Alcocer Maldonado, José Luis¹,²; Domínguez Gasca, Luis Gerardo¹,³; Domínguez Carrillo, Luis Gerardo⁴

Language: English/Spanish [Versión en español]
References: 5
Page: 165-167
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ABSTRACT

Lateral extreme disc herniations represent between 0.7 and 11.7% of all lumbar herniations classified as intraforaminal or extraforaminal, with respect to the foramen, described by Abdullah in 1974; the L4/L5 level is commonly affected. The dorsal root ganglion compression is the cause of the pain intensity; pain irradiation does not always occur in the dermatomal segment corresponding to the image, reported in more than 60% in the immediate root proximal to the extreme lateral lumbar disc herniation. Extreme lateral lumbar disc herniation.

INTRODUCTION

Extreme lateral disc herniations represent between 0.7 and 11.7% of all lumbar herniations described by Abdullah in 1974. The L4/L5 level is the most frequent; pain radiation does not always occur in the dermatome corresponding to the herniation, being reported in more than 60% of cases in the root immediately proximal to the disc herniation.

CLINICAL CASE

A 21-year-old female, who eight days prior developed disabling left sciatic pain preventing ambulation. Examination revealed: hypoesthesia in the left L4 territory, positive left Lasègue at 10°; diminished left patellar reflex, normal Achilles reflex; normal capillary refill and pulses. The magnetic resonance imaging showed an extraforaminal L5/S1 disc with left "extreme" lateral migration.

Surgical intervention was performed via hemilaminectomy with left L5 foraminotomy, finding the root normal throughout its course; the L4/L5 facet was partially removed, finding the extruded disc in the lower internal part of the L4 root. The extruded disc was entirely removed, leaving the root free. Evolution showed total disappearance of pain, and she was discharged 24 hours later (Figures 1 and 2).

COMMENTS

Extreme lateral extraforaminal disc herniation¹ (ELEDH) is defined as that occurring below or lateral to the vertebral facet; its incidence varies from 0.7 to 11.7%. The largest series of ELEDH correspond to Porchet and collaborators² (178 cases), Epstein¹ (170 cases), and Abdullah and colleagues³ (138 cases). Two series describe that the highest frequency is found at L4/L5, followed by the L5/S1 level, except in Porchet's group, which mentions a higher frequency at L3/L4.

Regarding symptoms, pain—whether sciatic or femoral—is the dominant symptom of radiculopathy; pain radiation does not always occur in the dermatome corresponding to the image, being reported in more than 60% of cases in the root immediately proximal to the position of the ELEDH. In the L2/L3 and L3/L4 levels, it usually only causes low back pain (76.2%), whereas in the lower levels, moderate or severe root compression symptoms originate more frequently (59.6%). The femoral nerve traction test is positive in 84.4%; motor deficits are more frequent (78.8%) than sensory ones (46.6%), generally of the monoradicular type.

A definitive diagnosis is only possible with imaging and instrumental investigation,³ with magnetic resonance imaging being the method of choice in diagnosis. Compression of the nerve root by the herniated disc in the extraforaminal area is clearly demonstrated in nine out of 10 cases when compared to the asymptomatic contralateral side using oblique lumbar magnetic resonance imaging.⁴

Regarding treatment, Epstein¹ compared the indications and benefits of various surgical approaches in 170 patients (average age 55 years) with lumbar disc herniations (LDH) identified by magnetic resonance imaging and computed tomography; with an intertransverse approach, good or excellent results reached 79% compared to facetectomy approaches (70%) and minimal laminectomy plus additional hemilaminectomy (68%). In the treatment of extreme lateral discs, total facetectomy provides the best exposure but increases the risk of instability. The new endoscopic transfacet approach⁵ is currently implemented.

REFERENCES

1. Epstein NE. Evaluation of varied surgical approaches used in the management of 170 far-lateral lumbar disc herniations: indications and results. J Neurosurg. 1995; 83 (4): 648-656. Available in: doi.org/10.3171/jns.1995.83.4.0648

2. Porchet F, Fankhauser H, de Tribolet N. Extreme lateral lumbar disc herniation: clinical presentation in 178 patients. Acta Neurochir. 1994; 127: 203-209. Available in: doi.org/10.1007/BF01808767

3. Abdullah AF, Wolber GP, Warfield RJ, Gunadi IK. Surgical management of extreme lateral lumbar disc herniations: review of 138 cases. Neurosurgery. 1988; 22: 648-653.

4. Kim DG, Eun JP, Park JS. New diagnostic tool for far lateral lumbar disc herniation: the clinical usefulness of 3-tesla magnetic resonance myelography comparing with the discography CT. J Korean Neurosurg Soc. 2012; 52 (2): 103-106. Available in: doi.org/10.3340/jkns.2012.52.2.103

5. De Zavalía M, Gobbi E, Yeregui S. Hernia extraforaminal en el espacio L5-S1 tratada por abordaje transfacetario endoscópico. Presentación de un caso y nota técnica. Rev Asoc Argent Ortop Traumatol. 2024; 89: 70-75. Disponible en: doi.org/10.15417/issn.1852-7434.2024.89.1.1856

AFFILIATIONS

¹ Hospital Angeles León. León, Guanajuato. México.

² Neurocirujano. División de Cirugía. ORCID: 0009-0001-7173-3418.

³ Ortopedista. Cirugía articular. División de Cirugía. ORCID: 0000-0002-4773-2140.

⁴ Especialista en Medicina de Rehabilitación. Catedrático de la Facultad de Medicina de León, Universidad de Guanajuato. México. ORCID: 0000-0002-1985-4837

If you wish to consult the supplementary data for this article, please contact editorial.actamedica@saludangeles.mx

CORRESPONDENCE

Dr. Luis Gerardo Domínguez Carrillo. Correo electrónico: lgdominguez@hotmail.com

Received: 2024-08-12. Accepted: 2024-10-07.