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

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Menoufiya Medical Journal 196 Surgical Aspects in Management Vol. 21 No . 2 July 2008 Ahmed Azab et al., 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
Menoufiya Medical Journal 197 Surgical Aspects in Management Vol. 21 No . 2 July 2008 Ahmed Azab et al., 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
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