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Franco Postacchini
SPIN: 10674039
In the past ten years, there has been an explosion in devoted to and information provided on not only the
the material published on low back pain. Franco background of lumbar radicular syndromes associated
Postacchini and his group have been active in this area with herniated disc, but also the techniques, both past
for some twenty years. This book represents the experi- and future, in the diagnosis and treatment of this com-
ence of Professor Postacchini and his co-authors and mon problem, as well as their current status.
their vast exposure to the lumbar disc. This unique text- I have enjoyed reading Franco Postacchini's textbook
book offers a broad yet concentrated look at the single and applaud him and his small number of colleagues
topic of lumbar disc herniation. While it is rare indeed on providing us with over 500 illustrations, 2800 refer-
to devote a full textbook to a single topic, lumbar disc ences and significant perspective on a common clinical
herniation deserves such attention. It is the most com- problem for which there remains much uncertainty and
mon diagnosis for which operative intervention occu rs, much variation in practice. It is only through a common
yet on the other hand we know, given time, that lumbar understanding of the epidemiology, the pathogenesis
disc herniation can be treated non-operatively in many and the natural history of disc herniation that we can
patients with equal success. Franco Postacchini and his provide medical decision models, using Bayesian theo-
colleagues have provided us with 24 unique chapters ry, which will enable our patients to understand the
ranging from a wonderful historical perspective probabilities of their treatment options. Furthermore, it
through anatomy, pathophysiology, biochemistry and should be our goal to incorporate into our practice and
biomechanics, and ending with diagnostic imaging treatment patient utilities derived from evidence based
treatment algorithms and complications. Further, they medicine. This approach will allow us to narrow the
have broadened the horizons of the usual discussion of variation patterns currently seen in practice and should
the lumbar disc to provide an insight into the issues of get us the right rate of intervention and the best out-
professional liability co-authored by a physician. The come for patients with herniated disc as their primary
wonderful figures, short tables, and easily read text diagnosis. I am grateful for being given the opportunity
make this an exceptionally useful book for those prac- to congratulate Franco Postacchini and his colleagues
ticing and treating patients with lumbar disc hernia- on this excellent textbook.
tions. The breadth of references in this book are second
to none on this single topic. There has been ample space James N. Weinstein
PREFACE
In recent years many monographs have been published mental aspects of the issue, already widely known to
on the pathologic conditions of the lumbar spine or on the expert, are analyzed. The ambition of this mono-
the surgical techniques used in their treatment. Few graph is to satisfy the requirements of both the expert
books, however, have been devoted to lumbar disc and neophyte. Thus, some chapters, or parts of them,
herniation and perhaps even then the analysis of the may not be of particular interest to the spine specialist,
condition has, as yet, not been really exhaustive. This whilst they are useful to the newcomer to gain insight
volume was initially conceived as a text that might into the topic. It should be pointed out, however, that
gather together all the available information on lumbar lumbar disc herniation is the subject of interest of
disc herniation. While writing the chapters, this aim several specialists, including biochemists, pathologists,
proved to be almost unattainable, at a time when scien- radiologists, neurophysiologists, rheumatologists,
tific literature becomes more and more thorough. physiatrists and orthopaedic surgeons and neurosur-
Nonetheless, I am of the opinion that this monograph geons. Therefore, an expert may also find it useful to
has to a large extent fulfilled its aims. In fact, an attempt refresh his memory on some general aspects, not close-
has been made to analyze, by means of a large number ly related to his speciality, but which could, nonethe-
of bibliographic references, all the aspects related to less, be necessary for a more complete mastery of the
the etiopathogenesis, pathomorphology, diagnosis and topic or for the diagnosis or treatment of particular
treatment of lumbar disc herniation, as well as to the patients.
history of knowledge on sciatica that has been gathered Over the last two decades clinical research and, in
over the centuries and the medicolegal implications in particular, the new imaging techniques, have shown
the treatment of this pathologic condition. that disc herniation may be associated with numerous
Needless to say that the aim of accomplishing an other pathologic conditions, especially lumbar spinal
exhaustive medical monograph can be achieved more stenosis. In this volume, stenotic conditions have also
easily with the involvement of various authors, each been analyzed both as far as concerns the pathomor-
specializing in a particular aspect of the pathologic phologic and diagnostic aspects as well as the indica-
condition. On the other hand, a monograph written by tions and modalities of surgical treatment. The analysis
a single author often has the advantage of providing has inevitably been limited, though it is probably suffi-
greater uniformity in the analysis of a given topic; cient to clarify the reciprocal role of the two conditions
moreover, it has the prerogative of expressing the in the etiology and evolution of lumboradicular
scientific thought and experience of a single indivi- syndromes, as well as in the results of treatment.
dual. In this volume, I endeavored to harmonize both Meanwhile, various methods of percutaneous treat-
approaches. In drawing up certain chapters, I sought ment of lumbar disc herniation have been developed.
the precious help of co-authors, experts in the anatomy Some of these techniques, after a period of considerable
and pathomorphology of the lumbar spine or in the success, have become less and less popular to the point
various physiopathologic and clinical aspects of lum- of being only very occasionally used and, even then,
bar disc herniation, whilst in other chapters I resorted almost exclusively by spine specialists. In this book, I
to my own experience, built up over decades devoted have deliberately given ample space also to these tech-
to the everyday treatment of patients with pathologic niques both on account of their historical importance in
lumbar conditions. In this respect, this volume perhaps the treatment of lumbar disc herniation and because
has no equal in its kind. they are still therapeutically valid, albeit with more lim-
A monograph on one particular pathologic condition ited indications than in the past. Yet another important
may be adressed to a public of experts or to young spe- reason was to give the volume the necessary complete-
cialists or clinicians with little experience, willing to ness to make of it a useful reference book for those
broaden their knowledge in that field. In the first wanting an overall view of the various aspects of
instance, some aspects of the condition are concisely lumbar disc herniation.
analyzed, whereas ample space is reserved for others,
which may appear marginal. In the second, the funda- Rome, October 1998 Franco Postacchini
ACKNOWLEDGEMENTS
I am deeply indebted to all those who, directly or indi- excellent prints from, at times, radiographs, CT or MRI
rectly, helped to conceive and realize this volume. films not of an excellent standard. I greatly appreciated
However, a few persons deserve special thanks, since the paintaking work of Cristina Bugno in reviewing the
without their efforts these endeavors would probably text and checking the correct citation of the large num-
never have been accomplished. I should thank ber of references. I am indebted to Rita Lieri who posed
Gianluca Cinotti and Stefano Gumina who were not for the gymnastics. Marian Shields deserves my great-
only my co-authors in several chapters, but also greatly est and more sincere gratitude for her tremendous help
contributed, with their patient and seemingly obscure in editing the English translation of the Italian version
work, by reviewing the pertinent literature of most of the book. Outstanding help, in this respect, was also
chapters, preparing the subject index and discussing provided by Adriana Shields, Amy Trustman Eve,
with me various aspects concerning not only basic Anna Connealy and Debra Gledenning. Without the
science but also the clinical topics involved here. Salva- extraordinary cooperation of all these friends and col-
tore Urso deserves special thanks for providing most laborators, this book would never have been possible.
of the myelograms reproduced in Chapter 9, as well as May I take this opportunity to acknowledge Raimund
for counseling in the preparation of the part concerning Petri-Wieder and Franz Schaffer from Springer Wien
myelography. New York, who, respectively, accepted to publish, and
I am extremely grateful to Silvia Diracca who tried spared no effort in organizing the printing of the
her best in producing the excellent drawings for the text English version of the volume.
and to Mario Termine, responsible for printing the
photographs, often several times in order to obtain Franco Postacchini
CONTENTS
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. XIV Site of herniation. .. . . . . . . . . . . . . . . . . . . . . .. . . .. . . . . . . 108
Cartilaginous and osteocartilaginous avulsion fractures
of vertebral end-plate. . . . . . . . . . . . . . . . . . . .. . . . . . . . 112
Chapter 1. Historical perspectives Processes of herniation of the disc . . . . . . . . . . . . . . . . . . . 113
F. Postacchini, 5. Gumina Degenerative changes of herniated disc. . . . . . . . . . . . . . 114
The Egyptian-Hebrew period . . . . . . . . . . . . . . . . . . . . . . . 1 Microscopic characteristics of herniated tissue ....... 115
The Greek-Roman period...... . . ... ............. .. . 1 Resorption of disc herniation ....................... 125
The Byzantine and Islamic civilizations ............. 3 Effects of disc herniation on the motion
The Middle Ages and the Renaissance .............. 4 segment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
The 17th and 18th centuries ........................ 4 Disc herniation and morphometric features
The 19th century.................... ............ ... 7 of spinal canal .......... . . . . . . . . . . . . . . . . . . . . . . . . . 126
The modern period ................................ 8 References. . . . . . . . .. . .... . . . .. . . . .. . . . .... ... . . .. . . 131
Lumbar spinal stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Chapter 6. Physiopathology of lumboradicular
pain
Chapter 2. Anatomy G. Cinotti, F. Postacchini
F. Postacchini, W. Rauschning Neuroanatomy .................................... 135
Lumbosacral spine ................................ . 17 Physiopathology of low back and
Neural structures ................................. . 41 radicular pain ................................... 138
Vertebral and meningo-radicular dynamics ......... . 47 Nerve-root compression. . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Blood supply ..................................... . 48 Chemical radiculitis. . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . 142
Lumbosacral anomalies ........................... . 52 Sympathetic system and low back pain . . . . . . . . . . . . . . 144
References ........................................ . 55 Hypothesis on pathomechanisms of
lumboradicular pain ...... . . . . . . . . . . . . . . . . . . . . . . . 144
References. . . . . . . . . . . .. . . . . . . . . . . . . . . . .. . . . .. . . . . . . 146
Chapter 3. Biochemistry, nutrition
and metabolism Chapter 7. Etiopathogenesis
5. Gumina, F. Postacchini F. Postacchini, G. Cinotti
Biochemistry ..................................... . 59 Epidemiology ..................................... 151
Nutrition ......................................... . 73 Risk factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Metabolism 75 Etiopathogenetic factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
References ........................................ . 76 Pathogenetic hypotheses ........................... 161
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Chapter 4. Biomechanics
G. Cinotti, F. Postacchini Chapter 8. Clinical features
Intervertebral disc 81 F. Postacchini, G. Gumina
Disc degeneration ................................. . 85 Principles of radicular anatomophysiology .......... 169
Effects of disc excision ............................. . 88 Symptoms. . . . .. .. . .. . .. . . . . . . . . . . . . .. . . .. . . . . . . . . . 175
Effects of laminoarthrectomy ...................... . 90 Clinical history .................................... 179
References ........................................ . 91 Physical examination .............................. 180
Clinical syndromes ................................ 201
Chapter 5. Pathomorphology Clinical features in adolescents. . . . . . . . . . . . . . . . . . . . . . 203
F. Postacchini, W. Rauschning Clinical features in the elderly ...................... 204
Radicular syndromes .............................. 204
Disc degeneration ................................. . 95 Syndromes due to herniation of the three lowest
Bulging of annulus fibrosus ........................ . 101 lumbar discs .................................... 206
Types of herniation ............................... . 102 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
XII.Contents.---------------------------
HISTORICAL PERSPECTIVES
F. Postacchini, S. Gumina
A historical study on the development of the concept of produced radicular involvement (21, 24, 29, 43, 80, 103,
disc herniation has necessarily got to refer to the symp- 104).
toms that it causes, since a prolapsed intervertebral disc In the Bible, there is what seems to be the first citation
has been identified as the most common cause of lumbo- of radicular pain in the lower limb. An episode is
radicular syndromes only in the second decade of this described, which, according to historians, took place
century. about 1800 years before Christ (Genesis 32,23-33). It is
the struggle between an angel and Jacob, which
occurred when the latter crossed Jacob's stream on his
way to his brother Esau. During the fight, the angel
The Egyptian-Hebrew period touched Jacob at the "commissura" (joint) of the hip,
causing him a sharp pain along the "big nerve", which
A few thousand years before Christ, the Egyptians lasted a few days. Since then, the descendants of
practised a type of medicine which was a mixture of Israel - the name given by the angel to Jacob, which
religion and magical ceremonies. Long before the means "he that fights with God" - do not eat, for devo-
Greek and Roman scientific culture established the tion, the "hip nerve", which crosses the hip joint. It has
principles of medical art, the Pharaoh chief physicians been hypothesized that the radicular-like pain might
used to write down on papyri anatomic, physio- have been produced by a herniated disc caused by a
pathologic and clinical observations. physical strain, since, before the fight with the Angel,
In 1930, Breasted (23) translated a papyri bought in Jacob had helped his two wives, two servants and
Egypt by Edwin Smith and later donated to the New 11 children to cross the stream by lifting and carry-
York Historical Society. The 377 lines of the papyri ing them on his arms (38, 73).
reported on 48 cases of pathologic conditions, such as
wounds, fractures, dislocations and tumors. Seven
cases dealt with the treatment of conditions of the spine
(60). Unfortunately, the papyri is incomplete and only The Greek-Roman period
describes lesions to the thoracic and cervical spine.
The papyri lists symptoms, such as "unconsciousness Hippocrates (460-357 B.C.) first used the term" sciatica",
of the arms" or "of the legs" possibly resulting from which comes from the Greek "ischios" (hip), in the
traumatic cord lesions. "Treatise of Diseases" (61, 65). With this term, he
It is uncertain whether the Egyptians knew the real indicated a pain in the joint "of the ischium with the
etiology of sciatica, however they were likely to be femur" extending "to the buttocks, the protuberance of
the first to describe certain clinical aspects of radiculo- the femoral neck, the thigh and the leg". To treat pain
pathies. Many human paleontological findings dating in the acute phase, Hippocrates suggested hot water
back to Ancient Egypt and Nubia, in fact, show evi- lotions on the sore area, fumigations and fasting. Once
dence of spinal pathologic conditions, which may have the acute phase was over, he prescribed a laxative and
2.Chapter 1 . - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
some boiled donkey milk. In the "Treatise of ably lived between 14 and 68 A.D., spoke of "coxae
Predictions" (61, 65), in describing the natural history dolor" (31). In the "Naturalis Historia" (Fig. 1.1), Pliny
of sciatica, Hippocrates stated that in elderly patients described the beneficial effect of a drink obtained from
with "cramps and cold at the loins and legs" the condi- the ascyron seeds juice, diluted in water.
tion would last at least one year, whilst young people Dioscorides (40-90 A.D.) (40), the physician of Nero's
"whose pain was not less severe compared with army, suggested to apply, on the patient's hip, some
elderly patients" would get rid of the illness in 40 heated goat dung, contained in an oily cloth. These
days. Hippocrates also stated that, when cramps were compresses had to be frequently changed until the
associated with pain in the lower limb, the thigh appearance of an ulcer on the application area.
would be tormented by "cold and heat". Galen (131-201 A.D.), a Greek who moved to Rome,
Phyliston of Locri (370 B.C.), a Greek historian quoted where he became emperor Marcus Aurelius' physician,
by Caelius Aurelianus (30), wrote about a thaumaturgus reaffirmed the usefulness of bleeding in the manage-
musician, probably the Theban Ismenias, who cured ment of sciatica ("De sanguinis missione") (54). He
sciatica by the sound of his bagpipes, which produced described the case of a soldier, who recovered from
muscle contractions capable of removing the "infected sciatica after a wound at the ankle had caused the resec-
matter" from the lower limb. This practice is also tion of a vein. Bleeding was aimed at removing, from
mentioned by Boethius in the "Cronito" (20). the lower limb, those "noxious humors" described by
To cure pains in the lower limb, Cato the Censor Hippocrates in the "Treatise of Remedies" (61, 65).
(234-149 B.C.), in "De re rustica" (28), suggested to According to Hippocrates, these "humors roam around
drink cold wine, previously boiled, together with the thigh and in the hemorrhoidal vein and where they
branches of juniper. stop, they cause terrible pains, however with no danger
Plutarch (1st century A.D.) reported that the Greek of death". Furthermore, Galen first used tractions in
captain Agesilaus, complaining of sudden cramp-like patients complaining of low backache. In a Galen's
leg pain, improved after a bleeding performed "by "Opera", published in 1625 in Venice, an illustration
incision of the vein situated under the malleolus" shows the use of spine traction, carried out by hanging
carried out by a doctor of his army (95). the patient by the ankles (53).
Pliny the Old (23-79 A.D.) was the first Latin author to The Greek and Latin physicians, though they
use the medical term "sciatica" (94). Celsus, who prob- described in great detail the clinical features of lumbo-
radicular pain, were far from understanding the real
etiology of sciatica. The concept of "pain" or "irrita-
. .", llil I'lm,/ t'Cllllun 11.llill'.11I1 b,'lto
tion" according to Hippocrates (De natura hominis)
,-0 n( tlt.-I · "rl'llll~ c'(pllnr. 'hlp,r II (61,65) and Galen (De ratione victus in acutis; De
/' ber·l<'\:n'·. II qllo Cl)llnnml' 1 nllool
-0 r.,mltl. C.lplnllllm.p:nllll).,p elementis iuxta sententiam Hippocratis) (54) was
O!jllt <:I:mn' !.IpltillllHp grnellllll!. related to the philosophical concept of "passion".
Furthermore, Galen initially believed that pain was
caused by alteration of any of the primary qualities:
heat, cold and dry (Ars Medicinales, chapter 80; De
compos. medic., book II) (54); eventually, he reached
I'1l" 11";\ ni
the conclusion that the only cause of pain was "the solu-
nmfl$ tion of continuity" (De simp I. medic., chapter 2) (54).
lit Imlr.1
111('0 In II<' Areteus (1st century A.D.) considered "ischiade" as a
(Ull~ fret disease of the hip joint and the thigh (Of the causes and
al.111'01 ,....
gCII'O"l .trnngell11l rhbnllClr Omlll~ signs of chronic diseases; book II, chapter 12) (8). As in
'Olmtnll . r:; t1l"Jllr n-tlr 1,",lIf Lap'''" other forms of arthritis, he recommended taking white
<V t\t1,rr.1 II<'\IIIIOtiolt6 l'Il1llt p.iml[
1'"gnU .1 !lImr pornc l!oI,ilDi ~(I':l hellebore, as well as radishes and decoctions of comfrey
r.t OG liltS 1Ill11C111(:11T rL'll"CIII111
• 11'111 ilhnllT'ro mo '1,,0) on"''' nC«ftl and cinquefoil. In his work (book III, chapter 12), he
llIi .1I1f 11.lnli die O"lIrrrl\~" ,. ,.
described an unusual remedy for sciatica, which con-
sisted in "letting a goat graze on iris grass to satiety and
when the time necessary for the grass to reach the guts
has passed, the goat is killed and the patient's feet are
plunged in the goat's stomach". Areteus also recom-
mended the application of "hot medications" on the
sore area, except when sciatica was associated with
Fig. 1.1. Pliny the Old. 14th century illuminated codex of the perimalleolar edema. In this instance, he suggested the
"Naturalis His taria ". Milan, Ambrosian Library. use of cold compresses.
- - - - - - - - - - - - - - - - - - - - - - - - - - - 0 Historical perspectives 0 3
Caelius Aurelianus (5th century A.D.) mistook sciati-
ca for "psoitis" (Tardarum Passionum, book V, chapter
1) (26) and, unlike his predecessors, he denied the use-
fulness of the frequent use of bleeding and reaffirmed
the concept of applying warm ointment on the painful
area (30).
Caelius Aurelianus and Themison of Laodicea (5th
century A.D.) (the latter quoted by Caelius Aurelianus)
(30) first gave importance to exercise therapy in the
treatment of sciatica. Both of them recommended exer-
cises on a stretcher or a horseback, thus anticipating the
modern methods of chiropraxis and vertebrotherapy.
These exercises caused the patient light shocks, similar
to frictions and unctions, which were considered
capable of removing the morbid matter from the limb.
D E
In 1764, the Italian Domenico Cotugno in "De Ischiade compared with other nerves, to the presence of wider
Nervosa Commentarius" (32) (Fig. 1.4) ascribed sciatica sheaths, .not tightly compressed by muscles (chapters
to the involvement of the sciatic nerve. He distin- 28 and 29).
guished "arthritic sciatica", responsible for hip pain, Cotugno had the intuition of considering sciatica
from "nervous sciatica". This was identified as "sciatica similar to other radiculopathies. In fact, he did not use
postica", when pain was located above the sacrum, the expression "cubital nervous ischia de" to describe
behind the greater trochanter, on the lateral aspect of the radiculopathies in the upper limb only because the
the thigh and leg, and on the dorsum of the foot (sciatic term "ischia de" would have aroused confusion with
pain) and as "sciatica antica", when pain was located in regard to the site of pain (chapter 31).
the groin and along the medial aspect of the thigh down Cotugno studied the spinal canal and the confluence
to the calf (crural pain). of the spinal nerve roots on many anatomic dissections;
Cotugno described in detail the clinical features of nevertheless, while performing an autopsy on a man
sciatic pain. He distinguished it as continuous, inter- who had complained of sciatica, he analyzed only the
mittent or cramp-like and reported that its course could macroscopic features of the sciatic nerve of the affected
be clearly indicated by the patient's finger. The Italian limb. He regretted not having had time to examine the
physician also described the muscle wasting (chapter 6) contralateral nerve, because of "the smell of the ulcers
and possible paresis, which may be associated with and the fear of infection" (chapter 35).
pain. However, he thought pain was caused by the The treatments that he recommended for sciatica
presence, in the sheaths of the sciatic nerve, of a humor were: bleeding (chapter 39), to be performed on the
coming from the brain or the arteries of the nerve affected . side, unlike that practised by Caelius
sheath. In patients suffering from sciatica, there would Aurelianus (30); "purgation of the bowels" with emet-
be an excessive amount of humor or there would be an ics and enemas (according to Caelius Aurelianus,
acrid humor, irritating the nerve itself (chapter 27). Hippocrates believed that dysentery was an effective
Among the causes of nervous sciatica, the author remedy for those who suffered from sciatica); "rubbing
included "lifting of heavy things" which would favor of the affected part" with cold oil; cauterizations and
an abundant flow of blood into the nerves of the thigh vesicatory therapy. Cotugno believed that the effect of
and, thus, of humors into the nerve sheath, or the pres- these treatments was to decrease the amount of sour
ence of a venereal bubo at the groin, that would release fluids in the sciatic nerve sheaths.
a "bothering atmosphere" in the adjacent tissues Cotugno also brought an important contribution to
(chapter 27). the history of sciatica. He quoted a Mr. Veratto (Physical
Cotugno believed that the subjects most predisposed and Medical Observations on Electricity in Bologna,
to sciatica are those with too thin or hard sciatic nerve 1748, page 99), who treated sciatica with electricity.
sheaths (chapter 30); furthermore, he attributed the According to Cotugno, the effect of electricity was "to
most frequent involvement of the sciatic nerve, excite palpitation of the muscles which surround the
6.Chapter 1.--------------------------------------------------------
sciatic nerve and to favor the removal of the stagnant Petrini described all the treatments known for the
humors" (chapter 41). Cotugno also refers to cure of sciatica, which, according to the author, were
Boerhaave, who experimented the effect of opium on aimed at favoring the resorption of the stagnant humor.
himself (chapter 42), and some Franciscan monks, who, He quotes bleeding, purgation, enemas, frictions (dry
once back from Jerusalem, performed cauterization and humid), the taking of mercury extract, antimony,
with a small pointed cautery that the Italians called opium (capable of slowing down the action of the
"saetta". nerves and decreasing their sensitivity), hemlock or
Zecchio (cited by Petrini) (92) believed that sciatica aconitum [(these already successfully used by Storck
might at times be caused by a liquid, which, descending (1731-1803), however in the treatment of arthritic sciat-
from the brain, reaches the femur. The treatment con- ica)]. Petrini also described the action of "electricism",
sisted in using a cautery on the nape "to intercept the successfully experimented by Van Swieten at the Upfal
new inflow" and one on the leg "to make the humor hospital, and of cold baths and showers (used by Floyer
flow out". to treat many "obstinate diseases"). However, he criti-
Van Swieten (1700-1772) (124) performed cauteriza- cized these procedures, since they would cause, respec-
tions along the lower limbs, by burning, on the skin, tively, migration into the main organs, and coagulation,
triturated leaves of artemisia, a plant which had been of the stagnant humor. Paragraph XII deals with the use
used in ancient times by the Chinese. of burns. The author denigrates this therapeutic modal-
In 1784, Giuseppe Petrini, a follower of Cotugno, ity and those who advocate it, including Hippocrates,
published a small monograph entitled "On the nervous who caused the death of Eupolemus by experimenting
sciatica and the new method to cure it" (92) (Fig. 1.5). burns on several body regions (Epidem., book V) (65).
The author, whose importance has been underesti- Petrini stated that burns, performed with the
mated, identified nervous sciatica as tibial (lateral aspect Hippocratic method, would only "torment the inferm";
ofthe leg and dorsum ofthe foot), sural (thigh, popliteal he recommended the gradual application of a small
region, calf and heel) and combined. He thought the source of heat on the painful area, so as to melt the stag-
tibial sciatica to be more frequent than the sural, since nant fluid in the sheaths. The author considered of no
the sheaths of the posterior branch of the sciatic nerve use the indiscriminate application of vesicants, capable,
are more tightly compressed by the calf muscles, which according to some physicians, of melting and modi-
thus hinder stagnation of the acrid humor. fying the morbid matter. However, he maintained that
the management of sciatica had to be based on the con-
cept of evacuation, rather than that of absorption, of the
sour humor. Petrini also supported the method used by
DELLA SCIATIC A a minor friar, consisting in introducing a small saetta
between the extensor tendons of the fourth and fifth
NERVOS ...L\. toe on the affected side, 2 centimeters proximally to the
E DEL UOV lET D DI GUAIWIl metatarsophalangeal joint. The aim of this treatment
OPE R A was to favor the removal of the acrid humor through" a
terminal branch of the anterior ramus of the sciatic
.A"i~tbi~. Ji lI1i/i$me """"r.,i",i ,,/I 11ft
J, (/lIIs.,II p..f~ " t .A". M,tJirll nerve", and was therefore used successfully for tibial
, Cbi,II"irll. sciatica alone. The author, however, recommended the
D El. $/GNOlt use of the saetta together with the seton and massage
GIUSEPPE P ET RIN I for other types of sciatica as well.
In a letter written in 1787 by an anonymous physi-
DoTTO ... Dr MUICIIIA • CHIU/aCI
N."L.a. eTTA: DI OaTOII". cian, a sciatica of unknown etiology is described, which
:1: -=====-..
,., ,;.,..101 ,ntI'jl • I"'""i' • ., ,.
was successfully treated with mercury, administered
by means of friction and orally (14). However, no infor-
mation is provided on the patient's history, and that
;"" wz'"n... '"''';'' /'''''III},., •.":,,, does not allow a precise evaluation of the clinical
II nt. Er l ,. lib. I
case. The physician, besides, appears to agree with
Sennert's doctrine (1572-1673), who attributed the onset
of sciatica to the accumulation, in the hip joint, of a
"pituitous, acrid and sharp humor" deposited by the
v I: NEZ I A MDe arterial blood.
Roussett, in his doctora te thesis (1804) (102), reported
Fig. 1.5. Giuseppe Petrini. Title page of the monograph "On the nervous that pressure on the posterior aspect of the thigh might
sciatica and the new way of recovering from it". Venice, 1784. produce pain along the whole lower limb. He also
- - - - - - - - - - - - - - - - - - - - - - - - - - - 0 Historical perspectives 0 7
pointed out that sciatica might often be associated with
sensory loss, unsteady movements and paralysis of the
foot muscles.
In the "De morbis nervorum" (52), Johann Frank
(1735-1821) stated that the causes of sciatica were
refrigeration, traumas, "uterine vices" and laxity of the
sciatic nerve sheaths. He also underlined that sciatica
may be associated with gastralgia and nausea.
the surgical treatment. These concepts were confirmed the two conditions often coexist, but also for the histor-
and enlarged in 1935 by Mixter and Ayer (82). ical evolution of the knowledge of the disease.
Filippi (48), based on studies and critical revisions on The first description of narrowing of the vertebral
disc disease (he quoted: Beneke, 1897; Kahlmeter, 1918; canal is attributed to the French anatomist Portal (96),
Keyes and Compere, 1932; Putti, 1933; Loeb, 1933), ana- who in 1803 observed cord compression of stenotic
lyzed the changes occurring in the intervertebral disc nature and severe muscle wasting in the lower limbs in
after removal of the nucleus pulposus in animals, subjects with a gibbus due to rickets, syphilis or both.
whilst De Seze (39) stated that the nerve root is affected However, Portal reports that a pathologic narrowing of
within the spinal canal before it enters the interverte- the spinal canal had already been described by
bral foramen. Lentand, as well as Morgagni in the "De sedibus et
In 1938, Love and Walsh (75) reported the clinical causis morborum" (Fig. 1.11). In the same period, other
results of surgery in 100 patients with disc herniation. cases of narrowing of the vertebral canal were
In their series, they included, for the first time, a recur- described by Olliver (86).
rent herniation. In 1940, the cases operated by Love Almost a century passed before Sachs and Fraenkel
and Walsh became 300 (76). (105) reported the case of a patient suffering from low
Over few years, many European and American back pain, weakness and tremors of the lower limbs and
schools contributed to the increase in knowledge on difficulty in walking. The patient, who walked with the
lumbar disc herniation through scientific articles and trunk bent forward and showed absence of the left knee
monographs, opening the way to the present etiopatho- jerk, underwent surgery, since a tumor or an inflam-
genetic and therapeutic theories. matory spinal disease was suspected, but only an abnor-
Some historical dates in the treatment of lumbar disc mal thickness of the T11 and T12 laminae, and an
herniation in the last 50 years are reported in Table 1.1. "enormously thickened lining membrane" were found.
In 1910, Sumita (117) reported the first cases of nar-
rowing of the spinal canal in achondroplasic subjects.
Lumbar spinal stenosis In 1911, Bailey and Casamajor (13), based on the clin-
ical and radiographic evaluation of five patients with
Stenosis of the spinal canal is strictly related to disc her- symptoms and signs of compression of the spinal cord
niation not only from the pathologic point of view, since or cauda equina, thought that the clinical syndrome
12.Chapter 1.-----------------------------------------------------------
DE SEDIBUS, BT CAUSIS
MORBORUM
PER ANATOMEN INDAGATIS
'-"Il ' 4l 17' ''4l 17 "
DtsnCTIONES, ~T ANIMADVUSIONtS, NlINC _0),1 IDITAS
COW!'l.U;rUNTIIIl PII.OPI!MODUM INNUW;IlAS, M2DICII.
CHIlUlII.GlS, """"TOMIClS PIlO1'\1TUI\AS.
V E NE T II S.
ANATOMY
F. Postacchini, W Rauschning
men. It mamly depends on two tactors: the wIdth ot the between the supenor margm ot the hrst sacral tor amen
pedicles and the shape of the vertebral foramen. A and the base of the sacrum is 23 mm (36).
marked shortness of the pedicles and a trefoil configu- The dorsal aspect is convex both in the sagittal and
ration of the vertebral foramen, as isolated conditions, horizontal plane and shows a markedly rough surface.
have little influence on the width of the lateral recesses. On the midsagittal line, there is the midsacral crest,
Their association, on the other hand, may cause marked which originates from the fusion of the spinous process-
narrowing of the recesses, which may be further nar- es of the sacral vertebrae. On each side, laterally to the
rowed by osteophytes of the superior articular process mid sacral crest, there are the posterior sacral foramens,
or the posterior border of the vertebral body. which are smaller than the anterior counterparts. They
are situated along the vertical line passing through the
Sacrum superior articular process of the first sacral vertebra.
Laterally to the foramens, the prominence of the lateral
sacral crest, derived from the original transverse
The sacrum, resulting from the fusion of five vertebrae,
processes of the sacral vertebrae, and the sacral tuberosi-
is markedly curved and tilted backwards, thus forming
ties give attachment to the dorsal sacroiliac ligaments.
a kyphosis, which follows the lumbar lordosis. The
lumbosacral transition zone, represented by the fifth
lumbar disc and the adjacent portions of the L5 and Sl
vertebrae, forms the so-called promontorium or
sacrovertebral angle.
On the ventral portion of the superior aspect, or base,
the sacrum shows an ovoid surface, with the major axis
orientated transversely, representing the upper verte-
bral end-plate of the Sl vertebral body. Laterally to this
surface, there are the lateral masses or alae, that bear the
auricular surfaces for articulation with the iliac bones.
Medially, the alae are contiguous to the sacral canal and
the first sacral foramen, which is directed obliquely
downwards and forwards, parallel to the upper aspect
of the sacrum. The mean transverse diameter of the
sacral alae at the level of the first sacral foramen is 27
mm in males and 29 mm in females; the mean obliquity
of the articular surfaces with respect to the horizontal
plane is 83° in males and 81 ° in females (55). The supe-
rior articular processes of the first sacral vertebra
originate posteromedially to the alae of the sacrum.
The posterior portion of the base of the sacrum shows
the proximal, approximately triangular, opening of the
sacral canal. The latter, proceeding distally, decreases in
size and flattens in the sagittal plane, and then tran-
forms, at S4 and S5 level, into a bony groove corre-
sponding to the sacral hiatus. The posterior portion of
the sacral canal is formed, on each side, by an osseous
lamina, which is thinner than the lamina of the lumbar
vertebrae. The sacral foramens originate from the sacral
canal. After a short distance, they divide into an anteri-
or and a posterior foramen, which contain the anterior
and posterior branches of the sacral spinal nerves,
respecti vel y.
The anterior surface of the sacrum is concave both in
the sagittal and horizontal plane. It is segmented by Fig. 2.5. Paramedian sagittal section of the caudal portion of the lumbar
four horizontal osseous ridges, each corresponding to spine. The L4 and L5 vertebrae show a concavity both of the proximal
the end-plates of two contiguous vertebrae. Laterally to and distal vertebral end-plates. As a result, the L4 disc has the shape of a
biconvex lens, whereas the L3 and L5 discs show a pronounced convexi-
the ridges, there are the openings of the anterior sacral ty of their caudal and cranial surface, respectively. The posterior aspect
foramens, which are separated by osseous septa giving of the lumbar vertebral bodies is markedly concave and the L3 and L4
attachment to the piriformis muscle. The mean distance discs show a posterior bulging of the annulus ftbrosus.
22.Chapter 2.-----------------------------------------------------------
Intervertebral disc al regions of the disc, the annulus fibrosus inserts into
the marginal zone of the vertebral end-plate (Fig. 2.7).
Macroscopic morphology In the anterior and posterior regions, the outermost
annular lamellae extend a few millimeters beyond the
The lumbar discs are the largest on transverse section vertebral end-plate and insert into the vertebral body,
and the highest of all intervertebral discs. They mea- merging with the periosteum and the longitudinal
sure 10-15 mm in height and are higher in the anterior ligaments (Fig. 2.8).
than the posterior portion. This holds particularly for The nucleus pulposus has a gelatinous appearance
the three lower lumbar discs and, even more, for the and, when the disc is sectioned transversely, it pro-
fifth. In the lumbar spine, the ratio between the height trudes from the plane of section. This is particularly
of the disc and that of the vertebral body is approxi- true for young or middle-aged subjects. The interverte-
mately 1 to 3. The lumbar discs, as all intervertebral bral disc, in fact, undergoes such considerable changes
discs, are shaped like a biconvex lens, fitting the con- with aging, that analysis of disc morphology, either
cavity of the end-plates of the adjacent vertebrae macroscopic or microscopic, cannot be independent of
(Fig. 2.5). The anterior aspect of the disc is slightly the age of the subject examined.
convex, whilst the posterior aspect is flat or slightly
concave. Age-related changes
The intervertebral disc consists of the annulus fibro-
sus and nucleus pulposus. The former is a dense fibrous In the early years of life, the annulus fibrosus and nucle-
structure showing a lamellar architecture. On axial sec- us puplosus are sharply distinct and the nucleus occu-
tion, it is thicker anteriorly than posteriorly. Thus, the pies more than half of the dimensions of the disc. The
nucleus pulposus does not occupy the center of the nucleus pulposus has a white-lucent color, a turgid
disc, but it is displaced slightly backwards (Fig. 2.6). appearance and a liquid-gelatinous consistency. It may
The annulus fibrosus shows a lamellar structure with easily be removed and, in its place, a roundish cavity
concentric rings in the outer three quarters, whilst it remains, showing clear-cut limits.
displays an homogeneous texture in the inner part, At 20 years, the two components of the disc are still
representing the so-called transition zone (Fig. 2.6). well distinct, although not so sharply as in the early
The lamellar zone is thicker in the anterior and lateral years of life (89). The nucleus pulposus occupies
portions, than in the posterior portion, of the disc (Fig. approximately one third of the disc volume. Its appear-
2.6). On sagittal or coronal sections, the outermost ance is less translucid and its consistency is slightly
lamellae show a uniform outward convexity, whilst the more solid than at a younger age.
inner lamellae may show a more marked curvature in At 30-40 years, the nucleus puplosus is still well dis-
the equatorial portion of the disc (Fig. 2.7). On the later- tinguishable from the annulus fibrosus, but the bound-
Fig. 2.7. Coronal section of lumbar intervertebral disc. The transition zone, showing no lamellar structure, is clearly visible. In the lamellar portion, the
peripheral layers show an outward convexity, whereas the innermost lamellae display a marked curvature in the equatorial portion of the disc. At the
level of the nucleus pulpusus, the transition zone and the innermost part of the lamellar portion of the annulus, the disc is separated from the vertebral
body by the cartilage end-plate, lacking in the peripheral portion of the annulus, where the collagen fibers directly insert on the bone surface.
ary between the two components becomes less and less Microscopic morphology of the annulus fibrosus
evident. The annulus fibrosus has a white-ivory color
and a distinct lamellar structure. At this age, thin cir- The microscopic morphology of the annulus fibrosus
cumferential fissures become apparent between con- has been investigated in animals and man. In rats, the
tiguous lamellae (106). The nucleus pulposus is white, annulus fibrosus has been studied at various ages at
but no longer translucid, and is of fibrocartilaginous histologic and ultrastructural level (94). In man, it has
consistency (89). been investigated sequentially over time only histo-
At 50-60 years, there is a progressive loss of demar- logically and histochemically.
cation between the nucleus pulposus and the annulus
Rat
fibrosus. The latter slowly acquires a greyish color,
whilst the nucleus pulposus is white-opaque in color; Newborn annulus fibrosus. The annulus fibrosus con-
occasionally, the disc is brown due to the presence of sists of three portions: a thin inner portion, containing
the so-called semile pigment. The nucleus is of clearly ovoid, chondroblast-like cells; a middle portion with
fibrous consistency, and has a turf-like structure, due to roundish or ovoid cells showing long cytoplasmic
the presence of fissures orientated in various directions. projections; and an outer portion, containing elongated
If the nucleus pulposus is removed, the residual cavity fibroblast-like cells, which also show cytoplasmic
shows irregular, star-shaped margins (72). The annulus projections (Figs. 2.9 and 2.10). In all three portions, the
fibrosus has a less distinct lamellar structure than cells are arranged in concentric rows, corresponding to
at younger ages; it often shows radial clefts, usually the interlamellar septa of older animals. In the middle
located posterolaterally or posteriorly. and outer portions, the cells in a row face each other
At 70-80 years, the nucleus pulposus is no longer dis- and their cytoplasmic projections cross the lamellae,
tinguishable from the annulus fibrosus. Numerous clefts joining the cells of adjacent rows (Fig. 2.10). The cells in
are present in both components, particularly in the annu- all three portions show an abundant cytoplasm, con-
lus, where only few lamellae are distinctly identifiable. taining a well developed rough endoplasmic reticulum
This description is a schematization of what occurs in (Fig. 2.11). The cells are surrounded by a narrow lacu-
the majority of individuals, in a paradigmatic disc. The nar space containing proteoglycan granules and amor-
changes described above may be more or less marked, phous or filamentous material.
depending on various factors, which are analyzed in the The lamellae between the cell rows are made up of
description of the degenerative processes of the disc. collagen fibers. In the inner portion, the fibers are ran-
24.Chapter 2.---------------------------------------------------------
c - _ -.... . .
within, the septa. There are no significant morpho- lar lacunae contain fewer proteoglycan granules com-
logic differences between the anterior and the posteri- pared with the young annulus, whereas the lamellar
or portion of the annulus fibrosus. In the posterior septa show a larger amount of collagen fibers.
portion, however, the lamellae are thinner and the In the lamellae, the collagen fibers are mostly of large
lamellar structure is less distinct than in the anterior diameter (mean, 1340 nm). The proteoglycan granules
portion. are less numerous and smaller than in the young (Fig.
2.19). Very few elastic fibers are visible and there are
numerous aggregates of electron dense-granular mate-
Old annulus fibrosus. Compared with the young rial (Fig. 2.20). The largest aggregates are located in the
annulus fibrosus, the transition zone is larger and in the interlamellar septa and may be as long as 15 ,.1. In the
rest of the annulus the lamellar structure is less distinct. lamellae and the transition zone, the aggregates often
In the entire annulus fibrosus there are fewer cells per surround one or more collagen fibers, or form a net-
unit of surface. The cell shape is similar to that of the work between them. The aggregates are not digested
cells in the young annulus, whereas the sizes are slight- by hyaluronidase, but disappear after incubation with
ly smaller. Most cells show a negligible amount of papain (94). They thus consist of proteins, but not of
rough endoplasmic reticulum (Fig. 2.18). The pericellu- proteoglycans.
26.Chapter 2.-------------------------------------------------------
Fig. 2.11. Annulus fibrosus of newborn rat. A cell of the middle portion showing granular arrangement of the nuclear chromatin and an extremely well
developed rough endoplasmic reticulum, filled with secretion material. The cell is surrounded by a pericellular lacuna (L).
Newborn
Young adult
A
Fig. 2.15. Annulus fibrosus of young rat. (A) A cell in
the outer portion of the lamellar zone. The cell, although
spindle-shaped as a typical fibroblast, shows short cyto-
plasmic projections and is surrounded by a pericellular
lacuna (L). (B) A cell in the middle portion of the lamellar
zone showing fibrocartilaginous features. The rough
endoplasmic reticulum is well developed and the cyto-
plasm is surrounded by a large pericellular lacuna (L).
(C) Transition zone. Two chondrocyte-like cells are visi-
ble, lying in a lamellar-like fibrous matrix, which consists
of bundles of collagen fibers interwoven with each other.
Lm: Fibrous lamella.
c
fibers, at times grouped in bundles. The mean thickness the tissue becomes more and more fibrosus as it
of the fibers is greater than in the central portion of the approaches the annulus fibrosus and many cells show
nucleus. intermediate features between chondrocytes and fibro-
cytes (Fig. 2.26).
Middle age
Old age
The cell morphology shows no significant differences
compared with the young age. However, the cells are The viable cells are less numerous than in middle age
more often surrounded by a distinct pericellular lacuna and the interterritorial matrix contains a large amount
or are grouped in small clusters. The interterritorial of small masses of amorphous material, which is
matrix is looser due to the presence of a denser network basophilic with the hematoxylin-eosin staining and
of fibrils and collagen fibers. The latter tend to be thick- positive to the PAS reaction. Aldan blue staining of the
er than in the young adult and are often aggregated in tissue is markedly weaker than in the young age.
small bundles. Furthermore, the matrix contains small At ultrastructural level, most cells show a small
aggregates of electron-dense granular material, which amount of cytoplasm, containing poorly developed
occasionally ensheath single collagen fibers (Fig. 2.25). organelles (Fig. 2.27). In some cells, a large portion of
In the peripheral portion of the nucleus pulposus, the cytoplasm is occupied by bundles of filaments. The
30. Chapter 2.---------------------------------------------------------
Fig. 2.17. Annulus fibrosus of young rat. Axial section of collagen fibers
of a lamella. The diameters of the fibers are of various dimensions.
intercellular matrix contains a larger amount of colla- material observed at light microscopy. It probably con-
gen fibers and fewer proteoglycan granules, compared sists of products of cell degradation.
with the middle age. Numerous aggregates of electron-
dense granular material, located between the collagen
fibers or around them, are also present (16) (Fig. 2.28). Cartilage end-plate
This material, similar to that observed in the annulus
fibrosus, as well as in the cartilage (81), presumably cor- The cartilage end-plate has been studied in mouse (49),
responds to the basophilic and PAS-reaction positive monkey (38) and man (6). In newborn mouse (49), the
----------------------------------------------------------oAnatomy o31
valent of the epiphyseal ossification center, whereas the
inner zone and the vertebral body below correspond,
respectively, to the growth plate and the diaphysis of
the long bone.
In man (6), the structure and the age-related changes
of the cartilage end-plate are similar to those observed
in animals. The inner zone, showing the morphologic
characteristics of the growth plate, is well developed
until the age of 10 years. Subsequently, it becomes thin-
ner and shows a decrease in number of proliferating
chondrocytes. Between 17 and 20 years, the deep zone
is replaced by trabecular bone. Between 20 and 40
years, the deep portion of the superficial zone becomes
calcified and, between 40 and 60 years, it is progressive-
ly replaced by bone. These changes, particularly carti-
lage calcification, might hinder the diffusion of
metabolites to the superficial portion of the articular
cartilage, with resulting nutritional defect of the carti-
lage itself and the nucleus pulposus. After 60 years, the
cartilage end-plate consists of a thin layer of tissue, rep-
resented by the superficial portion of the outer zone. In
old age, furthermore, the bone below the articular carti-
Fig. 2.19. Annulus fibrosus of old rat. High magnification view of a lage shows nutrient canals and medullary spaces, filled
lamella. Almost all collagen fibers have large diameters and the proteo- with amorphous substance and mostly avascular. The
glycan granules are smaller and fewer than in the young adult. sequence of changes occurring with advancing age is
depicted in Fig. 2. 29.
B
B
level of the disc. At intervertebral level, therefore, the which are located more deeply. This portion is firmly
ligament displays a characteristic rhomboidal shape. adherent to the disc only at the level of the margins of
The central portion is firmly attached to the vertebral the rhombus. The central part is very loosely attached
end-plates, whereas it does not adhere to the posterior to the posterior aspect of the disc, from which it can
aspect of the vertebral bodies. It is bowstrung across the easily be separated (Fig. 2.31). Also the dimensions of
concavity of the vertebral body, thus leaving a thin the rhomboidal portion decrease progressively procee-
space occupied by vessels entering the vertebral body ding in the craniocaudal direction. The lowest width
or exiting from it (Fig. 2.30). The width of the central decreases from 21 mm at Ll-L2 to 11.5 mm at L5-51; the
portion decreases progressively from L1 (mean, 9 mm) mean height diminishes from 25 mm to 14 mm (83).
to 51 (mean, 2.8 mm) (83). The fibrous bundles of the central portion are
In the rhomboidal portion, the central band is more prolonged for a few vertebrae, whereas the oblique
superficial compared with the two lateral expansions, bundles of the rhomboidal portion extend, at the most,
34.Chapter 2.-------------------------------------------------------
from one disc to that above or below. At histologic level, est at L5-S1. The thickness of the ligament increases
the posterior longitudinal ligament, like its anterior during extension of the trunk and decreases during
counterpart, is made up of bundles of collagen fibers, flexion. Tajima and Kawano (116) found, at L4-L5Ievel,
relatively few elastic fibers and typical fibroblasts. extreme values of 3.3 mm upon flexion and 4.3-5.9 mm
upon extension.
The ligamentum flavum joins two contiguous laminae. The superficial portion of the ligamentum flavum is
It inserts on the proximal border of the distal lamina composed of fibrous connective tissue and few elastic
and on the caudal margin, and caudal half of the deep fibers. The rest of the ligament consists of numerous,
surface, of the proximal lamina. This type of attachment large elastic fibers, which give the ligament the typical
transforms the deep aspect of the posterior wall of the yellow color, and thin bundles of collagen fibers
spinal canal into a uniformly smooth surface. On the (95, 111, 136) (Figs. 2.32 and 2.33). The elastic fibers,
posterior midline, the ligaments of the two sides join 1.1-6.5 11 in thickness, are orientated parallel to the
and blend with the interspinous ligament. Laterally, on longitudinal axis of the ligament. The cells, which are
both sides, the ligamentum flavum is prolonged ven- very few in number, have fibroblast-like features and
trally to the capsule of the posterior joint, forming the show little cytoplasm and few, long cytoplasmic
posterior wall of the intervertebral foramen. Then it projections (Fig. 2.34).
proceeds backwards, leaves the intervertebral foramen In proximity to the bone attachment, the ligamentous
and blends with the capsule of the posterior joint (99). tissue shows fibrocartilaginous features: chondrob-
The dorsal surface of the ligament is separated from the last-like cells, and fewer and thinner elastic fibers than
muscle layer by a thin stratum of fat tissue. in the central portion of the ligament (Fig. 2.35).
Several investigators (46, 92,142) have measured the In old age (95), the cells decrease in number and show
dimensions of the ligamenta flava, but have provided poorly developed cytoplasmic organelles. In a few areas
even very different data. This is probably due to the fact the elastic fibers are less numerous and thinner, whereas
that the dimensions of the ligament depend on several the collagen component is more abundant (Fig. 2.36).
factors, such as subject's age, presence of vertebral Chondroblast-like cells are occasionally visible. The
degenerative changes and original size of the spinal fibrocartilaginous zone near the bone attachment
canal. The ligamentum flavum is approximately 1.5-2 slightly increases in thickness. These changes decrease
cm in height and 1-2.5 cm in width. Thickness is 2-6 the elasticity of the ligament, which may protrude into
mm; it reaches the highest values at L4-L5 and the low- the spinal canal on extension of the trunk (95).
----------------------------------------------------------oAnafolny o35
Supraspinous and interspinous ligaments cesses. The deep layer, which is the thickest one, joins
the tip of two contiguous spinous processes; it is
The supraspinous ligament is a thick fibrous band, which reinforced, to a varying extent, by the tendons of the
usually reaches the spinous process of L4 or more rarely multifidus muscle.
that of L3 or L5 (lOS). Distally to its end, it continues In the first 2 decades of life, the ligament is entirely
with the tendineous rafe of the longissimus dorsi composed of tendon-like tissue. Subsequently, the
muscle. The ligament consists of three layers. The middle and deep layers undergo fibrocartilaginous
superficial stratum, showing a variable thickness, is metaplasia, until the tissue, after the fourth decade
made up of fibrous bundles joining 3 or 4 spinous of life, becomes entirely made up of fibrocartilage (105).
processes, to each of which they are attached. The The latter shows areas of calcification and ossification
middle, usually thin, layer joins 2 or 3 spinous pro- of varying size, particularly at the tip and the margins
36.Chapter 2.-------------------------------------------------------
of the spinous process. The elastic fibers are few and ligaments and, with increasing age, may become a cav-
thin, like in tendons. ity a few millimeters wide. In the middle portion, wide
The interspinous ligament is formed by fibrous bun- spaces may occasionally be visible, which have been
dles running in a posterocranial direction (47, 105). It interpreted as old ruptures of the ligament (lOS).
includes three portions. The ventral portion, consisting However, they are likely to be cavities which have
of two halves, right and left, represents a posterior become particularly wide as a result of degenerative
expansion of the ligamenta £lava. The middle portion, changes of the fibrous connective tissue.
which is the largest component of the ligament, The interspinous ligament is essentially made up of
inserts caudally, on the ventral half of the proximal bundles of collagen fibers. In the ventral portion, there
border of the caudal spinous processs and, cranially, on is a fairly large amount of elastic fibers. In the other
the dorsal half of the distal border of the cranial spinous portions, the elastic fibers are few and thin.
process. The bundles of the dorsal portion insert on the
dorsal half of the proximal margin of the caudal spin-
ous process and, running posterocranially, mingle with Meningovertebralligaments
the bundles of the supraspinous ligament. The middle
portion contains a median cleft, usually occupied by fat These ligaments, first described by Trolard (126) and
(47). The cleft is wider in the last two interspinous Hofmann (51), are fibrous bands joining the dural sac to
Outer
Zone
Inner
Zone
Fig. 2.29. Morphology of human cartilage end-plate at various ages. (A) First years of life. The outer zone, adjacent to the disc, is composed of a super-
ficial portion containing irregularly arranged chondrocytes and a deep portion made up of ovoid or spindle-shaped chondrocytes. The inner zone
consists of a portion showing chondrocytes arranged in columns and a portion with degenerated chondrocytes surrounded by calcified matrix.
(B) 20-40 years. The deep portion of the outer zone becomes calcified and is progressively replaced by a bony lamina; the inner zone is substituted by
trabecular bone. (C) 40-60 years. The remaining cartilaginous portion of the outer zone is replaced, to a large extent, by bone tissue.
-------------------------------------------------------------OAnatoIUy 37 0
Fig. 2.30. Midsagittal section of a cadaver spine at the level ofL4 verte-
bra. The posterior longitudinal ligament (arrowheads) is adherent to the
adjacent discs, but not to the vertebral body. Between the latter and the
ligament, an empty space occupied by vessels of the anterointernal
venous plexus (asterisk) is visible.
Lumbosacral ligament
Corporotransverse ligament
Fig. 2.35. Light microscopic view of lumbar ligamentum flavum near the Fig. 2.36. Electron micrograph of lumbar ligamentum flavum of a 68-
laminar attachment. The cells have chondrocyte-like features and few, year-old man. The elastic fibers (asterisks) are fewer and thinner than in
thin elastic fibers are present in the tissue. younger age.
pedicular portion, the canal is entirely bounded by by the articular processes. Posteriorly, depending on
bony structures: anteriorly by the vertebral body, later- the level examined, the spinal canal is delimited by the
ally by the pedic1es, and posteriorly by the superior laminae or the spinous process covered by the ligamen-
articular processes or the partes interarticulares, the ta £lava or only by the latter. When seen on a transverse
laminae and the base of the spinous process. In the sub- section, the spinal canal can be divided into three por-
pedicular portion, the vertebral body is separated from tions: the central portion, or central spinal canal; the lat-
the posterior arch by the intervertebral foramen, the eral portion, so-called lateral spinal canal or nerve-root
sagittal diameter of which reaches the highest values in canal; and the posterior portion. The former corres-
proximity to the inferior vertebral end-plate. The poste- ponds to the portion occupied by the thecal sac, the sec-
rior wall of the canal is formed by the articular process- ond to that occupied by the spinal nerve root in its
es, the laminae and the base of the spinous process, all extra thecal course and the third to the posterior recess
covered by the ligamenta £lava. In the intervertebral of the vertebral foramen.
portion, the posterolateral walls of the canal are formed The so-called lateral spinal canal has been variably
40.Chapter 2.---------------------------------------------------------
identified. Burton (17) distinguished a central and a The anterior wall of the neuroforamen is formed by
foraminal zone. Lee et al. (71) identified: an entrance the subpedicular portion of the body of the proximal
zone, situated ventrally and medially to the superior vertebra, the disc and the short suprapedicular portion
articular process; a middle zone located ventrally to the of the body of the distal vertebra. The superior and infe-
pars interarticularis and inferiorly to the pedicle; and rior walls are represented by the pedicles of the two
an exit zone, corresponding to the area situated lateral- contiguous vertebrae. The posterior wall is formed by:
ly to the pedicle. Van Akkerveeken (128) indicated the the lateral end of the ligamentum flavum, dorsally to
three zones as ostium internum, pedicular zone and which there is the pars interarticularis; the base of the
ostium externum. These authors include the interverte- inferior articular process; the posterior joint capsule;
bral foramen in the lateral vertebral canal, probably and the superior articular process. The entrance and
with the aim at indicating, using a single expression, the exit of the foramen correspond to the tangent planes to
entire area through which the radicular nerve runs to the medial and lateral aspect, respectively, of the
exit from the spine. This, however, appears to be incor- pedicle.
rect from the anatomic viewpoint, since the vertebral The neuroforamen may be oval, auricular or tear-
canal is an entity well distinct from the intervertebral drop shaped. The configuration depends on various
foramen. As lateral vertebral canal, therefore, one factors, such as the length of the pedicles, the height of
should indicate only the portion of the spinal canal sit- the disc, the prominence of the latter into the foramen
uated laterally to that occupied by the thecal sac. This and the size of the articular processes. Stephens et al.
portion has also been referred to as nerve-root or radic- (114) have analyzed, in cadavers, the shape, height and
ular canal, expressions which we prefer to that of lateral area of the foramen at the various lumbar levels. The
spinal canal. mean height ranges from 13 to 16 mm; it increases from
the first to the third neuroforamen, whilst decreases in
Nerve-root canal the fourth and, even more, the fifth foramen. The mean
area ranges from 83 to 103 mm' and shows the lowest
This canal, which is more an anatomic concept than a values at Ll-L2 and the highest at L5-S1. Both the shape
true canal, is the tubular structure in which the spinal and size vary depending on the vertebral level and the
nerve root runs from the exit from the thecal sac to the state of the disc (normal or abnormal, i.e., degenerated).
entrance into the intervertebral foramen. In the majority of cases, at the upper two lumbar levels
The nerve-root canal includes two portions: a proxi- the foramen is mostly oval when the disc is normal, and
mal - subarticular or intervertebral- portion; and a auricularly-shaped when the disc is abnormal; the size
distal portion, corresponding to the lateral recess (93). is not influenced by the state of the disc. At L3-L4level,
The proximal portion is delimited, anteriorly, by the there are similar proportions of auricular and oval fora-
intervertebral disc and, posterolaterally, by the ante- mens when the disc is normal; if the latter is abnormal,
rior border of the superior articular process, covered by the auricular shape prevails and the size decreases. The
the ligamentum flavum. The distal portion begins at the L4-L5 foramen is mostly auricular when the disc is
level of the superior vertebral end-plate and terminates either normal or abnormal; in the latter instance, how-
at the entrance of the intervertebral foramen. In this ever, the prevalence of tear-drop configuration increas-
portion, the nerve-root canal is delimited posteriorly by es; the dimensions are not influenced by the state of the
the base of the superior articular process and the pars disc. At L5-S1 level, the oval configuration prevails
interarticularis, and laterally by the pedicle. The nerve- when the disc is normal, whilst the auricular shape is
root canal has no true medial wall; this can be identified more frequent when the disc is abnormal; in the latter
with the lateral aspect of the thecal sac. Similarly to the instance the area decreases.
lateral recess, the nerve-root canal exists, as a clearly The values of the sagittal dimensions of the foramen
identifiable anatomic structure, only for the L4, L5 and at the individual lumbar levels have not been reported.
Sl radicular nerves. The more proximal nerves, after Magnusson (75) reports a mean value of 7 mm and
they have emerged from the thecal sac, enter almost Smith et al. (112) of about 8 mm.
immediately the intervertebral foramen, the entrance The main structure contained in the neuroforamen is
of which is almost in contact with the sac. the spinal nerve root (or radicular nerve), which occu-
pies up to 50% of the area of the foramen (115). The
Intervertebralforarnen spinal nerve root runs in the upper portion of the fora-
men, which also contains the anterior spinal branch of
The intervertebral foramen or neuroforamen is an the lumbar artery, the radicular artery and veins, and
osteofibrous canal, rather than a true foramen. It is the sinuvertebral nerve. The caudal portion of the fora-
formed by two adjacent vertebrae and the interverte- men contains intervertebral veins and fat tissue. The
bral disc in between. space not occupied by the neurovascular structures is
------------------------------------------------------------oAnatolny o41
used by the articular processes for their reciprocal vertebra. Distally to its end, the sac is in continuity with
movements during spinal flexion-extension. In the the so-called coccygeal ligament. This is a fibrous tube
sacrum, where there are no intervertebral movements, ensheathing the caudal portion of the filum terminale
the foramen is occupied almost entirely by the spinal and reaching the first coccygeal vertebra, on which it
nerve root. inserts. It represents a means of fixation of the thecal
sac to the spine.
The arachnoid membrane separates the dura mater
Neural structures from the C5F.
A 8
Fig. 2.38. (A) Lateral sagittal section of the lowermost portion of the lumbar spille, showing the thecal sac and the caudal nerve roots, two of which
(arrowheads) have pelletrated into the arachnoid and dura mater openillgs and have emerged in the epidural space. (B) Higher magnification view of
(A) at the level ofL4 vertebra. The L4 root is passillg, in its extra thecal, not visible portion, below the pedicle of the fourth lumbar vertebra. The poste-
rior concavity of the L4 vertebral body is filled with veins of the allteroilltemal plexus (asterisk). Note that the root is composed of multiple rootlets in
its illtrathecal course.
----------------------------------------------------------oAnatorny o43
At L3-L4Ievel, the arrangement is similar to that at The length of the radicular nerves, and their obliqui-
the level above. At L4-L5Ievel, the ventrolateral portion ty with respect to the sagittal plane, increases progres-
of the sac is occupied by the L5 roots, medially to which sively from 11 to 55. The 11 and L3 radicular nerves run
the 51 roots are visible. In each nerve root, the motor a very short distance in the vertebral canal, with an
rootlets are located ventrally and medially to the almost transverse course, before entering the respective
sensory rootlets. intervertebral foramens. The L4 radicular nerve has a
At L5-51 level, the 52 and 53 roots £lre joined to form slightly longer and oblique course than the upper
a bundle on each side. The 54 roots are separated from nerves. These four radicular nerves are in contact with
the 55 roots, which constitute a single bundle. the disc only at the level of the intervertebral foramen.
A posterolateral herniation of the three upper discs,
therefore, does not impinge on the radicular nerve, but
Radicular nerve on the corresponding nerve roots in the lateral portion
of the thecal sac.
The radicular nerve - commonly, though improperly, The obliquity of the L5 radicular nerve is 35°-40° and
referred to as spinal nerve root - is made up of the two its length is about 2.5 cm (131). Within the vertebral
spinal nerve roots, anterior and posterior, emerging off canal, it runs in the L5 nerve-root canal. The anterior
the thecal sac at a given vertebral level. The nerve wall of this canal is formed by the L4-L5 disc and the
extends from the thecal sac to the exit from the interver- body of the L5 vertebra. The posterior wall is represent-
tebral foramen, taking successively the name of spinal ed, up to down, by the L4-L5 ligamentum flavum, the
nerve. The spinal nerve roots, anterior and posterior, superior articular process of L5 and the pars interartic-
exit from the dural tube through two separated open- ularis. The medial wall is formed by the thecal sac and
ings, of which the ventral is occupied by the motor root the lateral aspect of the pedicle.
and the dorsal by the sensory root. Once emerged from The 51 radicular nerve shows, approximately, an
the thecal sac, the two nerve roots are surrounded by a obliquity of 25° and a length of 3 cm (131). The anterior
common fibrous sleeve, within which they are separat- wall of the corresponding nerve-root canal is formed by
ed by a dividing septum. This dural sleeve is lined, the L5-51 disc and the 51 vertebral body. The posterior
until in proximity to the spinal ganglion, by an exten- wall is constituted by the L5-S1 ligamentum flavum,
sion of the arachnoid, which is separated from the and the superior articular process and lamina of the 51
nerve by a thin layer of C5F. vertebra. The medial wall is represented by the thecal
The spinal nerve roots emerge from the thecal sac at a sac. Externally to the 51 radicular nerve, there is the
progressively more cranial level, descending from 11 to L5-51 intervertebral foramen, proximally, and the 51
55, with respect to the intervertebral foramen where pedicle, distally.
they run. The 11 roots (anterior and posterior) emerge
at the level of the center of the 11 vertebral body; the L2
roots, slightly above the center of the L2 vertebral body; Dorsal root ganglion
the L3 roots, at the level of the proximal one third of the
L3 body, and the L4 roots in proximity to the superior The dimensions of the dorsal root ganglion increase
vertebral end-plate of the homonymous vertebra. The progressively from 11 to 51 and then decrease from 52
L5 roots usually emerge at the level of the caudal end of to 55 (131). The 11 ganglion is, on average, 7 mm long
the L4-L5 disc and the 51 roots at the level of the middle and 5 mm large; that of the 51 root has a mean length of
portion of the L5-51 disc. The 52 roots exit from the 13 mm and a mean width of 6 mm. The ganglion may be
thecal sac opposite the distal portion of the 51 vertebral located in the spinal canal (intraspinal), the interverte-
body and the 52-55 roots at the level of the 52 body. bral foramen (intraforaminal) or outside the foramen
However, the site where the spinal roots, particularly (extraforaminal). The L2 ganglion is consistently
the L5 and sacral roots emerge, is strictly dependent on intraspinal, whilst the L3 ganglion is intraforaminal in
the level of termination of the thecal sac. If the latter half of the subjects and extraforaminal in the others
ends more cranially than normal, also the roots emerge (45). The L4 and L5 ganglions are intraforaminal in
more cranially, whereas the opposite occurs if the sac some three quarters of subjects (59). The 51 ganglion is
terminates more caudally. usually intraspinal (45, 59). At the level of the ganglion,
The spinal nerve roots emerge from the thecal sac the motor nerve root, which is located ventrally to the
obliquely with respect to the horizontal plane (Fig. 2. 38 sensory root, may be divided into two trunks. Likewise,
B). The angle at which they emerge from the sac is the sensory root may be bifurcated; in this instance,
approximately 40° for the 11-L5 roots (131). The 51 there are two distinct ganglions (59).
roots emerge with a mean angle of 22° and the more The dorsal root ganglion consists of: neurons of vary-
caudal roots with progressively more acute angles. ing sizes, showing various morphologic characteristics;
44.Chapter 2.-------------------------------------------------------
satellite cells, which surround the perikaryon of neu- niation, or other pathologic conditions, may impinge
rons and prolong along the initial portion of the axons; both on the radicular nerve proper of that level and the
and fibrillar connective tissue containing capillaries furcal nerve, thus causing atypical biradicular syn-
and venules (78, 91, 98). dromes (58). This may occur, for example, in the pres-
ence of an L5 furcal nerve, the branches of which pass
into the femoral and / or obturator nerves, as well as the
Spinal nerve sciatic nerve.
The spinal nerve originates at the lateral end of the
dorsal root ganglion, where the anterior and posterior
nerve roots join intimately. At this level, the dural Nervous plexuses
sleeve of the radicular nerve continues with the
epineurium. The spinal nerve, cylindrical in shape at its Constitution of the lumbar plexus varies considerably.
origin, flattens slightly and, after a course of approxi- In most individuals, it is formed by a branch of the
mately 1.5 cm, bifurcates into two terminal branches. anterior ramus of the T12 spinal nerve, by the anterior
The ventral ramus, thicker than the dorsal, proceeds rami of the Ll, L2 and L3 nerves and by two of the three
caudolaterally to form the lumbar and sacral plexuses. branches of the anterior ramus of the L4 nerve. The
The dorsal ramus runs dorsally to supply the periverte- third branch of this nerve joins the L5 spinal nerve to
bral muscles and the articular and ligamentous struc- form the lumbosacral trunk, which contributes to form
tures of the posterior vertebral arch. the sacral plexus. The most common variants in the
constitution of the lumbar plexus are those in which the
T12 nerve is entirely included in the plexus (prefixed
Furcal nerve plexus) and those in which the plexus includes the L5
nerve (postfixed plexus). Less commonly the plexus
The furcal nerve is an accessory spinal nerve, originat- includes both the T12 and the L5 spinal nerves.
ing from the cord independently of the other lumbar The sacral plexus consists of the lumbosacral trunk,
nerve roots and, like the latter, includes a ventral and a and the anterior rami of the 51, 52 and 53, and a branch
dorsal component. This nerve can be found in all sub- of the 54, spinal nerves. In the presence of variations in
jects, it is generally single and, in most cases, its roots the constitution of the lumbar plexus, the sacral plexus
emerge from the spinal cord and run within the thecal shows variations as well. When the lumbar plexus is
sac beside the L4 roots (58) (Fig. 2.39 A and B). In a small prefixed or postfixed, the sacral plexus is formed,
proportion of cases, there are two furcal nerves, L3 and respectively, by the L4-52 or 51-55 spinal nerves.
L4 or L4 and L5 ( Fig. 2.39 C). Occasionally, only one Normally, the second branch of division of the ante-
L5 furcal nerve is present. The dorsal root of the furcal rior ramus of the 54 spinal nerve joins the anterior
nerve has a ganglion, situated, as for the normal dorsal ramus of the 55 nerve and the coccygeal nerve to form
roots, at the level of the intervertebral foramen. The the coccygeal plexus.
nerve, once it has left the neuroforamen together with Variations in the constitution of the lumbar and
the roots proper of that level, with which it constitutes a sacral plexuses can be responsible for atypical neuro-
single radicular nerve, gives off three branches, con- logic syndromes, deviating from the pattern of normal
tributing to form, respectively, the femoral nerve, the radicular innervation. This is in keeping with the varia-
obturator nerve, and the lumbosacral trunk. tions observed in the furcal nerve, which are strictly
The clinical importance of this nerve is that disc her- related to those of the nervous plexuses.
L4
3
Fig. 2.42. Drawing showing the innervation of the intervertebral disc.
At least the outer one third of the annulus fibrosus is innervated.
the vessels, but no bundles of nerve fibers, were found; Vertebral canal
furthermore, Pacini or Ruffini's corpuscles were not
observed. This study, however, did not reveal these Upon spinal flexion, the laminae of two adjacent verte-
corpuscles even in the supraspinous and interspinous brae move apart and the interlaminar space widens,
ligaments, where they have later been demonstrated by thus producing lengthening and thinning of the liga-
another study (56). It is thus possible that these bodies menta flava. These changes and those of the disc lead to
are present also in the ligamenta flava. an increase in length and sagittal dimensions of the ver-
In the capsule of the posterior joints, capsulated and tebral canal. The opposite occurs upon extension of the
non-capsulated, and free nerve terminals have been spine: the ligamenta flava shorten, become thicker and
found (50, 54). Immunohistochemical studies have buckle, to a larger extent than the disc, into the spinal
demonstrated nerve terminals containing substance P canal, which decreases in length and narrows. Length
in the subchondral bone of articular processes (4) and differences between maximal flexion and maximal
the joint capsule (42), the synovial membrane (42) and extension are 3 mm, on average (73).
the fibroadipose meniscoids (44) of the facet joints. In The intervertebral foramen shows an increase in the
the synovial membrane and meniscoids, nerve endings vertical dimensions upon flexion, but narrows by about
containing galanin, another neuropeptide, were also one quarter both in the vertical and sagittal direction
found. The nerve terminals containing these neuropep- during extension of the spine (116). Narrowing is due to
tides were usually observed in proximity to the vessels. buckling, into the foramen, of the annulus fibrosus and
In the posterior joints, these nerve endings are probably the ligamentum flavum covering ventrally the apophy-
involved in local vasoregulation and only marginally in seal joint, as well as to the associated cranial sliding of
the transmission of sensory impulses (44). the superior articular process.
Electrophysiologic studies have shown, in the rabbit,
the presence of Group III mechanosensitive units in the
anterior surface of the annulus fibrosus (139) and Group Thecal sac
II, III and IV units in the capsule of the facet joints (138).
These units have a low or high mechanical threshold. Upon flexion of the spine, the thecal sac lengthens and
The units with a high threshold could play the role of decreases in size both in the sagittal and transverse
nociceptors and those with a low threshold of pro- plane. Upon extension, it shortens, decreases in caliber
pioceptors. and, in the cadaver, shows transverse ondulations,
particularly at intervertebral level (73). Dimensional
variations involve to a larger extent the portions corre-
sponding to the three lower intervertebral spaces,
which are the most mobile. Jointly with the portions
Vertebral and meningo-radicular above, the bottom of the sac moves cranially during
flexion and descends during extension. Changes in
dynamics length of the thecal tube upon flexion-extension are
slightly less than those of the vertebral canal.
Intervertebral disc
During flexion of the spine, the vertebral bodies adja- Nerve roots and radicular nerves
cent to a disc move closer ventrally and further apart
posteriorly, thus stretching the dorsal lamellae of the Radicular dynamics is different for the upper lumbar
annulus fibrosus, which loose entirely, or to a large nerve roots, which form the obturator and femoral
extent, their posterior curvature. The posterior portion nerves, compared with the lower lumbar and sacral
of the disc increases in height and reduces its promi- roots, giving rise to the sciatic nerve. The border
nence, when present, into the vertebral canal. The ante- between the two groups of roots is represented by the
rior portion of the disc undergoes opposite changes. L3 nerve root, which shows no significant dynamic
Upon extension, the height of the anterior portion changes (73).
increases and the anterior annular lamellae loose their The higher lumbar roots, during flexion of the spine,
curvature, whereas the posterior lamellae, particularly shorten and acquire an ondulating course; the corre-
those in the equatorial plane, show an increased poste- sponding radicular nerves move apart from the pedi-
rior convexity (Fig. 2.43). As a result, the posterior sur- cles and assume a slightly more transverse course.
face of the disc bulges into the spinal canal to a varying Opposite changes occur during extension: the nerve
extent. The nucleus pulposus tends to displace posteri- roots lengthen and become more vertical, whereas the
orly during flexion and anteriorly during extension. radicular nerves approach the pedicle above.
48.Chapter 2.---------------------------------------------------------
Upon flexion, the lower lumbar and sacral roots around the middle of the vertebral body. At the level of
increase in length and move cranially by a few millime- the intervertebral foramen, they send out three branch-
ters. The radicular nerves are stretched downwards, es: a ventral one (ventral spinal branch), entering the
acquire a more vertical direction, and approach the spinal canal anteriorly to the radicular nerve; a middle
pedicle and the anterior wall of the vertebral canal. one (radicular artery), which accompanies the radicu-
During extension, the nerve roots become winding, lar nerve; and a posterior one (dorsal spinal branch),
whereas the radicular nerves move apart from the penetrating into the spinal canal dorsally to the radicu-
pedicles and acquire a more vertical direction with lar nerve. Proceeding posteriorly, the lumbar artery
respect to the thecal sac. finally sends out a dorsal branch, which supplies the
In the straight leg raising maneuver, the lower posterior vertebral arch and the regional muscles.
lumbar and sacral radicular nerves on the side of the While running along the vertebral body, the lumbar
maneuver move caudally and laterally, and are slightly artery sends out primary periosteal arteries, which are
lengthened (page 184). At the same time, they attract directed proximally and distally (Fig. 2.44). Some of
the thecal sac to themselves and downwards. Those on them cross the adjacent discs to anastomose with the
the opposite side are tractioned cranially and attracted primary periosteal arteries from the adjacent segmental
towards the side on which the maneuver is carried out. vessels. In the proximal and distal one third of the ver-
The upper lumbar radicular nerves undergo similar tebral body, there is a horizontal branch (external meta-
dynamic changes when the knee is flexed with the physeal artery), which anastomoses with the primary
patient prone. periosteal arteries (Fig. 2.44). From these vessels small-
er branches are sent out, which represent the secondary
periosteal arteries.
Blood supply Ventrally to the pedicle, the lumbar arteries send a
branch, which runs caudally and anastomoses with the
branch from the underlying lumbar artery. This trunk
Vertebral vascular pattern (precentral anastomosis) (100) is larger at the level of
the L5 vertebra because of the small size of the fifth
Arteries lumbar artery, arising from the middle sacral artery
rather than the aorta.
Vascularization of the lumbar spine (26, 100, 133, 134 ) is The ventral spinal branch, once entered the spinal
provided by the lumbar arteries and the middle sacral canal, runs distally bordering the pedicle and anasto-
artery. The lumbar arteries, arising from the posterior moses with the underlying artery to form the postcen-
aspect of the aorta, follow a posterolateral course tral anastomosis (100) (Fig. 2.45). The latter gives off
----------------------------------------------------------oAnatolnyo49
2 --..,;
4-----t.lI!Ii2I"
Fig. 2.45. Arterial system within the spinal canal. (1) Anterior spinal
artery. (2) Postcentral anastomotic trunk. (3) Anastomosis joining the
trunk of the two sides (from Ref 10).
Fig. 2.44. Schematic drawing of the anteroexternal arterial system of the The dorsal branch of the lumbar artery runs posteri-
lumbar spine. (1) Lumbar artery. (2) Primary periosteal artery. (3) orly, surrounds the posterior joint, to which it sends
External metaphyseal artery. (4) Secondary periosteal artery (from Ref
10, modified). thin rami, and divides into a medial and a posterior
branch. The former follows the outer aspect of the
laminae and the spinous process, whereas the latter
periosteal branches, and transverse branches which supplies the lumbosacral common mass.
anastomose each postcentral channel to its opposite The nucleus pulposus is supplied by the branches of
number across the midline. The dorsal spinal branch the nutrient artery and by the metaphyseal arteries of
penetrates into the posterolateral portion of the spinal the vertebral body. These branches reach the subchon-
canal and divides into a proximal and a distal ramus, dral bone and supply the nucleus pulposus by diffu-
which form two longitudinal trunks anastomosed by sion of solutes through the cartilage end-plate. In the
transverse branches. These vessels provide the rami fetus and newborn, the peripheral portion of the annu-
supplying the structures of the posterior arch. lus fibrosus is vascularized (80). In adult life, the nor-
The arterial network of the vertebral body is formed mal annulus fibrosus contains no vessels. Most of the
by the equatorial and metaphyseal arteries. The former annulus is supplied by diffusion by the arterial network
arise from the postcentral anastomosis (nutrient artery) of the vertebral body, whereas the outer lamellae
and the lumbar arteries (radial arteries); they give off receive oxygen and nutrients from the periosteal arter-
proximal and distal branches, supplying that part of the ies. In the vertebral end-plate, the arteriole and capil-
vertebral end-plate which is subjacent to the nucleus lary networks show similar density in the area
pulposus. The latter stem from the external metaphy- corresponding to the nucleus pulposus and in that fac-
seal arteries or the periosteal arteries and send out thin ing the annulus fibrosus, however in the former the ter-
branches, directed to the peripheral portion of the ver- minal microvascular coils have more complex
tebral end-plates. convolutions (84).
50.Chapter 2 . - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Veins
Lumbosacral anomalies
Transitional anomalies
barized Sl vertebrae, because the thoracic vertebrae Generally, the anomaly is unilateral. The nerve roots
were not counted. However, there are few subjects who most frequently involved are L5 and S1, followed by L4
have 12 thoracic and six lumbar vertebrae, of which the and L3.
lowermost does not show morphologic anomalies of Several classifications of these anomalies have been
the transverse processes. In our opinion, the latter is a proposed. Cannon (18) described three types of anom-
further type - Type V - of transitional anomaly. alies: conjoined roots, anastomoses between roots, and
The disc below the anomalous vertebra may be nor- transverse course of the root. Bonola and Bedeschi (14)
mal (in Type I and V anomalies, and rarely in the other distinguished anomalies of origin, course, length and
types) or be vestigial or absent (Types II-IV). A vestigial diameter of the nerve roots. Postacchini et al. (97),
disc may have a decreased height, but a normal struc- based on the analysis of water-soluble lumbar myelo-
ture or, more often, it may have a small, or no, nucleus grams, have identified five types of anomalies. In Type
pulposus. In Type I and II, the anomalous transverse I, the roots of one or more radicular nerves emerge, in
process may show mild degenerative changes in the the presence of a thecal sac of normal length, at a more
area of contact with the sacral ala or the ilium (34). cranial level than normal. In type II, the root emerges at
The etiology of transitional anomalies may be related an abormally caudal level and the resulting radicular
to genetic factors, as suggested by reports of families nerve has a more transverse course than normal (Fig.
with a high prevalence of the anomaly (122). 2.50). In Type III, the roots of two distinct radicular
nerves emerge from the dural sac through closely adja-
cent openings (Fig. 2.51). In Type IV, the roots of two
Spina bifida occulta
radicular nerves emerge conjoined in a single trunk
(Fig. 2.52); after an extradural course of varying
This condition consists in a failure of fusion, on the mid-
length, the two radicular nerves separate and each runs
line, of the two halves of the posterior vertebral arch.
towards its own neuroforamen, or they remain con-
The latter are separated by a space of variable width in
joined and exit from the spine through a single interver-
the area normally occupied by the spinous process,
tebral foramen. Type V is characterized by the presence
which is generally absent; the laminae may be shorter
of an anastomotic branch, joining two radicular nerves
than normal or completely absent. Occasionally, in the
in their extrathecal course. The most common anom-
central portion of the defect, an isolated ossicle is visi-
ble, the so-called ossification center of the tip of the
spinous process. The dimensions of the vertebral canal,
at the levels above the anomaly, tend to be larger than
normal (86).
The vertebrae most frequently involved are L5 and
S1. Usually, in a single subject, only one vertebra is
anomalous. Occasionally, the defect involves all the
sacrum and/or two or more lumbar vertebrae. This
anomaly has been found in 1.9% of lumbosacral spines
in a large South African skeletal population (31). In
radiographic studies on living subjects, however, the
prevalence ranged from 5% to 15% (61, 109).
The etiology of spina bifid a occulta is unknown. An
important role is probably played by genetic factors, as
indicated by geographic variations in the prevalence of
the anomaly (113, 125, 135) and its markedly higher fre-
quency in subjects with spondylolysis (31). However,
also acquired factors seem to playa role. It has been
shown, in fact, that some substances, such as the valer-
ic and retinoic acids, may cause the anomaly (10, 121)
and that this is more frequent in the lower socio-
economic classes (70, 135).
Nerve-root anomalies
Fig. 2.50. Type II nerve-root anomaly. Left oblique myelogram. The left
L4 root has an abnormally caudal emergence from the dural sac and the
Anomalies of the lumbosacral nerve roots have been course of the corresponding radicular nerve is more transverse than
reported with a frequency of 0.34% to 2.7% (14,37,97). normal (arrowhead).
54.Chapter 2.-------------------------------------------------------
involved roots emerge from the spinal cord or to an
abnormal shortness of the cord (40).
Nerve root anomalies are more frequently observed
in subjects showing congenital anomalies of the
lumbosacral spine, particularly those with transitional
vertebral anomalies. This suggests an etiologic relation-
ship, which, however, is of unknown nature, between
the two types of anomalies.
In themselves, nerve root anomalies are asympto-
matic. However, the anomalous radicular nerves, par-
ticularly in Type III and IV anomalies, are less mobile
than normal. In the presence of a compressive agent,
such as disc herniation, they have less chances to escape
compression compared with normal radicular nerves.
They may, therefore, be markedly compressed and
cause severe radicular symptoms, even in the presence
of a small herniation.
Only rarely may the anomalous radicular nerves be
compressed in a radicular canal or neuroforamen that
has become moderately stenotic.
BIOCHEMISTRY, NUTRITION
AND METABOLISM
S. Gumina, F. Postacchini
Nucleus
Rough endoplasmic
reticulum (triple
helix formation,
hydroxylation)
a-Chain
Goigi apparatus
( synthesis of Procollagen
saccharidic chains
bound to hydroxylysine
residues)
Telopeptides
Fig. 3.1. Schematic drawing showing synthesis, secretion and extracellular aggregation of tropocollagen molecules.
reactions produce covalent and crossed links which methods. However, types I and II account for 80% of
bind the microfibrils to each other. the collagen in the intervertebral disc.
Collagen fibers can be decomposed, depending on Type I collagen is present in all layers of the annulus
the resolution of the different means of investigation, fibrosus and in the transitional zone (14, 129). It is par-
into 40-nm thick micro fibrils, 0.2- to 0.3-J..l fibrils or 1 ticularly concentrated in the outermost layer of the
to 12-J..l fibers. annulus (80%), decreases in the inner annular layer and
The amount of collagen present in the normal adult is absent in the nucleus pulposus (14). Since the synthe-
annulus fibrosus increases from L2-L3 to L5-S1 disc (3). sis of this type of collagen depends on two structural
genes, the triple helix consists of two different alpha
chains [u1(I)]2u2(I). Type I collagen shows a low con-
Collagen types tent of simple or glycosylate hydroxy lysine and forms
thick fibers with a clearly visible periodicity. By con-
Fourteen types of collagen have been recognized trast, type II collagen has a high content in hydroxyly-
(104, 159), which differ from one another in the amino sine and the fibers that it forms are thin and have very
acid sequence of the tropocollagen chains. Type 1, II, few visible periodic bands. Type II collagen is produced
III, V, IX, and XI collagens have been isolated from the by a single gene and is usually indicated with the formu-
normal intervertebral disc by immunohistochemical la [u1(II)]3 This collagen type is particularly concen-
- - - - - - - - - - - - - - - - - - - - 0 Biochemistry, nutrition and metabolism 061
trated in the nucleus pulposus, but it is present, even if Type IX collagen has a pericellular distribution and it
in decreasing amounts, in the transitional zone and in has been observed both in the nucleus and annulus
the inner and outer layers of the annulus fibrosus and, in the latter, particularly in the inner layer (30,129).
(14, 129). In type II collagen fibers, the interfibrillar This type, which represents 1%-2% of disc collagen,
spaces are wider, and the water content is thus higher was found to be closely associated with type II collagen
than in type I collagen fibers. Therefore, type II collagen (160,164). Roberts et a1. (129) extracted type IX collagen
fibers have a greater ability to undergo deformation from rat and bovine, but not from normal human,
and to withstand compressive load (90). Bailey et a1. (6), intervertebral disc. This could be due to the fact that, in
studying the different forms of bonds linking the the human disc, it is masked by other macromolecules
tropocollagen chains, observed that the proportion of not removed by digestion with hyaluronidase. It was
cross-links OH-LNH and HHMD (histidinohydroxy- also hypothesized that type IX collagen occurs in differ-
merodesmosine), which are more typical of type I, ent forms in the intervertebral disc and cartilage end-
than type II, collagen, appeared to be greater in the plate, as occurs in chick cartilage and cornea, due to a
lower, than the upper, spine. This suggests that type variation in transcription start sites on a same gene
II collagen is more abundant in these discs, which are (129).
those submitted to the greatest mechanical load. Type XI collagen was found in the nucleus pulposus
Type III collagen [a1(III)]3 has a low content of sim- associated to type II collagen (30). It represents about
ple and glycosylate hydroxylysine, and a high rate of 3% of disc collagen (30).
hydroxyproline. Its chains are linked by numerous Disc collagen fibers have many functions: they bear
disulphide bonds. The carboxylic terminal of type III compressive loads and are submitted to tensile
collagen maintains the telopeptides, which might have strengths; they form a network, in the meshes of which
the role of hindering the formation of thicker fibers. In a the proteoglycans are located; and they stabilize the
study on the disc tissue and cartilage end-plate of man, gelatinous tissue of the nucleus pulposus and anchor
rat and calf using immunolocalization techniques, it the disc to the cartilage end-plate. These functions are
was observed that antiserum to type III collagen pro- mainly carried out by type I and II collagens. The high-
duces a concentric pericellular staining, which is often er percentage of type II collagen in human interverte-
irregular in shape (129). In this study, type III collagen bral disc with respect to the bovine disc might be due to
was found in the pericellular and territorial matrix and, the greater compressive load to which the human spine
occasionally, in the pericellular capsule of the chon- is submitted (30). Little is known, instead, concerning
dron. The latter is formed by a cartilaginous cell sur- the function of the other types of collagen. Since type III
rounded by pericellular matrix (lacuna), pericellular and VI collagens are present in the pericellular and
capsule and territorial matrix. In human intervertebral intercellular matrix and the pericellular capsule of the
disc, the rate of type III collagen is higher than in the chondron, it has been hypothesized that they might
bovine disc. This type of collagen, as well as type VI act as strain sensors within the tissue, enabling the
collagen, are found in proximity to calcium pyrophos- cell to respond metabolically to a mechanical stimulus
phate crystals in three normal discs of a human subject. (11, 129). Staining of the chondronic capsule, in fact, is
In the annulus fibrosus, type V collagen, which more intense in the nucleus pulposus and the middle
presents a high content of simple and glycosylate and deep zones of the articular cartilage, which are sub-
hydroxylysine, was found to be associated with type I mitted to compressive load, than in the annulus fibro-
collagen. It represents 3% of the entire collagen in the sus and superficial zone of cartilage, where tensile
annulus fibrosus (30,151). stresses prevail. Type III and VI collagens of the
Type VI collagen was found in the capsule and peri- chondronic capsule might have the role of maintaining
cellular matrix of the chondron (129). Molecular lateral a constant microenvironment around the cell, by selec-
aggregates of type VI collagen lead to the formation of tively retaining some molecules. Thus, these types of
a band with a periodicity of 100-110 nm, as observed in collagen might retain pericellular proteoglycans in
cultures of skin and tendon fibroblasts (12, 13). Fibers order to control osmotic pressure around the cell and,
with this periodicity have at times been observed in the thus, the vitality of the latter (106).
nucleus pulposus (16, 20). Aldehyde-mediated cross- The role of type V collagen remains to be elucidated.
linking residues have not been found on direct analysis However, the fact that it is closely associated with type
in type VI collagen, whilst they have been observed in I collagen suggests that type V collagen might playa
other types of collagen (165). In the bovine interverte- role in regulating the spatial orientation and dimen-
bral disc, type VI collagen is unusually abundant; in sions of type I collagen. Type IX collagen might have a
the calf, it accounts for 20% and 5% of total collagen in similar role to that of type II collagen.
the nucleus pulposus and annulus fibrosus, respec- Little is known concerning the role of type XI
tively. collagen.
62.Chapter 3 . - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Proteoglycans Protein core
'~'" HO 0
occupies the intermediate region of the protein core
OH 0 ••••
- Chondroitin-6-sulphate (keratan sulphate-rich region); it seems to be linked to
OH NHCOCH s serine and threonine residues by N-acetylgalac-
tosamine (9), The other end of the protein core, showing
no glycosaminoglycan chains, is termed the hyaluronic
- Chondroitin-4-sulphate acid-binding region, In fact, proteoglycans may be
either in the form of monomers (protein core and
mucopolysaccharidic lateral chains) or as large macro-
molecular aggregates represented by monomers not
covalently bound to a long hyaluronic acid molecule
(53, 54, 84, 147, 148) (Fig. 3.4). The link is stabilized by
- Keratan sulphate protein complexes (link proteins) (35, 49), which make
the aggregate more resistant to pH changes, rise in tem-
perature or an increase in urea concentration (49).
Disc link proteins (LP) were first observed by
"",~O~ -o3S~O"", - Dermatan sulphate
Tengblad et al. (146) in moderately degenerated inter-
~"O~o"" vertebral discs of elderly subjects (grade 2 of Lewin's
OH NHCOCH s classification), These authors found that the LP in
the disc have less ability to aggregate proteoglycan
Fig. 3,2, Disaccharidic units of glycosaminoglycans of disc proteo- monomers to hyaluronic acid than those in the articular
glycans. cartilage, probably because, in vitro, the biophysic
____________________ 0 Biochemistry, nutrition and metabolism 063
Hyaluronic acid molecule With aging, proteoglycans lose, or undergo a decrease
in, their aggregating ability. This may be due to: the
PG Monomers inability of the newly-synthesized proteoglycans to
interact with hyaluronate; the physiologic decrease
in hyaluronic acid in the disc; or the reduced ability of
proteoglycans to interact with hyaluronic acid (3). As
a result, monomers could be degraded by enzymes
released in the matrix by necrotic cells. Neutral and
acid proteases might attack the protein core (116) or the
LP that stabilize the complex (45). Melrose et al. (108)
found that lysozyme may affect, in vitro, the shape and
aggregating ability of proteoglycans.
The functional significance of the ratio of monomer
to aggregate proteoglycans is not yet understood. It
has been suggested that aggregation keeps the proteo-
glycans in the tissue, since there is no evidence that
strong bonds exist between proteoglycans and other
matrix components (151). However, according to Eyre
Link proteins (29), KS rich regions are able to firmly bind to the
surface of collagen fibers or to glycoproteins which are
Fig. 3.4. Model of aggregated proteoglycans. They consist of monomers linked to them. CS-rich regions, on the other hand,
bound to a hyaluronic acid molecule. The link is stabilized by protein might have the role of maintaining collagen fibers
complexes (link proteins).
separated from each other, thus increasing the elastic
properties of the tissue.
conditions differ from those normally present in the With advancing age, proteoglycans decrease in size,
disc in vivo. In neonatal cartilage, three subpopulations possibly due to degeneration of the CS-rich region and
of LP-LPl, LP2 and LP3 - have been found. They are the loss of hyaluronic acid-binding region (57,59). The
glycosylated to various extent, in particular LP1 > LP2 resulting molecule is reach in KS, is of smaller size and
> LP3. In situ enzymatic digestion of LP1 and LP2 pro- has a higher ratio of glucosamine to galactosamine.
duces LP3 (111). The study on LP from cadaver discs of In the articular cartilage, hyaluronic acid accounts
postnatal and young adult subjects has shown that LP1 for less than 1% of total uronic acid (51, 53); therefore,
prevails in postnatal tissue, whereas LP3 predominates the molar ratio glucosamine / galactosamine essentially
in the young adult disc (27). This finding is not in keep- reflects that between KS and CS in the proteoglycans
ing with observations in the articular cartilage of (3).
subjects aged 50-70 years, in whom LP1 and LP3 have KS-rich proteoglycans have been found in the annu-
comparable concentrations. The proportion of LP1 is as lus fibrosus of discs from elderly subjects, probably
high as 63% in neonatal disc, whilst it is 26.5% and 45%, due to increased synthesis of proteoglycans rich in
respectively, in young adult disc and elderly human KS; greater resistance to enzyme degradation with
articular cartilage. By contrast, LP3 is the minor compo- aging; or selective diffusion of the smaller CS-rich
nent in postnatal disc tissue (11%), however, not in species out of the tissue (19). The two former hypothe-
young adult disc (59.7%) and elderly human articular ses are more likely, since, in the human intervertebral
cartilage (37%). These data suggest that LP of human disc, the KS-rich region of the proteoglycan protein
intervertebral disc undergo degradation with aging. core displays a greater resistance to proteolysis
This hypothesis is supported by the presence of peptide than the CS-rich region. Davidson and Small (21)
fragments originating from degradation of LP and reported that, in the rabbit nucleus pulposus, KS
proteoglycans in young adult, but not in postnatal, disc has a slower turnover than CS. Lohmander et al.
tissue. In adults, accumulation of catabolic products (92), however, found the half-life both of KS and CS
might prevent the chondrocytes from responding to to be 30 days.
feedback signals which stimulate synthesis of proteo- The amount of KS in the human adult disc depends
glycans and LP and this might affect the ability of disc on disc level. Adams and Muir (3), in fact, have found
tissue to respond to biomechanical stress. a lower concentration of KS in the lowermost lumbar
The ratio of monomer to aggregate proteoglycans discs.
changes not only with advancing age, but also in The monomers are smaller and more poly dispersed
different areas of the disc; the amount of monomers, in the intervertebral disc than in the articular cartilage
in fact, is higher in the nucleus pulposus (2, 5, 93, 126). (29,151) and, compared with the latter, present a short-
64.Chapter 3 . - - - - - - - - - - - - - - - - - - -_ _ _ _ _ _ __
Fig. 3.5. Proteoglyean monomers of the intervertebral disc (A) are Di Fabio et al. (24) submitted the proteoglycans extract-
smaller than those of the articular cartilage (B). Furthermore, the pro-
ed from nucleus pulposus and annulus fibrosus of three
tein core and the CS chains are shorter, whilst the KS chains are longer.
subjects aged 64, 67 and 72 years to chromatography
(Sepharose CL-2B) and obtained six and three pools
from nucleus pulposus and annulus fibrosus, respec-
er protein core and CS chains, and longer KS chains tively. The six pools from the nucleus correspond to:
(74) (Fig. 3.5). aggregate proteoglycans (pool 0); a mixture of aggre-
The amount of proteoglycans increases from the gate and non-aggregate proteoglycans (pool 1); and
outer layer of the annulus to the nucleus pulposus non-aggregate proteoglycans (pools 2, 3, 4, 5) contain-
(50, 142). In fetal and newborn nucleus, the proteogly- ing equimolar amounts of hexuronate, however, with
can rate is two- to three-fold compared with that in the decreasing hydrodynamic volume. The fractions corre-
annulus fibrosus (7). The latter, when immature, syn- sponding to pools 2-5, obtained by the chromato-
thesizes five times more proteoglycans than the adult graphic analysis of the annular proteoglycans, showing
annulus. In micro-autoradiography studies on imma- a greater proportion of aggregating proteoglycans,
ture rabbit discs using labeled sulphate, the highest were grouped in a single pool. Subsequently, each pro-
incorporation of radioisotope was observed in the teoglycan pool was submitted to electrophoretic analy-
peripheral portions of the nucleus and the inner two sis, which showed two or more distinct bands. Previous
thirds of the annulus fibrosus (137). Histologic studies electrophoretic studies on baboon (140) and human
have shown that in the immature annulus fibrosus the (105) discs had revealed only three bands. For human
most active cells are those located in the inner annular discs, two bands were attributed to aggregate, and
layers (7). On the other hand, in human annulus fibro- one to non-aggregate, proteoglycans. Instead, Di Fabio
sus, the cells producing the greatest amount of proteo- et al. (24) have found three bands for non-aggregate
glycans are those located between the outer and inner proteoglycans. According to these authors, bands I and
layer. However, the high level of biosynthetic activity in II correspond to the two distinct subpopulations of
this area does not appear to be related to the number of aggregate proteoglycans demonstrated by McDevitt
tissue cells, the degree of hydration or the amount of et al. (105) and refer to 0 and 1 pools. Band III was found
proteoglycans already present (155). Furthermore, pro- in pools 3-5, band IV in pools 4-5, and band V only
teoglycans in the nucleus pulposus differ from those in in poolS. Pool 2 had an intermediate mobility between
the annulus fibrosus. The KS / CS ratio is higher in the bands II and III. KS is the most abundant glyco-
nucleus, whereas the amount of monomers able to form saminoglycan present in band III proteoglycans, whilst
aggregates is higher in the annulus fibrosus (3). In the CS is scarcely. By contrast, band IV proteoglycans
adult, 40% of the proteoglycans in the annulus fibrosus contain primarily CS and only little KS. Band V
may aggregate, compared with only 15% in the nucleus contains CS alone and differs from the corresponding
pulposus (151). In the young disc, the respective per- proteoglycanic pool due to the low protein content
centages rise to 60% and 25%. Instead, in the articular (60). The composition of the protein core in band III
cartilage of the hip joint, 80% of proteoglycans are able differs from that in band IV. No differences have been
to aggregate (78). observed between nucleus pulposus and annulus
--------------------omochemistry, nutrition and metabolism 0 65
fibrosus as far as concerns these two bands, except for gated, to the entangled, shape by changing the solution
the larger amount of KS in band III from the annulus. viscosity. When entangled, they form a tridimensional
Band III contains more threonine and proline than band network, which occupies a considerably larger volume
IV, whereas the latter, which is rich in CS, contains more termed "dominion" or "excluded volume", since all the
serine and glycine compared with band III. The latter other molecules are excluded from it. Thus, disc resis-
might be a fragment arising from a proteoglycanic tance to compression depends on the dominion occu-
region near the hyaluronate-binding region, and this pied by proteoglycans, as well as on the collagen fibers.
might account for the high content in KS; band IV might The FCD of the nucleus pulposus in the adult lies
represent a fragment from a portion of the molecule between 0.2 and 0.4 mEq/ml and osmotic pressure
remote from the hyaluronate-binding region, since it is ranges from 0.1 to 0.3 mPa (1 to 3 atm) (158). Osmotic
rich in CS; and band V might be a short portion of the pressure is lower in the annulus fibrosus than the
protein core. nucleus pulposus, but is considerably higher compared
Jahnke and McDevitt (77), in an electrophoretic study with that in non-weight-bearing tissues.
of proteoglycans extracted from discs of human sub- In the intervertebral disc, cation concentration is
jects aged 17,20 and 21 years, found that non-aggregate higher than in the plasma. Sodium can reach values of
proteoglycans migrate as a single band. This finding, 300 to 400 mM. Its distribution varies in different disc
observed in younger discs than those analyzed by Di areas, with aging and with the degree of hydration of
Fabio et al. (24), led to the hypothesis that disc aging is the disc (85, 86). Divalent cations, such as magnesium
associated with changes in the catabolic and / or syn- and calcium, are even more sensitive to proteoglycan
thetic mechanisms that give rise to a different set of content and may reach concentrations as high as 10
non-aggregate proteoglycans. With aging, in fact, a times that in the plasma (101). By contrast, anions are
decrease in proteoglycans has been observed (19), affected by FCD and reach, as in the case of chloride,
which precedes degeneration of the nucleus pulposus concentrations less than half of that in the plasma.
