Postoperative intraradicular lumbar disc herniation: A case report

An unusual case is presented in which a fragment of herniated lumbar disc was found within the sheath of the right S-1 nerve root. Diagnosis of intradural and intraradicular lumbar disc herniation is difficult, so that it is rarely suspected preoperatively. Surgical treatment results in a satisfactory clinical outcome.     

Intraradicular herniation of a lumbar disc: a case report

The authors report an unusual case of intraradicular lumbar disc herniation. A large fragment of lumbar disc was found within the sheath of the right S1 nerve root. Surgical treatment results in a satisfactory clinical outcome. The literature on intradural and intraradicular lumbar disc herniation is reviewed.     

极外侧型腰椎间盘突出症诊治

目的对极外侧型腰椎间盘突出症的诊治进行分析,进一步提高对该病的认识。方法采用不同手术入路治疗12例极外侧型腰椎间盘突出症。结果3例出现延误诊断。12例均获得随访,优11例,良1例。结论极外侧型腰椎间盘突出症常累及同序数神经根,CT扫描是较好的检查手段;手术可选取不同的术式,单纯极外侧者以椎旁肌间隙为佳。缺乏系统认识是其延误诊断的主要原因。     

显微内窥镜下微创治疗椎间孔外型腰椎间盘突出症

目的探讨显微内窥镜下微创治疗椎间孔外型腰椎间盘突出症的可行性。方法对15例椎间孔外型腰椎间盘突出症手术患者进行回顾性分析。突出间隙:L3~46例,L4~59例。手术选择后侧旁正中入路,采用MED系统完成神经根探查、减压和椎间盘髓核摘除。结果15例术后随访6~12个月,平均8·3个月。采用改良Macnab标准评价:优8例,良5例,可2例,优良率86·7%。结论显微内窥镜下微创经后侧旁正中入路治疗椎间孔外型腰椎间盘突出症具有创伤小、手术时间短、恢复快等特点,是一种安全有效的手术方法。     

A pure fluid-filled intradural cyst associated with intradural disc herniation and possible pathogenesis: a case report

Background contextLumbar intradural disc herniation (IDH) is rare, and intradural cyst associated with IDH is quite rare. Only seven cases of an intradural cyst associated with lumbar disc herniation have been reported, and all were gas-filled cysts. We report the first case, to our knowledge, of a fluid-filled intradural cyst associated with IDH.PurposeTo report an extremely rare case of a fluid-filled intradural cyst associated with lumbar IDH and suggests the possible pathogenesis.Study designCase report.MethodsAn 82-year-old woman presented with right leg pain and motor weakness. Computed tomography and magnetic resonance imaging (MRI) scans showed calcified lumbar disc herniation and an intradural cystic mass at the L1–L2 level. An MRI, which was performed 2 years before admission, showed an IDH without a cyst at the same level.ResultsSurgical resection of the intradural cyst was performed. Intraoperative finding showed a fluid-filled intradural cyst with 1-cm diameter of displacing nerve rootlets. The cyst was connected with extradural cystic components through a ventral dural hole, but the tract was blocked by fibrous septum. Histopathologic examination showed a pseudocyst that consisted of degenerative cartilaginous and fibrous tissues, including degenerative disc materials. We concluded that the cyst was an intradural cyst transformed from the intradural disc fragment.ConclusionsThe current case is the first report to our knowlege of a fluid-filled intradural cyst associated with IDH. The possible mechanism may be focal degeneration and spontaneous absorption of the intradural disc with fluid production. Unlike the gas-filled intradural cysts, the cause of the pure fluid-filled cyst may be disconnection from the intervertebral vacuum because of a calcified disc and septation of the cyst.     

经椎问孔选择性神经根阻滞在复杂腰椎间盘突出症责任节段确定的应用

目的探讨经椎间孔选择性神经根阻滞技术应用于腰椎间盘突出症,以明确诊断及责任节段,为进一步手术治疗提供依据。方法42例复杂的腰椎间盘突出症患者进行47次选择性神经根阻滞,对可疑责任节段进行经椎间孔选择性神经根阻滞,根据患者症状改善情况明确腰腿痛的责任节段,并以此为依据进行手术治疗。结果93％（39／42）的患者结果为阳性,1例假阳性为隐匿性股骨颈骨折。神经根阻滞前下肢放射痛VAS评分为8．12＋1．43,选择性阻滞后下肢放射痛VAS评分改善为2．31±1．63。而后36例进行手术治疗。结论对于诊断复杂的腰椎间盘突出症,在常规诊断依据的基础上进行经椎问孔选择性神经根阻滞,能够明确诊断,为进一步手术治疗方案的确定提供了明确可靠的依据。     

