Ahmed Azab , Adel Hanafy , Alaa Essa, Khaled Aref, Hesham ...

Menoufiya Medical Journal 189 Surgical Aspects in Management 

Vol. 21 No . 2 July 2008 Ahmed Azab et al., 

SURGICAL ASPECTS IN MANAGEMENT OF DORSOLUMBAR 

JUNCTION & UPPER LUMBAR DISC LESIONS 

Ahmed Azab *, Adel Hanafy *, Alaa Essa $ , Khaled Aref $ , 

Hesham Abo El Enin $ and Mohamed Fahmy $ 

INTRODUCTION: 

*Minoufiya University & $ Alexanderia University 

Abstract: 

Background: Approximately 5% of lumbar disc herniations occur at the upper levels of the lumbar 

spine & dorsolumbar Junction (D12-L1, L1-2, L2-3, L3-4 levels) although the incidence reported 

in the literature varies from < 1% to 10.4%. This wide discrepancy in the incidence is partly the 

result of non standardized terminology regarding what constitutes an upper lumbar disc herniation. 

Some authors report upper lumbar discs as only D12-L1, L1-2, L2-3 & another as L1-2, L2-3. 

Aim of the work: This study aims at the evaluation of the clinical and radiological condition of the 

upper lumbar disc prolapse & the dorsolumbar junction disc and to evaluate the adequet surgical 

approach posteriorly either just posterior laminectomy only or transpedicular approach. PATIENTS 

AND METHODS: This prospective study included thirty patients with herniated discs at the upper 

lumbar & the dorsolumbar junction operated during the last two years. The posterior surgical 

approach done for the patients included: Decompressive laminectomy alone in patient with 

calcified discs with stenotic canal. Unilateral facetectomy with or without partial or total pedicle 

removal. Discectomy will be done for selected cases. Instrumental fusion was done when needed 

according to preoperativc radiological assessment and the planned surgical procedures. Results: 

Operative procedures: 60% of cases were treated with laminectomy uniletral facetectomy and 

discectomy at the involved level. 30% of cases were treated with laminectomy without discectomy 

due to hard spondylotic bar. In 3 cases constituting 10% at all cases, laminectomy, bilateral 

facetectomy, pediclectomy and discectomy was done followed by transpedicular fixation. 

Postoperatively 24 cases (80%) showed complete relief of their preoperative symptoms while 6 

cases (20%) showed partial relief of their preoperative. Discussion: All the patients were 

subjected to the posterior surgical approach as the most commonly used approach. Also because 

the patients of our study suffered not only isolated upper L.D.P but also, they were associated with 

lower lumbar canal abnormalities including the concomitant lower lumbar canal stenosis and lower 

lumbar disc prolapses, so the surgery was not directed only to the upper L.D.P, but also to the 

associated pathology, which are commonly treated with the posterior surgical approach. 

Disc pathology involving the proximal levels of 

the lumbar spine & dorsolumbar Junction have 

not been appreciated as well before the clinical 

use of magnetic resonance imaging (MRI) scan. 

Review of literature showed that most lumbar 

disc herniations are found in the lower levels. 

Disc herniation at D12-L1, L1-2, L2-3 levels 

were reported in less than 3% of the cases, of 88 

lumbar disc herniations reported by love et al 

two were found in D12-L1 & one in L1-2 & two 

in L 2-3. Scott et al reported that approximately 

MMJ ( July 2008)Vol. 21 N0:2:P 189-198 

5% of lumbar disc herniations occur at the upper 

levels of the lumbar spine & dorsolumbar 

Junction (D12-L1, L1-2, L2-3, L3-4 levels) 

although the incidence reported in the literature 

varies from < 1% to 10.4%. This wide 

discrepancy in the incidence is partly the result 

of non standardized terminology regarding what 

constitutes an upper lumbar disc herniation. 

Some authors report upper lumbar discs as only 

D12-L1, L1-2, L2-3 & another as L1-2, L2-3 (1). 