(124). Macromolecule solute distribution depends both on
the proteoglycan charge and the "partition coefficient",
i.e., the concentration on a molal basis in the disc
Function matrix, relative to the concentration in the surrounding
fluid or plasma. For instance, glucose, which has a mol-
Glycosaminoglycan chains have a negative charge, ecular weight of 200, is partially excluded from the disc,
and are, thus, able to bind organic and inorganic cations since its partition coefficient is only 0.7 to 0.8 in the
and proteins. CS and KS contain the negative charges in nucleus pulposus (153). On the other hand, solutes of
the sulphate and carboxyl groups. CS has two charges larger size, such as serum albumin (molecular weight
per disaccharide, whereas KS averages one (151). 60,000-70,000), may have lower partition coefficients
Therefore, the amount of negative charges in the (0.01-0.001) (151).
matrix-fixed charge density (FCD) - depends not only FCD also influences the disc response to mechanical
on the concentration of proteoglycans in the tissue, but loads, since the disc resists pressure exerted on it
also on the CS/KS ratio. The negatively charged com- and packing of the tissue with the repulsion force
ponents of the matrix affect both the distribution of the which develops between the negative charges of
solutes with a positive or negative charge (100) and glycosaminoglycans (151).
the osmotic pressure and, thus, the fluid contents of the
disc. Ions and other solutes are distributed as to form
an equilibrium (Gibbs-Donnan equation) between the Water
plasma and the disc matrix; therefore, due to the defi-
nitely negative electric charge of the disc tissue, the Water is the major component of the intervertebral
total number of ions in the disc is consistently higher disc. Due to the few cells in the disc tissue, most of the
than in the plasma (156, 157). Since osmotic pressure water is extracellular and is associated with collagen
depends on the difference between the number of par- and proteoglycans (66).
ticles dissolved in the plasma and those contained in In the young, 85%-90% of nucleus pulposus and
the disc, the large number of ions in the disc endows the 78% of annulus fibrosus consist of water (90). The water
latter with a high osmotic pressure (156). The latter also content of the disc decreases with age: in senile age,
depends, although to a lesser extent, on the morpho- water represents 70% of the nucleus pulposus and
logic characteristics of the proteoglycans, which, in annulus fibrosus (29, 44, 90).
turn, are affected by the electric charge of the elec- Much of the information on the biochemical and
trolytes bound to the acid mucopolysaccharides. In mechanical properties provided to the disc by its water
fact, proteoglycans can be transformed from the elon- content, stems from studies performed primarily on
66.Chapter 3 . - - - - - - - - - - - - - - - - - - - - - - - - - - - -
fragments of intervertebral discs obtained at surgery or have been extracted from annulus fibrosus. In effect,
autopsy. However, it must be borne in mind that discs some of these NCP are glycoproteins. They are particu-
removed 12-36 hours after death usually have a greater larly abundant in the nucleus pulposus of elderly
fluid content in the nucleus pulposus and a lower patients and contain large amounts of sialic acid (43)
content in the annulus fibrosus compared with disc and mannose (125). Ghosh et al. (40) maintain that some
tissue excised at surgery (79). After death, in fact, the of these glycoproteins are the so-called "link proteins",
exchanges of fluids between the cartilage end-plate which are involved in the aggregated proteoglycan for-
and intervertebral disc are interrupted (63, 120) and, mation; other NCp, in particular some glycoproteins,
thus, the water balance occurs only as a result of intra- might form a sort of primary framework for the subse-
dis cal redistribution and diffusion from and to the quent deposition of correctly orientated collagen fibers.
tissues surrounding the annulus fibrosus. Furthermore, At roentgendiffraction, NCP are poorly crystalline,
a prolonged immobilization of the patient in bed, however crystallinity varies in different areas of the
before death, may affect the water content of the disc. same disc (144). It is still unclear whether the dyshomo-
Disc hydration, in fact, depends on reciprocal perfu- geneous crystallinity is the result of different mechani-
sion between disc tissue and cartilage end-plate, cal loads to which the disc is submitted in different areas
and is partially influenced by the external pressure or whether disc mechanical properties depend also on
exerted on the disc by body weight, spatial position the amount and quality of NCP dyshomogeneously dis-
of the spine and muscle action (86, 112, 163). The disc tributed in the disc. The latter hypothesis appears to be
expells water when submitted to loading and draws more feasible, since a different crystallinity of NCP has
it from the adjacent vertebral bodies when the load is been found in the matrix of other cartilaginous tissues
removed. This may explain why nocturnal bed rest, submitted to high load, such as the menisci (145).
and the resulting intradiscal water imbibition, can
lead to recovery of even a few centimeters in body
height, which, in turn, are lost in the daytime, when Elastin
discs are submitted to loading.
Disc hydration depends on the difference between Elastin forms elastic fibers, which, in the disc, are
the hydrostatic and osmotic pressure. The latter is influ- few in number and irregularly distributed (IS, 109,
enced by the proteoglycan rate in the matrix. However, 128). Probably, the function of the elastic fibers is to
in vitro, intervertebral disc cells are able to synthesize permit disc shape recovery once the deformation pro-
large amounts of proteoglycans only if they are submit- duced by a mechanical agent ceases (29).
ted to a hydric equilibrium comparable to that present Elastin amounts to 1.7% ± 0.2% of the dry weight of
in vivo (8). Therefore, water content of the disc depends the human intervertebral disc (109). This percentage is
on proteoglycan concentration, but, in turn, regulates markedly lower than that found in human ligamenta
the synthesis of the latter. flava (46.7% ± 0.9%) (109), where the elastic fibers are 10
The proteoglycan-collagen complex, compared to times as thick as those in the disc. Quantitative analysis
collagen alone, is able to withhold much larger of elastin from 59 discs of subjects aged 10-71 years
amounts of water (25, 90). (average 43 years) showed no significant differences
between the annulus fibrosus and nucleus pulposus,
whilst ultrastructural studies have revealed that the
Noncollagenous proteins elastic fibers in the nucleus and annulus are different
both in shape and orientation (IS, 20). Furthermore, the
Noncollagenous proteins (NCP) of the disc are those elastin content is comparable in both sexes and does
proteins not involved in the formation of collagen not change significantly with age.
fibers. Thus, NCP also include elastin and enzymes, Disc elastin has a different amino acid composition
which, however, we have analyzed separately. compared with that from other human tissues, such as
NCP have been observed in the nucleus pulposus aorta wall, achilles tendon, joint capsule, ligamentum
and annulus fibrosus at all ages and in both genders nuchae and ligamenta flava (109, 135). It has both a
(144). They have been found, in varying amounts, in higher concentration of diamino-monocarboxylic
adjacent discs and in different areas of the same disc amino acids (histidine, lysine, arginine), the aminic
(42, 144). In the nucleus pulposus, NPC were found to extragroups of which enhance ionic bond formation,
be more abundant than in the annulus fibrosus (23). and threonine and serine, the oxydrilic groups of which
Fricke (36) and Fricke and Hadding (37) have isolated take part in hydrogen bond formation (99). Disc elastin
albumin, cd -glycoprotein, y-globulin and transferrin has a lower concentration of alanine, valine and leucine
from the nucleus pulp os us of human intervertebral than elastin in the ligamenta flava; this may be due to
discs; the same proteins, except for cd -glycoprotein, the fact that these amino acids, rich in lateral hydro-
- - - - - - - - - - - - - - - - - - - - . Biochemistry, nutrition and metabolism· 67
phobic chains, are poorly represented in proteins of cartilaginous tissues, has been found in the human
highly hydrated matrixes which are very rich in water, intervertebral disc and in the disc of immature dog (28,
such as disc matrix. Proline, glycine and alanine are 136). The level of intradiscal lysozime and its degree
the most common amino acids in the elastin of disc of activity increases with age (108). The enzyme dis-
and ligamenta £lava (109). plays a bacteriolytic action (33), which is enhanced by
complement proteins, which succeed in entering the
disc through the cartilage end-plate only when the lat-
Enzymes ter has undergone bacterial damage. In this case, com-
plement proteins, together with lysozime, form a
Collagenolytic enzymes, which are known to be pro- potent bacteriolytic complex, which makes the tissue
duced, in different amounts, by connective tissue cells, sterile. This could explain why the tissue obtained from
are the most common enzymes in human intervertebral discs in an advanced stage of infection may be sterile
disc (134). Little information is available on the role (108). Lysozime acts as an antagonist in the formation of
played by this family of enzymes in the normal disc. bonds between proteoglycans, hyaluronic acid and link
Harris et al. (52), in a study on collagenases produced proteins; in this way, it might control the amount of
by fibroblasts or leucocytes of non-discal tissues, found aggregated proteoglycan in the disc tissue (108).
the two enzymes to have a higher activity towards
type III and type I collagen, respectively. Instead, both
collagenases were poorly active towards type II colla- Degenerated disc
gen. The level of activity of disc collagenase against
different collagen types or the characteristics of the Our knowledge of the biochemical characteristics of
collagenolytic enzymes produced by the different types the degenerated disc is based on studies usually carried
of disc cells are still unknown. out on a limited number of discs, often obtained at
Disc collagenase displays the greatest activity autopsy and with an undefined degree of degeneration.
against type II collagen, whilst the activity towards Furthermore, it is unclear which biochemical process
type I collagen is low (117). The mean value of activity takes place first. For example, solute diffusion, which is
of nucleus pulposus collagenase towards type I colla- indispensable for disc nutrition and cell viability,
gen is similar to that found for annulus fibrosus and depends on a mutual relationship between collagen,
transitional zone collagenase (117). No significant dif- proteoglycans and water content; however, this rela-
ferences in collagenase activity have been found be- tion is preserved only if a reasonably cellular function
tween the various lumbar discs (117). Gelatinase, which persists, typical of non-degenerated tissue. The enzy-
belongs to the metalloproteinase family (MMPs) as matic mechanisms responsible for the calcification
collagenase, further breaks down the products of process remain to be elucidated. In fact, it is unclear
collagenase digestion. whether micro- or macrocalcification, which are often
Disc proteinases have similar characteristics, such as present in the matrix of the degenerated disc, result
the greatest activity at pH 7.4-7.6, the property to be from an initial biochemical change or whether they
inactivated by class-specific inhibitors and an activity themselves contribute to disc tissue degeneration by
dependence on tissue NaCl, lysine and calcium concen- hindering normal solute diffusion.
trations (107). Some proteinases exert a breakdown However, it is difficult to establish the boundaries
eft~ct on the bonds between proteoglycans and hyalur- between physiologic tissue aging and degeneration.
onic acid chains, whilst others, such as stromelysin
(MMP-3), act on the proteoglycan protein core. In
the normal disc, a perfect equilibrium exists between Collagen
neutral proteinases and endogenous inhibitors. The
possible excess of inhibitor activity decreases the The amount of collagen in the intervertebral disc
proteoglycan amount and leads to disc degeneration. increases progressively with increasing age. This struc-
It has been hypothesized that proteinases are tural change in the disc has been known for many
activated by cell membrane-bound activators (107). decades (22, 48, 110) and may offer an explanation for
This suggests that disc cells are able to form a microen- some of the macroscopic changes related to aging, such
vironment, which might regulate the exchange of as loss of the gelatineous appearance of the nucleus
solutes and catabolites with the pericellular matrix, pulposus and the decrease in the clear-cut distinction
thus creating ideal osmotic and electric conditions. between nucleus and annulus fibrosus.
Lysozime, which is a basic protein with a low molec- Discovery of new types of disc collagen and the intro-
ular weight (14,000 D), normally present in chondrocyte duction of new techniques, able to locate and calculate
lacunae and close to the intracellular lysosomes of non- the amount of each collagen type, have allowed us to
68.Chapter 3 . - - - - - - - - - - - - - - - - - - - - - - - - - - -
advance new hypotheses on the etiopathogenesis of proteoglycan amount is the result or the cause of disc
disc degeneration. With aging, type I collagen consider- dehydration. In fact, proteoglycan amount and shape
ably increases, particularly in those areas of the disc affect osmotic pressure, FCD, viscosity and water con-
and cartilage end-plate showing the most severe tent of the disc. In the degenerated disc, proteoglycan
degenerative changes (31, 129). Electrophoretic studies amount and shape considerably change. Electric charge
have shown an increase also in type II collagen (29). is also modified, due to the greater CS concentration
However, immunohistochemical investigations have of the newly-synthesized proteoglycans (66). Further-
demonstrated that, in the degenerated disc, the amount more, the ability of the newly-formed proteoglycans to
and distribution of type II collagen are comparable to form aggregates is higher than that of proteoglycans
those in the normal disc (129). already present in the degenerated disc, since some
In the interterritorial matrix of degenerated discs enzymes, normally present in the disc, have not yet
(grade III -V according to Galante's classification), type removed or altered the hyaluronic acid-binding region
III collagen was found to be much more abundant than of the proteoglycan protein core (3, 18, 95). The larger
in the normal disc (129). Antisera to type III collagen dimensions of the proteoglycans in the degenerated
occasionally form irregular concentric rings around disc might be due to: a more rapid proteoglycan
the cells. This suggests that the cells in the degenerated turnover with a faster synthesis of new large aggregat-
tissue produce type III collagen in a periodical way ing proteoglycans (98); or the difficulty for large
and in response to various mechanical stimuli (129). aggregating proteoglycans to diffuse out of the disc
Chromatographic studies carried out on degenerated (151). However, it is possible that the greater size of
discs of an elderly subject have shown type III collagen proteoglycans is only apparent; in fact, the low number
in the outer portion of the anterior annulus fibrosus, of small lateral chains of glycosaminoglycans makes
however not in the control disc of a young subject (1). proteoglycans appear larger in size (66).
Type IV collagen was found only in the degenerated Newly-formed proteoglycans are similar, as far as
disc, in particular in the walls of the blood vessels concerns composition and shape, to those in non-
which are often present in the outer annulus fibrosus degenerated young discs. Thus, a few authors (18, 43,
(162,167). 95) believe that the changes in proteoglycan structure
Antiserum to type VI collagen, as well as that to type result from a faster turnover of these molecules is an
III collagen, forms irregular concentric rings around the attempt at tissue repair.
cells. Furthermore, type VI collagen is also located In intervertebral discs of mice with hereditary
around the intra dis cal blood vessels present in the kyphoscoliosis, a higher proteoglycan synthesis was
degenerated annulus fibrosus. The presence of type IV observed in degenerated vertebral segments and in the
and VI collagens in, or close to, the walls of blood ves- areas showing a low number of cells (161). This sug-
sels is probably due to an attempt to occlude their gests that a larger amount of proteoglycans is synthe-
lumen. In the interterritorial matrix, type VI collagen sized by the remaining cells, probably as a result
was often found in smaller amounts than in the normal of the abnormal mechanical stress to which the disc is
disc (129). submitted. Increase in proteoglycan synthesis was also
Type IX collagen has been observed in few speci- observed in rabbit (91) and human (95) degenerated
mens, always in proximity to cells or a Schmorl's node discs.
(129). Ghosh et al. (41) maintain that the decrease in proteo-
No significant information is available on the possi- glycans and increase in collagen in the degenerated
ble qualitative and quantitative changes in the other disc are due to a change in biomechanical condition,
types of disc collagen. inducing the cells to synthesize a cartilage-like matrix
more suitable for supporting compressive loads. Thus,
the decrease in proteoglycan content would not be the
Proteoglycans result of an accelerated process of aging, but an attempt
at tissue remodeling.
In degenerated discs, proteoglycan concentration con-
siderably decreases with respect to that in control discs
of similar age (48, 64, 110, 115, 158) and the reduction Water
is directly related to the degree of degeneration (124).
Bayliss et al. (8) have shown that, in vitro, the rate of The decrease in water content is one of the most typical
proteoglycan synthesis changes as a function of disc features of disc degeneration. Due to the mutual control
tissue hydration. This phenomenon is more evident in between water and proteoglycan contents, it is still
the nucleus pulposus. However, these authors do not unclear whether the decrease in water occurs primarily
clarify whether in the degenerated disc the reduced or is the result of the reduction in proteoglycan con-
____________________ 0 Biochemistry, nutrition and metabolism 69 0
<
IgG,lgM
bFGF (basic fibroblast growth factor) _ _ Vascular ,
neogenesIs
Cytokine: • IL-1
NO (nitric oxyde) ... Vessel dilation
Enzymes
Increase in Collagenolytic: type I collagen
concentration Gelatinase
! or activity Elastase
• Metalloproteinases (MMP-1; MMP-3)
• Peroxidase - - • Lipofuscin
? - - • Amyloid
Phospholipase A2 (132) - ~ Arachidonic acid
Cyclo-oxygenases I Lipoxygenases
'>..~/'
/' '>.. ( Chemical
Prostaglandins Leukotrienes mediators of
G2; H2 inflammation
? Elastin
• Changes present also in degenerated non-herniated disc. DS : dermatan sulphate; CS : chondroitin sulphate;
KS : keratan sulphate.
centration, which is typical of the degeneration process. et a1. (23), the increase in NCP, which occurs particular-
It has been hypothesized that the decreased water con- ly between the fourth and sixth decade of life, involves
tent alters the intradiscal hydrostatic pressure; this several protein classes, containing different propor-
would lead to considerable mechanical and hydrostatic tions of tyrosine. Since disc degeneration increases with
changes, able to favor the formation of annular tears. aging, the increase in the amount in NCP is likely to be
Furthermore, the decrease in water negatively affects related to tissue degeneration. Taylor and Akeson (144)
the process of diffusion of solutes throughout the inter- have calculated the age-related changes in the
cellular matrix, which is already altered due to the collagen/noncollagenous protein ratio in the human
decreased peri dis cal blood supply related to aging. The intervertebral disc: the ratio increases linearly and con-
result is a low intradiscal oxygen tension, which is siderably in the nucleus pulposus, and to a lesser extent
responsible for an increased lactate production by the and irregularly in the transitional zone and annulus
cells and accumulation of it in the extracellular matrix. fibrosus. Furthermore, wide-angle x-ray fiber diffrac-
This leads to a reduction in pH level in the tissue, which tion studies have shown that NCP undergo an increase
causes first metabolic and biosynthetic cellular changes in crystallinity with advancing age (144). However, it is
and then cell death (14). unclear whether the increased crystallinity affects the
Grynpas et a1. (47) maintain that, in the degenerated mechanical properties of the disc.
disc, water is located, to a large extent, between the
collagen fibers and is, thus, unable to interact with
proteoglycans or other molecules. Elastin
which are chemotactic substances and powerful extent, the cartilage end-plate (10). Solute diffusion
mediators of inflammation. High phospholipase A2 occurs only in one third of the central region of post-
concentrations were also found in the synovial fluid of mortem human cartilage end-plate and only in one
arthritic joints (32), where the enzyme activity appears tenth of the peripheral portion of the cartilage end-
to be regulated by the equilibrium between inhibitors plate (102). The entire outer portion of the annulus
and activators of phospholipase. It has been hypothe- fibrosus, on the other hand, is permeable to solutes
sized that the change in this equilibrium in the disc may (Fig. 3.6).
induce phospholipase A2 activation, which might play The transport of molecules necessary for cell metabo-
a role in the genesis of disc degeneration (34, 132). lism occurs almost entirely (80%) by a diffusion process
However, this hypothesis is not in keeping with the across the cartilage end-plate and outer layer of the
findings of Gronblad et al. (46), who evaluated phos- annulus fibrosus (67, 73, 83, 102, 114). A role, however,
pholipase activity both in macroscopically normal may also be played by other physico-chemical trans-
and degenerated discs, with no significant differences port mechanisms, such as flow of lymph/fluid,
emerging between the two, both showing a low enzy- mechanical fluid pump - dependent on mechanical
matic activity. stimuli - and, probably, active transport mechanisms.
Detection of enzymes and other chemical mediators
of inflammation in the herniated tissue has opened the
way to new etiopathogenetic concepts on disc hernia- Solute transport
tion and radicular pain, and has led to a reappraisal of
the role of compression of the nerve root by the hernia- Diffusion
tion in the genesis of radiated pain. In fact, the nucleus
pulposus, which, on account of its avascular nature, is Diffusion is the solute motion that occurs when a mem-
considered as alien from the immune system (39), may brane separates fluids which have the same hydrostatic
cause inflammatory reactions leading to vein conges- pressure, but different solute concentration (concentra-
tion and edema within the nerve root (94, 141). tion gradient). When the solutes are freely diffusible, an
Nutrition
The intercellular matrix of the disc consists of a tight
network of collagen fibers and a gel formed by water,
NCP and proteoglycans. The protein component is syn-
thesized by the cells and regulates, directly or indirect-
ly, the hydric condition, electrical charge, viscosity and
osmotic pressure of the intervertebral disc. Thus, the
mechanical properties of the disc depend on cell func-
tion, which is guaranteed only by an adequate nutri-
tional supply. Nutritional deficiencies and inadequate
removal of the products of cell catabolism lead to a
reduction in the already low cell density of the disc,
changes in tissue pH and modification in water content
of the matrix (67, 69, 70, 72, 113, 114, 121, 153).
The mechanisms by which nutritional substances are
transported into, and catabolites are removed from, the
disc are unknown to a large extent. Since the normal
disc is avascular, nutrient supply depends on the blood
vessels of the vertebral body and epidural space. It has
been suggested that the decrease in number of the cap-
illaries in the vertebral body and peridiscal tissue due
to aging impairs disc nutrition and favors degeneration
of disc tissue (67). Fig. 3.6. Nutrient supply to the intervertebral disc depends on the blood
vessels of epidural space and vertebral bodies. Solute diffusion occurs to
It has been shown, using fluorescent substances, that a larger extent through the central region (white arrows) than the outer
solutes enter the rabbit intervertebral disc through the portion (black arrows) of the cartilage end-plate. The outer portion of the
outer layer of the annulus fibrosus and, to a lesser annulus jibrosus, instead, is entirely permeable (conic arrows).
74.Chapter 3.-------------------------------------------------------
equilibrium is rapidly reached on either side of the degenerated disc, the matrix of which is less hydrated,
membrane. Instead, if some solutes, as in the disc, are the diffusion process is reduced compared with the
unable to diffuse on account of their dimensions or normal disc (131).
electric charge, the division becomes unequal even
between freely diffusible solutes (Gibbs-Donnan equi-
librium). In dilute solutions, where the solute concen- Osmotic pressure
tration is low and the interactions between solutes are
minimal, the speed of molecular diffusion, based on The cartilage end-plate and the outer portion of the
the concentration gradient, is regulated by the Fick annulus fibrosus are similar to a semipermeable mem-
equation: brane, which allows solute inflow into the disc matrix
depending on solute dimensions and the difference in
dv / dt = J = ~ DA (de/ dx) concentration and electric potential between the disc
and peridiscal tissues. For instance, cations are attract-
where: 1) dv/dt is the diffusion speed, mols/sec; 2) ed into the disc by the negative charge of glycosamino-
de / dx is the concentration gradient through which glycans, whereas anion flow is obstructed. Even water
diffusion occurs, expressed in mols/ cm-3 / cm-1 (the molecules are able to move out of, or into, the disc
minus sign indicates that diffusion occurs in the direc- matrix depending on the water concentration gradient
tion in which the lowest concentration is present); 3) A and permeability coefficient of the matrix. However,
is the solution plane area described by the lines of mol- the flow of water molecules may also occur due to a
ecular diffusion; 4) D is the diffusion coefficient (the water chemical potential which may result, for exam-
number of molecules which diffuse in one second, the ple, from an increase in intradiscal hydrostatic pressure
concentration gradient being 1 mole/ cm-3 / cm-1 and or a different concentration in electrically charged
the plane area 1 cm2 ). solutes (Fig. 3.7). In the matrix, cations and glyco-
If electrolytes have to diffuse through an electrically saminoglycans tend to reach an electric equilibrium,
charged matrix, as in the disc, the chemical potential and thus they do not diffuse outside the disc. In diluted
depends both on the matrix and the solute concentra- solutions, the concentration of water molecules is lower
tion. When the electric potential is of equal intensity than in pure water. In fact, if a solute is added to one of
and of an opposite sign to the chemical potential, the two pure water containers separated by a semiperme-
electric and osmotic works are equal. The correspond- able membrane, the concentration of water molecules
ing potential is the so-called equilibrium potential, in the resulting solution is lower than that on the side
which can be calculated by the Nerst equation: where pure water is present. Therefore, in the disc, a
chemical potential for water is established, which
Eions = 61 mv log C1 / CO at 37° C
Collagen
where C1 / CO is the ratio of ion concentration inside fibers
and outside the membrane. However, this equation
does not take into consideration the interactions that
occur in the disc either between different solutes or sol-
vent and solute, which alter the electric gradient of the
matrix.
The diffusion coefficient of a solute in the disc matrix
is different from the coefficient that the solute would
have in a free solution. The difference is due to the pres-
ence, in the disc, of other components (proteins, carbo-
hydrates, lipids) which occupy space, thus reducing the
area of diffusion, and cause friction phenomena with
the moving molecules (61).
In the disc, small solutes which are, or not, electrical- Cartilage end-plate 0
ly charged, have a diffusion coefficient (depending on
the molecule size and solution viscosity) no greater
than 40%-60% of that which they would have in a free
Fig. 3.7. Flow of water molecules to the vertebra, and from the latter to
solution (122, 154).
the disc matrix, is regulated by the concentration gradient and perme-
Compared with the nucleus pulposus, the diffusion ability coefficient of the water and by a chemical potential which devel-
coefficients of solutes in the annulus fibrosus are lower ops due to the different concentration in electrically charged solutes or
due to the lower hydration (150). Therefore, in the an increase in intradiscal hydrostatic pressure.
____________________ 0 Biochemistry, nutrition and metabolism 075
causes water flow into the matrix (osmosis) until an the vertebrae of the fused motion segment (67). By
intradiscal hydrostatic pressure, able to oppose further contrast, increased movement and mechanical loading
flow, is reached. Disc osmotic pressure is produced by (as occurs in the discs adjacent to the fused segment)
the increase in hydrostatic pressure which should be led, in experimental disc models, to a greater uptake
applied to the disc itself to prevent water inflow. of the labeled nutritive substances by the disc tissue
Only proteoglycans permanently contribute to create (68,69).
a water chemical potential, since the other electrically A decrease in blood flow in the peripheral area of the
charged solutes are distributed between the two fases, disc may also occur due to vibrations (72), vasocon-
also due to Gibbs-Donnan's equilibrium. Osmotic pres- strictive activity of nicotine (71) or atherosclerosis
sure of any solution depends on the number of particles caused by some pathologic conditions, such as diabetes
present in the solution, rather than their shape or (65). In these cases, the reduced supply of proteins,
weight. Thus, each ion, originating from the intradiscal amino acids, carbohydrates and other solutes to the
dissociation of a molecule, has the same osmotic effect disc tissue produces a chronic nutritive defect, which
as a non-dissociated molecule. may lead to disc degeneration.
Water flowing into the disc due to the osmotic effect
penetrates into the tridimensional network formed by
the collagen fibers (where proteoglycans are located),
causing a sort of swelling of the meshes. Metabolism
A large amount of oxygen enters the intervertebral disc
Fluid flow by means of the diffusion mechanism. This process is
inversely proportional to disc thickness (67,139). Thus,
In vivo, an intervertebral disc submitted to an external disc cells, particularly those in the nucleus pulposus,
load becomes deformed if compression is slight and where the oxygen tension is only about 2 to 5 mm Hg
temporary; furthermore, it expels water if the load is (67), follow the anaerobic breakdown of glucose to
considerable and persistent. However, the amount of produce ATp, i.e., energy (131). The metabolic process
fluid expelled under loading is recovered by the disc is called Embden-Meyerhof's cycle. The latter starts
when compression ends. Therefore, the continuous with glucose phosphorylation, which leads to the for-
water movement from and towards the disc helps the mation of phosphoric esters. These are degraded into
flow of molecules and removal of cell catabolites. two triose molecules that are then transformed into
pyruvic acid. In the cycle, some coenzymes able to bind
hydrogen are involved, such as diphosphopyridine
Active transport nucleotide (NAD), which is reduced to NADH. The
piruvic acid, after a NADH molecule action, is reduced
No studies have so far been performed on the possible to lactic acid.
use, by the disc, of this facilitated transport route. For In the disc, degradation of the piruvic acid, amino
this route to be used, the solute should be bound to a acids and fatty acids into carbon dioxide and water
"carrier" with a particular affinity for the solute so that through Krebs' cycle, is scarcely feasible due to the low
the diffusion process can occur even against concen- tension of intra dis cal oxygen. Hydrogen ions and
tration gradients. An enzymatic reaction would then electrons originating, during Krebs' cycle, from
break the bond between the solute and the carrier. The reduced nucleotides (NAD+, NADp, FAD) are linked to
latter, after separation from the solute, would be avail- oxygen and contribute, although to a minimal extent, to
able for transporting another molecule. increase the water content in the disc.
However, active transport is unlikely to occur in the The entire anaerobic metabolic process leads to the
disc, since it implies a high waste of energy. formation of four ATP molecules, starting from two.
The anaerobic breakdown of glucose is, thus, less effi-
cient than the aerobic pathway, which produces 34 ATP
Nutrition disturbances molecules in addition to the two produced by the
anaerobic glycolysis.
Holm and Nachemson (68) found a reduced concentra- No studies appear to have analyzed the ability of the
tion of some solutes (sulphate-glucose-oxygen) in a disc to use, as a metabolic pathway, direct oxidation of
surgically fused motion segment and an increase in glucose, i.e., the hexosemonophosphate shunt. This
metabolic activity in the adjacent segments. It has been pathway would lead to oxidation of the glucose-6-
suggested that the decrease in concentration of nutri- phosphate molecules and their conversion into phos-
tive substances is due to a reduced blood supply to phorylate pentose, which may be catabolized until
3.-------------------------------------------------------
carbon dioxide and water are formed. Ribose-5-phos- structures in human nucleus pulposus. Clin. Orthop. 139:
ph ate produced through the hexosemonophosphate 259-266,1979.
17. Buddecke E., Sziegoleit M.: Isolierung, chemische
shunt can be used to synthesize nucleotides and nucleic
Zusammensetzung und Altersabhangigkeitsverteilung
acids, as well as reduced NADP. The latter represents a von Mucopolysacchariden menschlicher Zwischen-
reserve of reduction equivalents, which are indispens- wirbelscheiben. Hoppe Seyler. Physiol. Chern. 337: 66-78,
able in many synthesis reactions. 1964.
Oxygen consumption in the intervertebral disc is 18. Cole T. c., Burkhardt D., Ghosh P. et al.: Effects of spinal
fusion on the proteoglycans of the canine intervertebral
only about one twentieth of that in the liver or kidney.
disc. J. Orthop. Res. 3: 277-291, 1985.
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------·CHAPTER 4·------
BIOMECHANICS
C. Cinotti, F. Postacchini
of the disc matrix (7, 26, 47, 48). In particular, the water cases, occur simultaneously. For instance, during
and proteoglycan content of the tissue is related to its lifting, the disc is likely to undergo both flexion-com-
hydraulic permeability and compressive modulus, pression and axial rotation forces. When various loads
respectively (38). Thus, water and proteoglycan content act simultaneously, the disc is subjected to complex
affects the rate of creeping of the disc under loading. loading.
Moreover, since collagen fibers are more abundant in
the outer portion of the annulus compared with the
inner portion, which is rich in water and proteoglycans
(12,15,79), the biomechanical properties of the disc dif- Compression
fer depending on the region of the tissue analyzed (7).
This marked specialization of disc tissue may be essen- Under axial compression the nucleus pulposus
tial to provide an adequate mechanical strength under expands horizontally, thus inducing increased tensile
different loading conditions. stresses in the annular fibers. The magnitude of tensile
In conclusion, the viscoelastic properties of the disc stresses is maximum in the inner annulus and decreas-
are responsible for the biphasic behavior of the func- es progressively towards the external annulus (33, 68,
tional spinal unit under loading; this is highly flexible 71) (Fig. 4.2). Vertebral end-plates undergo compres-
at low loads, but becomes more rigid as the applied sion stresses, mainly in the area adjacent to the nucleus
load increases (52). The viscoelastic characteristics of pulposus (37).
the disc are due to the intrinsic properties of the tissue Axial compression causes circumferential disc
and, mainly, to the flow of fluid from the disc (7). The bulging in the horizontal plane, which is largest in the
proteoglycan content guides the fluid flow from the posterior annulus (68). The degree of disc bulging is
disc and regulates the osmotic pressure of the tissue. inversely related to the tensile status of the annular
As a load is applied, disc deformation results until a fibers and the intradiscal pressure. When the latter is
steady state is reached; this occurs when the swelling within normal values, compression load increases
pressure of the disc balances the external pressure tensile stresses in the annular fibers; this allows the
generated by the applied load. Disc tissue shows a annulus to withstand the nuclear expansion and disc
dishomogeneous biomechanical behavior, reflecting bulging is mild. However, when the intradiscal pres-
the unequal content of its biochemical components in sure decreases, annular fibers are subjected to low
the different regions (7). tensile stresses and this reduces their ability to resist
the nuclear expansion and to limit disc bulging under
load (9).
When an axial compression load exceeding the phys-
Disc under compression, flexion iologic limits is applied to the functional spinal unit,
and axial torque vertebral end-plates are the first structures to fail. They
fracture or deform under the compression forces
Upon daily activities the intervertebral discs are sub- generated by the nucleus (27, 61, 68). On the other
mitted to various mechanical stresses, which, in most hand, mechanical stresses caused by axial compres-
-------------------------------------------------------------Biornechanics- S3
• Axial torque
•
is associated with axial torque, mechanical stresses are
greatest in the posterior annulus (69).
Torsion causes an increase in intradiscal pressure,
which has been found to be higher compared with the
increase occurring in extension, but lower than that
A B induced by flexion (69). Likewise, it has been shown
that axial torque causes larger mechanical stresses in
Fig. 4.2. Mechanical stresses in the annular fibers under axial compres- the annulus fibers than during extension, but lower
sion loading. (A) Unloaded disc. (B) The compression load increases
the hydrostatic pressure in the nucleus which, in turn, increases tensile than those induced by flexion. Torsion, in itself, does
stresses in the inner annular fibers. not appear to cause failure of the annulus lamellae;
however, as a compressive load is combined with axial
torque, annular tears may occur in the posterior and
sion are not sufficient to provoke failure of the posterolateral regions of the disc (69). Under torsion,
annulus fibrosus. disc bulging takes place in the posterior and posterolat-
eral zones of the disc (69).
Degrees
motions may be difficult to assess. Numerous studies associated lateral rotation on the right, at L4-L5 and L5-
have analyzed vertebral motion on cadaveric speci- Sl levels, and an associated lateral rotation on the left
mens (2,6, 18, 40, 4t 63, 75). A major limitation of these at 11-L2 and L2-L3Ievels. The largest axial rotation was
studies is that the effects of spinal muscles on the stabil- found at L2-L3 levet the maximum value being 2° on
ity of the functional spinal unit are not taken into each side (52).
account. However, in vitro studies may be more accu- Vertebral motion resulted on in vitro and in vivo
rate than in vivo investigations, since they analyze ver- studies is reported in Figs. 4.5 to 4.7.
tebral motion under defined loading conditions and
evaluate both main and coupled motions.
Panjabi et al. (52) have evaluated, tridimensionally,
main and coupled motions on in vitro specimens of the Disc degeneration
lumbar spine. They found that during flexion-exten-
sion, the main motion is anterior-posterior rotation and Biomechanics of degenerated disc
the more relevant coupled motion is translation in the
sagittal plane. The latter occurs, during flexion, anteri- The biomechanical behavior of the degenerated disc
orly and cranially and, during extension, posteriorly has been assessed in vitro and with the use of finite
and caudally (52). The largest angular motion was element models. In vitro studies have shown that in
found at L4-L5 (17° to 20°) and L5-S1 (15° to 25°) levels degenerated discs the intradiscal pressure is decreased
(52, 56t and the largest sagittal translation at L2-L3 (49t thus leading to a reduction in tensile stresses in
level (3.3 mm) (52). annular fibers and a decrease in stiffness of the disc (32).
Upon lateral bending, lateral rotation is the main Degenerated discs show a reduced elastic modulus
motion and anterior rotation, axial rotation and lateral and, as a constant load is applied, creeping occurs to a
translation are the associated coupled motions. Axial larger extent and more rapidly compared with healthy
rotation occurs on the opposite side compared with the discs (32, 45, 76). Moreover, once the applied load has
direction of the applied load, whereas lateral transla- been removed, creep is recovered slowly and, unlike in
tion occurs on the same side. The main motion, i.e., lat- the healthy disc, the recovery curve varies depending
eral rotation, was found to be largest at L2-L3level and on the amount of the applied load (76). The effects of
averaged 5° on each side (52). disc degeneration may be even more severe in vivo,
During torsion, the main motion is axial rotation and since in vitro studies do not take into account physio-
the coupled motions are anterior rotation and lateral logic conditions, namely blood perfusion and breath-
rotation. The latter occurs on the same side as the direc- ing, which have been found to increase disc flexibility
tion of the applied load at the two lowest lumbar levels (28,31).
and, on the opposite side, at the two upper lumbar lev- Different mathematic models have been used to sim-
els. Thus, axial rotation, on the right side, causes an ulate disc degeneration. Kulak et al. (36t compared the
86.Chapter 4.-----------------------------------------------------
. ....... Panjabi et al. (52)
.... .•. ... Pearcy et al. (53) ~ Soni et al. (53)
-.......- Plamodon et al. (55) ___ Schultz etal. (63)
- Hayes et al. (24) _ Yamamoto et al. (82)
20'
- - - - Goel et al. (18)
16'
1S'
10'
,.,8' S'
2'
OO~-------r--------~------_r------~ O'+-------+-------+-------+-----~
L1.f...2 L 1·L2 L2·L3 L3·L4 L4-LS LS·S1
Level A Level B
Fig. 4.5. Flexion-extension motion in vivo (A) and in vitro (B).
----
.. _...... Panjabi et al. (52)
3' 3' - - Goel et al. (18)
Pearcy et al. (53)
..
2,5' Plamodon et al. (55) 2,5'
····x· .. ·· Hayes et al. (24)
2° 2' '
.......
....
...
1,50 1,5'
........... ..•..
.
l' l'
0,5° 0,5'
0° 0'
LS·S1 L1·L2 L2-l.3 L3-l.4 L4-l.5 LS-S1
L1·L2 L2·L3 L3·L4 L4·LS
Level A Level B
Fig. 4.6. Axial rotation in vivo (A) and in vitro (B).
3° 3'
2°
2't
l'
~:t+---------~------~I---------+I--------4I o'j
L 1·L2 L2·L3 L3·L4 L4-L5 L5·S1 L1·L2 L2·L3 L3·L4 L4·L5 LS·S1
Level Level
A B
Fig. 4.7. Lateral bending in vivo (A) and in vitro (B).
----------------------------------------------------------oBiomechanicsoS7
biomechanical behavior of a disc devoid of the nucleus, value of this technique may be limited by the low
but with intact annulus, to that of a disc with intact accuracy of the radiographic measurement (54).
nucleus and radial annular tears. They found that the Upon torsion, the instantaneous axis of rotation is
denucleated disc was less stiff whereas annular tears, in located in the spinal canal, anteriorly to the facet joints
themselves, did not lead to significant changes in disc and in the midline (22). However, after an injury to the
biomechanics. Other authors simulated disc degenera- disc or facet joints, the axis of rotation has been found
tion by removing the nucleus (68), decreasing the intra- to move posteriorly or anteriorl~ respectively (22).
discal pressure by 60% (69) or reducing the fluid content Thus, following a spinal injury, the axis of rotation in
of the nucleus by 12% compared to its original volume the horizontal plane moves towards the remaining
(70). These conditions were found to decrease tensile intact structures.
stresses in annular fibers and to increase compressive
stresses (5, 68, 70); hence, the annular lamellae become
Vertebral motion
lax, bulge inward or outward depending on whether
they are located in the inner or outer annulus, respec-
Degenerative changes decrease the stiffness of the disc
tively. Annular lamellae also tend to carry the com-
and its ability to maintain the stability of the functional
pressive loads individually and this may predispose to
spinal unit under loading. Thus, disc degeneration,
annular failure (70). Disc bulging increases mainly in
the anterior and posterolateral regions (40,60,68,69). in itself, increases the flexibility of the functional spinal
unit. However, as degeneration advances, a marked
Degenerative changes increase the flexibility of the
decrease in disc height restricting the angular motion
disc under axial torque and enhance mechanical stress-
may occur. Spinal motion may also be restricted by the
es on the posterior joints. Moreover, unlike in the heal-
thy disc, a combined axial rotation and compression presence of vertebral ostheophytes which, by increas-
load induces tensile radial strain in the annulus fibro- ing the end-plate cross-sectional area, further limit
vertebral motion (42).
sus, which may eventually cause annular tears (68, 69).
An in vitro investigation has shown that, in the pres-
Under normal conditions, compressive stresses are
transmitted from the disc to the vertebral bodies in the ence of a moderately degenerated disc, only lateral
region adjacent to the nucleus pulposus. However, as bending is significantly decreased, possibly because it
disc degeneration occurs, transmission of the compres- is the type of motion most influenced by disc height
sive forces shifts from the nucleus to the outermost
annulus (37) (Fig. 4.8). The increased compressive
stresses on the peripheral portions of the vertebral end-
plates may explain the formation of vertebral osteo-
phytes often associated with disc degeneration.
, ,
,",
A B c
(42). Flexion-extension was not significantly decreased the type of anulotomy performed, 2) the site in the disc
and axial rotation, which is not influenced by disc where anulotomy is carried out, and 3) the amount of
height, tended to increase due to the increased laxity of disc tissue excised.
annular fibers. Only marked disc degeneration led to a The biomechanical effects of a 5 X 5 mm rectangular
significant reduction of vertebral mobility in the three anulotomy, compared with the effects of a transverse
planes of motion (42). slit, have been investigated in animals. Both types of
In conclusion, disc degeneration may cause quanti- anulotomies caused significant changes in the intradis-
tative or qualitative changes in vertebral motion com- cal pressure and the flexibility of the functional spinal
pared with healthy discs. The magnitude of vertebral unit (4). However, these changes were significantly less
motion may be biased by disc height and the cross- pronounced following a transversal slit than a window
sectional area of the vertebral end-plates and, hence, its anulotomy. The increased flexibility induced by these
assessment may be of little value in diagnosing spinal types of anulotomies was found to be maximum 4
instability due to disc degeneration. Coupled motions weeks after surgery, but recovered to normal values
should be further investigated, because they might be after 6 weeks (4).
more useful to detect abnormal vertebral motion. A nucleotomy performed in vitro through a square
window of 5 X 5 mm on the right lateral side of the
annulus, causes a significant increase in the flexibility
Effects of disc excision of the functional spinal unit under flexion and left later-
al bending as well as under anterior and right shear
Surgical discectomy loads (51). It, thus, increases the flexibility of the disc
when the injured site is submitted to tensile stresses
The biomechanical behavior of the disc following sur- (51). Moreover, this type of nucleotomy was found to
gical discectomy has been analyzed in vitro, in animals increase coupled motions and creep deformation and
and by means of mathematic models (9, 18, 19, 29, 30, to cause asymmetric lateral bending. It should be
51). In the evaluation of the effects of discectomy on noted, however, that these findings resulted from a
disc biomechanics, it should be taken into account: 1) nucleotomy performed on the lateral annulus and they
------------------------------------------------------------oBiornechanicsoS9
might reproduce the effects of a discectomy carried out shear stresses (29, 74, 80); the creep rate also increases
through an extravertebral approach to remove an (30, 80). The most striking effect of chymopapain injec-
extraforaminal disc herniation. tion is the marked decrease in disc stiffness under tor-
Goel et a1. have shown that total nucleotomy carried sion and anterior flexion; the flexibility of the functional
out through a posterolateral disc incision, i.e. the usual spinal unit was, in fact, found to increase up to 50% and
site of discectomy, causes an increase in flexibility to 100% under torsion and anterior flexion, respective-
under lateral bending both on the injured site and the ly (29, 74). The marked increase in flexibility under
contralateral site (18). Moreover, total nucleotomy anterior flexion would suggest a more intense enzy-
induces an increased flexibility under flexion, exten- matic activity of chymopapain on the posterior region
sion and axial rotation and also increases translation of the disc, possibly due to the different biochemical
motion during anterior flexion and lateral bending. composition of the posterior annulus compared with
Conversely, partial nucleotomy wa,s found to increase other regions of the disc (74).
vertebral motion under anterior flexion (18, 19), lateral After 3 to 6 weeks of chemonucleolysis, the height
bending (18) and axial rotation on the side of the and stiffness of the injected disc, as well as the creep
nucleotomy (19); it, thus, affects spinal stability to a rate, were found to return to normal values (29, 74, 80).
less extent compared with total nucleotomy. Wakano et a1. (80) showed that, 3 months after
Brinckmann and Grootenboer (9) analyzed the chemonucleolysis, the stiffness of the disc under axial
changes in disc height, intradiscal pressure and radial compression tends to recover and, under torsion, is
disc bulging, after in vitro removal of I, 2 and 3 g of disc even larger than that of untreated discs. Moreover, dur-
tissue. Discectomy was performed through a postero- ing torsion or compression loads, there is no significant
lateral anulotomy. Specimens submitted to the test difference in the creep rate between treated and
came from donors aged 20 to 40 years and showed untreated discs. Spencer et a1. (74) found that flexibility
grade I or II disc degeneration. The authors found that under lateral bending had returned to control values
disc height decreased, on average, 0.8 mm and disc 3 months after chemonucleolysis, whereas flexion and
bulging increased 0.2 mm, for each gram of tissue torsion flexibilities remained substantially unchanged.
removed. As a compressive load was applied, disc However, 6 months after treatment, also the torsion
bulging increased by 0.5 mm in the discectomized disc flexibility had returned to control values. In keeping
and 0.15 mm in the intact specimen. After removal of with these results, Kahanovitz et a1. (29) observed that
3 g of disc tissue, intradiscal pressure was found to be, disc stiffness returned to normal values 5 months after
on average, 39% of the initial value. However, when chymopapain injection, though the flexibility under lat-
discectomy was performed on discs coming from eral bending was found to be increased by 30%.
elderly subjects, with grade III or IV disc degeneration, In conclusion, in keeping with histological studies
intradiscal pressure fell to zero. This finding indicates showing regeneration of disc tissue after chymopapain
that the effects of discectomy are markedly influenced injection (8), biomechanical properties of the disc
by the severity of disc degeneration; therefore, in vitro injected with chymopapain appear to return to normal
studies carried out on specimens coming from elderly values 3 to 6 months after treatment. Although these
subjects may accentuate the effects of discectomy on results seem to be extremely encouraging, it should be
disc biomechanics. noted that surgical discectomy perfomed in animals
provides comparable outcomes (29,30). However, with
respect to surgical discectomy, chemonucleolysis causes
a marked flexibility of the functional spinal unit under
Chernonucleolysis flexion and torsion loads in the first few weeks after
treatment. This may explain the greater back pain
Intradiscal injection of chymopapain, the proteolytic reported by patients treated with chymopapain, com-
enzyme most commonly used in chemonucleolysis, pared with those submitted to surgery, during the first
leads to a decrease in the nuclear and annular volume weeks after treatment.
(21) and in the intradiscal pressure (35), a finding that
may explain the relief of radicular pain occurring after
treatment.
The biomechanical behavior of the disc treated with Automated percutaneous nudeotomy
chymopapain is significantly modified during the first
few months after enzyme injection. Two to six weeks The effects of automatic percutaneous nucleotomy on
after chemonucleolysis, the flexibility of the disc disc biomechanics have been analyzed by Castro et a1.
increases under axial compression, anterior flexion and (13). Nucleotomy was performed on healthy discs for
lateral bending, as well as under axial rotation and 45 min and an average of 4.6 g of disc tissue was
90.Chapter 4.---------------------------------------------------------
removed. The height of the treated discs was found to lumbar levels, where the size of the spinal canal is often
be decreased by a mean of 0.7 mm after 15 min and 1.4 narrower with respect to the nervous structures con-
mm after 45 min. Intradiscal pressure was significantly tained. Furthermore, when disc herniation occurs with-
decreased after 45 min (5.7 bar) and disc bulging was in a stenotic spinal canal, bilateral laminotomy or
increased by 0.23 mm and 0.45 mm after 15 and 45 min, central laminectomy may be needed.
respectively. In contrast with these findings, Shea et al. The influence of spinal structures on the stability of
(67) found that the reduction in disc height and the functional spinal unit have been analyzed in vitro.
intradiscal pressure occur within 10 min of the begin- Posner et al. (56) found that during anterior flexion
ning of the nucleotomy and do not change significantly loading, complete failure of the functional spinal unit
with time. Moreover, the introduction of a trocar into occurs when the supraspinous and interpinous liga-
the annulus without removal of any disc tissue, led to a ments, facet joints, posterior annulus and posterior lon-
reduction in intradiscal pressure comparable to that gitudinalligament have been resected. Goel et al. (20)
produced by automated nucleotomy (67). These find- evaluated the mobility of the functional spinal unit (L4-
ings suggest that automated nucleotomy may relieve L5) in the three planes of motion after resection of the
radicular pain by decreasing disc height and, hence, by posterior ligaments associated with partial lamino-
reducing the tension of the nerve root caused by the arthrectomy performed bilaterally. This procedure was
herniated disc (67). found to cause a significant increase in angular motion,
under flexion-extension loads, and of axial rotation,
under torsion.
Abumi et al. (1) analyzed vertebral motion after uni-
Laser discectomy lateral or bilateral graded facetectomy, with or without
excision of the supraspinous and interspinous liga-
This technique has been proposed on the hypothesis ments. They showed that partial arthrectomy carried
that in a sealed space, such as the intervertebral disc, a out on one or both sides does not change the flexibility
small variation in volume of its content would result in of the functional spinal unit. However, partial arthrec-
a marked reduction of intradiscal pressure (14). In tomy, when associated with the division of the posteri-
keeping with this hypothesis, the intradiscal pressure or ligaments, causes a significant increase in spinal
measured during discectomy, performed with a 3 mm flexibility under anterior flexion. On the other hand,
cylindrical laser tract, was found to increase within the total arthrectomy, unilateral or bilateral, significantly
first minute, but then decreased by 44% and 56% after a increases spinal flexibility under anterior flexion and
mean of 9 min and 23 min, respectively. When a non- torsion, even when the posterior ligaments are left
operative cylindrical laser tract of equal diameter was intact (Tables 4.1 and 4.2)
inserted into the disc, as a control experiment, the In conclusion, total arthrectomy affects spinal flexi-
intradiscal pressure decreased by 6% (14). bility independently of the surgical procedure carried
Laser discectomy causes disc ablation by means of
vaporization and charring of disc tissue. The entity of
laser ablation was found to be related to the total
amount of energy used (57) and the laser wavelength Table 4.1. Increase in vertebral motion after partial or total arthrecto-
(39). By imparting a total energy of 1200 J and 3000 J, the my, unilateral or bilateral, with intact posterior ligaments
disc tissue ablation was found to be, on average, 2.7 cm3
and 4.3 cm3, respectively (39). Holmium (Ho :YAG) and Type of arthrectomy
CO2 lasers seem to induce a larger ablation compared Vertebral Partial Partial Total Total
with other lasers, possibly because their energy is large- motion unilateral bilateral unilateral bilateral
ly absorbed by the water of the nucleus pulposus rather
than transferred to the surrounding tissue (39). Flexion (-) (-) (++) (++++)
Left axial
Effects of laminoarthrectomy rotation (-) (-) (-) (++++)
Right axial
Standard discectomy and microdiscectomy are usually rotation (-) (-) (+) (+++)
accomplished through partial removal of laminae and
facet joints. However, in a few conditions, such as in the Lateral
bending (-) (-) (-) (-)
presence of intra- or extraforaminal disc herniations,
total facetectomy may be carried out deliberately or (-): Non-significant increase compared with intact specimen.
inadvertently. This may occur particularly at the upper (+): p = 0.05; (++): p = 0.02; (+++): p = 0.01; (++++): p = 0.001.
------------------------------------------------------------0 Biornechanics 091
Table 4.2. Increase in vertebral motion after partial or total arthrecto- lumbosacral spine with particular reference to the interverte-
my, unilateral or bilateral, after division of the posterior ligaments. bral disc. J. Bone Joint Surg. 39-A: 1135-1164, 1957.
12. Buckwalter J. A: The fine structure of the human inter-
Type of arthrectomy vertebral disc. In: Symposium on idiopathic low back pain.
White A.A., Gordon S. L., Eds. CV Mosby Co., St. Luis,
Vertebral Partial Partial Total Total 108-143,1982.
motion unilateral bilateral unilateral bilateral 13. Castro W. H. M., Halm H., Rondhuis J.: The influence of
automated percutaneous lumbar discectomy (APLD) on the
Flexion (+) (++) (+++) (++++) biomechanics of the lumbar intervertebral disc. An experi-
Extension (-) (-) (-) (-) mental study. Acta Orthop. Belg. 58: 400-405,1992.
14. Choy D. S. J., Altman P.: Fall of intradiscal pressure with laser
Left axial ablation. Spine: State of the Art Reviews 7: 23-29,1993.
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disc: interchanging radial distributions in annulus fibrosus.
Right axial
Biochem.J. 157:267-270, 1976.
rotation (-) (-) (++) (+++)
16. Galante J.O.: Tensile properties of the human lumbar annu-
Lateral lus fibrosus. Acta Orthop. Scand. Suppl. 100: 4-91, 1967.
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and segmental instability in degenerative disc disease. Spine
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51. Panjabi M. M., Krag M. H., Chung T. Q.: Effects of disc injury of the human lumbar annulus fibrosus. Spine 19: 1310-1319,
on mechanical behaviour of the human spine. Spine 9: 1994.
707-713,1984. 73. Soni A. H., Sullivan J. A., Patwardhan A. et al.: Kinematic
52. Panjabi M. M., Tech D., Oxland T. R et al.: Mechanical behav- analysis and simulation of vertebral motion under static
iour of the human lumbar and lumbosacral spine as shown load - Part I: kinematic analysis. J. Biomech. Eng. 104:
by three-dimensional load-displacement curves. J. Bone 105-111,1982.
Joint Surg. 76-A, 3: 413-424,1994. 74. Spencer D. L., Miller J. A. A., Schultz A. B.: The effects of
53. Pearcy M., Portek I., Shepherd J.: Three-dimensional x-rays chemonucleolysis on the mechanical properties of the canine
analysis of normal movement in the lumbar spine. Spine 9: lumbar disc. Spine 10: 555-561, 1985.
294-297, ] 984. 75. Tencer A. F., Ahmed A. M., Burke D. L.: Some static mechan-
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 0 Biotnechanics 0 93
ical properties of the lumbar intervertebral joint, intact and 80. Wakano K., Kasman R, Chao E. Y. et al.: Biomechanical
injured. J. Biomech. Eng. 104: 193-201, 1982. analysis of canine intervertebral disc after chymopapain
76. Twomey L., Taylor J.: Flexion creep deformation and hystere- injection. A preliminary report. Spine 8: 59-68,1983.
sis in the lumbar vertebral column. Spine 7: 116-122, 1982. 81. White A. A III., Panjabi M. M.: Physical properties and func-
77. Urban J. P. G., Holm S., Maroudas A et al.: Diffusion of small tional biomechanics of the spine. In: Clinical biomechanics of
solutes into the intervertebral disc: an in vivo study. the spine. White A A III., PanjabiM. M., Eds.J. B. Lippincott,
Biorheology 15: 203-223, 1978. Philadelphia, 1990.
78. Urban J. P. G., Holm S., Maroudas A et al.: Nutrition of the 82. Yamamoto I., Panjabi M., Crisco J. et al.: Three-dimensional
intervertebral disc: effect of fluid flow in solute transport. movements of the whole lumbar spine and lumbosacral
Clin. Orthop. 170: 296-302, 1982. joint. Proc. International Society for the Study of the Lumbar
79. Urban J. P. G., Maroudas A.: The chemistry of the interverte- Spine, Kyoto, 1989.
bral disc in relation to its physiological function and require-
ments. Clin. Rheum. Dis. 6: 51-76, 1980.
------·CHAPTER 5·------
PATHOMORPHOLOGY
F. Postacchini, W. Rauschning
-
of circle. In the presence of concentric clefts, the inter-
posed tissue may appear as sequestered from the rest
of the disc.
A peculiar type of horizontal fissure has been
described by Yasuma et al. (92). It is due to myxomatous
degeneration of the annulus fibrosus, leading to sepa-
ration of the middle annular lamellae and reversed
Type 1 Type 2 orientation of the inner lamellae, which become
convex towards the center of the disc.
The radial clefts are mostly located in the posterior
half of the disc. On sagittal sections, the clefts are
equidistant from the adjacent vertebral end-plates or
are situated in proximity to the latter (Figs. 5.3 and 5.4).
On transvere sections, the clefts have a sagittal (in the
middle or paramedian plane) or oblique orientation.
The oblique clefts are directed towards the postero-
Type 3 Type 4
Type 7
Fig. 5.1. Normal disc (Type 1) and various types of disc degeneration B
(Types 2-7) as they appear at discography.
Fig. 5.2. Axial section of intervertebral disc and vertebral canal in an
elderly subject. (A) Circumferential fissures are visible in the lateral
portions of the disc and afew incomplete radial fissures are present in the
central posterior portion (arrowheads); the fissures contain brownish
The fissures in the annulus fibrosus may have a material, probably consisting of the so-called senile pigment. The disc
circumferential or radial arrangement. The circum- shows, on the left, a mild posterolateral protrusion, which is in contact
ferential clefts result from disaggregation of contiguous with the nerve root (arrow). (B) High magnification of (A). The postero-
lateral protrusion of the disc is clearly visible (large arrow). The facet
lamellae and, on transverse sections of the disc, appear joints show short anteromedial osteophytes (thin arrows) and the left
to run along the circumference of the annulus fibrosus joint narrows the corresponding nerve-root canal. Both joints,
(Fig. 5.2). They extend for a few millimeters to one fifth particularly the left, display a narrow articular space and thinning
or one fourth of the circumference of the disc. In the of the articular cartilage.
___________________________________________________ 0 Pathomorphology 97 0
lateral portion of the disc and may be unilateral or the disc, fissures orientated at a right angle with respect
bilateral, the latter being symmetrical or asymmetrical; to the direction of the collagen bundles may be
the presence of two symmetrical fissures may lead to a observed in proximity to the attachment of the annulus
kind of sequestration of the posterior portion of the fibrosus to the vertebral body (rim lesions).
annulus fibrosus. The incomplete clefts extend for Nuclear or annular clefts may be empty or contain
varying distances from the central part to the periphery mucoid material or necrotic debris. When the disc is
of the disc. The complete clefts reach the posterior lon- resorbed, the disc tissue is often replaced, to a large
gitudinalligament (Fig. 5.4). In the anterior portion of extent, by a single or multiple empty clefts (Fig. 5.5).
98.Chapter 5.-----------------------------------------------------
Within the rim lesions, fibrovascular or fibrocartilagi- Fibrovascular tissue may invade the disc also
nous tissue has often been observed, which probably through defects in the cartilage end-plate resulting
results from attempts to repair the fissure (33). from degenerative or necrotic changes in the cartilage,
or from Schmorl's nodes (73, 84, 91). The latter mecha-
Fibrovascular invasion of disc nism, probably less common than the former, may lead
to widespread vascular invasion of the disc.
In the case of a complete radial tear in the annulus fibro- Vascular invasion of the disc has been observed (91)
sus, the inside of the disc, which is normally avascular only in subjects over 40 years of age and with a pro-
in the adult, is then in communication with vascular- gressively higher frequency with advancing age (from
ized structures, such as the posterior longitudinal 48% in the fifth decade to 60% in the ninth decade).
ligament and the epidural tissue. This may allow pene-
tration of vascular buds and fibroblasts within the disc.
Vessel ingrowth is presumably aimed at repairing the
Correlation with age and vertebral level
annular lesion, and it is probable that the repair often
occurs, at least in the peripheral portion of the disc. The various grades of degeneration of lumbar discs are
strictly related to the subject's age and the vertebral
Ingrowth of fibrovascular tissue usually occurs in the
level (2, 55, 57, 81).
posterior portion of the disc and can extend to the
Subjects younger than 30 years usually have Type 1
nucleus pulposus (Fig. 5.6).
or 2 discs. However, even adolescents may have discs
showing a Type 3 or 4 morphology. Between 30 and 50
years, there is a progressive decrease in number of Type
1 and 2 discs and an increase in Types 3 to 5. Between 50
and 70 years, it is extremely uncommon to find Type 1
discs, whilst Type 2 become less numerous; at this age,
most lumbar discs are Types 3 to 5, but also Types 6 or 7
are frequently found. After 70 years, the vast majority
of the discs are Type 4 to 7.
The upper two lumbar discs rarely show morpho-
logic features of Types 4 to 7, even in old age. The mor-
phology of L3 disc is usually of Types 2 to 4; it is rarely of
Types 5 to 7. The most marked degenerative changes are
observed in the two lower lumbar discs. However, while
in one study (55) the L4 disc showed the greatest ten-
dency to degenerative changes, in another study, the
more advanced stages of degeneration were most fre-
quently found at L5 level. These findings suggest that
disc degeneration is related to the amount of functional
stress to which the individual discs are subjected. This
may explain, at least partly, the greater tendency of
males to undergo disc degeneration (55). However, a
role might also be played by other factors, such as the
amount of lumbar lordosis (i.e., the inclination of the
disc with respect to the horizontal plane), the shape of
the disc and the symmetry of the articular processes (26).
of subjects, the disc at a given level shows physiologic then ossification of the deep portion of the superficial
changes ranging from mild to relatively severe. zone. True degenerative alterations may also be present.
Furthermore, these changes appear only at certain The alterations consist of degenerative or necrotic
stages of aging. For instance, in most subjects the L3 changes (73), vertical fissures and avulsions of portions
disc is Type 1 or 2 in the third decade of life, Type 3 in of cartilage from the bone surface. Tanaka et al. (79)
the fourth to fifth decade and Type 4 or 5 in the sixth to have identified two types of pathologic avulsion.
seventh decade. Transition from one type to the next In one type, the cartilage is separated from the bone
is, therefore, very slow and occurs harmoniously in the surface by a layer of fibrous tissue, whilst in the
two components of the disc. second, the cartilage fragment is completely detached
The degenerative process should be considered: from the vertebral body and is free in the disc tissue.
pathologic when: 1) at a given level, and at a given age, Avulsions of the cartilage end-plate have been observed
degenerative changes are abnormally marked com- in senile and pre-senile age, being more and more
pared with those found in the majority of subjects of the frequent with greater disc degeneration. Since the carti-
same age; 2) degenerative changes involve a compo- lage end-plate plays an important role in the nutrition
nent of the disc to a much larger extent than the other. of the disc, the avulsion, and, more generally, the
The result is that the mechanical stress on the disc is degenerative changes of the cartilage end-plate, possi-
exceedingly high compared with its structural charac- bly tend to enhance disc degeneration.
teristics at that age; or that the most impaired compo- In both cartilage end-plates, the zone most often
nent is not able to play the function normally required showing avulsions is that in the center, followed by the
to it, when the other component is normal or only posterior zone. This may explain the possibility both of
slightly impaired. From the morphologic viewpoint, avulsions of fragments of cartilage end-plate by the
however, the changes in the two components, consid- annulus fibrosus and extrusion of islets of cartilage
ered individually, are similar to those occurring in the together with disc tissue.
process of physiologic degeneration.
Effects on adjacent motion segments results from degenerative changes of the disc similar to
those responsible for a herniation and may occasionally
Degenerative changes of the disc lead to an increase or, evolve into a typical disc herniation.
more often, a decrease in mobility of the motion seg- Annular bulging may involve the anterior, lateral or
ment. Both conditions produce abnormal or excessive posterior portion of the disc. However, only bulging of
mechanical stress on the healthy adjacent discs (76). In the two latter portions may be of clinical relevance.
vivo radiographic studies have demonstrated that the Furthermore, annular bulging may be normal or patho-
disc above a degenerated disc shows increased mobili- logic.
ty on combined movements of lateral flexion and axial
rotation (82). Biomechanical investigations on cadaver
motion segments have demonstrated that the disc Normal bulging
underlying a disc that has been made hypomobile, thus
simulating a degenerative condition, shows, as a result The posterior aspect of the lumbar intervertebral discs
of compression loading, an increase in intradiscal pres- may be flat or concave, or may even be slightly convex.
sure and a more marked bulging of the' annulus fibro- In some subjects, the posterior aspect of one or more
sus. These findings suggest that degeneration of a disc discs displays a moderate convexity and protrudes into
tends to produce degenerative changes in the adjacent the vertebral canal. This occurs particularly in subjects,
healthy discs, particularly in the underlying one, due to such as achondroplastic dwarfs, presenting a marked
functional overloading. This is consistent with the concavity of the vertebral bodies in the sagittal plane.
clinical and pathologic observations indicating that In this condition, the disc displays the degenerative
subjects showing disc degeneration tend to present changes normally related to aging. Disc bulging, there-
this condition in multiple contiguous discs. fore, although contributing to narrowing of the spinal
canal, does not represent, in itself, a pathologic condi-
tion.
Bulging of annulus fibrosus
In this condition, the annulus fibrosus bulges beyond Pathologic bulging
the tangent plane to the posterior edge of the adjacent
vertebrae. Bulging of the annulus fibrosus must be dis- Annular bulging is pathologic when it is the result of
tinguished from disc herniation. In the former condi- pathologic degenerative changes of the disc.
tion, in fact, the bulging is relatively mild and affects a In an anatomo-radiologic study of discs showing
large portion of the disc and, in a normally-sized spinal posterior annular bulging, Kambin et al. (40) consis-
canal, does not cause compression of the nervous tently found moderate or marked disc changes, consist-
structures. On the other hand, the two conditions are ing in circumferential and radial tears of the annulus
strictly related. Annular bulging, in fact, generally fibrosus and migration of fragments of fibrotic nucleus
102.Chapter 5.----------------------------------------------------------
pulposus between the fissured annular lamellae. All the Extruded herniations are those conditions in which the
discs, furthermore, were decreased in height by at least herniated material entirely perforates the annulus
one third, which presumably favored the posterior fibrosus, but remains in part within the limits of the
protrusion of the outermost annular lamellae. Annular disc. In sequestered herniations, the herniated material
bulging, however, is not necessarily associated with a is found completely outside the disc, loosing any rela-
decrease in disc height and advanced degenerative tionship with it and becoming a free fragment of tissue.
changes of both disc components. Two conditions may, The fragment may remain in close proximity to the disc
in fact, be identified: or migrate at a distance.
1. The two components of the disc show changes of Another classification (53) distinguishes between:
similar severity. The nucleus penetrates into incom- contained herniations, which are equivalent to the disc
plete radial fissures and / or circumferential fissures of protrusions of the former classification; and non-
the annulus fibrosus, but does not cross the outermost, contained herniations, which include extruded - sub-
non-fissured, lamellae. These resist, but bulge under ligamentous or retroligamentous - herniations, and
the pressure of the nucleus pulposus. Bulging of this sequestered herniations. The sub ligamentous and
type can involve the entire posterior and/or lateral sequestered herniations may be migrated or non-
portion of the annulus fibrosus, or a more circum- migrated.
scribed portion of it. This is usually the mid-posterior The drawback of the former classification is that it
part, in which the resistance of the annulus fibrosus is reduces to only three, the possible types of disc hernia-
increased by the central strand of the posterior longitu- tion. The second classification uses different terms to
dinal ligament. The disc usually shows a mild to indicate conditions that are anatomically similar: a sub-
marked decrease in height, which contributes to the eti- ligamentous herniation that has migrated at a distance
ology of bulging. from the disc is usually a sequestered herniation; how-
2. The nucleus pulposus shows moderate degenera- ever, the term sequestration is used for only retroliga-
tive changes, whereas the annulus fibrosus is compara- mentous disc fragments free in the vertebral canal,
tively more impaired and/ or abnormally thin (4, 46), which mayor may not be migrated. Some authors (69),
and thus unable to withstand the pressure exerted by on the other hand, use this picturesque, but hardly
the nucleus pulposus. In these conditions, which are anatomic, term to indicate exclusively free fragments
less common than the former, the disc height is mostly migrated at a distance from the disc. These discrepan-
normal or slightly decreased. This type of bulging is cies lead to confusion in the description and interpreta-
typical of young subjects and usually involves the tion of pathologic findings.
entire posterior or lateral portion of the disc. We identify lumbar disc herniation as: contained,
The amount of annular bulging may vary consider- extruded or migrated. The extruded herniations are
ably. When it is marked, it may be difficult to differenti- sub ligamentous, transligamentous or retroligamen-
ate the condition of bulging from that of true herniation tous, but not migrated. This terminology has the
of the annulus fibrosus (Fig. 5.8). On occasion, in the advantage of not using the term sequestration; of using
same disc showing a large annular bulging, there may a specific term for each type of pathologic condition;
be a narrow zone with a herniation-like prominence. and of distinguishing between pathologic conditions
Bulging of the annulus fibrosus tends to increase implying different therapeutic indications. The term
on extension of the trunk, since in this position the retroligamentous indicates that the herniated disc
adjacent vertebral bodies get closer dorsally and the fragment is located in front of the disc, but is free, or
curvature of the outermost annular lamellae increases. substantially free, and cannot thus be removed with
Annular bulging, in the presence of a narrow or percutaneous intradiscal procedures. The term migrat-
stenotic spinal canal, can contribute to compression of ed herniation indicates that the only, or essential,
the neural structures. pathologic condition is at a distance from the disc,
which may be a secondary element in terms of surgical
treatment.
Types of herniation
Classification Contained herniation
The classifications commonly adopted distinguish This is the most typical form of lumbar disc herniation.
between 3 or 4 types of posterior or lateral herniation of The pathogenetic mechanism is related to the pres-
the disc. ence, in the annulus fibrosus, of large circumferential
One classification (6) identifies: disc protrusions, fissures extending also to the most peripheral lamellae
extruded herniations and sequestered herniations. or of radial fissures reaching to close proximity of the
- - - - - - - - - - - - - - - - - - - - - - - - - - 0 Pathomorphology 0103
Retrothecal migration
Site of herniation portions of the disc, can perforate the dural sac and
become intrathecal.
Midline herniation
Midline, or central, herniation occurs in the mid portion Paramedian herniation
of the disc (Fig. 5.18); that is, at the level of the central
strand and the most medial portion of the lateral This herniation is that occurring in the centro lateral
expansions of the posterior longitudinal ligament. portion of the disc (Fig. 5.19). This portion corresponds
Herniations in this site are rare at the high lumbar levels to the zone occupied by the base of the lateral expan-
and, at any vertebral level, are usually represented by sions of the posterior longitudinal ligament. The
bulging of annulus fibrosus; this holds particularly for anatomic limits of this zone, however, are not well
the high lumbar levels, where the central strand of the defined. Therefore, a herniation is often considered
ligament is wider. Extruded herniations, furthermore, paramedian because it is a large herniation extending
are mostly subligamentous, since in the middle portion towards either the midline or the lateral portion of the
of the disc the ligament is thicker and, therefore, more disc. In the centrolateral zone of the disc, the posterior
difficult for the extruded disc tissue to perforate. longitudinal ligament offers lower resistance than in
The extruded fragment tends to remain in close prox- the portion occupied by the median strap, but greater
imity to the disc, due to the tenacious adhesion of the than in the posterolateral portion. For this reason,
posterior longitudinal ligament to the posterior rim of paramedian herniations are often contained, and
the vertebral body. Less frequently the extruded tissue extruded herniations are more often subligamentous
is directed towards the right or left side, between the than transligamentous or retroligamentous.
longitudinal ligament and the annulus fibrosus, due to An extruded sub ligamentous fragment of disc tends
the poor adherence between the two structures over a to easily detach the posterior longitudinal ligament and
large part of the rhomboidal portion of the ligament. slide behind the subjacent, or more rarely suprajacent,
Often, part of the extruded tissue displaces towards one vertebra. If the ligament is completely detached in the
side, whereas the residual portion remains in the sub- caudal direction, or is perforated, the disc fragment
ligamentous midline region. tends to migrate medially to the emerging nerve root
The extruded fragment that succeeds in perforating and subsequently in the axilla of the latter. In both
the posterior longitudinal ligament is generally of large cases, it can impinge on both the emerging root and the
dimensions and, remaining in the midline, can impinge most lateral of the roots running within the thecal sac.
on the nerve roots of both sides in their intrathecal When detachment occurs in the cranial direction, the
course. The fragment may migrate in various directions fragment migrates towards the axilla of the nerve root
and, more easily than fragments extruded from other emerging from the thecal sac at the level above.
Fig. 5.18. Midline disc herniation. Fig. 5.19. Paramedian disc herniation.
----------------------------------------------------oPathonlorphology o1 09
Posterolateral herniation prevalently located; that is, a herniation located in the
foramen for more than half of its axial dimensions is
This develops in the zone comprised between the base referred to as intraforaminal, whereas that located
of the lateral expansion of the posterior longitudinal outside the foramen for more than half of its size is indi-
ligament and the entrance of the intervertebral foramen cated as extraforaminal. Similarly, the herniation is
(Fig. 5.20). In this zone, facing the nerve-root canal, the termed posterolateral when less than half of its exten-
disc is covered by the middle portion of the lateral sion is situated in the foramen and the remaining
expansions of the posterior longitudinal ligament. The portion, medially to the foramen.
lateral expansions are not only loosely adherent to the Intraforaminal herniations can be contained, extrud-
disc, but in the middle portion cover only part of the ed or migrated. Within the foramen, the disc is not
annulus fibrosus and this part progressively narrows covered by the posterior longitudinal ligament and,
from the first to the fifth lumbar disc. These anatomic thus, the extruded herniations cannot be classified as
characteristics may explain why posterolateral extrud- sub-, trans- or retroligamentous, like those of the poste-
ed herniations are more frequently trans ligamentous or rior wall of the disc. Extruded herniations can be of two
retroligamentous compared with midline or parame- types: a) the herniated fragment escapes partially or
dian herniations and why they are mostly located at the completely from the disc, but remains in close proximi-
level of the two lower lumbar discs (58). These hernia- ty to the disc itself; b) the herniated tissue detaches the
tions, developing in the nerve-root canal, electively annulus fibrosus from the body of the vertebra above
impinge on the emerging root and, thus, tend to pro- and locates just proximally to the caudal rim of the
duce more severe radicular signs and symptoms than proximal vertebral body (Fig. 5.22). The latter condition
midline or paramedian herniations. is more frequent than the former. A contained hernia-
tion impinges on the nerve root emerging from the the-
cal sac at the intervertebral level above the herniated
Intraforaminal herniation disc. The herniation, when it extends medially to the
foramen, may also compress the root emerging from
This herniation has been referred to with various the sac at the level of the herniated disc.
terms: lateral (28, 30, 69), extreme lateral (1, 7, 60), far Migrated herniations are characterized by the pres-
lateral (23, 29, 38), and foraminal (37). We prefer the ence of a free fragment of disc tissue in the interverte-
term intraforaminal and distinguish this from the bral foramen, at a distance from the disc. The fragment
extraforaminal herniation; we use the term lateral as can originate both from the intraforaminal and the
comprehensive of both types. Intraforaminal hernia- posterolateral zone, or even the paramedian portion, of
tions are those located within the limits of the interver- the disc.
tebral foramen (Fig. 5.21). Often the herniation is partly Intraforaminal migrated fragments locate ventrally
intra- and partly extraforaminal. In this instance, the and/ or inferomedially to the nerve root running in the
herniation takes the name of the site in which it is intervertebral foramen, i.e., behind the inferolateral
Fig. 5.20. Posterolateral disc herniation. Fig. 5.21. Intraforaminal disc herniation.
110.Chapter 5.----------------------------------------------------------
Extraforaminal herniation
This herniation is situated entirely, or at least for a large
part of its transverse dimensions, outside the neuro-
foramen (Fig. 5.23). It is much less frequent than the
intraforaminal herniation. Extraforaminal herniations
are generally contained or, at the most, extruded.
Migrated herniations are exceedingly rare, if they exist
as clinically symptomatic conditions. This holds partic-
ularly for those herniations which are entirely, or to a
large extent, extraforaminal. A migrated fragment
originating from a herniation in this site has, in fact,
Fig. 5.24. Anterior disc herniation.
few chances of impinging on the spinal nerves whether
it ascends proximally or descends caudally to the disc.
Extraforaminal contained herniations are often large
in size. Compared with intraforaminal herniations, generally due to a central herniation expanding to-
however, they tend to produce less severe compression wards the sides or to bulging of the whole posterior
on the nerve root, probably because it is easier for the aspect of the annulus fibrosus. True bilateral disc herni-
root to escape compression. ations usually occur when the portion of the annulus
fibrosus reinforced by the central strand of the posteri-
or longitudinal ligament resists the pressure by the
nucleus pulposus, which thus simultaneously proceeds
Bilateral herniation towards the two lateral expansions. Alternatively, these
herniations occur in the presence of bilateral radial
In this condition, there are two disc herniations at a clefts in the annulus fibrosus, allowing penetration of
single level, each on one side. This is a rare occurrence. nuclear tissue at the sides of the middle zone. Bilateral
Compression of both roots emerging at one level is lateral herniations are exceedingly rare. Less rarely, a
----------------------------------------------------oPathornorphology o111
posterolateral herniation on one side may be asssociat- Intravertebral herniation (Schrnorl's node)
ed with a foraminal bulging of the annulus fibrosus on
the other side. Schmorl's node is a herniation of the nucleus pulposus
Generally, bilateral disc herniations are contained or into the vertebral body through a fracture of the verte-
one herniation is contained and the other extruded. bral end-plate and subchondral bone. In the very large
amount of autopsy material studied by Schmorl (73),
the prevalence of these nodes was 38%, with slightly
higher values in males (39.9%) than females (34.3%).
Anterior herniation The frequency with which the nodes were visible on
radiographs, however, was only 13.5%. A possible
The nucleus pulposus may wedge itself into the anteri- explanation for this discrepancy is that most of the
or portion of the annulus fibrosus and cause bulging of nodes, particularly in the initial stage, are too small to
the latter or a true disc herniation (Fig. 5.24). This occur- be revealed by plain radiographs.
rence is not as rare as commonly believed, but nor as The formation of a Schmorl's node may be favored by
frequent as a posterior or lateral herniation. This is due the presence of areas of decreased resistance in the car-
to the considerable thickness of the anterolateral annu- tilage end-plate. According to Schmorl, these are repre-
lus fibrosus, the resistance of which is further increased sented by: 1) areas of thinning of the cartilage, located
by the thick anterior longitudinal ligament. On the in the zone where the vertebral end-plate shows, in
other hand, anterior herniations are of less clinical rele- many subjects, a depression resulting from incomplete
vance than posterior herniations, since, at the most, obliteration of the dorsal cord; 2) "vascular scars", i.e.,
they can cause only back pain, and, maybe for this areas of fibrous tissue situated in the zones of cartilage
reason, they are rarely diagnosed during life. which, during fetal life, are crossed by blood vessels;
The most marked anterior bulgings of annulus fibro- 3) "ossification holes" represented by degenerative or
sus are usually observed at L5-S1level. Disc herniations necrotic areas, with unknown etiology (73). An impor-
may occur anteriorly or, more often, anterolaterally, tant role may also be played by acquired factors, such as
where the disc is not covered by the anterior longi- senile degenerative changes of the cartilage end-plate
tudinal ligament. The herniation can be contained or and vertebral osteoporosis responsible for a decreased
extruded; migrated herniations, on the other hand, have mechanical resistance of the subchondral bone.
never been described. The extruded disc tissue may Herniation into the vertebral body may occur spon-
detach the periosteum from the vertebral body and thus taneously or as a result of repeated microtraumas
stimulate the formation of subperiosteal bone (17, 84). or traumas in flexion or compression. Trauma can
112.Chapter 5.----------------------------------------------------------
provoke a fissure in a structurally abnormal cartilage fracture of part of the remaining portion of the body. At
end plate, but also in a normal end-plate. Trauma is the least 90 cases of these lesions have been reported
most feasible etiology for most Schmorl's nodes, (25,72,78,88). However, they are likely to be less rare
at least in subjects showing no evidence of Scheuer- than generally believed, considering that Takata et al.
mann's disease (84). (78) observed 29 cases in a period of 3 years.
Once the defect in the cartilage end-plate has These authors have described three types of lesion
occurred, a part of the nucleus pulposus penetrates into (Fig. 5.26). Type I is a simple separation of the entire pos-
the vertebral body, causing a fracture of the bone terior margin of the cartilage end-plate. This lesion
trabeculae and necrosis of bone marrow. The bone occurs in teenagers in whom there is still the epiphyseal
niche subsequently becomes enlarged, either rapidly or ring apophysis, that becomes completely ossified
slowly, under the pressure of the herniated tissue. The between 18 and 25 years. The detached fragment is
size stops increasing once the forces causing further entirely cartilaginous and, on axial sections, has an arcu-
herniation decrease as a result of dehydration or senile ate shape. Type II is an avulsion fracture of the posterior
degenerative changes of the nucleus pulposus, or when rim of the vertebral body, including the overlying
the surrounding bone acts as a barrier against the pres- annulus fibrosus. Type II fragment is not arcuate and is
sure of the herniating tissue. The bone undergoes reac- thicker than Type I. This lesion occurs in adolescents or
tive phenomena leading to the formation of a cartilage young adults. Type III is a small fracture of the posterior
cap, probably due to metaplasia of the bone marrow border of the vertebral body. It occurs in the second to
cells. The sh~ll, however, can even be formed by scle- fourth decade of life and, depending on age, the frag-
rotic bone. This may show numerous microfractures, ment can be cartilaginous, osteocartilaginous or osseous.
resulting from repeated traumatic stress exerted on the To these types, Epstein et al. (25) have added a fourth
bone trabeculae (85). On occasion, the herniated disc one, characterized by a fracture of the posterior rim of
tissue is invaded by vessels and may undergo calcifica- the vertebral body extending along the entire posterior
tion or ossification. The herniated intervertebral disc is aspect of the body (Fig. 5.26). This lesion has been
usually narrowed as a result of the herniation or degen- observed only in adults.
erative changes of the disc tissue. The vertebral levels most frequently involved are
The herniation described by Schmorl occurs in the L4-L5 and L5-S1 (caudal part of L5). A disc herniation
central portion of the vertebral end-plate, correspond- is often associated with the lesion, particularly in
ing to the nucleus pulposus. In addition to this central adolescents.
type, a marginal type has been described, that develops In Type I and II lesions, the avulsed fragment, with
in the anterior part of the vertebra at the level of the the attached annulus fibrosus, largely encroaches on
inner portion of the annulus fibrosus (5, 52) (Fig. 5.25). the spinal canal. In Type III lesion, the usual aspect is
Marginal Schmor!' s node, the highest prevalence being that of a herniation of varying size showing a bone or
at L1 level, would generally result from a fracture cartilage fragment included in the herniated tissue. In
of the vertebral end-plate due to traumas in flexion or Type IV lesion, there may be a mild to massive invasion
flexion-compression. of the vertebral canal. In long-standing lesions, the
space between the detached fragment and the vertebral
body is occupied by fibrous tissue or bone. In the latter
Cartilaginous and instance, the vertebral body may present a posterior
osteocartilaginous avulsion prominence of one of the rims.
fractures of vertebral end-plate
Avulsion fractures in pre-senile
Two categories of lesions can be identified: avulsions in
young or middle age, and avulsions in pre-senile or and senile age
senile age. These conditions, though showing similari-
ties, should be considered separately on account of These fractures, which occur in subjects in pre-senile or
the different pathologic characteristics and, probably, senile age (32), consist in separation of a fragment of the
posterior portion of the cartilage end-plate, which is
different pathogenetic mechanism.
pulled out by the annulus fibrosus and extruded from
the disc together with an annular fragment. These
Avulsion fractures in young lesions are likely to occur more easily, or only, when the
and middle age cartilage end-plate shows degenerative changes, which
are responsible for detachment, at least partial, of a
These lesions consist in a separation of the posterior rim portion of the cartilage from the bone surface (79).
of the vertebral body, associated or not with an avulsion The inner one third of the annulus fibrosus is strongly
--------------------------------------------------oPathomorphology 113 0
anchored to the cartilage end-plate. If the latter progression, by dis torsion (increase in curvature and
becomes separated from the bone surface, the annulus packing) of the posterolateral annular lamellae, forma-
fibrosus, in a process of herniation, may drag with tion of a radial cleft, bulging of the outermost annular
itself the cartilaginous fragment after having detached lamellae and extrusion of nuclear material. A sudden
it completely. herniation has been obtained in moderately degenerat-
ed discs of subjects in the fourth to sixth decade
of life. In these cases, the nucleus pulposus is probably
Processes of herniation of the disc wedged in pre-existing radial clefts of the annulus
fibrosus and produces a contained herniation when the
Experimental herniations cleft is incomplete, or an extruded herniation when the
cleft is complete or becomes complete under the pres-
Adams and Hutton (3, 4) have produced a disc hernia- sure of nuclear tissue.
tion in motion segments submitted to compression
loading applied on the proximal vertebra positioned in
flexion compared with the distal vertebra. Two types of In vivo herniation
herniation have been obtained: gradual and sudden.
The former occurred slowly, in subsequent stages, fol- Stages of herniation of nucleus pulposus
lowing cyclic compression; the latter occurred in less
than 1 second after a single application of compression In the process of herniation in life several stages can be
loading. identified, which are similar to those observed in grad-
A gradual herniation has been obtained only in discs ual experimental herniations.
with a soft, pulpy nucleus pulposus and a posterior Stage I. The prerequisite for herniation of the nucleus
annulus fibrosus much thinner than the anterior. These pulposus is the occurrence of a radial fissure in the
discs mostly belonged to adolescents or young adults. annulus fibrosus. The fissure may form slowly, only as
Structural changes of the disc were represented, in a result of degenerative changes in the disc, or may
114.Chapter 5.--------------------------------------------------------
occur suddenly, due to an abrupt mechanical stress in the presence of a degenerated nucleus pulposus, an
flexion or torsion. increase in pressure on the peripheral annular lamellae,
Stage II. The nucleus pulposus penetrates into the which protrude out of the disc. If a cleft forms in the
annular fissure and may increase the length and width outermost lamellae, a portion of annulus fibrosus, of
of the latter. This occurs more easily if the nucleus is various dimensions, can be extruded from the disc. This
only slightly fibrotic and still highly hydrophile. type of herniation is observed particularly in the elderly.
Stage III. The nucleus pulposus penetrates the radial Another mechanism of herniation of annulus fibro-
fissure without perforating the outermost annular sus, possibly more frequent than the latter, is related to
lamellae, thus producing a contained herniation. In the the presence of annular fissures converging towards
passage through the annulus fibrosus, part of the the center of the disc. The portion of the annulus fibro-
nuclear material may insinuate into the circumferential sus comprised between the fissures can be sequestered
fissures originating from the radial cleft and subse- from the rest of the annulus, and can protrude or be
quently produce a new radial fissure at a distance from extruded in the spinal canal following a sudden
the original one. In this instance, part of the annulus mechanical stress in extension or torsion on the motion
fibrosus is surrounded and sequestered by the nucleus segment (page 163).
pulposus.
Stage IV. The outermost annular lamellae are also
perforated and the nuclear material comes into contact Degenerative changes
with the posterior longitudinal ligament or, where the
latter is lacking, protrudes into the spinal canal. of herniated disc
Stage V. The nucleus pulposus perforates the posteri-
or longitudinal ligament and migrates into the spinal Degenerative changes of the disc have been the subject
canal together with sequestered fragments of annulus of numerous pathomorphologic studies, none of
fibrosus. The surge to the tissue fragment that is abrupt- which, however, have analyzed the degenerative
ly extruded from the disc, may be such that it makes it changes in discs with a posterior or lateral herniation.
migrate even at a considerable distance. This is conceivable considering the benign nature of the
The herniation process may occur through all these condition. On the other hand, with time, the herniated
stages or from an intermediate stage it may suddenly tissue undergoes considerable changes and, thus,
reach the final one, for instance from Stage II directly to information that can be obtained from autopsy of
Stage V. Missing one or more stages usually occurs as a previously herniated discs is of little value.
result of mechanical stress producing abrupt compres- The information available on the structural changes
sion of the disc. Based on studies on experimental her- of a herniated disc derive from discography and MR
niations, it is presumable that the process tends to occur images, as well as from surgical findings. Schematically
slowly, with a gradual passage from one stage to the three conditions can be identified.
next, in the disc showing mild degenerative changes,
and more rapidly; possibly missing the intermediate
stages, in the presence of more severe degeneration. In Mildly degenerated disc
the latter instance, in fact, structural changes are still
present, which make it easier for a contained hernia- Usually, the disc height is markedly decreased.
tion, or extrusion of nuclear material, to occur. Discography shows a cottonball or lobular nucleus
pulposus, with an appendix crossing the annulus
fibrosus. On MR images, the nucleus displays normal
Herniation of annulus fibrosus or slightly decreased hydration.
At surgery, the annulus fibrosus appears brilliant-
The mechanism of herniation of the annulus fibrosus white, has a hard-elastic consistency and is strongly
has been analyzed by Yasuma et al. (92, 93) based on attached to the adjacent vertebrae. It can be excised
macroscopic studies on the intervertbral discs and his- with some difficulty, in small fragments, with surgical
tologic observations indicating that, in patients with a instruments. The nucleus pulposus has a turgid
herniated disc, the extruded or migrated fragments appearance and a jelly-like consistency. However, little
often consist only of portions of annulus. This type of nuclear material can be removed.
herniation would result from myxomatous degenera- This condition is found, in the most typical form, in
tion of the annulus fibrosus and consequent separation adolescents or young adults with a herniation of recent
of annular lamellae. The midlle and/ or inner lamellae onset. This is generally contained or extruded behind
become convex towards the center of the disc, i.e., the posterior longitudinal ligament, and, in most cases,
undergo a reversal in their orientation. This involves, in is located posterolaterally.
____________________________________________________ 0Pathomorphology 0115
Microscopic characteristics of
herniated tissue
Histology
The herniated tissue consists of cartilage-like cells and Fig. 5.28. Giant cell clone in which more than 30 cells are visible. The
an abundant intercellular matrix. The cells may be clone is surrounded by a large area of territorial matrix (asterisks).
116.Chapter 5.--------------------------------------------------------
lage-like appearance, may be formed by a network of or more of the four types of matrix may coexist in a
fibrous bundles in the meshes of which a cartilage-like herniation, or a single type forms the whole herniated
matrix is contained, or may consist of thin bundles of tissue. The morphologic characteristics of the cell
collagen fibers orientated in various directions and population show no significant differences depending
separated by an amorphous matrix; these features are on the type of tissue. However, in the areas showing the
typical of nuclear tissue (Fig. 5.29 A). In Type II, the morpholologic features of nucleus pulposus, the cells
matrix is mainly or exclusively formed, as the annulus have an irregular arrangement, whereas in those dis-
fibrosus, by lamellae consisting of fibrous bundles ori- playing clear-cut annular characteristics they often
entated in the same direction (Fig. 5.29 B); two adjacent tend to be arranged in rows and occasionally fibroblast-
lamellae can be tightly packed to each other or be sepa- like cells can be observed throughout the tissue. In
rated by a narrow area of homogeneous or finely fibril- elderly patients, the interterritorial matrix often has a
lar matrix. In Type III, there is a mixture of areas more homogeneous appearance than in young or
showing, alternately, the features of nucleus pulposus middle-aged subjects.
and those of annulus fibrosus; the two types of tissue Small calcified areas are rarely visible in the sections
are present in almost equal proportions. In Type IV, the stained with hematoxylin-eosin. Fragments or hyaline
matrix does not show the typical characteristics of cartilage may be intermingled with disc tissue (Fig.
either the nucleus pulposus or the annulus fibrosus; in 5.30). Generally, the cartilage adheres to portions of the
most cases, it has the appearance of common fibrous annulus fibrosus or to a tissue showing the characteris-
connective tissue showing no lamellar structure. Two tics partly of annulus and partly of nucleus pulposus.
Also the dimensions of the cartilaginous fragments
vary considerably, ranging from a few hundred
microns to several millimeters. Fragments of cartilage
may be present in all types of herniations, but particu-
larly in those extruded or migrated.
Areas of granulation tissue, consisting of thin vessels
delimited by a single layer of endothelial cells and of
mononuclear cells, are often visible (Fig. 5.31). Some of
the cells are macrophages, others have the morpholog-
ic characteristics of lymphocytes or fibroblasts, but the
majority cannot be identified as cells of a specific type.
The areas showing granulation tissue are generally
located in the peripheral areas of the herniated materi-
al. Usually, in a single herniation, only few (1 to 5) of
these areas are visible, each formed by a limited num-
ber of vessels (1 to 20). In rare cases the whole peri-
B
Fig. 5.31. Fragment of migrated herniation in a patient complaining of radicular symptoms of2S-day duration. (A) A few areas of granulation tissue
invading the disc tissue are visible (arrowhead). (B) Higher magnification of an area of granulation tissue. This consists of small vessels delimited by a
single layer of endothelial cells (arrows) and mononuclear cells with roundish or spindle-shaped nucleus.
pheral portion of the disc fragment is invaded by gran- Histochemistry and immunohistochemistry
ulation tissue. Occasionally, in the peripheral area or in
the center of the tissue, there are: vessels not surround- Alcian blue staining at low pH, that selectively demon-
ed by cell infiltrates; small groups of mononuclear cells strates chondroitinsulphate and keratansulphate, is
not associated with blood vessels; or areas where the strongly positive in the entire herniated tissue and, to a
cell population consists of typical fibroblasts (Fig. 5.32). larger extent, in the pericellular lacunae (Fig. 5.33). In
The areas of granulation tissue are seen in migrated or the portions with the appearance of nucleus pulposus,
extruded, and very rarely in contained, herniations. staining of the interterritorial matrix tends to be greater
Generally, granulation tissue is present when the herni- than in those consisting of annulus fibrosus, which are
ation has appeared at least 2 to 4 weeks previously. often only weakly stained. No significant differences in
Chitkata (15) found that the incidence increased pro- the intensity of tissue staining can generally be appreci-
gressively from 12% in the patients who had symptoms ated between young and elderly subjects.
less than 1 month at the time of surgery to 82% in the The PAS reaction, which is specific for glycoproteins,
patients in whom the herniation had appeared more is usually strongly positive (Fig. 5.34 A). As for alcian
than 6 months previously. blue, the positivity of the reaction is frequently greater
118.Chapter 5.------------------------------------------------------
With the Sudan black staining, the aggregates of
senile pigment acquire a black color. With the same
staining method, numerous small black globules are
visible throughout the tissue, particularly in proximity
to the cell clones (18). With the Congo red, aggregates of
amyloid can be seen in the zones consisting of annulus
fibrosus, but not in those showing the typical features
of nucleus pulposus (90).