The lateral microsurgical approach to the “extracanalicular” lumbar disc herniation

Summary The main aim in the surgery of the canalicular and extra-canalicular lumbar disc herniation is to remove safely the hidden fragment without complete destruction of the normal facet joint, without damage to the nerve root and with minimal compromise of the stability of the spinal column.This report describes a lateral approach for operations of extracanalicular lumbar disc herniations in which full visual control allows a decompression of the respective spinal nerve or ganglion and removal of the herniated disc. With this approach, there is minimal resection of bone and facet joint and minimal risk of injury to neural structures. If necessary, this approach can easily be combined with the classical interlaminar exposure.     

开放手术观察腰椎间盘突出症溶核失败45例分析

目的 通过开放手术观察分析椎间盘髓核化学溶解术治疗腰椎间盘突出症失败原因。方法 收集溶核失败的腰椎间盘突出症45例行开放手术治疗。结果 术中见45例硬膜外脂肪完全消失，43例髓核未见溶解，2例髓核溶解呈糊状但未被吸收，21例伴有侧隐窝狭窄，15例突出物与神经根粘连，20例黄韧带增厚，2例椎管骨性狭窄，14例突出物钙化。结论 腰椎间盘突出症病变间隙合并有侧隐窝狭窄、神经根粘连、椎管狭窄、突出物钙化等，不是溶核治疗的适应证。     

Intraoperative ultrasound imaging in lumbar disc herniation surgery

Summary The diagnosis of lumbar disc herniation has improved with metrizamide rhizography and CT. Also, visualization of the operative site has been enhanced with use of the operating microscope. However, evaluation of the completeness of herniated disc removal can be difficult, especially in the case of medially located lesions. Also, intradural extension of the herniation can be impossible to rule out in some cases without intradural exploration. Intraoperative ultrasound imaging is safe, rapid and readily available in most hospitals. Its application to real-time imaging control of 10 selected cases of herniated lumbar disc showed that the herniated material could be visulalized in relation to the interspace and dural sac in all cases. The effect of removal of the herniation on nerve root compression could also be evaluated. Especially in cases involving extension of the herniation to the medial region under the dura, or into the intradural space, the removal of herniated material could be adequately confirmed without the need for further manipulation with surgical instruments. With appropriate transducer design and frequency, the method can be applied to microsurgical technique to rule out sequestration outside of the surgical exposure.     

腰椎间盘突出症合并足下垂的外科治疗

目的：探讨腰椎间盘突出症合并足下垂的临床特点和外科治疗效果。方法：回顾分析我科1995年至2004年期间治疗的34例腰椎间盘突出症合并足下垂患者的临床资料，合并足下垂患者占同期同期收治腰椎间盘突出症1545例的2．2％。均行手术治疗，其中20例采用半椎板切除突出椎间盘摘除术，8例采用全椎板切除突出椎间盘摘除术，4例行间盘切除，椎弓根钉内固定，后外侧植骨融合术，另2例行内窥镜下病变节段椎间盘切除术。所有患者围手术期均辅以静脉滴注甲基强的松龙治疗。结果：术中可见受压神经根均有不同程度增粗，无并发症发生。术后随访3个月至5年，平均38个月，无复发病例。按患足背伸肌力较术前恢复程度评定，疗效优18例，良12例，可2例，无恢复2例。结论：腰椎间盘突出症合并足下垂患者选择合理的手术方式，围手术期应用甲基强的松龙，治疗效果较好。     

后路显微内窥镜治疗腰椎间盘突出症

目的 探讨后路显微内窥镜系统治疗腰椎间盘突出症的疗效。方法 总结自2002年10月以来，采用MED治疗腰椎间盘突出症58例，其中合并神经根管狭窄18例，评价其疗效。结果 24例患者术后次日原有腰腿痛症状消失．21例明显减轻。术后4～13个月的随访，根据疗效评定标准：优31例，良26例．进步1例。结论 MED治疗腰椎间盘突出症具有手术视野清晰．操作更为安全．攒伤小，不影响脊柱的稳定性，具有减压彻底．疗效显著等优点，同样适用合并神经根管狭窄。     

