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

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