Those reporting an incidence closer to 1 to 2% of 

all herniated lumbar discs tended not to include 

the L3-4 the L3-4 level in their definition (2).



The clinical presentation of disc proloapse at the 

level of upper lumbar spine & dorsolumbar 

Junction varies from; Low back pain which is 

usually dull aching pain , may be sever and 

causing abdominal pain. Pain exacerbates with 

coughing or valsalva maneuver as it increases the 

intra thecal pressure, Radicular pain in the 

dermatomal sensory distribution at the 

compressed root can be the only pain or 

associated with low back pain, Cauda equine 

compression syndrome due to central mechanical 

compression of the cauda equina, Neurogenic 

claudications as limited walking tolerance, back 

pain, much like patients with lower lumbar canal 

stenosis, Myelopathic manifestations, 

myelopathy with long tract signs, gait 

disturbance, weakness or spasticity, Conus 

medullaries compression resulting in paraparesis 

& even paraplegia with bowel & bladder 

dysfunction (3). 

Diagnostic investigations is very important for 

surgical decision such as plain radiography 

which can indirectly suggest pathology such as 

decreased disc space. The CT scan is one of the 

imaging modalities used for diagnosis of 

herniated lumbar disc in addition to its 

important role in detection of spinal canal 

stenosis. MRI gives excellent visualization of 

root anatomy, disc herniation and fragments 

including foraminal and far lateral pathologies (4). 

AIM OF THE WORK: 

This study aims at the evaluation of the clinical 

and radiological condition of the upper lumbar 

disc prolapse & the dorsolumbar junction disc 

and to evaluate the adequet surgical approach 

posteriorly either just posterior laminectomy 

only or transpedicular approach. 

PATIENTS AND METHODS: 

This prospective study included thirty patients 

with herniated discs at the upper lumbar & the 

dorsolumbar junction operated during the last 

two years. All patients were subjected to the 

following: 

Complete history including the inquirements 

about the age, sex, the onset, duration and nature 

of the complaints, the history of previous 

operations, also any associated diseases in 

addition to inquirement about available 

radiological investigations. 

General examination To assess the conditions 

of the chest, heart, abdomen and lower limbs, 

which is important to determine whether the 

patient is fit for surgery or not. 

Neurological examination including: Evaluation 

of patient's gait. Back examination for 

paravertebral spasm, limitation of movement, the 

lumbosacral angle and curve, any tenderness in 

the back and scar of any previous operations. 

Femoral stretch test is tested in both lower limbs. 

Straight leg raising test is tested in both lower 

limbs and its angle is recorded. Reflex changes is 

examined and recording any absence or 

diminution. Testing any dermatomal loss. 

Routine laboratory investigations including: 

Complete blood count. Liver function tests. 

Renal function tests. Bleeding and coagulation 

profile. Random blood sugar. 

Radiological investigations including: Plain X 

rays of the dorsolumbar and lumbosacral spine 

with Anteroposterior and lateral films, Stress 

films, Oblique films. MRI of the dorsolumbar 

and lumbosacral spine. CT scan was available 

with 50% of the patients on admission. 

The clinical indications for surgery were: 

Progressive neurological deficits. Pain not 

responding to conservative measures. 

The posterior surgical approach done for the 

patients included: 

The patient is under general anesthesia in a 

prone position. Midline back incision and 

incision of the fascia and then retraction of the 

muscles. Intraoperative fluoroscopy used when 

needed for levelling. Decompressive 

laminectomy alone in patient with calcified discs 

with stenotic canal. Unilateral facetectomy with 

or without partial or total pedicle removal.



Discectomy will be done for selected cases. 

Instrumental fusion was done when needed 

according to preoperativc radiological 

assessment and the planned surgical procedures. 

Postoperative follow up clinically and 

radiographically; 

Clinically; as regard the improvement of 

symptoms and signs and occurrence of 

complications including neurological deficits and 

infection. 

Picture( 1 ) MRI LSS showing D12-L1disc prolapse 

Picture( 2 ) MRI LSS showing L1-L2 disc prolapse 

Radiologically; by pain X-ray films of 

dorsolumbar and lumbosacral spine at one month 

and 6 months postoperatively to assess the 

development of segmental instability. 