腰椎间盘突出症的再手术治疗

目的　探讨腰椎间盘突出症术后再手术治疗的原因、方法和疗效。　方法　 1993年 1月至2 0 0 0年 1月共手术治疗腰椎间盘突出症 76 4例 ,其中再手术者 42例 (5 5 % )。再手术方式为经原椎板间扩大开窗切除椎间盘 2 5例 ,半椎板切除减压椎间盘切除 6例 ,全椎板切除减压椎间盘切除 9例 ,前路经腹膜外椎间盘切除 2例。　结果　 42例均获得随访 ,随访时间 2 0月～ 81月 ,平均 5 2月。按Macnab疗效评定标准 ,优19例 (45 3% )、良 14例 (33 3% )、可 6例 (14 3% )、差 3例 (7 1% )。　结论　腰椎间盘突出症再手术主要原因为术后椎间盘突出复发 ,术前及术中突出节段定位错误 ,术后出现腰椎节段性不稳定以及合并神经根管狭窄、侧隐窝狭窄和中央椎管狭窄。如果再手术时机及再手术方式选择适当 ,腰椎间盘突出症的再手术治疗仍可以获得较为满意的疗效。     

临床症状与髓核突出左右不一致的腰椎间盘突出症的诊治

目的探讨腰椎间盘突出症导致非对称性下肢放射痛的可能原因及术式的选择。方法25例经SCT、MRI检查证实为突出侧与临床症状侧别左右不一致的腰椎间盘突出症患者，均行手术治疗，其中14例行双侧开窗减压探查髓核摘除术，11例仅行突出侧开窗术。结果影像学上髓核突出侧别与术中所见相吻合，但该侧神经根未见到明显压迫或炎性水肿等病理表现；而症状侧无髓核突出，5例神经根未发现异常表现，9例存在不同程度的炎性水肿，其中6例探查发现神经根与对侧髓核不同程度粘连。术后所有患者症状均得到缓解，经过1～5年（平均2．4年）的随访，均无复发。结论SCT结合MRI检查有助于此类腰椎间盘突出症的明确诊断。纤维环无破裂的突出型腰椎间盘突出症，单纯突出侧减压可以获得较好的治疗效果；纤维环破裂的游离型及脱出型腰椎间盘突出症，宜同时行对侧开窗探查。     

高位腰椎间盘突出症

报告39例高位腰椎间盘突出症。L1-22例，L2-33例，L3-434例。均行手术治疗。术后平均随访4年5个月，疗效优25例，良10例，可3例，差1例。从发病机理、解剖结构及临床特点讨论了高位腰椎间盘突出症的诊断和治疗，并提出了术中的注意点及二次以上手术的预防。     

手术治疗高位腰椎间盘突出症60例

目的探讨高位腰椎间盘突出症的临床特点、诊断及治疗方法。方法60例高位腰椎间盘突出症患者中,15例行全椎板减压髓核摘除内固定,8例行半椎板减压髓核摘除,7例行双侧开窗髓核摘除,3例行经峡部外缘入路髓核摘除,27例行单侧开窗髓核摘除（其中神经根管扩大6例）。结果60例均获随访,时间6～36个月。术中硬脊膜破裂脑脊液漏3例,无神经损伤病例出现。参考陆裕朴疗效评定标准：优50例,良8例,可2例,优良率96.7%。结论高位腰椎间盘突出症的临床表现复杂,应根据临床查体结合影像学检查选择手术入路。对于年轻、单节段及旁侧型的椎间盘突出症者选择单侧开窗或半椎板减压髓核摘除;对多间隙、中央型突出髓核大者选择双侧开窗或全椎板减压髓核摘除加内固定。     

椎间盘镜与自制微型器械联合应用治疗腰间盘突出症

目的：介绍椎间盘镜与微型器械联合应用治疗复杂性腰椎间盘突出症,方法：40例复杂性腰椎间盘突出症患者,经脊柱后路显微内窥镜下,应用自制微型骨刀或微型环切除增生内聚的小关节突和钙化的椎间盘组织,行侧隐窝及神经根管扩大术。结果：术后随访3－6个月,按Nakai分级标准评定：优34例,良4例,可2例,优良率为95％,结论：改良手术器械的使用,扩大了椎间盘镜的适用范围,创伤小,操作安全。     

