal. Technical note

A new technique for percutaneous lumbar disc removal is described. The specially designed 2-mm blunt-tipped suction/cutting probe (nucleotome) is similar to the automated vitrectomy instrumentation used by ophthalmic surgeons. The procedure is performed under local anesthesia, with the patient in the prone position and with fluoroscopic guidance. The nucleotome is inserted into the appropriate disc space with specially designed instrumentation, guided by landmarks similar to those used in needle placement for chemonucleolysis. The technique has been evaluated in 20 patients with herniated discs (one at the L3-4 level and 19 at the L4-5 level) confirmed by myelography and/or computerized tomography scans after all conservative therapy for primarily radicular pain had failed. From 1 to 7 gm of disc material was removed in an average total operative time of approximately 1 hour. Eighty percent of the patients had good to excellent results in a short-term follow-up period of 6 months. Four patients subsequently required standard surgical excision of free disc fragments. No significant complications occurred. The procedure is contraindicated in patients with extruded or free fragments of disc in the spinal canal or in patients with herniations at the L5-S1 level pending development of additional instrumentation for insertion at that level. More extensive long-term studies are needed to further evaluate this procedure.     

极外侧腰椎间盘突出症的分型治疗

目的评价2种不同的手术方式治疗不同部位的极外侧腰椎间盘突出症的效果。方法极外侧腰椎间盘突出症11例,按突出部位分为椎间孔内型和椎间孔外型椎间盘突出,椎间孔内型椎间盘突出采用后路关节突切除,切除椎间盘、椎间植骨融合内固定术;椎间孔外型椎间盘突出采用经横突间入路单纯椎间盘切除术。结果横突间入路进行椎间盘切除平均手术时间50min,平均出血量180ml;后路椎间植骨融合内固定手术平均出血量330ml,平均手术时间120min。所有患者术后下肢疼痛症状均明显减轻或消失,神经根牵拉试验正常。经过平均术后12个月的随访,除2例术前部分肌力恢复不良外,其余患者恢复正常生活和工作。结论极外侧腰椎间盘突出症根据不同的突出部位分为2种类型,适宜采取不同的手术方式。     

腰椎间盘源性疼痛机理的临床研究

目的 :分析腰椎间盘突出症病人的临床症状、体征与椎间盘和神经根大体病理形态改变的关系 ,临床症状、体征和椎间盘突出类型与髓核中炎症介质 (磷脂酶A2 )水平的关系以及临床症状、体征和椎间盘突出类型与脑脊液 (以下简称CSF)中神经肽类递质变化的关系。从临床角度探讨腰椎间盘突出症疼痛机理。材料与方法 :分析161例腰椎间盘突出病人的髓核突出类型及神经根病理形态改变与腰腿痛程度的关系 ;分析 2 0例腰椎间盘髓核组织中磷脂酶A2 活性水平与神经根性疼痛程度的关系 ;3 1例腰椎间盘突出症病人脑脊液中P物质和降钙素基因相关肽含量与神经根性疼痛程度进行比较。结果 :①腰椎间盘的膨出、突出、脱出和脱出游离各组之间无疼痛程度的统计学显著差异。而神经根呈急性炎症反应的病人中重度疼痛高达 80 % (P <0 .0 1)。②腰椎间盘突出症病人椎间盘髓核中磷脂酶A2 活性显著高于自身血液中和健康人椎间盘髓核中磷脂酶A2 活性水平 ,腰椎间盘突出症病人的腰腿痛程度与其髓核中磷脂酶A2 活性明显相关。③腰痛病人脑脊液中P物质和降钙素基因相关肽水平高于正常对照组 ,并与疼痛等级有关。结论 :①腰椎间盘突出物的病理形态和对神经根的机械压迫与其引起的临床疼痛症状和神经根体征无明确关系 ,而神经根性疼痛与局部     

Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review

The effectiveness of surgery in patients with sciatica due to lumbar disc herniations is not without dispute. The goal of this study was to assess the effects of surgery versus conservative therapy (including epidural injections) for patients with sciatica due to lumbar disc herniation. A comprehensive search was conducted in MEDLINE, EMBASE, CINAHL, CENTRAL, and PEDro up to October 2009. Randomised controlled trials of adults with lumbar radicular pain, which evaluated at least one clinically relevant outcome measure (pain, functional status, perceived recovery, lost days of work) were included. Two authors assessed risk of bias according to Cochrane criteria and extracted the data. In total, five studies were identified, two of which with a low risk of bias. One study compared early surgery with prolonged conservative care followed by surgery if needed; three studies compared surgery with usual conservative care, and one study compared surgery with epidural injections. Data were not pooled because of clinical heterogeneity and poor reporting of data. One large low-risk-of-bias trial demonstrated that early surgery in patients with 6–12 weeks of radicular pain leads to faster pain relief when compared with prolonged conservative treatment, but there were no differences after 1 and 2 years. Another large low-risk-of-bias trial between surgery and usual conservative care found no statistically significant differences on any of the primary outcome measures after 1 and 2 years. Future studies should evaluate who benefits more from surgery and who from conservative care.     