With Von Kossa's method, calcium deposits are visi-
ble in about 20% of herniations. Generally, the calcified
areas are small in size and are often shaped like striae of
varying length and thickness (Fig. 5.35). In a single her-
niation, calcified areas are mostly multiple, but rarely
numerous. Usually, the calcium deposits are scattered
throughout the tissue; on occasion, they tend to be con-
Fig. 5.32. Area of herniated disc tissue containing typical fibroblasts centrated, and larger and denser, in the peripheral areas
(asterisk), adjacent to zones showing chondroid features in which cell
clones are visible. of the excised fragments.
In recent years, immunohistochemical methods have
in the areas consisting of nucleus pulposus. Areas con- contributed to determine the morphofunctional charac-
sisting entirely of intensely PAS positive granular mate- teristics of some of the cells in the granulation tissue
rial (Fig. 5.34 A), or areas of tissue containing small often present in extruded or migrated herniations.
lumps of material interspersed among the bundles of Many cells in the granulation tissue are immuno-
collagen fibers (Fig. 5.34 B), are often visible. This reactive to monoclonal antibodies to macrophages (Fig.
material has been identified with the so-called senile 5.36); and occasionally cells surrounding newly-formed
pigment (18) and presumably corresponds to the elec- vessels are immunoreactive to monoclonal antibodies
tron-dense granular material visible at ultrastructural to lymphocytes T and B (31,36). The use of anti-metal-
level. In the zones invaded by granulation tissue, the loproteinase-l (collagenase) and metalloproteinase-3
positivity of PAS reaction, like the alcian blue staining, (stromelysin) antibodies has demonstrated that the cells
is generally weaker than in the rest of the tissue. in the granulation tissue, as also the chondrocytes,
Fig. 5.33. Alcian blue staining, pH 2.5. Fragment of extruded disc tissue. Intense staining of the pericellular lacunae. Staining of the interterritorial
matrix is intense, but dyshomogeneous. The less stained portion appears to have a more fibrous texture.
- - - - - - - - - - - - - - - - - - - - - - - - . Pathomorphology'119
produce these substances (41, 42). Immunohisto- tissue produce inhibitors of tissue metalloproteinase-1
chemical methods, furthermore, have shown that the and -3, as well as various interleukins and other chemi-
chondrocytes and I or the cells in the granulation cal mediators of inflammation (22, 41, 42, 77).
120.Chapter 5.----------------------------------------------------------
proteoglycan granules. Usually, areas consisting of col- annulus fibrosus, the interterritorial matrix is formed
lagen fibrils and fibers scattered in an abundant amor- by collagen fibers with a parallel arrangement, either
phous ground substance (Figs. 5.41 and 5.42) alternate separated by narrow spaces or closely packed (Fig.
with areas showing a high density of medium- or large- 5.44). In these zones, the cells often present fib rochon-
thickness collagen fibers. Aggregates of electron-dense drocyte features and the matrix vesicles tend to be
granular material, probably consisting of degradation fewer in number. The aggregates of electron-dense
products of cell or extracellular matrix, are consistently granular material are also less abundant than in the
present in the tissue. In some cases the aggregates are areas with the features of nucleus pulposus. The mater-
few in number and small in size, whilst in other cases ial may form a sort of network between the collagen
large and numerous masses of the material can be seen fibers (Fig. 5.45) or large masses may entirely replace
(Fig. 5.43). At times, the material occupies up to one the fibrillar component of the tissue (Fig. 5.46).
third of the interterritorial matrix. Both the compact- In the zones with no definite annular or nuclear
ness of the tissue (density and thickness of the collagen characteristics, there are areas where the collagen fibers
fibers), and the number and size of the aggregates tend tend to form lamella-like structures (fibers with parallel
to increase with advancing age. orientation, but separated by wide spaces) and areas
In the zones showing the morphologic features of showing small bundles of parallel collagen fibers,
----------------------------------------------------0 Pathomorphology 0123
Barr (56), four consisted of annulus fibrosus, two of
nucleus pulposus and five of both components. Others
have found that in all (21), or the majority (93), of the
cases studied, the herniated tissue was formed by
nucleus pulposus and annulus in varying proportions.
Fragments of cartilage end-plate have been observed in
proportions ranging from 21 % (93) to approximately
60% (24, 32).
We carried out histologic studies on herniated
tissue obtained at surgery in 100 patients aged 16 to 76
years. In the contained and subligamentous extruded
herniations, we analyzed the first two and I or the
largest of the tissue fragments excised from within the
disc (contained herniations) or from the peripheral
portion (extruded herniations). In the other types of
herniation, all or a large part of the extruded or migrat-
ed tissue was examined. The herniations were classi-
fied according to the four patterns of intercellular
matrix that can be identified histologically (page 115).
Fig. 5.43. Herniated disc tissue of a 52-year-old patient. Large aggre- When in a single herniation more than two types of tis-
gates of electron-dense granular material (asterisks) in the intercellular sue were found, for instance Types I and IV, the hernia-
matrix of an area showing the features of nucleus pulposus at light tion was assigned to the type corresponding to the
microscopy.
prevailing tissue. The composition of the herniated
tissue was related to the type of herniation and the
patient's age (Table 5.1).
scattered in a tissue made up of abundant amorphous In contained herniations, the material examined con-
ground substance and isolated collagen fibers, orientat- sisted only of nucleus pulposus in 27% of cases and of
ed in various directions (Fig. 5.47). nucleus pulposus and annulus fibrosus in some one
third of the patients. In half of the remaining cases, the
material was represented by annulus fibrosus, whereas
Composition of herniated tissue related to in the other half, the tissue did not show the typical
type of herniation and age features either of nucleus pulposus or annulus fibrosus.
In 11% of cases, small fragments of cartilage end-plate
Numerous investigations have been carried out in an were present in the tissue.
attempt to determine the composition of the herniated Extruded herniations consisted of nucleus pulposus
tissue. Of the 11 specimens examined by Mixter and and annulus fibrosus in about half of the cases and of
Table 5.1. Composition of herniated tissue compared with type of herniation and patient age.
Compostion
of hernia ted
tissue Type of herniation Age
Contained Extruded Migrated 16-30y. 31-50y. 51-76y.
(n.28) (n.43) (n.29) (n.16) (n.59) (n.25)
Type I 8(27%) 6(14%) 3(10%) 9(56%) 8(13%) 0
Typell 5(18%) 10(23%) 7(24%) 1(6%) 11(58%) 11(36%)
Type III 11(39%) 23(53%) 16(55%) 6(37%) 34(58%) 9(36%)
Type IV 4(14%) 4(9%) 3(10%) 0 6(10%) 5(20%)
Cartilage 3(11%) 11(26%) 9(31%) 1(6%) 12(20%) 10(39%)
Fig. 5.47. Migrated disc herniation. Electron micrograph. The intercellular matrix shows no clear nuclear or anular characteristics. It consists oflamel-
la-like structures (arrowheads) and areas containing collagen fibers orientated in various directions and relatively abundant amorphous ground
substance (asterisks).
Fig. 5.48. Anatomic section at the level of the intervertebral disc. Combined stenosis of the spinal canal resulting from moderate constitutional
narrowing of the canal cind thickening of the ligamenta flava (asterisks) associated with mild hypertrophy of the articular processes.
similar, but less severe, than those found in degenera- sis of the spinal canal. It should be considered, howev-
tive stenosis, since less marked changes are sufficient to er, that narrowing of the neuroforamen as a result of
produce compression of the neural structures in a spondylotic changes is frequent, but rarely causes com-
developmentally narrow canal (Fig. 5.48). pression of the nerve root, and that when this occurs,
the compression is generally mild (Fig. 5.50). Stenosis,
in these cases, is generally asymptomatic.
Isolated nerve-root canal stenosis
Fig. 5.50. Stenosis of the intervertebral foramen caused by the tip of the
superior articular process covered by the ligamentum fIavum (asterisk)
in a L4-L5 motion segment showing marked disc resorption (D) and
marginal osteophytosis of the posterior border of the vertebral bodies
(long arrow). The nerve root running in the neuroforamen (arrowhead)
Fig. 5.49. Sagittal section at the level of the nerve-root canal in a spine is moderately compressed in spite of marked narrowing of the foramen.
frozen in moderate rotation. The L4-L5 disc shows afew fissures, one of The short arrow points to a vessel in the intervertebral foramen.
which extends to the attachment of the annulus fibrosus at L5 vertebral
body (arrowhead). The annulus fibrosus bulges into the spinal canal and
impinges on the L5 nerve root (black asterisk), which is compressed also
posteriorly by the superior articular process ofL5 (arrow). As a result of
rotation, the L4-L5 facet joint gapes (white asterisk). Also the L5-S1 disc Disc herniation in a narrow spinal canal
is fissured and shows marked posterior annular bulge.
A narrow spinal canal does not represent a predispos-
ing condition to disc herniation, but, other conditions
between the posterior arch of the slipped vertebra and being equal, it tends to make radicular signs and symp-
the body of the vertebra below. The effects of these two toms more severe.
processes are, however, related to the original width of Porter et al. (62) have measured, by echography, the
the vertebral canal. When the latter is wide and the ver- oblique sagittal diameter of the lumbar spinal canal
tebral slipping is of mild severity, compression of the in patients with disc herniation and in asymptomatic
nervous structures may not occur. In the presence of a subjects. In the former, the mean dimensions of the
normally sized spinal canal, the thecal sac is usually spinal canal were significantly lower than in the latter;
compressed at the level of its lateral portions. When the furthermore, in the patients successfully treated with
dimensions of the spinal canal are at the lower limits of conservative measures, the mean dimensions of the
normal or below, a marked compression of the dural canal were larger than in those requiring surgical treat-
sac occurs, even in the presence of spondylotic changes ment. In a similar study (89), the midsagittal and inter-
or vertebral slipping of mild severity. pedicular diameters of the spinal canal were measured
The orientation of the articular processes of the on lumbar spine radiographs in patients submitted to
slipped vertebra tends to be more sagittal than normal surgery for disc herniation and in asymptomatic sub-
and the vertebra may show a translational or angular jects. In the former, the sagittal dimensions of the spinal
hypermobility in flexion-extension movements or may canal were significantly smaller than in the latter. These
show no hypermobility. findings indicate that patients with a symptomatic disc
----------------------------------------------------·Pathomorphology·131
herniation tend to have a narrow spinal canal and that Degenerative and combined stenosis
the herniation causes a more severe compression of the
nervous structures in a narrow, than in a normal, spinal In stenosis of the spinal canal, or central stenosis, the
canal. This is due to the fact that, in a narrow canal, intervertebral discs in the stenotic area are generally
there is less reserve space for the neural structures. degenerated, however rarely show marked bulging of
These are therefore less likely to escape compression by the annulus fibrosus or a herniation. Usually this occurs
the herniation or, being displaced by the latter, are only when the disc height is normal or moderately
compressed also by the osteoligamentous walls of the decreased. The herniation is mostly contained and
canal. never migrated, and may be both central or paramedi-
No relationship appears to exist between the type of an, and posterolateral. Often a posterolateral herniation
herniation and the dimensions of the spinal canal. In extends into the foraminal area, whereas only rarely is
the series studied by Porter et al. (62), the dimensions of the herniation exclusively intraforaminal. Usually the
the canal were similar in the patients with a contained, contents of the disc are fairly abundant, considerably
to tho1'e with an extruded, herniation, the two groups dehydrated and brownish in colour due to senile
including a similar number of subjects. In our experi- degenerative changes in the disc tissue. Encroachment
ence, however, this does not hold for patients with a on the spinal canal by the herniation tends to be less
markedly narrow canal, i.e., with a midsagittal diame- and less marked the more stenotic the spinal canal.
ter measuring less than 12 mm. In these subjects there In isolated stenosis of the nerve-root canal, unlike in
is more often a bulging of the annulus fibrosus or a central stenosis, the disc disease plays a major role in
contained herniation than an extruded or migrated the compression of the neural structures. That is, very
herniation. Furthermore, the annular bulging or con- often stenosis becomes symptomatic only in the pres-
tained herniation are more often central than postero- ence of a bulging annulus fibrosus or disc herniation.
lateral and, even if small in size, occupy the spinal In most cases, the latter is contained, or extruded
canal to a large extent. Probably this is related to the beneath the posterior longitudinal ligament, and locat-
fact that an even mild disc pathology, scarcely symp- ed posterolaterally. It is generally small in size, since a
tomatic or asymptomatic in normal subjects, is readi- mild or moderate encroachment on the spinal canal may
ly symptomatic, and is diagnosed early, in those be sufficient to cause severe nerve-root compression.
presenting severe narrowing of the spinal canal. In degenerative spondylolisthesis, the disc below the
slipped vertebra is almost always degenerated, but
does not usually protrude into the spinal canal.
Occasionally, it is the site of disc herniation, which
Disc herniation in stenotic spinal canal usually develops in the presence of mild slipping and a
normal, or almost normal, disc height. The herniation is
Constitutional stenosis generally contained and may be central, posterolateral
or lateral.
In this form of stenosis, marked bulging of the annulus
fibrosus or a contained herniation is often present at
one or more of the stenotic intervertebral levels. The References
development of disc disease often makes a previously
asymptomatic condition symptomatic. The annular 1. Abdullah A. E, Ditto E. W., Byrd E. B. et al.: Extreme-lateral
bulging or herniation are often central and may thus lumbar disc herniations, clinical syndrome and special prob-
lead to compression of the nervous structures on both lems of diagnosis. J. Neurosurg. 41: 229-234, 1974.
2. Adams M. A., Dolan P., Hutton W. C: The stages of disc
sides. The discs most frequently involved are the third degeneration as revealed by discograms. J. Bone Joint Surg.
and fourth. The nuclear material that can be excised 68-B: 36-41, 1986.
from the disc ranges from very little to abundant. In 3. Adams M. A., Hutton W. C: Prolapsed intervertebral disc: a
most cases, it is relatively meager and moderately hyperflexion injury. Spine 7: 184-191, 1982.
degenerated. 4. Adams M. A., Hutton W. C: Gradual disc prolapse. Spine 6:
524-531,1985.
In the presence of disc disease, it is often difficult to 5. Alexander C J.: Sheuermann's disease - a traumatic spondy-
differentiate a narrow from a stenotic spinal canal. The lodystrophy? Skel. Radiol. 1: 209-221, 1977.
main differences are that: a) in a stenotic canal, unlike in 6. American Academy of Orthopaedic Surgeons. A glossary on
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cal sac is compressed also posteriorly or posterolateral- tomographic discography in the evaluation of extreme later-
ly by the osteoligamentouswalls of the canal. al disc herniation. Neurosurgery 14: 350-352,1984.
132.Chapter 5.--------------------------------------------------------
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------·CHAPTER 6·------
PHYSIOPATHOLOGY OF
LUMBORADICULAR PAIN
G. Cinotti, F. Postacchini
Fig. 6.1. Connective tissue in the peripheral and radicular nerve. The peripheral nerve (A) shows connective sheaths, the epineurium (Ep) and
perineurium (Pe) around the nerve and nerve fascicles, respectively, and the endoneurium (En) between nerve fibers. The radicular nerve (B) lacks
the epineurium and perineurium, and the endoneurium is less developed compared with the radicular nerve (Om dura mater; Ar arachnoid mem-
brane; Su subarachnoid space; Rs radicular sheath).
distal third of the radicular nerve (110), at the level of ganglion is even more susceptible to edema formation
the dural sheath ending, where a watershed zone in compared with the radicular nerve, since it exhibits
the blood supply of the radicular nerve occurs (160). endoneurial capillaries of the fenestrated type and is
However, the vulnerability of the radicular nerve to enfolded in a tight fibrous capsule which acts as a
mechanical compression in this zone of relative hypo- diffusion barrier (68). Hence, if the dorsal root gang-
vascularization does not appear to be increased (50). lion is submitted to mechanical compression, a similar
The radicular nerve shows a decreased vasculariza- condition to a closed compartment syndrome might
tion compared with the peripheral nerve; however, occur (125).
about 70% of its nutritional supply is provided by the
cerebrospinal fluid (55, 122). Conversely, the dorsal root
ganglion seems to be as rich in blood supply as the Sinuvertebral nerve
peripheral nerve (160).
Mechanical deformation and / or chemical irritation The sinuvertebral nerve provides innervation to the
of the radicular nerve may cause intraneural edema, posterior and posterolateral annulus, the posterior
an event which is largely affected by the degree of longitudinal ligaments and the anterior aspect of the
permeability of the endoneurial capillaries. Both dura mater of the thecal sac (44). Conflicting opinions
radicular and peripheral nerves exhibit endoneurial exist on the origin of the sinuvertebral nerve. It has
capillaries of the continuous type, i.e., endothelial been reported that the sinuvertebral nerve originates:
cells are linked by tight junctions which, by impeding entirely from the ventral ramus of the spinal nerve
the free transfer of molecules larger than 2-3 nm, (14,118,156); both from the ventral ramus of the spinal
form a blood-nerve barrier (68). However, this barrier nerve and the sympathetic trunk or its rami com-
is much less effective in the radicular nerve, since municantes (11, 83, 113, 143); or exclusively from the
the permeability of endoneurial capillaries is greater sympathetic trunk or its rami communicantes (44, 73,
and edema occurs more likely than in peripheral nerves 93). These discrepancies may be due to the difficulties
(68, 121). Moreover, the arachnoid membrane may act in exposing such a thin nerve on anatomic dissections
as a diffusion barrier, thus increasing intraneural and to the close relationship between the rami commu-
edema formation, whereas this is not the case for the nicantes of the sympathetic trunk and the spinal nerve
epineurium in the peripheral nerve. The dorsal root in the region where the sinuvertebral nerve originates.
- - - - - - - - - - - - - - - - - 0 Physiopathology of lumboradicular pain °137
Cr
Drg
It should also be borne in mind that gross dissections to be particularly abundant in the skin, arterial walls,
without any specific nerve staining have been carried periosteum and joint surfaces (47). In the functional
out in some studies, whereas, in others, reconstructions spinal unit, free nerve endings, possibly acting as noci-
of microscopic sections were analyzed (44). Results of ceptors, have been detected in the articular facets and
recent investigations carried out exposing the sinuver- facet joint capsules (51, 59, 108, 152), in the supraspi-
tebral nerve under the dissecting microscope suggest nous and interspinous ligaments (157), in the posterior
that the sinuvertebral nerve originates almost exclu- longitudinal ligament and in the external annulus (11,
sively from the rami communicantes of the sympathet- 51, 59, 62, 85, 118, 162). In degenerated discs, free nerve
ic trunk (44,73,93) (Fig. 6.2). endings were found even in the inner annulus (162).
Two to six sinuvertebral nerves are present in the Although the nociceptive function of these nerve end-
posterior longitudinal ligament at each intervertebral ings has not been unequivocally proven, some of them
level; moreover, ascending and / or descending branch- were found to contain neuropeptides, such as substance
es may reach the level above and below on the ipsilater- P and calcitonin gene related peptide (CGRP), which
al or opposite side. Commonly, in the region of the are known to be involved in the transmission of painful
posterior longitudinal ligament above the disc, a nerve stimuli (2,22, 70, 77, 153). Free nerve endings acting as
plexus is present, formed by the sinuvertebral nerve of nociceptors may be present in the nervi nervorum of
the corresponding level and branches coming from the radicular nerve and dorsal root ganglion (50, 134).
nerves of the levels above and below (44). In muscle tissue, free nerve endings were found in
The sinuvertebral nerve may include nociceptive, the connective tissue between muscle fibers and within
proprioceptive and vasomotor fibers (11, 72, 113, 143). the vessel walls (141). Moreover, about 40% of A-delta
Somatic fibers with a different destination may also run and C fibers present in muscles seem to function as
with the sympathetic fibers (11, 143). nociceptive fibers (89).
In the presence of chronic inflammation, mechano-
receptors, particularly those of type III and IV, may
become more sensitive to mechanical stimuli
N ociceptors (3, 133, 159); in these instances, they may function as
nociceptors or may induce a persistent spasm of para-
Nociceptors are free nerve endings involved in the vertebral muscles, which may eventually cause low
transmission of painful stimuli. They have been found back pain (117).
138.Chapter 6.------------------------------------------____________
Stenosis
ETIOPATHOGENESIS
F. Postacchini, G. Cinotti
4.5 • men
%
prevalence 4 ........•........ women
3.5
3
2.5 ...... ~.......
2 ...•. .. '
1.5
1 .....•..
.............
0.5 .....•
Fig. 7.1. Incidence of disc herniation
by age and gender (modified from Ref
45). Age 30-44 45-54 55-64 65-74 75
300 men
N° of hospitalizations - - - - - women
x 100,000 inhabitants
..............
150
levels (L4-L5 and L5-51) have been found in 6% to patients and on the right in 42%. Bilateral radicular pain
19% of patients (93, 134). was present in 4% of patients.
In younger patients, disc herniation occurs more fre-
quently at L5-51 level, but the proportion of herniated
discs at the upper lumbar levels increases with aging. It
has been found that the mean age of patients with disc Risk factors
herniation at L5-51 level (39 years) was significantly
lower than in patients with herniation at L4-L5 (42 Lifting
years) or L3-L4 (46 years) levels (115) (Figs. 7.3 and 7.4).
In a series of 21,524 patients undergoing disc excision Physical activities overloading the functional spinal
(55), radicular pain was on the left side in 51% of unit in flexion may cause repetitive tensile stresses,
%90
80
70
60 ....•............... ~..
50
40 .....
.......
....
30 " .....
.......
20 ......
.....•
10
Fig. 7.3. Percentage of operations for
herniated discs at L4-L5 and L5-S1levels
by age at operation (from Ref 115). Age 18 25 35 45 55 65 75
8
%
7
6
5
4
3
2
Professional and
white collar
Farmers
**
Drivers
_ _IAim
* mmmsmi** *
Building workers
I •••••tri*mm ***
**
Other industrial
workers
found an increased incidence of disc herniations in compression and hyperflexion loading caused disc her-
pregnant women (62, 91), it seems more likely that niation in 43% of the specimens and vertebral fractures
pregnancy may contribute to a deterioration of a preex- in 57% (1). In the herniated discs, the extruded tissue
isting sciatica (90, 125) or cause sciatic pain in women was represented by nucleus pulposus in 29% of cases
who had, prior to pregnancy, an asymptomatic disc and annulus fibrosus in 13%. Comparing the type of
herniation. It does not seem, however, that pregnancy herniated tissue (nucleus versus annulus) with the
can be considered a risk factor for disc herniation, even degree of disc degeneration (according to Galante) (31),
after numerous deliveries (45). it can be inferred that the majority of nuclear hernia-
tions occurred in discs with grade II degeneration,
whereas herniation of annular tissue occurred, mainly,
in grade III discs (Fig. 7.7). This experimental model has
Etiopathogenetic factors been criticized, since the compression loading was
applied with a flexion angle exceeding the physiologic
In the analysis of the pathomechanisms of disc hernia-
limits. However, hyperflexion of the lumbar motion
tion, it is necessary to evaluate: 1) the type of disc
segment may occur also in vivo in the presence of dam-
injuries which is needed to induce the extrusion of disc
age to the supraspinous and interspinous ligaments (1).
material and, 2) the possible mechanisms causing these
These ligament injuries were found to be very common
injuries.
in patients submitted to surgery for disc herniation
The severity of disc degeneration before the occur-
(105). Other studies have shown that cycling compres-
rence of a herniation has not yet been investigated; this
sion loading applied with a flexion angle within
because, before the onset of sciatic pain, most of the
the physiologic limits (2,3) causes vertebral fractures
patients complain of only occasional episodes of back
(38%), distortion of annular lamellae (31%) and com-
pain and, thus, imaging studies are not usually carried
plete radial tears (8%) (3); however, no disc herniation
out. On the other hand, the histologic examination of
occurred at the end of the test. By increasing the flexion
the disc tissue excised during surgery may be of limited
angle of the applied load to an extent slightly exceeding
value, since disc degeneration may continue during the
time interval between the diagnosis of herniated disc
(on imaging) and the time of surgery. Occasionally, in
young patients, disc degeneration might occur after an
isolated traumatic event; more often, however, the her-
niated disc shows degenerative changes of varying
degree, which are present before the herniation occurs.
This is supported by various observations: 1) disc
degeneration, of mild to considerable severity, has been
found in 76% to 97% of subjects in the age range of 30 to
50 years (82); 2) a large number of patients complain of
occasional or persistent back pain before the onset of
sciatica, possibly due to preexisting disc injuries predis-
posing to herniation; 3) only occasionally, at least in
adults, is the onset of sciatica related to a traumatic
event (55, 64, 119).
In the evaluation of the pathomechanism of disc her-
niation, biomechanical, biochemical and constitutional
factors need to be addressed.
Biomechanical factors
Mechanical stresses
Flexion-compression loading
60 ~ Nucleus
%
herniation
50 [{{}:::l Annulus
40
30
20
10
the physiologic limits, distortion of the annular lamel- (complete, incomplete or bilateral) in 15% of the speci-
lae was observed in more than 80% of L4-L5 discs (2), mens (2,3) (Table 7.3). However, some 50% of the discs
herniation of nuclear tissue in 7%-21% and radial tears showed no deformation of the lamellae after the test.
Table 7.3. In vitro injuries of the functional spinal unit (FSU) subjected to flexion-compression or to flexion-
compression and axial rotation loading.
Type of injury and frequency
Type of loading Vertebral Herniation Radial Lamella
fracture tear distortion
Hyperflexion and 57% 30%
compression 3000 N / sec (+ 13% protrusion)
increased until failure
of the FSU * (1)
Cyclic flexion (physiologic) 38% 0 8% 31%
and compression 500-4000 N
40 cycl/min, 5 h (3)
Cyclic mild hyperflexion 79% 21% 90%
and compression 500-4000N
40 cycl/min, 5 h * (+) (3)
Cyclic flexion (physiologic) 68% 7% 15% 56%
and compression 1500-6000 N
40 cycl/min, 4h (++) (2)
Hyperflexion and 55% 36% 9%
compression 2000 N
increased until failure
of the FSU *(81)
Cyclic flexion-rotation 29% 100%
and compression 1334 N (+ 71 % protrusion)
6.9 h (+) (35)
* Loading applied with a flexion angle exceeding the physiologic limits.
(+) Loading applied on healthy or slightly degenerated discs as seen on MRI or discography.
(++) The cyclic loading applied for 4 hours caused a failure of the vertebral bodies in 27% of the speci-
mens. The mechanical test was continued on the remaining specimens, which were subjected to
increased loading until failure of the FSU occurred.
___________________________ 0 Etiopathogenesis 01 59
McNally et al. (81), analysed the stress concentration fiber strain in the posterolateral annulus. For instance,
occurring in the annulus lamellae under compressive the fiber strain increases by 10% when an axial rotation
loads and anterolateral bending. They observed that, of 2.3° and lateral bending of 6.6° are associated to a
during the mechanical test, a significantly greater stress pure flexion load of 4000 N. Since the ultimate tensile
concentration occurred in the discs which had under- strain of collagenous fibers ranges between 10% and
gone herniation after application of the compressive 20% (12,41,60,83), it appears that non-symmetric lift-
forces. The authors hypothesized that stress concentra- ing plays a prominent role in the rupture of annular
tion may cause separation of the annulus lamellae, a lamellae. Furthermore, complex asymmetric loads pro-
predisposing condition for failure of the innermost duce maximum fiber strain in the innermost annulus,
annulus fibrosus. The latter may eventually extend to which is where the initial disc failure occurs (109). In
the outer annulus, leading to a complete radial tear. The healthy discs, the nucleus pulposus, which is under
causes of abnormal stress concentration in some of the high pressure, may readily penetrate into the annular
discs submitted to compressive loads are still unknown. fissure and extend the injury to the outer annulus. In
It has been hypothesized that stress concentration may degenerated discs, instead, the loss of nuclear pressure
be due to focal biochemical changes or structural dam- significantly decreases the tensile stresses on the inner-
ages to the lamellae, causing significant changes in the most annulus, and the disc fibers are less likely to fail,
hydrostatic behavior of the disc (81). The degree of even under non-symmetric lifting.
hydration of the nucleus pulposus may also play an
important role in producing stress concentration, since,
Facet joint tropism
as nuclear pressure decreases, the compressive forces
are shifted from the nucleus pulposus to the annulus
This condition consists in a different orientation, in the
fibrosus, and this may increase the risk of stress concen-
horizontal plane, of the articular facets on the two sides.
tration in the posterior annulus.
Facet joints playa significant role in limiting the axial
rotation of the motion segment under torsion; thus,
Axial torque facet tropism might expose the annulus fibers to asym-
metric strains under axial torque. Farfan and Sullivan
Pure axial rotation and compression loading do not (25) found facet tropism in 97% of patients with disc
appear to affect disc integrity, particularly when the disease; furthermore, in 95% of patients with radicu-
configuration of the laminae and the facet joint orienta- lopathy, the symptomatic side was that in which the
tion allow an axial rotation displacement less than 1.5° facet joint had a more coronal orientation. The authors
(24,74). On the other hand, when the axial torque caus- hypothesized that, in the presence of facet tropism, the
es an initial axial rotation greater than 1.5°, failure of the disc may undergo dangerous rotational strains on the
functional spinal unit may occur. In this case, however, side with the more coronal facet. Consistent with this
disc failure is almost consistently associated with frac- hypothesis, is the observation that patients with mid-
tures of facet joints and / or capsular tears (74). This line herniations have more symmetric facet joints than
finding suggests that torsion, in itself, should not be those with more lateral herniations (75). In biomechan-
responsible for initial disc failures; however, if axial ical studies, however, facet tropism was found to have
rotation increases, due to facet joint incongruence, it little influence on the behavior of the motion segment
may contribute to disc degeneration. under axial torque (4, 18). Facet joints with coronal ori-
entation, as occurs at L4-L5level, do not allow greater
axial rotation than facet joints with a more sagittal ori-
Complex loading
entation, such as those at L2-L3 level. Only flat facet
joints with marked coronal orientation may decrease
Upon lifting, the lumbar spine undergoes complex
the ability of the facet to resist axial torque. Facet tro-
loading, including flexion-compression, axial rotation
pism does not appear to cause significant strains of
and lateral bending. Gordon et al. analyzed the effects
annular fibers and, should this occur, the changes in the
of such combined loads applied on specimens with
strain profile would take place at different locations
intact or slightly degenerate discs, as seen on MRI (35).
from the posterolateral annulus (4, 18).
After an average of 6.9 h, 71% of the discs exhibited
annulus protrusions and 29% nucleus extrusions
(Table 7.3). Vibration
Using a three-dimensional finite element model,
Shirazi (109) has shown that the addition of lateral Occupations entailing prolonged exposure to vibra-
bending and twisting to pure flexion (or non-sym- tions, such as car or truck driving, were found to be
metric lifting), significantly increases the maximum associated with an increased risk of back pain and
160.Chapter 7.--------------------------------------------------------
sciatica (36, 64, 65). However, little is known on the The biochemical changes found in herniated discs
effects of body vibrations on the disc tissue. Ishihara may also result from disc injuries caused by mechanical
et al. (54), in a study on porcine coccygeal discs subject- overloading of the functional spinal unit. Experimental
ed to various vibratory loads, found that the biological studies have been carried out to investigate the effects
behavior of the disc was influenced by the frequency of of sudden annular injury on the structural and bio-
the vibrations of the applied loads. In the nucleus pul- chemical integrity of the whole disc. In these experi-
posus, the proteoglycan synthesis rate was reduced by mental models, the annular injury made with a scalpel
60% and 50% under vibratory loads of 10 Hz and 35 Hz, resembled a radial tear or a rim lesion (58, 95). Disc inci-
respectively (54). The decreased proteoglycan synthe- sion extended to the nucleus pulposus causes, in the
sis might be related to disc cell damage caused by vibra- early stage, a sharp decrease in proteoglycan and water
tions. The latter may generate dissipated energy, which content. Subsequently, attempts to repair the annular
is thought to be changed into heat. The dissipated lesion may be observed, leading to temporary restora-
energy, which increases progressively with the increase tion of the proteoglycan and water content. In a later
in frequency, may damage disc chondrocytes and phase, the proteoglycan and water contents decrease
matrix components (54). However, since in this experi- progressively and irreversibly (73).
mental model the coccygeal discs were also submitted When an annular incision leaves the nucleus intact,
to axial loading, the reduced synthesis of proteoglycans reparative processes occur in the outer lamellae, while
could be the result of the increasing osmotic pressure the nucleus undergoes marked biochemical changes
caused by the loading condition (57, 92, 108). (58). When the disc incision leaves the nucleus and the
inner third of the annulus intact, a progressive failure
may be observed in the inner annulus and in the nucle-
Biochemical factors us. In a later phase, reparative processes may occur, but
only in the outermost annulus (95) (Fig. 7.8). In conclu-
Abnormal enzymatic activities degrading disc matrix sion, these experimental studies suggest that discrete
could induce a weakening of the annulus fibrosus and tears of the external annulus may progress and cause
predispose to disc herniation. This hypothesis is sup- nuclear degeneration; these may represent an early
ported by the fact that different enzyme patterns have event in the pathomechanism of disc degeneration.
been detected in normal and herniated discs (88).
Normal discs have no enzymatic activity towards Type
II collagen and very low activity towards Type I colla-
gen and elastin; the herniated discs, instead, exhibit Constitutional factors
high enzymatic activity towards Type I collagen and
elastin, and little activity towards Type II collagen (88). Constitutional weakness of the annulus fibrosus may
Since Type I collagen is more abundant in the outer playa role in predisposing to disc herniation, particu-
annulus (22) and the elastic fibers are located mainly in larly in young subjects (37, 80). Patients under the age
proximity to the vertebral end-plates (56), enzymatic of 20 years with disc herniation show, on MRI scans, a
activity degrading Type I collagen and elastin may high prevalence of disc degeneration at multiple levels
weaken the external portion of the annulus and make (33, 118). An epidemiologic study (87) has shown that
the disc more susceptible to herniation. It should be 34% of the adolescents with disc herniation, compared
noted, however, that the presence of degrading enzy- with 2% of the general population, had a familial pre-
mes may be a consequence, rather than the cause, of disc disposition to low back pain. The prevalence of back
herniation. Furthermore, enzymatic activities degrad- pain in relatives of patients undergoing discectomy
ing elastin, collagen and proteoglycans have been was found to be significantly higher than in controls
detected also in degenerated (but not herniated) discs, (100).
and the concentration of these proteinases tends to It has been shown that 32% of patients under 21 years
increase as disc degeneration becomes more severe (30). of age at the time of discectomy had one relative, and
The mechanism underlying degradation of matrix 14% had two or more relatives, previously operated on
components remains to be elucidated. Proteinase for disc herniation (123 ); of the patients under 16 years
activity was found in the vertebral bodies but not in of age, 42% had one relative previously submitted to
normal discs. Since the adult annulus fibrosus is largely discectomy. In the control group, only 6% of the sub-
avascular, proteinases are unlikely to be able to reach jects had one relative, and none had two relatives, sub-
the cartilage matrix in normal conditions. However, mitted to surgery for disc herniation (p = 0.003). In
when disc degeneration occurs, microfractures may accordance with these findings, Matsui et al. (79) found
develop in the vertebral end-plates,leading to a flow of that, in patients under 18 years of age undergoing disc
proteinases from the vertebral bodies to the disc (30). excision, 19% had one relative who had undergone the
- - - - - - - - - - - - - - - - - - - - - - - - - - - - 0 Etiopathogenesis 0161
D E
Fig. 7.8. Effects of annular incision on the structural integrity of the disc. An annular incision extended to the nucleus pulposus (A) causes herniation
of nuclear material (B). An annular incision not reaching the nucleus and the inner annulus (C) causes a progressive failure of the nucleus and of the
innermost annulus (0). In a late phase, the defect of the external annulus tends to heal (E), whereas the nucleus pulposus shows marked features of
degeneration.
same operation compared with 3% of the controls true even in the presence, in the familial setting, of other
(p = 0.02). It is interesting to note that the relatives of risk factors for disc herniation.
patients in the study group had undergone discectomy
at a mean age of 19 years and about half of them had
two disc herniations. Pathogenetic hypotheses
The prevalence of a positive family history for disc
herniation seems to decrease with the increasing age of To explain the occurrence of disc herniation, different
patients undergoing discectomy. Of 134 patients (mean pathogenetic mechanisms may be hypothesized,
age 39 years) operated on for disc herniation, 10% had a depending on the grade of disc degeneration. The
relative who had undergone disc excision compared various mechanisms may act independently or, in some
with 1% in the control group (101). cases, the herniation may occur as a result of the associ-
Postacchini et al. (101) analyzed the HLA antigen fre- ation of multiple mechanisms.
quencies in patients undergoing discectomy and in
their first-degree relatives to determine whether the
familial predisposition to disc disease might be related Healthy or mildly degenerated disc
to genetic factors. Although no significant difference
was found between the HLA antigen frequencies in Disc herniation in a healthy or slightly degenerated
patients with disc herniation and in controls, it cannot disc may occur in adolescents or young adults, in the
be excluded that genetic factors, not linked to the HLA presence of constitutional structural weakness of the
system, may playa role in the familial predisposition to annular lamellae. An alternative, or additional, possi-
disc disease. bility is that repeated mechanical stresses, or a single
In conclusion, the high prevalence of a positive fami- trauma, may produce a tear in the inner lamellae of the
ly history for disc herniation in patients undergoing annulus fibrosus. In many of these cases, there is no pre-
disc excision indicates that, at least in young patients, existing radial tear in the annulus fibrosus, but the
there is a familial predisposition that makes the inter- nucleus, under high pressure, penetrates the fissure of
vertebral disc more susceptible to failure. This may be the innermost annulus and, by rupturing the adjacent
162.Chapter 7 . - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
longer being in connection with the annulus, is free to 17. Deyo R. A., Tsui-Wu Y.-J.: Descriptive epidemiology of low
herniate (Fig. 7.13). back pain and its related medical care in United States.
Spine 12: 264-268, 1987.
18. DuncanN. D., Ahmed A. M.: The role of axial rotation in the
etiology of unilateral disc prolapse. An experimental and
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93. Ostgaard H. c., Andersson G. B.: Previous back pain and Automotive Eng. Trans.: 1-23, 1973.
risk of developing back pain in future pregnancy. Spine 16: 116. Sward 1., Hellstrom M., Jacobsson B. et a!.: Disc degenera-
432-436,1991. tion and associated abnormalities of the spine in elite gym-
94. Osti O. 1., Vernon-Roberts B., Fraser R D.: Annulus tears nast. A magnetic resonance imaging study. Spine 16:
and intervertebral disc degeneration. An experimental 437-443,1991.
study using an animal mode!. Spine 15: 762-767, 1990. 117. Szypryt E. P., Twining P., WildeG. P. et al.: Diagnosisoflum-
95. Paine K W. E., Haung P. W. H.: Lumbar disc syndrome. bar disc protrusion: a comparison between magnetic reso-
J. Neurosurg. 37: 75-82, 1972. nance imaging and radiculography. J. Bone Joint Surg. 70-B:
96. Pokras R, Graves E. J., Dennison C. F.: Surgical operations 717-722,1988.
in short-stay hospitals: United States, 1978. Vital Health 118. Terhaag D., Frowein R A.: Traumatic disc prolapse.
Stat. 13, No 61, 1982. Neurosurg. Rev. 12, Supp!. 1: 588-592, 1989.
97. Pope M. H., Bevins T., Wilder D. et al.: The relationship 119. Thomas M., Grant N., Marshall J. et al.: Surgical treatment
between anthropometric, postural, muscular, and mobility oflow backache and sciatica. Lancet 2: 1437-1439, 1983.
characteristics of males ages 18-55. Spine 10: 644-648, 1985. 120. Troup J. D. G.: Driver's back pain and its prevention: a
98. Pope M. H., Wilder D., Frymoyer J. W.: Vibration as an etio- review of the postural, vibratory and muscular factors,
logic factors in low back pain. Institution of Mechanical together with the problem of transmitted road-shock. App!.
Engineers Conference Publications: 11-17, 1980. Ergon.9:207,1978.
99. Porter R w., Thorp 1.: Familial aspects of disc protrusion. 121. Uyttendaele D., Vandendriessche G., Vercauteren M. et a!.:
Orthop. Trans. 10: 524, 1986. Sicklisting due to low back pain at the Ghent State
100. Postacchini F., Lami R, Pugliese 0.: Familial predisposition University and University Hospita!. Acta Orthop. Belg. 47:
to discogenic low-back pain. An epidemiologic and 523-546, 1981.
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101. Pratt E. S., Green D. A., Spengler D. M.: Herniated interver- disposition for herniation of a lumbar disc in patients who
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15: 662-666, 1990. 124-128,1991.
102. Raaf J.: Some observations regarding 905 patients operated 123. Vernon-Roberts B.: The pathology and interrelation of
upon for protruded lumbar intervertebral disc. Am. J. Surg. intervertebral disc lesions, osteoarthrosis of the apophyseal
97: 388-399,1959. joints, lumbar spondylosis and low back pain. In: The lum-
- - - - - - - - - - - - - - - - - - - - - - - - - - - 0 Etiopathogenesis 016 7
bar spine and back pain. Jayson M. 1. V. Ed., Pitman Medical reinforcement workers. Scand. J. Work. Environ. Health
Publishing, Kent, 83-114,1980. (Supp!. 4) 1: 20-29, 1978.
124. Videman T., Nurminen T., Tola S. et al.: Low back pain in 130. Wilder D. G., Woodworth B. B., Frymoyer J. w. et al.:
nurses and some loading factors of work. Spine 9: 400-404, Vibration and the human spine. Spine 7: 243, 1982.
1984. 131. Wood P. H., Badley E. M.: Musculoskeletal system. In:
125. Vogt K.-H.: Egebnisse nach lumbaler Bandscheiben- Oxford texbook of public health. Vo!' 4. Specific applica-
operation. Z. Orthop. 112: 821-822, 1974. tions, Holland W. W., Detels R., Knox G., Greeze E. Eds.,
126. Webb J. H., Svien H. J., Kennedy R. 1. J.: Protruted lumbar Oxford University Press, Oxford, pp. 279-297,1985.
intervertebral discs in children. JAMA 154: 1153-1154, 1954. 132. Wood P. H. N., Badley E. M.: Epidemiology of back pain. In:
127. Weinreb J. c., Wolbarsht 1. B., Cohen}. M. et a!.: Prevalence The lumbar spine and back pain. Jayson M. 1. V Ed.,
of lumbosacral intervertebral disc abnormalities on MR Churchill Livingstone, London, pp.1-15, 1987.
images in pregnant and asymptomatic nonpregnant 133. Yasuma T., Makino E., Saito S. et a!.: Histological develop-
women. Radiology 170: 125-128, 1989. ment of intervertebral disc herniation. J. Bone Joint Surg.
128. Weiss J. B., Quennel R., Jayson M. 1. V: Abnormal connec- 68-A: 1066-1072, 1986.
tive tissue degrading enzyme patterns in prolapsed inter- 134. Zerbi E., Zagra A., Lamartina C. et a!.: Casistica, risultati e
vertebral discs. Spine 11: 695-701, 1986. cause di insuccessi in operati di ernia discale. Giorn. Ita!.
129. Wickstrom G., Hanninen K., Lehtinen M. et al.: Previous Ortop. Traumat. 6 (Supp!. 2): 25-34, 1980.
back syndromes and present back symptoms in concrete
------·CHAPTER 8·------
CLINICAL FEATURES
F. Postacchini, S. Gumina
°12
L1
,I
L2
L3
L4
L5
S1
Fig. 8.1. Dermatomes of the lower limbs according to
Keegan .
./7''71+-1- 011
L1
~-AI--+- 012
+-'1--1-- L2
1J,I....l....l,,-l,-.l,.4--\-+- S5
S4
L3
+-+-ll--'--- S3
- f - - - - - L3 L4
-+--- S1
S2
- - 1 - - - - - - L4
, + - - - - - - L5
+------ S1
}\
\ I
1\
Genital organs
or clitoris erection and vagina dilation. Orgasm, in both presence of a midline herniation or a posterolateral
sexes, is controlled by the sympathetic and somatic sys- herniated disc causing no significant compression of
tems. In the male, ejaculation is produced by the sym- the nerve roots due to its small size and/ or the large
pathetic system, which elicits contraction of the seminal size of the spinal canal. Both the prevalence and severi-
vesicles, and by the afferent parasympathetic and ty of low back pain tend to be greater in middle-aged
somatic pathways, which stimulate the contraction of patients. In adolescents and elderly patients, low back
the ischiocavernous, bulbocavernous and urethral pain is less frequent and tends to be less severe.
muscles. The most typical features of disco genic low back pain
Sexual function may be lost due to lesions of the sen- are: onset following a physical strain, a cough or a
sory and / or motor nerve roots or the conus medullaris. brusque trunk movement; the presence of postural
scoliosis; an increase in pain on trunk flexion and in the
sitting position, due to the high intradiscal pressure
that these postures involve (66, 67). However, none of
Level at which nerve roots emerge in these features is pathognomonic of discogenic low back
lumbosacral transitional anomalies pain. On the other hand, there are no clinical features
allowing the low back pain of patients with disc herni-
In our experience, transitional anomalies do not affect ation to be differentiated from that of patients with only
the level at which the lumbosacral nerve roots emerge disc degeneration.
from the thecal sac. In patients with sacralization of the Low back pain, although extremely variable in qual-
fifth lumbar vertebra, the L5 root usually emerges from ity and severity, can usually be of three types: 1) Severe
the thecal sac at the level of the last completely mobile pain, associated with postural scoliosis, and increased
disc and leaves the spine through the intervertebral by a cough, sitting and erect posture, and any physical
foramen situated caudally to the pedicle of the sacral- effort. 2) Chronic, continuous pain of moderate severi-
ized vertebra. In the presence of complete lumbariza- ty, affected only slightly, or not at all, by posture and
tion of the first sacral vertebra, the L5 root runs in the spine movements. 3) Low back pain with recurrent
last but one, and the Sl root in the last, intervertebral acute episodes between intervals of varying duration in
foramen. which the pain is absent or, more often, mild or moder-
These observations are not in keeping with the find- ate in severity; in the acute episodes, the characteristics
ings of McCulloch and Waddell (61). These authors, of pain are generally those of the first type.
based on electrophysiologic studies in patients with Most patients with discogenic low back pain report
lumbar disc herniation, held that, in the subjects with typically painful symptoms. Others complain of a gra-
lumbosacral transitional anomalies, the L5 root emerges vative or burning sensation. A feeling of spasm or
from the spine through the intervertebral foramen painful cramp in the lumbar area is rarely reported.
situated at the level of the last completely mobile disc. Pain is usually located in the lower lumbar region, even
Nerve roots emerge symmetrically on the two sides. when the upper lumbar discs are involved. Pain strictly
in the sacral area is rare, at least as an isolated symptom,
not associated with back pain. Pure sacral pain, there-
fore, should lead us to suspect a pathologic condition
Symptoms in the sacral region, rather than a herniated disc.
The severity of back pain may change even consider-
Low back pain ably during the day. In the morning, pain tends to be
more severe. This may be related either to prolonged
Low back pain refers to pain in the lumbosacral area, nocturnal immobility or to disc imbibition due to the
originating from the spine or myofascial perivertebral higher intradiscal osmotic pressure when spine is
structures; the pain is located in the central region of the unloaded. Taking a standing position, initially leads
trunk and tends to radiate transversely on one or both to an increase in the intradiscal pressure and, thus, in
sides. Radiation to the flank or abdomen is atypical and distension of the annulus fibrosus. The subsequent
would exclude the vertebral origin of the pain and, par- decrease in the water content of the disc induced by
ticularly, that it is caused by degenerative disc disease. prolonged loading probably leads to a decrease in the
Low back pain is an almost constant symptom in disc intradiscal pressure and, thus, in pain. During the
herniation. Often, however, there is no back pain at all second half of the day, low back pain often increases
or it is present only at the onset of symptoms or for a in severity, particularly in patients with postural scol-
limited time during the course of the disease. On the iosis. This increase is probably due to the prolonged
other hand, low back pain may occasionally be the only asymmetric loading on the posterior joints and the
symptom of disc herniation. This usually occurs in the prolonged muscle spasm.
176.Chapter 8.----------------------------------------------________
Radicular symptoms Radicular pain of a different nature is that due to
deafferentation. This is a non-somatic pain, caused by
Radicular symptoms, particularly pain, are typical of a direct stimulation of nerve fibers and occurs in the
herniated disc. Although modern imaging modalities presence of a traumatic lesion or a pathologic condition
occasionally show a typical herniated disc even in of the root. This pain is causalgic in nature and it is often
patients with only low back pain, the prevalence of associated with impairment of nerve conduction.
radicular symptoms in patients with herniation is so It is defined as pseudoradicular, a somatic, referred,
high as to make these symptoms those characterizing pain caused by stimulation of the nociceptors located in
disc herniation. In other words, a herniated disc should vertebral or perivertebral structures other than the
be considered by definition, at least in clinical terms, a nerve root. This pain is felt on the iliac or gluteal region
condition in which radicular symptoms are present. or in the lower limb, but it is not localized in a specific
This concept is useful not only from the taxonomic, but dermatome (48, 64). Furthermore, it may be felt in dif-
also, and particularly, from the therapeutic, viewpoint, ferent sites in individuals in whom the same anatomic
since management of patients with only low back pain structure is stimulated.
may differ considerably from that of patients with The term sciatica is derived from the neolatin term
radicular symptoms. ischialgia and literally means pain in the ischium. With
time, however, the term has assumed the meaning of
"sciatic neuritis", i.e., pain along the course of the
Pain sciatic nerve and its branches. As such, it has a similar
meaning to that of radicular pain, but is less precise
Definition of terms due to the presence, in the sciatic nerve, of fibers origi-
nating from several nerve roots. Similar considerations
The expression radicular pain refers to pain caused are valid for the expression "crural pain", which indi-
by stimulation (mechanical, chemical or electric) of a cates pain along the femoral nerve. The same expres-
nerve root. The radicular pain caused by disc hernia- sion is used when the upper lumbar nerve roots
tion would result, according to some authors, running in the obturator nerve are involved.
(100-102), from stimulation of the nociceptors of the
nerva nervorum situated in the nerve-root sheath.
Thus, this pain would be somatic in nature, being such Features
the pain caused, in the presence of a normal nervous
system, by stimulation of the nociceptors of an anatom- Site. Radicular pain may be located only in the buttock
ic structure. This pain, furthermore, is of the referred or may radiate, as usually occurs, down the lower limb.
type, since it radiates at a distance from the involved Alternatively, there may be pain only in the lower limb,
anatomic structure. According to Van Akkerveeken in the whole dermatome or a limited part of it. The
(100), the concept of pain located in the dermatome more severe the nerve-root compression, the more dis-
supplied by the involved nerve root is not implicit in tal the pain tends to be radiated. This is consistent with
the term radicular pain, since stimulation of a nerve the findings of Smith and Wright (92), who demonstrat-
root may cause pain even outside the dermatome that ed that the spreading of pain along the limb is related to
the root innervates, whilst, on the other hand, stimula- the intensity of the mechanical stimuli on the nerve
tion of different roots may induce pain in a single root.
dermatome. It should be borne in mind, however, that Pain in the buttock is much more frequent when the
no clear-cut borders exist between the various der- L5, 51 or 52 roots are involved, whilst it is fairly rare
matomes and, thus, that a cutaneous area may be when the upper lumbar roots are involved. In this
supplied by two or more nerve roots. Stimulation of a instance, the equivalent of buttock pain may be pain in
nerve root, therefore, may cause pain in the same area the groin. The latter can be reported, although rarely, by
in which there may be pain due to stimulation of an patients with L5 nerve-root compression. It may be due
anatomically close nerve root. On the other hand, most to anomalies of the furcal nerve, which may emerge
patients with lumbar disc herniation experience pain, together with the L5 root and contribute to the innerva-
or the most severe pain, in a specific area in the lower tion of the inguinal region through the branches which
limb, corresponding to the dermatome innervated by run in the lumbar plexus.
the involved root. In our opinion, the term radicular
pain implies the concept of pain radiated to a specific Quality. The patient generally describes the sensation
dermatome. This does not imply that pain is located which bothers him using the terms pain or discomfort.
over the whole dermatome, since it may be limited, as Occasionally, a sensation of burning, rather than true
often occurs, to only a part of it. pain, is reported. Almost always, this sensation corre-
- - - - - - - - - - - - - - - - - - - - - - - - - - - - o C l i n i c a l features 177 0
sponds to an irritative radicular syndrome of mild cases, there is initially an extruded disc fragment, which
severity. Even more rarely, the patient has no pain, then migrates in the median portion of the spinal canal
but is troubled by numbness. or on the opposite side to that of the initial herniation.
In patients with pain of similar severity in both
Severity. The severity of pain varies either in absolute extremities, one should always be wary as to whether
terms, or in relation to the way the patient lives and that pain is truely radicular in nature. This holds partic-
relates the painful experience. It is of paramount impor- ularly if the pain is mild and investigations fail to reveal
tance to evaluate the severity of the patient's pain as any neurologic deficit.
well as his/her psychologic traits, since the diagnostic
and therapeutic approach may depend to a large extent Posture-related changes. Radicular pain tends to
upon these two elements (Chapter 12). increase in the standing, and to decrease in the horizon-
The severity of pain is generally related to the severi- tal, position. This behavior, however, is not uniform
ty of the nerve-root compression, which, in turn, is and is more often found in patients with irritation, than
affected by the size of the herniation and the position of in those with marked compression, of the nerve root. In
the latter with respect to the nerve root. The patients the latter patients, the pain may be even more severe in
with the mildest radicular pain are usually those with a the horizontal, than in the standing, position. The prone
contained midline herniation, whilst the most severe position is usually more painful than the supine, since
pain is usually reported by patients with migrated in the latter the nerve root lies above the herniation and,
herniation. In these, the severity of pain often depends due to the effect of gravity, may be more severely com-
upon the position of the disc fragment with respect to pressed. This interpretation is supported by myelo-
the nerve root, rather than the size of the fragment graphic findings: on the posteroanterior myelogram in
itself. A small disc fragment migrated ventrally to the the prone position, a filling defect of the nerve-root
root may cause much more severe pain than a large sleeve is usually more clearly visible than on the myel-
fragment situated ventrally to the thecal sac. The most ogram in the supine position (which, for this reason, is
painful, or among the most painful, are lateral hernia- not usually performed).
tions. This may be due to the fact that the latter are often The sitting position often exacerbates radicular pain,
migrated herniations or that the herniation impinges particularly buttock and thigh pain. Exacerbation in
on the nerve-root ganglion, rather than on the root. this position is typical of patients with disc herniation
The severity of pain and, more in general, of nerve- and tends to occur more easily in the presence of mod-
root compression, is related to the width of the spinal erate or marked compression, than irritation, of the
canal. Porter et al. (79), in a series of patients with disc nerve root. Furthermore, an increased pain is more
herniation diagnosed on clinical grounds, found that often observed in the presence of contained or extrud-
the patients who had to undergo surgery had smaller ed, rather than migrated, herniation. In patients with
mean dimensions of the spinal canal than those in contained herniation, exacerbation of pain may be due
whom the clinical syndrome had resolved with conser- to an increase in intradiscal pressure, and thus in the
vative care. The patients with a narrow or stenotic canal prominence of herniation, that the sitting position
tend to present signs and symptoms of more marked involves (66, 67); an additional element may be the
nerve-root compression, the dimensions of the disc pro- trunk flexion that the sitting position implies. In
trusion being similar, than the patients with a normally- patients with migrated herniation, the exacerbation of
sized, or larger than normal, spinal canal. pain is probably due to a change of the reciprocal spa-
tial relationships between the disc fragment and the
Bilaterality. Radicular pain in both lower limbs is not nerve root and / or to increased nerve-root compression
frequent. Pain may be bilateral in the presence of a mid- produced by trunk flexion.
line large disc herniation, a large disc fragment migrat- A few patients report that radicular pain decreases in
ed in the median or almost median portion of the spinal the horizontal, or in the standing or sitting, position or
canal, bilateral disc protrusion or two-level herniation in other, at times even strange, positions. A few posi-
located on opposite sides. The two latter conditions, tions clearly represent a form of sciatic scoliosis. Other
however, are rare. In the vast majority of cases, pain is postures may possibly decrease, in a given patient,
more severe, and/ or radiated to the limb, on one side. the pressure exerted by the herniation on the nerve
Alternatively, pain is present only on one side, whilst structures.
on the opposite side only sensory disturbances, muscle
weakness or decreased reflexes are present. Another Changes with walking. Pain caused by mild nerve-
possibility is that pain begins on one side and, with root compression generally tends to decrease on walk-
time, decreases or disappears, concomitantly with the ing, whilst that produced by marked compression
appearance of pain on the opposite side. Often, in these tends to increase. This anamnestic element may con-
178.Chapter 8.--------------------------------------------------------
tribute to differentiate the patient with mild radicular outer aspect of the thigh, normally innervated by L2
irritation from that with marked nerve-root compres- and L3 roots, may also belong to the L4 or L5 der-
sion. matomes (70). However, sensory disturbances on the
lateral aspect of the thigh are more often due to annular
Increase with cough and sneeze. Lumboradicular bulging or pathologic conditions of the facet joint than
pain tends to exacerbate on coughing and sneezing. a herniated disc. It is thus likely that these symptoms
However, this is not a frequent phenomenon, since it may be caused either by direct involvement of the sen-
usually occurs in patients with an acute syndrome, par- sory fibers in the nerve root, or by antidromic impulses
ticularly in the presence of severe nerve-root compres- originating from the branches of the sinuvertebral
sion. Exacerbation of pain is due to an increase in CSF nerve which supplies the annulus fibrosus and the facet
pressure. This leads to: distension of the nerve-root joint.
sleeve, which is thus more severely compressed by the
herniation; and stretching of the meninges, which is
transmitted to the nerve root in the extrathecal course Motor deficits
and possibly results in an increase in compression by
the herniation. A herniated disc often causes muscle weakness in the
lower limb, but in most cases it is so mild, that the
patient is not aware of it. Only severe weakness pro-
Sensory disturbances duces a disability of which the patient is easily aware.
Also in these cases, the patient's attention is concentrat-
These may be represented by paresthesias in the form ed mainly on the pain, to which the disability caused by
of tingling, pins and needles, or by numbness. Often, muscle weakness is often attributed.
however, it is not easy to determine whether the patient The two most common motor deficits spontaneously
complaints should be interpreted as paresthesias, pain reported by the patient are that of the quadriceps due to
or numbness. disorder of L4 nerve-root function and those of the
Numbness in a region of the lower limb is fairly tibialis anterior and the peronei, when the L5 root is
frequent in patients with disc herniation. Quite often, involved. The patient reports, in the former case, that
however, the pain is so severe that the patient is almost the knee gives way or that he / she has difficulty in
not aware of the sensory disturbance. The latter may be climbing up or down stairs and, in the second, episodes
located in the same area as the pain or, more often, in a similar to ankle sprains or uncertainty in walking. More
different area, however, usually comprised in the same rarely the patient is aware of a severe impairment of the
dermatome. For instance, a patient with 51 nerve-root calf muscles causing difficulty in walking or climbing
compression may feel pain down the posterior aspect the stairs.
of the thigh and leg and numbness on the outer border A severe motor loss usually becomes apparent at the
of the foot. onset of the radicular pain and does not increase in
There is no close correlation between the presence of severity with time. Alternatively, it may initially be
numbness and the severity of nerve-root compression; absent or mild and then become suddenly severe in the
nonetheless, the latter is often severe in patients with course of the disease. A further possibility is that mus-
marked numbness. Similarly, it is unusual to find any cle weakness progressively worsens over time. This
direct relationship between the degree of motor loss occurrence is very unusual, if not exceptional. A severe
and the severity of numbness. Often, in fact, the patient motor deficit, in fact, is due to a sudden, marked com-
with a marked motor deficit reports numbness, which, pression of the nerve root, mostly caused by a disc frag-
however, is considerably less severe than muscle weak- ment that has migrated into the spinal canal either at
ness. Occasionally, the subjective symptoms are repre- the onset of the clinical syndrome, or suddenly in the
sented mainly by sensory disturbances, even in the course of the latter. When this occurs, the nerve-root
presence of clinical signs of mild nerve-root compres- impairment remains stable or tends to regress, rather
sion. Unlike pain, sensory loss is hardly affected by than to increase in severity.
posture or walking. Usually, patients with a severe motor loss are able to
The outer aspect of the thigh is often the site of numb- report, even only approximately, how long the weak-
ness or paresthesias. In this area, the patient may feel ness has been present. At times, it is not possible to
numbness, which becomes painful due to contact with determine the duration of muscle weakness, particular-
clothes, or a sensation of burning. These symptoms, ly when pain or motor loss are long-standing. This
which often exacerbate in the prolonged standing information, on the other hand, is important, since the
position, may be present in patients with irritation or possibility that weakness regresses is related, although
compression of various roots - from L2 to L5 - since the not strictly, to its duration.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - o C l i n i c a l features 0179
Cramps and fasciculations radicular symptoms absent at rest. The latter, consisting
in pain, paresthesias and I or disesthesias, progressive-
Cramps ly increase in severity until the patient is forced, in
many cases, to stop or sit down. With rest, the symp-
These are fairly frequent in patients submitted to toms improve or disappear, thus allowing walking to
surgery, who often complain of cramps during the first be resumed. Waking ability ranges from a few to sever-
few months or years after the operation. In non-operat- al hundred meters.
ed patients, cramps are usually reported when nerve- Intermittent claudication is typical of lumbar steno-
root compression is of long duration. In both instances, sis. It is rare in patients with disc herniation and occurs
the cramps probably result from intra- and perineural mostly in the presence of a midline disc herniation, par-
fibrosis affecting the threshold of excitability of the ticularly of the second to the fourth disc, when it is
nerve-root sensory fibers. responsib Ie for severe compression of the thecal sac and
There is no relationship between the size, site and emerging nerve roots. Claudication, however, is not
type of herniation and the severity of cramps. rare in patients with a herniated disc in a stenotic spinal
Conversely, the vertebral level appears to playa role: canal, in whom this clinical manifestation is probably
the root most frequently involved is the 51, followed by due to stenosis.
L5. The muscles most often affected by cramps are the The rare occurrence of claudication in patients with
triceps surae, hamstrings and plantar muscles. Muscle disc herniation alone might be related to the fact that a
spasm usually occurs at night and lasts a few seconds to herniated disc responsible for marked cauda equina
several minutes. During the daytime, the cramps tend compression is generally present at a single level.
to occur following brusque muscle stretching or con- Claudication, in fact, appears to be more easily caused
traction. Frequency varies considerably; they may by cauda equina compression at two or more adjacent
occur at intervals of weeks or months, or even several levels than by compression at a single level (82). This
times during the course of one night. may be due to the fact that compression at a single level
does not produce, or produces to a lesser extent,
changes in radicular blood circulation - venous stasis
Fasciculations and reduced capillary flow - responsible for the hypoxy
and decreased radicular metabolism, to which claudi-
These would be present, either spontaneously or due to cation is probably due (46, 73, 76).
mechanical stimuli, such as repeated percussions with A similar clinical manifestation to claudication,
the reflex hammer, in more than 50% of patients (33). In however not identifiable with the latter, is the increase
a few cases, however, fasciculations would be so rare in radicular pain on walking. This often occurs in
and of such short duration that the patient is not even patients with disc herniation, when the latter causes
aware of them. In our experience, this clinical manifes- severe nerve-root compression. In these instances, pain
tation is very rare and is only exceptionally sponta- is usually monoradicular and decreases at rest, but does
neously reported by the patient. not disappear. Furthermore, whilst it may be associated
Fasciculation is a typical sign of degenerative with paresthesias if these are present at rest, it is not
diseases of the anterior horn of the cord as well as an associated with tiredness.
expression of abnormal excitability of any portion of
the motor neuron. In lumbar disc herniation, it might
result from mechanical or chemical stimuli exerted by
the herniation on the nerve root. Summation of the Clinical history
stimuli at cord level might trigger off mono- or
plurisegmentary spinal reflexes, which are transmitted Onset
peripherally in the form of clonic muscle contractions
(87). The types of onset, which, in our experience are
encountered with progressively decreasing frequency
can be schematically identified as follows:
Intermittent claudication 1) In a patient who has never complained of low back
discomfort, or has had rare and short episodes of back
Various radicular or cord conditions may be responsi- pain, acute pain appears, which, after a few days or
ble for neurogenic intermittent claudication. The form weeks, becomes associated with radicular pain of vary-
caused by involvement of the cauda equina can be ing severity.
referred to as lumboradicular intermittent claudication 2) The patient reports having suffered, a few months
(83). It is characterized by the onset, upon walking, of before, from an episode of low back pain associated,
180.Chapter 8.-------------------------------------------------------
or not, with mild radicular pain of short duration. after a variable interval of time. There are no element by
Subsequently, occasional episodes of back pain occur- which to predict the evolution of the clinical syndrome.
red, intercalated with asymptomatic intervals. In the Nevertheless, patients who initially have moderate
last episode, which was of gradual or sudden onset, per- symptoms, mild muscle weakness, and a contained
sistent radicular pain became associated with back pain. small herniation tend to present regression of symp-
3) The clinical syndrome begins with radicular pain, toms. According to Nachemson (65), more than half of
associated with no or mild low back pain, which sub- the patients with acute sciatica are considerably
sides after a few hours or days. The radicular pain may improved or asymptomatic 2 months after onset.
be either very mild or exceedingly severe already at the Conversely, in patients both with severe pain and motor
onset of symptoms. deficit, the symptoms tend to persist for the first few
4) The clinical history is characterized by continuous months after onset, particularly in the presence of a large
or recurrent low back pain of long duration. In this extruded or migrated herniation. In our experience,
context, leg pain, usually associated with back pain of after 2 months of onset, the chances of complete resolu-
varying intensity, appears gradually or suddenly. tion of the symptoms progressively decrease with time.
5) The patient reports only acute low back pain of Another, less frequent, modality of evolution is
recent onset or a history of recurrent acute episodes of characterized by the little variability in the initial symp-
back pain. toms. These may present changes from one day to the
6) The patient, following a sudden low back and / or next, but remain essentially unchanged in quality and
radicular pain of short duration, found difficulty in severity, at least for the first 6-12 weeks. This modality
walking, due to weakness of muscles in the lower limb of evolution is independent of the severity of the initial
(paralyzing sciatica). Muscle weakness may be associ- symptoms and is, perhaps, more frequent in patients
ated with an area of numbness in the limb. Alterna- with moderate symptoms, gradual in onset.
tively, only numbness is present. The third modality is characterized by progressive
7) In the course of a few hours, days or weeks, a worsening both of pain and motor loss. This may often
cauda equina syndrome appears, associated, or not, occur during the first few days, but very rarely 3 weeks
with low back pain. or more after the onset of symptoms. In other words,
Numerous authors (3, 4, 58, 75, 104) have analyzed patients with muscle weakness will only rarely show a
the frequency with which low back, or radicular, pain progressive increase in the severity of weakness after
appears as the first symptom of the disease. The first the first few weeks of onset, in the absence of physical
symptom was found to be low back pain in some two strain or trauma. By contrast, motor loss often tends to
thirds of cases, radicular pain in some one fourth and regress, even if not completely, 2-4 weeks after presen-
both symptoms in some one tenth. These, however, are tation. This holds for moderate or marked weakness,
only very rough estimations, because they stem from however not for paresis or paralysis.
retrospective analyses or because of the frequent dif-
ficulty in establishing whether the onset of the clinical
syndrome coincides with the first episode of low back Physical examination
pain or whether only the last episode, usually associat-
ed with sciatica, should be considered. Spine
Physical examination may detect modifications in
Evolution posture, postural scoliosis, decreased spinal motion
and pain upon pressure and percussion on the lumbar
Analysis of the evolution of lumboradicular symptoms spine. The clinical patterns, however, vary to such an
coincides, to a large extent, with analysis of the natural extent that none can be considered pathognomonic.
history of the disease. In this chapter, we analyze only The two extremes are represented, one, by the patient
the evolution during the first few weeks after onset. with no abnormal objective findings and, the other, by
In most cases, particularly those with a sudden onset the patient with clear positivity of all the clinical signs
of symptoms, pain progressively exacerbates or typical of disc herniation. These two conditions do
remains stable for the first few days after onset and then not, however, represent the most frequent occurrence,
tends to decrease. This occurs in a variable interval of namely moderate positivity of only some of the typical
time, the duration of which may be affected by conser- clinical signs of disc herniation. Nonetheless, it should
vative treatments. This interval is usually 2 to 6 weeks. be stressed that none of these signs is pathognomonic of
Thereafter, lumboradicular symptoms may regress a herniated disc, which is usually diagnosed clinically
completely or almost, may remain constant over time only on the basis of the signs and symptoms involving
at moderate levels of severity, or may exacerbate again the lower limbs.
_____________________________ 0 Clinical features 181 0
Fig. 8.13. When the herniation is located medially to the emerging nerve
Fig. 8.11. A patient with an L4-L5 herniated disc showing homologous root, the concavity of scoliosis would be on the same side as the hernia-
sciatic scoliosis. tion.
182.Chapter 8.----------------------------------------------------------
responsible for postural scoliosis is the fourth lumbar ogous rather than heterologous. This depends on the
(18). topographic relationships of the herniation with the
According to the classic pathogenetic interpretation nervous structures, and these relationships are so vari-
(4,33,53,77,89), scoliosis is heterologous in herniations able that they cannot easily be schematized on the basis
situated laterally to the nerve root (Fig. 8.12) and not only of the imaging studies, but also of the surgical
homologous in those located medially to the root (Fig. findings, since these refer to a posture which is different
8.13); in midline herniations, scoliosis would be alter- from the standing position.
nating. The list would represent an attempt to ease In our opinion, trunk list, although possibly related
away the nerve root from the herniation in order to to limb dominance or some other unknown factors,
reduce the compressive effects of the latter. This inter- essentially represents an attempt to decrease the com-
pretation is not in keeping with the findings of Porter pression of the neural structures by the herniation. The
and Miller (80) who, in 20 patients with postural scolio- true situation, in any case, is likely to be much less
sis, found twice as many patients listing to the left as to schematic than hypothesized by the classic theory.
the right and no relationship with the side of herniation
or the topographic position of the latter with respect to
the nerve root. Only left-handed patients listed to the Mobility of lumbar spine
right; the majority of patients who were most comfort-
able crossing their left leg over the right listed equally Flexion of the lumbar spine is usually limited, to a vary-
to the left and right, whilst those who crossed the right ing extent. Patients with mild low back and radicular
leg over the left tended to list to the left. These authors, pain may show an almost normal spinal mobility,
thus, hypothesize that the side of the list may be related whereas those complaining of severe symptoms may
to hand or leg dominance, rather than to the topo- present an extremely limited range of active motion
graphic position of the herniation. These findings, (Fig. 8.14 A). The limitation of movements is due only
however, refer to a small series of patients who, preop- to back pain or, more often, to an increase also, or only,
eratively, underwent myelography, rather than CT or in radicular pain. To reduce nerve-root tension, the
MRI, which are better able to demonstrate the position patient typically tends to flex the hip and knee on the
of the herniation. Furthermore, it should not be forgot- symptomatic side: this is an extremely reliable sign of
ten that even in the presence, for instance, of a herniat- nerve-root compression. In a few patients, a list occurs
ed disc located laterally to the emerging nerve root, the from the beginning of trunk flexion. This has the same
latter may be less involved when the scoliosis is homol- significance as postural scoliosis. The degree of spine
The examiner takes the heel with one hand, while exert- The degree of limitation of SLR varies when the test is
ing, with the other, a slight pressure on the knee to performed by different examiners (interobserver vari-
avoid it bending when raising the limb. Normally, the ability), but the differences are generally slight (> = 10°)
limb can be raised through at least 60° without causing (51). The degree of limitation may also vary when the
the patient any discomfort. Patients with radicular pain maneuver is performed by the same examiner (intra-
experience a progressive increase in discomfort, upon observer variability) after intervals of a few hours,
limb raising, to which they begin to resist as soon as however also in this case the differences are mostly
pain becomes severe. Resistance is effected initially by slight (> = 10°) (68, 81).
contracting the hamstrings and then by raising the
homologous hemipelvis from the bed. The angle Pathogenetic mechanism. Radicular pain in straight
reached before the patient begins to offer resistance leg raising, as in the Lasegue's maneuver, results from
represents the extreme value of the maneuver. stretching of the nerve root compressed by herniation.
Positivity of the latter may be expressed by the degrees In several studies on cadavers, the motion of the lum-
corresponding to the extreme value or by +. In this bosacral roots was examined upon SLR (12, 26, 35, 40).
instance, + may be used for an angle of 60°-90°, ++ for Smith et aJ. (93) observed that both the nerve root (or
an angle of 30°-59° and +++ for a smaller angle.
In asymptomatic subjects, the degree of SLR ranges
between 50° and 120°, depending on various factors,
such as patient's age, constitutional muscle elasticity
and level of physical activity. Considering the variabil-
ity of these parameters, clinical evaluation is generally
made in relation to the opposite side. Troup (97) consid-
ered a difference of at least 15° between the two sides as
abnormal, whereas Blower (6) considered a difference
of 30° or more as pathologic. In effect, it is neither nor
necessary to establish precise values of normality, since
what, indeed, characterizes the pathologic SLRT is the
presence of pain, as opposed to the muscle stretching
felt by the asymptomatic subject.
Numerous studies have evaluated the sensitivity of
SLRT in patients with disc herniation: the values range
from 80% (19) to 99% (72). Specificity, however, does
not exceed 40% (19). In a prospective study, an almost
linear relationship was found between the degree of Fig. 8.17. On raising the lower limb with the knee extended, the lum-
positivity of SLRT and pain at rest, pain at night or bosacral nerve roots lengthen and move towards the pedicle. The new
upon coughing, and decrease in the ability to walk (44). position is indicated, on the drawing, by the dotted root.
-------------------------------------------------------oClinicalfeatureSo185
radicular nerve) and the dura mater undergo transla- conditions, than in subjects of more advanced age. This
tion and lengthening movements. Between 0° and 30°, holds particularly for teenagers, in whom the leg may
motion is very limited; between 30° and 60° the root often be raised, in the presence of disc herniation, by
moves in the vertical direction; and between 60° and only few degrees. Conversely, in elderly patients the
90° the displacement occurs perpendicularly to the maneuver tends to be less positive. These differences in
direction of the root, i.e., towards the pedicle (Fig. 8.17). the SLR, which often parallel the limitations of trunk
The average mobility is about 2 mm and the average bending, seem to be related to the degree of muscle
lengthening is 3%. The dura mater is less displaced, but spasm that the subject is able to develop in response to
is lengthened more than the root. stimulation of the dural nociceptors or the nociceptive
When a nerve root is deviated and compressed by a fibers of the nerve root. The different behavior in rela-
herniated disc, even mild displacement and I or length- tion to age might also result from different intensity of
ening of the root may stimulate the nociceptors of the the inflammatory process stimulated by herniation in
dural sheath (or the nociceptive fibers in the nerve the radicular and periradicular tissues.
root), thus leading to increased radicular pain. The
more inflamed the root, the more likely this will occur Posture-related changes. Positivity of the SLRT may
(88). This interpretation may explain why the more decrease by 10° or more after a few hours in a standing
acute the pain, the more positive the maneuver, regard- position and increases again after recumbency (81). The
less of the severity of nerve-root compression, and why increase probably results from increased hydration of
in a few conditions, such as lumbar stenosis, character- the disc when the spine is unloaded. This may cause an
ized by chronic nerve-root compression with no signif- increase in bulge of the outer annulus fibrosus, if this is
icant inflammatory processes, the maneuver is usually intact. The opposite occurs when the patient stands
negative or weakly positive. upright. This interpretation may explain why posture-
The greater positivity of the maneuver in postero- related changes of the SLRT are usually observed in
lateral herniations is due to the site of herniation, patients with a contained herniation, whilst they do not
which when is lateral directly compresses the root, occur, or are mild, in the presence of an extruded or
and to the fact that the root displaces both vertically migrated herniation. The posture-related changes are
and transversely, and thus tends to move towards the more marked for the L4-L5, than the L5-S1, disc. This is
lateral portion of the disc. probably related to a lower concentration of proteogly-
cans and hydration in the lowermost lumbar disc (98).
Muscle elasticity-related changes. In the presence of SLRT performed in the standing position (standing
little elasticity of the hamstrings, not only may it be SLRT) is generally less positive than in the supine posi-
impossible to raise the limb with the knee extended tion. This might be due to the less marked compression
beyond 60°-70°, but the patient may feel pain at even of the nerve root in the standing position.
lower degrees. Usually, radicular pain can be easily
differentiated from the discomfort caused by muscle Crossed-leg SLRT. Raising of the asymptomatic leg
stretching. The latter, in fact, differs from true pain and may cause pain on the symptomatic side. This clinical
is felt only in the thigh or behind the knee. When doubts maneuver, first described by Fajersztajn (25), generally
persist, the maneuver is performed on the asympto- elicits pain on the buttock and I or the posterior aspect
matic side and the resistance encountered on raising of the thigh and only rarely along the whole limb.
the leg, as well as the discomfort elicited on the two The patients who most frequently present a positive
sides, are compared. This may be done by watching the crossed-leg SLRT are those with a paramedian hernia-
patient's face while carrying out the maneuver or ask- tion. In these cases, stretching of the contralateral nerve
ing him/her whether the sensation is different on the roots involves traction on the thecal sac and, through
two sides. this, the compressed nerve root. The latter tends to dis-
The opposite may occur in patients with high tissue place towards the midline, and is thus compressed by
elasticity, in whom the leg may be raised through a herniation. However, contralateral pain in lifting the
wide angle without eliciting any pain, even in the pres- asymptomatic leg may also be observed in patients
ence of marked nerve-root compression. Furthermore, with midline or posterolateral herniation (23). The
in these patients the symptomatic leg may be raised, mechanism of production of pain, also in these cases, is
without effort, well beyond 90°. The subjects with the likely to be similar to that previously described.
greatest ability to raise the limb with the knee extended The sensitivity of crossed-leg SLRT is only 25% -44%
are most often women (5, 63). (19, 23), but specificity is as high as 90% (19). This
maneuver is extremely reliable for diagnosis not only of
Age-related changes. In young subjects the SLRT tends disc herniation, but particularly of herniation responsi-
to be more positive, under comparable pathologic ble for marked nerve-root compression. Most patients
186.Chapter 8.------------------------------------------------------
which pain begins, the asymptomatic limb is lowered,
the patient feels radiating pain along the symptomatic
limb. This might be due to sudden caudal stretching of
the symptomatic nerve root due to upward movement
of the thecal sac induced by lowering the healthy limb.
KFT is positive in some 15% of patients with disc sciatic pain is unknown. Knee flexion is likely to stretch
herniation at the two lower lumbar levels. However, not only the high lumbar nerve roots, but also the
its predictive value as far as concerns the presence of a lumbosacral roots; even a slight movement of the latter,
herniated disc is extremely high: 94% in a series of in the presence of severe nerve-root compression,
patients evaluated by the authors. Furthermore, the might cause radiated pain. Another possibility is that
majority of patients presenting a positive test display stretching of the lumbar plexus is transmitted to the
severe nerve-root compression resulting from a large sacral plexus through anastomotic branches between
contained, or an extruded or migrated, herniation. the two plexuses: this may occur when anastomoses are
The mechanism by which this maneuver provokes abnormally numerous or the L5 nerve root runs in the
Fig. 8.21. Femoral nerve stretch test. The maneuver can be carried out
with the patient in the prone position by bending the knee beyond 90 0
(Wassermann's maneuver) (A), performing knee flexion and
simultaneous hip extension (B), or extending the hip with the knee
c extended (C).
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - o C I i n i c a l featureso189
Fig. 8.22. The patient flexes the knee and hip on the
symptomatic side to reduce nerve-root tension when
he is invited to bend the trunk whilst in the sitting
position.
extension with the forefinger (Fig. 8.26A); the maneu- phalangeal joint of the big toe in an oblique direction
ver may be performed on one side at a time or simulta- with respect to the big toe itself, in order to develop
neously on both sides. With this technique, one easily more force (Fig. 8.26B). Both big toes should be tested
detects a marked weakness, but false findings, either while standing on the same side with respect to the
positive or negative, are often obtained. False positives patient. The greater efficacy of this technique is due to
(strength assessed as decreased when it is, in fact, nor- the fact that the simultaneous maximal contraction of
mal), because the patient is unable to develop the entire the tibialis anterior enhances the contractile ability,
strength of which he / she is capable or because the and thus the strength, of the EHL, probably due to a
examiner places his/her finger on the second phalanx, mechanism of synergic reinforcement of the muscle
which may often be pushed down even in the absence contractile power. Furthermore, with this technique,
of any weakness of the EHL. False negatives (strength the examiner is able to develop a greater force than with
assessed as normal when it is, in fact, reduced), when the previously described method and to more easily
the force exerted with the forefinger is lower than that use the index and middle fingers together. It is, therfore,
of the EHL; this may easily occur if the finger is placed possible to detect an even very mild weakness of the
too close to the metatarso-phalangeal joint. EHL, whilst, not rarely, an EHL assessed as weak with
The correct technique to test the strength of the EHL the current technique may be found to be normal.
is to stand on the patient's right side, to resist foot
dorsiflexion with the dorsum of the right hand and
resist the extension of the big toe with the middle finger Tibialis anterior
(which is stronger than the forefinger), or the index and
middle fingers together, of the left hand. The examin- In many charts depicting the radicular innervation of
er's finger(s) should be placed at the level of the inter- the muscles of the lower limb, the tibialis anterior (TA)
A B
c D
Fig. 8.27. Various methods of testingthe strength of the tibialis anterior: with the patient in the prone position and the knee extended (A); by inviting
the patient to raise the soles of the feet from floor (B); with the patient in the supine position and the knee flexed (C) or in the sitting position (D). The
latter two methods are more sensitive.
194.Chapter 8.------------------------------------------------------
Numerous textbooks report that the power of the roots, but predominantly by the latter. Weakness of
triceps surae may be tested by resisting plantar flexion the quadriceps is, therefore, found essentially in the
of the patient's foot with the hand (4, 34, 54, 56) presence of functional impairment of the L4 nerve
(Fig. 8.29 A). This maneuver, however, will reveal weak- root. A severe deficit of the L3 root may cause moderate
ness of the triceps surae only if it is extremely severe. or mild weakness of the quadriceps, whilst involve-
The triceps, in fact, is able to develop a considerable ment of the L2 root does not usually lead to muscle
strength, which, even if reduced, easily overcomes the weakness. However, even when the L4 root is
resistance opposed by the examiner's hand. involved, impairment has to be severe in order for
The strength of the triceps surae should be tested by weakness of the quadriceps to be detected clinically.
asking the patient to raise on tiptoe on the symptomatic This muscle, in fact, is so large and, thus, powerful, to
side three or four times (Fig. 8.29 B). The maneuver is make it difficult for the examiner to overcome muscle
positive when the patient is unable to rise on tiptoe as strength when the innervation is preserved to a large
high as on the asymptomatic side or is unable to raise extent.
the heel off the ground. The latter indicates a severe Evaluation of the strength of the quadriceps may be
deficit of the 51 nerve root. An alternative method is to performed with the patient in the supine, sitting or
ask the patient to walk on tiptoes. This method, howev- prone position. The best is the prone position (Fig. 8.30),
er, is less sensitive than the former and leads to less pre- since it is easier for the examiner to resist the strength of
cise evaluation of the severity of muscle weakness. the quadriceps; in fact, the more the knee is flexed, the
The ability to rise on tiptoe should be evaluated only less the strength exerted by the muscle.
when the ankle jerk is absent. It is useless to carry out
the maneuver if the reflex is only reduced, since, in this
instance, muscle strength is never reduced to the extent Adductor muscles
that the test is positive. However, the test should be
performed in patients with 51 radicular syndrome who The adductor muscles, which are predominantly inner-
show an absence of the ankle jerk on both sides. vated by the L3 nerve root, may be weak in the presence
Bilateral absence of the reflex, in fact, since it may be of marked compression of this root. These muscles are
physiologic or pathologic, does not allow us to deter- also innervated, in part, by the L2 and L4 nerve roots
mine whether the 51 root is impaired. and may, thus, be slightly weak when these roots are
impaired.
The strength of the adductor muscles is tested with
Quadriceps the patient supine and hips and knees flexed, feet
together, and limb externally rotated by about 40°. The
The quadriceps is innervated by L2, L3 and L4 nerve examiner resists the simultaneous adduction of the
196.Chapter 8.----------------------------------------------------
Glutei Fig. 8.32. Maneuver to test the strength of the leg flexor muscles.
reflex hammer and the less the decrease in reflex, the considered as normal, since a knee jerk which is patho-
less this strength should be. When the reflex is slightly logically depressed will be the same in both positions. If
depressed, in fact, a hard strike on the tendon may pro- the knee jerk cannot be elicited on both sides in the
duce a normal response, whilst a slight tap may easily supine position, it should be tested in the sitting posi-
reveal the depression. Occasionally, it may be conve- tion with or without Jendrassik' s maneuver.
nient to use the middle finger, or this and the ring finger
together, to give the tendon slight taps which will better
detect a mild decrease in reflex activity. Ankle
B o
Fig. 8.34. Ankle jerk elicited with the patient in the supine (A), prone (B), sitting (C) and kneeling (D) position.
whilst it was, respectively, slightly depressed, marked- should first be tested in the supine position. If the reflex
ly depressed or absent in the prone position; in other appears to be normal or slightly depressed, or it is
cases, it was uncertain whether the reflex was normal or uncertain whether it is normal or decreased, examina-
reduced in the three positions, whereas it was clearly tion should be repeated in the prone position, in which
depressed in the prone position. After the latter, the the reflex may easily be found to be depressed or more
sitting position was that in which the reflex was more severely depressed. If, in the latter position, it still
often found to be depressed or absent. The most feasi- appears normal or there is some uncertainty, it may be
ble explanation for the decreased activity of the ankle useful to test also in the sitting position.
jerk in the prone position is that the normal reflex
activity is slightly reduced in this position and, thus, a
pathologic depression may become more marked. Yet Minor reflexes
another possibility is that the prone position, which
allows full relaxation of the triceps surae, permits better Adductor
assessment of even slight differences in the reflex
activity on the two sides. This is likely to be the only This reflex is elicited by striking the adductor magnus
reason for the changes in reflex activity in the sitting muscle at the level of the adductor tubercle with the
position compared with the other positions. patient in the supine position, the hip externally rotated
In patients with 51 radicular syndrome, the ankle jerk and the knee flexed (Fig. 8.35). It may be reduced or
200.Chapter 8.----------------------------------------------------------
absent due to impairment of the L3 nerve root. This nerve-root dysfunction. The examiner can test them by
reflex, however, is of relatively little diagnostic value placing the patient's foot in plantar flexion and slight
since in many subjects it is physiologically weak, and supination, and striking his/her index finger applied
moreover because the L2 and L4 roots, which also sup- on: 1) the distal end of the first phalanx of the big toe,
ply the adductor muscles, may preserve reflex activity pushed in slight plantar flexion (extensor reflex); 2) the
in the presence of L3 nerve-root impairment. tendon of the extensor hallucis longus (identified by
asking the patient to dorsiflex the big toe against resis-
tance) proximally to the ankle; 3) the extensor hallucis
Midplantar brevis on the dorsum of the foot.
Superficial sensitivity The form most often affected in patients with lumbar
disc herniation is vibratory sensation, which is tested
In most patients with lumbar disc herniation, testing by placing a vibrating diapason on bony surfaces. The
of cutaneous sensitivity is, in a certain way, of sec- areas to examine are the lateral malleolus and the fifth
ondary importance in physical examination for several metatarsus (Sl), the medial malleolus and the first
reasons: 1) Sensory loss can be detected in a minority metatarsus (L5), and the patella and femoral condyles
of patients and these usually present motor loss or (L4). Changes in vibrating sensitivity, however, are
reflex changes, which, in themselves, allow diagnosis found in a minority of patients with disc herniation.
of nerve root compression, and often also of the level of Thus, the examination is of little use in the diagnosis
compression. 2) Sensory examination represents the either of nerve-root compression, or the level of com-
most subjective part of the physical examination, pression.
which, on the other hand, is seeking data as indepen- In the presence of severe superficial sensory loss,
dent as possible from the patient's will. As such, the there may be an impairment in deep tactile or pain
sensory examination may provide findings of uncer- sensitivity.
tain interpretation, particularly when sensory impair-
ment is mild. 3) The dermatomes of the lower limb
show a certain degree of overlapping and there may be Neurovegetative disorders
anatomic variations in dermatomal topography within
the population. This implies that sensory loss resulting Dysfunction of the fibers of the neurovegetative system
from impairment of nerve-root function may not be contained in the posterior roots manifest with circulato-
clinically manifest due to the functional integrity of ry distrurbances, which may be responsible for cuta-
adjacent roots or the sensory deficit is comparatively neous hypothermia and edema in the lower limb.
less than the nerve-root impairment, and that sensory Hypothermia, which subjectively results in a sensation
examination is not entirely reliable for identification of of coldness in the dermatome involved, usually affects
the level of the herniation. the leg and foot. It is usually found in the presence of
Sensory examination is, instead, of paramount severe deficit of the L5 or Sl roots.
importance in two situations: in the presence of severe Edema in the lower limb is a rare, but not exception-
motor and sensory loss, which may fail to recover al, finding in patients with disc herniation. It is usually
with treatment and should, thus, be accurately docu- located in the foot and ankle and, less frequently, in the
mented prior to management; and in the presence of a leg. A role is played, in its etiology, not only by impair-
cauda equina syndrome, in which there may be severe ment of the neurovegetative system, but also by muscle
sensory loss, particularly in the perineum and genitals, deficit, due to the reduced pump action exerted by the
in the absence of, or with mild, motor loss in the lower venous system on hypotonic muscles. This may explain
limbs. why edema is usually found in patients with severe
Of the three forms of cutaneous sensation - tactile, motor loss.
painful and thermic - those commonly tested are the
former two, particularly the second, since they are more
sensitive and easier to examine. The cutaneous areas in Clinical syndromes
which the innervation depends prevalently or exclu-
sively upon a single nerve root are the outer border of Lumbar disc herniation may be responsible for pure
the dorsum of the foot and the fifth toe (Sl), the big toe low back pain, neuroalgic or neurocompressive
and the adjacent portion of the dorsum of the foot (L5), syndromes, or cauda equina syndrome. These clinical
and the anteromedial aspect of the leg (L4). We may syndromes correspond, although not strictly, to pro-
202.Chapter 8.--------------------------------------------------------__
gressively more severe degrees of compression of the N eurocompressive syndrome
nervous structures. In a single patient, clinical sympto-
matology may start with any of these syndromes and This syndrome is characterized by very mild to
may remain unchanged over time, or signs and symp- extremely severe impairment of nerve-root function. A
toms indicating a progressive increase in nerve-root few authors (33,56) identify two syndromes, character-
involvement may appear. ized by partial nerve-root deficit or root paralysis,
respectively. In our opinion, this distinction is unneces-
sary, since the two syndromes represent different
Pure low back pain syndrome grades of the same clinical condition and, on the other
hand, it is exceedingly rare for a herniated disc to cause
In most patients, the clinical onset of lumbar disc herni- complete loss of nerve-root function.
ation manifests with low back pain, to which, with One or more caudal nerve roots may be impaired.
time, radicular symptoms become associated. In some Usually, in the latter instance, two contiguous nerve
cases, however, low back pain with the features of roots on the same side are affected. In most of these
discogenic pain remains the only symptom. cases, the functional deficit of one root is severe,
No clinical feature is able to identify, among patients whilst that of the other is mild or moderate. This is
with pure low back pain, those with a herniated disc. almost the rule when nerve roots on both sides are
Suspicious elements are the marked severity of pain, its involved.
long duration (more than 3 weeks), persistent postural All components of the nerve root - motor, sensory
scoliosis and the patient's report of pain radiating to the and sympathetic - or only one or two components may
buttock. be affected. Impairment of the motor component leads
to a decrease or loss in reflex activity and reduced
strength of only a few, or all muscles, supplied by the
root. In the presence of marked compression of long
N euroalgic syndrome duration, wasting of muscles innervated by the root
may be present.
This syndrome corresponds to that known as nerve- In patients with a compressive syndrome, there is a
root irritation syndrome (56, 60). It is characterized by tendency for the greater the nerve-root compression,
radicular pain, and often paresthesias, in the absence of the more marked the motor and sensory deficit. This,
clinical evidence of an impairment of nerve-root func- however, is not the rule. Even very large herniations
tion. In patients with disc herniation, the main cause of may produce a less severe deficit than that caused by a
radicular pain is likely to be nerve-root compression by small disc fragment migrated into the spinal canal.
the herniated disc. The neuroalgic syndrome, there- Similarly, there is no direct relationship between
fore, should also be considered as a root compression intensity of radicular pain and severity of nerve-root
syndrome, even if the severity is so mild that it does not compression.
determine any neurologic deficit. Distinction of the When the impairment of nerve-root function
two types of syndrome, however, is useful from a prac- becomes very severe, radiated pain may decrease and
tical point of view, since the neuroalgic syndrome is even disappear due to functional interruption of the
mostly caused by a small contained disc herniation, fibers of pain sensitivity. At the same time, sensory
whilst the neurocompressive syndrome often corre- deficit increases, whilst the nerve-root tension tests
sponds to more marked invasion of the spinal canal by tend to become negative.
the herniation and more severe nerve-root compres-
sion. Furthermore, the former condition has a marked
tendency to resolve spontaneously, whereas the latter is Grades of nerve-root compression
generally characterized by more severe symptoms and
shows less tendency to spontaneous regression. Based on clinical features, four grades of nerve-root
In patients with a neuroalgic syndrome, radicular compression, corresponding to increasing degrees of
pain often radiates to the cranial portion of the root impairment, may be identified.
dermatome supplied by the involved nerve root: Grade I. If the root innervates a reflex, this is
Furthermore, pain may decrease or disappear on decreased but not abolished. When the root supplies
walking, unlike in patients with marked nerve-root both small and medium-size or large muscles (for
compression. Only occasionally do patients report instance, EHL, tibialis anterior and triceps surae,
numbness, and paresthesias, when present, are often respectively), the former show mild weakness, whilst
mild and discontinuous. Nerve-root tension tets are the latter displays normal strength. There may be
usually slightly or moderately positive. sensory loss, but only in narrow, distal areas of the
dermatome. The severity of radicular pain varies con- consists in difficulty in initiating or maintaining an erec-
siderably. tion, or impotence. In the female, it is essentially related
Grade II. When the nerve root produces a reflex, to sensory loss in the labbra and vagina, which may
this is abolished. The strength of small muscles is present paresis or paralysis of the constrictor muscles.
moderately decreased, whilst that of medium-size or Tandon and Sankaran (94) have identified three
large muscles is slightly decreased or normal. Numbne- groups of patients with cauda equina syndrome:
ss may be more marked than in Grade I, but still located Group I, those with a sudden onset of the syndrome in
in a narrow area. Radicular pain is generally severe. the absence of previous lumboradicular symtoms;
Grade III. Even large-size muscles show moderate or Group II, patients with recurrent episodes of lumbo-
marked weakness. Numbness may be present in a large radicular pain and sudden appearance of the syn-
area of the involved dermatome. The patient may com- drome during the last episode; Group III, patients with
plain of a sensation of cold, and skin temperature may a slow and progressive manifestation of the syndrome.
be slightly decreased, in the distal portions of the Kostuik et al. (52) have identified only two groups, one
dermatome. of which includes patients with an acute syndrome
Grade IV. This corresponds to a very severe impair- and, the other, those with a slow onset, over a few days
ment of root function or root paralysis. There is severe or weeks. The latter represented two thirds of the 31
to complete loss of strength of all muscles supplied by reported cases. Almost half the patients had been treat-
the root and marked hypoesthesia or anesthesia in a ed in a same hospital and represented 2.5% of patients
large area of the dermatome involved. Skin tempera- with disc herniation operated in that hospital in the
ture is decreased. When the L5 or Sl nerve roots are period under consideration. In the vast majority of
affected, there may be edema in the foot and ankle. cases, herniation was located at L4-L5 or L5-S1 level.