Postoperative MRI L.S.S will be done when 

needed if patient deteriorated postoperatively.



Picture( 3 ) MRI LSS showing L2-L3 disc prolapse. 

Picture(4) Post operative Plain x ray LSS after L2-L3 discectomy & fixation



RESULTS: 

Table (I): Sex distribution: Males were more affected than females. Males (80%), females (20%). 

Gender No. of patients Percentage 

Males 24 80% 

Females 6 20% 

Total 30 100% 

Table (2): Age distribution: Most of patients affected were in the age group from 40-49 ys. 

Age group (years) No. of patients Percentage 

20-29 1 3.3% 

30-39 9 30% 

40-49 12 40% 

50-59 7 23.3% 

60-69 1 3.3% 

Total 30 100%



Table (3): Clinical picture: Low back pain was the main complaint followed by the crural and 

anterior thigh pain. The most dominant clinical sign was the positive femoral stretch test (70%), 

followed by motor weakness in (60%). The straight leg raising test (SLRT) was positive in 30% 

only with concomitant lower lumber disc affection: 

Symptoms No. of patients Percentage 

Low back pain (L.B.P) 30 100% 

Anterior thigh pain 27 90% 

Sensory changes 15 50% 

Claudication 12 40% 

Sphincteric disturbances 3 10% 

Signs 

Back signs 15 50% 

Positive femoral stretch test 21 70% 

Positive SLRT 9 30% 

Reflex changes 18 60% 

Sensory changes 15 50% 

Motor weakness 18 60% 

Table (4): The level of disc prolapse, the most frequent level affected was the L2-3 level, 

followed by Ll-2 level and lastly D12-L1 level. 

Level No of patients Percentage 

D12-L1 3 10% 

L1-L2 9 30% 

L2-L3 18 60% 

Total 30 100%



Table(5): MRI and CT findings: 

MRI and CT findings No. of patients Percentage 

Diffuse annulus disc bulge 24 80% 

Central hard disc protrusion 6 20% 

Indentation ofthecal sac 30 100% 

Encroachment on lateral recess and nerve root exit 

foraminae 

24 80% 

Caudal migration of disc prolapse 3 10% 

Lumbar spondylo degenerative changes 18 60% 

Concomitant lower lumbar disc prolapse 9 30% 

Concomitant lower lumbar canal stenosis 18 60% 

Sagittal stenosis 18 60% 

Table (6) Operative procedures: 60% of cases were treated with laminectomy uniletral 

facetectomy and discectomy at the involved level. 30% of cases were treated with laminectomy 

without discectomy due to hard spondylotic bar. In 3 cases constituting 10% at all cases, 

laminectomy, bilateral facetectomy, pediclectomy and discectomy was done followed by 

transpedicular fixation. 

Operative procedures 

No. of 

patients 

Percentage 

Laminectomy without discectomy at involved level. 9 30% 

Laminectomy, unilateral facetectomy with discectomy at 

involved level 

Laminectomy, bilateral facetectomy with pediclectomy 

discectomy and transpedicular fixation. 

18 60% 

3 10%



Table (7) Complications: One patient was complicated with dural tear and developed 

postoperative C.S.F. leakage. One patient developed post operative spondylodiscitis. One 

patient developed cauda equina syndrome due to post operative haematoma 

Complications No. of patients Percentage 

C.S.F. leakage 1 3.3% 

Spndylodiscitis 1 3.3% 

Cauda equine syndrome 1 3.3% 

Table (8) Operative outcome: Postoperatively 24 cases (80%) showed complete relief of their 

preoperative symptoms while 6 cases (20%) showed partial relief of their preoperative. 