极外侧型腰椎间盘突出症的特征及分型 --附36例报告

目的：探讨极外侧型腰椎间盘突出症的特征及分型。方法：对36例极外侧型腰椎间盘突出症患者的临床症状、体征及影像学结果逐项进行分析。结果：发现极外侧型腰椎间盘突出症具有症状重、体征明显、多损伤同位神经根，一半以上损害两神经根以及保守治疗效果差等特征。根据影像学突出物的位置作者将其分为3型：即神经根管型、外口型和混合型。根据不同的类型，采取不同的手术方式，取得了良好的效果。结论：极外侧型腰椎间盘突出症症状重，保守治疗基本无效，应尽早进行手术治疗。     

直腿抬高试验阴性的腰椎间盘突出症

目的 探讨腰4-5、腰5骶1椎间盘突出症中直腿抬高试验阴性的原因。方法 通过物理检查、影像学表现、手术所见对直腿抬高试验阴性的椎间盘突出症做了直观性的分析。结果 神经根变性、个体致痛性不敏感、突出物位置、病理环境下的神经根病态平衡、患病间隙的椎管容积大、腰背肌的保护性脊柱固定、职业因素等是造成腰椎间盘突出症中直腿抬高试验阴性的主要原因。结论 仔细的分析临床症状，参照影像学的客观性，排除直腿抬高试验阴性的原因是避免腰椎间盘突出症漏诊的重要方法。     

Posterior extrusion of Biocompatible Orthopaedic Polymer (BOP) graft mimicking a calcified lumbar disc herniation: case report

OBJECTIVE AND IMPORTANCE: We present a case of intracanalar extrusion of a L5S1 Biocompatible Orthopaedic Polymer (BOP) graft associated with a L4L5 disc herniation 19 years after a lumbar intersomatic fusion for a L5S1 disc herniation. Radiological aspect of this complication should be recognized by neurosurgeons. CLINICAL PRESENTATION: A 55-year old man presented with a right L5 sciatic pain. Neurological examination found a severe weakness in dorsal flexion of the foot. A lumbar CT scanner disclosed aspects consistent with right L4L5 and huge calcified L5S1 lumbar disc herniation. INTERVENTION: The patient was operated via a bilateral paravertebral approach and a L5 laminectomy. A dense and extensive epidural scarring was seen. The right L4L5 herniated disc was excised. At the left L5S1 level, fibres from a BOP graft had separated into large fragments extruded into the vertebral canal through the dura. The fibres could only be removed partially because of nerve roots adherence. The patient developed postoperative cerebrospinal fluid (CSF) leakage that required a second operation for dural closure. The postoperative course was uneventful and the patient recovered the right L5 root deficit. CONCLUSION: Neurosurgeons should be aware of the radiological aspect of this complication. If it is recognized on CT scan and asymptomatic, conservative management should be proposed because of the risk of nerve roots injury or postoperative CSF leakage.     

经皮内窥镜治疗腰椎间盘突出症的并发症及其处理

目的 总结经皮内窥镜腰椎间盘切除术( PELD)治疗腰椎间盘突出症中出现的并发症,探讨其处理对策.方法 2002年7月至2010年10月采用PELD治疗腰椎间盘突出症患者689例,男性448例,女性241例;年龄13 ～84岁,平均39.8岁.单间隙椎间盘突出669例,双间隙椎间盘突出19例,三间隙椎间盘突出l例.中央型突出66例,旁中央型365例,外侧型242例,极外侧型10例,游离型6例.观察术中和术后并发症及其处理.结果 术中髓核部分残留压迫神经根5例,2例术中改行开窗髓核切除术,2例二期行开窗髓核切除术,1例二期行经椎间孔腰椎体间融合术(TLIF);神经根纤维束部分损伤2例,术后3～6个月内完全恢复;硬脊膜破裂2例,给予缝合皮肤伤口后痊愈.689例患者随访6～96个月,平均33个月.出现椎间隙感染7例,1例保守治疗,4例给予经皮穿刺置管冲洗引流持续局部应用抗生素,2例行后路开窗感染腰椎间盘清除术,均痊愈;术后复发6例,4例患者再次行PELD术,2例患者采用TLIF治疗,术后症状缓解;术后神经根性痛觉过敏和灼样神经根痛19例,经过止痛药物、神经营养药及物理治疗后好转;腰椎管狭窄症行单个节段的PELD术,效果不佳,二期行多节段TLIF治疗10例.结论 术中主要并发症有髓核部分残留压迫神经根、神经根纤维束部分损伤、硬脊膜破裂;术后主要并发症有椎间隙感染、复发、神经根性痛觉过敏和灼样神经根痛等.严格的适应证选择、无菌、熟练操作及术后康复锻炼可以减少并发症的发生.