Radicular pain is mild or absent. One fourth of patients showed a large contained herni-
ated disc, whilst the others presented migrated hernia-
tion. All patients presented with urinary retention
Cauda equina syndrome and one third also had sexual dysfunction. Just over
half the patients complained of unilateral radicular
According to the classic description, this syndrome is pain; a similar proportion presented saddle sensory
characterized by multiple nerve-root compression loss, consistently associated with a decrease in anal
responsible for pain, bilateral motor and sensory loss in sphincter tone.
the lower limbs, saddle anesthesia and bladder and
bowel dysfunction, to which sexual dysfunction may
be associated (16, 43). This condition with massive pare-
sis or paralysis of the caudal nerve roots, including S3, Clinical features in adolescents
S4 and S5, which supply the bladder, rectum and geni-
tal organs, is, in effect, exceedingly rare. A more widely Adolescents usually complain of mild or moderate
accepted definition considers as cauda equina syn- low back pain, whereas radicular pain is mostly severe,
drome any condition characterized by signs and symp- even if often limited to the buttock or thigh. Severe
toms of compression of one or more roots innervating paraspinal muscle spasm is present, which may be
the lower extremities and by bladder dysfunction responsible for such a degree of spinal rigidity as to
(52, 62). Therefore, disorders in micturition are the nec- allow the patient to bend forwards only a few degrees
essary and sufficient condition for a lumboradicular (Fig. 8.36 A). In the upright position, there may be
syndrome to be considered a cauda equina syndrome. postural scoliosis, however this is rarely marked. The
Thus defined, this condition is rare, however not SLR is often limited to 20°-30° (Fig. 8.36 B) and, in most
exceptional. cases, the limb can hardly even be raised beyond 40°
Cauda equina syndrome may occasionally manifest without the patient raising the hemipelvis. In many
only with bladder dysfunction (22). In the most com- patients, no muscle weakness or depression of the
mon form, the syndrome is characterized by unilateral reflex activity is found, even in the presence of consid-
or bilateral radicular pain, severe motor and! or sensory erable nerve-root tension (9, 11, 41, 55, 59).
deficit of one or more nerve roots (excluding the S3-S5 In most adolescents with lumboradicular symptoms,
roots), saddle hypoesthesia or anesthesia and bladder the clinical picture is so typical as to allow diagnosis of
dysfunction, usually represented by urinary retention. disc herniation, or at least of nerve-root compression, on
Disturbance of bowel function, which is less common the basis of two features: the marked limitation of trunk
than bladder dysfunction, consists in constipation due flexion and positivity of the SLRT. However, it is often
to paresis or paralysis of the rectal smooth muscles. impossible to determine the level of herniation from the
Sexual dysfunction is fairly frequent. In the male, it clinical data either because pain is absent or shows no
204.Chapter 8.--------------------------------------------------------
Fig. 8.36. An adolescent with lumbar disc herniation. Marked spinal rigidity is present (A) and the SLR is limited
A to 20°-30° (B).
clear-cut distribution distally to the knee, or due to the Radicular syndromes (Table 8.2)
lack of sensory and / or motor deficits. In almost all
cases, however, the herniated disc is the last or the next Ll
to the last (15, 24, 55). A similar clinical picture to that
described above may also be observed in 20- to 30-year- Isolated involvement of the Ll nerve root is so uncomm-
old subjects, whilst it is very rare in older patients. on that the clinical syndrome of compression of this root
is almost unknown. Pain and sensory disturbances are
located in the iliac crest, the iliac fossa and / or the groin
Clinical features in the elderly (29, 31). In Grade III and IV neurocompressive synd-
romes, the strength of hip flexion may be decreased (34).
In elderly subjects (aged 65 years or over), the clinical
features are often considerably different from those in
younger patients. In the elderly, low back pain tends to L2
be milder and rarely has the typical features of disco-
genic low back pain. Trunk flexion is often normal or Pain is usually located along the lateral or anterolateral
only slightly decreased. Similarly, nerve-root tension aspect of the thigh. Alternatively, it is felt in the proxi-
tests may be negative or slightly positive, even in the mal part of the anteromedial region of the thigh. In the
presence of marked nerve-root compression. In the same areas, there may be paresthesias, as well as numb-
elderly, therefore, diagnosis of nerve-root compression ness, in the presence of severe root dysfunction. In
may be more difficult than in the younger patient. This Grade I and II neurocompressive syndromes, there
is also due to the fact that the ankle, and at times also is no motor deficit or only a slight decrease in strength
the knee, jerk may be bilaterally absent due to physio- of hip flexion. In Grade III and IV, the strength of hip
logic depression of the reflex activity. flexion is moderately or severely decreased, and mild
The mildness of low back pain in the elderly, com- weakness of the quadriceps may be present (31). The
pared with the young subject, may be due to the more adductor reflex may be depressed.
severe degenerative changes in the disc. This may
involve either less pressure of the nucleus pulposus on
the peripheral portion of the annulus fibrosus, or L3
greater chances for the herniation to become extruded
or migrate into the spinal canal. Slight positivity of the Pain is usually located in the anteromedial aspect of the
nerve-root tension tests might be related to increased thigh; in a few cases, it is also or only felt in the area of
pain threshold or lesser muscle spasm due to reduced the groin or the knee. Occasionally, the patient experi-
contractility of paraspinal or hamstring muscles. ences pain in the anteromedial region of the thigh.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - o C l i n i c a l features 205 0
Table 8.2. Symptoms and signs in L2-S2 radicular syndromes. In Grade I neurocompressive syndromes, the knee
L2 L3 L4 jerk is decreased, but no motor loss is present. In Grade
II syndromes, the patellar reflex is absent and, occa-
Pain Anterolateral Anteromedial Anterior aspect
sionally, the quadriceps is slightly weak. Grade III
aspect of thigh aspect of thigh of thigh
syndromes are characterized by moderate or severe
Sensory Lateral aspect Medial aspect Pretibial weakness of the quadriceps. Patients with a Grade IV
impairment of thigh of knee region
syndrome show severe weakness or paralysis of the
Muscle Hip flexors Thigh adductors quadriceps, to which a motor deficit of varying severity
weakness of the adductors, hip flexors and abductors (tensor
Quadriceps Quadriceps
fasciae latae and gluteus medius), and tibialis anterior
Reflexes Adductor Adductor Patellar may be associated.
decreased Patellar
L5 Sl S2
Pain Posterior aspect Posterior Posterior aspect L5
of thigh, lateral aspect of thigh
aspect of leg of thigh In most patients, pain radiates down the posterior or
and leg posterolateral aspect of the thigh and lateral aspect of
Sensory Lateral aspect Outer border Posterior aspect the leg. Pain may be felt in the entire dermatome or only
impairment ofleg, big toe of foot, heel, of thigh in part of it, for instance, the outer aspect of the leg or
sole of foot the area above the external malleolus. Severe pain
Muscle EHL Triceps surae Interossei, only in the latter site is almost pathognomonic of com-
weakness Tibialis anterior Gluteus Flexors of toes pression, often severe, of the L5 root. A few patients
maximus complain of pain in the area of medial gastrocnemius
Reflexes Tibialis Ankle or, less frequently, down the tibial crest or the medial
decreased posterior Midplantar aspect of the leg.
Paresthesias are frequent and are generally located in
the outer aspect of the leg and / or the big toe or the
whole first ray. In the same sites, but particularly in the
Paresthesias are usually felt in the knee, particularly big toe, there may be sensory loss.
in its medial aspect. In this area, there may be numb- In Grade I neurocompressive syndromes, only the
ness, which may also extend to the anteromedial aspect strength of the EHL is decreased. In Grade II syn-
of the thigh, when nerve-root impairment is severe. dromes, also the tibialis anterior and / or the peroneal
In Grade I neurocompressive syndromes, the adduc- muscles are slightly weak and the tibialis posterior
tor reflex can be, at the most, decreased, whereas in reflex is abolished. In Grade III syndromes, moderate
Grade II syndromes the reflex is generally absent. In or severe weakness of the tibialis anterior, peronei and
Grade III syndromes, the adductor muscles are moder- tibialis posterior is found; often, also the gluteus
ately or markedly weak, the knee jerk may be reduced medius and the leg flexors are weak and, in cases of
and, at times, the quadriceps is slightly weak. Grade IV long-standing root compression, wasting of the tibialis
syndromes are characterized by severe weakness of anterior and peronei muscles can be observed. In
the adductor muscles; the strength of the quadriceps is Grade IV syndromes, foot drop is present and the
moderately decreased. Trendelenburg test may be positive.
L4 51
Pain is generally felt in the anterior aspect of the thigh Pain radiates to the posterior aspect of the thigh and
and, occasionally, extends to the pretibial region. A few leg. Many patients with Sl syndrome, however, com-
patients complain of pain also, or only, in the lateral plain of pain in the posterolateral aspect of the leg,
aspect of the thigh and others only in the knee or the along the lateral head of the gastrocnemius. When
area of the tibial crest. only part of the dermatome is involved, this usually is
Paresthesias are located in the pretibial region and, the median posterior aspect of the thigh and calf.
occasionally, the anterolateral aspect of the thigh. Occasionally, pain is located on the lateral, or rarely, the
Numbness is felt in the proximal half of the pretibial medial, aspect of the leg.
region and, when root compression is severe, also the Paresthesias affect the calf and the outer border of the
anterior aspect of the thigh may be numb. foot. The most frequent sites of numbness are the little
206.Chapter 8.--------------------------------------------------------
toe and the outer border of the foot, followed by the the protrusion develops or a disc fragment migrates,
heel, sole of foot and calf. and the size of the protrusion or the migrated fragment.
In patients with Grade I neurocompressive syn- Herniation of a single disc may, therefore, produce dif-
drome, the ankle jerk is reduced and the flexor hallucis ferent clinical syndromes, each of which may be caused
longus may be slightly weak. In Grade II syndromes, by disc herniation at an adjacent interspace.
the ankle reflex is absent, but the large muscles sup-
plied by the root show no weakness. Grade III syn-
dromes are characterized by moderate or marked L3-L4 Disc
weakness of the triceps surae and gluteus maxim us,
which may be clearly hypotrophic; the strength of the Midline herniation
knee flexors may be moderately decreased. Already at
this stage, the patient's gait may be abnormal due to If the herniated disc is small, only low back pain will be
inability to raise the heel from the ground. In Grade IV present. When herniation is large, multiple nerve roots
syndromes, active plantar flexion and hip extension are are involved, which results in clinical syndromes of
extremely weak or abolished, and there is marked hypo- various types and severity, ranging from unilateral
esthesia or anesthesia in the calf and sole of the foot. neuroalgic L4 and / or L5 syndrome to cauda equina
syndrome with neurologic disorders in both limbs. The
most common is a bilateral cruralgic or sciatic
52 syndrome, occasionally associated with intermittent
claudication, with signs of a slight dysfunction of the
This nerve root is an ancillary of the 51 root. It supplies L4, L5 or 51 roots, on one or both sides.
the skin of the posterior thigh and the same muscles
innervated by the 51 root, playing a complementary
Paramedian herniation
role to the latter. The only muscles supplied predomi-
nantly by the 52 root are the intrinsic muscles of the foot
Clinical syndromes are generally biradicular (L4 and
and toe flexors (34).
L5) or triradicular (L4, L5 and 51). There are different
Pain and sensory disorders are located in the posteri-
types of syndrome, but usually the L4 root is that most
or region of the thigh. In Grade III and IV neuro-
affected and shows a mild or moderate deficit, whilst
compressive syndromes, moderate or severe weakness
the L5 or 51 syndrome are Grade I neuroalgic or neuro-
of the intrinsic muscles and flexors of the toes is found
compressive.
and the muscles prevalently supplied by the 51 root
may show slightly weak.
Posterolateral herniation
53, 54, 55, Co. Herniation in this site may cause a pure L4 syndrome,
particularly in the presence of a small disc fragment
These closely contiguous roots are usually involved migrated into the nerve-root canal, or a combined L4
simultaneously. and L5 syndrome. Usually, the latter is a Grade II or III
The patient may experience pain in the scrotum, neurocompressive syndrome as far as concerns the L4
labbra or perianal region, however this rarely occurs. root and neuroalgic or Grade I or II neurocompressive
Involvement of these roots usually produces saddle syndrome as far as concerns the L5 root.
hypoesthesia or anesthesia and may be associated with
the bladder, bowel and sexual dysfunction which char-
acterizes the cauda equina syndrome. When impair- Intraforaminal herniation
ment of root function is marked, the tone of the anal
sphincter is reduced and the anal wink reflex is This herniation produces a pure L3 syndrome, which
abolished. may be only neuroalgic, if herniation is contained, or
neurocompressive with motor and sensory loss of vary-
ing severity, when a disc fragment has migrated into
the intervertebral foramen. Occasionally, the L4 root
Syndromes due to herniation of the may also be mildly involved. Based on the clinical fea-
three lowest lumbar discs tures, however, an L3 syndrome is often indistinguish-
able from an L4 syndrome. Physical examination
Herniation of a single lumbar disc may impinge on usually demonstrates involvement of only upper lum-
different nerve roots depending both on the site where bar nerve roots.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - · C l i n i c a l features· 207
Extraforaminal herniation Intraforaminal herniation
Extraforaminal herniation is consistently responsible The L4 nerve root may be involved either alone or
for a pure L3 syndrome, generally characterized by together with the L5 root if the disc protrudes also
mild or moderate root dysfunction. posterolaterally. In this instance, a neuroalgic or Grade
I neurocompressive syndrome is observed. When the
herniation is contained, the L4 syndrome may be
neuroalgic or, more often, neurocompressive of Grade
L4-L5 Disc I or II. In the presence of a disc fragment migrated
into the neuroforamen, a neurocompressive syndrome
Midline herniation is consistently present, which is usually of Grade II
or III.
A small or medium-size herniation may be responsible Irrespective of the pathologic condition, the clinical
for low back pain alone or an L5, and occasionally also picture is characterized by mild or no low back pain
51, unilateral or bilateral neuroalgic syndrome. A larger and severe radicular pain, particularly at the onset of
herniated disc usually causes an L5 neurocompressive, symptoms. These features, in the presence of an L4
and 51 neuroalgic, syndrome in one or both extremities. syndrome, should lead us to hypothesize, first of all,
When both limbs are affected, signs and symptoms an intraforaminal L4-L5 herniation, which is certainly a
usually prevail on one side. Cauda equina syndrome more frequent condition than L3-L4 herniation.
rarely occurs.
Extraforaminal herniation
Paramedian herniation
This is characterized by a pure L4 syndrome, which is
Depending on the size of the herniation, there can be an usually of the Grade I or II neurocompressive type.
L5 neurocompressive, and an 51 neuroalgic, syndrome, 5evere nerve-root compression, as easily occurs in
a combined L5 and 51 neurocompressive syndrome or, intraforminal herniations, is rarely observed. This is
rarely, an 51 neurocompressive, and L5 neuroalgic, due to the fact that an extraforaminal herniation is
syndrome. usually contained and the nerve root can more easily
A combined L5 and 51 neurocompressive syndrome, escape compression than in the presence of a herniation
caused by a paramedian herniation or a disc fragment within the neuroforamen.
migrated in the axilla of the L5 root, is usually charac-
terized by pain in the L5 dermatome or, less frequently,
L5 and 51 dermatomes, moderate or severe motor
deficit of the L5 nerve root and depression or absence L5-51 Disc
of the ankle jerk, occasionally associated with weak-
ness of the triceps surae. This type of syndrome Midline herniation
should lead us to suspect, first of all, nerve-root com-
pression at L4-L5 level. Only rarely, in fact, is it pro- Midline herniation may cause pure low back pain or a
duced by discal or non-discal pathologic conditions at unilateral or bilateral 51 compressive syndrome,
other levels. depending on the size of the protrusion or the possible
presence of a migrated disc fragment. When both limbs
are affected, both the pain and the motor and sensory
Posterolateral herniation deficits prevail on one side. A large midline herniation
may cause a cauda equina syndrome.
Usually, a syndrome of irritation or compression of
the L5 nerve root alone is found. A large contained
herniated disc may cause an L5 neurocompressive Paramedian herniation
syndrome and an 51 neuroalgic syndrome due to
intrathecal compression of this root. Conditions of a The clinical syndrome is similar to that produced by a
more severe deficit of the L5 root are observed in posterolateral herniation. The only difference is that a
patients with a disc fragment migrated into the large paramedian herniated disc may impinge on the
nerve-root canal. When the fragment is located in the lowermost sacral roots (53-55) and cause pain in the
nerve-root axilla, there can be a combined L5 and 51 scrotum and sensory impairment in the perineum and
neurocompressive syndrome. genitals.
2oB.Chapter 8.--------------------------------------------------------
Posterolateral herniation 3. Alexander G. 1.: Prolapsed intervertebral discs. Edimb.
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Rumpfes und seiner Extremitaten. Morphol. Jahrb. 25:
465-543;26:91-211;27:630-711;28:105-146,1898-1899.
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11:1002-1007,1986. 1951.
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1988. Berlin, 1908.
210.Chapter 8.----------------------------------------------------------
75. Paine K. W. E., Haung P. W. H.: Lumbar disc syndrome. 91. Sherrington C. S.: Notes on the arrangement of some motor
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1964.
-------CHAPTER 9-------
IMAGING STUDIES
F. Postacchini, G. Gualdi
Fig. 9.1. Degenerative hypertrophy of the articular processes at L4-L5 Fig. 9.2. Marked shortness in the vertical direction of the L5 laminae,
level, suggesting lumbar stenosis. which tend to be orientated horizontally.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - 0 Imaging studies 21 3 0
(Fig. 9.3). It is important to recognize an even mild canal, and even more in achondroplasic patients, the
vertebral slipping (Fig. 9.4). Olisthesis of even mild pedicles may be shorter and often thicker than normal,
severity may, in fact, cause stenosis or be an expression whereas the intervertebral foramens may appear con-
of vertebral instability. Retrolisthesis is a sign of disc stricted in the sagittal diameter (Fig. 9.5). Some subjects
degeneration and / or vertebral instability; when severe, may also show marked concavity of the posterior
retrolisthesis may be responsible for lumbar stenosis. aspect of the vertebral body, with consequent posterior
Lumbarization of S1, or sacralization of L5, vertebra prominence of the vertebral end-plates. The sagittal
may be suspected in the presence of an abnormally diameter of the vertebral canal may be measured by
short or long sacrum, respectively. Ca udally to the tran- tracing a tangent line to the posterior aspect of the ver-
sitional vertebra, particularly a sacralized L5 vertebra, tebral body and a line passing through the tip of the
there may be a vestigial disc, which is usually narrower superior and inferior articular processes; the segment
than a normal disc. A vestigial disc may be differentiat- joining the two lines at the level of the midpoint of the
ed from a degenerated disc due to the absence of any pedicles should correspond to the sagittal diameter of
radiographic evidence of disc degeneration. the spinal canal (56, 232). This measurement, however,
Two types of vertebral body osteophytes have been is approximate and cannot be considered reliable.
described: more or less arcuate osteophytes, originat- The oblique views are useful in the evaluation of
ing from the border of the vertebral body, which may any pathologic conditions of the pars interarticularis or
form a complete or incomplete bridge between two the articular processes. The oblique view may show a
adjacent vertebrae; and traction spurs, originating at spondylolysis even when the bone defect is narrow and
5 mm or more from the margin of the vertebral body, not evident, or clearly evident, on the other views.
which are horizontally orientated for a few millimeters
(132). The former result from fissuring or bulging of
the annulus fibrosus, or are an expression of idiopathic Functional radiographs
spondylohyperostosis, characterized by ossification of
the annulus fibrosus and the adjacent soft tissues. The These are lateral radiographs of the lumbar spine car-
latter would be due to abnormal mechanical stress on ried out in maximum flexion and extension, or antero-
the peripheral attachment of the annulus fibrosus as a posterior radiographs performed in maximum lateral
result of vertebral instability. The significance of trac- inclination. Flexion-extension radiographs may be
tion spurs is still unclear, since they are often absent in
the presence of evident vertebral hypermobility.
In subjects with a constitutionally narrow spinal
Fig. 9.3. Degenerative spondylolisthesis of L5. Note the integrity of the Fig. 9.4. Mild degenerative spondylolisthesis of L4 (arrow). The
pars interarticularis. vertebral slipping suggests lumbar stenosis and/or vertebral instability.
214.Chapter 9 . - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Normal myelogram
Pathologic features
Disc herniation
Nerve roots
enlargement of the root in proximity to the compres- visible on the lateral view at the level of the disc space
sion; and cut-off of the sleeve of the emerging root and (Fig. 9.11), or at a distance from the disc in the presence
medial deviation, in the intrathecal course, of the root of a migrated herniation. Occasionally, lateral indenta-
emerging at the level below. tion on the thecal sac may be seen on the posteroanteri-
or view. In the presence of a partial block, the contrast
medium may opacify the CSF also distally to the site of
Thecal sac compression (when injected cephalad to the block). On
the lateral view, the sagittal dimensions of the thecal sac
The dye column may show a niche-like indentation, a are considerably.reduced in the compressed area. The
partial block or a complete block. The indentation is latter, on the posteroanterior view, appears very mildly
opacified compared with the suprajacent and subjacent
areas. A complete block consists in a total interruption
of the image of the dye column. The block caused by a
herniated disc shows, on the posteroanterior view, a
fringed or brush-like appearance (Fig. 9.12). The block
is situated at the level of the disc space or, more often, of
the caudal end-plate of the vertebra above. On the
lateral view, the thecal sac may show a typical anterior
indentantion (Fig. 9.12); more often, a circumscribed
filling defect is visible, of which the anterior wall
appears displaced posteriorly in proximity to the
margin of the block of the contrast medium. In this
event, the end of the sac may have a tapered appear-
ance.
Lumbar stenosis
Fig. 9.17. Myelograms of a patient operated for an intraforaminal disc herniation at L4-L5 level on the left. The left L4 nerve root sleeve is opacified
only in the proximal portion and has a tapered appearance on the oblique view due to periradicular fibrosis.
water-soluble contrast agents, at least in patients who radio-opacity of the contrast medium in the thecal sac
have not previously undergone myelography. Arach- due to absence of the radiolucent images of the roots;
noiditis is characterized by: non-visualization of the thinning of the caudal portion of the thecal tube, which
caudal nerve-root sleeves or visualization only of their may be abnormally short and ends like the tip of a
initial portion; homogeneous appearance and increased pencil or finger of a glove; jagged or smooth appear-
Indications
Until a few years ago, myelography was the investiga-
tion commonly performed to diagnose the cause of a
lumboradicular syndrome. With the advent of CT and
MRI, the indication for myelography has progressively
decreased, and patients have become less and less will-
ing to undergo the examination. Nowadays, myelogra-
phy should be carried out only when CT and/or MRI
Fig. 9.19. Arachnoiditis in a patient previously submitted to two do not provide adequate information for diagnosis of
myelographic studies and bilateral laminectomy at L4-LS level. On
the posteroanterior view, the thecal sac has a tapered appearance and the the pathologic condition responsible for a lumboradic-
margins are smooth due to failed opacification of the L4-52 nerve-root ular syndrome to be made.
sleeves. On the lateral view, the sac shows posterior dilation at the level The main prerogative of myelography is that it is able
oflaminectomy (arrow). to visualize lumbar nerve roots in the portion com-
prised between the site where they emerge from the
thecal sac and the entrance into the intervertebral fora-
ance of the thecal sac margins due to the lack of opacifi- men. The investigation is thus indicated when it is use-
cation of the nerve-root sleeves (Figs. 9.18 and 9.19). ful or necessary to demonstrate compression of the
In the myelogram of the operated patient, a charac- nerve root in the extrathecal course, rather than visual-
teristic feature, however devoid of pathologic signifi- ize the compressive agent, as occurs with CT and MRI.
cance, is the presence of a posterior protrusion of the In patients with a simple disc herniation, myelography
thecal sac at laminotomy or laminectomy level (Fig. may be indicated: 1) When CT findings are dubious or
9.19). in contrast with the clinical picture and it is difficult or
impossible to obtain MRI (non-availability of the equip-
ment; patients with pace-makers or metallic implants;
Diagnostic accuracy claustrophobia). 2) In the presence of lumbar scoliosis
which makes interpretation of CT and MRI images dif-
The diagnostic accuracy of an investigation cannot be ficult. 3) When CT and/ or MRI suggest, but do not
established by comparing the results with the surgical adequately demonstrate, a nerve-root anomaly, which
findings, since, in a condition such as disc herniation, may be useful to identify in view of the surgical treat-
the indication for surgical treatment is based upon the ment. 4) When CT and MRI do not show significant
pathologic features emerging from that investigation. pathologic conditions, whilst the clinical features sug-
In the event of normal diagnostic findings, which gen- gest nerve-root compression. However, in these cases,
erally lead to surgery not being performed, it is not which are fairly rare, the probability that myelography
possible to determine whether the investigation has will be positive is very low; for this reason, the exami-
provided a correct diagnosis or a false negative result. nation should generally be performed in the presence
On the other hand, it is well known that disc herniation of clear clinical evidence of nerve-root compression. 5)
may be asymptomatic (25, 100, 226); in these cases, In patients with persistent radicular symptoms after
in which surgery is not carried out, it may be impossible surgery, to demonstrate a possible nerve-root compres-
to determine whether the results are false positive. sion not clearly demonstrated by non-invasive imaging
A comparative analysis of the diagnostic accuracy of techniques; also in these cases, however, myelography
two or more investigations is easier, since the positivity rarely provides adequate diagnostic information. 6)
of one or several of them may lead to surgical treatment Extremely obese patients who do not fill within the
being carried out. gantry of CT or MRI, in whom, on the other hand, it
9.------------------------------------------------------------
may at times be difficult to obtain sufficiently good primary X-ray beam by the tissues. The degree of atten-
images with the non-invasive techniques. uation depends on the atomic number of the examined
Rather than for simple disc herniations, myelogra- substance and corresponds to density of the latter. The
phy may be indicated in the presence of lumbar steno- density is measured as Hunsfield Unit (HU). The scale
sis. The investigation, in fact, is able to reveal variations of densitometric values ranges from -1000, which cor-
in the severity of compression of the nervous structures responds to air, to 1000, which corresponds to bone. Fat
in flexion and extension of the lumbar spine; in the tissue has negative values (-100), whereas all other tis-
presence of mild os teo ligamentous compression of the sues have positive values. Water has a neutral value (0).
thecal sac visualized on MRI scans, it may be useful to The examination begins with digital radiographs of
determine whether the compression increases in sever- the lumbar spine in the lateral and anteroposterior
ity, and to what extent, in the standing position and/ or views. Radiographs are useful to identify the spine
in extension of the spine (218). Furthermore, stenotic segments to be studied after recognition of the lumbar
patients occasionally present idiopathic or degenera- vertebrae, starting from L5 or D12. In addition, radi-
tive scoliosis, which may make it difficult to determine ographs allow detection of possible spondylolisthesis,
the severity of compression of the caudal nerve roots decrease in height of the intervertebral spaces or struc-
with CT and / or MRI (165). tural changes in the vertebrae, including the upper
In patients with isthmic spondylolisthesis, CT and / or lumbar vertebrae usually not examined on axial sec-
MRI may not be able to demonstrate compression of tion. The lateral view radiograph should be taken in an
the emerging nerve root at the level of isthmic pseud- adequate scale, with optimal window values, and both
arthrosis. It may occasionally be useful to carry out with and without the scan lines in order to increase its
myelography in these cases. diagnostic efficacy (152). The anteroposterior view
should also be photographed, particularly if the patient
has not undergone plain radiographs.
Standard CT study is performed with contiguous or
Computerized tomography (CT) overlapped, 2-4-mm thick, slices. Thin slices provide
better spatial resolution (ability to identify small struc-
Technique tures presenting different contrast), but less contrast
resolution (ability to identify structures presenting dif-
The patient is placed in the prone position with a support ferent density). Slices thicker than 4 mm should be
under the legs to reduce lumbar lordosis. The gantry is avoided when a herniated disc is suspected, since they
tilted to direct the X-ray beam parallel to the interverte- cause partial average artifacts (i.e., the section includes
bral space. This is important, particulary for the L5-51 many structures with different densities which sum up)
disc, the angulation of which with respect to the hori- leading to a decrease in spatial resolution. The gap
zontal plane may exceed the degree of gantry tilting. If between the slices should be zero or less than the sec-
the scan plane is not parallel to the intervertebral space, tion thickness in order to reduce partial average arti-
the resulting image may simulate disc bulging. facts and to increase spatial resolution in reformatted
Scan time and amperage are usually preselected to images. If the examination is performed for suspected
reduce the radiation dose. In obese patients, however, spinal stenosis, it is preferable to perform 4-mm thick,
both scan time and amperage should often be 1 mm overlapped, sections to improve the quality of
increased, since the X-ray beam is weakened when sagittal reformatted images.
passing through fat tissue. Usually the axial sections are obtained at L3-L4, L4-
The radiation dose for standard CT studies of the L5 and L5-S1 levels, whilst the L2-L3 level, and very
lumbar spine is low, since the X-ray beam is collimated occasionally the LI-L2 level, are examined when
and there is, thus, no secondary radiation. The usual deemed necessary on account of the particular clinical
dose to the skin is about 3-5 rads, i.e., similar to that features. In the latter instances, the referring physician
absorbed in a routine radiographic study including should ask for studies to be made at the upper lumbar
lateral, anteroposterior and oblique views of the lum- levels, since the radiologist, who is unaware of the exact
bar spine. The further away from the skin and primary clinical features, may not be able to decide whether or
beam, so the radiation dose absorbed progressively not the examination should be extended to the upper
decreases. The deep tissues, therefore, are less and less lumbar spine.
irradiated as the distance from the skin increases; For each intervertebral level, sections should be
furthermore, gonadal irradiation ranges from 0.15 to obtained from the lower edge of the pedicle of the
0.75 rads when the CT study does not reach caudally cranial vertebra to the upper margin of the pedicle of
beyond the SI-S21evel (96). the caudal vertebra. If a disc fragment is seen to have
The CT image results from the attenuation of the migrated into the spinal canal, sections should include
the proximal and distal edge of the fragment to allow intervertebral foramen increases progressively from its
the surgeon to localize the exact site of the latter. The cranial end to the middle portion of the intervertebral
field of view (FOV) should include the whole vertebra, disc and then begins to decrease.
paravertebral muscles and retroperitoneal vessels. This The LS vertebra can generally be recognized on
allows identification of possible pathologic conditions account of the larger dimensions of the transverse
of the aorta or other retroperitoneal structures. processes, which are often roughly triangular in shape
After obtaining axial sections, multiplanar recon- on the scans at the level of the middle portion of the
structions may be made, in two or three dimensions. vertebral body (Fig. 9.20). Furthermore, the vertebral
Reformatted images are not usually indispensable for canal of LS often has a trefoil shape, which is rarely
diagnosis, but they can be useful for better evaluation observed at L4level and is normally absent at the level
of the pathologic condition. above. The L4 vertebra can often be distinguished from
Image photography is important in the interpreta- L3 due to the less sagittal orientation of the posterior
tion of the pathologic condition and should be obtained joints and the shape of the vertebral canal, which tends
with both soft tissue and bone algorithms (Figs. 9.20 to be more triangular. The Sl vertebra is easily recogni-
and 9.21). zable due to the presence of the sacral alae on the sides
When a herniated disc is suspected, CT study is usu- of the vertebral canal, which is triangular in shape. The
ally performed without contrast medium. Intravenous images obtained with a window level for soft tissues
contrast medium is used primarily in previously (Fig. 9.20) may not allow adequate visualization of
operated patients, when recurrent disc herniation is the bony structures, particularly of the articular
suspected. In non-operated patients, contrast medium processes, which, on the other hand, are well visible
is usually employed to exclude tumors, such as neuri- using a window level for bone (Fig. 9.21).
nomas or ependymomas, or to enhance a venous The transverse area of the bony vertebral canal
plexus simulating disc herniation. Disc tissue, in fact, measures lS0-300 mm2 when the spine passes from
is not significantly enhanced after administration of flexion to maximum extension (191).
contrast medium, since it is not vascularized, or con- The intervertebral disc has a density of 70-80 UH,
tains only a few vessels, unlike neoplastic lesions or i.e., similar to, or slightly greater than, the muscle tissue.
vessels. The usual dose of contrast medium is about 2 Generally, the nucleus pulposus cannot be distin-
ml/kg body weight and non-ionic media are preferred guished from the annulus fibrosus. However, the
in order to reduce the risk of an allergic reaction. peripheral portion of the disc occasionally displays a
slightly greater density than the central portion. This
usually occurs in young subjects, in whom the nucleus
Anatomy of lumbosacral spine is only mildly fibrotic. On axial sections, the posterior
border of the upper three lumbar discs is generally con-
Vertebrae and intervertebral discs cave on the sagittal plane, whilst the border of L4 disc is
rectilinear and that of LS disc is slightly convex (Fig.
On axial sections, the body of the lumbar vertebrae 9.20). The posterolateral margin of the disc (which
shows a slightly ovoid shape due to the larger dimen- delimits the intervertebral foramen) is slightly and
sions of the transverse, compared with the sagittal, uniformly convex at all lumbar levels.
diameter. The foramen through which the basivertebral On midsagittal and paramedian reformatted images,
vein emerges can be seen in the middle portion of the the posterior border of the intervertebral disc is nor-
posterior aspect of the vertebral body. mally flat or slightly convex. Lateral sections allow
The spinal canal appears to be entirely delimited by visualization of the articular processes and the post-
bony walls only at the level of the pedicles (Fig. 9.20). erior joints, the pars interarticularis and the interverte-
Caudally to these, the posterolateral wall of the canal is bral foramen. The latter is clearly visible on the sections
incomplete, on each side, due to the presence of the through the pedicles.
intervertebral foramen. Immediately below the pedi-
cle, the posterolateral bony wall is formed by the pars
interarticularis and the lamina and, more caudally, by Ligaments
the inferior articular process of the vertebra examined.
On sections close to the caudal apophyseal ring, the The anterior longitudinal ligament is not generally
superior articular process of the vertebra below visible on conventional CT scans. The posterior longi-
becomes apparent. It is situated anteromedially to the tudinal ligament is occasionally visible on the scans
inferior articular process and, proceeding caudally, the through the middle portion of the vertebral body, on
transverse area increases, whilst the area of the inferior which the two structures are separated by fat tissue and
articular process decreases. The sagittal diameter of the the branches of the basivertebral vein. The ligament
228.Chapter 9.--------------------------------------------------------
Fig. 9.20. Sequential axial CT scans from the caudal half ofL4 to the vertebral end-plate of 51. The arrowheads indicate the L4 nerve root in the L4-L5
intervertebral foramen (L4 and L4-5]), the L5 root in the L5 radicular canal (L5, and L5,) and L5-51 intervertebral foramen (from L53 to L5-51]), and
the 51 nerve root in the 51 radicular canal (L5-51, and 51). The double arrowheads indicate the 51 root emergingfrom the thecal sac (L5-51 ,). The short
black arrows indicate the epidural fat, which is typically hypodense, whilst the thecal sac shows the neutral density of the C5F. The asterisks are placed
on the superior articular processes of L5 (from L4-5 1 to L5]) and 51 (from L53 to L5-51,); the inferior articular processes are situated medially to the
superior processes and are well visible at L5] (inferior articular processes ofL4) and L5-51, and L5-51, (inferior articular processes ofL5). The long
black arrows indicate the ligamenta flava: the portion of the ligamentum located anteriorly to the facet joint can be seen at L4-5 1 and L54• The white arrow
indicates the median meningovertebralligament. Letter L indicates the laminae ofL4 (from L4 to L4-53 ) and L5 (from L5, to L5-51,).
- - - - - - - - - - - - - - - - - - - - - - - - - - - - . Imaging studies· 229
Occasionally, the caudal nerve roots may be seen with-
in the thecal sac on account of their greater density
compared with the CSF. With the patient in the supine
position, they appear as pointed structures close to each
other, generally situated in the posterior half of the
thecal sac. With change of position, the roots tend to be
displaced within the sac. The area of the thecal sac on
axial sections normally ranges from 130 to 230 mm 2
(28,191). The epidural fat may be easily recognized due
to its negative densitometric values. Little fat is present
in the upper lumbar region, whilst in the low lumbar
and sacral regions it becomes more and more abundant,
in parallel with the progressive thinning of the thecal
sac.
The spinal nerve roots in the extrathecal course
(radicular nerves) appear as symmetrical roundish
structures, running in the nerve-root canal on the sides
Fig. 9.21. Axial CTscan at intervertebral level, obtained with a window
level for soft tissues. Bony structures are clearly visible, whereas the of the thecal sac, of which they have the same density
structures with low and intermediate density, such as muscles, CSF and (Fig. 9.20). In the absence of nerve-root anomalies, the
nerve roots, are not easily identified. root on one side is similar in diameter to that on the
opposite side. In the intervertebral foramen, the nerve
may be identified, using high window levels, parti- root has an oblique course, which tends to approach the
cularly in the presence of abundant epidural fat, com- horizontal plane outside the foramen (Fig. 9.20). In the
pared to which it displays a greater density. intra- and extraforaminal portion, the root is in very
The ligamenta £lava appear as laminar structures, close proximity to the intervertebral disc and it varies in
with a similar density to that of the intervertebral disc, shape depending on the width of the angle between the
which delimit the vertebral canal posteriorly and are scanning plane and the plane parallel to its longitudinal
prolonged in front of the articular processes as far as axis. When the angle is small, the nerve root appears as
the intervertebral foramen (Fig. 9.20). an elliptical structure, whilst if the angle is wide, the
The meningovertebral ligament is occasionally root tends to be roundish in shape.
visible, particularly at L5-S1level and in the presence of On sagittal reformatted images, the thecal sac
abundant epidural fat, due to the different density of appears as a tubular structure adherent to the posterior
the two tissues (Fig. 9.20) (184). On high resolution wall of the vertebral bodies and the discs, or separated
images, the ligament usually appears as a septum con- from the latter by a thin layer of low-density tissue,
necting the thecal sac to the vertebral body. At times, corresponding to the epidural fat. Usually, the nerve
it is possible to observe two septa, one on each side, roots in the extra thecal course are not clearly identifi-
directed towards the posterolateral portion of the verte- able on the scans through the nerve-root canals, whilst
bral body. The small spur which is often visible at the they are visible, surrounded by the periradicular fat, on
center of the posterior border of the vertebral body the scans through the intervertebral foramen.
corresponds to the area of insertion of the anterior Coronal reformatted sections through the spinal
meningovertebralligament to the posterior longitudi- canal show the thecal sac and the spinal nerve roots
nalligament and the endosteum of the vertebral body, running in the nerve-root canals and the intervertebral
and may be particularly prominent when the ligament foramina. The roots are clearly visible on the sections
is calcified (184). The lateral meningovertebral liga- through the pedicles. However, the image of the ner-
ments are very rarely visible. vous structures may be ill defined in the presence of
High resolution CT scans (sections 1 mm thick) may marked lumbar lordosis, which may prevent visualiza-
allow visualization of the ligaments of the interver- tion of the entire extra thecal course of the nerve root on
tebral foramen (151). They appear as thin bands with a single scan.
fibrous density connecting the posterolateral border of
the disc to the anterior wall of the superior articular
process, the pedicle and lor the ligamentum £lavum. Nerve-root anomalies
Thecal sac and spinal nerve roots These anomalies are responsible for an asymmetric
axial image of homologous nerve roots (radicular
The thecal sac presents densitometric values close to nerves) if, as often occurs, the anomaly is unilateral.
zero due to the prevalently liquid content (Fig. 9.20). This holds particularly for the anomalies characterized
230.Chapter 9. - - - - - - - - - - - - - - - - - - - - - - - - - - - -
by two or three contiguous roots emerging through a ture on scans through the anomalous nerve trunk (Fig.
single dural hole or closely adjacent holes. In these 9.22). In dubious cases, it may be useful to perform the
cases, the transverse area of the anomalous nerve trunk examination after intravenous administration of
is considerably larger than that of the normal contralat- contrast medium or to carry out myelo-TC.
eral root. The nerve-root canal in which the anomalous
nerve trunk has its course may be wider than normal
(97). Epidural venous plexuses
Generally, the anomalous nerve trunk shows a simi-
lar density to that of the thecal sac and normal nerve Axial CT images often allow visualization of the antero-
roots (159); occasionally, however, the density may be lateral epidural venous plexuses. They appear as sym-
higher. In the latter instance, it may be difficult to metrical structures with a similar density to that of the
exclude that the anomalous structure is not a disc frag- disc, but greater than that of the CSF. Dilated epidural
ment or newly-formed tissue. Coronal reconstructions, veins may occasionally simulate a herniated disc. In
however, will easily allow identification of the struc- these instances, the use of intravenous contrast
L4-5
B
c
Fig. 9.22. Type-IV nerve-root anomaly of right L5 and 51 nerve roots.
(A) Axial CT scan at L5-51 level. On the left, the L5 root can be seen in
B
the intervertebral foramen (arrowhead), whereas on the right no root is
visible in the foramen. On this side, the thecal sac shows an anomalous Fig. 9.23. Axial CT scans at L3-L4 (A) and L4-L5 (B) levels showing a
morphology (arrow) due to the presence of the two roots conjoined. (B) bulging annulus fibrosus. The posterior border of the L3-L4 disc, which
and (C) Coronal reconstructions showing, on the right, an abnormally is normally rectilinear or concave, appears to be convex. At L4-L5 level,
large nerve trunk (arrows) probably consisting of two conjoined roots the posterior border of the disc exceeds the limits of the vertebral end-
(L5 and 51). plate.
_____________________________ 0 Imaging studies 23 1 0
medium allows the differential diagnosis to be made, and generally deforms the anterior border of the thecal
since vessels, unlike the disc, show an increase in sac; the nerve roots emerging from the thecal sac may
density. The intervertebral veins running in the neuro- appear to be compressed.
foramen are visible on the lateral sagittal reconstruc- A contained herniation appears as a focal convexity
tions visualizing the intervertebral foramen. of the posterior or lateral margin of the disc (Fig. 9.24).
Due to the integrity of the posterior longitudinalliga-
ment, the herniation has clear-cut and regular margins,
Bulging of annulus fibrosus showing no lobulation. The herniation does not usually
extend cranially or caudally to the disc, but it may be
This condition is characterized by the prominence of visible on the sections through the vertebral end-plate
the entire, or of a large part of the posterior, lateral or above or below.
anterior aspect of the annulus fibrosus (Fig. 9.23). In An extruded herniation has lobulated margins and is
the upper lumbar discs, which normally present a generally in continuity with the disc from which it orig-
slight concavity of their posterior border, bulging of the inates by means of a pedicle. Part of the tissue often
annulus fibrosus produces convexity of the posterior extends cranially or caudally to the disc, but remains in
border of the disc. The prominence of the annulus is close proximity to the vertebral end-plate above or
generally mild and, thus, extends only slightly beyond below (Fig. 9.25). In an extruded transligamentous or
the borders of the vertebral bodies. Furthermore, retroligamentous herniation, the disc material occupies
bulging is uniform, without focal areas of more marked a large part of the vertebral canal at the level of the
protrusion of the disc and, in a spinal canal of normal intervertebral disc, to which it may appear to be joined
width, does not cause any compression of the nervous by a thin pedicle of tissue. Very often the herniated
structures. In spite of these distinguishing features, it tissue extends also cranially or caudally to the disc.
may, at times, be difficult to differentiate this condition CT scans should visualize the caudal and cranial ends
from a contained disc herniation, particularly of the of the herniated disc tissue in order to give the surgeon
middle posterior portion of the disc. The most impor- adequate information on the site of herniation.
tant distinguishing feature is the integrity of the annu- A migrated herniation appears as a mass of disc
lus fibrosus, which, however, cannot be demonstrated tissue situated at a variable distance from the disc,
by CT. with no continuity with it. On sagittal reconstructions,
a thin pedicle may be visible, which from the migrated
tissue appears to be directed towards the disc of origin.
Disc herniation In these cases, it is easy to identify the disc from which
the migrated material originates. In some instances,
A disc herniation appears as a tissue, showing a similar instead, particularly when the disc fragment migrates
density to that of the intervertebral disc, which usually at a considerable distance, it my be difficult to identify
occupies the anterior extradural portion of the spinal the disc of origin. Useful elements in this respect are the
canal. The herniated tissue obliterates the epidural fat site of the migrated fragment and the characteristic
232.Chapter 9 . - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
features of the disc of origin. The migrated fragment should be classified according to the site in which most
usually comes from the closest disc; a fragment located of the herniation is located. For example, a herniation
in the axilla of the nerve root is generally derived from with 60% of its transverse dimensions contained within
the disc above; a fragment in the intervertebral foramen the limits of the intervertebral foramen, and 40% later-
originates, almost always, from the disc below. The disc ally to the external border of the pedicle above, should
from which the migrated fragment is derived often be considered intraforaminal.
shows a mild posterior or posterolateral bulging or Morphologic characteristics of lateral, contained or
protrusion; when the fragment is small in size, the extruded, herniations are similar to those of posterolat-
parent disc may show the focal convexity typical of a eral or midline herniations, i.e., focal convexities of the
contained or extruded subligamentous herniation. A disc or lesions with lobulated margins that occupy the
small fragment of disc tissue located in the lateral recess intervertebral foramen. A peculiar sign, present in
appears as a hyperdense structure, clearly recognizable some half of extraforaminal herniations, is the serrated
by comparing the two recesses; in these cases, the appearance of the border of the vertebral end-plate,
epidural fat may be normal or partially obliterated. It resulting from detachment of Sharpey's fibers by the
may be impossible to visualize a migrated fragment herniated tissue (29) (Fig. 9.27). An extruded herniation
with CT if it is located in the subpedicular portion may at times be differentiated from a migrated hernia-
of the spinal canal, which generally is not examined. tion. In the former, the herniated tissue is visible only at
Alateral herniation may be entirely intraforaminal or the level of the lower end-plate, and the most caudal
extraforaminal. Very often, however, the herniation is portion of the body, of the cranial vertebra (Fig. 9.28). In
located partly within and partly outside the interverte- the latter case, the disc fragment is visible (or it shows
bral foramen (Fig. 9.26). In these cases, the herniation large dimensions) also on the axial sections immediate-
_______________________________________________________ 0 Irnaging studies 233 0
A B c
D
Fig. 9.27. L4-L5 intraforaminal disc herniation on the left, associated with avulsion ofSharpey's fibers of the caudal end-plate of the vertebra above. (A)
Focal convexity of the intraforaminal portion of the disc and presence of a nucleus of disc tissue compressing the L4 root. (B) and (e) Sections at the level
of the vertebral end-plate, showing irregularities in the lateral margin due to detachment of the Sharpey's fibers (arrowheads); the two images have been
obtained with a window level for soft tissues and bone, respectively. (D) Coronal reconstruction . The intervertebral foramen is largely occupied by a
hyperdense tissue, corresponding to the herniation (arrow).
ly below the pedicle of the cranial vertebra (Fig. 9.29). particularly when the latter is in close proximity to the
Usually, multiplanar reconstructions (sagittal, coronal disc tissue or is surrounded by it. The same may occur
and para-axial) easily allow the extent of the herniation for a disc fragment migrated into the intervertebral
and the relationships of the latter with the nearby struc- foramen.
tures to be demonstrated (222). Occasionally, the disc tissue may display a low densi-
The image of the spinal nerve root leaving the ty and, thus, be poorly differentiated from the thecal sac
intervertebral foramen may occasionally be mistaken (Fig. 9.30). This is more likely to occur when the hernia-
for a lateral herniation. The parameters allowing tion is of recent onset, in young subjects, in whom the
distinction between the two structures are the dimen- disc has a greater hydration, or when the disc tissue is
sions and, especially, the morphology and density. The only slightly degenerated. In these cases, CT shows
shape of the nerve root is linear, whilst that of her- indirect signs of disc herniation, related to the "mass
niation is lobulated; the density of the root is close to effect". With use of contrast medium it is possible to
zero, unlike that of the disc tissue, which shows consid- exclude neoplastic tissue, which, unlike a herniated
erably higher values. In a few cases, the lateral margin disc, shows an increase in density. In the presence of a
of the disc in a scoliotic area, a perineurial cyst or a suspected herniated disc, isodense to the thecal sac,
paravertebral lesion may simulate an extraforaminal diagnosis may usually be confirmed by MRI, the high-
herniation. Differential diagnosis may be made based er resolution of which easily allows distinction of the
on the density of the abnormal structure, possibly with two structures (Fig. 9.31).
the use of intravenous contrast medium (233). Long-standing herniations, in which the disc tissue
The nerve root emerging from the thecal sac may be has undergone dehydration processes, may display a
reduced in caliber as a result of compression or, more higher density compared with the disc. In a long-stand-
often, has a larger transverse area than that of the ing herniation, there may be calcium deposits, which
contralateral root due to intraradicular edema. In this appear as small granules or a continuous band, mostly
instance, the hypodensity of the root with respect to convex posteriorly. Calcification of the herniated tissue
the disc tissue allows easier identification of the mar- is usually observed in contained or, less frequently,
gins of the herniation. A disc fragment migrated in the extruded herniations, whilst it is extremely rare in
nerve-root axilla may obliterate the image of the root, migrated herniations.
234.Chapter 9.--------------------------------------------------------
L4 -5
Fig. 9.29. L4-L5 migrated intraforaminal herniation on the right. The disc fragment
(arrow) is visible on the axial scan (A) immediately above the L4 pedicle. Coronal and
sagittal reconstructions (B) and (C) show the herniated tissue (arrows) reaching the
c L4 pedicle.
-------------------------------------------------------oIrnagingstudies 235 0
A B
Fig. 9.31. L5-5I disc herniation showing a low
density and, thus, poorly distinguishable from the
thecal sac on axial CT scans. The CT scan at the level
of the disc (A) appears to display afocal convexity of
the disc border and compression of the thecal sac.
However, on the CT scan at the level of the 51
vertebral end-plate (B), the disc herniation cannot be
distinguished from the thecal sac. The turbo spin-echo
T2-weighted (C), and the spin-echo TI-weighted (0),
MR images show a large disc herniation which
extends caudally to the 51 vertebral end-plate. On the
turbo T2-weighted image, the lower two lumbar discs
show a marked hyposignal due to degenerative
changes and a puntiform hyperintense area is present
c D in the posterior portion of L4-L5 annulus fibrosus.
to distinguish the hyperdensity of the herniated disc which may be due to annular calcification or a detach-
tissue. ment of the margin of the vertebral body in the pres-
Occasionally, in middle-aged or elderly subjects, the ence of a posterior Schmorl's node (78) (Fig. 9.32). In
herniation appears to be surrounded by a calcified rim, young subjects with an osteochondral avulsion, the
236.Chapter 9.------------------------------------------------------
both sides. In patients submitted to laminotomy, it is
possible to observe a mild defect or an irregularity of the
caudal border of the proximal lamina, the cranial bor-
der of the distal lamina and the medial border of the
articular processes, associated with the absence of a
variably large portion of the ligamentum flavum. The
less bone removed at surgery, the less evident will be the
bone defect or irregularity. When microdiscectomy has
been carried out, bone removal may be so limited that it
is not detected on the axial images. In these cases, it may
be difficult to identify the site of the previous operation,
particularly when only the most lateral portion of the
ligamentum flavum has been removed. If a fat graft has
been placed on the site of laminotomy or laminectomy,
the axial scans will clearly show the fat tissue.
CT carried out in basal conditions very often does not
allow a clear-cut distinction between peridural fibrosis
and persistent disc herniation or recurrent herniation.
c The distinction is difficult particularly in the first few
weeks after surgery. In this period, in fact, peridural
Fig. 9.32. Calcification of the posterior annulus fibrosus. Axial CT scar tissue is more abundant and lax, thus displaying a
images with a window level for soft tissues (A) and bone (B), and sagit- more comparable density to that of the disc, than in a
tal reconstruction with a window level for bone (C). Only from the later period. On the other hand, in the first few weeks
reconstruction is it possible to determine that the hyperdense bar visible the herniated disc often shows a persistent protrusion,
on axial images does not originate from the vertebral end-plate, but is an
annular calcification. being at times only slightly smaller than that present
preoperatively (142); this occurs, above all, in patients
with a contained central herniation or when the
axial images show a curved bony structure parallel to nucleus pulposus is only slightly degenerated.
the posterior wall of the vertebral body and associated At long time interval from operation, CT should
with the hypodense herniated tissue (15) (Fig. 9.33). always be performed without, and with, contrast
Sagittal reconstructions reveal the defect in the verte- medium, since the latter allows scar tissue to be more
bral edge. easily differentiated from the herniated disc tissue
(63,204).
In CT without contrast medium, scar tissue is hypo-
Postoperative CT dense compared with the herniated tissue (47). More
important distinguishing features, however, are the site
The changes in vertebral bony structures produced by and morphology of the abnormal tissue (32). A disc
surgery depend on the extent of the surgical approach herniation has the characteristics of a soft tissue
to the spinal canal. Hemilaminectomy or central originating from a limited area of the disc and tends
laminectomy are easily recognized due to the absence of to produce a mass effect on the thecal sac. The scar
a variably large portion of the posterior arch on one or tissue has a cord-like appearance and often surrounds
and retracts the thecal sac, with no mass effect on it. canal. Use of the contrast medium may help in making
After administration of contrast medium (fast infusion the diagnosis, since the scar tissue becomes hyperdense
of 2 ml/kg b.w.) a recurrent herniation shows no with respect to the nerve root, which does not take up
change in density, whereas the fibrous tissue shows an the contrast agent.
increase in density, thus enabling it to be more easily
distinguished from disc tissue (Figs. 9.34 and 9.35). The
increase will depend upon the volume of contrast agent Lumbar stenosis
injected (47), as well as the degree of vascularization
of the fibrous tissue. Stenosis of spinal canal
In the operated patient, stenosis of the spinal canal or
the nerve-root canal may be present at the level of With the exception of rare forms of stenosis (post-
surgery. In these cases, the stenosis was generally pre- traumatic, congenital or due to Paget's disease), the
sent prior to the operation and was not significantly axial CT scans at the level of the middle portion of the
modified by the latter. This holds particularly when the vertebral body consistently show a normal or narrow
articular processes have been left almost intact or spinal canal, but not stenosis. The latter appears to be
laminotomy was not extended adequately proximally present only on the sections between the zone immedi-
or caudally to the disc. However, in patients submitted ately proximal to the lower apophyseal ring of a verte-
to discectomy since a long time, stenosis may result bra and the cranial portion of the pedicle of the vertebra
from degenerative changes which have developed over below (Fig. 9.36).
the years following surgery. In constitutional stenosis, degenerative changes, if
With CT, it is often difficult to determine whether present, are only mild. The intervertebral disc often
narrowing of the nerve-root canal causes compression shows bulging of the annulus fibrosus or a herniation,
of the emerging root, due to difficulty in identifying the mostly on the midline. Usually the nerve-root canals
nerve root within the scar tissue present in the spinal are moderately constricted. The same holds for the
9.-------------------------------------------------------------------------
A B
B
Isolated nerve-root canal stenosis
Fi .9.37. Stenosis of the 51 nerve-root canal on the left. The axial section at the level of the disc (A) shows no pathologic conditions. The sections at the
le!l of the upper vertebral end-plate of 51 (B) and (C) show anterior osteophytes on the left, encroachmg on the nerve-root canal and zmpmgmg on the
51 root (arrows).
A B c
Fig. 9.38. Normal sagittal MR images. (A) Spin-echo (TR 500, TE 20) Tl-weighted slightly paramedian image. The vertebral end-plates (large arrow-
head) display a low signal intensity, since they consist of compact bone, whereas the trabecular bone of the vertebral body is hyperintense due to the pres-
ence of bone marrow. The intervertebral discs have normal height and are isointense to the muscle tissue. The thecal sac is considerably hypointense due
to the presence of CSF; a few rootlets of the cauda equina, showing slightly higher signal intensity, are visible within the sac (small arrowhead). The
epidural fat (black asterisk) displays high signal intensity. The posterior longitudinal ligament (short arrows) and the anterior longitudinal ligament
(double arrowhead) appear as thin hypointense lines. The basivertebral vessels (long arrows) are hypointense. The interspinous and yellow ligaments
(white asterisks) are visible between the spinous processes. (B) Spin-echo (TR 3000, TE 9) turbo T2-weighted midline image. The vertebral bodies are
hypointense; an hyperintense area (long arrows) due to the basivertebral vessels is visible in some of them. The intervertebral discs show a peripheral
hypointense portion corresponding to the annulus fibrosus, and a central hyperintense portion corresponding to the nucleus pulposus. Within the lat-
ter, small hypointense areas can be seen in afew discs. The hypointense area between the nucleus pulposus and the vertebral body (large arrowhead) cor-
responds to the vertebral end-plate. The CSF gives the thecal sac a marked signal hyperintensity. The epidural fat (black asterisk) is visible only dorsally
to the thecal sac and is only slightly less intense than the CSF. The short arrow indicates the posterior longitudinal ligament. The ligamenta [lava (white
asterisks) are hypointense. (C) Tl-weighted sagittal image at the level of the intervertebral foramens. The nerve roots (small arrowhead) surrounded by
epidural fat (black asterisk) are clearllf l'l·sible.
ble for the hypo signal on II-weighted, and the hyper- ments can be seen, connecting the thecal sac to the
signal on T2-weighted, images. The annulus fibrosus is vertebral body (Fig. 9.39).
slightly hypointense compared with the nucleus The ligamenta flava are not visible on midline sagit-
pulposus due to its lower water content. In adult tal sections, whilst they can be clearly seen on parame-
subjects, and particularly in the elderly, the nucleus dian scans and II axial sections (Fig. 9.39). They appear
pulposus often shows a transverse hypointense stria, as hypointense structures, which fill the interlaminar
resulting from age-related fibrotic changes. With space, on sagittal sections, and delimit the spinal canal
increasing age, the decrease in water content results in posterolaterally, on axial scans.
diffuse reduction in signal intensity of the disc. The ligaments contained in the intervertebral
The posterior longitudinal ligament is often clearly foramen have been visualized with high resolution
visible on T2-weighted midsagittal scans. It appears as techniques (151). In vivo, they may be visible on sub-
a linear structure, adhering to the discs and the verte- pedicular sections (Fig. 9.39).
bral end-plates, but not to the posterior aspect of the The epidural fat, on II-weighted images, shows a
vertebral bodies. The space between the ligament and high signal intensity, which clearly differentiates the
the vertebral body, occupied by fat tissue and the adipose tissue from the surrounding structures (Figs.
branches of the basivertebral vein, generates the 9.38 and 9.39). On T2-weighted sequences, the epidural
marked hypersignal typical of the slow blood flow. fat is hypointense and, thus, poorly distinguished
On axial sections the ligament appears as a midline from the other structures, except for the CSF. The latter,
septum, hypointense with respect to the fat tissue which have long relaxation times, generates a low
separating it from the thecal sac (Fig. 9.39). In these intensity signal on II-weighted sequences and a high
sections, the middle and lateral meningovertebralliga- intensity signal on T2-weighted sequences. Turbo T2
Fig. 9.39. Spin-echo Tl-weighted axial MR images. The images are sequential from the caudal half of the L4 vertebra to the 51 vertebral end-plate. The
arrowheads indicate the L4 nerve root in the L4 radicular canal (L4 1) and the L4-L5 intervertebral foramen (from L4, to L4-53 ), the L5 root in the L5
radicular canal (L5" L5,) and the L5-51 intervertebral foramen (L5 3, L5-51), and the 51 root in its radicular canal (51). The double arrowheads indi-
cate the L5 root emerging from the thecal sac (L4-5); the nerve roots are visible, in the sac, as roundish structures displaying a similar signal intensity
to the C5F. The short arrows point to the anterolateral venous plexuses of the spinal canal. The black asterisks indicate the considerably hyperintense
epidural fat. The white asterisks are placed on the superior articular processes ofL5 (from L43 to L4-5) and 51 (L5 3). At L4-5, level, an asterisk is placed
also on the inferior articular process of L4; the two asterisks are separated by two linear structures with no signal corresponding to the cortical bone,
between which there is a hypointense zone corresponding to the articular cartilage. The white arrow indicates the median meningovertebralligament
and the triangle indicates the lateral meningovertebralligament (L5 u L5). The long arrows indicate the ligamenta flava. The black triangles at L4-52
level indicate linear structures, probably represented by the ligaments in the intervertebral foramen. L indicates the laminae ofL4 (from L42 to L4-51),
L5 (L5 1, L5,) and 51 (51). Note the signal hypointensity of the disc compared with that of the vertebral body; the areas showing lower signal intensity
at L5-51 and 51 correspond to portions of the disc.
244. Chapter 9 . - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Disc degeneration
Degenerative changes of the disc present with a reduc-
tion in signal intensity on T2-weighted sequences.
Numerous studies have shown that the decrease in
signal intensity is related to loss of hydration and
proteoglycan, typical of physiologic (age-related) and
pathologic degeneration (22, 99, 109, 140, 155, 173,205).
Furthermore, several post-mortem and in vivo studies
have demonstrated that intervertebral discs showing
fissures in the annulus fibrosus or avulsions of the
cartilage end-plate present a decrease in signal
intensity (36, 189, 190, 238, 239).
In MRI studies on cadavers, circumferential and
radial fissures in the annulus fibrosus have been visua-
lized, on T2-weighted sequences, as areas of high signal
intensity in the context of the hyposignal of the rest of Fig. 9.43. Spin-echo T2-weighted MR image. Puntiform hyperintense
the annulus (241). The high signal intensity appeared to area in the annulus fibrosus of a disc showing a marked hyposignal due
be due to the presence of fluid or mucoid material in the to degenerative changes.
fissures. In vivo, fissures have initially been identified,
on II-weighted images after intravenous injection of
gadolinium (gadolinium-labeled diethylenetriamine
pentacetate), as areas of hypersignal in the peripheral
portion of the disc; the increased signal intensity would
thus be due to the presence of granulation tissue in the
fissures (178). On T2-weighted images, obtained in
basal conditions, two types of hyper signal, correspond-
ing to fissures in the annulus fibrosus, may be seen:
puntiform areas of high signal intensity showing no
communication with the nucleus pulposus and striae
communicating with the nucleus (Figs. 9.43 and 9.44).
The former may be observed in degenerated discs
(signal hypointensity of the nucleus pulposus) or in
otherwise normal discs. The latter result from penetra-
tion of the nucleus pulposus into the annulus fibrosus Fig. 9.44. Spin-echo T2-weighted MR image. Hyperintense stria, which
and are almost consistently associated with reduction from the nucleus pulposus reaches the peripheral portion of the annulus
in signal intensity of the nucleus pulposus. In the fibrosus.
9.----------------------------------------------------------
presence of high-signal-intensity areas of the first type, very initial signs of disc degeneration, preceding the
discography may show an annular fissure and may biochemical changes.
give rise to pain (10). In a study (187), the pain provo- In the posterior annulus fibrosus, large areas of
cation test was positive in 87% of cases in which the disc hypersignal on T2-weighted images are rarely visible
showed areas of high signal intensity in the annulus (Fig. 9.45). The high signal intensity might result from
fibrosus, whereas it was negative or only mildly posi- ingrowth of vessels and granulation tissue in the
tive in 97% of cases showing no hyperintense areas; peripheral portion of the disc.
this suggests that the presence of high-signal-intensity In severely degenerated discs displaying a vacuum
areas is a reliable index of symptomatic degenerated phenomenon, the gradient echo sequences are more
disc. On the other hand, it is well known that a disc with sensitive than spin-echo sequences in demonstrating
annular fissures demonstrated at discography may the intradiscal gas, which appears as an area of marked
appear normal at MRI (36, 116, 240, 242). hyposignal (21, 83).
These findings indicate that a disc with normal
features at MRI may not have necessarily a normal
structure and that the decrease in signal intensity only Bone marrow
demonstrates that the disc presents biochemical
changes, which may not be associated with macroscop- Modic et al. (141), in the presence of degenerative disc
ic or microscopic changes in the nucleus pulposus or changes, described three types of changes in the verte-
the annulus fibrosus (205). This, however, is likely to be bral end-plates and bone marrow of the vertebral body.
very uncommon when the disc shows a loss of height In Type I, the yellow marrow in the subchondral bone is
and is considerably hypointense at MRI. On the other replaced by fibrovascular tissue; this causes a decrease
hand, markedly degenerated discs may display an in signal intensity on Tl-weighted images and an
increase in signal intensity, probably due to replace- increase on T2-weighted sequences. In Type II, there is
ment of fibrocartilaginous tissue with degenerated an increase in the amount of yellow marrow in the sub-
tissue presenting a high fluid content (238). chondral bone, wich results in signal hyperintensity on
Scheibler et al. (189), using high TRITE, have Tl-weighted images and isointensity, or slight hyper-
observed two types of changes both in otherwise nor- intensity, on T2-weighted sequences (Fig. 9.46). Type III
mal discs and in degenerated discs. The changes con- is characterized by thickening of the bone trabeculae in
sisted in curving of the inner annular lamellae and the the subchondral region, resulting in a decreased signal
presence of a hypointense puntiform area in the central intensity both on Tl- and T2-weighted images. Only
zone of the disc. These abnormalities could represent occasionally do these three types of change co-exist in
A B c
Fig. 9.45. (A) Spin-echo T2-weighted MR image. A large hyperintense area (arrowhead) is visible in the posterior portion of the annulus fibrosus of the
L4-L5 disc, which shows a decreased signal intensity. (B) Turbo spin-echo T2-weighted MR image. The area of high signal intensity in the annulus
fibrosus is roundish on axial section (arrow). (C) Spin-echo Tl-weighted MR image. The posterior portion of the L4-L5 annulus fibrosus shows a zone
of decreased signal intensity with puntiform hyperintense areas (arrow).
_______________________________________________________ 0Imaging studies 0247
Furthermore, on lateral para sagittal sections, the lower- respect to the epidural fat, whereas on T2-weighted
most intervertebral discs may show a non-pathologic scans the herniation shows a lower signal intensity than
posterior bulging, usually due to a decrease in disc the CSF contained in the thecal sac and the nerve-root
height. During the day, posterior bulging of the annu- sleeves. When the disc of origin is severely degenerated
lus fibrosus may increase, whereas the signal intensity or the herniation is long-standing, the herniated tissue
of the disc shows no significant change (195). may be markedly hypointense and, thus, be difficult to
distinguish from osteophytes of the vertebral body.
A contained herniation is characterized by the pres-
Disc herniation ence of a peripheral hypointense rim, corresponding to
the still intact portion of the annulus fibrosus (Fig. 9.48).
The signal intensity of herniated tissue is similar to that In extruded herniations, the hypointense rim typical
of the disc from which it originates. On Tl-weighted of a contained herniation cannot be seen (82). In the
sequences, the herniated tissue is hypointense with extruded subligamentous herniation, the annulus fibro-
A 8 c
Fig. 9.49. Retroligamentous extruded L4-L5 disc herniation. Spin-echo Tl-weighted sagittal image (A), turbo spin-echo T2-weighted sagittal image
(B) and spin-echo Tl-weighted axial image (C). A mass of disc tissue is visible in front of the disc and behind the posterior longitudinal ligament. A thin
pedicle of tissue joins the mass to the parent disc.
-------------------------------------------------------o Imagingstudies o249
sus is interrupted, whilst the posterior longitudinal shows a high signal intensity compared with the disc of
ligament is intact. Occasionally, the ligament appears origin (129). This occurs particularly when the fragment
to be raised and displaced posteriorly by the extruded has only recently migrated from the disc. At long term,
fragment. Instead, in transligamentous or retroliga- on the other hand, the signal becomes hypointense on
mentous extruded herniations, the ligament appears T2-weighted sequences. It may, at times, be difficult to
to be interrupted (Fig. 9.49). In extruded herniations determine whether a herniated disc is extruded or
of any type, a strand of disc tissue joining the extruded migrated. This holds particularly when a large frag-
fragment to the intervertebral disc is almost always ment has migrated at a distance from the disc, but still
visible. The connecting strand is clearly visible on sagit- appears to have a thin strand of tissue connecting it to
tal T2-weighted sections (129). the parent disc (Fig. 9.51). In these cases, it is preferable
In migrated herniations, the disc fragment has no to consider the herniation as migrated, at least for
connection with the disc of origin (Fig. 9.50). On T2- surgical purposes, since, when operating, the surgeon
weighted sequences, the migrated fragment usually should look for the herniated tissue at a distance from
B c
Fig. 9.51. Retroligamentous extruded disc herniation, migrated proximally, at L5-S1 level. Spin-echo T1-weighted (A) and (B), and turbo spin-echo
T2-weighted (C) sagittal images. The herniated disc fragment has migrated cranially as far as the proximal one third of L5, but it appears to be
connected to the disc by a thin pedicle of tissue on the turbo T2-weighted image. This herniation may be classified as extruded or migrated. From the
surgical viewpoint, it is preferable to classify it as migrated.
9.------------------------------------------------------
the disc. The disc fragment may migrate cranially or which occupies the intervertebral foramen and obliter-
caudally. In some studies, the frequency of cranial ates the fat that it contains. Often the herniation is better
migration was found to be comparable to (188), or only visible on sagittal paramedian sections than on axial
slightly greater than (46), that of caudal migration; in scans. The herniated disc tissue may be clearly seen on
other studies, there was a definite predominance of Tl-weighted sagittal sequences due to its considerably
cranial (68) or caudal (229) migration. In our experience, lower signal intensity compared with the epidural fat.
caudal migration is much more common, if migrated Intraforaminal herniations frequently migrate behind
intraforaminal herniations are excluded. If these herni- the body of the vertebra above. Generally, the migrated
ations, which almost always originate from the disc fragment is clearly visible on Tl-weighted axial sec-
below, are included, cranial migration prevails. The tions, showing the disc tissue at the level of the infero-
disc fragment almost consistently migrates laterally to lateral portion of the vertebra above the herniated
the midline. This is due to the presence of the median disc (Fig. 9.53). On Tl-weighted sagittal sections, the
meningovertebralligament; only when the latter is per- fragment may be barely recognizable, since its signal
forated or detached from the vertebra, will the herniated intensity is similar to that of the nerve root.
tissue migrate in the midline (188). Exceptionally, a disc Extraforaminal herniations cannot generally be
fragment may migrate behind the thecal sac (Fig. 9.52). seen on sagittal sections, but are clearly visible on axial
Lateral herniations may be intraforaminal, extra- sequences (Fig. 9.54). In these sequences, the lateral
foramina I or, more often, both intra- and extraforami- margin of the disc shows a focal convexity, obliterating
nal. They represent 1% to 11% of all lumbar disc the paravertebral fat tissue and impinging on the nerve
herniations (1, 150). root in its extraforaminal portion (81). The herniated
An intraforaminal herniation appears as disc tissue tissue is almost always in contact with the contents of
-~---------------------------·lmaging studies· 251
the disc. In these herniations, the lateral portion of the In osteochondral avulsions of the posterior border of
vertebral end-plate may appear hypointense and the vertebral end-plate, MRI shows a hypo intense
display thin spurs resulting from avulsion of Sharpey's linear structure corresponding to Sharpey's fibers
fibers. which have remained intact posteriorly to the hernia-
Intraforaminal and extraforaminal herniations may tion, and a structure showing the features of the cortical
be difficult to recognize at a superficial evaluation of bone at the level of the posterior margin of the vertebral
MRI or CT scans; indeed, in the series of Osborn et al. end-plate. The result, on sagittal scans, is a Y or 7
(154), the herniation was not diagnosed at first evalua- configuration at the level of the disc and the avulsed
tion in 15 out of 50 cases. Conversely, lateral bulging of end-plate (15) (Fig. 9.55).
annulus fibrosus, or the nerve root in the intra- or Usually, disc herniations can easily be differentiated
extraforaminal course, may be mistaken for a lateral from synovial cysts. These can be recognized by their
herniation. lateral extradural location, adjacent to the apophyseal
In intradural herniations, a tissue with the features joint from which they originate, and the characteristics
of the intervertebral disc inside the thecal sac may be of the MRI signal, which is usually hyperintense on
observed at MRI. In these cases, administration of T2-weighted images and hypointense on II-weighted
gadolinium is necessary to exclude the condition to scans due to the serous content of the cyst (106,124, 174).
be an intradural tumor. It will be easier to make diag-
nosis if a strand of tissue is seen connecting the Gadolinium
intradural portion of the herniation with the parent disc.
Furthermore, T2-weighted images may show a hyper- The use of gadolinium is not usually necessary in
intense rim, indicating inflammatory processes (103). patients who have not previously undergone surgery,
252. Chapter 9. - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
A B
A B
unless differential diagnosis has to be made between a lesion has the features of a herniated disc, but, when
herniated disc and a neoplastic condition. there is any doubt, administration of contrast medium
A disc herniation does not usually show an increase may solve the problem, due to enhancement of signal
in signal intensity after administration of contrast intensity by the tumor.
medium. Occasionally, however, signal hyperintensity In the presence of a nerve-root anomaly, axial sec-
may be observed in the peripheral portion of the herni- tions may show, in the site normally occupied by the
ation, particularly in extruded forms, due to the pres- nerve root, two contiguous halos of hyperintensity or a
ence of granulation tissue (175) (Fig. 9.56). An abundant halo of periradicular increase in signal intensity larger
fibrosis around the herniated disc may be predictive of than normal, which may allow the anatomic anomaly
a decrease in size or disappearance of the herniation to be differentiated from a disc herniation.
with time. Similarly, the compressed nerve root, or
sometimes even the contiguous roots, may appear
hyperintense after gadolinium injection as a result of Postoperative MRI
inflammatory processes; in some cases, the hyper-
intensity disappears with time (43). The changes in lamino-articular bony structures pro-
Lumbar neurinoma or meningioma consistently duced by surgery are similar to those visible on CT
show an increase in signal intensity after administra- scans. A fat graft placed at the site of the surgical
tion of gadolinium, which easily allows a disc hernia- approach appears as a hypointense structure on T1-
tion to be distinguished from tumoral conditions. weighted sequences, which occupies the site of lamino-
Occasionally, also a herniated disc shows an increased tomy or laminectomy (Fig. 9.58). Occasionally, in the
signal intensity after gadolinium administration; how- site of surgical approach, images of decreased signal
ever, unlike in tumors, the enhancement is dyshomoge- intensity are visible, which represent an artifact due to
neous because it occurs in the granulation tissue which small residual metallic fragments, originating from
surrounds the herniation, but not in the central portion surgical instruments (95) (Fig. 9.59).
of disc tissue (Fig. 9.57). Pseudoenhancement in signal In the immediate postoperative period, blood accu-
intensity of a herniated disc may occur in the presence mulates in the site of the surgical approach. The blood
of hyperplasia of the venous epidural plexus which subsequently undergoes a process of organization and,
surrounds the herniation (12). Lateral disc herniations in the next few months, the initial hematoma is replaced
may simulate a neurinoma of the nerve root, since the with fibrous tissue. The signal of the extravasated
herniated tissue may be difficult to distinguish from the blood is isointense to the muscle tissue, on Tl-weighted
compressed root. MRI may clearly demonstrate that the sequences, and markedly hyperintense, on T2-weighted
254· 9.--------------------------------------------------------------
nervous structures and had an intermediate signal
intensity with peripheral enhancement after adminis-
tration of gadolinium in 38% of cases 3 weeks after
surgery and in 12% after 3 months. Thus, in the first few
months after surgery, and particularly in the first few
weeks, MRI is of little diagnostic value as far as con-
cerns the presence of herniated disc tissue responsible
for the persistence or recurrence of radicular symp-
toms. Therefore, in the early postoperative period, the
investigation should usually be carried out only when
surgical complications are suspected, such as a large
hematoma, pseudomeningocele or discitis, or the
persistence of an extruded or migrated disc fragment.
When radical discectomy has been performed, the
adjacent vertebral end-plates may show a focal or
diffuse hypo signal on II-weighted images in basal
conditions and an increased signal intensity after
Fig. 9.58. Spin-echo Tl-weighted axial MR image showing a fat graft
(arrows) in the site of laminotomy. administration of gadolinium (79). This change, which
may simulate a disci tis (27), is probably due to reactive
processes in the bone marrow as a result of the surgical
trauma.
Following chemonucleolysis, the disc decreases in
height and, on T2-weighted images, displays a hypo-
signal that tends to persist over the time (112).
In a patient submitted to surgery for lumbar disc her-
niation in whom radicular symptoms reappear at some
considerable time interval after operation, the differen-
tial diagnosis which should most frequently be made is
between recurrent herniation and peridural fibrosis. In
basal conditions, the two diseases may be differentiated
by their morphologic features rather than the signal
intensity (101). The main morphologic characteristics
allowing for identification of the peridural scar tissue
are the irregular configuration and unsharp margina-
tion, and the absence of mass effect on the thecal sac,
which may appear as attracted by the fibrous tissue; the
signal is of varying intensity, but it is generally
hypointense with respect to the disc. In contrast, a
recurrent herniation usually exerts a mass effect 01). the
thecal sac, has curved or lobulated margins and gener-
Fig. 9.59. Turbo spin-echo T2-weighted MR image of a patient operated ally presents the same signal intensity as the disc. In
for disc herniation. Dorsally to the disc, a small hyperintense structure spite of these differences, it may be difficult to differen-
(arrowhead) is visible, presumably represented by a metallic fragment. tiate a recurrent herniation from postsurgical scar
tissue; it is even more difficult to determine the clinical
images. The granulation tissue which develops during significance of scar tissue, which is normally present in
the first few weeks after surgery displays a higher signal operated patients.
intensity than disc tissue and may exert a mass effect on The use of gadolinium considerably increases the
the thecal sac. Both the signal intensity and the mass ability of MRI to differentiate scar from disc tissue,
effect tend to decrease in the first 3 months after surgery thus making the diagnostic accuracy of the investiga-
(Fig. 9.60). Between 3 and 6 months, the mass effect dis- tion very high.
appears and the scar tissue shows a further decrease in After administration of gadolinium, the scar tissue
signal intensity. After 2 years, the scar tissue is generally displays a uniform enhancement of signal intensity
hypointense on T2-weighted sequences (176,197). (Fig. 9.61), whilst in the presence of a recurrent hernia-
In a prospective study on patients successfully oper- tion, no enhancement is observed or the signal intensity
ated on for lumbar disc herniation, Boden et al. (26) increases only in the peripheral portion of the patho-
observed a tissue that exerted a mass effect on the logic tissue (Fig. 9.62). The increase in signal intensity is
A B
related to the density of vessels in the tissue, permeabil- In the presence of a small recurrent herniation sur-
ity of the endothelium of the capillaries (characteristics rounded by abundant scar tissue, the effects of partial
of the tight junctions and pynocytotic vesicles of volume may mask the herniated tissue. Therefore, MRI
endothelial cells, and size of intercellular fissures) and should be carried out prior to, and following adminis-
the dimensions of the extracellular spaces (35, 177). The tration of, the contrast medium, in two spatial planes
scar tissue takes up a relatively large amount of con- (sagittal and axial). The examination in basal condi-
trast, since it has a limited number of vessels, at least in tions can be avoided if the fat suppression technique is
a late phase, but has large intercellular spaces through employed (23, 138). In fact, with this technique, the
which the contrast medium may diffuse. The signal increase in signal intensity of the scar tissue is more
intensity of the scar tissue increases about 1 min after evident and the differentiation of the latter from the
administration of gadolinium, reaching the maximum disc tissue is easier.
values after 5 to 10 min (lOS, 177) and then slowly After administration of gadolinium, radicular hyper-
decreasing. MRI sequences should, therefore, be intensity may occasionally be observed, which may be
obtained within 10 min of injection of the contrast due to chronic inflammation. This change tends to
medium, preferably after 5 min. The increase in signal resolve spontaneously (Fig. 9.63).
intensity of scar tissue after gadolinium may persist for
years after surgery. Usually, however, the enhancement
decreases or even disappears after the first postopera- Lumbar stenosis
tive year (75).
The herniated tissue displays an increased signal Stenosis of spinal canal
intensity after administration of gadolinium, but the
enhancement is less than that of scar tissue and com- MRI has many of the diagnostic potentialities of CT and
mences after 35 min (177). On the sequences obtained myelography. Compared with the latter, MRI has two
later, therefore, it may be difficult to differentiate the disadvantages: 1) dynamic examination cannot be per-
scar tissue from a possible recurrent herniation. formed; 2) in the presence of scoliosis, sagittal images
9.-----------------------------------------------------------------------------
may provide false positive findings or findings of dubi- vertebral end-plate or, in the presence of degenerative
ous interpretation due to the obliquity of the scanning spondylolisthesis, the posterosuperior border of the
plane with respect to the longitudinal axis of the spine vertebra below the slipped one (Fig. 9.65). On T2-
in the scoliotic area (164). The latter inconvenience may weighted sequences, lateral sagittal sections reveal an
be partially overcome by modifying the direction of the interruption of the image of the sac at intervertebral
scanning plane when examining the various portions level due to stenosis of the nerve-root canal.
of the scoliotic curve. II-weighted axial scans show similar findings to
In the presence of a narrow spinal canal (constitution- those of CT: a decreased transverse area and / or defor-
al or achondroplasic), MRI shows short interpedicular mation of the thecal sac, which may be compressed
and/ or sagittal diameters of the spinal canal and short ventrally by a bulging annulus fibrosus or a disc herni-
sagittal and transverse dimensions of the thecal sac. ation; a decrease in amount or disappearance of the
In stenosis of the spinal canal, the T2-weighted epidural fat; a possible thickening of the ligamenta
sequences, simulating the myelographic images, are £lava; lack of distinction of the spinal nerve roots in the
the most suggestive (Fig. 9.64 A). The latter, and even radicular canal (Figs. 9.64 C and 9.65 C). In a study
more the T2-star sequences, enhance the signal of the (90), a transverse area of the thecal sac less than 100
CSF and, thus, the severity of thecal sac compression. mm 2 was found to be indicative of a clinically sympto-
Midsagittal and paramedian scans show constriction matic stenosis.
of the central portion of the spinal canal. Sagittal and Compared with CT, MRI is better able to reveal the
axial II-weighted images at the level of stenosis show a ligamentous structures and a disc herniation that may
decrease in amount or complete lack of the epidural fat be associated with stenosis (Fig. 9.66). The osteophytes
and a posterior indentation of the thecal sac. The inden- may be distinguished from the herniated disc tissue
tation is produced by the posterior vertebral arch since they show a marked hyposignal in all sequences,
and / or thickened ligamenta £lava encroaching on the both II- and T2-weighted. However, it may be difficult,
spinal canal. Ventrally, the thecal sac may be com- also with MRI, to obtain good visualization of the thecal
pressed by the intervertebral disc, osteophytes of the sac when this is markedly constricted.
____________________________ 0 Imaging studies 0257
A c
Fig. 9.62. Recurrent L4-LS disc herniation on the left. (A) and (B) Spin-echo Tl-weighted MR sagittal image and spin-echo Tl-weighted axial image
showing pathologic tissue, isointense to the disc, anteriorly to the thecal sac. (C) Spin-echo Tl-weighted axial image obtained after injection ofgadolin-
ium: the pathologic tissue shows signal enhancement in the peripheral, but not the central, portion (arrowhead). These findings indicate the presence of
a recurrent disc herniation surrounded by scar tissue.
Isolated nerve-root canal stenosis stricti on of only the lateral portion of the osteoligamen-
tous spinal canal, to which a bulging annulus fibrosus
This condition may be demonstrated both by axial Tl- or a contained disc herniation may be associated. Of the
weighted scans and sagittal scans. The axial images sagittal sections, the most diagnostic are the paramedi-
show constitutional narrowing or degenerative con- an T2-weighted sections, showing constriction or inter-
258.Chapter 9 . - - - - - - - - - - - - - - - - - - - - - - - - - - - -
B c
Fig. 9.64. Stenosis of the spinal canal at L3-L4 and L4-L5. The turbo spin-echo T2-weighted
sagittal image (A) shows, at the stenotic levels, posterior compression of the thecal sac by
thickened ligamenta flava (arrows), as well as anterior compression by the disc. The spin-echo
Tl-weighted axial image at the level of L4 pedicle (B) reveals the normal width of the spinal
canal. By contrast, the spin-echo TI-weighted axial image at L4-L5 intervertebral level (C)
shows constriction of the canal, thickening of the ligamenta flava. absence of the epidural fat
and reduced diameters of the thecal sac.
B c D
Fig. 9.65. Stenosis of the spinal canal at L4-L5 level in the presence of degenerative spondylolisthesis of L4. The turbo spin-echo T2-weighted sagittal
image (A) reveals marked compression of the thecal sac between the posterosuperior border ofL5 and the posterior arch ofL4. The spin-echo T2-weight-
ed axial images at the level of the pedicle ofL4 (B) and L5 (D) show a normal spinal canal, whereas that at L4-L5 intervertebral level (C) shows severe
constriction of the canal.
- - - - - - - - - - - - - - - - - - - - - - - - - - - . Imaging studies· 259
A c
B o E
Fig. 9.66. Multiple disc herniations in a patient with mild constitutional stenosis of the spinal canal. On CT scans at L3-L4 and L4-L5 levels (A) and
(B), the image of the thecal sac is hardly distinguishable from that of the disc herniation. On the spin-echo Tl-weighted axial MR images at the same
levels (C) and (D), the thecal sac compressed by the disc herniations (arrowheads) and narrowing of the spinal canal are clearly visible. The pathologic
conditions are even better evident on the turbo spin-echo T2-weighted sagittal image (E).
ruption of the image of the CSF in the lateral portions of nerve root. It should be stressed, however, that narrow-
the spinal canal at intervertebral level; this holds both ing of the foramen is a frequent finding in patients with
for pure forms of stenosis and those associated with a marked arthrotic changes, whilst an unequivocal com-
herniated disc (Fig. 9.67). Coronal sections may also be pression of the nerve root by the bony structures or the
useful to demonstrate compression of the nerve root in ligamentum flavum covering the superior articular
a stenotic radicular canal. process is rarely observed.
In isthmic spondylolisthesis, the intervertebral fora-
men may appear stenotic and distorted on paramedian
Stenosis of intervertebral foramen sagittal images. In these cases, an indication of stenosis
is provided by the lack of the periradicular fat, which is
MRI is the most useful investigation in stenosis of the clearly demonstrated by Tl-weighted sagittal images
neuroforamen, since it allows both the osteoligamen- (84).
tous walls of the foramen and the nerve root surround-
ed by the periradicular fat tissue to be visualized.
The bony degenerative changes are better seen on T2- Diagnostic accuracy: MRI compared
weighted sequences, whereas the nerve root, periradic- withCT
ular fat and ligamentous structures are more clearly
visible on Tl-weighted sequences. In the presence of Numerous studies have analyzed the diagnostic accu-
compression of the nerve root or the dorsal root gan- racy of MRI and CT in lumbar disc herniation, in
glion, sagittal scans reveal narrowing of the foramen, patients submitted to only one of the two investigations
generally due to spondylotic changes, disappearance of or both. The reported percentages range from 76% to
periradicular fat and a decreased transverse area of the 96% for MRI (50, 53, 65, 92, 106, 108, 115, 139,202) and
260.Chapter 9.--------------------------------------------------------
Fig. 9.67. Left L4-L5 disc herniation associated with nerve-root canal stenosis. (A) Turbo spin-echo T2-weighted sagittal left paramedian image show-
ing a subligamentous extruded L4-L5 disc herniation and posterior compressioll of the thecal sac by hypertrophic ligamelltum flavum (arrow). (B) and
(C) Spill-echo Tl-weighted axial images showing the disc herniation on the left (arrowheads) and cOllstriction of the nerve-root canal.
from 72% to 93% for CT (19, 20, 30, 50, 62, 93, 106, 139, that ofCT.
145) (Table 9.1). In most studies, diagnostic accuracy The diagnostic ability of the two investigations
both of MRI and CT was found to be approximately seems to be comparable also in lumbar stenosis, isolat-
80%-90%. The studies (50, 106, 139) in which both ed or associated with a herniated disc (113). In operated
investigations were analyzed report similar diagnostic patients, instead, the diagnostic accuracy of MRI seems
accuracy for the two modalities (Table 9.1). Even using to be slightly higher than that of CT (page 586).
the ROC (receiver operating characteristic) analysis, Studies on the accuracy of diagnostic methods in disc
few differences have been found between the two types herniations or lumbar stenosis have several limitations
of investigation (209). In a study (4), in which the diag- which may affect the results. The evaluation of diagnos-
nostic ability of both investigations was evaluated by tic accuracy is usually based on surgical findings. These,
ER (expected regret) factor, the largest amount of however, do not necessarily represent an accurate refer-
diagnostic information was provided by CT. This, on ence, since not only is surgery generally carried out only
the other hand, was found to provide more information at the levels where the preoperative investigations
than MRI in differentiating contained, from non- show a pathologic condition, but also the detection and
contained, herniations (50). The available data, there- evaluation of the latter depend, to a large extent, on
fore, indicate that the ability of MRI to identify the site its characteristics and the experience of the surgeon.
and type of herniation is not Significantly better than Furthermore, an important role is played by other fac-
tors, such as quality of the equipment used and
improvements made over the years to their technical
Table 9.1. Diagllostic accuracy of CT and MRI in lumbar disc
herniatiolls. characteristics. Comparisons between CT and MRI
made in the 80's may no longer be valid, since the actual
CT MRI
CT equipment has not significantly changed, whereas
Haughton (1982) 88% Edelman (1985) 90% the spatial resolution of MRI has considerably
Berlin (1983) 80% Modic (1986) 82% improved. Also the differences in the interpretation of
images by different observers, related to the ability of
Moufarrij (1983) 72% Forristal (1988) 90%
the latter to correctly evaluate the investigations, may be
Bell (1984) 72% Szypryt (1988) 88% important, and this holds more for a recently developed
Bosacco (1984) 92% Jackson (1989) 76% diagnostic modality, such as MRI, than for CT. In spite of
these observations, CT still plays a primary role in the
Firooznia (1984) 93% Hashimoto (1990) 77%
diagnosis of lumbar disc herniation and spinal stenosis.
Modic (1986) 83% Kim (1993) 85% This does not hold, instead, for disc degeneration, in
Jackson (1989) 73% Janssen (1994) 96% which MRI is definitely better than CT, since the latter
provides no information on hydration of the disc or the
Dullerud (1995) 87% Dullerud (1995) 93%
presence of fissures in the annulus fibrosus.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - . Imaging studies· 261
A B c
Fig. 9.71. Myelo-CT scans in a patient with an osteochondral avulsion of the posterosuperior border of the LS vertebral body. The axial scans at L4-LS
level show a herniated disc and a defect in the posterior portion of the vertebral body (A) and (B) and a bony fragment impinging on the thecal sac (B).
The osteochondral avulsion is clearly visible on the saxittal reconstruction (C).
-------------------------------------------------------0 Illlaging studies 0263
c
5
A
Fig. 9.72. L4-L5 intradural disc herniation in the presence of spondylolisthesis ofL4.
The lateral myelogram (A) shows a complete block of the contrast medium, which, on the
oblique view (B), has clear-cut, dome-like margins. On axial myelo-CT (C), the thecal
sac appears almost completely occupied by a tissue with a similar density to the disc
(arrow) and in continuity with it. Sagittal (D) and coronal (E) reconstructions confirm, __------~~~--___ D
respectively, that the block of contrast is due to disc herniation and that the block has
dome-like margins as typically occurs in the presence of an intrathecal mass.
Diagnostic accuracy and indications the severity and cause of compression of the nerve root
running in a stenotic radicular canal; and 3) demon-
The diagnostic accuracy of myelo-CT has been found to strate nerve-root compression by a small disc hernia-
range from 57% to 89% (65, 106, 108, 139, 221), being tion. Also in these cases, however, myelograms should
approximately 80% in most studies. Myelo-CT was generally be obtained prior to myelo-CT scans.
generally found to be more diagnostic than myelo- In patients with suspected recurrent disc herniation,
graphy and CT, and equally or less diagnostic than MRI. myelo-CT is rarely indicated, since it is no better than
However, if myelo-CT and myelography are evaluated CT in differentiating scar tissue from recurrent hernia-
together, the proportion of cases correctly diagnosed tion. One exception, however, concerns the patients
increases considerably (221). In stenosis, myelo-CT has with metallic vertebral implants, in whom MRI may
a higher diagnostic capacity than CT or MRI. not be carried out and the CT images may show artifacts
Secondary myelo-CT is indicated when myelo- making identification of the anatomic structures
graphy does not demonstrate adequately the pathologic difficult. Usually, the presence of the contrast medium
condition. This may occur in the presence of a migrated considerably improves the visalization of the nervous
disc herniation or, more often, of nerve-root canal structures.
stenosis or a block of the contrast medium of uncertain
etiology. Primary myelo-CT may be useful to: 1) differ-
entiate isolated central stenosis from stenosis associat- Discography
ed with disc herniation, and to evaluate the severity of
compression of the nervous structures, in patients who Discography, introduced into the clinical practice by
cannot undergo MRI; 2) demonstrate and/ or evaluate Lindblom (123), consists in the injection of contrast
-------------------------------------------------------0 Imaging studies 0265
medium into the area occupied by the nucleus pulpo- After discography, the patient is allowed to walk
sus. This investigation may provide two types of diag- with no restriction, unless the pain caused by the pro-
nostic information: 1) the fluoroscopic or radiographic cedure is unusually severe. Discography may, there-
image reveals the morphology of the nucleus pulposus fore, generally be carried out on an outpatient basis.
and the possible presence of clefts in the annulus fibro- Occasionally, the patient may experience asthenia,
sus; 2) distension of the annulus fibrosus by the contrast vertigo or nausea soon after the procedure. These
medium may provoke low back and / or radiated pain; disturbances are due to a decrease in blood pressure
this may allow differentiation of an asymptomatic caused either by psychologic stress or by the local
degenerated disc from a degenerated disc responsible anesthetic, both of which are usually resolved within a
for back pain. few minutes.
annulus fibrosus, may be visible. In the severely degen- Pain provocation test
erated disc, the contrast agent can completely or exten-
sively opacify the disc. The image of the contrast Injection of contrast medium into a normal disc usually
medium may be either homogeneous or irregular due causes no pain or produces only a feeling of painful ten-
to opacified areas alternated with radiolucent zones. sion. When injected into a degenerated disc, the con-
A contained herniation is characterized by the trast agent may produce no pain or the pain usually felt
Disco-CT
B
Fig. 9.80. Disco-CT. (A) Axial scan. (B) Sagittal reconstruction.
Subligamentous extruded herniation: the contrast medium opacifies the
herniated tissue (arrows).
the root when the patient is awake causes a sharp radic- Discography is highly accurate in identifying a degen-
ular pain, leading the operator to change the direction erated disc responsible for low back pain, provided the
of the needle. radiographic image and the response to the pain provo-
The frequency of spondylodiscitis, in clinical series cation test are evaluated concomitantly (223). In studies
including discographies of more than 1500 discs based on the evaluation of both parameters, the
(11, 41, 196, 227, 234), ranges from 0.05 (41) to 0.6% proportion of false positives (1 / specificity) ranged from
(227). In contrast with these figures, Fraser et al. (66) oto 13% (87,220,223). On the other hand, Vanharanta
found disci tis in 2.3% of 432 patients submitted to et al. (220) found that 93% of patients in whom the pro-
discography. The prevalence of infectious complica- voked pain was of similar intensity as the preprocedur-
tions was 2.7% when the procedure was carried out al pain had severely or moderately degenerated discs.
using a single needle with no stylet. In the patients in However, in patients with chronic low back pain who
whom two needles with a sty let - a guiding needle and have an abnormal disco gram and a negative pain
a needle, inserted in the former, to penetrate into the provocation test, no studies have demonstrated that the
disc - the prevalence of complications decreased to back pain cannot originate from the degenerated disc.
0.7%. This is probably due to the lower risk of contami- In a prospective study, the clinical success rate
nation of the needle pricking the skin by the bacteria following spine fusion was found to be comparable in
present on the cutaneous surface. The micro-organisms patients with, or without, typical provoked pain (58),
usually responsible for infection, are, in fact, stafilococ- Numerous studies (61, 85, 86, 130, 131, 136,215) have
cus aureus and epidermidis, and E. coli. (3, 88). The analyzed the diagnostic ability of discography and
disco-CT in disc herniations. In a prospective study found to be useful in the selection of patients for auto-
comparing several investigations (106), discography mated percutaneous nucleotomy (37).
was found to have a greater sensitivity, but a lower
specificity and a lower diagnostic accuracy (58%) than
CT (73%) and myelography (70%); disco-CT, on the Radiculography and anesthetic
other hand, appeared to be the most sensitive and spe- nerve-root block
cific investigation, the diagnostic accuracy being 86%.
In particular, disco-CT displayed a very high diagnostic Radiculography consists in visualizing the spinal nerve
accuracy in lateral herniations (91%) and in patients root in the extrathecal course (radicular nerve) and the
previously operated on (100%). The high diagnostic spinal nerve using contrast medium injected into the
value of disco-CT is related to the ability of the investi- nerve-root sleeve. With anesthetic nerve-root block,
gation to demonstrate the route followed by the dermatomal anesthesia is produced by injecting local
herniation (149) and to the greater capacity of the disc anesthetic into the nerve-root sleeve. The two investi-
tissue to take up the contrast medium compared with gations may be carried out singly, but they are general-
the epidural tissue and, in operated patients, scar tissue lyassociated.