A retrospective analysis of the efficacy of epidural steroid injections

Forty patients were studied retrospectively to evaluate the effect of epidural steroid injections on low back pain and sciatica characteristic of spinal stenosis or a herniated lumbar disc. All but one of these patients had radicular symptoms. The average age was 55 years, and the average follow-up time was eight months. All patients were injected by the same anesthesiologist with 2 cc of Depomedrol-40. Thirty-six patients received either one, two, or three injections. Four patients received either four or five injections. The overall results were poor, with about 60% of patients reporting varying degrees of relief from leg and back pain immediately after injection. However, at follow-up examination, only 24% were asymptomatic; 40% reported no change in preinjection numbness, weakness, or pain; and approximately 35% had varying degrees of relief with no consistent pattern. Of those who had complete relief, there was no correlation between relief of pain, age, or number of injections. From this study, it appears that approximately 50% of patients with radicular symptoms may receive temporary relief with steroid injection. However, long-term relief occurs in less than 25% of patients.     

Anterior lumbar microdiscectomy and interbody fusion for the treatment of recurrent disc herniation

OBJECTIVE: To demonstrate the feasibility of anterior lumbar microdiscectomy in patients with recurrent, sequestered lumbar disc herniations. METHODS: Between 1997 and 1999, six patients underwent a muscle-sparing "minilaparotomy" approach and subsequent microscopic anterior lumbar microdiscectomy and fragmentectomy for recurrent lumbar disc extrusions at L5-S1 (n = 4) or L4-L5 (n = 2). A contralateral distraction plug permitted ipsilateral discectomy under microscopic magnification. Effective resection of the extruded disc fragments was accomplished by opening the posterior longitudinal ligament. Interbody fusion was performed by placing cylindrical threaded titanium cages (n = 4) or threaded allograft bone dowels (n = 2). RESULTS: There were no complications, and blood loss was minimal. Follow-up magnetic resonance imaging revealed complete resection of all herniated disc material. Plain x-rays revealed excellent interbody cage position. Radicular pain and neurological deficits resolved in all six patients (mean follow-up, 14 mo). CONCLUSION: Anterior lumbar microdiscectomy with interbody fusion provides a viable alternative for the treatment of recurrent lumbar disc herniations. Recurrent herniated disc fragments can be removed completely under direct microscopic visualization, and interbody fusion can be performed in the same setting.     

Herniated lumbar disc in patients over the age of fifty

Fifty patients ranging in age between 50-78 years (mean, 56) underwent surgery for a herniated lumbar disc between January 1986 and July 1988. All had objective clinical and radiographic evidence of a herniated disc. All had had failure during an appropriate period of conservative treatment. Far lateral herniation occurred in 8%, and 28% had disc herniations at L2 or L3. Surgical results were 64% excellent, 28% good, 6% fair, and 2% poor. Complications including urinary tract infection, wound infection, myocardial infarction, and pulmonary embolism were observed in 8% of patients. Lumbar disc herniation in the elderly is common. After thorough evaluation to exclude neoplasm or infection, decompression of neural structures can lead to 90% good to excellent results. Spinal stenosis must be carefully considered both preoperatively and intraoperatively. Also, a higher incidence of more cephalad lumbar herniations and far lateral herniations was observed in older patients.     

Experiences with lumbar disc herniations in adolescents

AIM: Lumbar disc herniation is rare in adolescents and often misread. The difference of etiology, symptoms and therapy in comparison to adults were investigated and the long-term outcome of conservative and surgically treatment evaluated. METHOD: We analysed informations obtained from the medical records of 51 patients younger than 20 years with 79 lumbar disc herniations. For the long-term follow-up we prepared a questionnaire composed of general questions about the patient's lifestyle, pain level and remaining symptoms. RESULTS: The average period from the beginning of the symptoms to the finding of the right diagnosis took about 14,3 months. We compared disc herniations in adolescents with the current literature of disc herniations in adults and found differences in etiology and symptoms. In 16 % of our patients the beginning of the pain was associated with a trauma, in 12 % the pain began during sports activity (microtrauma). In 49 % we found radiological signs of spinal aberrations. Low back pain and monoradicular sciatica were the main complaints, but findings of neurological deficits were rare. 27 patients were managed conservatively and 24 surgically. On the day of discharge 94 % of patients reported excellent or good results. The outcomes of the follow-up period were similar in both treatment groups. Almost all patients were able to attain a normal activity level and few reported restrictions of their daily life. The success rate of the pain frequency was 85 % and pain intensity was 81 %. CONCLUSION: The etiology of lumbal disc herniations in adolescents has a multifactoral basis. Conservative treatment should be pursued as a mainstay of treatment. Only if conservative treatment fails, surgical treatment should be considered.