Postoperative sequel No. of patients Percentage 

Complete relief 24 80% 

Partial relief 6 20% 

DISCUSSION: 

Approximately 5% of lumbar disc herniations 

occur at upper levels of the lumbar spine (L1- 

2,L2-3,L3-4), although the incidence reported in 

the literature varies from < l-10.4% (5 ' 6 ' 7) This 

wide discrepancy in incidence is partly the result 

of non standardized terminology regarding what 

constitutes an "upper" lumbar disc herniation - 

some authors report upper lumbar discs as only 

L1-2and L2-3 (1) . Those reporting an incidence 

closer to 1-2% of all herniated lumbar discs did 

not include the L3-4 level in their definition (2). 

In the present study, the disc herniation at the 

level of L3-4 was not included among our cases 

of upper lumbar disc herniations, so the disc 

prolapses at D12-L1, L1-2 and L2-3 were the 

target of the present study. 

Similarly, Scott P. Sanderson et al in 2004, in 

their study about the unique characteristics of 

upper lumbar disc herniations, reported that disc 

herniations at L3-4 are different in their patient 

population and surgical outcome from those at 

L1-2 and L2-3 levels, and also reported that disc 

herniations at L3-4 are more similar to those 

occurring at L4-5 and L5-S1in their surgical 

outcome and patient population (8). 

The lower incidence of upper L.D.P. may be 

attributed to the decreased motion of the upper 

lumbar spine compared with the lower lumbar 

spine that may lead to less spondylosis, less disc 

degeneration and thus fewer herniated discs (9). 

In the present study, the MRI of L.S.S. was 

regarded as the most important and main 

investigation done for all patients and surgery 

was decided up on it. 

Similarly, Albert et al in 1993, recommended the 

MRI as the main diagnostic tool in the work-up 

of patients with upper L.D.P (10) Also, Mark 

Weidenbaum et al in 2002 reported that MRI has 

become the imaging procedure of choice in



evaluating disc pathology, neural structures and 

muscloligamentous components and also gives 

excellent visualization of root anatomy, disc 

herniation and other conditions that may mimic it 

such as synovial cyst, neurofibroma or perineural 

cyst (11). 

All the patients were subjected to the posterior 

surgical approach as the most commonly used 

approach. Also because the patients of our study 

suffered not only isolated upper L.D.P but also, 

they were associated with lower lumbar canal 

abnormalities including the concomitant lower 

lumbar canal stenosis and lower lumbar disc 

prolapses, so the surgery was not directed only to 

the upper L.D.P, but also to the associated 

pathology, which are commonly treated with the 

posterior surgical approach. Intraoperatively, in 

18 cases constituting (60%), there was a soft disc 

bulge encroaching upon the nerve root exit 

foramine, while in 3 cases constituting (10%) 

there was a sequestrated disc prolpase with 

unilateral encroachment on the nerve root exit 

foramina. But in 9 cases constituting 30% of all 

cases in the present study, there was a hard 

spondylotic bar with a lateral recess stenosis and 

so, the surgical procedure done for this group 

was just a laminectomy and foraminotomy at the 

involved level without discectomy. While in 18 

cases constituting 60% of all cases in the present 

study were subjected to laminectomy (including 

formal and hemilaminectomy) unilateral 

facetectomy and discectomy at the involved 

level. Three cases with disc prolapses at D12-L1 

had an additional surgical procedures aiming to 

gain a lateral access to the disc prolapse with 

avoidance of manipulation to mobilize the 

sensitive neural structures at the upper lumbar 

levels including the conus medullaris and cauda 

equina. These additional surgical procedures 

included bilateral facetectomy with pedicle 

removal which necessitated an additional 

transpedicular fixation of one level above and 

one level below the involved level with 

instrumentation to avoid the late instability. So, 

the instrumental fusion was done for these 

patient depending only on one indication that 

was the extensive facetectomy to avoid the late 

instability. 

However, Scott P. Sanderson et al in 2004 in his 

retrospective study about patients with upper 

L.D.P, he mentioned that the fusion in patients 

with upper L.D.P treated surgically was done if 

the patient had incapacitating back pain, had 

preexisting spondylolisthesis or required such 

extensive facet removal to access the disc that 

predisposed the patient to instability (8). 