(106, 107). The false negative results of discography
might depend, at least in part, on the characteristics of
the herniation. The investigation, in fact, may be nega- Technique
tive in herniations of the annulus fibrosus when the
annular cavity does not communicate with the nucleus For radiculography oflumbar nerve roots, the patient is
pulposus (237). placed in the lateral decubitus, lying on the sympto-
In lateral herniations, reproduction of typical pain, matic side; to examine the SI root, the patient is placed
which is obtained in about half the patients (126), has in the prone position with the symptomatic side raised
little diagnostic value, since it does not usually influ- by 15° from the radiologic table to align the anterior
ence either the interpretation of the disco graphic and posterior sacral foramens. Alternatively, the
images, or the therapeutic indications. patient is placed, for examination of any root, in the
oblique anterior position at 45° with the symptomatic
side in contact with the radiologic table (219). An 18-22
Indications G needle, 15 cm long, is used.
To examine the lumbar nerve roots, the needle is
Discography, associated or not with CT, is indicated for advanced under fluoroscopic control using the same
the selection of patients with discogenic low back pain technique as that for discography, but it is directed
to be submitted to spine fusion. The alternative investi- towards the pedicle under which the involved root
gation is MRI, but this may be normal even in the pres- runs. The needle is advanced until the tip is visible, on
ence of degenerative disc changes (36, 116, 242) and the lateral (or oblique) view, just below the pedicle and
does not allow us to differentiate between a sympto- inside the intervertebral foramen and, on anteroposte-
matic, and an asymptomatic, degenerated disc. rior view, below the pedicle and laterally to the line
In patients with a herniated disc, plain discography joining the center of the two pedicles delimiting the
may be indicated only as an intraoperative investiga- intervertebral foramen. To examine the SI nerve root,
tion prior to chemonucleolysis or percutaneous discec- the needle is introduced vertically through the first
tomy. Disco-CT, which has a higher diagnostic ability posterior sacral foramen until it reaches the SI root.
than discography, has, like the latter, several disadvan- When the needle enters the nerve-root sleeve, the
tages: it is invasive, implies a fairly high exposure to patient experiences a sharp pain in the lower limb and
ionizing radiations, and involves the risk of disci tis. paresthesias in the distal portion of the dermatome.
This investigation cannot, therefore, represent a routine Then, 1 ml of contrast agent is very slowly injected
diagnostic modality. It is indicated when CT, MRI under fluoroscopic control. When the needle is correct-
and / or myelography fail to provide conclusive diag- ly positioned, the contrast medium surrounds the nerve
nostic information; in particular, to differentiate a root giving a tubular image, with rectilinear margins,
recurrent herniation from postoperative fibrosis and in within which the radiolucent outline of the root is often
patients with a lateral disc herniation. visible. If the needle is wrongly positioned, a striated
However, disco-CT is useful in the selection of image with irregular margins is observed laterally to
patients for chemonucleolysis, since the uptake of the the vertebra or an irregularly-shaped deposit of con-
contrast medium by the herniation indicates that the trast medium is seen within the intervertebral foramen.
enzyme may reach the herniated fragment (54). The While injecting the contrast medium, the examiner
characteristics of the disco gram, furthermore, were asks the patient whether the pain elicited in the lower
9.---------------------------------------------------
limb is in the same site as the pain usually felt. In the the results of the routine investigations failed to pro-
affermative answer, 0.5 ml of 1%carbocain are injected. vide a clear-cut diagnosis; this is the situation in which
This leads to immediate disappearance of the provoked the test is more likely to be indicated. 2) In patients with
pain and dermatomal hypoesthesia. Occasionally, a persistent radicular symptoms, when CT, MRI and
temporary myotomal muscle deficit may occur. After myelography are negative or show mild nerve-root
obtaining radiographs in the anteroposterior and obli- compression not clearly correlated with the clinical fea-
que views, the patient is invited to walk or perform the tures. 3) In the presence of nerve-root compression at
physical activities which are usually painful, to confirm two or more levels, of which only one is probably
the disappearance of the preprocedural radicular pain. symptomatic; if one prefers to perform the operation at
Radiculography may be performed at one or more only one level, the anesthetic block may allow the
levels. In the latter case, the anesthetic block is general- symptomatic level to be detected. 4) In patients with
ly carried out at only one level. pathologic conditions both in the hip and lumbar spine,
The only reported complication is temporary epidur- in order to determine which condition is the main or
al anesthesia resulting from excessive medial advance- only cause of symptoms.
ment of the needle (219). On the whole, the indications for anesthetic nerve-
root block are fairly rare. With the technologic improve-
ments in CT and MRI equipment, it has become easier
Diagnostic accuracy and easier to detect, in the non-operated patient, the
cause of a radicular syndrome. When the other investi-
Some authors (114, 203) believe that radiculography gations are negative, there are high chances that the
may allow detection of the site of the nerve-root com- block will give a negative, or false positive, result. The
pression. In most studies, however, no relationship has anesthetic block, however, does not usually allow the
been found between radiculographic findings and the cause of a radicular syndrome to be determined; in the
site of nerve-root compression or the nature of the com- operated patient, therefore, the test does not allow us to
pressive agent. This indicates that radiculography determine whether the radiated symptoms are due to
serves essentially to ascertain the correct position of the extrinsic compression of the nerve root or intra-per-
needle before nerve-root anesthetic block. ineural fibrosis, i.e., a condition in which surgery has
Several studies have analyzed the diagnostic accura- little chance of successful results. In both the virgin and
cy of anesthetic nerve-root block as related to the surgi- operated patient, a positive test does not represent an
cal findings and the results of operative treatment. indication for surgical treatment, but should be consid-
Krempen and Smith (117) performed an anesthetic ered as one of the elements useful to establish the ther-
block in 22 patients, almost all previously operated on. apeutic protocol to be followed.
Of the 18 patients with a positive test, 16 underwent
surgery, with satisfactory results in 12. In a retrospec-
tive study of 46 patients with a positive test submitted to Bone scanning
surgery, it was found that, in all cases, a pathologic con-
dition involving the tested nerve root had been detect- This diagnostic modality has a low specificity, but is
ed at surgery (48). The pathologic condition was mostly highly sensitive in various pathologic conditions,
represented by disc herniation or arachnoiditis. Exclud- such as tumors, fractures or infections. In patients
ing the patients with arachnoiditis, the results of surgery with lumbar disc herniation and/or stenosis, bone
were satisfactory in 85% of cases. In a series of 24 scans are usually negative. If positive, this is generally
patients with disc herniation and 18 with isolated nerve- due to vertebral degenerative changes, causing a slight
root canal stenosis who underwent surgery, the predic- increase in the radioisotope uptake.
tive value of a positive test (true positive/true + false With planar scintigraphy, it is generally impossible to
positive) was 100% and 95%, respectively (219). Stanley determine whether the increased radioisotope uptake
et al. (200) have compared the diagnostic value of anes- in a vertebra is related to pathologic conditions of the
thetic nerve-root block, myelography and CT in 19 oper- vertebral body or the posterior arch, on account of the
ated patients; the anesthetic block was found to be much superimposition of the images of the various vertebral
more reliable than the other two diagnostic modalities. components. This limitation is overcome with Single
Photon Emission Computerized Tomography (SPECT),
which provides multiplanar images of the anatomical
Indications structures. This modality has shown an increased
uptake of radioisotope in the articular processes of
The nerve-root anesthetic block may be useful in sever- patients with persistent low back pain after unilateral
al situations: 1) In previously operated patients, when or bilateral laminectomy (125). Positivity of the investi-
-------------------------------------------------------oImagingstudies o271
gation has been interpreted as an expression of instabil- the diagnostic accuracy of echography and the repro-
ity and! or functional overloading of the facet joints. duciblity of the measurements. In a few studies, mea-
Suspected spondylodiscitis is one of the conditions surements were found to be accurate and reproducible
for which bone scanning is most frequently performed (57,120), whilst in others they were found scarcely
in patients with low back pain. The investigation may accurate and unreliable for use in the diagnosis of lum-
be carried out using technetium-99-phosphonate bar stenosis (14,17,104).
(Tc-99) or Gallium-67-citrate (Ga-67), autologous white The possibility of visualizing a herniated disc by
blood cells labeled with Indium-Ill (In-Ill WBC) or echography performed by a dorsal approach has been
Tc-99 (Tc-99 WBC), or immunoglobulins labeled with described by Engel et al. (57). In echographic studies
Tc-99. This radioisotope, although non-specific for bone carried out to measure the size of the spinal canal, they
infections, may detect areas of increased blood flow or observed, in patients with a herniated lumbar disc, a
bone metabolism and may be used to exclude bone third echo at the interface between the disc and the
infection when scintigraphy is negative (7). Ga-67 is spinal canal. In patients with this "triple density", the
both highly sensitive and specific in detecting a tumor sensitivity and specificity of echography was 89% and
or a chronic inflammatory condition. In spondylodisci- 100%, respectively. In a study (111) comparing the echo-
tis, its sensitivity is about 80% (2, 224); false negative graphic, with the surgical, findings in 40 operated
results are usually observed in patients with chronic patients, the diagnostic accuracy of ultrasound reached
infection. In-Ill WBC bone scanning, in spondylodisci- 78%; of the 40 non-operated patients, 24 (60%) had a
tis, has revealed a low sensitivity, a high specificity and, positive echographic diagnosis, which, in 13, was in
approximately, a diagnostic accuracy of less than 30% keeping with the clinical diagnosis (which, however,
(224,236). The proportion of false negative results was had a sensitivity of only 50% in the operated patients).
found to reach 93% in patients who had undergone With transabdominal echography, introduced as an
antibiotic treatment during the 6 months prior to the alternative to the dorsoventral technique, the ultrason-
investigation (224). In patients with spondylodiscitis, ic beam crosses the intervertebral disc and reaches the
therefore, bone scan should be done using Tc-99 spinal canal, thus allowing visualization of the disc
and! or Ga-67, and only when the test is negative and itself and the dural sac at intervertebral level (207,211).
the patient is not under antibiotic treatment might it be With this technique, however, not all lower three lum-
useful to use In-Ill WBC or Tc-99 WBe. The latter bar discs can be visualized in one third, and the L5-S1
seems to be more sensitive and specific than In-Ill. In level in half, of patients examined, the reasons being:
both instances, however, the diagnostic ability is high- obesity, severe loss of disc height, spondylolisthesis
er in acute than in chronic infections. Tc-99 labeled and, for the L5-S1 level, marked obliquity of the disc.
immunoglobulins may be useful in differentiating The dimensions of the thecal sac, on transabdominal
inflammatory processes from postsurgical or post-trau- ultrasonic scans, differ by ± 5 mm compared with those
matic changes (127). obtained by myelography (207).
In patients with a herniated disc (206, 208), the sensi-
tivity of the investigation was as high as 91% in 23
operated patients; in 53 non-operated patients, the
Echography specificity of transabdominal echography was 85% and
88% as far as concerns myelography and CT, respec-
The diagnostic use of ultra sounds in the lumbar spine tively.
was introduced by Meire (134), but Porter (161, 162) Transabdominal echography may allow diagnosis
was the first to apply the method on a large scale. He also of degenerative disc disease. In a study comparing
used ultra sounds to measure, with a probe placed on echography with disco-CT, the sensitivity of the former
the back of the patient, the oblique sagittal dimensions in diagnosing a degenerated disc painful at discography
of the spinal canal and, thus, detect a constitutionally was as high as 95%, but the specificity was only 38%.
narrow spinal canal or a stenotic condition. With the Echography may be used intraoperatively to detect
dorsoventral technique, the scanner is placed on the residual disc fragments or stenotic areas non-adequate-
patient's back laterally to the midline and the ultrason- ly decompressed. A study (143) has shown that 41% of
ic beam, crossing the ligamentum flavum, is reflected at patients with disc herniation and 23% with lumbar
the interface between the ligamentum flavum and the stenosis had residual disc fragments or persistent
spinal canal and at the interface between the spinal stenotic compression of the nervous structures, detect-
canal and the posterior longitudinal ligament or the ed intraoperatively with echography.
vertebral body (104,110); the distance between the two
echos corresponds to the diameter of the canal. Several Conclusions. Echography by the dorsal approach,
studies have analyzed, with conflicting conclusions, although able to detect a constitutionally narrow spinal
272.Chapter 9 . - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
canal, displays a low diagnostic capacity in lumbar The first report on the use of this diagnostic modality
stenosis. After the initial enthusiasm, therefore, this in patients with lumboradicular syndrome appeared in
diagnostic modality has been less and less used in the 1964 (5). Since then, the use of thermography has
screening of stenotic conditions. Similar considerations become more and more widespread, at least in a few
are valid for transabdominal echography, in which the countries. Meanwhile, numerous studies have been
margins of error in the measurement of thecal sac carried out to establish the diagnostic ability of this
dimensions are too high to make it useful in clinical technique in lumbar disc herniation and stenosis, when
practice. With the transabdominal technique, further- related to the clinical data, the findings of other investi-
more, the bony walls of the spinal canal are not visual- gations (EMG, myelography, CT, MRI) and/or the
ized and no information is thus obtained on the causes surgical findings (34, 38,74,77,80,137,148,158,216).
of the possible constriction of the thecal sac. In one of these studies (74), the sensitivity of ther-
In patients with a herniated disc, sensitivity both mography was 98% when related to the clinical data
of dorsoventral and transabdominal echography is and 100% with respect to the surgical findings. In
approximately 85% and specificity is probably similar. another study (34), the results of thermography agreed
However, with this diagnostic modality, a tissue frag- with surgical findings in 92% of cases. Chafetz et al. (38)
ment migrated behind the vertebral body cannot be found that the sensitivity of thermography was 100% in
visualized, since the ultrasonic beam is arrested by the 19 patients with pathologic conditions of the disc
lamina, in dorsoventral echography, and the vertebral demonstrated with CT. However, in the more carefully
body, in the transabdominal modality. The latter, fur- performed study from the methodological viewpoint
thermore, does not provide diagnostic information in a (137), sensitivity and specificity of this diagnostic
high proportion of patients. Echography may, there- modality were approximately 50%.
fore, be used in the screening of patients with a herniat- In a meta-analysis of the diagnostic accuracy of ther-
ed disc, but its value is limited in clinical practice. In the mography, Hoffman et al. (102) analyzed the results of
presence of positive or negative findings, in fact, CT or 28 studies. Of these, only 5 were considered as method-
MRI should generally be carried out to obtain a more ologically good. In almost all studies, the sensitivity of
reliable diagnosis. thermography exceeded 80%, but in the majority, the
Intraoperative echography is of little use in patients proportion of false positives was over 40%. The predic-
with disc herniation, since it may not be able to distin- tive value of a negative test was 33% to 100% and that of
guish normal from pathologic tissues. Furthermore, a positive test was 26% to 100%. The data in the litera-
this modality may be used only if an adequately large ture, therefore, indicate that thermography is positive
window is created in the posterior vertebral arch for the in a large proportion of patients with lumbar radicu-
ultrasonic beam. Thus, it may not detect a disc fragment lopathy, but also that a large proportion of positive
migrated at a distance from the disc if sufficient exci- patients have no radiculopathy.
sion of lamino-articular structures is not performed. It has been suggested that thermography could be
used, in patients with little clinical evidence of radicu-
lopathy, to decide whether CT or MRI should be
Thermography obtained. The risk remains, however, of performing CT
or MRI in many patients with a positive thermography,
Thermography provides a map of the body surface but no significant radiculopathy; on the other hand,
temperature. The map may be obtained using an elec- since most of the studies carried out so far are clearly
tronic infrared telethermograph camera or applying, imperfect from a methodological viewpoint, the report-
on the region to be examined, liquid crystal sheets, ed percentages of sensitivity cannot be considered
which change color depending on the energy of the totally reliable (102). At present, therefore, thermo-
absorbed infrareds. The images obtained are photo- graphy does not appear to playa significant role in
graphed and compared with a scale of colors, each the diagnosis of lumbosacral radiculopathy.
corresponding to a given temperature.
The surface temperature of the body is normally
symmetrical. Lumbar radiculopathy may cause a Lumbosacral ascending flebography
decrease in skin temperature with a metameric distrib-
ution in the involved lower limb and an ipsilateral This investigation is performed using a catheter insert-
increase in the lumbosacral region. The decrease in the ed in the femoral vein and advanced under fluoroscop-
lower limb is due to reflex sympathetic vasoconstric- ic control as far as the ascending lumbar vein on the
tion, whilst the increase in the lumbosacral region symptomatic side. While the patient performs the
results from muscle spasm, metabolic changes and/ or Valsalva maneuver, 35-40 ml of contrast medium are
cutaneous vasodilation. injected and radiographs are then obtained. The
- - - - - - - - - - - - - - - - - - - - - - - - - - - . Imaging studies· 273
catheter is then introduced into the ascending sacral 13. Arkin A. M.: The mechanism of rotation in combination
vein on the same side and the procedure is repeated. In with lateral deviation in the lumbar spine. J. Bone Joint
Surg. 32-A: 180-188, 1950.
the presence of posterolateral disc herniation, the 14. Asztt~ly M., Kadziolka R, Nachemson A.: A comparison of
anterointernal epidural veins appear to be deviated, sonography and myelography in clinically suspected
thinned or interrupted at the level of the disc. Similar spinal stenosis. Spine 8: 885-890, 1983.
flebographic changes, but bilateral, are produced by a 15. Banerian K G., Wang A. M., Samberg 1. C. et al.:
midline herniation. A lateral herniation produces an Association of vertebral end plate fracture with pediatric
lumbar intervertebral disk herniation. Value of CT and MR
interruption, albeit difficult to demonstrate, of the veins imaging. Radiology 177: 763-765, 1990.
in the intervertebral foramen. 16. Bannon K R, Braun I. F., Pinto R S. et al.: Comparison of
This investigation was quite popular in the 70's, radiographic quality and adverse reactions in myelography
but has been completely abandoned since then, as the with iopamidol and metrizamide. AJNR 4: 312-316, 1983.
flebographic images may be difficult to interpret and 17. Battie M. c., Hannson T. H., Engel J. M. et al.: The reliability
of measurements of the lumbar spine using ultrasound
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Furthermore, very little information can be obtained in 18. Begg A. c., Falconer M. A.: Plain radiography in intraspinal
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the accuracy of ascending flebography in diagnosing a operative findings. Br. J. Surg. 36: 225-239, 1949.
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cases, accuracy was found to reach 84% (73). of herniated lumbar disc and spinal stenosis. Spine 9:
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20. Berlin 1., NovetskyG. J., Epstein A. J. et al.: Efficacy of com-
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278.Chapter 9.------------------------------------------------------
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------·CHAPTER 10·------
ELECTROPHYSIOLOGIC
INVESTIGATIONS
F. Postacchini, M. Pizzetti, D. Fredella
Fig. 10.10. Sensory conduction velocity. The small amplitude of the H reflex
response makes it necessary to use an averager, which calculates the
mean amplitude of the responses recorded.
The H reflex is a sensory-motor monosynaptic reflex
arc, which is evoked by stimulating the posterior tibial
from the muscle may be reduced. This rarely occurs, nerve in the poplitea fossa. The electric stimulus not
since usually only a part, mostly small, of the nerve- only elicits a direct muscle contraction (M wave), but
root fibers undergoes degenerative changes and, on the also activates the sensory fibers. Through the latter, the
other hand, the pluriradicular composition of a periph- impulse reaches the spinal cord centers, travels to the
eral nerve ensures that the deficit of the nerve fibers of a motor fibers of the nerve root and then reaches the
root is compensated by the normal function of the fiber soleus and gastrocnemius muscles, where the impulse
derived from the non-compressed roots. This compen- is recorded (Fig. 10.11). This electrophysiologic phe-
sation mechanism may not be valid in the presence of a nomenon provides information on the conduction of
pluriradicular compressive syndrome, such as that both the sensory and motor fibers of the Sl root and can
possibly caused by a large disc herniation or lumbar thus be regarded as the equivalent of the Achilles
stenosis. In the latter condition, there may be not only a tendon reflex. Unlike the EMG changes, the reflex be-
decreased amplitude of the potentials, but also a mod- comes abnormal immediately or shortly after the onset
erate reduction of the MCV, particularly when nerve- of the nerve deficit. Furthermore, it may be altered due
root compression is severe (25). This indicates that a
pluriradicular compression may affect, to some extent,
the nerve conduction in the distal segments of the
axon (43).
Dist.
I
CV
1 lA 39.3ms 2.06mV
potentials from the background noise of the equipment.
The SCV is calculated in the same way as the MCV. The Fig. 10.11. H reflex. The latency is measured on the second potential
mean normal values are 50-60 m! sec. (1 A).
- - - - - - - - - - - - - - - - - - - - - - . Electrophysiologic investigations· 285
to impairment not only of the sensory, but also of the ly remains indefinitely absent or abnormal in patients
motor, pathways. who have suffered from an Sl radiculopathy. The
Recording of the latencies of the M and H waves absence or alteration of the reflex, therefore, does not
allows evaluation of the conduction velocity of the necessarily indicate radiculopathy. On the other hand,
afferent and efferent nerve fibers of the Sl root and of the H response may be present in patients not showing
the peripheral nerves in which the fibers travel (sacral an Achilles tendon reflex. Alterations of the H reflex
plexus, sciatic nerve, posterior tibial nerve). This may may result not only from a radiculopathy, but also from
be done by dividing the distance between the T12 a functional deficit of the various nerve trunks in which
vertebra (where the Sl medullary center is located) the nerve impulses travel. However, when an electro-
and the popliteal fossa, by the difference of the Hand magnetic stimulator, rather than an electric stimulus, is
M latencies. In clinical practice, however, the altera- used, it is possible to apply the stimulus along the entire
tions of the reflex are evaluated by comparing the laten- course of the sciatic nerve (58). This may allow the dif-
cy on the pathologic side with that on the opposite side, ferential diagnosis to be made between radiculopathy
rather than by measuring the conduction velocity. The and peripheral neuropathy of the sciatic nerve.
normal latency of the H wave is 29.5 ± 2.4 ms (29). A
difference of more than 1.5 ms, or complete absence of
the reflex, should be regarded as pathologic. The ampli- F response
tude of the H response is an expression of the degree of
excitability of the neurons of the reflex arc. The normal A maximal electric stimulus applied to a motor nerve,
amplitude is 2.4 ± 1.4 mV (29). A comparative evalua- after eliciting a direct contraction of the dependent
tion of the amplitude on the two sides is also made. In a muscle due to orthodromic diffusion (M wave),
series of 42 patients with clinical evidence of monolat- antidromically travels up along the nerve to the spinal
era I Sl radiculopathy, we found a mean latency time of cord centers and, through interneuronal circuits, again
the H reflex response of 38 ms on the affected side, com- becomes an orthodromic impulse, which reaches the
pared with 32.5 ms on the opposite side; the amplitude dependent muscle, where it is recorded after the M
of the response ranged from 1.7 and 11.7 mV, the mean wave as a small amplitude potential (Fig. 10.12). The
values being 4.1 m V. mean latency of the F response is on average 26 ms for
The H reflex is usually studied to diagnose an Sl the main nerve trunks. A normal latency of the M wave
nerve-root lesion and is considered an indicator of the and an increased latency of the F response indicates
function of this root. However, like the ankle jerk, it that the orthodromic conduction along the stimulated
may be absent bilaterally in elderly subjects and usual- nerve is normal, whilst the conduction between the
tude of the evoked potentials (0.1-3 microV), an aver- ficial peroneal nerve (for the L5 root) and the sural
ager is used, which provides the mean of the evoked nerve (for the 51 root), Eisen and Hoirch (12) found
potentials by repeated stimulations (usually 100-300) abnormalities in the amplitude and shape of the po-
and eliminates the background noises of the recording tentials recorded from the scalp in patients with proven
apparatus which do not have a constant temporal radiculopathy. Further studies, however, have shown
relationship with the stimulus. The characteristic main- that the sensory nerve SEPs (SSEPs) have a low sensi-
ly evaluated is the latency of the evoked potentials. This tivity and specificity (47). The main reason for the
is considered as pathologic when it exceeds 2.5-3 poor diagnostic accuracy is likely related to the fact
points of standard deviation, as referred to subjects that also the sensory nerves contain nerve fibers of
with the same height as the patient. Besides the latency, multiple nerve roots.
amplitude and morphology of the potentials may also Dermatomal SEPs (DSEPs) are obtained by stimulat-
be evaluated. However, it may be difficult to determine ing the skin of a specific dermatome; the recording is
whether these parameters are pathologic, since they performed on the scalp. To examine the lumbar nerve
vary considerably even in normal conditions. roots, the areas usually stimulated are the lateral aspect
For intraoperative monitoring, the same techniques of the foot (SI), the dorsum of the big toe and the second
may be used as for clinical diagnosis, or subdermal toe (L5), and the distal portion of the pretibial region
electrodes may be employed to avoid their displace- (L4). There are conflicting opinions concerning the
ment and / or drying out during the operation, which diagnostic value of the DSEPs in lumbar radicu-
can result in an increased resistance at the electrode lopathies. A few authors (26, 34, 38, 45), in fact, believe
skin interface and an altered impulse transmission. The that these evoked potentials are of high diagnostic
intensity of the stimulus must be increased due to the value, whilst others (3, 40) consider these potentials
neurodepressive effects produced by anesthesia. less useful than needle EMG. The limitations of DSEPs
are that the dermatomal areas are innervated by multi-
ple roots and that these potentials, like the other SEPs,
Mixed nerve SEPs provide no information on the function of the motor
pathways.
Mixed nerve 5EPs (M5EPs) are those most frequently The pudendal evoked responses (PERs) are elicited
studied. In lumbar radiculopathies, the tibialis posteri- by cutaneous stimulation of the dorsal nerve of the
or and common peroneal nerves are generally stimulat- penis or clitoris. The impulses travel along the puden-
ed. The latency and amplitude of the recorded dal nerve, the S2-S4 sacral nerve roots and more
potentials may be decreased in the presence of a radicu- proximal nervous pathways up to the cortical centers,
lopathy. It should not be forgotten, however, that the where they are recorded (18). These potentials provide
large mixed nerves contain fibers derived from multi- information on the function of the sensory fibers of the
ple nerve roots: the M5EPs that are obtained by stimu- lower sacral roots, which are affected in the cauda equi-
lating these nerves may, thus, be normal in the presence na syndrome. Stimulation of the dorsal nerve of the
of a monoradiculopathy. Furthermore, slowing con- penis or clitoris can be performed even unilaterally,
duction in a short portion (nerve root at the level of thus obtaining information on the function of the
compression) of the long pathway travelled by the pudendal nerve or the nerve roots of only one side. If
nerve impulse from the site of peripheral stimulation to ring electrodes are used, the evoked responses can be
the site of recording of the potential may not signifi- recorded at vertebral level; this technique increases the
cantly affect the velocity of conduction of the impulse diagnostic ability of the PERs in radiculopathies, since
(56). M5EPs, instead, are useful for evaluating the possible impairment of nerve conduction in the spinal
spinal cord pathways in patients with myelopathy, as cord is excluded.
well as for the intraoperative monitoring of patients
undergoing surgery due to pathologic conditions of the
thoracolumbar spine, or a lumbar herniated disc Motor evoked potentials (MEPs)
in the presence of thoracic cord conditions which may
deteriorate on account of the operating position or the Electric or electromagnetic stimulation at spine level
operation in the lumbar area. can elicit motor responses in the muscles of the limbs.
The evoked potentials have been recorded from the
tibialis anterior and soleus muscles for the evaluation
Sensory nerve, derma to mal and pudendal SEPs of the L5 and SI nerve roots, respectively. In patients
with compression of these roots, an increased latency
By stimulating exclusively the sensory nerves, such as and a reduced amplitude of the potentials compared
the saphenous nerve (for L3 and L4 roots), the super- with the opposite side have been observed, even in the
288.Chapter 1 0 . - - - - - - - - - - - - - - - - - - - - - - - - - - -
absence of clinically evident muscle deficits (5, 53). functional impairment. Furthermore, electrophysiolo-
Analysis of the motor potentials has also been used for gic testing may demonstrate a deficit in the nerve root
intraoperative monitoring; stimulation may be cortical, when other studies are negative, it may determine the
electric or electromagnetic, or can be performed at cord entity of radicular functional impairment more precise-
level (33, 35). However, the study of these potentials for ly than the clinical examination and allow the evolution
both diagnostic purposes and intraoperative monitor- of radiculopathy over the time to be analyzed. A further
ing is still in the experimental phase; therefore, they are prerogative of electrodiagnostic studies is that they
not currently used in clinical practice. may allow us to discriminate a recent radiculopathy
from a long-standing radicular deficit. This informa-
tion may be important both in the planning of treat-
Bulbocavernous reflex ment and for the prognostic evaluation.
Electrophysiologic investigations, however, have
The bulbocavernous reflex is studied by stimulating the numerous limitations. They do not allow diagnosis of
dorsal nerve of the penis or the clitoris and recording the quality, and often of the anatomic site of the patho-
the motor response from the bulbocavernous muscle or logic condition responsible for radiculopathy. A few of
other muscles of the pelvic floor (50). Usually, it is elicit- these investigations, such as needle EMG, become
ed by applying a ring stimulating electrode around the positive only some time after the onset of the radicular
glans of the penis or the clitoris and applying a single deficit. Furthermore, with time, the EMG abnormalities
stimulus or successive stimuli with a frequency of less may disappear as a result of muscle reinnervation
than 50 Hz (41). The reflex is recorded with electrodes processes; thus, it may not be possible to determine the
inserted in the bulbocavernous or ischiocavernous presence, or the entity, of a chronic nerve-root compres-
muscles on both sides. The reflex may be elicited on sion. Due to the pluriradicular innervation of the mus-
only one side, as well as bilaterally. Normal latency is cles in the limbs and / or technical defects in carrying
30-35 ms (13). This reflex allows functional evaluation out the electrodiagnostic testing, errors may be made in
of the fibers of the pudendal nerve and the 52-54 sacral identifying the level of the involved nerve root or, more
nerve roots. Therefore, it may integrate the information often, it may be difficult to determine which one of two
provided by the pudendal 5EPs. Like the latter, study of roots (for example L3 and L4) is impaired. At times,
the bulbocavernous reflex may be useful in cauda these investigations are negative even in the presence
equina syndrome to demonstrate a neurogenic bladder of nerve-root compression, particularly when chronic,
or impotence. as in compressions of stenotic origin. This may easily
Two other reflexes have a similar functional signifi- occur when only a part of the nerve-root fibers are
cance to that of the bulbocavernous reflex. The first may compressed. On the other hand, electrodiagnostic stud-
be elicited by stimulating the perineal skin and record- ies may be positive even in the absence of significant
ing the motor response from the anal sphincter with radicular sypmtoms and signs. Even more often, they
coaxial electrodes (42). The second is elicited by stimu- may indicate a moderate or severe radicular deficit in
lation of the proximal urethra and is recorded from the patients with mild radicular symptoms. This informa-
anal sphincter (17). tion may be useful for a purely diagnostic evaluation,
but is of little use or may even hamper the clinician in
his/her decision concerning the best approach to
Prerogatives and limitations management, since he / she may be tempted to indicate
unnecessary surgery.
Only electrodiagnostic investigations allow evaluation 5EPs studies are of considerable importance in the
of the functional integrity of the nerve roots and detec- diagnosis of myelopathies, but have various limitations
tion of even slight abnormalities in nerve function. in the diagnostic evaluation of compressive radiculo-
Clinical examination may, in fact, demonstrate the pres- pathies. In this case, the somatosensory potentials
ence of a radiculopathy only when the nerve root become pathologic when there is a functional impair-
impairment causes such a decrease in muscle strength, ment of the sensory pathways, but not when only the
sensibility or reflex activity that it can be appreciated by motor pathways are impaired. Cortical recording of the
the examiner. Imaging studies show compression of the potentials, which is that most commonly used, does not
nervous structures or identify the cause of radiculo- exclude that alterations in the medullary pathways,
pathy, but they do not detect the degree of nerve-root rather than radicular compression, may be responsible
functional impairment; these investigations, on the for the increase in latency. The radicular compression,
other hand, may demonstrate a pathologic condition, on the other hand, may not cause a significant slowing
such as disc herniation or lumbar stenosis, which of nerve conduction, particularly if of slight severity.
causes no nerve-root compression or a significant Precise identification of the pathologic level may be
- - - - - - - - - - - - - - - - - - - - - - . Electrophysiologic investigations· 289
difficult or impossible, since no peripheral nerve or suggests that the diagnostic accuracy of EMG is compa-
dermatome is strictly monoradicular. rable to that of CT. In a prospective analysis of 100
patients with radicular pain of more than 6 months'
duration (19), a correlation was made between symp-
toms, neurologic deficits, electrodiagnostic findings
Diagnostic ability (EMG, H reflex and F response) and CT findings. The
electrodiagnostic tests often demonstrated radiculo-
In a prospective study (57), the diagnostic accuracy of pathy in patients with equivocal clinical signs. The
needle EMG has been analyzed in 100 patients with L5 results of CT did not allow the nature of the symptoms
or 51 nerve-root compression due to disc herniation or the electrodiagnostic findings to be predicted. The
and / or nerve-root canal stenosis, submitted to surgical latter, instead, showed the greatest ability to predict the
treatment. EMG identified the involved nerve root in CT findings.
84% of the 95 patients with positive surgical findings; in In a study (32) of 50 patients operated upon for
the remaining five, the investigation was negative. No nerve-root compression due to zygoapophyseal degen-
significant differences emerged between the L5 and erative changes, needle EMG, associated or not with
51 root as far as concerns the diagnostic ability of the recording of the H reflex, demonstrated 90% diagnostic
investigation. However, in another prospective study accuracy, compared with 52% of water soluble myelo-
(51), the EMG results agreed with the surgical findings graphy. In a series of patients with stenosis of the
in only 70% of 74 patients with disc herniation at the lumbar spinal canal (25), needle EMG showed neuro-
three lower lumbar levels. genic abnormalities in all 16 cases with a complete
Aiello et al. (1) have evaluated 25 patients with a clin- myelographic block, in 94% of the 48 with partial block,
ical picture of compression of the L3 and / or L4 nerve and in 54% of the 24 with intermittent claudication
roots. Needle EMG was positive in all 24 patients with and normal myelograms. In most of the stenotic
positive surgical findings. However, in only two of patients, neurogenic changes were bilateral and multi-
them was the investigation able to identify the level of segmentary. EMG has also been found to be of high diag-
nerve-root compression. In the patient with negative nostic value in other studies (24, 46). In stenotic patients,
surgical findings, EMG was also negative. The negative findings are likely to be obtained when the
H reflex was abnormal in 96% of patients with positive thecal sac is compressed but the emerging nerve roots
surgical findings, but also in the patient with negative are not affected to a significant extent (39).
findings. In another study (2), the same authors exam- D5EPs are the evoked potentials which appear to be
ined 50 patients with a single, surgically confirmed, of the greatest diagnostic value. In one study (44), 93%
disc herniation at L3-L4, L4-L5 or L5-51 level. The per- of 27 patients with herniation of the two lower lumbar
centages of true positives were, respectively, 100%,96% discs showed abnormalities of the D5EPs evoked by
and 71%, and those of true negatives, 88%, 38% and electric stimulation of the L5 and 51 dermatomes. In a
79%. Thus, the lowest diagnostic accuracy was found in similar study (34), in which DSEPs were simultaneous-
the herniations located at L4-L5Ievel. The H reflex was ly evoked on both sides in 40 patients submitted to
found to be abnormal in all patients with an L5-51 her- surgery, the electrodiagnostic findings were in keeping
niated disc and in some two thirds of those with L4-L5 with the surgical findings in all cases but one. Using
(58%) or L3-L4 (71%) herniation. In contrast with these DSEPs, Dvonch et al. (11) identified the compressed
findings, however, Braddon and Johnson (4) found an nerve root in 86% of patients with lumbar radiculopa-
increased latency of the H reflex in only two out of 16 thy. In contrast with these findings, Aminoff et al. (3)
patients with absence of the ankle jerk, whilst in the found that in patients with isolated compression of the
other 14, the reflex could not be elicited; in the same L5 or 51 nerve roots, diagnosis was confirmed by
study, of the nine patients with preserved ankle jerk, D5EPs in 25% of cases and by needle EMG in 75%. In
seven were found to have an increased latency of the lumbar stenosis, abnormalities of the MSEPs and 55EPs
Hresponse. (28) or D5EPs (52) were found in over 90% of cases.
A series of patients with radicular pain underwent
needle EMG and CT and were then submitted to
surgeryortreated conservatively (27). In 35 cases, EMG Conclusions
was pathologic and CT showed a herniated disc: at
I-year follow-up, the clinical picture had improved in In lumbar disc herniations, the sensitivity of needle
81 % of the 16 operatedpatients-and 47% of those not EMG in identifying nerve-root impairment ranges,
operated on. In 24 patients, EMG and CT were normal approximately, from 70% to 90% and specificity is only
and none of the patients underwent surgery: at I-year slightly lower. The diagnostic ability further increases
follow-up, 67% of patients had improved. This study in L5-51 herniations, when the H reflex is recorded.
290.Chapter 1 0 . - - - - - - - - - - - - - - - - - - - - - - - - - - -
However, the electro diagnostic tests are of little value syndrome and allow the degree of root involvement to
in the identification of the pathologic disc, particularly be determined. In these cases, electrodiagnostic tests
when the L3 or L4 roots are involved. Probably, one of usually have a purely confirmatory role. These tests,
the reasons for this lack of success is that intraforaminal however, may be useful, prior to surgical treatment, to
and extraforaminal herniations, which compress the establish whether the radicular deficit is recent or long-
root emerging from the thecal sac at the level above, standing. It seems, in fact, that the surgical results tend
usually occur at these lumbar levels. In lumbar steno- to be less satisfactory in patients with a long-standing
sis, needle EMG, associated or not with the study of the functional deficit compared to those with nerve-root
F response and the H reflex, appears to have a high sen- compression of recent onset.
sitivity, but a relatively low specificity. Even in this In patients with disc herniation who clinically pre-
pathologic condition, and particularly in stenosis of the sent an irritative radicular syndrome, the electrodia-
spinal canal, electrodiagnostic studies do not often gnostic tests may be useful to demonstrate the presence
allow identification of the vertebral level where the of nerve-root functional deficits and their severity. It
nervous structures are compressed. Data available should be stressed, however, that in these cases, the
seem to indicate that DSEPs are of high diagnostic diagnosis and the indication for treatment, particularly
value both in disc herniation and lumbar stenosis. surgical management, cannot be based on the results of
the electrophysiologic investigations, but should stem
from the overall evaluation of the clinical picture, imag-
Indications ing studies and electrophysiologic tests. In other words,
the latter cannot represent the main laboratory tests on
Diagnostic evaluation which the indication for surgery is based.
There is usually no indication for the study of MSEPs
In clinical practice, the investigations usually per- and SSEPs in patients with lumbar disc herniation,
formed in patients with lumbar disc herniation are since these tests appear to have a low sensitivity and
needle EMG and the study of Hand F responses. diagnostic accuracy in monoradiculopathies. The eval-
The indications for these electro diagnostic tests can uation of SEPs may, at times, be indicated in the pres-
be classified as absolute or relative. ence of concomitant lumbar stenosis to demonstrate a
The indication is absolute in patients with a severe nerve-root compression not clearly detected by imag-
motor deficit of one or multiple nerve roots and in those ing studies. DSEPs, unlike the other evoked potentials,
with a cauda equina syndrome. In these cases, the appear to have a high diagnostic ability also in mono-
investigation may be carried out purely for diagnostic radiculopathies. It should be borne in mind, however,
purposes, in the rare cases in which other investiga- that the study of these potentials is technically difficult
tions show no pathologic condition or a condition and requires experience both in recording and inter-
which appears to be unable to cause a severe radicu- preting the traces. For this reason, and the uncertainty
lopathy. The most common aim of this investigation, still existing on their actual diagnostic ability, DSEPs
however, is to document the severity of radicular are not usually studied in patients with simple lumbar
impairment before surgical treatment, either for disc herniation. Their evaluation may be indicated,
medico-legal reasons or for monitoring the postopera- however, when needle EMG does not provide reliable
tive recovery of nerve function. Furthermore, the indi- information due to the very short time which has
cation is absolute when the clinical picture tends to elapsed from the onset of the clinical syndrome or when
suggest a peripheral neuropathy, partly or entirely the Hand / or F responses are negative or uninforma-
responsible for the radicular syndrome. This occurs tive due to the level of radiculopathy.
particularly in diabetic patients, who may have a neu- Patients with a cauda equina syndrome usually
ropathy simulating the symptoms of disc herniation appear for clinical observation a few hours or days after
or lumbar stenosis (6, 22, 48). In these cases, the study the onset of the syndrome, when needle EMG provides
of nerve conduction velocity is determinant, since this no diagnostic information. If there is a clinical or
is generally decreased in the presence of diabetic medico-legal need to document the neurologic deficits,
neuropathy, whilst it is normally, or occasionally the various types of SEPs should be studied. Study of
reduced to a mild extent, in patients with nerve-root the pudendal potentials, as well as the bulbocavernous
compressive syndromes (6). reflex and the anal wink, may occasionally be useful to
In the vast majority of patients with lumbar disc her- determine whether sphincteric or sexual disorders,
niation, an accurate and correctly performed clinical possibly associated with a lumboradicular syndrome,
examination is able to detect motor or sensory deficits, are neurogenic in origin.
or decreased reflex activity, of even mild severity, which The somatosensory evoked potentials are abnormal
demonstrate the existence of a nerve-root compression in peripheral neuropathies and in the presence of cord
- - - - - - - - - - - - - - - - - - - - - - . Electrophysiologic investigations· 291
compression or diseases, and may thus play an impor- myography, late responses and somatosensory evoked
tant role in the differential diagnosis between these potentials. Neurology 35: 1514-1518, 1985.
4. Braddon RI., Johnson E. w.: Standardization of H-reflex and
conditions and a lumbar radicular syndrome. diagnostic use in Sl radiculopathy. Arch. Phys. Med. Rehabil.
55:161-166,1974.
5. Chokroverty S., Sachdeo R, DiLullo J. et al.: Magnetic
Intraoperative monitoring stimulation in the diagnosis of lumbosacral radiculopathy.
}. Neurol. Neurosurg. Psychiat. 52: 767-772, 1989.
6. Cinotti G., Postacchini E, Weinstein J. N.: Lumbar spinal
In patients undergoing lumbar spine fusion using stenosis and diabetes. Outcome of surgical decompression.
pedicle screw fixation, intraoperative study of the J. Bone Joint Surg. 76-B: 215-219,1994.
EMG activity mechanically evoked (23, 37) by insertion 7. Cohen B. A., Major M. R, Huizenga B. A.: Predictability of
of the screws or electrically evoked (36) by stimulation adequacy of spinal root decompression using evoked poten-
tials. Spine 16: S 379-384,1991.
of the pedicle screws and the exposed nerve roots may
8. Cracco R. Q.: Spinal evoked response: peripheral nerve stim-
be useful to avoid mistaken screw positioning, which ulation in man. Electroencephalogr. Clin. Neurophysiol. 35:
may lead to nerve-root injury. In the event a screw 379-386,1973.
breaks the cortex of the pedicle and irritates or com- 9. Cusik J. E, Myklebust J., Larson S. J. et al.: Spinal evoked
presses the adjacent nerve root, continuous neurotonic potentials in the primate: neural substrate. J. Neurosurg. 49:
551-557,1978.
discharges originating from the involved root may be
10. Delbeke J., McLomas A .J., Kopec J. J.: Analysis of evoked
recorded. lumbosacral potentials in man. J. Neurol. Neurosurg.
Herron and Trippi (20) have proposed intraoperative Psychiat. 41: 293-302, 1978.
monitoring of DSEPs in patients undergoing discecto- 11. Dvonk v., Scarff T., Bunch W. H. et al.: Dermatomal
my to evaluate the adequacy of nerve-root decompres- somatosensory evoked potentials: their use in lumbar
radiculopathy. Spine 9: 291-293, 1984.
sion; the procedure, however, is not in routine use, since
12. Eisen A., Hoirch M.: The electro diagnostic evaluation of
it has not been demonstrated to improve the surgical spinal root lesions. Spine 8: 98-106,1983.
outcomes in common disc herniations. Monitoring 13. Ertekin c., Real E: Bulbocavernous reflex in normal men and
may, instead, be useful in particular conditions, such as in patients with neurogenic bladder and! or impotence.
a herniation of the first lumbar disc responsible for cord J. Neurolog. Sci. 28: 1-15, 1976.
14. Fisher M. A., Shdive A. J., Texeira C. et al.: Clinical and elec-
compression. Monitoring of MSEPs or SSEPs (28) or of
trophysiological appraisal of the significance of radicular
DSEPs (7, 21) has also been performed during decom- injury in back pain. J. Neurol. Neurosurg. Psychiat. 41:
pressive surgery for lumbar stenosis to make sure that 303-306,1978.
complete decompression of the nerve roots is carried 15. Fisher M. A., Shdive A. J., Teixera C. et al.: The F-response - a
out; monitoring was found to be useful in this respect, clinically useful physiological parameter for the evaluation
however there is at present no convincing evidence that of radicular injury. Electromyogr. Clin. Neurophysiol. 19:
65-75,1979.
better clinical results are obtained in monitored 16. Glanz R. H., Haldeman S.: Other diagnostic studies.
patients than in those not monitored. Intraoperative Electrodiagnosis. In: The adult spine: principles and practice.
DSEPs have recently been employed during operations Frymoyer J. W. Editor-in-chief, Raven Press, New York, 1991.
of spinal fusion with pedicle screw fixation to detect 17. Haldeman S., Bradley W. E., Bathia N. N.: Evoked responses
nerve-root functional impairment resulting from mal- in clinical neuro-urology. Bull. Los Angeles Neurol. Soc. 47:
76-90, 1982.
positioning of screws (54). In these cases, however, the 18. Haldeman S., Bradley W. E., Bathia N. N.: Evoked responses
usefulness of DSEPs for preventing nerve-root lesions from the pudendal nerve. J. Urol. 128: 974-980,1982.
is very limited. In fact, they allow monitoring essential- 19. Haldeman S., Shouka M., Robboy S.: Computed tomography,
ly of the spinal cord rather than the nerve roots and, electrodiagnostic and clinical findings in chronic workers'
then, only the sensory component of the latter. compensation patients with back and leg pain. Spine 13:
345-350, 1988.
Furthermore, DSEPs may become abnormal only after 20. Herron L. D., Trippi A. c.: Intraoperative use of dermatomal
the nerve root has been injured (37). somatosensory evoked potentials in lumbar disc surgery.
Proc. North Am., Spine Soc., Bolton Landing, New York,
1986.
21. Herron L. D., Trippi A. c., Gonyeau M.: Intraoperative use of
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3. Aminoff M. J., Goodin D. S., Oarry G. J. et al.: Electrophysio- 24. Jacobson R E.: Lumbar stenosis: an electromyographic
logical evaluation of lumbosacral radiculopathies; electro- evaluation. Clin. Orthop.115: 68-71, 1976.
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25. Johnsson K-E., Rosen I., Uden A: Neurophysiologic investi- 43. Rydevik B., Brown M. D., Lundborg G.: Pathoanatomy and
gation of patients with spinal stenosis. Spine 12: 483-487, pathophysiology of nerve root compression. Spine 9: 7-15,
1987. 1984.
26. Katifi H. A, Sedgwick E. M.: Evaluation of the dermatomal 44. Scarff T. B., Bunch W. H., Dallman D. E. et al.: Herniated lum-
somatosensory evoked potential in the diagnosis of lum- bosacral discs. Lancet 8185: 93,1980.
bosacral root compression. J. Neurol. Neurosurg. Psychiat. 45. Scarff T. B., Dallman D. E., Toleikis J. R et al.: Dermatomal
50: 1204-1210,1987. somatosensory evoked potentials in the diagnosis of lumbar
27. Khatri B. 0., Baruah J., McQuillen M. P.: Correlation of elec- root entrapment. Surg. Forum 32: 489-491,1981.
tromyography with computed tomography in evaluation of 46. Seppalainen AM., Alaranta H., Soini J.: Electromyography
lower back pain. Arch. Neurol. 41: 594-597, 1984. in the diagnosis of lumbar spinal stenosis. Electromyogr.
28. Keirn H. A, Hadju M., Gonzalez E. G.: Somatosensory Clin. Neurophysiol. 21: 55-66, 1981.
evoked potentials as an aid in the diagnosis and intraopera- 47. Seyal M., Sandhu S. L., Mack Y. P.: Spinal segmental
tive management of spinal stenosis. Spine 10: 338-344,1985. somatosensory evoked potentials in lumbosacral radiculo-
29. Kimura J.: Electrodiagnosis in diseases of nerve and muscle: pathy. Neurology 39: 801-805, 1989.
principles and practice. Davis Co., Philadelphia, 1994. 48. Simpson J. M., Silveri C. P., Balderston R A et al.: The results
30. Larson S. J., Sances A., Christenson P. c.: Evoked somatosen- of operations on the lumbar spine in patients who have
sory potentials in man. Arch. Neurol. 15: 88-92, 1966. diabetes mellitus. J. Bone Joint Surg. 75-A: 1823-1829, 1993.
31. Levy W. J., York D. H., McCaffrey M. et al.: Motor evoked 49. Simpson R K, Blackburn J. G, Martin H. E et al.: Peripheral
potentials from transcranial stimulation of the motor cortex nerve fiber and spinal cord pathway contribution to the
in humans. Neurosurgery 15: 287-302, 1984. somatosensory evoked potential. Exp. Neurol. 73: 700-715,
32. Leyshon A, Kirwan E. 0' G., Wynn Parry C. B.: Electrical 1981.
studies in the diagnosis of compression of the lumbar root. 50. Siroky M. B., Sax D. S., Krane R S.: Sacral signal tracing: the
J. Bone Joint Surg. 63-B: 71-75, 1981. electrophysiology of the bulbocavernous reflex. J. Urol. 122:
33. Maccabee P .J., Levine D. B., Pinkhason E. 1. et al.: Evoked 661-664,1979.
potentials recorded from scalp and spinous processes 51. Spengler D. M., Quellette E. A, Battie M. et al.: Elective dis-
during spinal column surgery. Electroencephalogr. Clin. cectomy for herniation of a lumbar disc. Additional experi-
Neurophysiol. 56: 569-582, 1983. ence with an objective method. J. Bone Joint Surg. 72-A:
34. Machida M., Asai T., Sato K et al.: New approach for diag- 230-237,1990.
nosis in herniated lumbosacral disc. Dermatomal somato- 52. Stolov W. c., Slimp J. c.: Dermatomal somatosensory evoked
sensory evoked potentials (DSSEPs). Spine 11: 380-384,1986. potentials in lumbar spinal stenosis. Am. Assoc. Electromyo-
35. Machida M., Weinstein S. 1., Yamada T. et al.: Spinal cord graphy and Electrodiagnosis, Am. Electroencephalography
monitoring. Spine 10: 407-413, 1985. Soc. Joint Symp.17-22, 1988.
36. Maguire J., Wallace S., Madiga R et al.: Evaluation of intra- 53. Tabaraud E, Hugon J., Chazot E et al.: Motor evoked respons-
pedicular screw position using intraoperative evoked elec- es after lumbar spinal stimulation in patients with L5 or Sl
tromyography. Spine 20: 1068-1074, 1995. radicular involvement. Electroencephalogr. Clin. Neuro-
37. OwenJ. H., KostuikJ. P., Gornet M. et al.: The use of me chan- physiol. 72: 334-339,1989.
ically elicited electromyograms to protect nerve roots during 54. Toleikis RJ., CarlvinA 0., Shapiro D. E. et al.: The use of der-
surgery for spinal degeneration. Spine 19: 1704-1710, 1994. matomal somatosensory evoked potentials (DSSEPs) to
38. Perlik S., Fisher M. A, Patel D. V. et al.: On the usefulness of monitor surgical procedures involving intrapedicular fixa-
somatosensory evoked responses for the evaluation of lower tion of the lumbo-sacral spine. Proc. Am. Electroencephalo-
back pain. Arch. Neurol. 43: 907-913, 1986. graphic Soc., Philadelphia, Pennsylvania, 1991.
39. Postacchini E: Lumbar spinal stenosis. Springer-Verlag, Wien 55. Wilbourn A. J., Aminoff M. J.: AAEE minimonograph n° 32:
New York, 1989. the electrophysiologic examinations in patients with radicu-
40. Rodriguez A A, Kanis L., Rodriguez A A et al.: Somatosen- lopathy. Muscle Nerve 11: 1099-1114, 1988.
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indicator of L5 and Sl radiculopathy. Arch. Phys. Med. ination and thermography in the diagnosis of lumbosacral
Rehabil. 68: 366-368,1987. radiculopathy. In: Lumbar disc disease. Second edition.
41. Ruthworth G.: Diagnostic value of the electromyographic Hardy R W. Jr. Ed., Raven Press, New York, 1993.
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Neurophysiol. Suppl. 25: 65-73, 1967. of muscle innervation by the L5 and Sl nerve roots. Spine 8:
42. Ruthworth G: Electrophysiological investigations in lum- 616-624,1983.
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Arnold, London, 1991. ulation of lower limb nerves. Arch. Neurol. 49: 66-71, 1992.
------·CHAPTER 11·------
DIFFERENTIAL DIAGNOSIS.
I. ORGANIC DISEASES
F. Postacchini, G. Trasimeni
Dermoid cyst appears, on CT scans, as a hypodense Plain radiographs often show enlargement of the
mass due to the presence of colesterinic material. On spinal canal, erosion and thinning of the pedicles and
II-weighted MRI images, dermoid cyst is isointense or scallop ping of the vertebral bodies. Upon myelogra-
only slightly hyperintense due to the presence of abun- phy, a complete block of the contrast medium is visible,
dant keratin, which decreases the high signal intensity showing irregular margins.
of the adipose tissue. On T2-weighted images, the cyst CT scans reveal an intraspinal mass with parenchy-
appears as a hyperintense mass, containing areas of matous density, which increases dyshomogeneously
low signal intensity. The signal intensity of the epider- after administration of contrast medium. Since the
moid cyst may be similar to that of CSF and, thus, may tumor usually spreads extensively in a vertical direction,
not be easily visualized with MRI. In these cases, it may sagittal and coronal reformatted images can be useful to
be useful to obtain proton density images, in which the determine the cranial and caudal limits of the mass.
cyst occasionally shows a high signal intensity with MRI may allow characterization, as well as exact
respect to the CSF. visualization of the limits, of the neoplasm. Ependi-
momas generally have the same signal intensity as
the muscle tissue on the II-weighted images; on T2-
Ependymoma weighted images, instead, they are weakly hyperin-
tense. After administration of gadolinium, the tumor
Ependymomas of the lumbar region originate princi- shows a marked, though generally dyshomogeneous,
pally from the filum terminale. Therefore, at least enhancement (Fig. 11.4). In a recent study (60), the
initially, they are extramedullary. They may also origi- tumor was found, in most patients, to be located at L2
nate from the conus medullaris and, in this instance, level and in no case did it extend cranially to T9.
they are primarily intramedullary. The increase in size
of the tumor, which is usually benign, is slow and diag-
nosis is usually retarded. The clinical picture is initially Subarachnoid metastases
characterized by pain and sensory disturbances in the
lower limbs, and much later by motor deficits. Signs A few tumors of the central nervous system, such as
and symptoms may simulate a lumbar disc herni- medulloblastoma, ependymoma or germinoma, can
ation, though this occurs less frequently than for neuri- metastasize to the subarachnoid space via the CSF.
nomas. This is related to the fact that the pain, even in Less commonly, neoplasms of other organs or tissues,
the initial stages of the disease, usually has no der- such as tumors of the lung or breast and melanomas,
matome distribution and the sensory disturbances, may lead to subarachnoid metastases. In these cases,
often dissociated, lead to suggest spinal cord diseases CT can be diagnostic only after intravenous adminis-
(30). tration of contrast medium. With MRI, the diagnosis is
- - - - - - - - - - - - - - - - - - 0 Differential diagnosis. I. Organic diseases 0297
This is a rare pathologic condition, that may have an Lumbosacral radicular meningeal cysts are frequently
acute or insidious clinical onset. In the former case, the observed and often are multiple in a single subject.
hematoma may cause a cauda equina syndrome or They are usually of no pathologic significance and do
progressive paraplegia, whilst in the latter, only neuro- not compress the nerve root. Occasionally, the cyst may
logic deficits of multiple nerve roots can be present. reach a few centimeters in diameter and cause erosion
Hemorrhage may occur following a trauma or a lumbar of the pedicle and / or the vertebral body. In these
puncture, or may be spontaneous (117, 159). In both exceedingly rare cases, the cyst may impinge, directly
cases, the etiology can be related to coagulopathies or or indirectly, upon the nerve root or the thecal sac and
intradural vascular malformations. require surgical treatment (11, 35). On CT scans, radi-
CT rarely reveals a subdural hematoma, whereas cular cysts have the same density as CSF. On MR
MRI demonstrates a signal hyperintensity of the CSF images, the signal intensity of the cyst is similar to, or
on the Tl-weighted images due to the presence of meta- greater than, that of CSF; the increased signal intensity
hemoglobin, that has a paramagnetic activity. On T2- is due to the larger quantity of proteins in the cystic
weighted images, instead, there are no changes in liquid, particularly when communication with the
Signal intensity. subarachnoid space of the thecal sac is narrow.
- - - - - - - - - - - - - - - - - - . Differential diagnosis. I. Organic diseases' 299
emptying out of the cyst or decreased compression
of the adjacent neural structures due to reduced hydro-
static pressure.
Case report
to us 3 months later. Examination of the preoperative CT signal intensity is low on Tl-weighted, and high on T2-
scans, which were offairly low resolution, showed an LS-Sl weighted, images. (Fig. 11.9). The content may occa-
disc protrusion, but also led to suspect the presence of a syn- sionally be hematic due to intracystic hemorrhage (91);
ovial cyst of the posterior joint at the same level and side as in this instance, the cyst shows a high signal intensity
the herniation. MRI confirmed the presence of the cyst, also on Tl-weighted images due to the presence of
impinging on the thecal sac and the LS nerve root in the inter- products of blood degradation.
vertebral foramen. Surgical excision of the cyst and the
anteromedial portion of the zygoapophyseal joint, which was
severely arthrotic, completely relieved the radicular symp- Vertebral tumors
toms.
Benign primary tumors
Diagnosis can easily be made by CT or MRI, where-
as myelography is aspecific, since it shows only a pos- The tumors most commonly encountered are heman-
terolateral compression of the thecal sac. On CT scans, gioma, osteoid osteoma and osteoblastoma, followed
the cyst appears as a roundish lesion, with a hyper- by osteochondroma, aneurysmatic bone cyst, giant cell
dense wall with respect to the thecal sac. The lesion is tumor and eosinophilic granuloma.
located anteromedially to the facet joint, which consis- Hemangiomas of the vertebral body are found in
tently shows degenerative changes of varying severity. about 10% of subjects (190), however only exceedingly
On MR images, synovial cysts have a characteristic rarely do they deform the vertebral body and impinge
appearance as far as concerns both the site and the flat on the neural structures.
base, which is in contact with the facet joint (111, 154). Osteoid osteoma and osteoblastoma are very similar
The signal intensity depends on the density of the fluid osteoblastic tumors, often occurring in the spine, most-
filling the cyst. The content is generally serous and the ly in the components of the posterior vertebral arch
A B c
Fig. 11.11. Eosinophilic granuloma in the vertebral body and left pedicle ofL4. CT scans (A) and (B) show an osteolytic area interrupting the cortical
bone delimiting the spinal canal anterolaterally. In the vertebral body, the lesion is surrounded by a rim of sclerotic bone. On the turbo T2-weighted
image (C), the lesion appears hyperintense and encircled by a rim of low signal intensity resultingfrom bone sclerosis (arrow). The remainder of the ver-
tebral body is hyperintense due to edema of the trabecular bone.
(Fig. 11.10). These tumors may simulate a lumbar disc arch of the lumbar vertebrae and may easily cause
herniation when compressing one or, rarely, multiple radicular signs and symptoms. Giant cell tumors are
nerve roots. This easily occurs when the lesion is locat- uncommon, locally aggressive, lesions that can be
ed in the pedicle or the articular processes. A mistaken responsible for radicular pain and neurologic deficits
diagnosis of herniation is even easier in adolescents, in (162). Eosinophilic granuloma usually develops in the
whom the tumor often gives rise to scoliosis, which can vertebral body and occasionally spreads to the pedicle;
be interpreted as an antalgic scoliosis resulting from a the tumor may mimic the clinical features of a herniat-
herniation (116,137). Differential diagnosis may be dif- ed disc when it erodes the cortical bone and encroaches
ficult particularly for osteoid osteoma, which may not upon the spinal canal (Fig. 11.11).
be readily visible on plain radiographs due to its small
size (75); this holds especially in the absence of the char-
acteristic nocturnal exacerbation of pain and in the Primary malignant tumors
presence of neurologic radicular deficits. Bone scan-
ning is consistently positive in these two pathologic All primary malignant tumors of the lumbar spine -
conditions. CT and MRI may not demonstrate the solitary and multiple myeloma, chordoma, osteosarco-
tumor - particularly osteoid osteoma - if the investiga- ma, chondrosarcoma, Ewing's and Paget's sarcomas
tion is not directed to disclose the lesion. Negative CT - may give rise to clinical syndromes mimicking those
or MRI findings, therefore, do not exclude the presence of a lumbar disc herniation. However, chordoma is the
of these lesions. In both tumors, there is an osteolytic tumor that can most often lead to making a diagnosis of
zone surrounded by a sclerotic rim. In osteoblastoma, disc herniation. Chordoma originates from residues of
the osteolysis is larger, and the sclerotic rim thinner, notochordal tissue in the sacrococcygeal region or the
than in osteoid osteoma; furthermore, in osteoblastoma body of the lumbar vertebrae. It grows slowly and,
MRI shows a marked inflammatory reaction of the when originating in the sacrococcygeal area, may give
surrounding soft tissues, which are hyperintense on rise to sciatic symptoms resulting from compression of
the T2-weighted images (41). the sacral nerve roots, before eroding the sacrum and
Osteochondroma is very rarely found in the lumbar becoming visible on plain radiographs. When arising
spine, but it can readily simulate a disc herniation in the body of lumbar vertebrae, the tumor has to
(115, 185); the two conditions may also be associated encroach upon the vertebral canal to cause radicular
(109). Aneurysmatic bone cysts, which are very uncom- symptoms. In some one fifth of cases, the initial clinical
mon in the spine, are usually located in the posterior presentation is paraparesis (22). On CT scans, the
- - - - - - - - - - - - - - - - - - - . Differential diagnosis. I. Organic diseases· 305
A B c
o
Fig. 11.12. MR images showing a L2 chordoma. (A) Sagittal T2-weighted spin-echo image. (B) Tl-weighted spin-echo image. (C) and (D) Axial Tl-
weighted spin-echo postgadolinium images. Large lesion, markedly hyperintense on the T2-weighted image, destroying the vertebral body. The thecal
sac is compressed by the neoplasm, which invades extensively the anterior epidural space.
grows towards the pelvis and, at the time of diagnosis, ic fracture. Pain may be associated with neurologic
is generally large in size (155, 192) (Fig. 11.13). deficits, but these are often mild or absent, at least in the
initial stages of the radicular syndrome. The clinical
features may be indistinguishable from those of a her-
Metastatic tumors niated disc, but a few elements may lead to the suspi-
cion of a different pathologic condition: age over 50
In the skeleton, metastases are by far more common years, marked severity of pain, multiradicular distri-
than primary tumors. This holds especially for the bution of symptoms, mildness or absense of neurologic
spine: of 1971 patients with neoplasms, only 1.5% had a deficits, poor general conditions, and a previous histo-
primary tumor in the thoracolumbar spine (45). The ry of neoplastic disease. Metastatic lesions of the L1 ver-
tumors most often metastasizing to the spine are breast tebra can impinge on the conus medullaris and produce
and lung cancer, followed, in most series, by prostate a cauda equina syndrome of acute onset, with rapid
and kidney cancer, and lymphatic tumors (19, 50, 62, 65, deterioration of the neurologic status, as often occurs in
83,136,165,194). The prevalence of metastases increas- cervicothoracic metastases (36).
es with advancing age, particularly after 50 years. The In the presence of a lumboradicular syndrome,
lesion is generally located in the vertebral body. An radiographs usually show at least one bone lesion, gen-
autopsy study showed that 36% of subjects dying as erally osteolytic in nature (Fig. 11.14). In the initial
the result of a tumor had vertebral metastases and in stages of metastatic invasion, however, radiographs
26% these were not visible on plain radiographs (194). may be negative; in fact, for the lesion to be radio-
The initial symptom of lumbosacral spinal meta- graphically evident, destruction of bone trabeculae has
stasis is almost consistently vertebral pain, but many to reach 30%-40%. Three investigations are indicated
patients with metastases have no back pain. The latter, in these cases: bone scanning, which, however, has
when present, is usually insidious in onset, tends to the drawback of being aspecific; CT, that has a high
increase with time and is often characterized by exacer- diagnostic ability (188), since it demonstrates the
bation at night. Symptoms in the lower limbs appear lesion when the latter has destroyed only 10 % -15% of
when the tumor deforms the vertebral body or the the bone trabeculae, but may not provide evidence
pedicle and narrows the spinal canal or the interverteb- of a discrete encroachment on the epidural space;
ral foramen, or when it erodes the cortical bone and and MRI. This is the investigation with the highest
invades the epidural space. In a few cases, lumboradic- diagnostic ability, since it can reveal the tumor before
ular symptoms become apparent following a patholog- destruction of bone structure, i.e., in the stage of inva-
- - - - - - - - - - - - - - - - - - . Differential diagnosis. I. Organic diseases· 307
sion of bone marrow; furthermore, MRI may show com- Extravertebral diseases
pression of the neural structures better than CT and
allows the whole spine to be visualized.
Abdominopelvic organs
Case report and retroperitoneum
A 64-year-old male had been complaining of pain in the left Tumors of various pelvic organs - ovaries, uterus,
lower limb for 4 months. Pain was located in the posterior colon, rectum - may swarm upon the retroperitoneal
aspect of the thigh and leg, and was not affected by walking or space and infiltrate the lumbar or sacral plexus, or the
rest. No low back pain was present; pain in the lower limb had spine itself, and give rise to lumboradicular syndromes
considerably exacerbated in the last month, in spite of simulating radiculopathy. In these cases, however,
antalgic and anti-inflammatory drugs. No radiographs of the there is seldom a problem of differential diagnosis with
lumbosacral spine had been obtained. CT scan performed a a herniated disc, since usually visceral disturbances
few weeks earlier showed moderate spinal stenosis at L4-L5 coexist, and pain is dull, nocturnal, independent of
level and an intraforaminal protrusion of the L3-L4 disc on physical activity and multiradicular in distribution.
the left. Upon physical examination, a mild positivity of the An abscess in the pelvic organs may invade the
SLRT was found, as well as absence of the ankle jerk on both retroperitoneal space and irritate or encroach upon the
sides and mild weakness of the triceps surae on the left. nervous plexuses or the sciatic nerve and give rise to
Radiographs of the lumbar spine revealed an uncertain oste- radicular symptoms (5).
olytic lesion of the left sacral ala. The latter was not visible on Neoplasms in the retroperitoneal space, such as
the CT scans, since the lowermost scan had been obtained at lymphomas or sarcomas, may infiltrate the neural
the level of the caudal border of the L5-S1 disc. MRI showed a structures and the spine, causing lumboradicular syn-
massive invasion of neoplastic tissue in the left half of the dromes (120). The same holds for masses of extra-
sacrum (Fig. 11.15), but no other spine lesions. Total body CT medullary hemopoietic tissue located in front of the
demonstrated a lung cancer. lumbar spine or the sacrum (73). These pathologic
conditions, once of difficult diagnosis, are now easily
On MRI, metastatic lesions appear as areas of low demonstrated with CT or MRI.
signal intensity on Tl-weighted images due to replace-
ment of bone marrow, rich in fat, with pathologic tissue.
Occasionally, MRI shows metastatic invasion before
bone scanning becomes positive. Vessels
In patients with a clinical history of primary extra-
vertebral tumor, a lumboradicular syndrome should It is well known that an aneurysm of the abdominal
lead us to suspect a metastatic lesion. This, however, aorta may manifest with low back pain, associated or
may coexist with a disc herniation, in which case it is not with abdominal pain. There is seldom pain also in
the herniation that may simulate the neoplasm (71). the lower limb. In a series of 51 patients with aneurys-
308.Chapter 1 1 . - - - - - - - - - - - - - - - - - - - - - - - - -
matic rupture, six complained of abdominal pain radi-
~ting t.o the thigh (10). However, in two large series,
mcludmg 951 patients with aneurysms of the abdomi-
nal vessels, no cases of radiation of pain to the lower
limb were found (43, 59). Exceptionally, an aneurysm of
the aorta or iliac arteries causes pain in the lower limb
only of the cruralgic or sciatic type (6, 20, 81,161,184).
Case report
A B
Fig. 11.17. Neurinoma of the right sciatic nerve. Axial turbo T2-weighted spin-echo MR image (A) and axial Tl-weighted spin-echo image after injec-
tion of gadolinium (B). Between the gluteus maximus and internal obturator muscles, a mass is visible, which is weakly hyperintense on both images
(arrows). Histologic examination of the excised tumor revealed a neurinoma.
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-------CHAPTER 12-------
DIFFERENTIAL DIAGNOSIS.
II. PSYCHOGENIC PAIN
F. Postacchini, G. Giannicola
Introduction only low back pain of the chronic type, and often idio-
pathic in nature, i.e., not due to a demonstrable organic
Knowledge of the influence of the psychologic factors condition. Only few studies have analyzed also patients
on low back or lumboradicular pain have considerably with acute low back pain, and an even smaller number
improved in the last 50 years (48). In the 50' sand 60' s, a have been focused on patients with lumboradicular
dichotomous opinion prevailed, according to which pain or disc herniation diagnosed with imaging stud-
low back pain was purely organic or psychologic in ies. The presence of psychologic disorders may play an
nature. Clinical studies, in that period, were mainly important role in the genesis and persistence of pain in
aimed at identifying the psychologic factors which the latter group of patients as well. Such role, however,
might predict the results of surgery. However, many of is likely to be less relevant than in patients with idio-
these studies had methodological defects and the pathic chronic low back pain. Nevertheless, the assess-
results were often conflicting. In the 70's, the clinical ment of the psychologic factors is of considerable
studies were carried out on patient populations, mostly importance also in patients with suspected or demon-
small and selected, often consisting of "difficult" cases strated disc herniation, either from the diagnostic point
unresponsive to various treatments, using different cri- of view or, particularly, in the choice of treatment, since
teria for the diagnosis of psychologic disorders. This numerous evidences indicate that the results of surgery
led to obtain extremely different percentages of preva- are related to the patient's personality and psychosocial
lence of the psychologic disorders in patients with low factors. On the other hand, the clinical picture of lumbar
back pain. In recent years, the evaluation methods have disc herniation varies considerably and also includes
attained a higher level of standardization and many syndromes characterized by only chronic low back
studies have been epidemiological in nature, with the pain, continuous or intermittent in nature.
aim of clarifying the relationships between low back
pain and the patient's psychologic traits. These studies
clearly show that the prevalence of neurotic or psycotic
Psychologic disorders related to low
disorders, or behavioral abnormalities, is higher in back pain
patients with low back pain, particularly if chronic,
than in the general population. Meanwhile, the analysis Depression
of the demographic, social and psychosocial factors has
revealed that some factors may playa relevant role in This is a psychopathologic state characterized by
the etiology of pain and the results of management. depressed mood and alteration of affectivity and the
The available knowledge on the role of the psycho- feelings related to it (92). The most typical symptoms
logic factors was mainly obtained from patients with are sadness, feeling inefficient and useless, loss of
320.Chapter 1 2 . - - - - - - - - - - - - - - - - - - - - - - - - - - -
affection, reduced interest, pessimism, anxiety, hope- masked depression is the dominant factor; in still oth-
lessness, somatic disorders, such as asthenia, insomnia, ers, the component "role" given to pain is prevalent,
and neurovegetative disorders, often painful, such as i.e., pain is incorporated by the patient (usually after an
headache. Many types of depression have been identi- illness) and used to justify behaviors that ensure him
fied, which differ as far as concerns quality and severi- certain privileges.
ty of the clinical presentation. One of the mildest forms
is the so-called masked depression, in which the patient
tends to have an hypochondriac behavior, which con- Anxious neurosis
ceals the typical depressive symptoms, that he often
denies to suffer from. This type of depression is usually This psychoneurosis is characterized by an abnormally
dominated by somatic disorders. high level of anxiety, which is manifested by alarming
Depression is one of the most frequent neurotic syn- reactions and worries absolutely out of proportion to
dromes associated with low back pain (1, 24, 45, 58, 96, the anxiety-inducing event. Certain events, or even any
98,120,125). Depressive symptoms have been identified event, provoke sensations of existential insecurity and
in proportions ranging from 60% to 100% of patients emotional instability or, at times, of danger, threaten or
with chronic low back pain (6,54); a study on 80 patients persecution. At times, anxiety may also, or only, be
(31) revealed that 21% had a major depression, 54% lived as a somatic disorder (such as vertigo or lipo-
presented intermittent depressive disorders, 5% had thimic crisis), which may become stable with time.
minor depressive symptoms and 20% showed no This condition has often been observed in patients
evidence of depression. However, these studies were with chronic low back or lumboradicular pain, fre-
carried out on selected patient populations. An epidemi- quently in association with SYlc.ptoms of depressive
ologic psychiatric survey of 220 Finnish patients neurosis (34, 55,71,100). However, ill a psychiatric epi-
complaining of low back pain who were identified by demiologic study by Youkamaa (48), the prevalence of
the responses to a questionnaire and of 101 control sub- anxious neurosis was found to be slightly greater in
jects has shown that 31% of patients had psychologic patients with chronic low back pain than in the
disorders (including depression), compared with 20% controls, however only in males.
in the control group (48). Conversely, in the epidemio-
logic study of Westrin (132), no significant differences Hypochondriasis
in the prevalence of neurosis were found between the
patients with low back pain and the controls. According This is a neurotic syndrome characterized by an exces-
to a few authors, low back pain, similarly to headache, sive worry for ones own health or for the integrity of
vertigo and gastroenteric disturbances, can be a somatic some parts of the body or mind, anxiety and depres-
expression of a masked depression (60,118) or a variant sion, unpleasant somatic feelings, morbid attachment
of the depressive disease (12). to doctors and medication, and apathy for what does
An abnormal prevalence of affective disorders, not affect ones own disorder. The hypochondriasis
including depression and alcoholism, has been found syndrome should be distinguished from the hypochon-
in both the first-degree relatives of patients with low driasis symptom, which may be present in many other
back pain or sciatica, and in the relatives of patients neurotic or psycotic syndromes.
with depression (1, 76). In a study (32), the prevalence Hypochondriac symptoms are often observed in
of major depression was found to be significantly high- patients with chronic low back pain, however usually
er in the relatives of patients with low back pain and as an expression of anxious-depressive or hysteric
major depression than in the relatives of patients with syndromes, rather than as a specific syndrome.
low back pain and no evidence of depression, whilst the
familial prevalence of alcoholism was similar in the two
groups. These findings suggest that major depression Hysteria
in patients with chronic low back pain may be related to
a genetic predisposition to depression. In effect, the The hysteric syndrome is a combination of various
etiologic relationship between chronic back pain and symptoms, of even opposite nature to one another, of
depression, particularly the minor forms of depression, which the common denominator, according to the clas-
is still unclear. It is possible that depression is a result sic theory, is that they do not have a demonstrable
of somatic pain (54, 117) or that the latter represents a organic pathologic substratum. The hysteric subject has
form of somatization in subjects with primary depres- abnormal modalities in seeing himself in relation to
sive disorders (6, 50). A further possibility (72) is that reality, the others and himself (22). The hysteric person-
pain may have a multifactorial etiology: in some cases ality is extremely vulnerable in facing external reality
the somatic component prevails; in others, overt or and reacts to it in a distorted way and to an exaggerat-
- - - - - - - - - - - - - - - - - . Differential diagnosis. II. Psychogenic pain· 321
ed extent, with pathologic psychologic states (psycho- an overt syndrome and, at the opposite end, forms of
logic conversion) or organic symptoms, ranging from mild severity with less than 12 somatic complaints (20,
neurovegetative disorders to functional motor paraly- 27). Patients with chronic low back or lumboradicular
sis (somatic conversion). The hysteric personality is pain often complain of multiple symptoms (30, 86). In
abnormally unstable and easily influenced, and it is a study on chronic low back pain patients (7), it was
inclined to use the repression mechanism in a patholog- found that, during lifetime, 25% of subjects had 12 or
ic measure in order to avoid psychologic conflicts. more of the symptoms in DSM III list, 51% had experi-
Furthermore, the hysteric subject tends to victimism enced only seven to 11 symptoms and the 22% had none
and autodevaluation, as well as to mythomania and to six symptoms; in the controls, the percentages in the
exhibitionism, of which dramatization of feelings and three groups were 4%,8% and 87%, respectively.
actions, and hystrionism, are an expression. Epidemiologic studies have revealed that high
In the past, conversion hysteria was believed to be degrees of somatization are associated with psychiatric
present in all patients with chronic low back pain disorders, including depressive syndromes. On the
(83, 97, 104). More recently, many authors have denied other hand, chronic pain is often associated with
a close relationship between hysteria and low back pain depression as well. It has therefore been hypothesized
(11,48,62). Hysteric traits may, at times, appear evident that the mechanism of somatization may, in these
at a superficial analysis, however not in a thorough patients, represent the link between pain and depres-
psychiatric evaluation. Maruta et al. (62) initially diag- sion (7). That is, the depressed patient tends to be a
nosed a conversion hysteria or an hysteric personality somatizer and low back pain may be one of the somati-
in 48% of patients with chronic low back pain who were zation symptoms through which he manifests psycho-
hospitalized for psychiatric assessment, but during logic or psychosocial disorders.
the hospital stay many patients showed an anxious-
depressive, rather than, hysteric syndrome.
Abnormal illness behavior
Alexithymia Parson (82) first analyzed the social role of the illness
condition and identified the privileges and obligations
This term was coined by Sifneus to indicate a psycho- related to the role. For instance, the rights are that the
logic dysfunction characterized by difficulty in express- individual is not considered responsible for his /her ill-
ing feelings and emotional distress, particularly ness and that the social obligations change proportion-
hostility and anger (101). Patients with this disorder ally to the severity of illness; the obligations are to
have an extremely poor imagination, rarely dream, use aknowledge that it is not desirable to be ill, and to
actions to avoid inner conflicts and concentrate on irrel- accept in part the responsability for one's own illness
evant details and trivial somatic symptoms. In these and cooperate with those who are in charge of restoring
patients, pain would be a kind of physical language to the health state (129). The normal role of the illness con-
communicate feelings they do not know how to express dition may, in certain circumstances, become abnormal,
in other ways. This disorder can be present alone or be particularly in chronic illness, since the patient does not
one of the symptoms of depression; it has also been adequately adapt to it.
hypothesized that alexithymia may be the cause of The expression "illness behavior" was coined by
masked depression. Several studies point out that alex- Mechanic (68), who initially used it to indicate the way
ithymia is present in a high proportion of patients with some symptoms can be perceived, assessed and turned
chronic pain (3,70,108), but can be difficult to measure into action in different ways by different personality
by questionnaires or psychiatric interview (84, 114). types. The successive evolution of the concept of illness
behavior has led to the use of the expression to indicate
the different perceptions, thoughts, feelings and
Somatization actions, which influence the personal and social mean-
ing of symptom, illness, disability and their conse-
Diagnosis of somatization is based, according to the quences (67). Pilowsky (87,88) integrated the concept of
DSM III of the American Psychiatric Association (2), on illness behavior with that of hypochondriasis and trans-
a lifetime history of at least 12 - from a list of 37 - med- ferred it into a sociological context, thus identifying a
ically unexplained somatic complaints reflecting normal and an abnormal behavior. In the former case,
disturbances in multiple organ systems. So defined, the sick role put on by the patient is proportionate to the
this condition is rarely observed (51, 94). More recent objective pathologic condition and it is congruous with
definitions imply that a spectrum of severity exists in the role assigned to him. In the latter, the behavior is out
somatization disorders, which includes, at the one end, of proportion to the objective findings and the patient
322.Chapter 1 2 . - - - - - - - - - - - - - - - - - - - - - - - - - - -
obstinately keeps an inappropriate role of sick person, dissatisfaction, excessive stress or professional respon-
despite the physician's reassurance on his state of sability, conflictual relationships with the colleagues or
health. Waddell et aI. (126) recognized that an abnormal superiors.
illness behavior is an expression of cognitive and affec- The prevalence of domestic conflicts, especially
tive disorders and defined, on a clinical basis, the illness marital, and libido disorders was found to be higher
behavior as a complex of actions and behaviors which in patients with chronic low back pain than in those
express and communicate the individual's perception complaining of no back pain (5, 29,75,102); on the other
of an altered health condition, and the abnormal illness hand, there seem to be an increased prevalence of
behavior as a behavior correlated to a physical disease, painful syndromes in relatives and consorts of patients
which is manifestly maladjusted and disproportionate with chronic low back pain (12, 26, 50). This might be
to the disease and attributable to cognitive and affective due to a greater sensibility to pain or to behavioral
disorders, rather than to an objectively demonstrable disorders involving the whole domestic group,
pathologic condition. This behavioral disturbance, like possibly related to educational or socioeconomic fac-
hypochondriasis and somatization disorders, can be tors (26, 123). It has been found, for instance, that a high
isolated (in patients with cognitive disorders represent- proportion of patients with chronic low back pain
ed by an excessive attention to somatic symptoms and belong to large families (36, 48, 63) and that the
affective disorders consisting in an increased somatic patient's cultural level plays a primary role in the
awareness) or it can be one of the pathologic features in quality of the results of treatments for chronic low back
various neurotic syndromes. pain (23). Similar results have been obtained in the eval-
uation of psychosocial disorders related to the work
environment, which have been observed more fre-
Passive coping strategies quently in patients with, than in those without, low
back pain (29, 75, 111). Heaton et aI. (44), however,
Patients with chronic low back pain, like those with found an abnormal prevalence of psychosocial dys-
other chronic painful conditions, may use active strate- functions also in patients with chronic low back pain
gies (i.e., minimizing, "gritting" one's teeths, insisting considered as organic in nature.
in physical activities) or passive strategies (i.e., praying,
hoping, groaning, avoiding social life and physical
activities) to cope with pain. The passive-avoidant cop- Psychometric tests
ing strategies have been interpreted as an expression of
psychologic dysfunction and maladjustment to pain, Facing a patient with low back or lumboradicular pain,
which favor development of chronicity of the symp- the physician often wonders: who is this patient? That
toms and disability (52, 93, 113). Furthermore, decrease is, has he / she psychologic dysfunctions or is he / she
in physical activity may have de conditioning effects on psychologically stable? Are the complaints that he / she
the musculoskeletal structures, thus favoring develop- reports entirelly organic, or partially or entirelly func-
ment of chronic pain (42). On the other hand, passive tional ? What is the real severity of pain and functional
strategies are often adopted by depressed patients pre- impairment ? If both a psychologic disorder and a
senting no painful pathologic condition (10, 28). These demonstrated organic disease are present, what will be
strategies, therefore, might be due to dysfunctions of the outcome of the conservative or surgical treatment?
the emotional sphere rather than to pain. This hypothe- The psychometric tests are the instruments developed
sis is supported by a controlled study on depressed or to answer these questions, before asking a psychiatric
non-depressed patients, complaining of chronic low consultation or in addition to this.
back pain: an increased rate of passive-avoidant coping Three categories of psychometric tests can be distin-
responses was found to be associated with the combi- guished: the questionnaires, the pain drawing test and
nation of chronic low back pain and depressed mood, the inappropriate physical symptoms and signs test.
rather than with chronic back pain alone (130). Numerous questionnaires have been developed, some
of which are very similar; those described herein are
some of the most frequently employed.
Psychosocial factors
Numerous studies have shown that various psycho- Minnesota Multiphasic Personality
social factors may be associated with chronic low back Inventory (MMPI)
pain. They are mainly represented by domestic
conflicts, general or marital in nature, and by psycho- The Minnesota Multiphasic Personality Inventory is
logic conflicts in the workplace, correlated to work one of the oldest and most utilized psychometric
_________________ 0 Differential diagnosis. n. Psychogenic pain 0323
instruments in patients with low back or lumboradic- one with very slight elevations on the three scales and
ular pain. The questionnaire, consisting of 566 state- an elevated K-scale (correction scale); and one, clearly
ments to which the patient is asked to respond "true" or psychopathologic, with elevations on the three scales as
"false", has three validity scales and 10 clinical scales. well as on that of Schizophrenia. Several investigations
The questionnaire requires 90 minutes or even more have later validated this subgroup model (4, 41,
to complete, as well as a cultural level at least of 66, 103). Furthermore, two studies (41, 66) found the
secondary school. four-group model to be valid for both sexes. In conclu-
Sternbach et al. (109, 110), who first employed the test sion, it is now clear that a unique type of personality
in patients with low back pain, found elevations on the correlated to low back pain does not exist and that
scales measuring Hysteria (Hy), Depression (D) and MMPI does not allow us to distinguish organic, from
Hypochondriasis (Hs). At the same time, Gentry et al. functional, patients. The available data indicate that,
(36) observed that, in many patients, the scales corre- among the low back pain patients, at least four
sponding to hypochondriasis and hysteria were higher subtypes of personality exist, which show various
than the depression scale. Since in the test histogram, differences in the affective, cognitive and behavioral
the D scale is in between the two others and the profile characteristics, or distortions, regarding pain.
thus displayed a "V" pattern, the authors labeled this The correlations between the MMPI profiles and
profile conversion "V" and considered it as typical of treatment outcomes have usually been analyzed in
patients with chronic low back pain (Fig. 12.1). Later on, operated patients. In many studies (25, 46, 47, 56,
many studies have been performed to determine the 59, 79, 80, 85, 119), a correlation was found between
validity of the MMPI and its clinical usefulness in the a few MMPI scales and the results of discectomy: in
assessment of patients with low back or lumboradicu- all studies, it was noted that patients with poor results
lar pain. This has been done in two ways: by evaluating had high scores on the Hs scale; in the majority of inves-
the results of the test in patients with organic disorders tigations, the Hy scale was elevated as well; and in
compared with patients considered as functional; and a few studies, the poor outcomes were related to an
by correlating the results of conservative or surgical elevated D-scale. Sorensen (105-107) has evaluated the
treatments to the psychometric characteristics emerged scores on the MMPI scales at short, medium (2 years)
from the test. and long term (5 years) after discectomy for lumbar
The studies in the first group have provided conflict- disc herniation. Elevations on the D scale were found
ing results. Hanvic (40) developed a low back pain (LB) only at short term; the Admission of Symptom scale
scale, which was supposed to correctly identify cases of (which measures the degree of somatizzation) was that
psychogenic pain. However, this ability has not been showing the highest predictive value for both the good
confirmed by other studies (6, 16, 33, 57, 116, 133). and poor results, either at short or long term. In a
Another scale, developed by Pichot and called Dorsal retrospective study (133), fair or poor results of spinal
(DOR) scale (16), was also found to be unable to identify fusion were found to be associated with high post-
subjects with psychogenic pain (33, 115). Multivariate operative scores on the conversion-V scale. In addition,
cluster analysis (13) of the MMPI results in patients Wiltse and Rocchio (135), found a significant correla-
with low back pain have led to identify three homoge- tion between the scores on the Hy and Hs scales and the
neous subgroups of patients (and a fourth in females): clinical response to chemonucleolysis. Therefore, the
one group with elevations on the Hs, D and Hy scales; scores on the conversion-V scale of the MMPI appear to
90
80
70
...
....•..
60 -_ .. _- ....•.... --
-
.~
-"-'
50 Fig. 12.1. MMPI profile of two patients
with chronic lumboradicular pain. One
40 patient (dotted line) has a normal profile,
with slight elevations in the scales of
30 Hysteria, Depression and Hypochondriasis.
In the other patient (continuous line) the
20 higher scores in the scales of Hysteria and
Hypochondriasis compared with that of
10 Depression give the profile a V shape
HS D HY Pd Mf Pa PI Sc Ma Si (conversion V).
324.Chapter 12.-----------------------------------------------------
be good predictors of the surgical results, at least as far introvert, denying / minimizing, prone to adapting
as concerns the poor outcomes. However, it should be (with potential psychosomatic disorders), and with
taken into account that the examiners have usually psychopathologic disorders.
assessed the results of surgery in a subjective and In two studies, the MBHI was found to be predictive
empiric way, and this may partially decrease the valid- of the results of rehabilitation programs (35) or surgical
ity of the correlations with the MMPI scores. The latter treatment (78). Barnes et al. (8) observed that only a few
may probably predict also the responses to conserva- scales are predictive of the results of a functional reha-
tive treatments, but the available data do not allow def- bilitation program. Sweet et al. (112), however, found
inite conclusions to be drawn. The outcomes of the no significant differences between the MBHI and the
conservative treatments seem to be related to the scores MMPI in the ability to predict the treatment outcome.
on the conversion-V scale (64, 65), but the correlation is
less certain than for the surgical outcomes. The results
of the anesthetic block of spinal nerves (IS, 19) and the McGill Pain Questionnaire (MPQ)
application of epidural stimulators (14), were not found
to be related to the MMPI profile. Only few studies, This questionnaire has been developed by Melzak (69)
however, have analyzed patients submitted to conserv- to assess the quality and intensity of pain. It consists of
ative treatments. 20 sets of adjectives, which describe the sensorial, emo-
tional and cognitive components of pain. The patient is
asked to choose the adjectives which best describe
Beck Depression Inventory (BDI) and Zung his/her pain. In addition, a Present Pain Intensity scale
self-rating depression scale is present, which is aimed at measuring the severity of
current pain.
The BDI (9) consists of 21 items pertaining to cognitive, The MPQ can detect affective and cognitive disorders
affective, behavioral and somatic symptoms. The Zung in pain perception in patients with low back pain (100),
(136) scale is structured in 20 statements, to each of but it does not seem to be effective in differentiating
which the patient is asked to give a score of 1 to 4, based patients with organic, from those with partially or
on how he believes it truthful. Both questionnaires are entirely functional, pain.
designed to identify patients with depressive symp-
toms. Crisson et al. (21) have shown that, in patients
with low back or lumboradicular pain, the BDI is not Illness Behavior Questionnaire (lBQ)
influenced by the organic condition: in patients with a
clear organic pathology, such as disc herniation, in fact, This questionnaire (89, 90) assesses the illness behavior
they observed similar depressive patterns to those in under various aspects. It includes seven first-order
patients with little or no evidence of organic disease. scales: General Hypochondriasis, Disease Convinction,
The Zung scale was found to have a high sensitivity Psychological vs Somatic Perception of Illness,
and specificity in identifying psychologic disorders in Affective Disturbance, Affective Inhibition, Denial,
patients with low back pain, particularly when it is Irritability. Some of these scales reflect attitudes and
combined with the Modified Somatic Perception feelings regarding the illness, whilst others evaluate the
Questionnaire and the combined test was not found to degree of the dysphoria (Affective Inhibition), difficul-
be affected by pain or socioeconomic and cultural fac- ty in communicating feelings (Affective Disturbance)
tors (37). and interpersonal irritability (Irritability). Combining
these scales, two second-order scales have been
obtained: Affective State and Disease Affirmation.
Millon Behavioral Health Inventory Various studies (17, 49, 53) have found the first-order
(MBHI) scale Disease Convinction to have a high ability to
identify an abnormal illness behavior. Waddell et al.
This questionnaire (73) consists of 150 statements that (129) have compared, in patients with chronic low
the patient has to judge as "true" or "false" and 20 back pain, the results of IBQ with the objective clinical
clinical scales (such as, Introverted, Cooperative, signs of pain and physical disability, with psychometric
Respectful, Pessimism, Pain Treatment Responsivity, measures of psychologic dysfunction and with the
Chronic Tension, Somatic Anxiety) which reflect psy- inappropriate physical symptoms and signs of illness,
chologic features or behaviors related to medical and have analized the predictive value of these
aspects. In one study (74), the questionnaire allowed symptoms and IBQ pattern regarding the results of the
four types of personality to be identified in chronic low surgical treatment. The IBQ scores (particularly those
back pain patients attending a rehabilitation program: on the second-order scale Disease Affirmation, which
includes the first-order scales Disease Convinction and uses mechanisms of diversion of attention from pain
Psychological vs Somatic Perception of Illness) were and the strategies of prayer and hope to face the symp-
found to be strictly related to affective disorders and tomatology; these patients have a high level of pain and
psychologic dysfunction, and both the questionnaire functional impairment. The use of the questionnaire
scores and the inappropriate symptoms and clinical was found to be predictive of the surgical outcome in
signs were found to be predictive of the surgical results. patients submitted to decompressive surgery on the
lumbar spine (38).
A
Fig. l3.2. This 62-year-old male had undergone
excision ofLS-51 disc herniation on the left in
1982 and ipsilateral L4-LS intraforaminal
herniation in 1994. Tn 1996, sciatic pain, not
associated with low back pain, appeared quite
suddenly on the right side. The pain, extremely
severe, was located in the 51 dermatome, but
particularly in the buttock and thigh. Physical
examination revealed limitation of 5LR at 60 0
A c
B D
Fig. 13.3. This 44-year-old female fell down the stairs and sustained trauma to the lumbar region and right buttock. After afew days, plain radiographs
of the lumbar spine were obtained due to persistence of pain in the lower lumbar region, as well as in the right buttock and groin. Since the radiographs
were normal, disc herniation was suspected and the patient was referred to a neurosurgeon, who requested CT scan of the lumbar spine, which showed
no abnormalities. Sixteen days after the trauma, the patient was examined by another neurosurgeon, who requested MRI studies of the lumbar spine;
since even the latter were normal, bed rest and anti-inflammatory therapy were prescribed. After 1 week of bed rest, the patient still complained of pain
in the buttock and groin, particularly in the upright position and on walking. When examined by an orthopaedic surgeon, 26 days after the trauma, the
patient presented slight limping due to groin pain, radiating to the upper portion of the anterior aspect of the right thigh. Neurologic examination was
normal. Hip rotations and flexion were limited and painful. Plain radiographs of the hip were normal. MRI of the hip - (A) and (B) - showed abnormal
signal intensity in the region of the right acetabulum on Tl- and T2-wighted images (arrows). Bone scan (e) showed increased uptake in the right
acetabulum (arrowhead), and the subsequent CT (D) revealed a fracture of the acetabulum (arrow). In this case, scrupulous physical examination
should have led the examiner to suspect a pathologic condition of the hip, soon after the trauma.
the presence of lumbar scoliosis. Another pathway con- bone scan; neurophysiologic investigations, if not
sists in carrying out discography and disco-CT, if low already performed; and CT and / or MRI of the pelvis
back pain prevails. However, if one of the two types of and abdomen.
investigation (myelography and/or myelo-CT, and In the presence of atypicallumboradicular or radicu-
discography and disco-CT) is negative or dubious, the lar-like symptoms, plain radiographs of the pelvis and
other type may be indicated. A further option is to sub- femur may be indicated. If the latter are normal or of
mit the patient to psychologic evaluation (psychome- uncertain interpretation, lumbar MRI or bone scan,
tric tests and possibly psychiatric examination), respectively, should be obtained. In these cases, howev·
straight away or after performing the appropriate er, it is of paramount importance to accurately take the
neurophysiologic tests. Another diagnostic pathway, if clinical history and examine the patient (3, 15), to avoid
MRI suggests or demonstrates discitis, is aimed at missing the diagnosis or performing long and tortuous
evaluating the blood tests for infection and the possible pathways (Fig. 13.3). Occasionally, before carrying out
indications for biopsy. Apart from the latter, the last lumbar MRI, it may be useful to perform doppler exam-
step of the algorithm includes: anesthetic nerve-root ination or have the patient seen by a general surgeon,
block and / or myelography, at least in patients with a urologist or gynecologist, if inguinal hernia or diseases
monoradicular, or at the most biradicular, syndrome; of the retroperitoneal organs or the genitourinary
338.Chapter 1 3 . - - - - - - - - - - - - - - - - - - - - - - - - - - -
Typical
Atypical
<50 y. >50 y.
-??
apparatus are suspected. In the event of radiographic diseases, osteoporotic fracturest which are better
changes of the sacroiliac joint, rheumatic tests should demonstrated by MRI. If the latter is of uncertain inter-
be performed, prior to or after bone scan. pretation, discography or disco-CT may be indicated
and, if diagnosis still remains uncertain, a thorough
psychologic evaluation of the patient or MRI of the
Prevalently lumbar syndromes pelvis, before or after abdominal echography, should be
carried out. If MRI is negative or of extremely dubious
In patients complaining prevalently of low back pain -
interpretation, a further diagnostic pathway includes
for instance, acute or subacute back pain and mild
radiographs of the pelvis, hematologic blood tests
pseudoradicular pain - diagnosis may not be as easy as
and / or bone scan, and evaluation of the patient by
in those with lumboradicular or only radicular pain,
other specialists, such as the general surgeon, gynecolo-
due to the multiplicity of the vertebral or extravertebral
gist or rheumatologist. In patients with isthmic or
pathologic conditions producing the syndrome. It is
degenerative spondylolisthesis, flexion-extension radi-
thus more difficult to schematize the diagnostic path-
ographs may be indicated after lumbar CT and / or MRI
ways, which, on the other hand, are less rigid than in
studies. When the latter suggest or demonstrate discitis,
the lumboradicular syndromes.
blood tests and possible biopsy should be performed.
Also the prevalently lumbar syndromes can be classi-
In atypical syndromes, the investigation of choice,
fied into two groups: syndromes with clinical charac-
after plain radiographs, is generally lumbar MRt since
teristics typical of a pathologic condition of the disc and
the syndrome may easily be caused by pathologic
atypical syndromes from this point of view (Fig. 13.4).
conditions not related to the disc.
In typical syndromes of young or middle-aged
patients, CT is indicated and, if this is negative or of
uncertain interpretation, lumbar MRI should be carried
out. In older patients, MRI should be preferred because Computerized algorithms
of the better chances to find annular bulging or disc
degeneration at multiple levels, or non-dis cal patholog- Most computer-aided diagnostic systems are of two
ic conditions (tumors, inflammatory or hematologic types (5, 13). A few calculate the likelihood of different
- - - - - - - - - - - - - - - - - - - - - - - - - - 0 Diagnostic algorithm 0339
diagnoses, using the probability theory, in particular, methods of treatment, has been computerized for use
the Bayesan theorem (1). Other protocols make use of as a monitoring system in a large population (17). A
systems of artificial intelligence to imitate the human prospective study has demonstrated the practicality of
reasoning process (10, 11, 14). In both cases, most com- the computerized system and its validity in the diag-
puterized programs include a diagnostic algorithm and nostic and therapeutic monitoring of workers in
a therapeutic algorithm strictly related to the former. industry.
An example of a diagnostic-therapeutic algorithm Computerized programs of diagnostic algorithm,
based on the calculation of probability is LOBAK (8,9). despite the considerable enthusiasm evoked in the
With this protocol, the patient with a suspected disc 80' s, have never been widely used. One of the main rea-
herniation is first assigned to one of seven clinical sons is that the data are introduced into the computer
groups, which have a pre-test probability of 98% by man, who has to interpret and catalogue a clinical
("good" neurologic and mechanical signs) to 10% (only sign or the result of a diagnostic test; in this process,
low back pain, no neurologic and mechanical signs). man may make mistakes, thus negatively affecting the
The program then analyzes the clinical signs and elaboration of the data by the computer. For instance,
symptoms and indicates the interspace where disc her- the clinician has to interpret whether CT or MRI studies
niation is most likely to be located. If the signs and are negative or positive, and, in the latter instance,
symptoms suggest a stenotic condition, spondylolis- whether a disc prominence into the spinal canal should
thesis, spinal tumor or inflammatory disease, the pro- be considered as annular bulging or disc herniation,
gram makes recommendations for diagnostic testing or and whether the latter is midline, posterolateral or
treatments. If these conditions are excluded, the lateral herniation. Depending on the interpretation of
anamnestic data, clinical signs and the results of inves- the clinician, the diagnostic pathway followed by the
tigations are analyzed to detect possible conflicting computer may be considerably different. Other reasons
data. In the absence of the latter, the program analyzes for the lack of use are the risk of excessive simplification
the results of diagnostic tests and lists the tests to be of the clinical problems, when the system of probability
performed. Finally, it calculates the post-test probabili- is used (4, 5), or the complexity and inadequacy of the
ty for disc herniation using the Bayesan analysis. Based mathematical models employed in some expert
on the value of probability calculated, the program systems (11, 12).
recommends further diagnostic tests or specific types
of treatment.
Mathew et al. (11) have developed an "expert" com-
puterized system for the differential diagnosis of References
pathologic conditions of the lumbar spine. The system
1. Bayes T.: An essay toward solving a problem in the doctrine
uses the mathematical theory termed inductive learn- of chance. Phil. Trans. R Soc. London 53: 370, 1763.
ing, which mimics the human ability to learn from 2. Boden S. D., Davis D.O., Dina T. S. et al.: Abnormal lumbar
example patients. These are first assigned to one of four spine MRI scans in asymptomatic subjects: a prospective
diagnostic categories: simple low back pain, radicular investigation. J. Bone Joint Surg. 72-A: 403-408, 1990.
pain, spine pathologies (infections, tumors, inflamma- 3. Boden S. D., Wiesel S. W., Spengler D. M.: Lumbar spine algo-
rithm. In: The lumbar spine. Second Edition. Wiesel S. W.,
tory diseases), and abnormal illness behavior (psyco- Weinstein J. N., Herkowitz H. et al. Eds., W. B. Saunders Co.,
genic pain). The expert system uses two diagnostic Philadelphia, 1996.
methods: without and with dialogue. With the former 4. Feinstein A. R: Clinical biostatistics XXXIV: the haze of
method, all the data are entered and a diagnosis com- Bayes, the aerial palaces of decision analysis and the comput-
puted. With the latter, the computer imitates the focus- erised ouija board. Clin. Pharmacol. Ther. 21: 482-496,1977.
5. Fox J., Alvey P.: Computer assisted medical decision making.
ing skills of a human expert and engages in an Br. Med. J. 287: 742-745, 1983.
intelligent dialogue during which it requests specific 6. Hitselberger W. E., Witten R M.: Abnormal myelograms in
items of information. The dialogue is interrupted by the asymptomatic patients. J. Neurosurg. 28: 204-206, 1968.
system itself when it has gathered sufficient informa- 7. Holmes H. E., Rothman R H.: The Pennsylvania Plan: an
tion to be certain of its diagnosis. In a prospective study algorithm for the management of lumbar degenerative disc
disease. Spine 4: 156-163, 1979.
of 200 patients - 50 in each of the four diagnostic cate- 8. Hudgins W. R: Computer-aided diagnosis of lumbar disc
gories - the authors found that the computer outper- herniation. Spine 8: 604-615, 1982.
formed a large number of clinicians, specialists and 9. Hudgins W. R: Computerized decision-making in disc dis-
non-specialists, even though its patient data base was ease. In: Lumbar disc disease. Second Edition. Hardy RW. Jr.
relatively small. Ed., Raven Press, New York, 1993.
10. Mann N. H., Brown M. D.: Artificial intelligence in the diag-
A diagnostic and therapeutic algorithm for lumbar nosis of low back pain. Orthop. Clin. North Am. 22: 303-314,
disc disease (7), developed in the 70' s and continuously 1991.
updated with the advent of new investigations and 11. Mathew B., Norris D., Hendry D. et al.: Artificial intelligence
in the diagnosis of low-back pain and sciatica. Spine 13: accuracy of history, physical examination, and erythrocyte
168-173,1988. sedimentation rate in diagnosing low back pain in general
12. Norris D. E., Pilsworth B. W., BaldwinJ. E: Medical diagnosis practice. A criteria-based review of the literature. Spine 20:
from patients records: a method using fuzzy, discrimination 318-327,1995.
and connectivity analyses. Fuzzy Sets Systems 23: 73-88, 16. Wiesel S. w., Bell C. R, Feffer H. L. et al.: A study of comput-
1987. er-asisted tomography: I. The incidence of positive CAT scans
13. Sutton C. c.: Computer-aided diagnosis: a review. Br. J. Surg. in an asymptomatic group of patients. Spine 9: 549-551, 1984.
76: 82-85, 1988. 17. Wiesel S. W., Feffer H L., Rothman R H: Low back pain:
14. Szolovitz P., Patil R S., Schwartz W. B.: Artificial intelligence development and five-year prospective application of a com-
in medical diagnosis. Arch. Intern. Med. 108: 80-87, 1988. puterized quality-based diagnostic and treatment protocol.
15. Van den Hoogen, Koes B. W., Van Eijk J. Th. M. et al.: On the J. Spinal Disord. I: 50-58,1988.
------·CHAPTER 14·------
CONSERVATIVE TREATMENTS
F. Postacchini, 1. Caruso, v: M. Saraceni
Natural history of lumbar months. All patients were instructed to observe com-
plete bed rest for 1 week and some were treated with
disc herniation Piroxicam, whilst the others were given a placebo. No
significant differences in the evolution of signs and
The natural history of a pathologic condition may be
symptoms were observed between the Piroxicam, and
analyzed from two different points of view: natural
the placebo, group. During the first 4 weeks after the
evolution of clinical signs and symptoms, and natural
onset of symptoms, some 70% of patients had a con-
evolution of the pathomorphologic changes. In either
siderable decrease in pain and almost 60% resumed
case, the patients under study should not be submitted
work. After 1 year, some 30% of patients complained of
to any treatment. However, whilst the clinical natural
back pain, decreased working ability and limitations
history may be, to some extent, affected by any conser-
in recreational activities, and 19.5% had not resumed
vative treatment, the pathomorphologic natural evolu-
work. Four patients had been treated surgically.
tion is not presumably influenced by most conservative
In a prospective randomized double-blind study
treatments currently carried out in patients with disc
carried out by Fraser (60), 30 patients underwent chy-
herniation. Regarding the latter aspect, therefore, also
mopapain chemonucleolysis and 30 were injected with
clinical studies including patients submitted to treat-
the same volume of saline. Disc herniation was diag-
ments with no known effects on the pathologic changes
nosed by myelography in all patients. At 6 weeks, only
of the disc may be reliable.
37% of patients in the placebo group had a satisfactory
clinical result. The proportion of satisfactory outcomes
Clinical evolution reached 57% at 6 months and decreased to 47% at 2
years (61). Surgery had been performed in 40% of
In the Western world, it is extremely difficult, at pre- patients. The results of this study are not consistent with
sent, to study the clinical natural history of a pathologic those reported by Weber (196). A possible explanation is
condition causing pain, since patients almost inevitably that, in Weber's study, diagnosis of disc herniation was
undergo some form of treatment. This may explain the made solely on clinical grounds, by non-specialists. In
paucity of information on the natural evolution of Fraser's study (60), on the other hand, the clinical mate-
clinical signs and symptoms of disc herniation. rial was more selected, since the patients had been
In a multicenter prospective study, Weber et a1. (196) referred to a specialist center, probably after failure of
have analyzed 208 patients with a mean age of 48 years, conservative management, and the clinical diagnosis of
presenting the clinical features of lumbar radiculo- disc herniation had been confirmed by myelography.
pathy probably due to disc herniation. In no case was
herniation (or the pathologic condition responsible for
radiculopathy) diagnosed by means of imaging stud- Pathomorphologic evolution
ies. All patients were examined within 2 weeks, and at
4 weeks, of the onset of symptoms, whilst a question- In recent years, numerous studies (17, 23, 119, 169, 182,
naire was used to evaluate the clinical status at 3 and 12 183) have shown that disc herniation may decrease in
342.Chapter 1 4 . - - - - - - - - - - - - - - - - - - - - - - - - - - _
size or disappear in the course of a few months. The contained herniations, the main mechanism is likely to
process may occur in contained, extruded or migrated be represented by dehydration of the herniated nucleus
herniations of either small or large size (Figs. 14.1-14.3). pulposus. This may account for the higher frequency
In a prospective study (23), 111 patients with disc herni- with which young subjects, who tend to have greater
ation or annular bulging diagnosed by CT underwent a hydration of the nucleus pulposus, present a decrease
second CT study 1 year later, following one or more in size of their herniation (23). In extruded or migrated
epidural injections of steroids. Of the patients with disc herniations, phagocytosis of herniated tissue by
herniation (contained, extruded or migrated), 76% macrophages probably also plays a primary role
showed a decrease in size (four fifths of cases) or dis- (page 125).
appearance of the herniation (one fifth) on control CT
scans. Similar findings were observed only in 29% of
patients with bulging annulus fibrosus. In only four
(5%) patients with disc herniation, did the control CT Modalities of conservative treatment
show deterioration in the pathomorphologic picture.
Similar results were reported by Maigne et al. (119): of Bed rest
48 patients treated conservatively and submitted to CT
studies 1 to 48 months after the initial CT study, 64% Bed rest is the oldest and simplest of conservative treat-
showed a decrease of over 75% in the size of the hernia- ments for lumbar disc herniation. Its effects are related
tion on the control CT and 17% presented a decrease in to a decrease in intradiscal pressure, spine motion
size of 50% to 75%. and lumbar lordosis as well as to relaxation of the
Large herniations tend to decrease in size to a larger paras pinal muscles.
extent (37, 119, 169). By contrast, extruded herniations Bed rest may be particularly useful during the first
of small size seem to show less tendency to sponta- few days after onset of lumboradicular symptoms. The
neous resolution. A decrease in size may occur even in bed should be hard and the position to be preferred is
the course of a few weeks, before complete resolution of that which most reduces lumboradicular pain. This is
the symptoms. A retrospective study (98) has shown usually the supine position with the hips and knees
that, after a mean period of 262 days, the vast majority slightly flexed or the lateral decubitus in the fetal
of extruded herniations had decreased in size or disap- position. The prone position should be avoided if, as
peared following conservative management. Almost usually occurs, it exacerbates lumboradicular pain.
none of the contained herniations, on the other hand, In effect, it is not known whether this therapeutic
showed any significant change. All those patients with modality is really effective and what should be consid-
a decrease in size or disappearance of the herniation ered the optimal duration of bed rest. Two studies have
presented excellent or good clinical results. analyzed the therapeutic efficacy of bed rest in patients
Little is known about the mechanisms leading to a with only low back pain in the acute phase. The patients
decrease in size or disappearance of the herniation. In were randomly assigned to two groups: no bed rest or
- - - - - - - - - - - - - - - - - - - - - - - - - . Conservative treatments· 343
A 8 c
A B
The rate of complications is certainly very low com- pain, manipulation may be indicated or contraindicat-
pared with the large number of patients undergoing ed. The presence of neurologic deficits is usually con-
manipulation therapy. However, the risk of severe com- sidered the discriminating factor in this respect. In our
plications should make us very cautious in the indica- opinion, other factors should also be evaluated before
tion for this type of treatment in patients with disc deciding upon the indication for manipulation therapy.
herniation. Furthermore, manipulators should be well In acute or subacute lumboradicular syndromes,
aware that the possibility exists of causing or increasing manipulation is generally contraindicated: 1) In the
compression of the nervous structures when they treat presence of motor or sensory deficits, or depression of
patients with herniation or suspected herniation. pertinent reflexes (for instance, the ankle jerk in a SI
radicular syndrome). This form of treatment is also
contraindicated both in patients in whom CT or MRI
Indications have demonstrated disc herniation, and in those who
have not yet undergone diagnostic tests; on the other
Manipulation therapy may be indicated in patients hand, clinical evidence indicates that most patients
with only low back pain, particularly in acute syn- with neurologic deficits tend to have poor results with
dromes, in which manipulation may provide even bet- manipulation (96, 144, 164). 2) In patients with no
ter results than other forms of conservative treatment neurologic deficits not submitted to CT or MRI, when
(51,68,162, 166). Similarly, patients with predominant- nerve-root tension tests are moderately or markedly
ly low back pain and referred discomfort in the lower positive; in these cases there may be even a large mid-
limb may be good candidates for manipulation therapy line disc herniation, or extruded herniation, which may
(158). In the presence of radicular or lumboradicular increase in size or undergo transformation into an
- - - - - - - - - - - - - - - - - - - - - - - - - - . Conservative treatments· 351
extruded or migrated herniation after manipulation. neurologic deficits considerably decreases the chances
3) In those patients with no neurologic deficits in of a satisfactory result (96).
whom diagnostic tests show a contained middle-size In previously operated patients, the indications for
or large herniation, an extruded or migrated herniation, manipulation are similar to those outlined for nonoper-
or lumbar stenosis. ated subjects. In those operated on, however, the pres-
In addition to these specific contraindications, there ence of neurologic deficits, particularly of reflexes,
is a long series of generic contra indications, such as may not represent a contraindication even in acute
severe osteoporosis, vertebral fractures or tumors, syndromes.
rheumatoid arthritis or ankylosing spondylitis.
Of the patients with acute lumboradicular syn-
drome, good candidates for manipulation therapy are: Traction
1) Those not submitted to CT or MRI, who show no
neurologic deficit and slightly positive nerve-root ten- Traction of the lumbar spine can be performed in vari-
sion tests; in these cases, however, a neuroradiologic ous ways. Usually, beds with electric traction able to
imaging study is recommended before performing generate forces of up to 100 kg are used. The patient is
manipulation. 2) Those patients showing no neurologic placed on the bed in the supine position and the direc-
deficit, in whom CT or MRI have demonstrated a tion of the traction force is parallel to the longitudinal
bulging annulus fibrosus or small contained disc herni- axis of the body. Traction may be continuous or inter-
ation. In the latter case, manipulation, particularly mittent. Continuous traction is usually employed,
forced or brusque rotations, should be stopped if they applying forces as high as 25% - 50% of the patient's
produce or exacerbate radicular pain (158). body weight, for periods of a few minutes to more than
In subacute or chronic lumboradicular syndromes, 1 hour. In intermittent traction, the application of the
the indications may be extended to those patients in force lasts a few seconds and is followed by a resting
whom a middle-sized contained herniation has been period of comparable duration.
present for a few months at least, provided radicular Autotraction, first proposed by Lind and then
pain has considerably decreased or disappeared over improved by Natchev, is performed by the patient him-
the time, or CT or MRI show that the pathologic self/herself, who pulls, for few seconds at intervals of
condition has not changed or the disc protrusion has 30-60 seconds, on a harness located at the head of the
decreased in size. In these cases, structural changes bed. The most modern beds consist of two parts operat-
occurring over time in the herniated disc make it very ed electrically independently from one another; the
unlikely that disc protrusion will increase following patient generates traction by pulling on bars placed at
manipulation. The absence of a pertinent reflex (which the head of the bed (Fig. 14.6). The duration of each
often does not return once it has disappeared, even autotraction is 3-6 seconds and the session lasts 30-40
if the nerve root is not significantly compressed) does minutes. With a few beds, only longitudinal traction is
not represent a contraindication to manipulation. possible, whereas others allow also flexion, extension
However, also in chronic syndromes, the presence of and rotation of the lumbar spine. Beds of the latter type
r Fig. 14.8. Paraforaminal injection. The needle reaches the area of the
Fig. 14.7. Schematic drawing of paras pinal injection. intervertebral foramen.
354.Chapter 1 4 . - - - - - - - - - - - - - - - - - - - - - - - - - -
initial form of treatment, in patients with lumbar disc patient feels acute radicular pain, which diminishes or
herniation (64), but there are no unequivocal scientific disappears by withdrawing the needle a few millime-
data demonstrating the efficacy of the treatment in ters. This technique is simple, but not precise, since one
relieving low back or radicular pain. has the certainty that the tip of the needle is in close
proximity to the nerve root only if this is punctured.
With the use of the fluoroscope, the technique is the
Paraspinal injection same as that for radiculography (page 269).
A few clinicians inject only a local anesthetic with
Paraspinal injections are made 2-3 cm from the spin- normal or slowly absorbable characteristics, the effects
ous processes using a 20 G or 22 G spinal needle, which of which, however, last only a few hours (99). The addi-
is advanced until the bone surface is reached (Fig. 14.7). tion of a slowly absorbable corticosteroid may prolong
At this point, injection of the pharmacologic agent the effects due to a decrease in the inflammatory
begins. The direction of the needle is then changed to reaction which may be induced by the drug.
inject the medication above and below the initial site of After the injection, the patient should be under sur-
inoculation. Finally, while withdrawing, the remainder veillance for 30-60 minutes, particularly if the nerve
of the drug is injected into the paraspinal muscles. root has been punctured and the anesthetic may, thus,
The injection is made either on one or both sides. have entered the thecal sac. In this event, motor or
Fluoroscopic guidance is not needed. The medications sensory deficits may be produced, which however
currently used are slowly absorbable corticosteroids disappear in a few hours.
diluted in 10 ml of local anesthetic. If the injection is not performed under fluoroscopic
The pharmacologic agents may act on the facet joints guidance, the procedure can be repeated several times,
and the paraspinal muscles either directly or indi- even daily; in this instance, 4 days should be allowed to
rectly through the posterior branch of the spinal nerve. elapse before adding the corticosteroid again to the
The medications may decrease the muscle spasm and anesthetic. If the fluoroscope is used, the number of
articular and periarticular inflammatory processes injections should be limited to 2 or 3 in order to avoid
in patients with acute low back pain. Although some excessive exposure of the patient to ionizing radiation.
patients undergoing paraspinal injections obtain relief The greatest therapeutic effect is reported to be
of low back pain, there is no evidence that these injec- obtained after six injections (99). However, also for this
tions are more effective than systemic administration technique, there is no evidence that it is more effective
of anti-inflammatory drugs or analgesics. Paraspinal than placebo or other conservative therapies, if the tem-
injections do not relieve radicular pain produced by porary pain relief produced by the anesthetic is exclud-
disc herniation. Thus, they are usually not indicated in ed. This form of treatment may be indicated in patients
patients with clinical evidence of nerve-root compres- with nerve-root irritation syndrome after failure of
sion. epidural injection, when there is no indication for more
aggressive invasive treatments (23).
Paraforaminal injection
Epidural injection
The medication is injected in the area surrounding the
exit of the intervertebral foramen (Fig. 14.8). The injec- The epidural injection of local anesthetics in patients
tion mayor may not be performed under fluoroscopic with lumboradicular pain is a therapeutic procedure
guidance. The injection under fluoroscopic vision is already practiced in the 1920's (186). Over the last
carried out with the patient in the sitting position. To few decades, a slowly absorbable corticosteroid has
reach the L4 or L5 nerve root (radicular nerve), the usually been associated with the anesthetic. Injections
spinal needle (22 G) is introduced 6-8 cm from the mid- merely of anesthetic agents may be used for anesthetic
line, in close proximity to the iliac crest, and is purposes (179).
advanced medially with an angulation of some 60°,
until the area of the L5 transverse process is reached (or,
possibly, the transverse process is touched). The needle Technique
is then advanced, proximally to reach the L4 nerve root
or distally to reach the L5 root, at a depth of 1-2 cm. To The injection may be made in the lumbar region or
reach the 51 nerve root, the needle should be inclined through the sacral hiatus.
by about 45° in the cranio-caudal direction until the tip The injection in the lumbar spine is usually per-
is seen in proximity to the first sacral foramen. If, whilst formed at L3-L4 level, using a 22 G or 25 G spinal
advancing the needle, the nerve root is punctured, the needle, connected to a syringe containing saline or
_________________________ 0 Conservative treatments 0355
Therapeutic effects
Re-education
Intrathecal injection
Exercise therapy
Injection of a corticosteroid, associated or not with a
local anesthetic, into the subarachnoid space is proba- Of the numerous techniques proposed for exercise ther-
bly more effective than epidural injection, since the apy, three represent the cornerstones in the rehabilita-
medications act directly on the nerve roots in their tion of patients with low back or lumboradicular pain.
- - - - - - - - - - - - - - - - - - - - - - - - - . Conservative treatments· 357
Flexion exercises hypertone. According to this method, isotonic contrac-
tions, which tend to shorten muscles, should be strictly
Flexion exercises, which are, even today, the most fre- avoided.
quently performed, are designed to open the interverte-
bral foramens, to mobilize the posterior joints, to
lengthen the extensor muscles of the trunk, and, in par- McKenzie's method
ticular, to strengthen the abdominal muscles. The aim is
to increase intra-abdominal pressure, thus stabilizing This method is based on the concept that the applica-
the lumbar spine, and to reduce lumbar lordosis by acti- tion of mechanical forces by mobilization of the lumbar
vating the abdominal and gluteal muscles. The criticism spine in flexion-extension or lateral bending up to end-
addressed to these exercises is that they may be harmful range motion makes it possible to better determine the
in patients with discogenic pain, since those activating pathogenesis of low back pain by referring to three
the recti abdomini muscles increase intradiscal pres- main categories in the spectrum of nonspecific pain:
sure, whilst those designed to flex the trunk, particular- the postural, dysfunction and derangement syndromes
ly when performed in the standing position, may lead (130, 131). Furthermore, it is possible to determine the
to an increase in posterior protrusion of the disc. nature of the mechanical disorder responsible for low
These drawbacks are partly overcome by isometric back pain and to identify the direction and intensity of
exercises, performed in the supine or upright positions, the mechanical forces to be applied in order to obtain
and carried out in a single session for few minutes pain relief. In the derangement syndrome, for instance,
several times a day (95). there may be posterolateral protrusion of the interver-
tebral disc needing mobilization in lateral bending or a
condition of anterior protrusion in which pain will be
Mezieres's method diminished or abolished by flexion.
A characteristic phenomenon described by
In 1949 Fran<;;oise Mezieres presented her program of McKenzie is centralization of pain, i.e., the change in
re-education of the spine in a small volume entitled location of pain from a peripheral area, for instance the
"Revolution en gymnastique orthopedique" (139): calf, to a more central area, such as the buttock, when
"Spinal muscles should be elongated in all their length taking up a certain posture or performing an end-range
rather than toned up and shortened by backward flex- movement. Centralization of pain has a favorable
ion of the trunk and the head against the resistance ... ". prognostic significance and the postures or end-range
A true revolution, therefore, with respect to the con- movements which have produced it are used in the
ception predominating at that time and still today treatment. However, although the criteria described by
strongly held in consideration, according to which, McKenzie allow a detailed classification of the different
strengthening of the extensor muscles of the trunk forms of nonspecific low back pain and a rational ther-
plays a pivotal role in re-education of patients with apeutic planning, the modalities of treatment are in
back pain. effect dictated by pain. Thus, a painful syndrome which
Mezieres based her method on six principles: 1) The should in theory be treated with mobilization in exten-
back muscles behave as a single functional unit. Thus, sion, may improve in effect with flexion treatment.
the spastic contraction of even one single muscle in the The mechanical force can be produced in a static way
kinetic chain leads to shortening of all the muscles in by assuming specific postures or in a dynamic way by
that chain. 2) The muscles of the posterior kinetic chain active exercises. Postures generate lower mechanical
are always in a condition of shortening and increased forces and should be reserved for conditions character-
tone, whereas the anterior muscles are always hypoton- ized by severe pain. In other conditions, a single exer-
ic. 3) Any action finalized to shorten or lengthen one cise should be performed several times a day: as a rule,
element of the kinetic chain leads to shortening of the 10-15 repetitions every 2 hours. The criterion for judg-
whole system. 4) The attempt to resist shortening, ing whether the treatment is correct is the modification
immediately produces lateral bending or rotation of the in pain. If pain centralizes or decreases, the treatment is
spine and the lower limbs. 5) Hypertone of the muscles continued, whilst an increase or change in location of
in the lower limb consistently produces internal rota- pain to a more pheripheral area of the body indicates
tion of the limb. 6) Any elongation implies a respiratory that treatment needs to be modified. Once the method
block in expiration. has been taught, the patients, guided by pain, rapidly
The methodology of postural re-ed ucation stemming learn the modalities of prevention and self-treatment.
from these principles is based on postures in eccentric There is little indication for the extension exercises of
isometric contraction, which, during expiration, the McKenzie technique in patients with osteoarthrosis
produce muscle stretching and a decrease in muscle of the facet joints or lumbar stenosis. Furthermore,
3S8.Chapter 1 4 . - - - - - - - - - - - - - - - - - - - - - - - - - -
these exercises may easily lead to an exacerbation of ology and pathophysiology of back pain. In the second,
symptoms in patients with an acute lumboradicular discussion is focused on the basis of physiotherapy and
syndrome due to disc herniation. the effectiveness of back care. The third describes the
place of emotion in chronic pain and the psychiatric
aspects of back trouble. The fourth lesson is a practical
Low back schools demonstration of relaxation methods and exercise
therapy.
The first low back school was developed in Sweden by The California back school, developed in 1976, has
Zachrisson-Forsell in 1969 (200). The inspiring concept strictly ergonomic and more individualistic character-
was to transform the patient with low back pain from istics than previous schools (127). It consists of three
a passive subject in the fruition of the most disparate 90-minute lessons held for a maximum of four patients
therapies to an active and responsible subject able at weekly intervals. At the end of the program, the
to manage his pathologic condition. This therapeutic patients are taught exercises to reinforce body mechan-
modality was aimed at instructing the patient about ics. A unique element of this program is the use of an
the static and dynamic mechanisms responsible for obstacle course to evaluate physical performance skills.
low back pain in order to prevent it and at educating A few low back schools include individual tuition, as
him to the daily routine of exercises for the maintenance well as group, programs (54, 127). In a few schools (86),
of normal tone, strength and elasticity of the muscles. in addition to 4-hour courses, 12-hour programs have
been developed to make teaching more gradual and
analytic. In others (so-called mini-back schools), teach-
Modalities ing is concentrated into a single 4-hour course (12) or a
45-minute lesson, in which no exercises are taught (177).
The Swedish back school program consists of four 45- In Italy, the first low back schools were set up
minute lessons held by a physiotherapist teaching 6-8 between the end of 1970's and the beginning of 1980's
patients, in a 2-week course (200). In the first lesson, the (149, 163). Postacchini's school (163) consisted of four
patients are taught about the anatomy and function of 90-minute sessions, for two consecutive days, held by
the spine, the clinical features and natural history of an orthopaedic surgeon, a physiatrist, a psychiatrist
low back pain, as well as the modes of treatment of the and a physiotherapist. This school had intermediate
disease. In the second lesson, the mechanical strain characteristics between the Swedish and Canadian
occurring in different positions and in the course of var- schools. In fact, it was aimed at: providing adequate
ious movements is discussed, and the relationship information on the anatomy and physiology, as well
between the center of gravity and strain on the back is as on the diseases of the lumbar spine (orthopaedic
explained. The function of the muscles and their influ- surgeon); explaining the fundamentals of ergonomy
ence on the back is demonstrated and some relaxation and biomechanics of the vertebral column, and the
exercises are taught. The third lesson consists in the objectives and methodology of exercise therapy (physi-
practical application of this theoretical knowledge. The atrist); clarifying the role of psychologic factors in the
patients are also taught isometric abdominal muscle genesis of pain (psychiatrist); and practical teaching of
training and advised to continue the exercises at home. the exercises that the patients were encouraged to
The fourth lesson consists mainly in encouraging the perform every day at home (physiotherapist).
patients to increase their level of physical activity and The low back school set-up by Saraceni and collabo-
to take part in sports to improve their psychophysical rators was started in 1987 and later developed to reach
tolerance to pain and stress. This lesson is concluded by the present-day form (58, 171). It includes an initial
seeing how much the patients have assimilated during 2-hour lesson on theory, held for classes of six patients,
the course. the contents of which are much the same as those of the
Many other low back schools have since been set up, other schools. The program then continues with I-hour
which have been structured either like or differently lessons twice weekly for 8 weeks, during which the
from the original Swedish school. patients are taught some 20 postural gymnastics exer-
The Canadian back education units, set up in 1974, cises, of increasing difficulty, a few of which are shown
have stressed the importance of the psychologic in Figs. 14.10-14.17. The methodologic approach is
aspects in the therapeutic control of low back pain, by summarized in the following principles: 1) all exercises,
including, in the teaching group, a psychiatrist and a aimed at reducing lumbar lordosis, are carried out in
psychologist in addition to an orthopaedic surgeon and the supine position; 2) the exercises are performed
a physiotherapist (79, 80). The program consists of four simultaneously with breathing, according to two differ-
90-minute lessons held at weekly intervals for classes of ent modalities, the active movements being always
15-25 patients. The first session covers anatomy, physi- carried out in the expiratory phase; 3) the primary
_________________________ 0 Conservative treatments 0359
A .......______.......=""""
Fig. 14.12. Dorsiflexion of one foot (A) and both feet (B) during expiration.
aim is to lengthen the posterior kinetic chain and streng- with acute lumbar or lumboradicular pain. Of four
then the abdominal and quadriceps muscles; 4) the studies, two reported positive results (l0, 143) and two
exercises are always performed in flexion of the spine negative results (110, 177). In one trial (10), 70 patients
to avoid the mechanical stress produced by extension. took part in a Swedish low back school program, 72
were submitted to manual therapy and 72 to placebo
treatment (shortwave diathermy at very low intensity):
Therapeutic efficacy the patients in the first group had significantly better
results compared with those in the placebo group, but
Acute pain. Few randomized controlled trials have not with those udergoing manual therapy. In another
analyzed the efficacy of low back school in patients study (110), a group of 24 patients followed a low back
- - - - - - - - - - - - - - - - - - - - - - - - - - . Conservative treatments· 361
A
Fig. 14.17. Active (A) and passive (B) stretching of the hamstrings. These exercises should be performed when radicular pain is considerably decreased
or disappeared. Usually they should be carried out in the advanced or final phase of the re-education program.
- - - - - - - - - - - - - - - - - - - - - - - - - - . Conservative treatments· 363
school-like program of postural education, whilst does not allow us to determine the role of these two
another group of 32 patients were taught not to stress forms of treatment in this pathologic condition.
the lumbar spine and to use analgesics when needed; However, the information available indicates, on the
the percentages of pain-free patients after 1, 3 and 6 one hand, that physical inactivity has negative decon-
weeks, respectively, were 21%,75% and 83% in the first ditioning effects on the musculoskeletal system and,
group and 16%, 66% and 81% in the second. on the other, that in patients with chronic lumbar or
Numerous randomized controlled studies have com- lumboradicular pain of undefined etiology both forms
pared exercise therapy alone (not associated with a low of treatment are effective.
back school program) with other forms of conservative In our experience, exercises are often poorly tolerat-
management or a placebo treatment (36, 38, 50, 52 ,53, ed by patients with an acute lumboradicular syndrome
55, 118, 152, 154, 177, 178, 192). Most of these studies and may even exacerbate pain, at least in the first few
(36, 50, 52, 53, 55, 118, 152, 192) failed to find exercise weeks after the onset of symptoms; in this phase, there-
therapy significantly better than other treatments, fore, exercises should usually be avoided. Later, it may
including bed rest, manipulation, mini-back school, a be useful to encourage the patient to perform simple
placebo or no treatment at all. exercises of postural gymnastics. If the latter exacer-
It should not be forgotten, however, that in the vast bates pain, the exercise program should be stopped or
majority of these trials, no clear-cut distinction was limited to non-painful exercises.
made between patients with low back pain alone and In the subacute, and even more in the chronic, phase,
those with lumboradicular pain or, as far as concerns postural gymnastics is generally well tolerated by the
the latter, between those with disc herniation diag- patient and symptoms often improve, particularly back
nosed by imaging studies and patients with radicular pain. In this instance, it should represent one of the key
pain of unproven etiology. points of the treatment, since exercise therapy, once
learned under the supervision of a physiotherapist, may
Subacute or chronic pain. A large number of random- be done at home by the patient, and it is, thus, a low-cost
ized controlled studies have attempted to analyze the treatment, as well as a treatment with no adverse effects.
therapeutic efficacy of the various types of low back Low back school, independently of exercises, is indi-
school (44, 83, 84, 89, 90, 92-94, 102, 113, 132, 133, 162, cated in patients with chronic pain and may be useful in
170). Most of them, including those employing the most those with a subacute syndrome, if this is recurrent. 50-
rigorous methodologies (83, 84, 89, 90, 113, 132, 133), called mini-schools, and those attended by a large num-
indicate that low back school is more effective than ber of patients, are less effective than those of longer
placebo and probably also than other forms of con- duration and with a limited number of patients
servative treatment, such as physiotherapy, N5AIDs, (12, 163, 177).
manipulation, exercise therapy alone or a placebo treat-
ment (ultrasounds or detuned short-wave diathermy).
Exercises alone appear to have a significant thera- Orthoses
peutic efficacy in patients with chronic low back pain,
as shown by several randomized controlled trials of The orthoses currently used in patients with lumbar
good methodological quality (41, 48, 82, 107, 111, 112, disc herniation may be classified, according to their
121-123). The latter as well as other investigations, rigidity, as elastic, semirigid and rigid.
however, seem to indicate that no significant differ- The elastic corsets have no stays of rigid or semirigid
ences exist, as far as concerns the therapeutic efficacy, material and are usually short, i.e., limited to the lum-
between the various types of exercises. bosacral region (Fig. 14.18). The most typical example
However, also for the subacute or chronic syn- of a semirigid corset is the canvas lumbosacral corset,
dromes, as well as for the acute forms, there are no pre- made of cloth with lateral and posterior metal stays
cise data on the therapeutic efficacy of either low back (Fig. 14.19). This corset, which extends from the lum-
school or exercise therapy alone in patients with low bosacral region to the lower part of the chest, follows
back or lumboradicular pain caused by proven disc the lordotic curve of the lumbar spine without modify-
herniation, compared to patients with pain due to other ing it. The rigid orthoses consist of plastic non- or
pathologic conditions or idiopathic pain. scarcely flexible material; these may be short or long
(thoracolumbar brace) (Fig. 14.20).
The semirigid, and particularly the rigid, orthoses,
Role in lumbar disc herniation have three points of fixation: two applied at the upper
and lower ends of the brace, and the third midway
Lack of reliable data on the efficacy of exercises and low between the two. The proximal support is generally
back school in patients with lumbar disc herniation located at the level of the lower end of the sternum and
364.Chapter 1 4 . - - - - - - - - - - - - - - - - - - - - - - - - - -
below the scapulae, and the distal one at the level of the
sacrum. The intermediate counterforce is situated at the
level of the suprapubic region or in the middle of the
lumbar spine. An anterior support tends to flex the
lumbar spine, whereas a posterior counterforce may
maintain normal lordosis or increase it.
A rigid orthosis may incorporate the thigh in order to
immobilize the hip joint. This type of brace consider-
ably decreases the movements of the pelvis and the
lower lumbar spine.
Biomechanical effects
Restriction of trunk movements decreases the amount instance, the load is partly transmitted, through the
of displacement of the center of gravity; this leads to a brace, from the upper portion of the trunk to the pelvis.
decrease in both the movements and the concomitant This mechanism could explain the lower myoelectric
vertebral compression and tension of the erectores activity of the erectores spinae muscles recorded dur-
spinae muscles which is necessary to maintain trunk ing movements performed under effort while wearing
equilibrium (103). The decrease in mobility may reach a rigid orthosis, compared with those carried out with a
20% for flexion and 48% for extension, lateral bending canvas lumbosacral corset (104).
and axial rotation. With the canvas corset, mobility is Decrease in load on the lumbar spine may produce a
less limited than with the thoracolumbosacral orthosis decrease in the intra dis cal pressure. The available data,
(TLSO). The decrease in load on the lumbar spine however, are conflicting also in this respect. In one
(regardless of the possible effects of the intra-abdomi- study (147), analyzing the changes in the intra dis cal
nal pressure) is probably proportional to the degree of pressure produced by an inflatable corset, it was found
reduction of trunk mobility. that a non-inflated corset produced no changes of the
intradiscal pressure, which decreased by about 25%
when the corset was inflated. In another study (148),
Decrease in load the intradiscal pressure was measured during various
movements performed under effort in subjects wearing
The decrease in load on the lumbar spine may be the or not an orthosis: the latter often decreased, but occa-
result of the reduction in trunk movements (analyzed sionally increased (only on flexion), the intradiscal
above) or the increase in intra-abdominal pressure, or pressure.
may be directly produced by the orthosis.
The intra-abdominal pressure does not appear to be
affected in a single way and to a significant extent by Change of posture
corsets and braces (142, 147, 148). If these increased the
intra-abdominal pressure and, thus, reduced the load Vertebral orthoses may modify the posture by decreas-
on the lumbar spine, the myoelectric activity of the ing or increasing lumbar lordosis, or correcting trunk
trunk muscles would decrease. Electromyographic list.
studies performed in normal subjects, during numer- The kyphosing braces have a suprapubic support
ous movements carried out under isometric effort which exerts pressure on the low abdomen. A brace with
(104), have shown that the mean myoelectric signals of these characteristics would have various effects: to
the abdominal or erectores spinae muscles ranged from reduce a posterior annular bulging; to produce an
-9% to +44% when the physical tasks were performed increase in size of the spinal canal; and to increase the
with the corset or brace, compared with the values intra-abdominal pressure and reduce the load on the
recorded without orthosis. facet joints (99). The latter effect, however, would
The orthosis may reduce the load if it is rigid and well involve an increased load on the vertebral bodies and
fitting to the body proximally and distally; in this the intervertebral discs. Furthermore, it remains to be
366.Chapter 14.-----------------------------------------------------
elucidated whether the braces which produce abdomi- The reasons for the different clinical response to the
nal compression really increase the intra-abdominal use of corsets or braces are still unclear. On the other
pressure or have little effect on it, like those braces which hand, there are conflicting opinions on the possible dif-
do not exert a marked abdominal counterforce (104). ferences, in terms of therapeutic efficacy, between the
The braces preserving lumbar lordosis, particularly various types of orthoses - semirigid or rigid, short or
those which increase it, tend to displace the load from long, kyphosing or lordosing. The orthosis most com-
the anterior vertebral pillar (vertebral bodies and inter- monly used in patients with pathologic conditions of
vertebral discs) to the posterior joints. These braces lumbar discs is the canvas lumbosacral corset, but
may also have an anterior support exerting abdominal many clinicians prefer more rigid orthoses. Further-
compression, which might increase the intra-abdomi- more, a few believe that the kyphosing braces are more
nal pressure. effective; others have had little success with these
Orthoses may decrease sciatic scoliosis. The decrease braces (140), whilst they have obtained pain relief in a
is probably due to reduction of muscle tension resulting significant proportion of patients by restoring lumbar
both from restriction of trunk motion and the tendency lordosis (130).
of the orthosis, when rigid, to straighten the spine in the In patients with symptomatic disc herniation, the use
coronal plane. of an orthosis is indicated when the clinical features
require prolonged conservative treatment. Since restric-
tion of trunk movements appears to be the main, or
Conclusions only, biomechanical effect of corsets and braces, rigid
orthoses would be the most indicated. Often, however,
Studies on the effects of corsets and braces on vertebral the latter are poorly tolerated by patients. We thus
mobility have led to conflicting results; most of the prefer, in most cases, a lumbosacral corset. The patient
experimental data indicate that orthoses do not should be informed that the orthosis may not relieve
decrease intervertebral mobility in the lower lumbar the pain, in which case use of the corset or brace should
spine. Orthoses decrease trunk movements to a varying be withdrawn. When effective in relieving pain, the
extent depending on the rigidity and height of the orthosis should be worn for 3-6 weeks, initially full
corset or brace. Reduction of trunk motion probably time and then for a few hours each day.
involves a decrease in the load on the lumbar spine and Confusion is increased by the little and, at times,
in the tension of lumbar paraspinal muscles. Rigid conflicting information on the biomechanical effects of
braces may partly transfer the load from the upper part orthoses, which would appear to inconsistently
of the trunk to the pelvis: this might, to some extent, decrease the load on the lumbar spine and only to a
decrease the load on the lumbar spine. mild extent (104). However, the clinical response to
Intra-abdominal pressure does not seem to be influ- corsets and braces should not be evaluated only in bio-
enced in a single way and to a significant extent by mechanical terms, since their therapeutic efficacy may
orthoses. The available data, although conflicting, sug- also be related to other factors. The orthosis may repre-
gest that the orthoses currently used have little effect on sent a stimulus for the patient not to perform trunk
intradiscal pressure. The kyphosing braces tend to dis- movements or physical efforts, or it may have a thermic
place the load on the anterior pillar of the spine (verte- effect, if fitting close to the skin (74). In addition, the
bral bodies and intervertebral discs), whereas those orthosis may have a placebo effect, the role of which is
with lordosing effects tend to shift it over the posterior not negligible in pathologic conditions characterized
joints. However, there is no experimental evidence or by pain.
quantitative data, in this respect. In patients with chronic lumboradicular pain, there is
usually little indication for the use of orthoses. The lat-
ter may be worn during periods of exacerbation of pain
Therapeutic efficacy and indications or in specific circumstances or physical activities.
Prolonged use of orthoses full time should be avoided,
In many patients with acute or subacute low back pain, since they may lead to wasting and fibrosis of the trunk
corsets or braces are effective in relieving pain. This muscles, and psychologic dependence (145, 173).
holds also for patients with lumboradicular pain, in The use of orthoses is not indicated to prevent recur-
whom, however, the radicular symptoms are less fre- rences of low back or radicular pain in patients
quently improved, and often to a lesser extent, than low involved in manual work, since experimental evidence
back pain. Many patients, on the other hand, do not indicates that corsets and braces produce a slight and
report significant improvement with the use of orthoses inconstant decrease in the load on the lumbar spine,
and a few may even have exacerbation of pain, particu- even in activities requiring physical efforts.
larly of radicular pain. Orthoses, particularly those exerting compression on
- - - - - - - - - - - - - - - - - - - - - - - - - 0 Conservative treatments 0367
the abdomen, may be contraindicated in patients with surgical therapy (epidural or paraforaminal injections
gastrointestinal disorders, diaphragmatic herniation of anesthetics and steroids) led to satisfactory results.
or inguinal herniation. Obesity and respiratory dis- Similar outcomes - 90% satisfactory results with a
orders may also make the use of orthoses poorly combination of several treatments (bed rest, NSAIDs,
indicated. epidural injections of steroids, corset) - have been
reported by Maigne et al. (119).
Much clinical evidence exists indicating that in a large Over the last few decades, with the increased use of sur-
proportion of patients conservative treatments relieve gical therapy, we are faced with the question of whether
pain after a period of time ranging from a few days to or not conservative therapy provides comparable
several months. Resolution of symptoms may occur in results to surgery in terms not only of the proportions
the presence of herniations of any type or size (Fig. of satisfactory results, but also of the quality of the
14.21). latter and rapidity with which resolution of symptoms
In a retrospective study (168), 58 patients with disc is reached.
herniation treated conservatively (analgesics, anti- Hakelius (77) retrospectively analyzed 417 patients
inflammatory medications, epidural injections of treated conservatively (bed rest, corset, physical thera-
steroids, low back school, exercises) were followed-up py) and 166 submitted to surgery. The patients were
for a mean period of 31 months. Due to inadequate res- evaluated monthly for the first 6 months after the
olution of the symptoms, surgery was necessary in 10% beginning of treatment or surgery, and the majority
of cases. Of the remaining 52 patients, 50 had an excel- were followed-up for a mean period of 7.4 years. In the
lent or good clinical result and 48 resumed work after a first month, 76% of patients treated conservatively had
mean period of 3.8 months. Of the patients with extrud- "benefitted" from treatment, compared with 97% of the
ed herniation (26%), 87% obtained satisfactory results operated patients; at 6 months, the percentages were
and all returned to work (mean, 2.9 months). The similar (93% and 99%, respectively). In the first month,
patients with a neurologic deficit presented similar the proportion of asymptomatic patients in the conser-
results to those with no deficit. In a series of 114 cases vatively treated group was considerably lower than
(23),14% of patients underwent surgery in the course of that in the surgical group, but at 6 months there were
conservative treatment; in the remaining cases, non- no significant differences between the two groups.
Fig. 14.21. Sagittal and axial MR images of a 37-year female with large midline disc herniation migrated caudally (arrowheads). Symptoms gradually
disappeared over a 40-day period with medical anti-inflammatory therapy (steroids for 10 days and then NSAIDs for 2 weeks) and physiotherapy (mas-
sage, TENS and magnetic field therapy for 3 weeks).
368.Chapter 1 4 . - - - - - - - - - - - - - - - - - - - - - - - - - -
The mean time off work was only slightly longer in the Conclusions
conservatively treated cases than in those submitted to
surgery. However, at 6 months, the percentage of 1. Conservative management ensures satisfactory
patients still off work was 37% in the conservatively results in a large proportion of patients with lumbar
treated group with disc herniation demonstrated by disc herniation. There appear to be no significant dif-
myelography and 7% in the surgical group. At long ferences between the various conservative treatments.
term, the results were only slightly better in the patients In most cases, it is advisable to associate more than one
in the surgical group. Regression of motor and sensory form of treatment.
deficits was found in similar proportions in the two 2. In 10%-20% of cases, improvement in the clinical
groups. The incidence of recurrences of radicular pain syndrome is not sufficient. These percentages increase
in the years following conservative treatment was if we include those patients in whom the severity of
twofold (20%) that observed in the operated patients pain and neurologic deficit makes surgical treatment
(10%). The limitation of this important study is that the indicated without waiting to see the results of conserv-
choice of treatment was not randomized, thus the two ative therapy. The percentage of patients in whom this
groups of patients are not comparable. occurs is not yet known, however, in our experience, it
In a prospective study by Weber (194), 280 patients does not exceed 20%. Thus, some one third of patients
with disc herniation demonstrated by myelography need surgery, whereas in the remaining two thirds
were assigned to three groups. Group I included 87 symptoms are resolved with conservative therapy.
patients with mild symptoms who were treated 3. In most cases, with conservative therapy, a longer
conservatively. The 67 cases in Group II, in which there time period is required to obtain satisfactory results
were absolute indications for surgery, underwent compared with surgery. This is particularly true for
operative treatment. Group III included 126 patients complete resolution of pain, which is usually obtained
with an uncertain surgical indication: these patients after a significantly longer time interval in patients
were randomly assigned to conservative (81) or treated conservatively than in those operated upon. It is
surgical (73) management. Conservative treatment unclear whether, in patients with a satisfactory out-
consisted in bed rest, administration of analgesics, come, the quality of the result regarding both low back
isometric exercises and low back school. All patients and radicular pain is, on average, better or worse after
in Group III were followed-up for 1, 4 and 10 years conservative therapy than after surgical treatment.
after treatment. At I-year follow-up, the proportion 4. At medium and long term, there are no statistical-
of satisfactory results was significantly lower in the ly significant differences in the quality of the result
conservative (61%), than in the surgical (80%), group. between conservative and surgical treatment. The
At 4-year evaluation, the percentage of satisfactory chances of recurrence of radicular pain are slightly
results was still lower in the conservative group, but higher in patients treated conservatively.
the difference was no longer statistically significant. 5. The presence of motor or sensory deficits of mild
Comparable results were observed at 10-year follow- or moderate severity is not a contraindication for con-
up. Of the 66 patients in the conservative group, 25% servative therapy, since the chances that these will be
had undergone surgery during the first year of follow- resolved are comparable to those following surgical
up due to persistence or worsening of symptoms. treatment.
Neurologic deficits improved or disappeared in com- 6. The time off work is slightly longer in patients
parable proportions of cases in the two treatment treated conservatively than those operated upon. For
groups. The main defect of this study is that only the employees, there are no significant differences between
patients with an uncertain surgical indication were the costs (medical expenses + salary during sick leave)
randomized to treatment. of the two types of treatment in the first few years after
A recent investigation (175) retrospectively evaluat- onset of the disease, even if conservative therapy is
ed 55 truck drivers, 30 of whom were submitted to pro- prolonged over time.
longed conservative management (over 3 months) and
25 underwent surgery. The results of treatment were
analyzed, as well as the cost of health care (medical Treatment regimens
expenses + salary in the period off work) in the 5 years
following the beginning of treatment. In both groups, Treatment of a lumboradicular syndrome due to disc
80% of patients presented a satisfactory outcome; no herniation varies in the different clinical phases - acute,
significant differences in the costs of treatment emerged subacute or chronic. The first 5 weeks may be consid-
between the two groups. Also in this study, only ered as the acute phase, subacute that comprised
patients with uncertain indication for conservative or between 6 and 12 weeks and chronic that after 12 weeks
surgical management were included. (62).
- - - - - - - - - - - - - - - - - - - - - - - - - - . Conservative treatments· 369
As far as concerns most of the treatments currently ly in the presence of sciatic scoliosis. Muscle relaxants
performed in syndromes due to disc herniation, there is may be administered by the parenteral route, mixed
no definite proof that any of these are actually effective with NSAIDs, if the two medications do not interact;
(39). This may have one of two meanings. First, these otherwise, they should be given by the oral or rectal
treatments are really ineffective and the improvement route. If pain is not sufficiently decreased with NSAIDs,
obtained is only due to the natural evolution of the it may be useful to administer analgesics, twice or more
disease. Second, the treatments do have a therapeutic a day for a few days. The use of sedatives is indicated
efficacy, but this has not yet been demonstrated due only in patients who are clearly anxious or agitated.
to methodological defects in the studies in which their When radicular pain is as severe as low back pain or
clinical effects have been evaluated. Although the for- prevails over the latter, it is preferable to administer a
mer hypothesis appears to be the most plausible, it steroid, provided there are no contraindications.
should be taken into account that a) it is extremely dif- Steroid therapy should be given at high doses for 2
ficult to determine the therapeutic efficacy of conserva- days, medium doses for 4-6 days and then low doses
tive treatments in a pathologic condition, such as disc for further 2 days. The steroid may then be replaced by
herniation, which may undergo spontaneous resolu- oral administration of a NSAID. In the presence of
tion, and b) a conservative therapy may have multiple radicular pain alone, there is no indication for the use of
effects, including a placebo effect, which may not have muscle relaxants.
been fully ascertained or difficult to quantify. These If adequate pain relief is not obtained by systemic
considerations should not lead us to resort to treat- pharmacologic therapy, protracted for at least 7-10
ments of highly uncertain therapeutic efficacy; howev- days, it may be indicated to carry out epidural injec-
er, they justify the use of therapies, of which the efficacy tions of a slowly absorbable steroid combined with a
is not definitely proven, but which the clinical experi- local anesthetic. Epidural injections may be the treat-
ence indicates to be effective in a large number of ment of choice when systemic pharmacologic therapy
patients. at high doses cannot be performed on account of
comorbidity. There is, instead, no indication for per-
forming paras pinal injections, as these will likely not be
effective. It may also be useful to perform mesotherapy,
Acute lumboradicular syndrome
both in the lumbosacral region and the areas where the
pain radiates.
The therapeutic approach varies depending upon the
Physical therapy is usually indicated at least a
severity of the lumboradicular pain. Whatever the
week after the onset of pain. This is useful especially in
treatment performed, it is important to inform the
patients with prevalently low back pain, whilst it is
patient that: pain will last for at least a few weeks; there
of little usefulness in those complaining only of radicu-
are good chances that it will resolve with conservative
lar pain. In the first few days, the only forms of physical
treatment; if this does not occur within a few weeks,
therapy indicated are analgesic electrotherapy and
there can be an indication for surgery.
massage of the lumbosacral area. TENS appears to be
the form of electrotherapy with the greatest therapeutic
efficacy, and should be performed for at least 30 min-
Severe pain utes, one or more times a day. Massage is aimed at
reducing muscle spasm and, thus, the lumbar compo-
The patients with severe pain should be confined to nent of pain. If massage exacerbates pain or the patient
bed for a few days. Usually, bed rest needs not be has difficulty in maintaining the prone position, the
absolute: if the pain allows it, the patient should get up treatment should be discontinued.
3-6 times a day, for 15-30 minutes each time. In the If, 3 weeks after the onset of symptoms, lumboradic-
supine position, the use of two pillows below the legs is ular pain is considerably decreased, it may be useful to
useful to ensure relaxation of the hamstrings and begin light exercise therapy. This, however, should be
paraspinal muscles. Bed rest should not exceed 4-7 stopped if it exacerbates low back and / or radicular
days, unless the pain is so severe as to prevent pro- pain. In a few cases, it may be useful to have the patient
longed standing. fitted with an orthosis, which he / she should wear all,
If low back pain prevails over radicular pain, it is or most of, the day. The most suitable orthosis is the
preferable to administer NSAIDs via the parenteral lumbosacral canvas corset. If the patient refuses this
route, at high doses for 2-4 days and then at medium type of corset, a semielastic corset may be used, the
doses for about 1 week; thereafter, the oral or rectal biomechanical efficacy of which, however, is very
route is preferable. During the first week of treatment, it uncertain. The corset should be worn 2-4 weeks and
may be useful to associate muscle relaxants, particular- gradually left off.
370.Chapter 1 4 . - - - - - - - - - - - - - - - - - - - - - - - - - - -
The treatment guidelines are given in Table 14.1. Table 14.1. Treatment guidelines in acute lumboradicular syndromes.
Severe pain
Bed rest is not necessary. Usually it is sufficient to Bed rest Bed rest
2-4 days 2-7 days
limit physical activity and stay off work, if physically
demanding, for at least 2 weeks. NSAIDs, muscle relaxants, Steroids, then
Anti-inflammatory medications play the key role in analgesics NSAIDs
the treatment. Usually, it is sufficient to give NSAIDs, TENS, massage (1-2 weeks TENS
initially by the parenteral route at medium doses and after onset of symptoms)
then by the oral or rectal route for an overall period of Light exercises (3 or more Epidural injections
2-3 weeks. When radicular pain is the only or prevail- weeks after onset of symptoms) (if failure with sys-
ing symptom, it may at times be advisable to start temic therapy)
with a steroid at a medium dose for 5-7 days and
then continue with a NSAID by the oral route. Muscle Orthosis (if severe pain persists)
relaxants are useful only in the presence of low back
pain, particularly when there is paraspinal muscle
spasm. Sedatives are usually not indicated. Table 14.2. Treatment guidelines in acute lumboradicular syndromes.
It may be useful, 1-2 weeks after the onset of pain, to
carry out physical therapy. Initially this should consist Moderate pain
in analgesic electrotherapy and massage of the lum- Prevalently Prevalen tly
bosacral and gluteal regions. Microwave diathermy or lumbar radicular
phototherapy may be useful in prepearing for the mas- Work leave Work leave
sage. Autotraction may also be indicated. Manipulation
NSAIDs, muscle relaxants NSAIDs, or steroids and then
according to the principles of manual medicine may be NSAIDs
indicated in patients with bulging annulus fibrosus or
small contained disc herniation, when no neurologic TENS, phototherapy, TENS, autotraction
massage, autotraction
deficit is present.
The patient is instructed, 2-3 weeks after the onset of Light exercises Epidural injections
symptoms, to do exercises for 5-10 minutes, several (2 or more weeks after (if failure with systemic
onset of symptoms) therapy)
times a day. In the presence of motor deficits in the lower
limb, the program should include isotonic and isomet- Mobilization and Light exercises (2 or more
ric exercises for the weak muscles. Exercise therapy manipulation weeks after onset of symptoms)
should be stopped if lumboradicular pain increases. Orthosis (rarely)
When symptoms are not significantly relieved 3-4
weeks after onset, two other therapeutic measures may
be considered: wearing a corset and epidural injections may be useful only in the presence of muscle spasm
of steroids. The corset should be worn for a large part of resulting from recurrence of acute low back pain.
the day for the first 2 weeks and during physical activi- In patients with still fairly severe radicular pain, 1 or
ties which may be more demanding than usual for 2-3 2 epidural injections of steroids may be required. There
weeks. If the first injection has only partially relieved is usually no indication for paraforaminal or paras pinal
pain, a second injection may be indicated after 2 weeks. injections, due to the unlikelihood of obtaining pain
Table 14.2 summarizes the recommeded treatments relief. The only exception is represented by lateral
in these syndromes. herniations, in which paraforaminal injection may be
helpful in relieving leg pain.
In subacute syndromes, physical therapy represents
Subacute lumboradicular syndrome an important therapeutic tool, the most indicated being
analgesic electrotherapy, shortwave diathermy or
Anti-inflammatory medications may be indicated for ultrasounds and massage in patients with prevailing or
short periods, particularly during temporary exacerba- exclusive low back pain, and analgesic electrotherapy
tion of radicular pain. Those most comonly employed in those with prevalently radicular pain. Manipulation
are NSAIDs; it is usually sufficient to administer these may be performed, according to the above-mentioned
by the oral route for periods of 1-2 weeks. Generally, indications, when therapy with physical agents is
there is no need for the use of steroids. Muscle relaxants ineffective.
- - - - - - - - - - - - - - - - - - - - - - - - - . Conservative treatments • 371
Exercise therapy may be useful, particularly in Acupunture may be attempted, particularly when
patients with prevalently low back pain. Low back other conservative measures have been ineffective.
school is indicated in patients with recurrent symp- Patients resuming work should follow, at least for a
toms. few months, all the ergonomic measures available in
A corset may be employed during periods of exacer- the attempt to avoid excessive mechanical stresses,
bation of pain, particularly in the low back. which may induce exacerbation or recurrence of lumb-
The treatment of these syndromes is summarized in oradicular symptoms.
Table 14.3. The recommended treatments are reported in Table
14.4.
PERCUTANEOUS TREATMENTS
F. Postacchini, H. M. Mayer
After injection of the enzyme, the herniated disc nomenon, caused by digestion of the nucleus pulposus,
decreases in height within the first 2-3 weeks. This phe- is likely to be one of the main causes of postprocedural
380.Chapter 15.-----------------------------------------------------
low back pain. The extent of the decrease in height of Numerous studies have evaluated the modifications
the disc space is related to the dose of chymopapain in the herniation by comparing preprocedural CT with
injected and the extent of the digestive action, which, in CT performed at varying time intervals after treatment
turn, is affected by the characteristics of the disc tissue (IS, 61, 97, 98, 108, 17S). Konings et al. (97) have com-
and the possible leakage of enzyme from the disc. High pared preoperative CT with the study performed 3
doses of enzyme tend to produce a marked decrease in months after chemonucleolysis in 30 cases; of the 28
disc height. Similarly, a disc with a high proteoglycan patients whose preoperative CT revealed disc hernia-
content tends to lose more height than a disc with tion, 20 showed a decrease in size or disappearance of
marked fibrotic changes. Therefore, in young or mid- herniation, a diffuse annular bulging being present in
dle-aged subjects, disc height tends to decrease to a 23. These authors found a close correlation between the
greater extent than in elderly subjects. The doses of clinical outcome and CT changes. By contrast, other
enzyme currently employed (3000-4000 U) usually investigators (17S) found no relationship between the
lead to a reduction of disc height by 20% - SO% (Fig. clinical outcome and the results of CT carried out 2-3
lS.3). The decrease in height, on the other hand, also months after nucleolysis. However, of the 91 patients
confirms the digestive action of the enzyme. In our examined (including 11 cases subsequently operated
experience, the vast majority of patients who, after on due to failure of the procedure), 32 showed a clear-
chemonucleolysis, show a decrease in height of at least cut decrease, and 12 a moderate decrease, in size of the
one third have a satisfactory clinical result, unlike the herniation; in the remaining 47, herniation was slightly
patients presenting no change in disc height. On the decreased in size or showed no changes. After 1 year, 27
other hand, in patients assessed more than 6 months patients underwent a third CT: 77% showed a consider-
after treatment, we found no correlation between the able or moderate decrease in size of the herniation.
extent of decrease in height of the disc and severity of An MRI study (63) on patients who had undergone
the postprocedurallow back pain. chemonucleolysis showed that chymopapain pro-
Before the advent of CT and MRI, it was difficult to duces, on T2-weighted images, a progressive decrease
determine the in vivo effects of chymopapain on disc in signal intensity of the nucleus pulposus until com-
herniation. In fact, only occasionally did the patient, plete loss of signal, which occurs at least 6 weeks after
submitted to myelography preoperatively, underwent nucleolysis. Subsequent studies (93, 9S) on patients
repeat myelography after chemonucleolysis. In our with a satisfactory clinical outcome revealed that the
series, this occurred in two patients, who, a few months signal intensity of the disc begins to decrease 2 weeks
after a successful nucleolysis, presented with recurrent after chemonucleolysis and continues to decrease in the
radicular symptoms, which required new myelograph- next weeks, until it completely disappears in the major-
ic studies. In both cases, repeat myelography showed ity of cases. The reduction in size of the herniation
disappearance of herniation and no evidence of com- begins after 4 weeks and continues progressively over
pression of the neural structures at the level of the the next 12 months. At this time, the signal of the treat-
injected disc (Fig. lS.4). ed discs is still decreased. In one fifth of patients, the
_________________________ 0 Percutaneous treatments 0381
A B c
vertebral end-plates show changes in signal intensity, tory outcome almost always present a considerable
consisting in a transient increase in intensity on T-2 decrease in size or disappearance of the herniation
weighted images; the changes appear 3 months after (Fig. 15.5); a diffuse disc bulge with no significant com-
treatment and disappear after 2 years. In another one pression of the neural structures often remains, particu-
fifth of the patients, the vertebral end-plates present a larly in the first few months (Fig. 15.6). Annular bulging
progressive increase in signal intensity on Tl-weighted is likely to be due, at least to a large extent, to the
images and an isointense or hypointense signal on T2- decrease in disc height.
weighted images; these changes appear after 2 years
and are associated with sclerotic changes of the sub-
chondral bone in the vertebral bodies on plain radio- Regeneration of nucleus pulposus
graphs. These changes are an expression of spondylotic
alterations of the motion segment. In studies on dogs aged about 9 months, Garvin and
Radiologic investigations or MRI, therefore, indicate Jennings (58) found that, 2 years after chymopapain
that the vast majority of patients with a satisfactory out- injection, all discs injected with low doses of enzyme
come present a decrease in size or disappearance of the (0.1-1 mg) had reached a normal height, and gross and
herniation after nucleolysis. Changes on CT or MRI microscopic features similar to those of the normal
tend to occur slowly, over a few months. When per- discs. Those injected with 10 mg of the enzyme - a dose
formed too early, therefore, these investigations may considerably higher than that effective - had increased
not display clear-cut changes in the size of herniation, in height, but were still not as high as the controls; fur-
even if the patient has already obtained a good clinical thermore, the nucleus pulposus was decreased in vol-
result. After 6 months or more, patients with a satisfac- ume and few viable cells were visible.
382.Chapter 15.-----------------------------------------------------
Little is known also about the structural changes retraction of the r~sidual collagenous portion of the disc
occurring, with time, in human discs submitted to might lead to a progressive decrease in size, until possi-
chemonucleolysis. The histologic and histochemical ble disappearance, of the herniation (95).
examination of fragments of disc tissue excised at A few authors have also hypothesized a direct anti-
surgery in patients undergoing surgical discectomy inflammatory effect (124), or a chemical effect (151), on
due to unsuccessful nucleolysis, may show, during the the nerve root. However, none of these mechanisms,
months immediately after the procedure, a tendency of have been proved.
the cells to proliferate and synthesize proteoglycans, Chymopapain, being dissolved in water, can reach
with a return to similar histologic and histochemical any part of the disc where the injected solution can
features to those of the normal disc (Fig. 15.8). spread and digest any reachable portion of the nuclear
However, this is likely to occur only in those discs tissue, including extruded fragments. However, since
which were not markedly degenerated prior to nucleo- the enzyme does not affect the collagen fibers, the her-
lysis (68, 140). niated tissue made up entirely, or to a large extent, of
annulus fibrosus is not digested or is insufficiently
digested by the chymopapain, and this results in treat-
Mechanism of action ment failure.
c _~-'-- ..... D
Fig. 15.8. Fragments of disc tissue excised at surgery in four patients at varying time intervals after chemonucleolysis. (A) 5 days after nucleolysis;
Mowry staining. Marked decrease in proteoglycan content. No viable cells are visible. (B) 34 days after nucleolysis; Mowry staining. The interterrito-
rial matrix is poorly stained, whilst the cells are in active proteoglycan synthesis, as revealed by the intense staining of the territorial matrix. (C) 51 days
after nucleolysis; Mowry staining. The cells are actively proliferating. Intense staining of the interterritorial matrix, which again shows a high proteo-
glycan content. (D) 53 days after nucleolysis; alcian blue staining. The disc tissue contains numerous cells and the intercellular matrix presents a
normal proteoglyean content (from Ref 68).
good chances of a successful outcome. However, the five for instance a large disc herniation - satisfactory in
parameters indicate the presence of a herniated disc, some studies and unsatisfactory in others.
rather than determining the indication for nucleolysis, Postacchini (143,146) has defined the indications for
since they do not take into account either the type of the procedure based on the size of herniation, severity
herniation or the severity of nerve-root compression. of neurologic deficits and type of herniation. The con-
The only points upon which all authors agree are that cept that must orientate us in the choice of the patient
chemonucleolysis should be carried out only in the to treat is that nucleolysis should not be considered an
presence of a herniated disc responsible for radicular extreme semi conservative therapeutic attempt, before
pain, after failure of conservative management pro- resorting to surgery, but a mode of treatment which
longed for an adequate period. On all other points, should have high chances of success, within a time
opinions are very conflicting. The procedure has been interval not very dissimilar to that of surgery. Based on
carried out in patients with contained or extruded her- this concept and the results of the procedure, we believe
niations of all sizes, in the absence or presence of neuro- that nucleolysis is indicated when the following criteria
logic deficits, even severe, and in patients of all ages, are satisfied: 1) contained herniation of small or medi-
results being in the same type of pathologic condition- um size (i.e., encroaching on the spinal canal, respec-
- - - - - - - - - - - - - - - - - - - - - - - - - . Percutaneous treatments· 385
tively, for less than 25% or for 25% to 50%) or subliga- gy department, however it may be difficult to obtain
mentous extruded herniation of small size, when the not only adequate assistance of an anesthetist, in the
extruded fragment is in front of the disc or an adjacent event of allergic reactions, but also conditions of
vertebral end-plate; 2) absence of neurologic deficits or absolute sterility. To reduce the risk of infection, the
presence of slight or moderate deficits (for example, operator should wear a sterile gown as in an open sur-
muscle strength 4/5 or 3/5); 3) non-excruciating radic- gical procedure and this can be done more easily in an
ular pain. When the herniation is large, in fact, the operating room.
enzyme may not be able to digest the entire herniated
tissue, or herniation is likely to be extruded behind the
Anesthesia
posterior longitudinal ligament and, thus, cannot be
reached by the enzyme, or may consist, to a large extent,
Anesthesia can be general or local. The advantages of
of annulus fibrosus, which is not digested by chymopa-
general anesthesia are that the procedure is not painful
pain. The presence of a severe neurologic deficit indi-
and, in the case of anaphylaxis and laryngospasm, the
cates that the nerve root is markedly compressed and
latter can be more easily controlled in the intubated
this occurs more easily in the presence of a migrated or
patient. The three main advantages of local anesthesia
transligamentous extruded herniation than in other
are: 1) there is no risk of the needle perforating the
types of herniation; on the other hand, the severity of
nerve root emerging from the intervertebral foramen,
the neurologic deficit makes a fast and complete nerve-
since with the patient awake, he / she feels a sharp
root decompression necessary, which may be better
radiated pain as soon as the needle tip approaches
achieved by surgery than nucleolysis. Likewise,
the root; 2) if an anaphylactic reaction occurs, the con-
excruciating radicular pain, which should be rapidly
scious patient can describe the prodromal symptoms
relieved, is not a good indication for nucleolysis, since
(warmth, tingling, nausea and a feeling of impending
this often improves pain gradually, over a few weeks.
doom) of the reaction, thus allowing treatment to be
Patient's age does not affect the indications; however, it
immediately commenced (71). Laryngospasm, on the
should be borne in mind that, in the elderly, concomi-
other hand, can be more easily controlled when treat-
tant stenosis is often present or herniation consists of
ment is commenced without delay. Furthermore,
annulus fibrosus, rather than nucleus pulposus.
anaphylaxis can be treated more effectively when no
Chemonucleolysis is contraindicated in patients
anesthetic agents have been administered, particularly
with known papaya allergy, cauda equina syndrome,
halothane, which sensitizes the heart to epinephrine
migrated herniation, stenosis of the spinal canal or non-
(the drug of choice for hypotension) and increases the
dis cal pathologic conditions. Pregnancy is generally
probability of arrythmia (3, 81); 3) the risks related to
considered a contraindication, although no studies
general anesthesia are avoided. For these reasons, the
have been carried out on the use of the procedure in
procedure is generally performed under local anesthe-
pregnancy. Stenosis of the spinal canal is usually a
sia, with the assistance of an anesthetist.
contraindication, at least when the condition appears to
Our protocol includes: application of an intravenous
playa significant role in nerve-root compression. A pre-
needle for administration of fluids; intravenous Fentan-
vious chymopapain injection has long been considered
est; cutaneous and subcutaneous local anesthesia with
a contraindication for repeat treatment due to the high-
a standard needle and, then, deep anesthesia along the
er risks of allergic complications. Sutton (169) observed
needle path using a 22 G spinal needle, administering a
an anaphylactic reaction in 14% of the 21 patients sub-
total volume of 15-20 ml anesthetic. A further dose of
mitted to a second injection; however, in the 12 cases
sedative may be given upon enzyme injection.
preoperatively treated with HI and H2 antagonists
(respectively, hydroxizine and cimetidine), no anaphy-
lactic reactions occurred. Similar findings are reported Patient positioning
by others (11). A recurrent herniation following surgical
treatment is generally a contraindication for chemonu- The patient may be placed in the lateral or prone posi-
cleolysis, since the disc tissue has a low proteoglycan tion. The choice is largely one of personal preference.
content and a high collagen fiber content, which reduce We prefer the lateral decubitus on the left side (Fig.
the digestive efficacy of the enzyme. 15:9). In this position, the disc is approached on the
right side. However, there seem to be no great differ-
ences between the right or left approach (121). In order
Technique to widen the disc space, a support (a pillow, a rolled sur-
gical sheet or a radiotransparent rigid support) is
The procedure should preferably be carried out in the placed under the patient's left flank. The patient is posi-
operating room. It can also be performed in the radiolo- tioned with the hips and knees flexed, and a pillow is
386.Chapter 15.---------------------------------------------------
Postoperative monotoring
Complications
At the end of chymopapain injection, the patient is
placed supine on the operating table and checked by the Chemonucleolysis with chymopapain may give rise to
anesthetist. If there is no evidence of an allergic reac- three main types of complications, namely allergic,
tion, he is taken to the recovery room and again repeat- neurologic and infective (Table 15.1). In addition, very
edly checked by the anesthetist for a further 30 minutes occasionally cardiac, visceral or thromboembolic
after the end of the procedure, since anaphylaxis complications have been reported (Table 15.1).
usually occurs within this time interval. In the presence
of severe low back pain, administration of analgesics
and muscle relaxants is started in the recovery room. Allergy
Mean age 38.1', 34.9 b 37.1 a, 37.2 b 37.9', 39.9 b 37.2', 38.7 b
Dose 4mg 8mg 8mg 8mg
Placebo CEI Saline Saline CEl
Follow-ups 2-11 mesi 1.5-6m. 1.5-6m. 1.5-6m.
Successes 58% 80% 73% 71%
chymopapain
Successes 49% 57% 42% 45%
placebo
cleolysis, assessed by questionnaire on average 2 years Table 15.3. Long-term and very long-term results of chemonucleolysis
after treatment, revealed that the results were excellent with chymopapain.
or good in 40% of cases, fair in 18% and poor in 42%. Author No. of cases Follow-up Success rate
Loew et al. (105), based on a series of 19 cases, conclud- (years)
ed that chymopapain was ineffective, since only 42% Postacchini (1991) 68 5-10 82%
had satisfactory results, however in two of the failures, Dubuc (1986) 842 5-12 81%
nucleolysis had been performed at a wrong level. Wilson (1994) 200 5-13 71%
An interesting observation is that most of the nega- Sutton (1986) 208 6-11 79%
tive studies have been carried out by neurosurgeons. Jabaay (1986) 130 8-10 71.5%
Dabezies (1986) 94 8-12 80.6%
Nordby (1986,2) 739 8-13 76%
Positive studies. In a randomized double blind study Thomas (1986) 42 9-13 81%
(52), 30 patients were treated with chymopapain, Maciunas (1986) 268 10 80.1%
whereas in 30 only saline was injected into the herniat- Gogan (1992) 30 10 80%
ed disc; at 6-month follow-up, the results were satisfac- Mansfield (1986) 146 10-14 66%
Flanagan (1986) 357 10-20 74%
tory in 80% of patients treated with chymopapain and
57% of controls. In a similar study (86) carried out in
seven centers, 55 patients received chymopapain and anesthesia without discography; a 73% success rate
53 only saline; the rate of successes, 6 months after treat- was obtained in the former group, and 83% in the latter.
ment, was 73% in the chymopapain group and 42% in In two multicenter studies (4123), each analyzing more
the control group. Dabezies et al. (33) evaluated 78 than 1000 patients, the success rate were 70% and
patients treated with chymopapain and 81 with CEI, 87%, respectively.
based on a randomized double-blind protocol, by 30
surgeons; at 6-month follow-up, the success rate was Long-term and very long-term results. Numerous
71 % in the former group and 45% in the controls studies have analyzed the results of chemonucleolysis
(Table 15.2). after more than 5 years (Table 15.3). In a series of 189
In numerous other prospective or retrospective stud- patients assessed by questionnaire after 6-11 years (169),
ies' the rate of satisfactory results has been 70% or more 79% were found to be satisfied with the treatment. In
(8,38,50,57,60,70, 120, 124, 143, 159). McCulloch (119) numerous other studies which assessed the results 5-13
followed 480 patients treated at one or more levels for a years after nucleolysis, the proportions of satisfactory
mean period of 18 months; of the patients with typical outcomes ranged from 71% to 82% (32,41,82,107,109,
disc herniation not previously operated on, 70% had 129,171,183). Postacchini and Perugia (147) evaluated 68
satisfactory results, whereas most of the patients with patients after 5-10 years; six patients had been operated
stenosis, a psychogenic component in pain or a history on; of the remaining 62, 91 % had obtained an excellent
of previous surgery in the lumbar spine reported a fail- or good result. Gogan and Fraser (66) assessed, after 10
ure. Hill and Ellis (79) treated 225 patients at one or years, the patients of a previous randomized double-
multiple levels under general anesthesia after discogra- blind study (52); of the patients treated with chymopa-
phy and 110 patients at a single level under local pain, 20% had undergone surgery; of the remainder,
394· 15.-----------------------------------------------------------
80% maintained that the treatment had been successful, retrospective study by Maroon and Abla (111), compar-
whilst the outcome was rated as satisfactory by only ing chemonucleolysis with microdiscectomy (58% and
34% of patients treated with saline, who meanwhile had 90% of successes, respectively). The main criticisms
not undergone surgery. Nordby (128) analyzed the that can be directed to some of these studies are that: the
results obtained by 13 authors in 3130 patients assessed chymopapain groups included patients with hernia-
7 to 20 years after treatment; satisfactory results ranged tions of any size, as pointed out by Wilson and
from 71% to 93%, mean 77%. An analysis of 357 patients Mulholland (183) for the series studied by Crawshaw;
10-20 years after treatment (49) revealed that 44% had no distinction was made between contained, extruded
no pain, 30% complained of slight discomfort and only or migrated herniations (46); the presence of severe
6% reported a failure. neurologic deficits, which is usually in contrast with the
An important finding emerging from these studies is diagnosis of contained herniation, or the presence of
that the results of chemonucleolysis do not tend to concomitant stenosis were not considered possible cri-
change with time. An excellent or good outcome at teria for exclusion from chemonucleolysis (111, 178).
short term rarely becomes poor at long term; likewise, Postacchini et a1. (146) studied prospectively 72
patients with a fair or poor outcome generally remain patients treated with chymopapain injection and 84
in these categories (183). submitted to conventional surgery. Herniations were
classified as small, medium-sized or large and three
Comparison with surgery. In a study (2), 100 mili- types of clinical presentation were identified, corre-
tary servicemen submitted to chemonucleolysis sponding to mild, moderate or severe nerve-root com-
(51 cases) or treated surgically (49 cases) were assessed pression. The final follow-up was carried out a mean
about 1 year after treatment. All patients had been period of 2.8 years after treatment. In the patients with
considered good candidates to either treatment and small herniation who had undergone chymopapain
the choice depended on the patient's preference. injection, the proportion of satisfactory results (84%)
Satisfactory results were obtained in 78% of patients in was comparable with that in the surgical series (82%).
the chymopapain group and 80% of those in the surgi- In medium-sized herniations, the percentage of satis-
cal group; the rate of complications was 4% in the for- factory results was slightly higher in the surgical
mer group and 10% in the latter. Comparable results (86%), than the chymopapain (76%), group. In the latter
were found in a retrospective study (179), in which 85 group, most of the patients with excellent or good
patients submitted to chemonucleolysis and 71 treated results showed evidence of mild or moderate nerve-
surgically were assessed at short (1 year) and long term root compression, both in small and medium-sized
(10 year). At long term, the results were comparable in herniations. In large herniations, surgery led to a signi-
the two groups; both at short and long term, the per- ficantly higher percentage of satisfactory results (89%)
centage of repeat procedures was slightly higher in the compared with nucleolysis (50%). This study indicates
surgical, compared with the chymopapain, group. that, in patients with presumably contained herniation,
Javid (85), in the follow-up of 104 patients submitted to the degree of preoperative nerve-root compression and
chemonucleolysis and 68 treated surgically 1-4 years size of herniation are of considerable prognostic value
after treatment, found that results were satisfactory in regarding the results of chemonucleolysis.
86% of cases in the former, and in 83% of those in the lat-
ter, group. In a comparative analysis (173) of patients
injected with chymopapain or treated surgically, after a Adolescents and elderly patients
mean time of 10 years, satisfactory results (excellent,
good or fair) were 72% in the chymopapain group and In patients younger than 20 years, chemonuc1eolysis
83% in the surgical series. provides satisfactory results in a comparable, or even
In several other studies, however, the percentage of higher, proportion than in adults. Lorenz and
satisfactory outcomes was found to be higher after con- McCulloch (106) followed 55 patients aged 13-19 years
ventional surgery (31, 46,174,178) or microdiscectomy for a mean time of 4.5 years. The percentage of success
(111, 177, 187) than after chemonucleolysis. In the was 80%. Similar rates of success were obtained in other
prospective randomized study by Crawshaw et a1. (31), series (40, 170, 183). Our experience also indicates that
satisfactory results were obtained in 48% of the 25 most adolescents are good candidates for nuc1eolysis,
patients submitted to chemonucleolysis and in 89% of although they frequently reach a satisfactory outcome
the 27 undergoing conventional surgical treatment. In more slowly than adults. In most adolescents, in fact,
the series of Zeiger (187), the outcome was satisfactory herniation is contained, however the annulus fibrosus
in 60% of the 45 patients treated with chymopapain often bulges considerably into the spinal canal, thus
injection and in 98% of the 81 submitted to microsurgi- contributing significantly to compression of the neural
cal discectomy. Similar success rates were found in the structures. Digestion of the nucleus pulposus reduces
_________________________ 0 Percutaneous treatments 0395
disc bulging, but does not affect the annulus fibrosus, Table 15.4. Recurrence of disc herniation following chemonucleolysis.
which tends to retract slowly, over a few months, and Author No. of cases Follow-up Surgical dis-
only when this process has occurred, does the clinical (years) cectomy
result become satisfactory. On the other hand, in ado- Gogan (1992) 30 10 3%
lescents, once a satisfactory result is reached, it almost Wilson (1992) 364 5-13 4%
always remains stable, even at long term (129). Lavignolle (1992) 190 10 4.5%
Only two studies have analyzed the efficacy of Mansfield (1986) 146 10-14 5%
chemonucleolysis in patients over 60 years of age. In Maciunas (1986) 268 10 5%
Postacchini (1991) 68 5-10 7%
one series of 19 patients, satisfactory results were Dabezies (1986) 100 8-12 7.5%
obtained in 63% of cases (110). Benoist et al. (5) assessed Sutton (1986) 189 6-11 9.5%
the results of the procedure in 42 patients with a mean Tregonning (1991) 145 10 9%
age of 67 years, on average 4.5 years after treatment. All Javid (1985) 105 9-12 16%
patients, except for three, had a medium-size hernia-
tion. The results were excellent in 43% of cases and condition rather than a true recurrent herniation.
good in 35%. Of the nine patients with an unsatisfacto- Postacchini and Perugia (147) analyzed 68 patients
ry outcome, two underwent surgery and four contin- after a mean time of 7.2 years; those patients who had
ued to complain of lumboradicular symptoms, despite undergone surgery a short time after nucleolysis were
the disappearance of herniation on postoperative CT, excluded from the study. Of the patients with a satisfac-
which showed persistent herniation in the remaining tory outcome at short term, six (7%) underwent surgery
three. In most of the elderly patients in whom clinical due to recurrent herniation at the same level and on the
success was obtained, the signs and symptoms were of same side as the primary herniation 1.5 to 4 years after
less than 6 months' duration. nucleolysis, and one patient was operated due to
bulging of the annulus fibrosus in a stenotic nerve-root
Low doses canal. Of the remaining patients, 12% reported one or
more episodes of radicular pain of more than 1 week's
Low doses of enzyme are as effective as the standard duration.
dose, but do not lead to a significant decrease in post-
operative low back pain. Benoist et al. (6) injected a
Surgery after failure of chemonucleolysis
standard dose (4000 U in 2 ml) in 60 patients and a
lower dose (2000 in 2 ml) in 58 randomly selected
The pathologic conditions usually found in those
patients. Both the percentages of satisfactory results
patients operated on in the first few months after failed
and the severity of postoperative low back pain were
chemonucleolysis are: a migrated, extruded or con-
comparable in the two groups. Similar results were
tained herniation; bulging of annulus fibrosus associat-
obtained in other studies, in which the enzyme was
ed or not with nerve-root canal stenosis; or only
injected at a dose of 500 to 1500 U (35, 87, 180).
isolated stenosis of the radicular canal.
With the advent of CT and MRI, a migrated disc
Recurrence of herniation fragment can generally be diagnosed or suspected pre-
operatively, with the exception of intraforaminal herni-
The rate of recurrences of herniation after chemonucle- ations, in which even these imaging studies may not
olysis seems comparable to that observed after surgery. demonstrate the type of herniation. On the other hand,
In a series of 30 patients studied prospectively by since most intraforaminal herniations are extruded or
Gogan and Fraser (66) for 10 years, the percent recur- migrated, there is little indication for nudeolysis in
rence was 3%. On the other hand, of 124 patients fol- these types of herniated disc. Extruded herniation,
lowed by Javid (84) for 9-12 years, 16% showed a instead, is frequently encountered after failure of
recurrent herniation. Table 15.4 reports the percent chemonucleolysis. In most cases, the herniation is small
recurrence of herniation in 10 clinical series, the mean inasmuch as it was small even before nudeolysis or on
percentage being 7%. In most of these series, however, account of partial digestion of the herniated tissue by
only those cases operated on at variable time intervals the enzyme; often the herniated tissue consists of an
after nucleolysis are considered as recurrences; it is, annular fragment not digested by chymopapain. A true
thus, not known how many patients had a recurrent contained herniation is a fairly rare finding and, when
herniation and did not undergo surgery, in how many found, it is usually large.
cases the herniation was at the same level as the prima- Stenosis of the spinal canal is rarely a cause of failure,
ry herniation or at other levels, and in how many since this condition is usually easily diagnosed pre-
patients surgery was performed due to a stenotic operatively. Isolated stenosis of the nerve-root canal,
396.Chapter 15.---------------------------------------------------
instead, is a frequent cause of failure either because this Collagenase
condition is more difficult to diagnose preoperatively or
because narrowing of the nerve-root canal may increase Collagenase, injected in lumbar discs of monkey, dis-
as a result of a decrease in height of the disc space. solves the nucleus pulposus and the adjacent portion
When disc height is markedly reduced, in fact, it may of annulus fibrosus and, on average, leads to a 40%
be responsible for annular bulging and / or an increased decrease in disc height; the enzyme, when brought in
bulge of the ligamentum flavum into the spinal canal. contact with the L4 root in the intervertebral foramen,
Previous nucleolysis does not affect the results of causes a slight perineural inflammatory reaction, but
surgery, which are comparable to those obtained after no significant changes in the nerve tissue (188).
a first operation for disc herniation as far as concerns In patients with lumbar disc herniation, the success
both pain and restoration of working ability (17, 39, rate with collagenase chemonucleolysis ranges from
107,109,119,184). 69% to 85% (20, 21, 30, 101). Hedtmann et al. (74)
A small proportion of patients with chronic low back assessed 61 patients treated with a high dose of collage-
pain after nucleolysis undergo spinal fusion, with a nase (600 ABC units) and 43 with a low dose of the
similar percentage of satisfactory results to that enzyme (400 ABC units); the success rate was 63% with
observed in patients with chronic low back pain pre- a high dose and 71 % with a low dose at the 3-month fol-
sumably of discogenic nature. According to some low-up, and 72%, using a high dose, at 6-month follow-
authors (155), arthrodesis would be indicated in many up; in comparable groups of patients treated with
cases of persistent low back pain following nucleolysis, chymopapain, the results were similar to those of the
since the latter might cause or increase vertebral insta- cases treated with low dose collagenase. With this dose,
bility (155). However, several studies indicate that, a postoperative low back pain is less severe and of simi-
few months after nucleolysis, the normal biomechani- lar entity to that produced by chymopapain, compared
cal properties of the disc are restored (page 89). to which collagenase is slower in improving radicular
Persistent postprocedural low back pain, therefore, is pain (22). As for chymopapain, short-term results do
probably not due to vertebral instability, unless this is not tend to change with time. Wittenberg et al. (185)
present prior to treatment. assessed, after 5 years, 42 of the first 50 patients treated.
Of these, 28% had undergone surgery, mostly within
the first few months after treatment. Of the remaining
Cost patients, 93% presented satisfactory results.
Collagenase very occasionally causes allergic reac-
In one study (148), the cost of chemonucleolysis was tions of mild severity. In the series of Chu (30), includ-
compared with that of conventional surgical discecto- ing 252 patients submitted to epidural, rather than
my, both procedures having been performed at a single intradiscal, injection of the enzyme, no neurologic com-
level. Mean hospital stay was 1.4 days in the nucleoly- plications occurred. Other investigators (74, 185), how-
sis group and 6.4 days in the surgical series. Of the ever, have reported a high rate (18%) of neurologic
patients in the former group, 7.5% had a failure and complications, consisting of monoradicular motor or
underwent surgery, whilst repeat surgery was carried sensory deficits, but also three cases of cauda equina
out in 10% of the patients in the surgical group. The syndrome.
mean cost of treatment, taking into account the cost of
the repeat procedure, was some 15% lower in the nucle-
olysis group than in surgical group. The higher cost of Other enzymes
surgical treatment was essentially due to the longer
hospitalization. It should not be forgotten, however, Chondroitinase ABC (CABC) is a disaccharidase with a
that, at present, the mean hospital stay is considerably specificity for chondroitin sulphate types A, Band C.
less than in the past decade, even for conventional dis- The enzyme, which is a product of metabolism of
cectomy. Furthermore, if microdiscectomy is carried Proteus vulgaris, does not induce microhemorrhages
out, the mean hospital stay is comparable to that of after subcutaneous injection and has no effect on
chemonucleolysis. At present, therefore, the cost of intathecal nerve tissue or peripheral nerves at doses
nucleolysis is comparable to that of surgery, or even (200 U / ml) 4-8 times higher than the effective dose
higher, if one takes into account the costs of postproce- (94,132). In rabbits and dogs, intradiscal injection of 10,
dural treatments in the patients with unsuccessful 50 or 100 U / ml of CABC causes a decrease in disc
nucleolysis who do not undergo surgery, and the costs height and in proteoglycan content in the ventral por-
related to the longer time off work that nucleolysis tion of the annulus fibrosus adjacent to the nucleus pul-
implies (177). posus (48, 56). In rabbits, injection of even 1 unit of the
- - - - - - - - - - - - - - - - - - - - - - - - - . Percutaneous treatments· 397
enzyme produces cell death and a decrease in the pro- procedure has been used indisciminately, often by the
teo glycan content in the nucleus pulposus in a few days inexperienced. Experienced physicians have never
(76). Despite these promising findings and the very reported serious neurologic complications or anaphy-
slight chance that pre-sensitization to this exogenous lactic reactions leaving permanent sequelae. On the
protein exists in human beings, CABC has not as yet other hand, it should not be forgotten that, in recent
been used for clinical purposes. years, the use of antiallergic prophylaxis has further
Cathepsins Band G, obtained from liver and human reduced the chances of uncontrollable anaphylactic
leucocytes, respectively, and chymotripsin, extracted shock. However, nucleolysis with chymopapain
from pancreatic juice, are endogenous proteases, which should not be considered, for these reasons, a minor
should have a lower antigenicity compared with chy- therapeutic modality, representing the last stage of con-
mopapain, an exogenous protein. In rabbits, all three servative management, but rather a procedure with
enzymes lead to a reduction in disc height following clear-cut indications, which is performed on account of
intradiscal injection. Cathepsin G and chymotripsin its intrinsic advantages.
are able to remove 80% of disc proteoglycans, whilst Chemonucleolysis requires very careful patient
cathepsin B removes only 45% (34). selection, which greatly affects the chances of a success-
Calpain I, like chymopapain, is a cysteinic protease, ful outcome. In our experience, good candidates for
which leads to degradation of proteoglycans in vitro. chemonucleolysis are those patients presenting with
This enzyme is present in human erithrocytes and is small or medium-size herniation, mild or moderate
thus devoid of antigenic properties, when obtained neurologic deficits, no marked disc narrowing, radicu-
from the same subject in whom it is injected. In the rab- lar symptoms of less than 8 months' duration, and no
bit, intradiscal injection of calpain I leads to a decrease evidence of nerve-root canal stenosis. This does not
in disc height and in the content of proteoglycans, imply that patients with other pathologic conditions
which, over 2 months, tend to return to the initial levels (large contained herniation, sub ligamentous extruded
(176). Proteolytic action, however, is lower than that of herniation or severe radicular deficits) may not have
chymopapain. Prior to its possible use for clinical pur- also satisfactory results. In these cases, however, the
poses, various problems should be solved regarding chances of success are considerably less and the proce-
dose and sterilization of the enzyme as well as the dure, to a certain extent, becomes a therapeutic attempt
inhibitory effects of endogenous calpastatin. aimed at avoiding surgical treatment. This approach,
instead, should be avoided, since nucleolysis is not a
form of treatment to be taken lightly and should be car-
Conclusions ried out not as a makeshift or as an attempt, but rather
because it is technically simple, has high chances of suc-
Chemonucleolysis with chymopapain is a technically cessful outcome and the results obtained, when satis-
simple procedure not only for L4-L5 disc, but also for factory, are comparable to, or even better than, those of
L5-S1 disc, in which it may be difficult, or at times surgery. Compared with patients submitted to surgery,
impossible, to enter with instruments used for other those undergoing chemonucleolysis have similar
percutaneous methods. Of all the percutaneous proce- chances of recurrence of the herniation.
dures, nucleolysis is that which provides the highest Collagenase does not offer any significant advan-
rate of satisfactory results. In the three most recent ran- tages with respect to chymopapain. The absence of
domized double-blind studies (Table 15.2), the mean major allergic reactions is, in fact, balanced by a lower
rate of success at short term was 74% with chymopa- therapeutic efficacy and a comparable or higher rate of
pain and 48% with placebo, and in 12 retrospective neurologic complications with respect to chymopa-
studies in which the long-term or very long-term pain. The enzymes still under experimentation do not
results were evaluated (Table 15.3), the mean percent- appear to be able to compete with chymopapain.
age of successful outcomes was 77%. The high thera-
peutic efficacy of nucleolysis is probably related to the
fact that the enzyme, carried in a liquid agent, is able to Percutaneous automated
reach any portion of the disc into which the injected nucleotomy (PAN)
solution can penetrate.
Compared with the other percutaneous procedures, Percutaneous automated nucleotomy (PAN) was intro-
chemonucleolysis implies a higher risk of complica- duced by Onik, who, in the early part of the 80's,
tions, particularly of a serious type. The prevalence of developed a smaller sized instrumentation than those
the latter, namely neurologic complications, has used by other surgeons for manual percutaneous
become an issue of concerns, particularly when the nucleotomy (55, 78, 90), which had a novel mechanism
398.Chapter 15.---------------------------------------------------
of automatic cutting and aspiration. After experiments Suction is applied to the center of the cannula aspirat-
in animals and cadavers (133), a straight instrumenta- ing the disc material into the port of the needle. The end
tion was put on the market, allowing discs located at of the cannula is pneumatically driven across the port,
the level of, or proximally to, the iliac crest to be thus cutting off the disc tissue, which is then aspirated
approached. The technique quickly became very popu- through the cannula to a collecting bottle. The cutting
lar due to its technical simplicity and innocuity, and the instrument operates at up to 300 cycles/min. The
high rate of satisfactory results initially reported. A nucleotome, as well as the dilator and trephine, are
curved cannula was later developed to approach the moderately flexible in order to adapt to the curved
L5-S1 disc (134). After an initial period of great acclame, guiding cannula, which is rigid.
the popularity of this technique started to wain, as In recent years, a flexible nucleotome has been
results of clinical studies only partly confirmed the developed, which can be angled from 0° to 90°. One can
therapeutic efficacy of PAN. This technique is, howev- reach, with this nucleotome, those areas which cannot
er, still used by many doctors, although much less be reached with the standard nucleotome, particularly
frequently than at the beginning. the posterior portion of the disc.