In addition, to the surgical intervention at the 

involved level, patients who suffered 

concomitant lower lumbar canal stenosis were 

subjected to decompressive laminectomy at 

lower lumbar levels, those patients were 18 cases 

constituting 60% of all cases of the present 

study. While patients who suffered concomitant 

disc herniation at lower lumbar level were 9 

cases: 5 cases of them were associated with disc 

prolapse at L4/5 level while 2 cases were 

associated with disc prolapse at L3/4 level and 

another two cases at L5/S1 level, and those 

patients were subjected to concomitant surgical 

intervention at the affected level in the form of 

laminectomy and discectomy in addition to 

surgical intervention at the upper lumbar disc 

prolapse. 

Regarding the postoperative sequelae of the 

patients operated in the present study, 24 patients 

(80%) showed complete relief of symptoms 

postoperatively, while 20% of patients showed 

partial relief of their complaints and those 

patients were found to have significant 

neurological deficits preoperatively mainly the 

motor weakness and sphincteric disturbances. 

Among this group of patients that showed partial 

relief of symptoms postoperatively, one patient 

was complicated with unintended durotomy 

intraoperatively and developed C.S.F. leak 

postoperatively which was managed in the ward 

conservatively till the leakage stopped and 

patient was discharged with relief of preoperative 

symptoms. Another patient developed 

postoperative spondylodiscitis and was treated 

with conservative measure and showed relief of 

preoperative symptoms after a period of one



month. One patient was complicated with cauda 

equina syndrome postoperatively, MRI was done 

that showed postoperative extradural hematoma 

compressing the thecal sac, this patient needed 

another immediate intervention for evacuation of 

the hematoma and showed rapid recovery 

immediately after evacuation of the hematoma. 

REFERENCES 

1- Su H, Zucherman J, Shea W. High lumbar 

disc herniation, incidence and etiology. Spine. 

1990;15:679-82. 

2- Bosacco Sj, Berman AT, Raisis LW, 

Zamarin RI. High lumbar disc herniation case 

reports. Orthopedics. 1989;12:275-8. 

3-Lee DY, Kim HS, Lee SH. Multi access for 

diagnosis of missed upper lumbar disc 

herniation. J Korean Neurosurgery Soc. 

2005;38:144-6. 

4- Abrishamkar S, Mansour BA, Arti H. The 

effectiveness of computed tomography scans 

versus magnetic resonance imaging for decision 

making in patients with low back pain and 

radicular leg pain. Journal of Reserch in Medical 

Sciences. Nov & Dec 2006;11 (6):351-4. 

5- Aronson HA, Dunsmore RH. Herniated 

lumbar discs. J Bone Joint Surg.1993;45-A:311-7. 

6- Greenberg M et al. Lumbar spoinal stenosis, 

Handbook of Neurosurgery. 6 th ed. New York: 

Thieme;2006;289-369. 

7- Albert TJ, Baiderston RA, Heller JG, 

Herkowitz HN, Garfin SR, Tomany K, et al. 

Upper lumbar disc herniations. J Spinal Disord. 

1993;6:351-9. 

8- Sanderson SP, Houten J, Errico T, 

Forshaw D, Bauman J, Cooper PR. The 

unique characteristics of upper lumbar disc 

herniation. Neurosurgery. 2004; 55:385-9. 

9- Fontnesi G, Tartalgia I, Cavazutti A, 

Giancecchi F. Prolapse intervertebral disc at the 

upper lumbar level. Ital J Ortop Traumatol. 

1987;13:501-7. 

10- Albert TJ, Baiderston RA,Heller JG, 

Herkowitz HN, Garfin SR, Tomany K, et al. 

Upper lumbar disc herniations. J Spinal Disord. 

1993; 6:351-9. 

11- Weidenbaum M. Lumbar disc herniation 

and radiculopathy. In: Frymoyer JW, editor. 

Adult and pediatric Spine. 3 rd ed. Philadelphia: 

Lipincott- Williams and Willikins; 2004;19:920.

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