Instrumentation Technique
The instrumentation developed by Onik consists of a The procedure is performed in the operating room,
disposable kit and pneumatic suction equipment. under local anesthesia with a similar technique to that
The kit includes the instruments to approach the disc for chemonucleolysis. General anesthesia is not
and a drain tube which can be connected to a bottle, advised due to the risk of injuring the nerve root emerg-
where the material aspirated is collected. The approach ing from the intervertebral foramen.
instruments include: 1) a guiding needle 1 mm in diam- The patient is placed in the lateral decubitus or prone
eter with a removable hub; 2) two coaxial cannulae. The position. Unlike in chemonucleolysis, the prone posi-
outer cannula (guiding cannula), 2.6 mm in diameter, tion is preferable, since the procedure lasts longer,
contains a tapered dilator (inner cannula), 2 mm in which may make the lateral decubitus position uncom-
diameter, the end of which is cutting and just out from fortable for the patient. The operating table may be bent
the outer cannula by 2 mm. A straight cannula is avail- to allow the hips to be flexed at 45° or a radiotranspar-
able for the L4-L5 and more cranial discs, and a slightly ent support, kyphosing the lumbar spine and making
curved cannula for the L5-S1 disc (Fig. 15.17); 3) A 2 use of the fluoroscope easier (10), may be employed.
mm wide trephine with a cutting end to perforate the The disc is approached on the side of the herniation or,
annulus fibrosus (Fig. 15.17). 4) A nucleotome probe, in the case of a midline herniated disc, on that corre-
which has a needle 2 mm in diameter attached to it (Fig. sponding to the more symptomatic lower limb.
15.17). The needle has a rounded end with a port near to A few doctors use a paramount CT of the abdomen,
the distal end. A cannula with the end sharpened to a performed with the patient in the prone position at the
surgical blade is fitted through the center of the needle. level of the affected disc (and also at the level above
when the LS-Sl disc is involved), to exclude a retropsoic mentation is used, the tip of the needle is positioned in
position of the colon and vascular, ureteral or renal contact with the outer surface of the annulus fibrosus.
anomalies, and to calculate the distance of the cuta- The curved guiding cannula containing the dilator is
neous entry point from the midline and the path of the placed over the guiding needle and advanced until it
instruments. reaches the annulus fibrosus; if the trephine, and then
The disc is approached with a technique similar to the nucleotome, hit against one of the vertebral end-
that described for chemonucleolysis. As for the latter, a plates, the guiding cannula is orientated cranially or
few operators perform a preprocedural discography. In caudally until the instruments can enter the disc as par-
this case, the needle should be placed as precisely as allel as possible to the vertebral end-plates. This is
possible in the center of the disc, so that it can be used made easier with the use of the 18 G needle and the
for inserting the guiding needle of Onik's instrumenta- curved needle previously inserted into the disc parallel
tion. There are two options in this respect: if the guiding to the vertebral end-plates (Fig. 15.18).
needle of the instrumentation is used, it is inserted in The nucleotome is advanced to the center of the disc
close proximity and parallel to the discography needle; and then switched on, using first a high cutting fre-
alternatively, a thinner guiding needle is used, which is quency and then a lower frequency so that small frag-
passed through the discography needle, that is then ments of disc tissue are more easily attracted into the
removed, leaving in place the guiding needle. port of the instrument. The port should be advanced in
When the guiding needle has been confirmed fluoro- all those areas that can be reached within the nuclear
scopically to be in the center of the disc, the hub of the space and slowly deepened and retracted, with unin-
needle is removed. After a small skin incision, the coax- terrupted movements, so that it can encounter and suck
ial cannulae (guiding cannula and dilator) are passed out new disc material. Furthermore, the instrument
over the guiding needle and advanced to the outer should be rotated so that the port is orientated in the
aspect of the annulus fibrosus. The dilator is removed, direction in which nucleotomy is needed. The saline
leaving the guiding cannula and needle in place. The flowing in the drain tube, in which the fragment
trephine is then inserted and a 8-mm deep hole is creat- of disc tissue passes, should always be transparent.
ed by rotating the instrument. The trephine and guid- Sometimes, usually at the beginning of nucleotomy, the
ing needle are removed and replaced by the saline may be pinkish in color due to the presence of
nucleotome, which has a maximum excursion of 3 mm blood. The nucleotome should then be switched off,
beyond the end of the guiding cannula. and its position checked and possibly changed. During
A curved guiding cannula is used for the LS-Sl disc, the procedure, the guiding cannula should be main-
since it cannot usually be entered with a straight instru- tained in contact with the outer aspect of the annulus
ment. The cannula is placed over the guiding needle of fibrosus; this avoids not only injuries to the peridiscal
the instrumentation or a thinner curved needle passed tissues if the nucleotome is inadvertently extracted
through an 18 G needle, using the technique described from the disc, but also excessive penetration of the
for chemonucleolysis. When the needle of the instru- instrument into the disc space.
-I
Technical difficulties
excised. Shapiro (156) followed 57 patients for a mean difficult to approach and, occasionally, the nucleotome
period of 27 months: relief of radicular pain was report- cannot be inserted in the disc space or this is possible
ed by 88% of patients at 2 weeks, but by only 70% at 2 only after numerous attempts, which make the proce-
months; at the latest follow-up, 58% reported pain relief dure poorly tolerated by the patient and also increase
and only 5% were asymptomatic. Similar results emerg- the risk of infectious complications. These are the only
ed from another study (43) carried out on 142 patients: real complications, even if exceptional cases of neuro-
the rate of satisfactory outcomes was 67% at 3-month logic injuries, resulting from errors in the surgical tech-
follow-up and 56% after a mean time of 21 months. nique, have been reported. These prerogatives - easy
Wilson and Kerslake (182), analyzing the results of technique and low frequency of complications - made
PAN in 50 patients 1 year after treatment, found satis- the procedure very attractive, until serious doubts
factory results in 72%. Another later investigation (69) arosed concerning its therapeutic efficacy. In several
assessed 115 cases, including also the 50 patients in the studies, in fact, the proportion of satisfactory results, at
previous study (182), a mean time of 55 months after short term or medium term, did not exceed, or only
the procedure. Prior to treatment, the patients com- slightly exceeded, the success rates obtained with a
plained primarily of radicular pain rather than low placebo in the double-blind studies carried out to assess
back pain, had positive nerve-root tension tests, and the therapeutic effects of chymopapain (Tables 15.1 and
presented no stenosis, no decrease in disc height 15.5). This suggests that PAN might not be truely effica-
greater than 50% or herniation encroaching on the cious, the successful outcomes being essentially due to
spinal canal for more than 50% of the midsagittal diam- spontaneous resolution of the symptoms. This hypo-
eter of the canal. The percentage of excellent or good thesis is in keeping with studies using serial CTs, which
results was 45%; of the patients in the former study who showed that, after a mean period of 6 months, the size
had an excellent or good outcome (36 out of the 50), two of the herniation was not modified or had increased in
thirds had remained in the same category, whereas in some 75% of patients submitted to PAN (44). On the
one third the result deteriorated to fair or poor. other hand, the indications for this form of treatment
are so limited that only a small proportion of patients
Comparison with other percutaneous methods. A with disc herniation are good candidates for PAN and,
prospective randomized multicenter study (149) moreover, in these patients conservative management
analyzed 69 patients submitted to PAN and 72 injected has a good chance of relieving \ the symptoms.
with chymopapain. At I-year follow-up, the percent- Furthermore, it should be borne in mind that little is
age of satisfactory results was 37% in the former group known concerning the mechanism of action of this
and 66% in the chymopapain group. However, it technique and the few available studies suggest that
should be taken into account that in the patients in PAN may increase, rather than reduce, the disc bulge in
this study the indication for percutaneous treatment, the spinal canal.
on the basis of the findings of imaging studies, may
be partially questionable. In fact, in some 60% of
patients, the herniation occupied one fourth to half of
the sagittal dimensions of the spinal canal and in some Manual percutaneous discectomy
75%, the herniation had migrated as far as 5 mm and laser discectomy
cranially or caudally to the vertebral end-plate.
No clinical investigation has been carried out to Historical aspects
compare PAN with manual percutaneous nucleotomy,
with or without discos copy. In a study on cadavers, The first description of manual percutaneous discecto-
it was found that neither PAN nor manual nucleotomy my dates back to 1975, when Hijkata (78) reported on a
with discoscopy allow removal of the entire nucleus series of patients with lumbar disc herniation in whom
pulposus (141). With the latter technique, however, less removal of nucleus pulposus was performed by a per-
amount of nuclear material can be excised and the tech- cutaneous posterolateral approach to the disc space.
nique is less effective in severely degenerated discs. However, Kambin (90) and Hoppenfeld (80) claimed, in
Pre-treatment with chymopapain did not lead to an papers published in the 80's, that they first used this
increase in the amount of tissue removed by PAN. method in 1973 and 1974, respectively. In 1983, a group
of orthopaedic surgeons (166) reported on the endo-
scopic control of nucleus pulposus removal. During
Conclusions this period, however, the methods of percutaneous
nucleotomy did not gain popularity. Indeed, they were
PAN is a simple technique, at least for the L4-L5 and used in few centers and in a limited number of patients;
more cranial levels. The L5-S1 disc, instead, may be moreover, there was no commercial interest from the
404.Chapter 15.-----------------------------------------------------
biomedical industry, no specific surgical instruments Several types of instrumentation have been developed,
being produced at that time. It was also the "flowering but they are very similar. The instrumentation descri-
time" of chemonucleolysis, which switched from the bed below (Fig. 15.22) is that used by us.
USA to Europe and the rest of the world. Thus, percuta- The approach instruments include: 1) an 18 G needle,
neous nuleotomy appeared to be simply an unnecessary 155 mm long; 2) a guiding wire 0.8 mm in diameter and
method, with no demand for its routine clinical use. 350 mm in length, with both tips rounded off; 3) a blunt
With the increase in reports on technical and anaphy- obturator 4.5 mm in diameter and 180 mm in length,
lactic complications of chemonucleolysis, the populari- which has a central drilling 0.9 mm in diameter; the
ty of chymopapain injection began to decrease, parallel instrument has a removable luer lock cone; 4) a work-
to the introduction in clinical practice of percutaneous ing sleeve 155 mm long, with an inside diameter of 4.6
automated nucleotomy. The advent of this technique, mm; the sleeve has a large luer lock cone for suction and
and in particular its limitations, led to increased interest a smallluer lock stop cock for irrigation; 5) a trephine
both in manual percutaneous surgery and microdiscec- with a small diameter tip (3.5 mm) and another with a
tomy, which, from the second half of the 80's, reached larger tip (4.5 mm).
a rapid and widespread popularity amongst spine The instruments for discectomy consist of rigid or
doctors as well as spine patients. flexible, straight or angled forceps, 205 mm long with
The pioneer of laserdiscectomy was Choy, who real- cup sizes of 3, 3.5 or 4.5 mm. The flexible forceps are
ized that ablation of the nucleus pulposus by laser passed through a sleeve, which allows the end of the
might lead to a decrease in intradiscal pressure and forceps to bend in order to reach the lateral and pos-
nerve-root compression caused by a contained hernia- terolateral portion of the disc. A special reverse opening
tion (26, 27). The first laser discectomy in man was forceps can be used for removal of the nucleus from the
carried out in 1986 by Ascher and Choy (28). In 1987, posterior part of the disc. The instrumentation includes
Choy et al. (29) reported on the results of percutaneous automated resectors connected to a high-power suction
laser discectomy in 12 patients treated with Nd: YAG device, which cut the disc tissue, sucking up the tissue
1064 nm laser. Over the next 3 years, Ascher and Choy fragments and, thus, allowing a more rapid discectomy
treated 377 patients with the same type of laser, using (72,73).
primarily a wavelength of 1320 nm (28). In those same Endoscopic instrumentation for PED includes rigid
years, Mayer et al. (118) carried out experimental stud- optical systems (0°, 30°, 70° and 90°), which allow
ies on the effects of Er: YAG 2940 nm laser on disc tis- inspection of a large portion of the cavity created
sue, whereas other authors began to use different laser within the disc (Fig. 15.23). The light source and the
systems, such as XeCl-Excimer 308 nm (186), Ho: YAG TV monitor are identical to those used for arthro-
2100 nm (7) and KTP 532 nm (37, 126). scopy. The optical systems, 2.7 mm in diameter, are
introduced into the working sleeve, which allows
both irrigation and suction.
Manual percutaneous discectomy
Types and terminology Technique
Percutaneous excision of nucleus pulposus can be The procedure is carried out in the operating room,
carried out without or with the use of an endoscope. under sterile conditions. The patient can be placed in the
The former procedure, which is scarcely used now- prone or lateral decubitus position. The latter position
adays, has been referred to as manual percutaneous can be used for discectomy without discoscopy or endo-
discectomy, percutaneous discectomy or percutaneous scopic discectomy with intermittent discoscopy, when
nucleotomy. The latter, in turn, has been termed percu- the disc is approached on only one side. For a bilateral
taneous nucleotomy with discoscopy, endoscopic approach, (if bilateral PD, or PED with continous
microdiscectomy, endoscopic nucleotomy or endo- endoscopy, are performed) the patient should be placed
scopic percutaneous discectomy. in the prone position. We use this position also for a
We prefer the term percutaneous discectomy (PD) for unilateral approach, since it is more comfortable for
the former technique and percutaneous endoscopic the patient, who can better tolerate a long procedure.
discectomy (PED) for the latter. The patient is positioned with the hips and knees flexed
at 30°, by means of pillows placed ventrally and/ or
Instrumentation by bending the operating table in order to reduce
lumbar lordosis. Antibiotic prophylaxis is carried out,
The instrumentation for PD includes instruments to generally with third generation cephalosporins. The
approach the disc and instruments for discectomy. procedure is performed under local anesthesia.
__________________________ 0 Percutaneous treatments 0405
Results
continuous discoscopy, the disc is approached bilater- cases with failure of PO, surgical discectomy was car-
ally, using one working cannula for discectomy and the ried out within 1 year of percutaneous treatment. In
other for endoscopy (Figs. 15.28 and 15.29). Usually, it another study (80), 50 patients with L4-L5 disc hernia-
is sufficient to perform a discontinuous discoscopy, tion were followed for 10 years. In 86% of cases, pain
associated with fluoroscopy to check the location of the and sensory disturbances disappeared, but only one of
end of the forceps within the disc space. the eight patients with motor deficit had complete reso-
lution of the deficit. No patients were subsequently
submitted to surgery and all returned to previous levels
Early postoperative treatment of physical activities. Hijikata (77) reported on the
results of PO in 136 patients treated over a 12-year
This is similar to that performed after automated period. Outcomes were excellent or good in 72% of
percutaneous nucleotomy. cases and fair or poor in 28% of patients, 19% of
408.Chapter 1 5 . - - - - - - - - - - - - - - - - - - - - - - - - - - -
Laser discectomy
Lasers
D Absorption
•
~ Reflectio n
80 Scattering
%
70
60
50
40
30
20
10
0
XeCI KTP Nd:YAG Nd :YAG Ho :YAG
Fig. 15.30. Absorption, reflection and scattering of various lasers by degenerated disc tissue.
Lasers for percutaneous nucleotomy of this laser is thermic. Disc tissue exposed to 0.5 sec
pulses of 15 watts shows areas of thermal damage of
Ultraviolet wavelengths less than 0.9 mm in width. In clinical practice, 0.2 sec
pulses of 12 watts, emitted at intervals of 0.5 sec, are
XeCI-Excimer 308 nm. The Excimer (EXCIted diMERs) currently employed, using 400-600 micrometer optic
laser is a gas-pulsed laser, which emits light at wave- fibers.
lengths between 157 and 351 nm. The laser medium is a
mixture of halogen with an inert gas (e.g. xenon/ chlo-
ride, argon/ fluoride). The most commonly used wave- Infrared wavelengths
length is 308 nm, emitted by the XeCl-Excimer laser.
Due to the high energy density which is achieved on the Neodymium: YAG 1064/1318 nm. This is the most
tissue surface, this laser light initiates the non-linear widely used medical laser system. The laser wave-
process of photoionization; this means that the molecu- lengths of 1064 or 1328 nm are emitted by neodymium
lar bonds of the tissue are disrupted and the irradiated embedded in an yttrium-aluminum-garnet crystal. The
tissue is ablated in a microexplosion. Since the ablation absorption of these wavelengths by biological tissues is
process proceeds very rapidly, there are virtually no low. The scattering effect is thus pronounced and leads
thermal side-effects. This is the main advantage of this to a distribution of the applied energy throughout the
type of laser. The disadvantages are the low radiation tissue. Penetration in the cartilaginous tissue can reach
power (which makes the ablation process time-con- 6 mm in depth. However, with controlled application of
suming), the mutagenic and carcinogenic potential, powers between 20 and 40 watts and pulses of 0.05-0.1
and the high cost. For these reasons, few clinical appli- sec, the coagulation zone can be reduced to 0.6 mm,
cations have been reported. using a contact probe. Experimental and clinical studies
have shown that this laser is effective in coagulating
and removing lumbar disc tissue. Its advantages are:
Visible wavelengths fiberoptic delivery, possibility of using in dry and
acqueous media, and ability of coagulation and hemo-
KPT 532 nm. The device uses a potassium titanyl phos- stasis. The disadvantges consist in heat generation and
phate crystal to produce laser light which is visible energy transmission through the tissue, risk of tip
(green), with a wavelength of 532 nm. Since the nucleus breakage and high costs, which, however, have
pulposus has no absorption peak at 532 nm, the action decreased in recent years.
410.Chapter 15.-------------------------------------------------------
Holmium: YAG 2100 nm. This is a pulse near-infrared the disc or it may be used on its own. The laser applica-
laser, which produces light with a wavelength of 2100 tor is passed through the guiding sleeve and advanced
nm. It is absorbed mainly by tissue water. This laser until it reaches the center of the disc and / or the posteri-
delivers 400 microsec, 0-2 Jpulses, at a repetition rate of or portion of the disc space, checking its position by
1-20 Hz. The application on cartilaginous tissue leads fluoroscopy. The applicator can be rigid or flexible
to its instant vaporization. The thermal effects are less (Figs. 15.31 and 15. 32). With the flexible instrument,
marked as compared with those of the Nd:YAG lasers. the posterior portion of the disc is more easily reached.
The reported clinical applications in arthroscopic Discectomy may be performed without or with
surgery and percutaneous discectomy are as yet limit- endoscopy. The latter allows the position of the applica-
ed, but promising. The main advantages are: fiberoptic tor, and particularly the completeness of discectomy, to
delivery, use in dry and aqueous media, limited zone be checked (Fig. 15.33). The optimal instrument is a
(0.4-0.6 nm) of thermal lesion in cartilaginous tissues, laser applicator which includes a deflectable arm for
possibility of hemostasis, coagulation and vaporization. the quarz fiber, two suction and irrigation openings
The disadvantages are still the high cost and the low and a 70° angled optical system (Fig. 15.34). The use of
power range, which may prolong surgery. laser does not expose to greater risks than the flexible
forceps for manual discectomy, since the tissue is co-
Erbium: YAG 2940 nm. This is a solid laser, which agulated or ablated for a very limited extent.
contains ions of the element erbium, embedded in an
yttrium-aluminum-garnet crystal. It delivers micro-
pulses of laser light with a wavelength of 2940 nm, Results
a duration of 1-340 microsec and an energy density
which can reach 500 mJ /mm2 • The ablation threshold In a series of 333 patients with contained disc hernia-
for nucleus pulposus is 7 mJ / mm2; 5 grams of tissue can tion submitted to percutaneous laser discectomy using
be ablated in 30 minutes, with a peripheral zone of ther- Nd: Yag 1060 nm or 1320 nm, who were assessed after a
mal lesions of less than 0.5 mm. Despite these preroga- mean of 26 months (28), satisfactory results were
tives, this laser is not used at present in endoscopic observed in 78% of cases; in 63% of these, pain was
techniques, since no safe and adequate flexible means relieved or resolved during the procedure. Some one
of light transmission is as yet available. third of the MRI studies performed 4-6 months after
the procedure reveled a slight to moderate decrease in
size of the herniation. Mayer et a1. (117) assessed their
Surgical technique
first 40 patients treated with laser at least 2 years after
The laser may be used at the end of manual percuta- treatment. The patients had a L4-L5 or L3 L4 disc herni-
neous discectomy to remove the posterior portion of ation responsible for lumboradicular pain, and some of
them reported sensory deficit (25) or mild motor loss
(3). In 77% of cases, radicular pain had disappeared
and no patient had motor deficits. In four cases,
microdiscectomy was subsequently carried out due to
persistence or recurrence of radicular symptoms.
However, Matthews et a1. (114) found that, whilst at
3-month follow-up 81% of patients treated with KPT
532 nm had a satisfactory outcome, at 2-year follow-up
the success rate had dropped to 55%, and 35% of
patients had undergone surgery.
In a multicenter study (131), 164 patients were evalu-
ated 1 year after treatment by means of a questionnaire.
In this retrospective analysis, it was found that only in
41 cases were all the criteria for the indication to
laser discectomy satisfied (radicular pain, neurologic
deficits, contained herniation at discography, absence
of stenosis or spondylolisthesis); of this group of
patients, 70% had a satisfactory outcome. In the group
in which the selection criteria were not satisfied, the
percentage of successes was 28%, whilst of the patients
who could not be assigned to one or other of the
Fig. 15.31. Rigid laser applicator placed in the L4-L5 disc. groups, 55% had a satisfactory outcome.
__________________________ 0 Percutaneous treatments 0411
Fig. 15.34. 5.4 mm wide laser applicator with suction and irrigation
tubes and endoscope with 70 0 vision angle.
whom KTP 532 nm laser had been used, all followed for
1 year after treatment. The percentage of successes was
70% in the former group and 75% in the latter. In this
group, the satisfactory outcomes had decreased to 72%
at 2-year follow-up.
Complications
Classification
Fig. 15.32. Fluoroscopic view of aflexible laser applicator placed in the
disc. The possible complications of PD, PED or laser discec-
tomy may be classified as intraoperative and postoper-
ative, both including complications related to the
surgical procedure and general complications (118).
The intraoperative complications depending upon
the procedure are either related to the disc approach
or to discectomy, and they may be correlated to the
surgical technique or the instrumentation. The general
complications are usually due to patient positioning or
anesthesia, or may be represented by allergic reactions
to the contrast medium.
The postoperative surgically-related complications
may be specific, when associated with the technique of
discectomy (hematoma of psoas muscle or retroperi-
toneal hemorrhage) or aspecific, such as spondylodisci-
tis. General complications refer to those associated
with the entire surgical procedure (e.g., cardiovascular
problems).
Analysis of complications
SURGICAL TREATMENT
F. Postacchini, G. Cinotti
to the new situation and, when the acute radicular symptoms in a different dermatome than expected,
inflammation has subsided, the radiated symptoms based on the level of herniation (for example, anterior
may gradually disappear, even if moderate compres- thigh pain in the presence of herniation of the fifth lum-
sion of the nerve root persists. 3) Presence of nerve-root bar disc). In these conditions, further investigations
canal, or central spinal canal, stenosis. The chances of should be performed, but, anyway, the indication for
spontaneous resolution of symptoms are significantly discectomy should be considered with caution. 5) In
higher if the size of the spinal canal is normal. The ner- patients whose radiated pain is confined to the buttock,
vous structures, in fact, may more easily escape com- who very often are not good candidates to discectomy.
pression by a herniated disc in the presence of a large The latter is rarely indicated in patients complaining
reserve space in the spinal canal. 4) Quality and severi- of only low back pain, in whom fusion of the motion
ty of symptoms. Surgery is more indicated in patients segment should be considered in case there was an
with severe, exclusively radicular, pain than in those indication for surgery.
with moderate low back and leg pain, since in the for-
mer, symptoms are less likely to resolve spontaneously
and the results of surgery tend to be better.
The presence of a mild or moderate motor deficit Planning of surgery
does not necessarily affect the indication for surgery or
conservative management, since the chances of resolu- Disc herniation at two levels
tion of the deficit are similar with the two types of
treatment. With the advent of CT, and even more of MRI, patients
Surgery should be performed in all patients with a are frequently observed presenting a herniated disc at
relative indication when no significant improvement two, usually adjacent, levels, on the same side or oppo-
has been obtained with conservative care. The duration site sides. The problem of planning of surgery general-
of the latter has not been well defined; however, in most ly arises when both herniations are on the same side.
cases, it should not be less than 2-3 months, since it is in In the majority of patients, one of the herniations is
this interval that an improvement in symptoms usually contained and small in size, and clearly asymptomatic;
occurs. Patients who do not improve considerably after as such, it should not generally be excised (Fig. 16.1). In
this period have fewer chances of achieving an ade- a minority of cases, there may be some doubt that both
quate resolution of symptoms with increasing time. herniations are symptomatic on account of their site,
The risk of waiting too long is to find a patient who still type and/ or dimensions (Figs. 16.2 and 16.3). In gener-
has so severe pain as to make him dissatisfied and al, an acute or subacute lumboradicular syndrome is
unable to work, but not so severe as to make surgical caused by a single herniated disc and only this should
management strictly necessary. be removed, particularly when one of the herniations is
of large dimensions and / or extruded or migrated,
whilst the other is small and contained, and there is no
Contraindications clinical evidence that the smaller herniation is responsi-
ble for nerve-root compression (Fig. 16.4). The choice to
The only absolute contraindication is represented by carry out operative treatment only at one level may
disc herniations discovered incidentally in asympto- lead to the risk of leaving a symptomatic condition
matic subjects. The other contraindications are relative. untreated. When such a risk appears to be high, discec-
Discectomy is generally contraindicated in five situa- tomy should be performed at both levels. When this is
tions: 1) When the only clinical abnormality is a mild or not the case, surgical treatment should possibly be lim-
moderate motor loss. However, even when weakness is ited to only one disc for several reasons: operative time
severe, surgery is rarely indicated. The same holds for is shorter and postoperative recovery faster; postopera-
sensory deficits, which usually disappear spontaneous- tive low back pain tends to be milder; the spinal canal is
ly with time. 2) In patients with psychologic disorders not invaded by scar tissue, which may lead to radicular
or legal controversy, unless a clear-cut and severe symptoms not present preoperatively; and the risk is
organic pathologic condition is present. Even in this avoided of recurrent herniation at the asymptomatic
instance, however, the result may not be satisfactory. 3) level. Furthermore, it should not be forgotten that the
When disc pathology is bulging of the annulus fibrosus. asymptomatic disc herniation may undergo sponta-
This rarely requires discectomy, unless the spinal canal neous regression over the months or years following
is narrow or stenotic, since in this event, particularly in surgery (Fig. 16.2); and that it is very unlikely for a
the presence of nerve-root canal stenosis, annular small contained or extruded herniation, asymptomatic
bulging may cause significant nerve-root compression. at the time of the first operation, to become subse-
4) In the presence of vague radicular symptoms, or quently symptomatic.
____________________________ 0 Surgical treatment 0421
Occasionally, both disc herniations are clearly symp- originates from the closest interspace and may, thus,
tomatic; this occurs, for instance, when they are located be more easily removed by exposing the latter; the disc
on opposite sides and the patient complains of bilateral of origin often presents a moderate protrusion, which
symptoms which correspond to the site of the hernia- needs to be excised (Fig. 16.5).
tions. In these cases, there is generally no doubt A disc fragment migrated into the intervertebral
concerning the need to excise both herniations. foramen originates almost consistently from the disc
below and laminotomy should, therefore, be per-
formed at this level and extended proximally. In those
Migrated herniation rare cases in which the fragment rises as far as the cra-
nial part of the foramen or medially to the caudal end of
In the presence of a migrated disc herniation, laminoto- the pedicle of the vertebra above, there may be some
my should be performed at the intervertebral level doubt as to whether laminotomy should be carried out
from which the disc fragment originates. There are two at the intervertebral level above the involved neuro-
reasons for this choice: the disc fragment usually foramen and extended downwards. Such an approach,
16.-----------------------------
Bilateral syndrome
A B c
Fig. 16.6. MR images and radiograph of a patient who had undergone surgical removal of right midline-paramedian disc herniation responsible
for radicular pain prevalently on the left. (A) Spin-echo Tl-weighted sagittal image showing a large extruded disc fragment at L3-14 level (arrow).
(B) Spin-echo Tl-weighted axial scan showing a midline and right paramedian herniation and a narrow spinal canal (arrow). (C) Postoperative radio-
graph showing the laminotomy (arrows) through which the herniation was excised with complete resolution of symptoms.
small amount of disc tissue is removed by discectomy There is no doubt concerning the choice of the side
on one side. when disc herniation is located on the side where the
In the rare cases of bilateral disc herniation, discecto- radicular syndrome is more severe. When the signs
my should generally be performed on both sides. This and symptoms prevail on the opposite side to that on
holds particularly when on the side with milder symp- which the herniation is located, or located to a larger
toms, these are moderate or severe, or in the presence of extent, laminotomy should generally be performed on
a narrow spinal canal. that side (Fig. 16.6). In fact, the greater severity of the
In patients with a retroligamentous or transligamen- clinical syndrome usually indicates that the nervous
tous disc herniation, or a disc fragment migrated in structures are more severely compressed, and that the
the midline or centrolaterally, a unilateral approach is disc fragment is located, at least to a large extent, on
usually adequate, since the disc fragment can almost that side. When, operating on this side, the herniation
always be removed by operating on one side only. cannot be completely excised, or doubts exist on the
424.Chapter 1 6 . - - - - - - - - - - - - - - - - - - - - - - - - - - -
complete removal of the extruded or migrated disc tis- 2% carbocain or 1% xylocain. Prior to sectioning the
sue, contralateral laminotomy should be carried out. thoracolumbar fascia, the entire thickness of the para-
vertebral muscles are infiltrated. When a Taylor retrac-
tor is used, both the muscles lateral to the facet joints
Central laminectomy and the joint capsule are injected, after muscle detach-
ment. Once the spinal canal is opened, local anesthetic
Central laminectomy may be indicated when disc is instilled on the posterior epidural tissue, the emerg-
herniation is associated with stenosis of the spinal ing nerve root and, after retracting the laUer, the anteri-
canal (page 541). Other conditions in which central or portion of the spinal canal. If the patient complains of
laminectomy may be planned are: a cauda equina syn- pain on retraction of the nerve root, 0.5 ml of anesthetic
drome, and intradural herniation. In the former, central are injected into the subdural space, at the level of the
laminectomy should be performed to be certain that proximal portion of the root, using a 30 G needle.
complete decompression of the neural structures is Excision of disc herniation does not usually cause any
obtained; in the laUer, disc herniation has very often to pain. If this occurs, a small amount of anesthetic is
be removed through an intradural approach and this instilled into the disc. The total amount of anesthetic
may be done only by a central laminectomy. should not exceed 25 ml in a patient of medium body
weight.
of a long surgical operation, the antibiotic should be line is traced on the skin, at the level of the interspinous
administered again if its halflife in the blood is shorter space, using a dermographic pen. The alternative is to
than the operation itself. use the small saw employed to cut the neck of medici-
Antibacterial prophylaxis is of paramount impor- nal vials.
tance in diabetic patients, in whom the most adequate
prophylaxis is represented by the association teico-
planin-gentamicyn, administered before anesthesia
is induced. Preoperative fluoroscopic identification
After skin disinfection, the surgeon manually identifies
Identification of pathologic level the intervertebral level involved and inserts a 20 G
spinal needle vertically, in close proximity to the distal
Preoperative manual identification spinous process. Use of sterile gloves allows the inter-
spinous space and the proximal margin of the distal
Palpation of the interspinous spaces allows, in many spinous process to be palpated with the left hand, while
cases, identification of the intervertebral level where introducing the needle with the right hand. The fluoro-
the herniation is located, particularly when this is the scope is positioned so as to obtain a lateral view of the
fourth or fifth lumbar interspace. The surgeon, before lumbar spine, and the position of the needle is checked.
draping the surgical field, stands on the patient's left The latter should be pointed towards the proximal end-
side and, while grasping the iliac crest with the left plate of the vertebra below the disc involved (51) (Fig.
hand (when right-handed), palpates first the middle 16.10). In this case, it is difficult, at the time of surgical
sacral crest and then the lumbar interspinous spaces exposure, to slide into the interlaminar space above or
with the right hand (Fig. 16.9). The middle sacral crest below. Conversely, when the needle is inserted into the
is usually felt as a continuous bony prominence, at the proximal portion of the interspinous space and its tip is
cranial end of which, the depression of the lumbosacral directed towards the lower end-plate of the proximal
interspinous space is found. The latter is, at times, nar- vertebra, it is easy, during surgical exposure, to slide
rower than the upper spaces. The bony prominence of inadvertently into the interlaminar space cranial to the
the L5 spinous process, and then the successive depres- required interspace. If the needle appears to be located
sion, are palpated proximally to the lowest inter- too proximally, it should be inserted more distally and
spinous space. its position checked again.
For identification of the interspinous processes, it is
useful to examine an anteroposterior radiograph of the
lumbar spine including the entire iliac crests in order to
detemine the vertebral level to which they correspond.
In most subjects, the iliac crests correspond to the L4-L5
interspinous space. In many subjects, however, the
crests are slightly above or below the fourth lumbar
disc, and this should be known while checking the posi-
tion, with respect to the iliac crests, of the interspinous
space detected by palpation.
In nonobese patients, particularly if young and with
no lumbosacral transitional anomalies, it is generally
easy to identify the intervertebral levels by palpation.
This may be difficult in obese subjects, since the level of
the iliac crests may appear to be more cranial, on
account of the fat layer that the palpating hand encoun-
ters above the crests. Errors in the identification of the
vertebral levels may easily occur in the presence of lum-
bosacral bony anomalies and in patients with narrow
interspinous spaces due to hyperlordosis, ossification
of the interspinous ligaments or marked loss of disc
height. Furthermore, the more proximal the pathologic
Fig. 16.10. Preoperative fluoroscopic identification of the involved
vertebral level, the greater the chances of mistakes. interspace. To decrease the risks of slipping into the interspace above or
Once the pathologic level has been identified, and below, the needle tip (arrowhead) should be directed towards the proxi-
following disinfection of the surgical field, a transverse mal end-plate of the vertebra below the disc to be explored.
428.Chapter 1 6 . - - - - - - - - - - - - - - - - - - - - - - - - - -
In patients with lumbarization of the 51 vertebra, In general, it is preferable to make the intraoperative
the L4-L5 interlaminar space corresponds to that check, rather than to begin laminotomy with the risk of
which, in normal conditions, is the L3-L4 or L4-L5 a mistaken identification of the interlaminar space. In
space, depending upon whether or not an 51-52 inter- fact, the waste of time that the check involves is repaid
laminar space exists. by the ease of mind with which the surgeon operates,
the time that is saved in the event the surgeon has
mistaken the level and realizes the error during the
L3-L41evel
operation, as well as the advantages for the patient
When conventional discectomy is carried out, the skin by avoiding a useless laminotomy.
In a few cases, it may be more useful to decide not to
incision may be prolonged downwards as far as the 51
carry out the preoperative control and to perform only
lamina to identify the two lower interlaminar spaces.
This, however, should be avoided if possible, since it the intraoperative. This choice may be made when
there is the certainty, or likelihood, of doubts in the
implies extensive vertebral exposure.
identification of the pathologic level. This occurs partic-
Usually, the L3-L4 interspinous process is the first to
ularly in patients with severe spondylotic changes and
be encountered proximally to the iliac crests. Palpation
considerable narrowing of the interspinous and inter-
of the latter, and simultaneous evaluation of the posi-
laminar spaces. In these cases, the intervertebral level
tion of the third interspinous space compared with
presumably involved is identified before skin incision
the iliac crest on the anteroposterior radiograph of
and, once the interlaminar space is exposed, fluoro-
the spine, may allow us to check whether the exposed
scopic control is carried out. By thus doing, it is possible
interspinous space is the third lumbar; having done
to avoid preoperative fluoroscopic control, but one
this, the lateral aspect of the spinous processes is
runs the risk of having to prolong the skin incision in
followed to identify the corresponding laminae. This
case of error in the manual preoperative identification
method, however, is open to error, especially in obese
of the intended interspace.
patients or in those with narrow interspinous spaces.
The L3-L4 interlaminar space is generally more elon-
gated in the vertical direction than the space below, and
this should be recognized on the anteroposterior radi- Definition of terms
ograph. If the surgical findings do not correspond to the
Numerous terms are used to indicate the various stages
radiographic picture, one should suspect the wrong
level having been exposed. 5imilarly, when the Taylor of excision of a lumbar herniated disc or decompression
retractor is used, one should cast some doubt that the of the nervous structures in a stenotic spinal canal. A
same term is often used to indicate different procedures
exposed level is the third lumbar, if retraction of the
paraspinal muscles requires a similar weight to that or several terms are used for a same procedure.
Conventional or standard discectomy is the opera-
usually necessary for the subjacent levels or a much
tion for removal of disc herniation accomplished with
lower weight, as occurs for the L2-L3level.
the naked eye. Microdiscectomy is the operation car-
ried out using the operating microscope, regardless of
Intraoperative fluoroscopic identification the width of the interlaminar access to the vertebral
canal and radicality of discectomy.
Occasionally, once the interlaminar space has been The term laminotomy means removal of part of a
exposed, some doubts may arise concerning the correct lamina. The term is generally used to indicate the
identification of the pathologic level. This may easily approach to the spinal canal through a very limited
occur in one or more of the following circumstances: excision (not more than one third) of the two adjacent
obese patients; herniation of the second or third lumbar laminae; usually, the procedure implies removal also of
disc; interlaminar spaces abnormally narrow or orien- the most medial portion of the articular processes. The
tated more vertically than normal; laminae with very same procedure is referred to as interlaminar fenestra-
transverse (vertical in the surgical field) orientation. In tion (4).
these cases, before proceeding with laminotomy, it may The term hemilaminectomy is used to indicate, at
be useful to check, by means of fluoroscopy, that the times, the removal of the whole lamina on one side and,
exposed intervertebral space is the intended inter- at others, of the cranial or caudal one half of the lamina
space. As for the preoperative control, a spinal needle is on one side. 5ince one vertebra has two laminae, exci-
inserted into the interspinous space and its position sion of the entire lamina on one side should be referred
is checked with the fluoroscope. Alternatively, (or in to as laminectomy. The term hemilaminectomy should
addition), a dissector is placed on the ligamentum be used, as is generally the case, to indicate removal of
flavum and maintained by means of cotton swabs. one half, or a large part, of two adjacent laminae, even if
430.Chapter 1 6 . - - - - - - - - - - - - - - - - - - - - - - - - - - -
this use is incorrect, because the term refers to a single ner) and deep hand-held retractor (such as
lamina. The expression partial hemilaminectomy, Mathieu).
rarely used, should indicate a similar procedure to 3. A periosteal elevator 2 em in width. A too narrow
laminotomy. elevator exposes to the risk of inadvertently perfo-
Excision of the laminae of a vertebra may be called rating the ligamentum flavum.
bilaminectomy (2) or bilateral laminectomy. The proce- 4. Straight curettes with a long shaft and large (1.3 em),
dure is also indicated as central or complete lami- medium-size or small (3 mm) cup.
nectomy.
5. 0.5-1.5 em large osteotomes.
The term foraminotomy indicates removal of a part
of the posterior wall of the intervertebral foramen, 6. Bayonet forceps.
whilst the term foraminectomy refers to complete exci- 7. Bone rongeurs with straight or angled, medium-
sion of the wall of the foramen. size, cutting cups.
Facetectomy consists in the resection of the articular 8. Kerrison rongeurs with small (2 mm) medium-size
facets of the zygoapophyseal joints. The term, however, (3 or 4 mm) or large (5 mm), 90° or 45° angled, for-
is generally used to indicate removal of the articular wards or backwards angled, bite.
processes, at the end of which the facets are located (2). 9. Deep self-retaining retractor. We use Taylor retrac-
It is synonymous of the term arthrectomy, which is tors of three widths (1.3 em, 2 em and 3 em), to
anatomically more correct. which a weight of 1.8 or 2.3 kg is hung (Fig. 16.11).
10. Basket cutter for arthroscopic meniscectomy with
90° angled bite, used to cut the ligamentum flavum
(Fig. 16.12).
Conventional discectomy
11. Medium-size and small suckers.
Indications 12. Pituitary rongeurs with varying size, straight, 30°
or 45° forwards angled, and 30° backwards angled,
The conventional procedure is indicated in any patient bite.
with a herniated disc. It is also the only possible proce- 13. Blunt dissector, such as Freer dissector (Fig. 16.13).
dure when an arthrodesis of the motion segment is per- If used to retract the neural structures, the retractor
formed in association with discectomy or when, in the should not be too narrow (less than 4 mm) in order
presence of lumbar stenosis, bilateral laminectomy has not to traumatize the nerve root, or too wide (more
to be carried out prior to discectomy. Furthermore, the than 6 mm) not to hinder the surgical maneuvers.
conventional modality may be the procedure of choice The working end of the dissector should be only
in patients with disc herniation at multiple levels or a slightly curved forwards.
recurrent herniation. In the latter case, it may, at times,
be indicated to start the operation with the naked eye
and use the operating microscope only when the neur-
al structures are visualized. The advantage of perform-
ing surgery with the naked eye is to have a paramount
vision of the surgical field and the anatomic structures,
and this, at times, may make the surgical maneuvers
considerably easier. The conventional operation, on
the other hand, does not necessarily imply a large
exposure of the spine and a large laminoarthrectomy,
even if discectomy performed with the naked eye
through a limited approach may be more difficult
than microdiscectomy.
Surgical instruments
Surgical technique
Fig. 16.15. Detachment of the ligamentum flavum using a small curette Fig. 16.16. Removal of the caudal end of the proximal lamina using a
inserted beneath the caudal end of the proximal lamina. Kerrison rongeur.
- _ - - - - - - - - - - - - - - - - - - - - - - - - - 0 Surgical treatment 0433
resect the medial one third or one half of the inferior
articular process of the vertebra above. The ligament is
then detached and laminotomy carried out, if this is
easy, or, still with the use of the osteotome, the distal
one third of the proximal lamina is removed (Fig.
16.17). The use of the osteotome in resecting the inferior
articular process does not usually imply any risks, due
to the protection provided by the superior articular
process of the distal vertebra. Similarly, excision of the
distal portion of the lamina implies little risk of damage
to the neural structures due to the presence of the
underlying ligamentum flavum.
A B
Fig. 16.19. Removal of the lateral portion of the ligamentum flavum following its longitudinal section. (A) The ligament is raised with a Frazier probe
and sectioned with a scalpel. (B) The ligament is grasped by aflap; this allows exposure of the epidural fat and fast completion offlavectomy.
Fig. 16.23. Frazer probe used to detect whether migrated disc fragments
are present beneath the thecal sac and emerging nerve root.
Fig. 16.22. Frazier probe may be used to break the most medial portion Fig. 16.24. The Frazier probe, introduced into a narrow or stenotic
of the annulus fibrosus. This allows the herniated tissue to be mobilized, radicular canal, may help to determine whether there is enough space for
pushed into the disc and then removed with the pituitary rongeur. the nerve root or whether the radicular canal should be opened.
438.Chapter 1 6 . - - - - - - - - - - - - - - - - - - - - - - - - -
necessary, opening of the canal until a complete latter bulges excessively or extruded disc fragments are
foraminectomy is performed should be avoided, since found. Care should be taken, however, not to damage
this decreases vertebral stability. the cartilage end-plates. This procedure, which is inter-
mediate between radical and partial discectomy,
enables the drawbacks of the latter types of discectomy
Radical or partial discectomy ? to be avoided and adequate disc excision to be accom-
plished.
Radical discectomy consists in the removal of all the In our opinion, radical discectomy should be avoid-
contents of the disc, i.e., the nucleus pulposus and the ed, since the potential drawbacks are more numerous
inner portion of the annulus fibrosus, that can be than the advantages. Partial discectomy may be indi-
reached with the pituitary rongeur, as well as the medi- cated in patients with a large extruded or migrated disc
an posterior portion of the annulus fibrosus, which fragment and a small amount of nuclear tissue within
may be cut with a scalpel or ruptured by means of the the disc. In the other cases, complete discectomy should
Frazier probe. In addition, curettage of the cartilage be preferred. This holds particularly for patients with
end-plate may be carried out (21). midline disc protrusion and those with only slightly
The aim of partial discectomy is to remove only that degenerated nucleus pulposus, who often show
portion of the disc impinging on the emerging nerve marked annular bulging. In these patients, only ade-
root (35, 74). The procedure may be accomplished in quate excision of disc contents gives the surgeon the
one of two ways: only the extruded disc fragment, or certainty of complete removal of the tissue which may
the portion of the disc protruding beneath the annulus impinge on the neural structures.
fibrosus, may be excised; or also a limited amount of the
nucleus pulposus located in the central area of the disc
space may be removed. Migrated herniation
Radical discectomy has several drawbacks: it length-
ens the operative time, it may compromize the stabiliz- The disc of origin of the migrated fragment is usually
ing function of the disc and favor a decrease in disc the closest to the fragment itself, and this disc should be
height, and it appears to increase the severity of post- exposed before searching for the migrated tissue.
operative low back pain (6). Furthermore, radical disc In the presence of a migrated disc fragment of large
excision increases the risks of infectious complications size, the disc of origin may be evacuated, or only the
due to lengthening of the operative time and removal of migrated fragment may be removed, with the advan-
the cartilage end-plates, which allows possible penetra- tage, in the latter instance, of decreasing the operative
tion of bacteria into the bone tissue. This may occur time and preserving, to a larger extent, vertebral stabil-
even when no curettage of the cartilage is carried out, ity. In our opinion, discectomy should always be car-
since radical excision of disc contents easily produces ried out, for several reasons. The disc often presents
interruptions in the cartilage layer. Radical discectomy, slight or moderate posterior bulging or protrusion,
on the other hand, ensures a better guarantee of not which may be responsible for persistent compression of
leaving residual portions of disc tissue, which may be the neural structures (Fig. 16.25). Evacuation of the disc
responsible for persistent compression of the neural often helps to identify and remove the migrated frag-
structures. On the other hand, it is unknown whether ment, if this is located in proximity to the disc.
there are fewer risks of recurrence of the herniation at Occasionally, in addition to the migrated fragment,
medium or long term. extruded disc fragments are present, which may be
With partial discectomy, portions of the nucleus pul- excised only by discectomy. One often suspects the
posus possibly impinging on the nerve structures may presence of a migrated fragment, but has no certainty
not be removed, particularly in the median or parame- preoperatively; discectomy may eliminate the suspi-
dian posterior zone of the disc. We have experience of cion, or provide the certainty, that a migrated fragment
many cases where only a tenacious search for possible is present when the disc contents are negligible. In these
extruded disc fragments allowed detection and removal cases, however, discectomy may even be partial.
of large pieces of disc tissue, generally situated in the The search for migrated fragments which do not
midline. It is not yet clear, however, whether partial dis- appear evident at first inspection, and of which the
cectomy involves (66) or not (6) a higher risk of recur- exact site is unknown preoperatively, should be made
rence of herniation compared with radical disc excision. sistematically. The first sites to be explored are those
A third type of discectomy, which may be referred to where a migrated fragment is more often located, i.e.,
as complete, consists in excision of all tissue contained the spinal canal beneath the emerging nerve root and
in the central and posterolateral portion of the disc, and the central portion of the canal distally to the disc.
removal of the middle posterior portion only when the Subsequently, the nerve root axilla and the area behind
__________________________ 0 Surgical treatment 0439
the cranial vertebral body are explored. To do this, dissect the thin fibrous sheath which usually envelops
laminotomy should be extended proximally and distal- the migrated tissue, until it is ruptured. At this point,
ly until we are sure, based on the preoperative investi- disc tissue is seen to emerge, which may be freed from
gations, that the spinal canal has been explored for an the surrounding adhesions and excised. Occasionally,
adequate extension (Fig. 16.25). The exploration is car- the migrated fragment is in continuity with the disc of
ried out with the help of the dissector and the Frazier origin and cannot be removed by grasping and pulling
probe. the portion situated in the nerve-root axilla. In these
The most difficult site to explore is the nerve-root cases, attempts are made to dissect the tissue connect-
axilla. To explore this area, first the nerve root and then ing the fragment to the disc with the use of the probe. If
the tissue separating it from the thecal sac are identi- this is not possible, the annulus fibrosus is sectioned in
fied. In normal conditions, this tissue consists of close proximity to the vertebral end-plate and pushed
epidural fat. In the presence of a migrated disc frag- down with the probe until it breaks.
ment, it is usually impossible to clearly identify the The second most difficult site to explore is that
anatomic limits of the root and the thecal sac, and the behind the median posterior portion of the cranial ver-
nerve-root axilla appears to be occupied by a tissue of tebral body. For exploration of this area, after removal
fibrous consistency and white in color. To verify the of at least one half of the proximal lamina, the sac is
presence of a migrated fragment, attempts are made to retracted as proximally as possible, while the probe is
440.Chapter 1 6 . - - - - - - - - - - - - - - - - - - - - - - - - - - -
moved beneath the sac to palpate and attract any disc particularly on MRI scans, the characteristics of the sus-
fragments possibly present. If necessary, prior to this pected discs and the distance between the fragment
maneuver, the fibrous wall of any possible bulges that and the adjacent interspaces: a disc which is the site of
may appear as migrated disc tissue are ruptured, using herniation is usually degenerated and shows posterior
the tip of the dissector. At the level of the vertebral bulging of the annulus fibrosus on the midline and/ or
body, the posterior longitudinal ligament may give the posterolaterally; a migrated fragment originates almost
false sensation of disc material. However, a tissue frag- always from the closest disc.
ment migrated in this site, is almost consistently of Laminoarthrectomy is performed in the usual man-
large size and it is rarely mistaken with the fibrous bun- ner. After exposure of the involved disc, discectomy is
dles of the posterior longitudinal ligament. carried out. Disc excision may be avoided in those rare
Migrated fragments in other sites are generally easily cases in which the disc shows no posterior prominence
excised. This holds particularly for fragments located and is hard in consistency. However, not to excise the
ventrally or laterally to the nerve root. disc when it protrudes, even slightly, may expose to the
Whatever the location, before grasping and remov- risk of recurrence of herniation posterolaterally or of
ing the fragment, it is wise to expose it as extensively as persistence of radicular symptoms. Once the disc has
possible and grasp a large portion of tissue. In this been evacuated in the central and posterior area, the
instance, the fragment may often be excised intact or nuclear tissue still present in the lateral portion is
almost; if not, it should often be removed piecemeal, removed using a backwards angled pituitary rongeur
with the risk of leaving some portions behind. or a forwards angled rongeur handled in the opposite
direction to the usual.
Intraforaminal and extraforaminal herniations Contained or extruded disc herniation. If disc hernia-
tion is contained or extruded, a discrete or abundant
These herniations may be excised through the usual amount of disc tissue can usually be excised piecemeal
interlaminar approach or through approaches leading or a large fragment of disc may be grasped and
to the outer aspect of the intervertebral foramen with- removed from the most lateral portion of the inter-
out passing through the vertebral canal. Para-articular, space. This may provide the certainty that herniation is
paraspinal and lateral extravertebral approaches have contained or extruded. If this was coincident with the
been described. preoperative diagnosis, there is no need to search for
free disc fragments in the upper part of the neurofora-
men, but the lateral portion of the disc is completely
Interlaminar approach evacuated. To do this, it may be necessary to enlarge
arthrectomy laterally, in front of the disc, until little
The spinal canal is generally entered at the level of the more than one half of the articular processes is resected.
disc of origin of the migrated fragment. When the disc Furthermore, a Frazier probe may be introduced ven-
tissue has migrated very cranially, there may be some trally to the articular processes to push down the later-
doubt concerning the disc of origin. Almost always, al non-visible portion of the disc, and then the pituitary
however, the fragment originates from the disc below, rongeur be used to remove the disc tissue displaced
when it is located, entirely or to a large extent, caudally towards the center of the disc space. This maneuver is
to the pedicle of the proximal vertebra. The fragment repeated several times, using first the short-foot, and
should, thus, be removed through a laminotomy expos- then, the long-foot, probe. The risk, in using the long-
ing the underlying disc. Alternatively, one may start foot instrument, is to damage the nerve root running in
from the intervertebral level above and resect the whole the foramen; this, however, does not occur if care is
distal lamina until the nerve root running in the fora- taken to mantain the foot of the probe in close contact
men is visualized. This procedure should generally be with the disc surface.
avoided, for several reasons: to visualize the area of the Not only intraforaminal, but also extraforaminal disc
foramen caudally to the nerve root contained therein, herniations may be removed through the interlaminar
subtotal or total arthrectomy should be carried out; if access, since a forwards angled pituitary rongeur, used
the disc of origin is that below the disc initially exposed, in the opposite direction to the usual, may reach the
opening of the spinal canal should be prolonged down- outermost part of the disc (Fig. 16.26). Removal of an
wards to evacuate the latter disc; an extensive access to extraforaminal herniated disc, which is generally con-
the spinal canal causes profuse epidural bleeding, tained or extruded, does not require total arthrectomy.
which may make detection of a small migrated frag-
ment exceedingly difficult. To identify the disc of origin Migrated herniation. If preoperative investigations
of the migrated fragment, it may be useful to analyze, demonstrate, or lead to suspect the presence of, a
___________________________ 0 Surgical treatment 0441
Peridural scar tissue originates from the deep surface tive period. The skin is closed with discontinuous
of the paraspinal muscles and, to a lesser extent, from stitches or 4-0 quickly dissolvable subcuticular suture.
the hematoma invading the spinal canal (43); following
discectomy, also the annulus fibrosus contributes to the
formation of scar tissue (36). Postoperative CT scans in Postoperative care
patients with a free fat graft (80) have shown that the
The patient remains in bed, free to assume any position,
graft forms a barrier between the deep surface of the
for 24-48 hours after surgery; if a drain has been
paraspinal muscles and the thecal sac, thus preventing
contact between the scar tissue originating from the applied, this is removed the day after the operation.
muscles and the dural wall. However, the graft does not The patient is then encouraged to get up and walk. This
is advisable soon after surgery as muscle activation
hinder the formation of scar tissue from the deep
hematoma and development of a fibrous membrane decreases postoperative pain and the risks of deep
venous thrombosis in the lower limbs. On the first day,
anterolaterally to the emerging nerve root.
the patient is invited to get out of bed 2-4 times, for a
Fat graft, therefore, undoubtedly makes repeat
few minutes each time, with or without the use of a
surgery easier, but there is no evidence that it improves
walker. The day after, the number of times the patient
the results of surgery as far as concerns the radicular
gets up is increased to a maximum of 6-8. The patient
symptoms. No prospective study, in fact, has compared
is usually discharged on the third or fourth postopera-
the results of surgery in patients with or without a fat
graft. It should be borne in mind, on the other hand, tive day. However, patients complaining of only a slight
that in a thin person the withdrawl of fat may create an low back pain may even be discharged on the second
postoperative day.
empty space subcutaneously, which favors the forma-
tion of serosity in the immediate postoperative period The use of steroids, at high doses (8 mg betametha-
sone) on the first day after surgery and at medium
and may hinder healing of the skin wound; this holds,
doses (3-4 mg) on the following 2 or 3 days, consider-
in particular, when access to the spinal canal has been
extensive. We believe, therefore, that the indication for ably decreases postoperative radicular pain. Subse-
the use of a fat graft is still uncertain and that grafting quently, cortisone may be withdrawn, or continued
should be avoided in the thin patients undergoing at low doses for a few days in patients complaining of
extensive opening of the vertebral canal. moderate or severe radicular pain following surgery.
At home, the patient walks 8-10 times a day for 10
to 30 minutes each time until the eight-tenth postope-
Drain rative day and thereafter at his/her discretion. An
excessive physical activity in this period is discour-
It is not usually necessary to apply a drain. This is use- aged, since it may favor the formation of subcutaneous
ful when there has been profuse bleeding in the deep serosity and delay healing of the skin incision.
surgical field, which continues, even moderately, at the Once the skin wound has healed, the patient starts
time of wound closure. A drain should always be the exercise program.
applied when bilateral laminectomy has been per-
formed. It may be removed after 18-24 hours. Postoperative immobilization
Learning curve
A o.....a....;__ B
c o
Fig. 16.28. Microsurgical view of various stages of discectomy. (A) Exposure of the interlaminar space. The arrow indicates the ligamentum flavum.
(B) Detachment of the ligamentum flavum from the proximal lamina (L). (C) Retraction of the emerging nerve root (asterisk) and exposure of the
herniated disc (arrows). (0) Extrusion of disc tissue (arrows) following disc incision.
B
Fig. 16.30. Microsurgical approach. (A) Use of a 1·3 cm wide Taylor
retractor with a weight hung on the end. (B) Higher magnification view
of the surgical incision and the retractor.
Surgical technique
Laminoarthrectomy
Fig. 16.32. With the microsurgical technique preferred by the authors, Some surgeons excise only the ligamentum flavum or
the thoracolumbar fascia is sectioned in close proximity to the spinous perform a minimallaminoarthrectomy. In this case, the
processes. ligament is sectioned first longitudinally and then
transversely (or viceversa) along the edge of the distal
lamina. The sectioned flap is subsequently grasped and
the ligament is excised using a scalpel or Kerrison
rongeur. Such a limited access to the spinal canal repre-
sents a useless technical virtuosity. It exposes to three
risks: excessive trauma to the neural structures when
retracted medially to carry out discectomy; not to ade-
quately excise the herniated disc or leave residual
extruded or migrated disc fragments; not to sufficiently
decompress the emerging nerve root in the presence of
radicular canal stenosis. Laminoarthrectomy should be
wide enough as to allow easy access to the disc as well
as safe and complete decompression of the neural
structures.
Most of the laminoarthrectomy may be performed
with a high speed air drill (Fig. 16.33). This is generally
used to remove the proximal lamina and the medial
portion of the articular processes, particularly the infe-
rior one.
The technique we prefer is similar to that described
for conventional discectomy. The ligamentum flavum
is detached from the proximal lamina using a small
curette and 5-10 mm of the lamina are resected with
Fig. 16.33. High speed air drill may be used to resect the distal end of the Kerrison rongeurs. Very often, the innermost portion of
proximal lamina and the medial portion of the articular processes.
the inferior articular process is also removed at this
stage. When the interlaminar space is narrow and the
Positioning of microscope inferior articular process is hypertrophic, the medial
part of the process may be resected using an osteotome.
The operating microscope may be used from the begin- Then, again using the curette, the ligamentum flavum
ning of the procedure (3) or, as we prefer, after placing is detached from the distal lamina, which is resected for
the self-retaining retractor. The objective is positioned 5-Smm.
perpendicularly to the surgical wound or is inclined The ligamentum flavum is removed with the
slightly lateromedially if, by doing so, the medial por- Kerrison rongeur or the basket cutter used for arthro-
450.Chapter 16.----------------------------------_________________
scopic meniscectomy, or is sectioned longitudinally. In
the latter case, in order to protect the nerve structures,
the ligament is cut along the foot of the Frazier probe or
a cottonoid is inserted deep into the ligament (55, 85).
The choice of the method will depend, to a large extent,
upon which is easier to perform in that particular case.
For instance, when herniation is on the left, it is often
easier to use the rongeur or the basket cutter than sec-
tioning the ligament with the left hand, while the right
hand raises it with the probe. The opposite occurs when
herniation is on the right.
Arthrectomy is then performed by introducing the
Kerrison rongeur between the residual lateral portion
of the ligamentum flavum and the epidural tissue. Fig. 16.34. Microdiscectomy. Exposure of the herniated disc (arrow-
Ligament excision using the rongeur is easy if the heads) and emerging nerve root (arrow).
instrument has a well cutting bite. Conversely, the liga-
ment should be torn to some extent, with the risk of
tomy (Fig. 16.35}. This site, which we term the "safe cor-
causing dural tears.
ner" of laminotomy, is usually proximal to the zone
Approximately the inner one fourth of the articular
where the root emerges from the thecal sac; thus, the
processes is initially resected. This usually allows visu-
disc is unlikely to be mistaken for the root in this area
alization of the emerging nerve root and exposure of
(Fig. 16.35). The disc is often located more proximal
the disc. If the herniation can be easily excised, as often
than expected and, therefore, it is easier to find it in the
occurs at L5-S1 level, bone removal is stopped.
upper than the lower portion of laminotomy. This
Otherwise, laminoarthrectomy is extended as far as
occurs, in particular, when the portion of the proximal
necessary. Very often, the initiallaminoarthrectomy is
lamina excised is too small or the latter is more caudal
wide enough to carry out discectomy with the straight
than normal with respect to the vertebral body.
pituitary rongeur, but not to use the forwards angled
The surface of the disc is often covered by epidural
rongeur or to introduce the Frazier probe beneath the
fat or fibrous bands obstructing the vision of the inter-
thecal sac. In these cases, the disc contents may first be
space. It is useful, in this instance, to clean the disc sur-
partially evacuated with the pituitary rongeur and then
face with a cottonoid, pressed or slightly rubbed on the
arthrectomy enlarged until the forwards angled pitu-
disc to remove the underlying tissue.
itary rongeur can be introduced into the interspace.
The disc is incised and evacuated as described for
Some one third of the articular processes should usual-
conventional discectomy.
ly be resected. In the presence of a migrated disc
fragment or nerve-root canal stenosis, laminoarthrecto-
my is enlarged until the migrated fragment is visual- Respect of anatomic structures
ized or the emerging nerve root is adequately
decompressed. During excision of the herniated disc, great care should
Undercutting, rather than vertical, arthrectomy may be taken to avoid traumas to the emerging nerve root,
be carried out by removing only the deep portion of the particularly in the presence of a severe preoperative
articular processes using the angled Kerrison rongeurs. neurologic deficit, which may increase following exces-
The advantage is to better preserve the facet joint and, sive manipulation of the root. The latter may be avoid-
thus, vertebral stability. ed as follows:
I} By exerting no excessive medial retraction of the
nervous structures. One runs the risk of excessive
Discectomy retraction particularly when herniation is in the mid-
line or one likes to visualize the middle portion of the
The interspace is exposed as in conventional discecto- disc. The risk is higher when using the microscope, as
my. The disc is white-opaque and fibrous in consisten- the visual field is narrower than with the naked eye. In
cy and is thus clearly distinguishable from the order not to exceedingly retract the emerging nerve
emerging nerve root (Fig. 16.34). If any doubts exist root, the objective may be inclined towards the midline
concerning the nature of the structure being exposed, and the Frazier probe used to palpate, rather than see,
the nerve root should be clearly visualized. An alterna- the middle portion of the disc. The probe may be
tive method is to retract the neural structures at the employed as a rake to attract an extruded fragment or
level of the superoexternal corner of the laminoarthrec- used to push down the middle part of the disc in order
- - - - - - - - - - - - - - - - - - - - - - - - - - - · S u r g i c a l treatment· 451
A B
Fig. 16.35. Microdiscectomy. (A) By retracting the nervous structures as proximally as possible, that is in the superoexternal corner of the laminoto-
my, it is more difficult to mistake the nerve root (arrow) for the disc (arrowheads). (B) Distal retraction of the emerging nerve root and exposure of the
herniated disc (arrowheads).
to displace the herniated tissue towards the center of the removal of all, or a large part of, the nucleus pulpo-
the disc, where it can be easily grasped. sus, particularly the part located ventrally to the poste-
2) By retracting the thecal sac, rather than the emerg- rior central zone of the annulus fibrosus.
ing nerve root. This may be done by retracting the nerve Two maneuvers can be used to excise the posterior
structures at the level of the upper end of the laminoto- central portion of the disc. The former consists in apply-
my. This maneuver is easy, for a right-handed surgeon, ing pressure to the posterior annulus fibrosus using the
when herniation is on the left. When the herniated disc foot of the Frazier probe and then removing the herniat-
is on the right, a very cranial retraction with the left ed tissue pushed into the central part of the disc. This
hand may hinder disc excision with the right hand. maneuver can be done only when the annulus fibrosus,
3) By retracting the emerging nerve root only when being degenerated, can be ruptured by means of mild
the pituitary rongeur is introduced into the interspace
to grasp disc material. When the rongeur is extracted,
pressure on the root should be reduced. A too pro-
longed root retraction with the dissector, produces a
depression on the lateral aspect of the root and may
cause intraradicular edema, possibly responsible for
pain and / or dermatomal hypoesthesia in the first few
days or weeks after surgery.
4) By using a root retractor rather than a dissector.
The nerve-root retractor causes less trauma to the root.
However, we usually prefer the dissector, since it is
smaller and easier to handle.
Extent of discectomy
A B
Fig. 16.39. Microdiscectomy. (A) Operative field at the end of discectomy. The arrow indicates to the emptied disc and the asterisk the emerging nerve
root. (B) The epidural fat around the emerging nerve root (asterisks) has been preserved.
disc fragments, the epidural fat should be excised as far incision should be slightly longer (some 4 em) and more
as is necessary to obtain a good view of the anatomic cranial than normal. At least half of the proximallami-
structures. na is resected, together with the medial half of the infe-
rior articular process of the cranial vertebra. In doing
this, great care should be taken not to resect a too large
Intraforaminal and extraforaminal herniations part of the pars interarticularis to avoid it breaking (Fig.
16.40). This risk is relatively low when using the micro-
Interlaminar approach scope, since the excellent vision makes extensive bone
resection unnecessary in order to visualize the deep
Laminotomy should be performed at the level of the anatomic structures. The ligamentum flavum should
disc showing herniation or from which the migrated gradually be excised as laminoarthrectomy is accom-
fragment originates. This is usually the disc below the plished.
fragment (page 440). Discectomy should generally be carried out, since the
disc very often shows a more or less marked bulging or
Contained or extruded herniation. After peforming a protrusion in the posterolateral or lateral portion.
laminotomy, the disc is evacuated first in the postero- Discectomy, however, may be less radical than normal,
lateral and then in the lateral portion. The technique is particularly if the disc has little contents.
that described for conventional discectomy, the main After discectomy, the objective of the microscope is
difference being that, with the microscope, arthrectomy inclined upwards and laterally to visualize the infero-
is usually less extensive, although slightly wider in the lateral area of the proximal vertebral body, just above
transverse direction than in the other types of hernia- the interspace, where the migrated fragment or frag-
tion. A too narrow arthrectomy, in fact, does not allow ments of disc are mostly located. It is extremely impor-
adequate space to maneuver either the pituitary tant to have excellent lighting of this area to easily
rongeurs or the Frazier probe employed to depress the identify the abnormal tissue. The control of bleeding,
lateral portion of the disc, without excessively stretch- which tends to be profuse in the foraminal area, is
ing the thecal sac and emerging nerve root. A few sur- equally important.
geons (1) occasionally resect the cranial end of the The herniated tissue is situated primarily just above
pedicle below the involved disc in order to enlarge the the lower end-plate of the proximal vertebra, in the hol-
access to the neuroforamen; this has never been low of the posterior aspect of the vertebral body (Fig.
deemed necessary in our experience. 16.41). In this instance, the nerve root running in the
neuroforamen usually needs not to be exposed if the
Migrated herniation. When preoperative investiga- excised fragment is large and / or has the size of that vis-
tions clearly show that the herniation has migrated into ible on CT or MRI scans. After excision of the fragment,
the upper part of the intervertebral foramen, the skin which is usually removed whole, the Frazier probe is
__________________________ 0 Surgical treatment 0455
Extravertebral approaches
ed by the author to perform discectomy or decompres- cutaneous tissue, the thoracolumbar fascia is incised
sion of the neural structures through an inter laminar and the lateral edge of the iliocostalis muscle is identi-
approach in association with fusion, to decompress fied. Blunt dissection is deepened between the ilio-
the nerve root laterally to the pedicle or to excise costalis and quadratus lomborum muscles, in a
intraforaminal or extraforaminal herniations (87). lateromedial direction, until the tip of the transverse
The skin incision, 6-8 cm long, is made on the mid- processes is palpated (Fig. 16.45). To expose the L5-S1
line (87) or 3-5 cm off (51). When incision is on the mid- interspace, resection of a small portion of the iliac crest
line, the skin is separated from the thoracolumbar may be needed. The level exposed is checked by fluo-
fascia on the side of the herniation and the fascia is roscopy and, after applying a self-retaining retractor
incised 2 cm laterally to the spinous processes. After maintaining the paravertebral muscles displaced medi-
retracting the lateral fascial flap, the intermuscular sep- ally, the transverse processes, articular processes and
tum between the multifidus and longissimus dorsi is pars interarticularis are exposed.
identified, the two muscles are separated with the
finger, and dissection is made deeper with a slightly Comparison of the extra vertebral approaches. In
lateromedial oblique direction as far as the articular our experience, the best approach is paraspinal,
processes are palpated (Fig. 16.44). Dissection is further which is almost bloodless and allows the multifidus
continued as far as the transverse processes of the muscle not to be detached from the spinous processes
two intended vertebrae. Fluoroscopy or radiographic and medial portion of the laminae and the interverte-
images are used to check the level exposed, using a dis- bral foramen to be easily reached. Furthermore, with
sector placed between the two transverse processes. A this approach even an interlaminar access may be per-
self-retaining retractor is applied in order that the entire formed, after detaching the multifidus from the lateral
length of the transverse processes, the articular processes portion of the laminae.
and the pars interarticularis remain exposed. The oper- The disadvantages of the para-articular, compared
ating microscope is positioned after having detached with the paraspinal, approach are: the need to detach
all muscle insertions from the exposed bony surfaces. the multifidus from the spinous processes and laminae,
the more profuse bleeding and the slightly greater diffi-
Paralateral approach. This approach, described by Ray culty in adequately retracting the paravertebral mus-
(60, 61), is very rarely used. The skin incision is made at cles to expose the transverse processes.
the level of the lateral junction of the spinal muscles With the paralateral approach, the area of the inter-
(multifidus, longissimus dorsi and iliocostalis) with the vertebral foramen is deeper with respect to the skin sur-
quadratus lomborum. The location of the junction, face compared with other approaches, thus making
which is at 10-16 cm from the midline, is identified by surgical maneuvers more difficult. Furthermore, with
palpation or by measuring the distance between the this approach, a simultaneous interlaminar access, or a
spinous processes and the lateral edge of the iliocostal- contralateral approach through the same skin incision,
is muscle on CT scans. The incision is 5-8 em long and is not feasible.
has a slightly curved, J-like, shape, particularly at L5-S1
level, for which the curved portion of the incision is Excision of herniation. The operating table should be
placed along the iliac crest. After dissection of the sub- inclined towards the opposite side to obtain a better
- - - - - - - - - - - - - - - - - - - - - - - - - - · S u r g i c a l treatment· 457
underlying nerve root. The latter should be preferred
when the pars interarticularis and the articular process-
es are resected by means of Kerrison rongeurs.
The dorsal branch of the lumbar artery, crossing the
superomedial portion of the intertransverse space, is
identified and cauterized. The nerve root and dorsal
root ganglion are exposed by dissecting the periradicu-
lar fat. Upwards retraction of the nerve root allows
exposure of the disc and the possibly migrated frag-
ment (Fig. 16.46). If the latter is situated in the middle
portion of the neuroforamen, the pars interarticularis
and the articular processes are resected until the herni-
ated tissue is sufficiently visible. The disc is then incised
and discectomy carried out using, in particular, for-
wards angled Kerrison rongeurs. Finally, a Frazier
probe is introduced into the foramen to make sure that
A no other disc fragments, migrated ventrally or caudally
to the portion of the root contained in the spinal canal,
are present.
- - - -..................'------ --- 8
Fig. 16.43. Preoperative CT scan and postoperative radiograph of a
patient who underwent surgery for an extraforaminal herniation. (A)
CT scan showing an L4-L5 extraforaminal herniation on the left (arrow-
head). (B) Postoperative radiograph showing the laminotomy carried out
to remove the herniation (arrows). The articular processes were under-
cut to allow removal of the herniation with no extensive arthrectomy.
Fig. 16.46. Paraspinal approach. (A) Exposure of the transverse processes and the intertrasversarii muscles. (B) Excision of the muscles and inter-
transverse ligament. (C) Following retraction of the nerve root, the disc is exposed and the extruded or migrated disc fragment is seen.
With extravertebral approaches, there is less risk of tive time is longer, and surgery is more demolitive and
affecting the stability of the motion segment, but appears to be associated with a higher rate of unsatis-
greater risk of leaving behind a migrated intraforami- factory results compared with the extravertebral
nal disc herniation when the free fragment extends con- approaches performed singly (20); furthermore, com-
siderably into the vertebral canal. Furthermore, the bined approaches, compared with the interlaminar
extravertebral approaches do not allow for elimination approach alone, may more easily lead to interruption of
of a concomitant nerve-root canal stenosis, not rarely the pars interarticularis and complete arthrectomy.
present in patients with a lateral herniation (Fig. 16.47). Extravertebral approaches are electively indicated in
On the other hand, with combined approaches, opera- contained or extruded extraforaminal herniation and
__________________________ 0 Surgical treatment 0459
Operative technique
The operation is carried out in the supine position.
Muscle relaxants may be administered to decrease ten-
sion of the abdominal muscles. Skin incision is 6-8 cm
long. It is generally performed on the left side, but may
also be carried out on the right for L5-S1Ievel, taking, as
reference, the line joining the umbilicus to the anterosu-
perior iliac spine. For L4-L5 level, the skin is incised in
the center of this line, whilst for the levels above or
below, the incision is placed, respectively, at the level of
the outer or inner half of this line (Fig. 16.48).
After dissection of the subcutaneous tissue, the exter-
nal aponeurosis of the rectus abdominis muscle is sec-
tioned along the line of the skin incision and the muscle
bundles of the obliquus externus, obliquus internus
and trasversus abdominis (79). Alternatively, the exter-
nal aponeurosis of the rectus abdominis is sectioned
almost vertically, the muscle is retracted medially and Fig. 16.48. Anterior discectomy. The drawing depicts the skin incisions
the internal aponeurosis is then incised (53). Beneath made, proceeding craniocaudally, for L3-L4, L4-L5 or L5-51 discecto-
my.
the muscle layer, the peritoneum, which should be care-
fully preserved, becomes apparent; if incidentally
incised, it should be immediately repaired. As the peri- psoas muscle laterally, thus exposing a limited area
toneum and abdominal viscera are retracted medially, (1 or 2 X 2 cm) of the involved disc (Fig. 16.49). Lumbar
the vertebral column can be palpated. The iliac vein vessels do not need to be ligated, since only the disc is
and / or the vena cava are retracted medially and the exposed. The sympathetic chain is not mobilized, since
60. Ray C. D.: The paralateral approach to lumbar decompres- 75. Striffeler H., Groeger U., Reulen H.-J.: Standard microsurgi-
sions. Am. Assoc. Neurol. Surg. Annu. Meet. 1983: 191 (poster cal lumbar discectomy vs. conservative microsurgical discec-
session, abstract 21 W). tomy. A preliminary study. Acta Neurochir. (Wien) 112:
61. Ray C. D.: Decompressions and the "inaccessible zone". In: 62-64,1991.
Lumbar disc disease. Hardy R W Jr. Ed., Raven Press, New 76. Surin V. v.: Duration of disability following lumbar disc
York,1993. surgery. Acta Orthop. Scand. 18: 466-471, 1977.
62. Rechtine G. R, Reinert C. M., Bohlman H. H.: The use of 77. Thomas A. M. c., Afshar E: The microsurgical treatment of
epidural morphine to decrease postoperative pain in lumbar disc protrusion. J. Bone Joint Surg. 69-B: 696-698,
patients undergoing lumbar laminectomy. J. Bone Joint 1987.
Surg. 66-A: 113-116, 1984. 78. Tsuji H.: Extraperitoneal anterolateral discectomy for lumbar
63. Recoules-Arches D.: La hernie discale lombaire du canal de disc herniation. Seikei-Geka 35: 795-803, 1984 (in Japanese).
conjugaison: a propos de 37 hernies operees. Neurochirurgie 79. Tsuji H., Hirano N., Ohshima H. et al.: Extraperitoneal
30:301-307,1984. anterolateral discetomy for lumbar disc herniation: indica-
64. Reulen H.-J., Pfaundler S., Ebeling u.: The lateral microsur- tions, techniques, and time-related clinical results. J. Spinal
gical approach to the" extra canalicular" lumbar disc hernia- Disord. 5: 424-432, 1992.
tion. I: A technical note. Acta Neurochir. (Wien) 84: 64-67, 80. Van Akkerveeken P. F., Van De Kraan W., Muller J. W. T.: The
1987. fate of the free fat graft. A prospective clinical study using CT
65. Riley 1. H., Banovac K, Martinez O. V. et al.: Tissue distribu- scanning. Spine 11: 501-504,1986.
tion of antibiotics in the intervertebral disc. Spine 19: 81. Weber H.: Lumbar disc herniation: a controlled, prospective
2619-2625,1994. study with ten years of observation. Spine 8: 131-140, 1983.
66. Rogers 1. A.: Experience with limited versus extensive disc 82. Williams R W.: Microlumbar discectomy: a conservative sur-
removal in patients undergoing microsurgical operations for gical approach to the virgin herniated lumbar disc. Spine 3:
ruptured lumbar discs. Neurosurgery 22: 82-85, 1988. 175-182,1978.
67. SaaIA.J., SaaiJ. S.: Nonoperative treatment of herniated lum- 83. Williams R W.: Microlumbar discectomy: a surgical alterna-
bar intervertebral disc with radiculopathy. An outcome tive for initial disc herniation. In: Lumbar Spine Surgery.
study. Spine 14: 431-437, 1989. Williams and Wilkins, Baltimore, 1983.
68. Samii K, Chauvin M., Viars P.: Postoperative spinal analge- 84. Williams R w.: Microlumbar discectomy. A 12-year statisti-
sia with morphine. Br. J. Anaesth. 53: 817-820, 1981. cal review. Spine 11: 851-852, 1986.
69. Scuderi G. J., Greenberg S. S., Banovac K et al.: Penetration of 85. Wilson D. H., Harbaugh R: Microsurgical and standard
glycopeptide antibiotics in nucleus pulposus. Spine 18: removal of the protruded lumbar disc: a comparative study.
2039-2042,1993. Neurosurgery 8: 422-427,1981.
70. Siebner H. R, Faulhauer K: Frequency and specific surgical 86. Wiltse 1. 1., Bateman J. G., Hutchinson RH. et al.: The
management of far lateral lumbar disc herniations. Acta paraspinal sacrospinalis-splitting approach to the lumbar
Neurochir. (Wien) 105: 124-131, 1990. spine. J. Bone Joint Surg. 50-A: 921-930, 1968.
71. Silvers H. R: Microsurgical versus standard lumbar discec- 87. Wiltse 1. 1., Spencer C. W.: New uses and refinements of the
tomy. Neurosurgery 22: 837-841, 1988. paraspinal approach to the lumbar spine. Spine 13: 696-706,
72. Sivers H. R, Lewis P. J., Asch H. 1. et al.: Lumbar diskectomy 1988.
for recurrent disk herniation. J. Spinal Disord. 7: 408-419, 88. Yaksh T. 1., Rudy T. A.: Analgesia mediated by a direct spinal
1994. action of narcotics. Science 192: 1357-1358, 1976.
73. Spannare B. J.: Prolapsed lumbar intervertebral disc with 89. Yong-Hing K, Reilly J., DeKorompay V. et al.: Prevention of
partial or total occlusion of the spinal canal. Acta Neurochir. nerve-root adhesions after laminectomy: Spine 5: 59-64,
42: 189-198, 1978. 1980.
74. Spengler D. M.: Lumbar discectomy: results with limited 90. Yong-Hing K, Reilly J., Kirkaldy-Willis w.H.: The ligamen-
disc excision and selective foraminotomy. Spine 7: 604-607, tum flavum. Spine 1: 226-234, 1976.
1982.
------·CHAPTER 17·------
POSTOPERATIVE FUNCTIONAL
RECOVERY
F. Postacchini, S. Gumina
Fig. 17.5. The thighs are approached to the chest, keeping the knees
Fig. 17.4. Rising on tiptoes. together and flexed.
or on all fours position. The sessions last 5 to 10 minutes hand, the aim of strengthening the paras pinal muscles
and are repeated twice or more times a day. and mobilizing the trunk in extension and lateral
bending. The sessions last 15 to 20 minutes and take
Third and fourth week. The exercises become more place twice a day. During the third week, the first half of
demanding and have, on the one hand, the same objec- the session is dedicated to the exercises from the first
tives as those of the previous phase and, on the other phase and, the second half, to new exercises. During the
_____________________ 0 Postoperative functional recovery 469 0
fourth week, only the new exercises from the second Where to exercise
phase are done and the number of repetitions of each
exercise is increased gradually. Exercises to control Postoperative exercises may be done at a functional
trunk posture are incremented in this phase. rehabilitation center or independently by the patient
at home, or a mixed approach can be adopted. The
Second month. There is only one session lasting at former approach is preferable by far, since the exercises
least 20 minutes. Young and middle-aged patients are are carried out under supervisirn by a physiotherapist,
advised to prolong exercise therapy up to 30 or 40 but it may present some drawbacks. The patient must
minutes. This holds paticularly for those who perform go to a rehabilitation center daily or even twice a day;
manual labour or intend to resume sport. this involves wasting time for the patient and compa-
During the initial 2 weeks, the first half of the session nions, as well as use of specialized staff and relatively
is dedicated to the exercises taught in the previous high costs, if the exercise therapy is completely individ-
phase and the second half to new exercises. These are ualized.
isotonic exercises aimed at stretching abdominal, Following the second approach, the patient may be
gluteal and paravertebral muscles, strengthening the given a pamphlet, illustrating the exercises to be done
anterior and posterior muscles of the lower limbs and (37). This method is simpler and cost effective. In our
abdominal and trunk muscles, and increasing spine experience, the large majority of patients are able to do
mobility both in flexion and extension. Exercises of lat- the exercises independently and almost all do so, at
eral bending of the trunk are also carried out. During least during the first few weeks after surgery, although
the session, exercises to control trunk posture are with varying commitment and frequency. An analysis
repeated many times. The patient avoids the exercises of the compliance in performing exercise therapy car-
causing low back or radicular pain and suspends all ried out by means of a questionnaire filled in periodi-
exercises for a few days in case of persistent pain. cally by 100 patients submitted to microdiscectomy,
4700Chapter 1 7 0 - - - - - - - - - - - - - - - - - - - - - -_ _ __
Fig. 17.13. Lateral bending towards the wall, while pushing the pelvis
with the hand placed on the flank.
severe deficit of a muscle group, more time should be exercise therapy for at least 1 more month. The same
dedicated to doing exercises aimed at activating those holds for those with a long preoperative history of back
weak muscles. pain, who are invited to continue exercising for at least
Elderly patients should generally perform only the a few months and, often, also to attend a low back
exercises of the first 4 weeks of the re-education school. In these cases, we often advise the patients to do
program, in a single daily session. the postural exercise therapy performed by patients
treated conservatively.
Effects of exercise therapy
Physical therapy
At the first postoperative follow-ups, patients who
perform exercise therapy usually complain of less back No form of physiotherapy is usually needed in patients
pain than those who do not. They often report that, after with successful surgical outcome and a normal post-
the exercise session, back pain improves or disappears, operative course, except for those with preoperative
or that they feel more backache when, for whatever motor loss in the lower limb. In these patients, it is gen-
reason, exercise therapy is stopped for a few days. erally useful to carry out electrotherapy of muscle stim-
Exercise therapy accelerates recovery of trunk mobil- ulation, associated with massage and active assisted
ity in flexion and extension, even if the latter is largely exercises, since the first few days after surgery. Before
influenced by the patient's constitutional muscle starting treatment, an intensity / duration electrodiag-
elasticity. At 30- to 45-day follow-up, the majority of nostic test should be carried out to measure the intensi-
patients who regularly follow the exercise program ty and duration of the electric stimulus to be applied to
report that their trunk flexibility is comparable to that the muscle (36). Usually, the duration of the sessions
they had before the onset of symptoms due to disc her- should not exceed 10-15 minutes, since, subsequently,
niation. Similarly, patients with long-standing preoper- muscle fatigue appears, which may not allow valid
ative sciatic scoliosis recover normal alignment of the contractions. Electrotherapy should be continued
spine faster than patients who do not perform exercise until clear clinical and / or electromyographic findings
therapy. We did not carry out any comparative analysis appear, indicating advanced functional recovery.
of patients who follow an exercise program with The muscles which most often need electrotherapy
respect to those who do not, since all our patients with are the tibialis anterior, the peronei, the triceps surae
a normal postoperative course are invited to perform and the quadriceps. The extensor hallucis longus does
exercise therapy. However, the occasional observation not usually need electrotherapy, both because it does
of patients who do no exercises, has shown that these not have a primary functional role and it may be
patients tend to recover vertebral mobility and normal difficult to carry out a selective electrostimulation of
posture (if they presented severe preoperative sciatic this small muscle.
scoliosis) 1 or 2 months later compared with those
who carry out exercise therapy.
Return to work
The intensity of the postoperative rehabilitation pro-
gram seems to influence its therapeutic efficacy. In a
There are no definite time limits as to when to resume
randomized study (28), the results of a traditional
work after surgery for lumbar disc herniation.
rehabilitation program consisting of mild, generally
Numerous factors may influence postoperative sick-
mobility-improving exercises within pain limits were
leave, besides the patient's ability to return to work
compared with those of a program of high-intensity
(page 514).
dynamic exercises with the occurrence of back pain
Patients who do a sedentary job can generally return
being the limiting factor. At 6- and 12-month follow-
to work 3 to 6 weeks after surgery. Those who return
ups, the patients who had done the more strenuous
earlier should work on a part-time basis in the first few
exercises had less lumboradicular pain, less physical
weeks. Prolonged sitting may cause back pain; in this
disability and better working ability levels.
event, the patient should frequently get up and move
around or do some exercises. On the other hand,
Continuation of rehabilitation program patients whose jobs require prolonged standing should
have the possibility of sitting frequently for a few
After the second month following surgery, patients minutes.
who do not report a long preoperative history of low Patients who do moderately heavy work (frequent
back pain are not invited to continue exercising, unless lifting or carrying objects weighing 15 kg and / or occa-
they wish to do so or they still complain of significant sional lifting of no more than 25 kg at a time) (52)
back pain. The latter patients are advised to continue should not resume work before 6 to 8 weeks after the
472.Chapter 1 7 . - - - - - - - - - - - - - - - - - - - - - - - - - - -
operation. During the first month, they should carry early exposes the patient to greater risks of episodes of
out a semi-sedentary job or at least not lift objects acute low back pain and increases the probability of
weighing more than 10-15 kg. Driving a heavy vehicle early recurrence of disc herniation.
is comparable to moderately heavy work: during the In patients who intend to return to sport, it is advis-
first month back at work, patients should not drive able to start a supplementary rehabilitation program
more than 4 to 6 hours a day. If the hours driven are 2 months after surgery, aimed at restoring muscle co-
consecutive, the patient should get out of the vehicle ordination and endurance. This holds in particular for
and have a brief stroll or do some simple exercises. those who are returning to competitive sport. This
Those who do heavy or extremely heavy work program lasts 1 to 2 months and should be carried
(frequent lifting or carrying of objects weighing 25 kg out at a rehabilitation center under the supervision of
or more and / or occasional lifting of 50 kg or more at a physiotherapist.
a time) (52) should not return to work before 3 months The exercise program aimed at reconditioning to
after the operation. These patients should also do a sporting activity includes exercises directed at streng-
lighter work for a few weeks before returning to their thening trunk and upper and lower limb muscles,
usual activity. stabilizing the pelvis, speeding up muscle contraction
Patients who do moderately heavy or heavy work and preparing the patient for specific situations in
should attend a low back school and continue to regu- sport activity, such as falling or physical contact. The
larly perform the exercises taught for at least 3 to 6 exercise program should gradually be incremented as
months after returning to work. far as concerns the difficulty of exercises, the number of
repetitions and the duration of sessions. For competi-
tive sport, the rehabilitation program precedes return
Sport to specific sport training.
these cases, the usual postoperative exercise program, useless in patients with a normal postoperative course,
or any exercises, should be avoided not to run the risk also taking into account that studies on the action of
of an increase in leg pain. Alternatively, patients can be corsets show that these orthoses have little biomechan-
invited to perform the postural exercise therapy that is ical effects on the lumbar spine. However, in patients
done by patients with disc herniation treated conserva- with persistent postoperative back pain, not relieved or
tively. Exercises, in fact, may improve low back pain exacerbated by exercising, it may be useful to wear a
and, at times, also radicular pain caused by initial peri- lumbosacral canvas corset for 1 to 3 months, if it
radicular adhesions or persistent nerve-root irritation, relieves pain. Subsequently, the corset should be left off
either spontaneous or related to surgical trauma. After because of the negative effects it may have on trunk
an initial period of postural exercise therapy, the usual muscle tone.
postoperative exercise program may be started, if The use of a rigid corset may be indicated only in
radicular pain has improved or disappeared. patients with proven postoperative vertebral instability.
In patients with severe postoperative radicular pain,
exercises should be avoided. The same holds in the
presence of severe back pain, particularly when post- Return to work
surgical complications are suspected.
In patients with persistent lumboradicular pain, return
to work should be delayed compared with patients pre-
Medical and physical therapy senting a normal postoperative course. As for the latter,
there are no definite time limits for work resumption,
Anti-inflammatory drugs are often less effective on which largely depends on the type of activity and the
radicular pain than in non-operated patients. Never- physical demand. Work should possibly be resumed
theless, in the presence of severe leg pain, it is advisable once symptoms have considerably decreased or disap-
to administer analgesics for 2 to 3 weeks following peared. It has been shown that return to work before 3
removal of skin suture. If pain is moderate, it is usual- months, in the presence of persistent lumboradicular
ly sufficient to reassure the patient by explaining symptoms, negatively affects the long-term results of
that occasionally the symptoms regress slowly, over a surgery or chemonucleolysis (51). In this respect, how-
period of a few weeks. ever, many factors, such as the patient's will to return to
Massage and various types of physical therapy are work and the cause of persistent lumboradicular symp-
often prescribed to patients who still complain of low toms, may playa relevant role. Sick-leave of more than
back or lumboradicular pain a few weeks after the 4 months is generally unjustified in the absence of clear
operation. However, there are no reliable studies, as far evidence of a pathologic condition responsible for an
as concerns the methodological quality, on the effects of abnormal postoperative course and, thus, for persistent
these treatments in patients with persistence of lumbo- symptomology.
radicular symptoms a few weeks after surgery. In our
experience, massage and other forms of physical thera-
py have little or no effect on radicular pain. However,
they may often improve a specific back pain. Of the Percutaneous procedures
various forms of physical therapy, the most effective
are electrotherapy, particularly TENS, and ultrasounds. Chemonucleolysis
Some forms of exogenous thermotherapy, such as
infrareds, may be used in preparation for massage. The modalities and timing of rehabilitation treatments
Physical therapy is indicated in patients with mod- following chemonucleolysis are different from those
erate or severe back pain showing no improvement carried out after surgical discectomy. The main reason
with exercises or when the latter are avoided. Usually, is that patients undergoing nucleolysis tend to com-
treatments are started 3 to 4 weeks after surgery and plain of more severe postprocedural back pain com-
last for 2 to 6 weeks. pared with those treated surgically, and that radicular
pain often persists for some weeks. This requires a more
prolonged rest during the first few weeks following
Corsets the procedure and a more gradual return to normal
physical activities.
In the past, many surgeons, regardless of the presence In the fourth week after chemonucleolysis, the
of residual symptoms, prescribed a corset for a few patient who complain of little or no lumboradicular
months after surgery and many still continue to do so pain should be encouraged to walk, use a cyclette, and
(3, 10, 21). In our opinion, this therapeutic practice is swim, if desired. Until the sixth week, patients should
474·
avoid frequent long-distance car journeys, medium if the lumboradicular symptoms have disappeared
physical efforts (lifting 15 kg), prolonged standing or or only occasional backache persists. Otherwise, the
sitting (more than 5 hours) with no pause of rest, and indications outlined for patients treated surgically are
frequent trunk flexion, extension or lateral bending. valid.
In patients with severe lumboradicular pain, the level
of physical activity is conditioned by the intensity
of pain: patients should perform only activities that Other procedures
cause little or no discomfort.
In patients complaining of moderate or severe lum- Postprocedural radicular symptoms in patients under-
boradicular pain, it may be useful to prescribe physio- going automated percutaneous nucleotomy, manual
therapy 3 to 4 weeks after nucleolysis. The type of percutaneous nucleotomy or laser discectomy are com-
physical therapy most commonly used by us is mas- parable to those in patients submitted to chemonucleo-
sage and infrareds (in preparation for massage), TENS lysis, except for back pain, which is often more severe
and ultrasounds. Vertebral mobilization is also advised following nucleolysis. The limitations of physical activ-
by some authors (43). However, it should be taken ity, treatments and time off work are related to the type
into account that these types of treatment are more and severity of symptoms and are similar to those
effective in low back, than radicular, pain. They are described for chemonucleolysis.
thus indicated particularly in patients who complain
only or prevalently of back pain.
Exercise therapy is usually begun 5 to 6 weeks after
chemonucleolysis. If started earlier, exercises may easi- Chronic postoperative pain
ly cause, or exacerbate, low back or radicular pain, thus
not only causing negative psychologic effects on the Some of the patients submited to surgery or percuta-
patient, but also slowing down the process of function- neous procedures complain of chronic low back or
al recovery. Furthermore, at least initially, the exercises lumboradicular pain in the absence of definite patho-
are different from those recommended to operated logic conditions, or in the presence of conditions requir-
patients. During the first 4 weeks, patients perform the ing no repeat surgery or for which the patient refuses
postural exercise therapy taught to patients with lum- invasive treatments. These conditions, as well as
bar disc herniation treated conservatively. The exercis- numerous other lumbar pathologic conditions, are the
es are done under the supervision of a physiotherapist, cause of "the failed back syndrome". This may be
autonomously by the patient or, preferably, by using treated with numerous rehabilitation therapies, which,
the mixed approach, as described for patients treated however, often fail or provide only partial or temporary
surgically. The exercise sessions take place either once pain relief.
or, preferably, twice a day. In the former case, the ses-
sion lasts 20 to 40 minutes, whilst in the second, each
session lasts 20 minutes. Exercises which cause pain Physical therapy, manipUlation
are either eliminated from the program or suspended, and acupuncture
if the majority of exercises cause or exacerbate low
back or radicular pain. After the phase of postural All patients with chronic postoperative pain undergo
exercise therapy, muscle strengthening and stretching some form of physical therapy sooner or later. Some
exercises, similar to those performed by patients treat- patients have no benefit, whilst others obtain pain relief
ed surgically, are usually carried out, particularly in of varying duration. However, little is known on the
young or middle-aged patients. This second phase real therapeutic efficacy of most forms of physiothera-
lasts 1 month, or longer if the patient has persistent py. This is true in absolute, but particularly for operated
back pain which improves with exercises. patients, since studies on the efficacy of these thera-
Moderately heavy work may be resumed 2 months peutic modalities have rarely distinguished between
after the procedure if lumboradicular pain has disap- operated and non-operated patients. The few studies
peared or is very mild. If moderate or severe lumbo- carried out using rigorous methodologies have provid-
radicular pain persists, it is advisable to delay return to ed conflicting results even for the most common and
work for at least 1 month. For heavy or very heavy most studied forms of treatment, such as traction and
work, the indications are the same as for patients treat- TENS (7, 22, 29, 49). The conclusion is that for no
ed surgically. form of physical therapy is there irrefutable proof of
Swimming may be resumed 3 to 4 weeks after therapeutic efficacy. Manipulation was found to be
chemonucleolysis. Other sports may be performed 2 to 4 more effective than placebo and other forms of treat-
weeks earlier with respect to patients treated surgically, ment, such as analgesics, massage and low back school
- - - - - - - - - - - - - - - - - - - - - - . Postoperative functional recovery· 475
(2, 13, 17, 19, 20, 45, 50). However, these findings refer it is unknown whether low back schools are equally
almost exclusively to non-operated patients or patients effective in operated, as in non-operated, patients.
for whom no mention is made on whether surgery had, None of the many prospective randomized studies
or had not, been carried out. In one of the few studies carried out to evaluate the effectiveness of this form of
which analyzed patients operated for lumbar patholog- treatment have specifically analyzed patients with
ic conditions (22), electroacupuncture was found to be chronic postoperative pain.
significantly more effective than TENS and placebo in
relieving low back pain and increasing trunk extension
strength at 3- and 6-month follow-ups. Psychologic therapy
Psychologic therapies carried out in patients with
chronic lumboradicular pain are essentially represented
Exercise therapy by operative behavioral, and cognitive behavioral,
treatments.
Usually exercises have little or no effect on chronic
Operative behavioral treatments are aimed at elim-
radicular pain, whilst they represent one of the key-
inating maladjustment to pain (for instance, reduction
stones in the treatment of patients with low back pain.
of general level of physical activity and refusal of activi-
Exercises should be done daily, for at least 20 minutes
ties causing pain) and at promoting well-being be-
a day, for long periods of time. In our experience, the
haviors (increased level of physical activity or return to
most suitable method is the mixed approach, i.e., the
work). One of the methods to increase physical activity
exercises are done at home and once or twice a week
is to progressively modify the duration of periods of
at a rehabilitation center under the supervision of a
rest and physical activity. For instance, initially the
physiotherapist. This method stimulates the patient to
patient is encouraged to perform exercises for 15 min-
continue treatment and makes it easier to perform
utes every hour. Subsequently, the period of activity is
exercise therapy, particularly if the latter should be
increased progressively, whilst the period of rest is
continued for a long time. Usually the efficacy of exer-
proportionally decreased. The same schedule may be
cises can be noted 2 to 4 weeks after the onset. Only
applied to the uptake of analgesics. Another method is
following this period should the exercise program be
to provide social support in the form of appreciation
suspended, if the symptoms are not relieved.
and attention by the physician or the therapist when
We start with the postural exercise therapy per-
positive behavior is shown, and to reduce social
formed by patients with disc herniation treated conser-
support when excessive pain is manifested.
vatively, and then we advise more strenuous, dynamic
Cognitive behavioral treatments include various
exercises, aimed at strengthening and stretching the
therapeutic modalities, such as muscle relaxation,
anterior and posterior muscles of the trunk and lower
diversion of attention, imaginative activities and active
limbs.
strategies to cope with pain. Of the various muscle
Numerous randomized studies have compared
relaxation techniques, the most commonly used is
the effects of an exercise program with those of other
teaching the patient to relax various muscle groups
conservative treatments in operated and non-
in a progressive order and symmetrically, with or
operated patients with chronic low back pain (7, 12,
without the use of biofeedback techniques. Diversion
15, 23-25, 30, 39, 40, 50). In the majority of studies,
of attention from pain may be obtained by means of
exercises were found to be more effective than control
mental concentration on specific thoughts or physical
treatments (physical therapy, rest, behavioral therapies,
activities, such as walking or exercising. Imaginative
placebo or no treatment). In a meta-analysis of the
activities consist in concentrating the mind on pleasur-
literature, no significant differences emerged, in terms
able or gratifying images or transforming the percep-
of therapeutic efficacy, between the various types of
tion of pain into another sensation, for instance a warm
exercises (9).
sensation. The strategies to cope with pain are aimed
at transforming negative thoughts and attitudes into
rational ideas in order to minimize the importance of
Low back school the painful stimuli.
The majority of studies (1, 8, 11, 18, 24, 33, 34, 42,
Back schools may be useful in patients with chronic 46-48) that have analyzed the efficacy of behavioral
lumboradicular pain. However, it is still unclear therapies, have shown that these are effective in reduc-
whether the benefits are essentially due to the exercise ing chronic low back pain, however almost all prospec-
therapy or whether the implementation of correct pos- tive randomized studies present methodological flaws,
tures plays a relevant role in this respect. Furthermore, and this leaves many doubts on the real efficacy of these
17.---------------------------
forms of treatment. Furthermore, it is not clear whether quality of outcome, the type of work, the pre-existent
operated patients have similar results to those not oper- degenerative vertebral changes and the nature and
ated on. severity of the possible neurologic lesions.
The Social Security Rulings in the United States (41)
attributes patients with disc herniation a permanent
Functional restoration programs disability rate of 0 to 25%, depending on the type of
treatment and residual symptoms. These rulings estab-
At the beginning of the 80's, Tom Mayer developed a lish that a patient with disc herniation should do less
multidisciplinary program for physical, occupational physically strenuous work than a patient with no
and psychosocial restoration in patients with chronic pathologic lumbar condition. This is conceivable, taking
low back pain at the Productive Rehabilitation Institute into account that a patient operated on for disc
of Dallas for Ergonomics (PRIDE). The program, real- herniation is more likely to have low back pain if
ized under the guidance of physicians, psychologists, he / she is engaged in a heavy or very heavy work.
physiotherapists and occupational therapists, lasts Neurologic lesions are generally evaluated separately
8-10 hours a day for 3 weeks, and then continues for from vertebral impairment. According to the Guides to
1 and a half days a week for a maximum of 6 weeks, the Evaluation of Permanent Impairment of the American
depending on the level of functional restoration Medical Association (14), the percentage of permanent
attained during the intensive phase. The program starts partial impairment of the lower limb for a complete
with patient's functional, occupational and psycholog- neurologic deficit of L3-S1 nerve-roots ranges from
ic assessment. After this phase, three types of treatment 24% to 40%. By means of conversion tables, these per-
are carried out: physical reconditioning of the whole centages are transformed into percentages of disability
body by means of exercises of increasing difficulty, of the whole person. The AMA Guides are based on the
occupational therapy carried out through simulated concept that every part of the body is a portion of the
work activity (for example, lifting objects of increasing whole person, and the percentage assigned to each part
weight, climbing stairs, sitting in front of a computer is based on the notion of function. The spine contributes
for progressively longer periods of time) and psycho- a maximum of 60% of the functions of the whole person.
logic therapy or support, aimed at modifying behav- The Bareme des accidents du travail et maladies profes-
ioral dis torsions and conflicts in the familial and social sionnelles (4) assigns a percentage of disability of
environment. In addition, principles of postural educa- 10%-60% for disc herniation with monolateral sciatica
tion and ergonomics, as well as active strategies to and 40%-85% when sciatica is bilateral. The percent-
cope with acute pain, are taught. ages vary depending on the severity of pain, the degree
Other functional restoration programs have been of vertebral range of motion and the severity of neuro-
developed, based on the PRIDE program (5, 16,35, 44). logic deficit.
All the programs are directed primarily at returning the In Italian industrial injury legislation, rating of
patient to a productive workplace. physical impairment caused by disc herniation is
Few studies have evaluated the results of the func- not provided for. In the Tabelle delle valutazioni del grado
tional restoration programs. In most of the trials di invaliditil permanente, which evaluate the degree of
(5,16,31,32,44), it was found that a large proportion of permanent impairment and are attached to the
patients who participated in the programs obtained Industrial Injury Act, the percentages of impairment
pain relief, a decrease in physical and psychologic produced by disc herniation or nerve-root lesions are
disability, and an increase in physical performance. not listed (26). The percentages of disability for periph-
Furthermore, the majority of patients (56%-87%) eral nerve lesions range from 15% to 50% for monolat-
returned to work, whereas less than half (27% -41 %) of eral paralysis of the posterior tibial nerve and sciatic
the control patients did. In the only study reporting nerve, respectively. Evaluation of permanent neurolog-
negative results, 23% of patients had resumed work 18 ic lesions caused by disc herniation can be based on the
months after the end of the program (35). degree of loss of function of the respective peripheral
nerve or nerves.
Work disability
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-------CHAPTER 18-------
COMPLICATIONS OF SURGERY
F. Postacchini, G. Cinotti
Morbidity and mortality (23). In the last series, the mortality rate during hospi-
talization reached 0.6% in patients older than 75 years.
The incidence of surgical complications has been The most frequent causes of death are cardiac, vascu-
reported to range between 1.6% and 9.1%, in series in lar and respiratory complications, and severe infections
which more than 1500 cases have been analyzed (23, with septicemia.
100,114,137). The complications have a slightly higher
incidence in women and increase in proportion to the
patients age; in patients over 65 years old the complica- Cardiovascular complications
tion rate is more than twofold compared with patients
aged less than 40 years (23). The incidence of complica- Cardiac complications
tions is significantly higher in reoperated patients (114),
in those with lumbar stenosis and in patients submitted The reported incidence of myocardial infarction ranges
to spinal fusion (23). No difference in the complication from 0.002% to 0.15% (100, 114, 137). Together with
rate has been reported between patients operated on injuries to abdominal vessels, myocardial infarction is
by orthopaedic surgeons or neurosurgeons (100). The the most frequent cause of intraoperative or early post-
most frequent complications are: hemorrhages or operative mortality. In one series (100), 52% of patients
hematoma infections (superficial or deep), dural sac who had a heart attack died. A similar mortality rate
or nerve-root injuries, cardio-pulmonary disturbances due to myocardial infarction is reported for others
and urinary and gastrointestinal dysfunctions.
In a series of 22,888 operations for herniated discs
reported by 53 studies, Spangfort (124) found a mortal- Table 18.1. Percent of mortality in operations for lumbar disc
ity rate of 0.3%, while in a series of 2504 cases analyzed herniation.
by the author, the mortality rate was 0.1% (Table 18.1). Author No. of operations % of mortality
In a multicentric study of 3032 cases, Oppel (88) report- Love (1947) 1217 0.2
ed an incidence of 0.29%. In studies carried out more Busch et al. (1950) 1200 0.3
recently, however, a markedly lower mortality rate has Gurdjianetal. (1961) 1176 0.2
been reported: 0.013% of 68,329 cases analyzed by Semmes (1964) 5000 0.0
Spangfort (1972) 2504 0.1
Wildf6rster (137), 0.017% of 17,058 patients reported Oppel et al. (1977) 3032 0.29
by Roberts (102), 0.059% of 28,395 cases analyzed by Roberts (1988) 17,058 0.017
Ramirez and Thisted (100) and 0.07% of 18,122 lumbar Ramirez et al. (1989) 28,395 0.059
spine operations (84% of which performed for disc Wildforster (1991) 68,329 0.013
herniations or lumbar stenosis) analyzed by Deyo et al. Deyo et al. (1992) 18,122 0.07
480.Chapter 18.-------------------------------------------------------
non-cardiac operations (43). Less frequent and less fatal of 28,395 patients analyzed by Ramirez and Thisted
cardiac complications are represented by congestive (100), a fatal pulmonary embolism occurred in 0.01 % of
heart failure and atrium or ventriculum arrhythmia. cases; such a low rate indicates that discectomy should
be included among the operations presenting a low risk
of fatal pulmonary embolism.
Thrombophlebitis and pulmonary Due to the low incidence of thrombophlebitis, a
embolism prophylactic treatment with heparin is not usually
needed after discectomy. However, an anti thrombotic
Thrombophlebitis in the lower limbs is reported as prophylaxis, including the application of elastic stock-
having an incidence ranging from 0.1% to 1.4% (23, ings during the operation and / or administration of
24,38,39, 114, 124). The incidence is higher in patients heparin, is recommended in elderly patients, particu-
submitted to spinal fusion. Usually this complication larly if the operation is of long duration (stenosis asso-
becomes evident within 2 weeks of surgery. In excep- ciated with arthrodesis), and it is always necessary if
tional cases an extensive thromboflebitis may occur the patient is left in bed for a few days after surgery.
(Fig. 18.1).
The incidence of pulmonary embolism in patients
who undergo discectomy ranges between 0.008% and Cerebral circulatory disorders
0.8% (12,24,100,114,124, 137). In one series (124), pul-
monary embolism was diagnosed in more than one The reported incidence of strokes and cerebral ischemia
third of patients who had thrombophlebitis. In a series is 0.02% and 0.005%, respectively (100, 137). The inci-
A B c
Fig. 18.2. Patient submitted to laminectomy at L2-L4levels and discectomy at L2-L3 with postoperative plurisegmental spondylodiscitis and diffusion
of the infective process to the thoracic spine. Radiographs were negative 25 days after surgery while TC 99 bone scan (A) showed an increased uptake
at L1-L3 and TlO-Tll levels (arrows). Sixty days after surgery (B), radiographs showed spondylodiscitis at L1-L2, L2-L3 and L3-L4 levels with
destruction of the anterosuperior aspect of the L2 vertebral body, resulting in segmental kyphosis at L1-L2 level. At Tl 0- Tll level (C) a marked reduc-
tion in the disc height with irregularity of the vertebral end-plates and subchondral bone sclerosis were present.
tis is characterized either by the persistence of intense all the patients showed a deviation from the normal
low back pain immediately after surgery or, more postoperative course 3 to 9 days after surgery. This
frequently, by the appearance of severe pain after an finding suggests that an infective complication is
initial period of well-being or by an unexplainable and usually already clinically manifest during the first few
progressive daily worsening of the normal post- days after the operation, but it can initially be
operative low back pain. The pain increases both in overlooked if the immediate postoperative course is
the standing and sitting position and upon trunk not carefully observed.
movements. For this reason, the patient, who has Spondylodiscitis very rarely causes meningitis or
started to get up several times a day during the first septicemia. In the first case, the clinical picture is
postoperative days, gets up less and less willingly that typical of meningitis, with which encephalitis may
and eventually refuses to get up at all. Even bed move- be associated. Septicemia may occur in debilitated
ments are painful and become increasingly difficult. patients.
Radicular pain, on the other hand, is not usually
characteristic of discitis.
The fever is variable. In the first few days after the Diagnosis
clinical onset of spondylodiscitis, it is often present,
but rarely exceeds 38°C. Subsequently, it disappears Laboratory investigations
or a light persistent fever may be present for variable
periods of a few days or weeks. However, the pre- Various studies (8, 55, 59, 96) have analyzed the ESR
sence of fever alone, without low back pain, is never a values in patients submitted to discectomy who had
characteristic feature of disci tis, while the absence of not had postoperative infective complications. In the
fever does not exclude disci tis. majority of cases, ESR does not increase after the
The surgical wound is rarely entirely normal, though operation. In a minority of patients, however, the ESR
it is also true that marked signs of cutaneous infection values increase, sometimes even considerably. This
are seldom present. Generally, the skin is slightly tends to occur particularly in patients showing a high
swollen and reddened, and scant serous-purulent preoperative ESR (normally less than 25 mm/h) or
material may leak out if pressure is exerted around the when a spinal fusion is performed. In these cases, how-
wound. The wound may take a normal amount of time ever, ESR very rarely exceeds 70 mm/h and almost
to heal, or it may take a few days, or in rare cases weeks, always tends to return to the preoperative values in the
to heal. second or third week after the operation. In no case,
Generally, 2-3 weeks after the onset of clinical symp- however, has a tendency towards increasing ESR val-
toms, the patient complains of extremely severe low ues been found after the first postoperative week. Of
back pain, which is accentuated by even the slightest the 70 patients analyzed by Postacchini et al. (96), who
trunk movements. Often the pain radiates to the underwent an uncomplicated discectomy, 14 showed
abdomen or more rarely to the groin. Severe spasm a sharp increase in ESR 1 week after surgery, whilst
of the paravertebral muscles is present as is, in some after 2 weeks, the ESR values had decreased in all but
cases, postural scoliosis in the standing position. two cases.
Usually, there is no fever and the surgical wound is In patients with spondylodiscitis, ESR almost con-
healed. stantly increases from the 10th day after surgery. The
Some authors (72, 111) have described subacute and most characteristic finding, however, is that the ESR
chronic forms of postoperative spondylodiscitis. The value tends to increase further 2 to 3 weeks after the
subacute form usually appears 2 to 4 weeks after operation. Subsequently, it remains stable for a few
surgery and is characterized by milder low back weeks and then tends to gradually decrease with the
symptoms with respect to the forms with an earlier resolution of the infective process. The maximum
onset. The chronic form usually manifests itself 1-2 values usually range from 60 to 120 mm/h. Therefore,
months after the operation, with mild low back pain. a marked increase in the ESR after discectomy should
These forms may be due to low-virulence micro-organ- be considered suspect, particularly if the value exceeds
isms; a more convincing hypothesis, however, is that in 70 mm/h in patients with normal pre-operative values.
most cases they are the result of spondylodiscitis being In these cases, the ESR should be evaluated 2 weeks
diagnosed late. Postacchini et al. (95, 96) reported on after surgery. If the value increases further, it is proba-
two groups of patients with spondylodiscitis who were ble that discitis is present and this becomes a clinical
analyzed retrospectively and prospectively. In the ret- certainty if it is accompanied by fever and/or abnor-
rospective group, two thirds of the patients related the mally severe low back pain.
onset of the first symptoms back to 3-4 weeks after the C-reactive protein (CRP) usually increases after a
operation. Instead, in the group analyzed prospectively, discectomy without infective complications. It reaches
484. Chapter 18 . - - - - - - - - - - - - - - - - - - - - - - - - - - -
the maximum value (about 30 mg/l) on the second usually shows a decrease in height, often of marked
postoperative day and returns to normal values within entity. In the late phase, sclerotic changes of the portion
the first week after the operation (59). In patients of the vertebral bodies adjacent to the disc are visible.
with spondylodiscitis CRr generally shows a marked
increase in the first postoperative days. High CRr Tomography. Anteroposterior and lateral tomograms
concentration usually persists for a few weeks and then may reveal the initial changes of the vertebral end-
tends to decrease to normal values more rapidly than plates only 3-5 weeks after the onset of the infective
the ESR. CRr shows higher specificity in diagnosing process. Hence, tomography has a higher diagnostic
an infective process compared with ESR. value than plain radiographs, but it entails exposure
Only a minority of patients with spondylodiscitis to a high dose of radiation.
present hematic leukocytosis and, usually, this is of mild
entity. Sometimes, in patients with high fever, a blood
culture may allow detection of the micro-organism Bone scanning
reponsible for the infective process.
Although not very specific, bone scan is very effective
in identifying a spondylodiscitis (Fig. 18.2). The investi-
Imaging studies gation should be carried out with TC 99 or GA 67 (page
271). With the advent of MRI, however, the diagnostic
Radiography utility of the bone scan has considerably decreased.
It may, in fact, become positive after a discectomy
Radiographs are negative in the first 4-6 weeks after without any infective complication (119) and it does
the operation. This interval corresponds to the time not usually become positive earlier than MRI.
needed for the occurrence of osteolytic changes in the
vertebral bodies adjacent to the affected disc. One
month after surgery, irregularities in the profile of the Computerized tomography
vertebral end-plates are initially visible, followed by
areas of erosion in the subchondral bone (Fig. 18.3). CT scans may show: osteolytic lesions, usually multiple,
Successively, if the infection has not been stopped, of the vertebral bodies; inflammatory reactions in the
the destructive process involves the trabecular bone prevertebral and/ or laterovertebral soft tissues, along
of the vertebral body, which may undergo severe or with obliteration of the fat tissue or formation of
even massive osteolytic changes. Generally, one perivertebral abscesses; and edema or purulent epi-
vertebral body is affected to a greater extent than the dural collections (Fig. 18.4). The latter are more evident
other. Moreover, the anterior part of the vertebral body when the investigation is carried out after intravenous
usually shows a more marked destruction. In the injection of contrast medium and they may represent
course of 2 or more months the intervertebral disc the first changes that can be seen on CT scans, being
already visible just 2 weeks after surgery (45). However, sequences; and an increased signal intensity of the disc
CT scans do not show a high specificity since similar and the adjacent portion of the vertebral bodies invad-
changes to those found in spondylodiscitis can be noted ed by the inflammatory process on T2-weighted images
in other conditions, such as fractures, tumours or (Fig. 18.5). On Tl-weighted images, the reduction in
marked degenerative changes of the vertebral bodies. signal intensity, presumably due to a decreased vascu-
A discitis can be diagnosed on CT images only when all larization of the vertebral body, may involve the whole
the three typical changes characteristic of spondylo- vertebral body or only a part of it; furthermore, on Tl-
discitis are present (61). weighted sequences it is often impossible to distinguish
the disc from the vertebral body. (Figs. 18.5 and 18.6).
On T2-weighted images, the signal hyperintensity may
Magnetic resonance imaging involve the whole disc or only a part of it; moreover, the
disc does not show the normal band of nuclear
Numerous studies have analyzed the role of MRI in hypointensity (intranuclear cleft) (Fig. 18.6). In these
diagnosing a primary spondylodiscitis (3, 37, 82). images, the vertebral body may show an extensive
However, little is known on MRI changes, and its increase in signal intensity or, more frequently, local-
diagnostic accuracy, in postoperative spondylodiscitis. ized areas of hyperintensity, often in continuity with
In patients with spondylodiscitis, MRI shows two the disc.
types of change: a decreased signal intensity of the In postoperative spondylodiscitis the first changes
disc and adjacent vertebral bodies on Tl-weighted are already visible 3 weeks after the operation (95).
With the resolution of the infective process, the changes ond biopsy is carried out. In this case, we use a trocar
in the signal intensity slowly disappear; this occurs with a 5-7 mm caliber to collect an adequate amount of
more rapidly in the disc than in the vertebral bodies. disc tissue and bone from the adjacent vertebral bodies.
Biopsy Treatment
Surgical treatment
Surgical treatment can be carried out either in the early Dural tears
stage, i.e., the first weeks after discectomy, or after 2 or
more months. Incidence
Some authors have performed an early surgical
treatment to evacuate the infective material in all cases Dural tears are among the most frequent complications
(27) or occasionally (127, 130, 132). Surgery has led to a of surgical treatment. The incidence varies from 1.6%
- - - - - - - - - - - - - - - - - - - - - - - - . Complications of surgery· 489
to 7.5% (4,24,25,39,62,87, 124, 129, 137) and is higher Pathogenesis, site and dimensions
in reoperations.
There does not seem to be a significant difference The dural sac is very rarely injured when the ligamen-
between patients submitted to either standard discec- tum flavum is divided. Lesions caused by the Kerrison
tomy or microdiscectomy. In fact, in some studies in or pituitary rongeur are also rare. In most cases, th!=
which the two techniques were compared, the rate of injury occurs during the dissection of the emerging
this complication was higher in patients who under- nerve root and the thecal sac from adhesions with the
went microdiscectomy (4, 135), whilst in other studies herniated disc tissue or, in the case of reoperations,
the opposite was found (129). Probably the incidence of from the scar tissue around the nervous structures. In
the injury is more related to the surgeon's skill than to the presence of stenosis, the probabilities of a dural
the surgical technique. injury are higher, due to the possible adhesion of the
Fig. 1S.11. Schematic drawing showing the most frequent sites of intra- Pseudomeningocele and duro-cutaneous
operative dural tears. cerebrospinal fluid fistula
ligamentum flavum to the dura mater and the thinning An unrepaired dural tear through which CSF leakage
of the dura in the areas subjected to long standing- continues after surgery may cause a pseudomeningo-
compression (64). cele or a duro-cutaneous fistula. Overall, these compli-
Usually, the lesion is detected some time after its cations have been reported with an incidence ranging
occurrence, due to the sudden leaking of cerebrospinal from 0.01% to 0.5% (89, 100, 114, 124).
fluid. At times an incomplete dural tear is produced, Pseudomeningocele is a condition in which the CSF
which then becomes complete as a result of the contin- collection does not communicate externally. The fluid
ued manipulation of the nerve structures. An incom- collection can be localized only in the spinal canal or
A B c
Fig. 1S.12. MRI scans of a patient with pseudomeningocele after bilateral laminectomy and discectomy at L4-L5 level. (A) and (B) Spin-echo Tl-
weighted and T2-weighted sagittal images, respectively, demonstrating a fluid collection at the operated level (arrows). (C) Spin-echo Tl-weighted
axial image which shows the close relationship between the liquid collection and the posterior portion of the thecal sac (arrows).
- - - - - - - - - - - - - - - - - - - - - - - - · C o m p l i c a t i o n s of surgery' 491
it can be extraspinal. In the latter case, it may not than 5 mm, two overlapping flaps of hemostatic
exceed the fascial plane, or it may extend into the sponges can be applied to occlude the lesion. This is
subcutaneous space. A eSF collection located only in particularly true for those areas where suturing the
the spinal canal is rare. The collection, usually of small tear is demanding or even impossible, such as the
entity, may not cause any symptom or it may compress ventral portion of the dural sac or the medial aspect of
the thecal sac and / or the emerging nerve root and the emerging nerve-root sleeve. Alternatively, the
produce radicular symptoms; the same applies for a tear can be sutured with one or two 5-0 silk stitches.
sub fascial pseudomeningocele (26, 81, 85, 92). Both In both cases, the surgeon should be certain that
conditions can be diagnosed by eT or MRI (Fig. 18.12). once the dural tear has been closed, the eSF leakage
When the fluid collection exceeds the fascial plane, a will stop. This can be done by positioning the patient in
fluctuating swelling measuring a few centimeters in the anti-Trendelemburg and asking the anesthetist to
diameter develops in the area of the cutaneous wound. increase the depth of breathing, and / or by carrying out
In these cases, the differential diagnosis is with a serous the Valsalva manoeuvre. If hemostatic sponges are
subcutaneous collection. This is usually smaller than used, the patient should be left in bed in the horizontal,
a pseudomeningocele and a clearly serous fluid is or slight Trendelemburg, position for 4-5 days and
collected by puncturing the swelling area. In the pres- should be asked not to lie on the side corresponding to
ence of pseudomeningocele, on the other hand, the the dural injury; successively, only 3-4 short walks
leaking fluid is tendentially white; in addition, the sub- are allowed daily until the 7th postoperative day.
cutaneous swelling tends to reform within a few hours With this treatment, carried out by us in numerous
of the fluid's evacuation. It is often the case that a defi- cases of small dural tears, we have always obtained
nite diagnosis can only be made by using imaging the healing of the lesion. When the dural tear has
studies. These show a subcutaneous fluid collection, been sutured, the patient is left in bed for 4 days after
which extends deeply into the spinal canal. the operation. Experimental studies, in fact, have
In the majority of cases, a eSF leakage occurs shown that a sutured dural lesion is already healed
through a dehiscence of the cutaneous wound, forming after 4 days (18).
a duro-cutaneous fistula. Due to the external com- Fibrin glue can be used in place of hemostatic
munication, an infective process can develop which sponge. It is prepared when needed and drops of the
may cause spondylodiscitis and / or meningitis (26). liquid solution obtained are put in the site of the dural
Usually, when abundant eSF with the characteristic tear and on the adjacent portion of the dural sac. The
aspect of crystal clear water leaks externally, the substance strongly adheres to the dura mater, forming
diagnosis is easily made. However, the diagnosis is an impermeable layer which resists to significantly
more difficult, when a dural tear has occurred but not higher pressures than the simple dural suture (18).
been detected by the surgeon, or when the leaked eSF, After a few days the fibrin glue is invaded by a granu-
mixed with blood, assumes a reddish-white color. lation tissue and resorbed. The substance may also be
This can occur in the first few postoperative days. used in addition to the suture, particularly when this is
As the days pass by, not only does the leakage of eSF not tight. Whatever the method of repair used, the
continue, but it tends to become whiter. Moreover, the thoracolumbar fascia should be seal sutured so as to
patient often complains of headache, particularly in obstacle the possible flow of eSF into the subcu-
the upright position, and persistent fever may be taneous layer (26, 104).
present. If there are diagnostic doubts, chemical For dural tears exceeding 5 mm, the treatment of
analysis of the fluid may be carried out to identify choice is the suture of the lesion. Three conditions
the typical components of the eSF. In the early stage, can be distinguished: linear tears which can be easily
even MRI may not aid diagnosis due to the difficulty sutured due to their position; wide tears with tissue
in differentiating a eSF collection from a hematoma loss, in which a direct suture may not be possible;
or a serous collection. and tears which cannot be sutured due to their
position.
The first-type lesions can be sutured either with
Treatment isolated stitches or a continuous suture. The latter
provides a better seal, but may be more difficult to
In the presence of an incomplete dural tear, it is suffi- perform due to the restricted space of the laminotomy.
cient to apply one or two overlapping flaps of hemosta- One of the main difficulties in suturing a dural tear,
tic sponge on the injured area and to keep the patient in fact, is the limited operating field in which it is
at bed rest for 2-3 days after the operation. to be accomplished. This is particularly true when
The treatment of a complete dural tear depends on microdiscectomy is carried out. In these cases, it may
the width and the site of the lesion. For tears no longer be advisable to enlarge both the skin incision and
492.Chapter 18.-----------------------------------------------------
A CSF fistula can be treated surgically or by sub-
arachnoid drainage. Surgical treatment should always
be performed when there are clinical signs of an infec-
tive process, due to the potential risk of septic meningi-
tis. As an alternative, before considering surgery, it may
be indicated to attempt a simpler treatment, such as
the application of a subarachnoid drainage. This holds
particularly when it is known that the lesion, already
identified intraoperatively, is located at an inaccessible
site, or when the surgeon is not aware that a dural tear
has occurred during the operation. In this case, in fact,
there is a risk that the dural tear, although small, may
be located at a hidden site, thereby its suturing could
require an extensive resection of the posterior vertebral
arch or an intrathecal approach.
Subarachnoid drainage
Fig. 18.13. Repairing of an anterior dural tear: a small incision in the This treatment, first described by Mc Callum et al.
posterior aspect of the thecal sac is carried out and a fragment of fat or (78), consists in introducing an epidural catheter into
muscle graft is introduced through it. The graft is then attracted
towards the lesion so as to occlude it. the subarachnoid space and leaving it for a few days so
as to allow the dural tear to heal spontaneously.
muscle disinsertion, and the laminotomy before carry-
ing out the dural suture. Care should be taken in
suturing so as not to catch intrathecal nerve roots.
In the presence of the second-type lesions, it may be
necessary to close the tear with a flap of thoracolum-
bar fascia or with lyophilized dura. The margins of
the lesion should be trimmed and sutured to the
borders of the flap of the chosen material with dis-
continuous stitches. After the operation, the patient
should be left in bed for 5-8-days depending on the
seal of the suture.
When injuries occur in inaccessible zones (third
type), a division of the thecal sac in its posteromedial
portion can be performed in order to introduce a small
fragment of fat or muscle graft into the dural tube. The
fragment will be attracted towards the tear and will
therefore occlude it (26, 27) (Fig. 18.13). This procedure,
however, may be extremely demanding, whereby it
may be preferable to occlude the tear externally with
hemostatic sponge and apply a catheter cranially to
the lesion.
Table 18.3. Clinical data of the patients with postoperative radicular deficit operated by one of the authors (F.P').
Cases Sex Age Diagn. Level Postop. Nerve Type of Recovery Recovery
deficit root surgery time
F 72 Hernia- L4-L5 Paralysis L5 Laminot. No
stenosis
2 F 29 Hernia L4-L5 Paralysis L5 Hemilam. Complete 4m
3 F 56 Hernia- L3-L4 Paresis L4 Multiple Complete 2m
stenosis L4-L5 laminot.
4 F 74 Hernia- L4-L5 Paresis L5 Laminec. No
stenosis
5 F 58 Hernia L3-L4 Paralysis L4 Laminot. Complete 7m
6 F 52 Hernia- L4-L5 Paresis L5 Laminot. Complete 5m
stenosis
494.Chapter 1 8 . - - - - - - - - - - - - - - - - - - - - - - - - - -
dermatomal distribution, or a marked accentuation of weeks. Therefore, a severely disabling outcome is not
preexistent sensory deficits. Normally, hypoesthesia usually observed. When a motor nerve root is involved,
considerably diminishes or completely disappears in on the other hand, the functional consequences are
the course of 1-3 months. much worse, since the motor deficit does not usually
A more severe postoperative neurologic deficit is improve with time.
the onset or accentuation of moderate motor deficits,
usually associated with sensory impairment. Even this
condition usually resolves completely or almost com-
pletely in the course of a few weeks or months. Incidence
To detect a complete radicular paralysis after surgery
is a dramatic event for the surgeon, who often is not The incidence of isolated nerve-root injuries, in the
aware of the occurrence of any significant nerve-root series in which it is reported, varies from 0.1% to 0.9%
trauma during surgery. In these cases, it cannot be (76, 79, 100, 129, 137). Stolke et al. (129), in a series of
excluded that radicular ischemia caused by the surgi- 412 patients, observed three cases (0.7%) of post-
cal trauma, rather than a marked mechanical com- operative worsening of radicular deficits. Two of the
pression of the nerve root during the operation, is patients had undergone conventional discectomy
responsible for the functional impairment. The prog- whilst the third had undergone a reoperation; no
nosis of a postoperative paralysis probably depends on cases, however, were found in the group of patients
various factors, such as the pathogenetic mechanism submitted to microdiscectomy. It can be supposed that
(often unknown), the patient's age and the severity of microdiscectomy, because it allows a better vision of
the preoperative deficit. In the vast majority of cases, the anatomic structures than a standard discectomy, is
radicular paralysis regresses completely, or almost less likely to cause nerve-root injuries. The few data
completely, over 2-6 months. In our experience, this available, however, do not allow any conclusions to
holds particularly for young or middle-aged patients be drawn in this regard.
with minor or moderate preoperative deficits. Elderly In the series of one of the authors (F. P.), six cases of
patients have less chance of a functional recovery, postoperative radicular paresis or paralysis occurred in
particularly if severe and long-standing preoperative patients who had mild or moderate motor deficits
deficits were present. There is very little probabilities preoperatively (Table 18.3). Four of these patients had
of a functional recovery if a complete motor loss persists been submitted to conventional discectomy and two to
after 4 months, and almost none after 6 months. microdiscectomy. The cause of the complication was
identified with certainty in only one case, in whom
postoperative MRI revealed an epidural hematoma.
Laceration
Causes
Fig. 18.17. Pathomechanism of a big vessel injury during lumbar The injury is caused by the perforation of the anterior
discectomy (From Ref 83). wall of the annulus fibrosus and the anterior longitu-
498.Chapter 18.-----------------------------------------------------
dinalligament by a surgical instrument, usually a pitu- causes an acute hemorrhagic shock. A venous injury
itary rongeur (Fig. 18.17). leads to a hypovolemic shock which may be evident
Marked degenerative changes of the anterolateral only a few hours after surgery, since blood extravasa-
annulus fibrous may render the perforation by a tion may occur slowly due to the low venous pressure
surgical instrument more likely. This probably occurs and the hematoma may reduce the hemorrhage. In both
more frequently than is commonly thought. Solonen cases, a myocardial infarction or prolonged hypoxia
(123), by performing an intraoperative discography at should be considered in the differential diagnosis.
the end of disc excision, found the contrast medium to Additional clinical elements, which may be detected
leak through the anterior annulus in 12% of 25 patients, in the postoperative period, may be: reduction or
none of whom had shown a leakage of contrast medi- absence of the femoral pulse together with pallor and a
um at preoperative discography. An anterior perfora- decreased temperature in the lower limbs, on one or
tion of the disc might occur more easily in the presence both sides; abdominal distension accompanied by
of an anterior disc herniation. Another predisposing nausea, vomiting and abdominal pain which persist for
factor is a surgical position causing compression of the more than 24 hours after the operation; the presence of
patient's abdomen, since in this case the retroperitoneal a palpable hematoma in the retroperitoneal space; and
vessels may be in closer contact with the lumbar clinical signs and symptoms of lumbosacral nerve-root
spine. The variability of the anatomic relationships compression.
between the retroperitoneal vessels can explain the The clinical presentation of an arteriovenous fistula
injury to one vessel rather than another, or the occur- is more subtle and multiform. During the operation
rence of an arteriovenous fistula instead of an isolated there may not be a hemorrhage from the disc space or, if
vessel injury. there is, it may be mild; very often, however, there is a
The main cause of a vascular injury, however, is an drop in the arterial pressure along with an increase
excessively vigorous discectomy and especially a vio- in the pulse frequency. After the operation the patient
lent trauma caused by the pituitary rongeur to the may present palpitations, pallor, ileus and abdominal
anterolateral annulus fibrosus or discectomy carried pain. Physical examination reveals congestive heart
out too ventrally. The best ways to prevent an annular failure, which may eventually be associated with car-
perforation are to avoid forcefully penetrating the disc diomegaly; an increase in the systolic and a decrease
with the pituitary rongeur, particularly at the begin- in the diastolic pressure, due to reduced peripheral
ning of the discectomy, when the opening made in the arterial resistance; direct local signs (vessel fremitus or
posterior annulus is still narrow, and to avoid even murmur) and indirect signs (edema in one or both
touching the anterior wall of the annulus fibrosus with lower limbs, vascular peripheral insufficiency, pulsat-
the pituitary rongeur during the removal of tissue in ing varices). Given the relatively poor initial clinical
the disc space. Furthermore, it is advisable to open the presentation, an arteriovenous fistula is often diag-
pituitary rongeur immediately after this has been intro- nosed late (6, 22), sometimes after years (13, 126) and
duced into the disc space: it is in fact easier to perforate not rarely the patient is treated for thrombophlebitis.
the anterolateral annulus fibrosus when the jaws are Diagnosis is made by arteriography and CT and I or
closed than when they are open (6). Another precaution abdominal MRI.
may be that of applying a mark (a metallic collar or thin
strip of plastic material) on the pituitary rongeur,
indicating the safety depth when penetrating the Treatment
disc space (51). Such depth would be of about 3 cm (2).
If vascural injury is detected during surgery, the disc
space must be filled with hemostatic material and
Clinical presentation and diagnosis abundant blood transfusions or hematic substitutes
administered. If the general condition of the patient
The two main clinical signs of an abdominal vessel appears to be very serious, the skin should be rapidly
injury are: an abundant hemorrhage from the disc closed with sparce stitches, the surgical wound protect-
space and an unexplainable arterial pressure drop ed with two adhesive plastic sheets and the patient
during or immediately after the operation. prepared for laparotomy. The latter should be carried
Vascular injury should be suspected in the presence out by the orthopaedic surgeon or neurosurgeon only
of profuse bleeding from the disc space and is certainly if there is a high risk of the patient's immediate death
present when a stream of blood comes out from the and a vascular or general surgeon is not immediately
interspace. The color of the extravasated blood has available. In this case, the surgeon should only clamp
little diagnostic value, since venous blood is highly the injured vessel and wait for a vascular surgeon who
oxygenated during anesthesia (83). An arterial injury can adequately repair the lesion. Usually, however, the
________________________ 0Complications of surgery 0499
operation should be postponed until the arrival of a The surgeon realizes that an injury to the bowel has
vascular surgeon; this holds particularly when the occurred when a fragment of mucosa or smooth muscle
diagnosis has been made in the postoperative period. tissue is removed from the disc space with the pituitary
An arteriovenous fistula should not usually be treated rongeur. If adipose tissue is excised, a bowel injury
as an emergency. is very likely. In the majority of the reported cases,
If the vascular injury is diagnosed and treated early, however, the surgeon did not realize that a bowel
the mortality rate is very low. In DeSaussure's series injury had been provoked.
(22), the mortality rate, in cases treated within 24 hours The injury may cause, since a few hours after the
of the operation, was little more than half of that in operation, a clinical picture of acute abdomen with
patients treated later. A fatal outcome mainly occurs in peritonitis or abdominal distension associated with
patients with severe injuries to the aorta or vena cava, gastric disturbances (7). In some of the cases reported,
who may decease during, or shortly after, the end of the injury caused a deep infection and was diagnosed
surgery. The mortality rate for arteriovenous fistula is late (117, 120). In one case, the intestinal injury (appen-
lower than that for isolated vessel injuries, but a periph- dix avulsion) was recognized during the repairing of an
eral vascular insufficiency persists in some of the arteriovenous fistula (7).
patients treated surgically. In the presence of persistent abdominal disturbances
after surgery, the possibility of bowel injuries should
be considered. In these cases it may be useful to take a
radiograph of the abdomen to detect the presence of
Ureter injuries free gas and the postoperative clinical course should
be carefully monitored. The subsequent appearance of
These injuries are very rare (10, 22, 51, 57, 84, 90, 110,
signs of deep infection can confirm the suspected bowel
137). WildfOster (137) found only one case in a series
injury.
of 68,329 herniated discs operated on in 37 hospitals.
The treatment includes an exploratory laparotomy
This injury can occur during discectomies carried out
and repairing of the lesion.
either at L4-L5 or L5-S1 level. In some cases it was
associated with vascular injuries. The right ureter, in
fact, runs close to the vena cava and the left ureter is
close to the aorta. Complications due to patient's
Borski and Smith (10) positioned three marks in the wrong positioning
L4-L5 disc in a cadaver, in order to simulate the course
of a pituitary rongeur introduced into the disc on the
right side. The subsequent abdominal exploration
Peripheral nerve injuries
showed that two of the marks were close to the com-
Brachial plexus and nerves of upper limbs
mon iliac artery and the third was in contact with the
left ureter. According to the authors, an ureter injury
Brachial plexus injuries can be due to nerve stretching
tends to occur more easily on the opposite side to that
or compression. They occur when the limb is posi-
in which the discectomy is carried out.
tioned at 90° abduction, extrarotation and extension. In
This complication usually becomes manifest a few
these position, the humeral head protrudes into the
days after the operation with variable symptoms,
axilla and may lead to stretching of the brachial plexus
including hematuria, fever, flank pain and abdominal
and compression of the axillary nerve. Nerve stretching
pain associated at times with a paralytic ileum. The
increases further if the neck is tilted towards the oppo-
diagnosis is made with an intravenous urogram or a
site side. These injuries usually occur in the supine or
retrograde ureterogram, which reveal a leakage of the
lateral position (91), but they can exceptionally happen
contrast medium from the ureter. The treatment is
in patients placed in the prone position. The prob-
surgery.
ability of a plexus injury, as well as any peripheral
nerve injury, increases in proportion to the duration of
surgery. Usually, the neurologic deficits recover in a
Bowel injuries time lapse ranging from a few days to several months;
however, they can be also irreversible (91).
Approximately 10 cases of this complication have been The ulnar nerve can be compressed in the epitrochlea-
described (7, 22, 48, 60, 89, 115, 117, 120, 121), some of olecranon groove due to malpositioning of the elbow
which were associated with vascular injuries (7, 22). on the arm support. The anterior interosseous nerve of
In most cases the lesion occurred during an L5-S1 the forearm can be compressed with the same mecha-
discectomy. Generally, the small intestine was injured. nism. In this case, the clinical picture is characterized
soo.Chapter 1 8 . - - - - - - - - - - - - - - - - - - - - - - - - - - -
by difficulty in the flexion movements of the distal the anterior superior iliac spine in the prone position.
interphalangeal joint of the index finger and the inter- This can occur when the Wilson frame is used, if the
phalangeal joint of the thumb, and by reduced strength iliac supports are not sufficiently padded. The patient
of the pronator quadratus (better evaluated with the complains, immediately after the operation, of hypoes-
elbow completely flexed); the lesion can be favored thesia in the lateral or anterolateral region of the thigh,
by anatomic anomalies of the nerve or perineural which in a few cases is accompanied by burning pain.
structures. Usually the disturbance decreases progressively until
it disappears over 2-7 days. At times the hypoesthesia
can last for some weeks, but in our experience it dis-
Sciatic nerve and peroneal nerve appeares in all cases. No treatment is necessary.
This complication, which is rather frequent when the
The sciatic nerve can be compressed, in patients oper- Wilson frame is used, can be avoided by adequately
ated on in the kneeling position, by the support lying padding the iliac supports or, in obese patients or those
on the gluteal region, if this is a bar. The latter can submitted to long operations, by placing a small soft
compress the nerve when it is positioned at the level of pad or a thick layer of cotton on the support.
the inferior portion of the glutei or at the proximal
extremity of the thigh.
Cutaneous injuries
An excessive pressure on a limited cutaneous area can
Case report cause edema or necrosis of the skin. This can occur on
the thorax, scrotum, penis, on the face and on the knees
A 57-year-old woman underwent discectomy for a con- during operations performed in the prone position, and
tained herniated disc at L4-L5 level on the right. The opera- on the trochanteric region when surgery is performed
tion was performed in the kneeling position with the glutei in the lateral decubitus (103, 122). If the Wilson frame
held up by a metal bar 8 cm high, padded with foam rubber. is used, the skin of the abdomen or the scrotum may
The operation was carried out without complications. After get stuck in the rack at the base of the frame when the
surgery, the patient presented a paralysis of the right sciatic iliac rests are raised.
nerve. When she was examined by one of us 10 days after the
operation, a marked hypoesthesia was found in the entire sci-
atic nerve dermatome, as well as marked to complete motor Ocular injuries
loss of all the leg muscles and flexor muscles of the thigh, and
mild deficit of the gluteus maximus and medius. No sphinc- The prone position, whatever type of operation is
ter dysfunction was present. MRI of the lumbar spine showed performed, exposes the patient to the risk of ocular
the presence of granulation tissue in the laminotomy area, complications (67). These are usually represented by
but no significant compression of the nervous structures. A excoriations and contusions of the eyelids. In rare cases,
probable compression of the sciatic nerve caused by the glu- a compression of the eyeball occurs, which may lead
teus support during the operation was diagnosed. to transitory or permanent decrease in, or loss of, vision
The patient underwent physiotherapy and neurotrophic (50,53, 103, 125, 133). The pathogenetic mechanism, in
medication. Six weeks after the operation the neurologic the most severe cases, is a thrombosis in the central
deficits began to regress and completely disappeared over artery of the retina, which causes a retina ischemia. If a
3 months. complete ischemia occurs for more than 15-20 minutes,
it causes irreversible damage to the retina associated
The peroneal nerve may be compressed when a with atrophy of the optic nerve and permanent blind-
lateral decubitus position is used (91). This complica- ness. Arterial thrombosis can occur more easily if the
tion can be avoided by placing a pad under the knee operation is carried out under hypotensive anesthesia
lying on the operating table. (67). The ocular injury becomes manifest with exoph-
thalmos, which is already present upon the patient's
awakening, or appears 1 hour after the end of the
Femoral cutaneous nerve operation, with visus loss. The possible recovery of the
sight occurs during the first 4-6 weeks.
This nerve can be compressed due to an excessive flex- The injury can occur when either a horseshoe head
ion of the hip in the knee-chest position or in the lateral holder for cervical spine surgery is used or the patient's
decubitus position (102). The most common cause, head lies on the operating table in a twisted position. In
however, is an excessive compression at the level of the first case, eyeball compression can occur even
- - - - - - - - - - - - - - - - - - - - - - - - - · C o m p l i c a t i o n s of surgery' 501
bilaterally (103); in the second, the compression can
more easily occur in patients with a marked stiffness of
the cervical spine. This complication can be prevented
by taking extreme care when positioning the head,
using a soft pad when the head is placed on the operat-
ing table, checking for possible head displacement from
the pad during surgery (for instance if the patient
moves due to lightening of the anesthesia) and by
frequently evaluating the ocular region during the
operation.
Case report
A 63-year-old patient, 1.85 m tall and weighing 115 kg, Fig. 18.18. Axial CT scan at the orbital level in a patient with severe
underwent a bilateral laminotomy at L4-L5 and L3-L4levels exophthalmos of the left eye which occurred after excision of a disc her-
and bilateral discectomy at L4-L5 level, due to a central disc niation in a stenotic spinal canal. The image reveals a thickening of the
herniation in a constitutionally stenotic spinal canal. The rectus medialis and lateralis muscles (asterisks), of the left subpalpebral
patient complained of chronic cervical pain and had a consid- tissue (arrow) and dysmorphy of the eyeball.
erable rigidity of the cervical spine due to spondyloarthrosic
changes. The operation was carried out in the prone position,
motor loss, generally resolve within 1-2 days. In
using a Wilson frame. The patient's head was turned towards
patients operated on in the lateral decubitus position, a
the right and rested on afoam rubber ring. The operation was
Horner syndrome can occur due to the stretching of the
performed without any particular difficulty and controlled
cervical sympathetic chain when the neck is excessive-
hypotension was not carried out.
ly flexed laterally (40).
When at the end of surgery the patient was placed in the
supine position, a semicircular ecchymosis in the medial
region of the left orbit was noted. After 20 minutes, a consid-
erable edema in the left eyelids appeared together with a pro- Retention of foreign bodies
gressive exophthalmos. The patient had a complete vis us loss.
Furthermore, he had paresthesias, hypoesthesia and mild In two very large series, the incidence of this complica-
motor deficits with a C6 and C7 radicular distribution. An tion was 0.07% (100) and 0.012% (138), respectively.
ophthalmologist diagnosed the presence of a cornea abrasion These rates, however, are probably lower than the true
and probable thrombosis of the central artery of the retina. CT incidence of the complication, since foreign bodies that
scans of the left orbit showed a marked exophthalmos due to a do not cause any symptoms are not usually detected.
retroeyeball edema and a dysmorphia of the eyeball (Fig.
18.18). The patient was treated with high doses of vasodila-
tors, heparin and corticosteroids. The radicular disturbances
disappeared in the course of2 days. The eyelid edema and the Cottonoids and hemostatic gauzes
exophthalmos regressed within 3 weeks, but the patient had a
complete and permanent loss of sight of the left eye. A cottonoid or hemostatic gauze left in the surgical
Probably, the marked stiffness of the neck did not allow an wound can provoke a foreign body inflammatory reac-
adequate axial rotation of the head during surgery, whereby tion responsible for a fistula from which serous-puru-
the malpositioning of the head had favored the eyeball com- lent material leaks out. This can occur even a few
pression. months after the operation (34). Occasionally, the for-
eign body may compress a nerve root, with consequent
persistent radicular symptoms; these can be caused
Cervical neurologic injuries either by nerve-root compression or the aseptic inflam-
matory reaction produced by the foreign body.
In patients with marked arthrosic changes in the cervi-
cal spine, hyperextension and / or a marked axial rota-
tion of the neck in the prone position can cause spinal Case report
cord compression or accentuate a preexistent one, or
lead to a compression of the cervical nerve roots. The A patient who underwent excision of a disc herniation at L5-
radicular disturbances, including hypoesthesia and 51 level in 1989 continued to complain of radicular symp-
502.Chapter 18.-------------------------------------------------------
toms as severe as prior to the operation, from the first postop- Intraoperative hemorrhage
erative day. The symptoms regressed with the administration
of corticosteroids, but they recurred as soon as the therapy The amount of epidural bleeding is extremely variable.
was discontinued. The cutaneous wound healed in the usual It is often abundant, especially with arterial hyper-
time without complications. Successively, the patient under- tension patients or in those with coagulation defects,
went prolonged physiotheraphy with no improvement. but it is never uncontrollable for a sufficiently expert
The patient was seen by one of us 4 months after the surgeon. In our series of patients operated on for disc
operation. The clinical picture suggested an incomplete herniation, blood transfusion has never been necessary.
removal of disc herniation. The patient underwent CT of In the series of Stolke et al. (129), abundant intraopera-
the lumbar spine, which revealed a round formation about tive bleeding was found more often during conven-
1cm in diameter, which was interpreted as a disc fragment, tional discectomies than microdiscectomies.
situated caudally to the LS-S1 disc. During the second The bleeding should be carefully controlled, particu-
operation, afragment ofhemostatic gauze was found, wound larly at the end of surgery, since the persistence of an
up in the 51 radicular canal, without any apparent local abundant hemorrhage after closing the thoracolumbar
inflammatory reaction. The foreign body compressed the 51 fascia can cause a postoperative epidural hematoma
root, to which it was loosely adherent. It was removed responsible for compression of the nervous structures.
without difficulty, leading to a complete resolution of the This complication should be prevented by coagulating
symptoms. the largest epidural vessels, using hemostatic material,
tamponing tightly the bleeding vessels for a few min-
utes before suturing and applying a wound drainage.
Prevention
RESULTS OF SURGERY
F. Postacchini, S. Gumina
worthwhile pointing out that in all the longitudinal after all treatments, results were excellent in 57% of
studies carried out so far, the results were evaluated cases, good in 38% and poor in 4%. A similar proportion
clinically, but plain radiography, CT or MRI were not of reoperations (18%) to that reported in the latter
carried out to determine the nature and severity of study, was found by Taylor (119) in a series of 39
postoperative degenerative vertebral changes. patients assessed, on average, 5 years after surgery.
Deterioration of the results with time may be due to Also in the past, discectomy has rarely been associat-
degenerative vertebral changes at the level where ed with fusion in patients under the age of 20 years. The
surgery was carried out and / or degenerative changes results, in patients submitted to fusion, did not differ
of d\scs or facet joints at different levels from that significantly from those in patients who had no
operated on. Epidemiologic studies (92) have shown arthrodesis (14, 27, 57).
that a constitutional predisposition to degeneration
of intervertebral discs exists, as suggested by the
frequent detection, on MR images, of degenerative Elderly patients
changes of multiple discs, in patients with a single-level
disc herniation. This tends to suggest that the persis- The proportion of satisfactory results at short-medium
tence or recurrence of low back pain is often due, also term in patients over the age of 60 years is similar to
or only, to degenerative changes at levels different that in middle-aged subjects.
from that operated on. Maistrelli et al. (69), who evaluated 32 patients aged
over 60 years, found an excellent or good outcome in
87% of cases and no poor results. Comparable percent-
Teenagers ages of satisfactory outcomes (88% and 90%) had previ-
ously been reported by other investigators, who had
Immediate or short-term results are satisfactory in assessed only patients over 60 years (109) or aged 50-72
almost all patients. The percentages reported are usual- years (86). An et al. (6) found satisfactory results in
ly over 90% (11, 21, 27, 29, 80, 102) and only a small 92% of 50 patients aged 50 to 78 years, followed-up
minority of patients have a poor outcome. Sensory and at short or medium term. Most of the patients had an
motor deficits almost always disappear and vertebral extruded disc herniation and one fifth also a con-
rigidity resolves within a few weeks. The majority of comitant stenotic condition.
subjects return to preoperative sporting activities a
few months after the operation (70).
In contrast, conflicting results have been reported Lateral herniations
regarding the long-term and very long-term outcomes.
Savini et al. (102) evaluated 101 cases, 2 to 22 years after Many studies (1, 24, 30, 34, 51, 87, 93, 103, 107) have
surgery, and personally examined 84 of them. In the lat- selectively analyzed the results of surgical treatment in
ter group, the results were rated as excellent in 79% of intraforaminal and extraforaminal disc herniation
cases and good in 18%; both patients with a poor (Table 19.4). In the majority of cases, the outcome,
outcome had an L5-S1 disc herniation and spondyloly- regardless of the type of surgical approach (interlaminar
sis of L5, which had transformed into spondylolisthesis or extravertebral), was, on average, not as satisfactory
at the time of follow-up. Of the 101 patients, only three as that generally reported for other types of disc
had undergone repeat surgery for disc disease (one herniation.
with recurrent disc herniation at the same level and two In a short-term analysis of 16 patients treated by the
with herniation at a different level). Similar results were inter laminar approach, it was found that 62% had
observed in other studies, in which small groups of satisfactory results (51); in one of the two cases with a
patients were followed-up at medium, long or very poor outcome, the extraforaminal disc herniation had
long term (13, 57, 80, 100, 125). The results of two stud- not been excised at surgery. The same occurred in two
ies carried out at very long term, in a same hospital, patients, out of 60, in another series (30), in which the
were less encouraging. In one of these two sudies (21), herniation was removed by an interlaminar approach
50 patients were evaluated, on average, 19 years after and a partial (47%) or total (53%) arthrectomy; in this
surgery: 24% had been reoperated and the result was series, only one patient required fusion due to post-
rated as poor in 26% of cases. In the other study (27) surgical instability. However, in the largest reported
(probably including all, or some of the patients in the series (1), including 138 cases operated through an
previous study), after a mean of 18 years, 16 (20%) interlaminar approach, a satisfactory result was ob-
patients out of 74 had undergone discectomy and/or tained in 82% of patients.
fusion, mostly at the same level as the initial operation, Postacchini et al. (90) evaluated the outcome of
and seven had a third or fourth operation. However, surgery in 43 patients with intraforaminal (34 cases) or
512.Chapter 19.-------------------------------------------------------
Table 19.4 . Percentages of satisfactory results in intraforaminal Discectomy at multiple levels
or extraforaminal disc herniation.
Author No. of patients Satisfactory results Little is known concerning the quality of the surgical
Postacchini (1979) 9 77%' results in patients operated on at multiple levels, com-
Faust (1992) 12 92%' pared with those submitted to surgery at a single level.
Jackson (1987) 16 62%' In a study on teenagers (21), it was found that of the
Darden (1995) 25 80%' patients operated on at two or more levels for excision
Donaldson (1993) 29 72%d
Siebner (1990) 40 70%'
of multiple disc herniations or only surgical explo-
Postacchini (1995) 54 89%b ration, almost half underwent repeat surgery over the
Epstein (1990) 60 95%' next few years. The available data on adult patients
Abdullah (1988) 138 82%' with disc herniation at multiple levels are too few and
'Conventional discectomy. incomplete to draw any definite conclusions. This
bMicrodiscectomy through an inter laminar approach. holds particularly for patients with a symptomatic disc
'Extravertebral approach. herniation and an asymptomatic annular bulging or a
d Combined inter laminar and extra vertebral approach.
small contained herniation. These conditions are
frequently observed with the modern imaging studies,
extraforaminal (9 cases) disc herniation excised through but the surgical indications are often uncertain, due to
an inter laminar approach using the operating micro- the lack of data on the long-term clinical evolution in
scope. Posterolateral disc protrusion or spinal stenosis patients in whom also the asymptomatic disc is excised,
was present at the level of the lateral herniation in compared with those undergoing removal of only the
four and seven cases, respectively. In intraforaminal symptomatic herniation.
herniations, the results were satisfactory in 88% of
cases at 3-month follow-up and 91% at 2-year follow-
up. In extraforaminal herniations, an excellent or good
outcome was obtained in 89% of cases in the im- Discectomy through an anterior approach
mediate postoperative period and in all cases at 2-year
follow-up. In only one patient was total arthrectomy In a series of 80 patients, Tsuji et al. (123) carried out
carried out inadvertently. In no case, did surgery cause repeat surgery through a posterior or anterior approach
vertebral hypermobility. in nine cases. In the remaining patients, followed-up at
The results of operations performed through short and long term, the percentage of satisfactory out-
extravertebral approaches do not appear to be better comes was 93% at short term and 91% at long term; no
than those carried out through an interlaminar patient had a fair or poor result. The operated disc
approach (19, 24, 107). In a short-term study (107) of 40 showed an average decrease in height of 2 mm 3 years
patients operated through a para-articular approach after the operation, and of 3 mm at long term. Similar
using the operating microscope, the result was satisfac- results were reported by Nakano and Nakano (76), who
tory in 70% of cases; of the six patients with a poor out- observed an excellent outcome in 90%, and a good out-
come, five had persistent or recurrent herniation and come in 6%, of 304 cases, half of whom were followed
one of these also had stenosis of the radicular canal. A for more than 5 years after surgery. In this series, so
similar rate of satisfactory results (72%) was obtained in gratifying for the surgeons, poor results were reported
a study on medium-term results in 29 patients operated in only 0.6% of patients.
through a combined interlaminar and para-articular
approach (24). In contrast, Faust et al. (34) found a satis-
factory outcome in 92% of 12 patients with extra for am-
inal or intraforaminal herniation, operated through a Discectomy and fusion
paraspinal, or occasionally a combined, approach.
In our experience, the use of the operating micro- Several studies have found higher rates of satisfactory
scope makes the operation through the interlaminar outcomes in patients submitted to discectomy and ver-
approach considerably easier and also increases the tebral fusion than in those undergoing only discectomy
percentage of satisfactory results. However, the rate of (66,75,126,132). However, a large number of investiga-
excellent or good results is higher in patients with tions indicate that, in patients with disc herniation,
migrated or extruded herniation than in those with arthrodesis does not provide significantly better results
contained herniation. The patients with a contained or than discectomy alone (8, 35, 39, 64, lOS, 122). In
extruded extraforaminal disc herniation tend to have a patients undergoing only discectomy, the proportion
better outcome than those with an intraforaminal disc of reoperations over the following years tends to be
herniation of the same type. higher than in fused patients (122, 126). Despite this
- - - - - - - - - - - - - - - - - - - - - - - - - - - 0 Results of surgery 0513
advantage, in patients undergoing arthrodesis the rate 3-4 months after surgery, an adequate recovery is
of postoperative complications is higher, the hospital unlikely to occur and the probability will progressively
stay is longer and the treatment is more expensive (23). decrease with increasing time.
These findings indicates that arthrodesis should not be Sensory deficits recover to a large extent or complete-
used as a matter of routine in patients with a clinical ly in the majority of patients (36). If recovery is only
syndrome typical of disc herniation. Fusion may be partial, hypoesthesia is usually limited to a narrow
recommended in selected cases, together with, or area in the distal part of the dermatome. The areas
following, discectomy. where most frequently hypoesthesia persists are the
big toe, the lateral border of the foot and the heel.
Osteotendinous reflexes do not usually return when
they were absent preoperatively (36, 59). When they are
Recovery of neurologic deficits decreased, they often normalize, even if with some
delay.
Slight or moderate motor deficits, in the absence of a
cauda equina syndrome, usually recover completely
within 1-3 months after surgery. Severe motor loss, Cauda equina syndrome
instead, may recover only partially or may remain
unchanged. This occurs in 10%-20% of cases (36, 78, The results of surgery regarding bladder function
101,113). The frequency of complete recovery of motor depend on the severity of sphincter dysfunction, which
deficits was found to be higher in patients undergoing is strictly related to the rapidity of onset of the syn-
microdiscectomy compared with those operated con- drome. In the presence of an abrupt onset, which tends
ventionally (78). to be associated with bladder paralysis and bilateral
Usually, the greater the preoperative deficit, the perianal anesthesia, sphincter function recovers com-
slower the recovery. The entity of recovery depends on pletely in half to two-thirds of cases (63, 113). Patients
the severity and duration of the deficit before surgery. with a slow onset of the syndrome and / or bladder dys-
Severe muscle weakness may not improve, if it is of function and unilateral perianal anesthesia or bilateral
long duration (77). Unfortunately, the time limit hypo esthesia nearly always recover complete bladder
beyond which the probability of recovery decreases function. There is no correlation between preoperative
considerably or chances become nil, is not known. duration of the syndrome and quality of the results
Certainly, the limit varies in different individuals and (37, 52, 63, 81, 113). In the series by Kostuik et al. (63),
may depend on either the patient's age or the muscle no significant differences emerged between patients
group, and thus the root, involved. Elderly patients operated within 48 hours and those operated 3-5
appear to have less ability to recover motor loss than days after the onset of the syndrome. Spannare (113)
young subjects. The quadriceps rarely presents severe reported better results in patients treated surgically
weakness and only exceptionally remains considerably after the first week compared with those operated
impaired; this is likely to be due to the pluriradicular within the first few days (who had greater degrees of
innervation of the muscle. The extensor hallucis longus bladder dysfunction). Usually, in patients with a satis-
is the muscle which most frequently presents a partial factory final outcome, bladder function is partially
recovery; however, an even severe weakness of this recovered within the first 2 weeks and completely
muscle is almost never disabling. The tibialis anterior restored between 2 and 5 months after surgery; occa-
and peronei muscles are, after the extensor hallucis sionally, however, longer intervals, even of years, may
longus, those most frequently showing an insufficient, be necessary (3, 118).
or even no, recovery, usually leaving the patient, in this Sexual dysfunction often persists, particularly in
case, with a disabling functional deficit. The triceps males. This may consist in a decreased sensitivity of the
surae muscle rarely remains weak, but when this penis or sexual impotence; this residues in approxi-
occurs the patient is considerably disabled. matelya quarter of cases (63).
In our experience, in the presence of severe muscle Preoperative motory deficits recover completely in
weakness (strength equal to, or less than, 2/5) lasting the vast majority of patients, but, if severe, they may
less than 1 month, there is a high probability of com- improve only partially or persist unchanged. There is
plete or almost complete recovery; the probability is no correlation, also for muscle weakness, between qual-
fairly low when the deficit lasts since 1-4 months and ity of the results and rapidity of intervention, if surgery
the chance then progressively decreases, until it disap- is carried out within the first few weeks after the onset
pears, after 8-12 months. Usually, a partial recovery is of syndrome. Sensory deficits recover less frequently,
clinically appreciable after the second postoperative and in longer periods of time, compared with motor
month. If there is no clinical evidence of improvement loss (118).
514.Chapter 19.-----------------------------------------------------
Return to work However, conflicting data exist on the prevalence of
this change, the percentages ranging from 30% (77) to
Return to work after surgery for lumbar disc herniation 98% (44). After surgery, the operated disc often decreas-
depends on various factors, which are not only med- es in height, or shows a further decrease, usually of
ical, or however vertebral. They are essentially repre- mild entity. Kambin et al. (56) analyzed the spondylotic
sented by: the patient's will to resume work; the type changes (decrease in disc height, marginal osteophytes,
of work; the patient's cultural level; and the possibility hypertrophy of the facet joints) appearing after surgery
of obtaining workmen's compensation. The variability in 39 patients, who showed no appreciable changes on
of these factors may affect the percentage of patients preoperative radiographs. An average of 5 years after
who return to work and the average time off work, in surgery, 61 %of patients had mild to severe spondylotic
different historical periods and different countries. changes. Of these patients, 30% showed a decrease in
Of 695 Scandinavian patients (101) treated surgically height also of the disc above. Naylor (77) observed that
between 1960-1965 and followed-up at long term, 66% in 50% of 72 cases followed for 10-25 years, the opera-
had returned to preoperative work, 8% had changed tion had no effect on the onset or increase in severity of
to a lighter work, 2% had resumed a heavier work, 7% the spondylotic changes. The result of surgery, howev-
were not working and 17% had a disability pension. er, does not appear to be influenced by the spondylotic
In various long-term studies (65, 67, 129) carried out changes present before surgery or developed subse-
in North America and Europe, approximately 90% of quently (44, 77).
patients had resumed the same work, or a lighter work
(10-30%). In Switzerland, in the long or very long term,
14% of patients were partially or totally unable to work
(25). Similar proportions of work resumption and Predictive factors of the outcome
working inability were found in studies on patients
treated surgically over the last decade (26, 60, 124), and Many studies have attempted to determine which fac-
assessed at short or medium term. tors may be of prognostic value regarding the result of
The mean time off work varies, in the majority of surgery. Two factors were found to be predictive in
reports, between 6 and 12 weeks. However, various fac- almost all studies: the duration of preoperative pain
tors affect the rapidity with which a patient returns to and type of herniation. A third factor - the degree of
work. Usually, sedentary workers resume work before positivity of the straight leg raising test - was predictive
manual workers, and the latter before those doing a in the majority of studies in which the prognostic value
heavy job. In a prospective study (130), the average of the test was analyzed (Table 19.5).
time off work after surgery was found to be 15 days for Patients with long-standing low back and/ or radicu-
professionals, 30 days for office workers and house- lar pain tend to have less favorable results than those
wives, 46 days for manual workers and 51 days for with a short painful period before surgery, as already
heavy manual workers; these figures, however, are observed by Mixter and Barr (74). The time limit
lower than those commonly reported for the various beyond which the result is negatively affected has not
categories of workers. There is strong evidence indicat- been well defined. In some studies, it was found to be
ing that patients with a shorter duration of preopera- very short - 2 or 3 months (43, 48, 61, 117) - and in
tive pain (less than 2 to 6 months, depending on others rather long - 1 year or more (16, 65, 67).
the studies) return to work faster than patients who Presumably, the limit is 4-8 months and it is shorter
have a longer period of illness (43,58,60,77). However, for patients with continuous pain than for those with
a too fast return to work, in the presence of persistent intermittent pain. Surin (117) analyzed the chronic
lumboradicular symptoms, might negatively affect history of lumboradicular pain preceding the episode
the long-term results of surgery (129). Several studies which had led up to surgery, but no significant differ-
(10, 78, 131) have revealed that patients submitted to ences emerged, regarding the duration of postopera-
microdiscectomy resume work quicker than patients tive inability to work, between patients with a short,
operated conventionally; Tullberg et al. (124), instead, and those with a long, history of pain.
found no significant differences between the two In patients with contained disc herniation and, more
procedures. so, in those with annular bulging or negative surgical
findings, the percentage of satisfactory results, evaluat-
ed clinically or on the basis of the length of the time off
Spondylotic changes work after surgery, is significantly lower than in
patients with extruded or migrated herniation (48, 65,
In many patients with disc herniation, the herniated 67, 112, 115, 117). No significant difference would
disc presents a decrease in height of varying degree. appear to be present between the latter two conditions.
- - - - - - - - - - - - - - - - - - - - - - - - - - 0 Results of surgery 51 5
0
Table 19.5. Predictive factors of the surgical result. survey (2), it was observed that the presence of pre-
Highly predictive factors operative muscle weakness implies an increased pro-
Duration of preoperative symptoms bability of failure in the resolution of the radicular
Degree of limitation of SLR syndrome, whereas the presence of sensory deficits
Type of disc herniation increases the probability of persistent postoperative
Moderately predictive factors low back pain.
Age Obesity appears to playa role on the outcome of
Neurologic deficits surgery according to some authors (48), but not accord-
Obesity
ing to others (65).
Diabetes
Nicotinism In a retrospective study comparing diabetic and non-
Fibrinolytic activity diabetic patients with disc herniation, it was found that
Type of work the rate of satisfactory results was considerably lower
Social and psychologic factors in diabetics (35%) than in non-diabetics (96%) (110);
Workmen's compensation similar findings were obtained in stenotic patients. The
Duration of sick-leave cause of failure in diabetic patients has been related to
Other painful areas in the body
the coexistence of diabetic neuropathy or microan-
Width of surgical approach
giopathy. However, Cinotti et al. (17) did not observe
significant differences in the results of surgery between
The volume of disc tissue removed at surgery does not stenotic patients with or without diabetes; the failures
seem to affect the outcome of surgery (104). in diabetics were due to errors in identifying the etiolo-
In the majority of studies analyzing the relationship gy of the clinical syndrome (diabetic neuroangiopathy,
between the degree of positivity of the SLRT and the rather than stenosis).
proportion of satisfactory surgical results, a close cor- In heavy smokers, the outcome tends to be worse, as
relation was found between the two parameters (2, 45, far as concerns the relief of low back pain, than in non-
48, 65, 127, 130). Moreover, it was noted that a positive smokers (44).
crossed SLRT (45) or absence of low back pain in raising Normal fibrinolytic activity (evaluated from euglo-
the leg (2) is predictive of a satisfactory outcome. In a bin clot lysis time and concentration of plaminogen
few investigations, however, no relationship emerged activator inhibitor 1) seems to favor satisfactory surgi-
between positivity of the SLRT and quality of the result, cal results, unlike reduced fibrinolytic activity (41). A
whilst in others (67) a short-term, but not a long-term, defect in fibrinolytic activity, in fact, might imply
correlation was found. inadequate removal of fibrin deposits, and lead to
Considerable doubt still exists concerning the influ- chronic inflammation and more abundant formation of
ence of many other factors upon outcome, namely, age, peridural scar tissue (94).
neurologic deficits, obesity, diabetes, nicotinism, fibri- Data on the relationship between the type of pre-
nolytic activity, type of work, social and psychologic operative work and the outcome of surgery are also
factors, compensation, total duration of sick leave conflicting. A few investigators found a weak correla-
in the years preceding the operation, presence of other tion between these two factors (48). Other investigators
painful areas in the body, and width of the approach to (10,35,65, 111) observed that sedentary workers obtain
the spinal canal (Table 19.5). much more satisfactory results than manual workers.
In a few studies (2, 61, 65), the age at the time of In a prospective study of 100 patients assessed 1 year
surgery was not found to affect the result. In other stud- after surgery, Weir (130) observed comparable results in
ies (43, 46, 48, 101), patients under 40 years of age pre- sedentary and manual workers, except for postopera-
sented a higher rate of satisfactory results than older tive low back pain, which was more frequent in manu-
patients. Spangfort (112) reported that the proportion al workers. The latter return to work, on average, after
of patients with complete relief of radicular pain after a longer time interval and less often than sedentary
surgery progressively decreases with increasing age, workers (101).
but this holds only for patients with contained disc her- In a prospective survey (48) of 357 patients, evaluat-
niation, annular bulging or negative surgical findings. ed 1 month and 6 months after surgery, it was found
On the other hand, it is worthwhile pointing out that that social factors, such as the desire to resume work
the studies which analyzed only elderly patients report after the operation, marital status (normal marital life
comparable proportions of satisfactory results to those compared with divorce or widowhood) and patient's
in which patients of all ages were included. satisfaction with his/her own life situation, were posi-
The presence of motor and/or sensory deficits was tively correlated to the quality of the result, whilst
found to be predictive of a good surgical result in some depression, hypochondriasis and somatization were
studies (115), but not in others (10, 65). In a prospective negative prognostic factors. These findings are in keep-
516.Chapter 19.-----------------------------------------------------
ing with the observations of Spengler et al. (115), who very long term seem to indicate that less than half of
found that patients with abnormal scores on MMPI the patients are asymptomatic. The remaining patients
tended to have less satisfactory results, regardless of complain of some symptoms, usually in the low back
the surgical findings. These observations have been area, the presence and severity of which seem to be
confirmed in numerous other studies (page 323). related to degenerative vertebral changes, apparently
However, it has been claimed that psychologic exami- independent of the operation.
nation of the patient may not be necessary, since the With microdiscectomy, the postoperative hospital
prognostic evaluation can be carried out on the basis of stay may be of 24 hours or less (133). This is possible on
the standard clinical data (2). account of the mild postoperative low back pain, due to
The possibility of obtaining workmen's compensa- the limited extent of muscle dissection and moderate
tion is generally considered as a negative prognostic excision of the laminae and, particularly, the facet joint.
factor as far as concerns a satisfactory surgical result Better vision of the deep surgical field allows more
(38, 71, 96). Various authors (85, 108, 130), however, complete removal of the herniated tissue, with less
found no significant differences between patients trauma to the nervous structures. Reduced pain per-
with compensation claims and those without such mits a more rapid functional recovery in the immediate
problems, except for the duration of the time off work. postoperative period and a faster return to sedentary
It has been noted (117) that patients with an abnor- work. The advantages of using the operating micro-
mally long total period of absence from work due to scope are no longer evident a few weeks after the
lumboradicular pain over the years preceding surgery, operation. Indeed, after 6-12 weeks, the results of
tend to have rather unsatisfactory results and an abnor- microdiscectomy are similar to those of conventional
mally long period of sick-leave in the years following surgery, provided the arthrectomy is only slightly
the operation. In two prospective studies (53, 54), wider than that currently performed with the micro-
which evaluated various clinical and sociodemograph- scope.
ic factors, it was found that the most important predic- Elderly patients have the same probability of surgical
tive factors of an unsatisfactory result were a long success as younger patients.
preoperative inability to work and the presence of other Motor or sensory deficits of slight or moderate
painful areas in the body. severity usually recover completely after surgery.
A few studies have shown that a wide access to the Severe impairment, instead, may recover only partially
spinal canal is associated with a higher percentage of or remain unchanged. The probability of recovery is
unsatisfactory outcomes (16, 48). This finding is in inversely proportional to the severity and duration of
keeping with the observation that arthrectomy increas- impairment. In the presence of severe deficits lasting
es the probability of surgical failure due to persistent more than 1 month, the higher the number of months
low back pain (2). However, the rate of satisfactory elapsing from their onset, the lower the chances of
results after bilateral laminectomy was found to be complete recovery.
similar to that usually obtained after unilateral hemil- Recovery of bladder function is obtained in ap-
aminectomy (50). Furthermore, it has been stated that proximately 60% of the patients with a cauda equina
bilateral laminotomy would increase the probability of syndrome presenting bladder paralysis and saddle
a satisfactory outcome (42). anesthesia. Patients with partial bladder dysfunction,
instead, nearly always achieve a good functional recov-
ery. The time interval (in terms of days or weeks)
between the onset of the syndrome and surgical treat-
Conclusions ment does not affect the outcome. Nevertheless, in the
presence of a cauda equina syndrome, it is advisable to
The results, 2-3 months after surgery, are satisfactory in carry out surgery rapidly, even if not as an emergency;
approximately 85% of patients. In the short term, the in order to avoid partial sphincter and motor or senso-
percentage of satisfactory results ranges, in the majori- ry dysfunction becoming worse and, thus, decreasing
ty of studies, from 75% to 95%. At medium term, the the chances of a complete postoperative recovery.
results do not significantly differ from the short term The vast majority of patients return to their preoper-
results. In the long term, surgical results tend to deteri- ative, or a lighter, work. This usually occurs 8-10 weeks
orate in a limited number of cases, due to recurrence after surgery, and earlier for sedentary, than manual,
of radicular pain, or exacerbation or recurrence of low workers.
back pain. At this stage, approximately 10% of patients Three factors seem to significantly affect the result of
have undergone repeat surgery, because of degenera- surgery, particularly regarding radicular signs and
tive conditions at the same level as the previous opera- symptoms. These are the preoperative duration of the
tion or at different levels. The few data available for the clinical syndrome, the surgical findings and the degree
__________________________ 0 Results of surgery 0517
of positivity of nerve-root tension tests. Patients with 16. Chhabra M. S., Hussein A. A., Eisenstein S. M.: Should
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answer. Clin. Orthop. 301: 177-180, 1994.
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tion tend to present less satisfactory results than stenosis and diabetes. Outcome of surgical decompression.
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19. Darden B. v., Wade J. E, Alexander Ret al.: Far lateral disc
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1994.
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-----------------------------------------------------oResultsofsurgeryoS19
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90. Postacchini E, Cinotti G, Gumina S.: Microdiscectomy 113. Spannare B. J.: Prolapsed lumbar intervertebral disc with
through interlaminar approach in foraminal disc hernia- partial or total occlusion of the spinal canal. A study of 30
tions. J. Bone Joint Surg. 80-B: 201-207, 1998. patients with and 28 patients without cauda equina symp-
91. Postacchini E, Cinotti G, Perugia D.: Microdiscectomy toms. Acta Neurochir. (Wien) 42: 189-198, 1978.
in treatment of herniated lumbar disc. Ita!. J. Orthop. 114. Spengler D. M.: Lumbar discectomy: results with limited
Traumato!. 18: 5-16, 1992. disc excision and selective foraminotomy. Spine 7: 604-607,
92. Postacchini E, Lami R., Pugliese 0.: Familial predisposition 1982.
to discogenic low back pain. An epidemiologic and 115. Spengler D. M., Quellette E. A., Battie M. et al.: Elective dis-
immunogenetic study. Spine 13: 1403-1406, 1988. cectomy for herniation of a lumbar disc. Additional experi-
93. Postacchini E, Montanaro A: Extreme lateral herniations of ence with an objective method. J. Bone Joint Surg. 72-A:
lumbar disks. Clin. Orthop. 138: 222-227, 1979. 230-237,1990.
94. Pountain G. D., Keegan A. 1., Jayson M. I. V: Impaired fib- 116. Spurling R G., Grantham E. G.: The end-results for ruptured
rinolytic activity in defined chronic back pain syndromes. lumbar intervertebral disc. J. Neurosurg. 6: 57-64, 1949.
Spine 12: 83-86,1987. 117. Surin V V.: Duration of disability following lumbar disc
95. Raaf J., Berglund G. : Results of operations for protruded surgery. Acta Orthop. Scand. 18: 466-471,1977.
intervertebral discs. J. Neurosurg. 6: 160-168,1949. 118. Tay E. C. K, Chacha P. B.: Midline prolapse of a lumbar
96. Rish B. 1.: A critique of the surgical management of lumbar intervertebral disc with compression of the cauda equina.
disc disease in a private neurosurgical practice. Spine 9: J. Bone Joint Surg. 61-B: 43-46,1979.
500-504,1984. 119. Taylor T. K. E: Intervertebral disc prolapse in children and
97. Ross P., Jelsma E: Postoperative analysis of 366 consecutive adolescents. J. Bone Joint Surg. 53-B: 357, 1971.
cases of herniated lumbar discs. Am. J. Surg. 84: 657-662, 120. Thomas A M. c., Afshar E: The microsurgical treatment of
1952. lumbar disc protrusion. Follow-up of 60 cases. J. Bone Joint
98. Roukoz S. Haddad, S., Okais N. et al.: Etude critique de 200 Surg. 69-B: 696-698, 1987.
hernies discales lombaires operees. Ann. Chir. 44: 4448, 121. Thomas M., Grant N., Marshall J. et al.: Surgical treatment
1990. oflow backache and sciatica. Lancet 2: 1437-1439, 1983.
99. Ruggieri E, Specchia 1., Sabalat S. et al.: Lumbar disc 122. Tria A J., Williams J. M., Harwood D. et a!.: Laminectomy
herniation: diagnosis, surgical treatment, recurrence. A with and without spinal fusion. Clin. Orthop. 224: 134-137,
review of 872 operated cases. Ital. J. Orthop. Traumatol. 1987.
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1977. removal of lumbar disc herniation lead to better results
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Traumatol17: 505-511, 1991. vanile. Arch. Putti 13: 11-22, 1983.
103. Scaglietti 0., Fineschi G: Ernie discali postforaminali nella 126. Vaughan P. A, Barry W. M., Maistrelli G. 1.: Results of L4-
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520 • 19.-------------------------------------------------------
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------·CHAPTER 20·------
A 8 c
Fig. 20.1. Thirty-nine-year-old female with marked low back pain and mild radicular pain on the right side. Spin-echo T2-weighted sagittal MR scan
(A) showing a small contained herniation at L4-L5level and disc degeneration at L4-L5 and L5-S1Ievels. An instrumented posterolateral fusion at L4-
Sllevels (B) and (C) was performed along with laminotomy and discectomy on the right (arrowheads).
- ____________ 0 Spinal fusion and disc prosthesis at primary surgery 523 0
possibility of carrying out flexion-extension radio- are high chances that the pain may be, at least in part,
graphs and discography should be evaluated. psychosomatic in nature. On the other hand, if the
Flexion-extension radiographs should be taken in the patient shows a complete tolerance of the corset and
presence of traction spurs at the level of the herniated spinal immobilization causes a significant decrease
disc or at the adjacent levels and when plain radio- in low back symptoms, spinal fusion may well be
graphs suggest that vertebral instability may be pre- successful. Similar considerations are valid for the
sent. The presence of vertebral hypermobility at one of application of an external fixator, which, however, we
the levels adjacent to the herniated disc, should suggest do not use.
either that this level has to be included in the fusion area
or that fusion should be avoided.
Discography is indicated when MRI scans show two Assessment of indication for spinal fusion
non-adjacent degenerated discs. Usually one of the
two, often that most proximal, is asymptomatic and In patients who have the prerequisites for spinal
should not be included in the fusion area. Likewise, fusion, several factors may render surgery more or
in a patient with disc herniation at L4-L5 level, in less appropriate.
whom MRI shows a mild or uncertain reduction in In subjects aged less than 30 years, fusion is seldom
the signal intensity of the L5-S1 disc on T2-weighted indicated due to their long life expectancy and, hence,
sequences, discography may be carried out to deter- higher chances that degenerative changes may develop
mine whether the disc is normal or degenerated and, at the adjacent vertebral motion segments as a result of
thus, whether it should be included in the fusion area fusion. Fusion is also rarely indicated in subjects over
or not. In the remaining cases, discography may not 65 years old, since discogenic low back pain is more
be necessary, particularly when MRI scans show disc likely to be tolerated by elderly patients due to the
herniation at one level and normal discs at the adjacent decrease in physical activity which occurs with aging.
levels. Patients aged between 45 and 60 years are the best
Patients with chronic low back pain may show candidates for spinal fusion since they are physically
abnormalities in their psychologic profile more fre- active, but have a life expectancy of a few decades.
quently than those with a typical syndrome of a disc In assessing the indication for fusion, the morbidity
herniation. Therefore, if spinal fusion is indicated, the associated with the operation and the limitations of
possible influence of psychologic disturbances on the physical activities during the first postoperative
patient's symptoms should be assessed by means of months should be taken into account. These factors
psychometric tests. If the latter clearly show a func- should be taken into consideration particularly in
tional component in the patient's complaints, fusion patients with a typical syndrome of disc herniation and
should be avoided, whereas mild changes in the psy- chronic low back pain, in whom the surgical alternative
chologic profile might not represent a contraindication is discectomy alone, which entails a short operative
to fusion, particularly when only some of the psycho- time, a low morbidity and a postoperative course
metric tests reveal abnormalities. without significant limitations of physical activities. On
Wearing a rigid corset or a plaster jacket for 2-4 the other hand, it should be borne in mind that fusion
weeks - the so-called trial corset - is a diagnostic test does not guarantee a complete relief of low back pain
sometimes used in candidates for spinal fusion. The and that the effectiveness of discectomy alone in
test is positive when more than 50% of low back pain is relieving low back pain may not be predicted.
relieved. The rationale of the test is that the corset Severe osteoporosis may be a contraindication for
should provide a comparable immobilization of the fusion because, during the subsequent years, the bone
lumbar spine to that achieved by fusion. In effect, the mineral density of the vertebral motion segments
efficacy of a lumbar corset (a plaster jacket should have included in the fused area tends to decrease as a result
similar effects) in decreasing vertebral motion, particu- of the reduced mechanical stresses, whereas the adja-
larly at the two lower lumbar levels, is not well known cent motion segments may be more exposed to patho-
(page 364). On the other hand, to associate an immobi- logic fractures as a result of the increased mechanical
lization of a hip joint with a lumbar brace extended to stresses occurring at these levels. Likewise, the
the thigh does not seem to significantly increase the presence of a lumbar scoliosis cranially to the levels
efficacy of the brace. In our experience, a trial brace is which should be fused may be a contraindication for
more reliable in patients with segmental instability arthrodesis due to the possible worsening of the spinal
than in those with discogenic low back pain. In the curve as a result of the increased mechanical stresses
latter, the trial may be useful when there is a functional caused by fusion.
component in the patient's complaints. If the patient In patients complaining of chronic pain in the
tolerates the corset for only a few days or hours, there cervical and thoracic spine also, fusion is generally
20.---------------------------------------------------------
less indicated than in those complaining of pure low cal stresses on the adjacent vertebral motion segments
back pain because, in the former, a hidden distress and, thus, the possibilities that subsequent degenera-
status or a fibromyalgic syndrome which negatively tive changes may develop. Furthermore, the chances of
affects the result of spinal fusion may be present, or obtaining a solid bone mass do not decrease when a
because the resolution of low back pain only may be "floating" fusion is performed (5, 29).
of little satisfaction to the patient.
Results
Type and extension offusion
Numerous studies have analyzed the results of dis-
It is commonly believed that solid fusion, by eliminat- cectomy alone compared with discectomy and fusion,
ing vertebral motion, avoids mechanical stresses on the in patients submitted to primary disc excision (chapter
intervertebral disc and might thus relieve disco genic 19). However, no study has analyzed prospectively
low back pain. However, it has been shown that in the results of the hvo procedures in patients with
patients with a solid posterior or posterolateral fusion discogenic low back pain in whom the degree of
who complain of persistent low back pain, discography degeneration of the discs and facet joints adjacent to
of the discs included in the fused area may reproduce the level of herniation had been assessed prior to
the low back symptoms (40, 52). This finding suggests surgery.
that in these patients an interbody fusion performed Vaughan et al. (51) performed L4-L5 fusion, in
through an anterior or posterior approach or a circum- patients with disc herniation at this level, only when
ferential fusion would be more appropriate than a discography showed no degenerative changes of the
posterolateral fusion. In effect, the possibility that disc above or below. The retrospective analysis of these
discogenic low back pain may persist in the presence of patients, compared to those submitted to discectomy
a solid posterolateral fusion is based on findings which alone, revealed that, after a mean of 7.3 years, the pro-
are too rare to be accepted as a realistic event. It is pre- portion of satisfactory results was significantly higher
sumable that a posterolateral fusion eliminates the low in the fused group (85%) than in the non-fused group
back symptoms when these are caused by a disc which (39%). In the latter, the most frequent causes of failure
has been included in the fused area, providing that a were the occurrence or progression of disc degen-
solid fusion has been achieved. eration (as seen on plain radiographs) and recurrent
Instrumented fusion with pedicle screw fixation has herniation; in the fused group, pseudarthrosis and
become widely used due to the advantages provided donor site pain were the most frequent causes of
by the instrumentation. In patients with disco genic failure. However, even this study does not address
low back pain, in whom the vertebral motion segment the question of the role played by fusion in these
is not preoperatively unstable, a unilateral instrumen- patients, i.e., whether they have a significantly greater
tation may be indicated. Interbody cages may be used in improvement of low back symptoms than non-fused
performing posterior interbody fusion to avoid a rigid patients.
immobilization of the lumbar spine after surgery. These In our experience, patients with long-standing and
devices may also be implanted through an anterior severe low back pain, in whom preoperative MRI
laparoscopic approach. and / or discography do not show any degenerative
Usually, the vertebral motion segments to be includ- changes at the levels adjacent to the fused area, usually
ed in the area of fusion should encompass the herniated report a greater improvement of low back symptoms
disc and the adjacent levels showing disc degeneration. compared with non-fused patients. This holds particu-
However, the intervertebral level adjacent to the larly when fusion is performed at a single level. Failure
herniation, when showing a marked decrease in height in resolving low back pain after a spinal fusion may be
due to severe disc resorption, does not need to be due to pseudarthrosis or a wrong surgical indication.
included in the fused area if discography fails to pro- Pseudarthrosis is the first condition which should be
voke the patient's symptoms. This situation is more investigated in patients complaining of persistent low
likely to occur at the L5-S1level in the presence of disc back pain, even though it is well known that pseu-
herniation at L4-L5. In this case, there may be a risk of darthrosis is not necessarily associated with a poor
persistent pain after surgery, originating from the pos- clinical result (10, 20, 45, 49). Surgical failures in the
terior joints of the unfused vertebral motion segment. presence of a solid fusion may be due to a wrong
However, in the authors' experience this risk is very preoperative diagnosis or concomitant psychologic or
low. On the other hand, the advantage of limiting the psychosocial dysfunction which may negatively affect
extension of the fused area is to decrease the mechani- the clinical outcome.
Zygoapophyseal arthrosis associated conditions, such as scoliosis or degenerative
spondylolisthesis, implying specific diagnostic and
Clinical relevance and diagnosis therapeutic evaluations (chapter 21).
Fusion may be indicated in middle-aged or early-
In the presence of disc degeneration, particularly when senile patients with marked arthrosis of the facet joints
associated to a decrease in disc height, degenerative affecting only the level of the herniated disc or, at the
changes of the facet joints are often present. However, most, the first adjacent level, when the degenerative
the role of this condition in the etiology of low back changes are the result of peculiar pathologic conditions,
symtpoms is controversial. Degenerative changes of such as congenital anomalies, old fractures or infective
the facet joints, in fact, are essentially an age-related diseases.
phenomenon: 50 -90% of the subjects over 45 years old
show evident degenerative changes at one or more
levels, the entity of which tends to increase with aging Results
(25,36). On the other hand, in patients with disc degen-
eration, and even more in those with symptomatic disc Little is known on the results of spinal fusion in patients
herniation, it may be difficult or even impossible to with degenerative changes of the facet joints without
determine the role played by degenerated facet joints associated spinal conditions, such as scoliosis or
in the pathogenesis of low back pain. spondylolisthesis. This is probably due to the fact that
Plain radiographs and CT scans may show previous studies carried out in patients submitted to
arthrotic changes of the facet joints (hypertrophy, fusion for degenerative changes of the lumbar spine
osteophytes and irregularities of the joint surface), did not specifically assess this condition. Of the 12
but they may also show normal findings. In a series of patients submitted to fusion by Eisenstein and Parry
12 patients submitted to fusion for chronic low back (13), two had previous failed back surgery and one
pain presumably due to a facet syndrome, Eisenstein had degenerative scoliosis. One patient was reopera-
(13) did not find radiographic changes in the posterior ted on for pseudarthrosis, but all of them reported a
joints; in all cases, the histologic analysis revealed chon- considerable improvement in low back pain.
dromalacic changes of the joint cartilage. To diagnose
the source of pain, arthrography of the posterior joints
may be carried out. Arthrography may reproduce the Iatrogenic instability
patient's typical symptoms, which may improve after
intra-articular injection of local anesthetic (15). In Stability and instability of vertebral motion segment
effect, this procedure is of little diagnostic value,
particularly in a patient with a concomitant disc A vertebral motion segment may be stable, potentially
herniation. unstable or really unstable. The concept of spinal insta-
bility has not yet completely been elucidated and the
assessment of vertebral mobility on flexion-extension
Indications for fusion radiographs is the only clinical investigation used to
demonstrate spinal instability. The vertebral motion
In patients with severe and long-standing low back segment is considered to be stable when it does not
pain who show marked arthrotic changes of the facet show any angular or translatory hypermobility and
joints in addition to a herniated disc, doubts may arise unstable when an excessive and/ or abnormal angular
on whether discectomy should be associated to fusion motion or sagittal translation is present (11). A condi-
In our experience it is extremely rare that spinal fusion tion of potential instability occurs when a vertebral
is indicated in these cases for several reasons: 1) It is motion segment has higher chances of becoming unsta-
very rare that zygoapophyseal arthrosis causes severe ble or of developing vertebral slipping, compared to a
low back pain and that the latter cannot be resolved normal vertebral motion segment, once the integrity of
with conservative treatment. 2) In most cases arthrotic the stabilizing structures of the spine has been compro-
changes involve several lumbar motion segments and mised. For instance, in the presence of lumbar scoliosis,
the possibility that the motion segments not included in particularly of the degenerative type, there are higher
the fused area are symptomatic cannot be ruled out; on chances that a unilateral facetectomy may cause verte-
the other hand, fusion tends to increase degenerative bral hypermobility and/ or lateral displacement of the
changes at the adjacent non-fused levels. 3) Patients affected vertebra than in a normal spine. A vertebra
with marked arthrotic changes are mainly elderly which shows an initial tendency to olisthesis due to
subjects for whom fusion is seldom indicated. Younger degenerative changes is potentially unstable: in this
adults with severe arthrotic changes usually show case, even a limited impairment of the stabilizing
526.Chapter 20.-----------------------------------------------------
spinal structures may accelerate vertebral slipping and extension radiographs show no vertebral hypermo-
render the motion segment really unstable. Degenera- bility. Probably, in these cases, the vertebral motion
tive spondylolisthesis represents a condition of potential segment was preoperatively stable and the instability
instability if the slipped vertebra does not show any caused by surgery is of moderate entity and gradually
hypermobility on flexion-extension radiographs, or a decreases until it becomes asymptomatic or only
condition of true instability if the olisthetic vertebra is slightly symptomatic as the reparative processes in
hypermobile. the excised disc take place. In the few patients in whom
Biomechanical in vitro studies (1, 24) have demon- flexion-extension radiographs show postoperative
strated that, in a stable vertebral motion segment, vertebral hypermobility, severe low back pain may
laminotomy and partial facetectomy performed unilat- persist even in the long term: this possibly occurs only
erally or bilaterally do not affect spinal stability. when the vertebral motion segment is preoperatively
Clinical experience, on the other hand, demonstrates unstable. The chances of postoperative instability
that bilateral laminotomy does not make the operated increase if laminotomy and discectomy have been
vertebral motion segment unstable even when a carried out on the opposite side also.
bilateral discectomy is carried out, particularly if the A total bilateral facetectomy performed at the same
central portion of the posterior annulus and the posteri- level as disc excision, very often determines vertebral
or longitudinal ligament are preserved. However, hypermobility and low back pain due to spinal insta-
spinal stability is significantly reduced in vitro after bility, even when the vertebral motion segment is
total facetectomy performed unilaterally or bilaterally preoperatively stable; this is particularly true when
(1). discectomy has been carried out bilaterally. A bilateral
When the vertebral motion segment is potentially total facetectomy, however, is an extraordinary event in
unstable, disc excision may critically reduce spinal patients with a herniated disc only.
stability, already decreased by the laminoarthrectomy.
This holds particularly if a bilateral discectomy or total
unilateral facetectomy has been carried out. Likewise, Indication for fusion
when the vertebral motion segment is preoperatively
unstable, any decompressive surgery, particularly if When a total facetectomy has been planned preopera-
associated with discectomy, tends to increase spinal tively or carried out accidentally during surgery in
instability. patients with a herniated disc only, there may be doubts
on whether fusion needs to be performed. Many sur-
geons feel that fusion is necessary when a total face-
Instability after surgery for disc herniation tectomy along with ipsilateral discectomy has been
performed. In the authors' experience, fusion is not
When disc herniation is associated with other spinal necessary when flexion-extension radiographs show
conditions, such as stenosis, isthmic spondylolisthesis no evidence of potential instability. Such evidence,
or scoliosis, decompression of the nervous structures however, cannot be represented exclusively by traction
is likely to cause spinal instability. These conditions are spurs, since the clinical relevance of this finding
analyzed in chapter 2l. remains uncertain.
However, postoperative instability rarely occurs When a total facetectomy has been carried out
when disc herniation is the only spinal condition accidentally, the opportunity to perform fusion during
present, with the exception of possible disc pathol- the same procedure should be carefully evaluated. The
ogies at other lumbar levels. In this case, the vertebral patient, in fact, may subsequently object against spinal
motion segment at the level of the herniated disc is fusion if he / she had not been informed preoperatively
usually stable and the laminotomy and discectomy that fusion might be necessary. Since opinions on the
do not affect postoperative stability. Spinal instability need for fusion after a unilateral total facetectomy and
may occur when a unilateral or bilateral total facetec- ipsilateral discectomy are controversial, it is usually
tomy has been carried out. prudent to avoid fusion if the patient has not given
A unilateral total facetectomy may be performed an informed consent prior to surgery.
deliberately to remove an intraforaminal or extra- Fusion is advisable when a total facetectomy and
foraminal disc herniation, or it may occur accidentally, discectomy have been performed on one side and
mainly at the upper lumbar levels, where the facet laminotomy with partial facetectomy and discectomy
joints have a sagittal orientation. In most patients have been carried out on the contralateral side. Fusion,
submitted to unilateral total facetectomy, postoperative however, is necessary when a total facetectomy and dis-
low back pain is more severe than usual, however cectomy are performed bilaterally. If this procedure has
only in the first few months after surgery, and flexion- not been planned before surgery, but it is found to be
- - - - - - - - - - - - - - 0 Spinal fusion and disc prosthesis at primary surgery 0527
necessary during the operation, the surgeon is justified when present, is usually located at the level below the
in carrying out a fusion, even if the patient had not been retrolisthetic vertebra (Fig. 20.2). This condition is
informed preoperatively, due to the high chances that a commonly regarded as a type of segmental instability
symptomatic postoperative instability may occur. (21, 47). In effect, the retrolisthetic vertebra rarely
exhibits an abnormal angular motion or sagittal trans-
lation on flexion-extension radiographs.
Retrolisthesis
A 8
Fig. 20.2. A patient with retrolisthesis
of L3 and disc herniation at L3-L4
level. (A) and (B) Spin-echo T2-
weighted and Tl-weighted sagittal
MR scans, respectively, showing
marked retrolisthesis of L3 and
extruded herniation at the level below
(arrow). Mild retrolisthesis ofL4 and
isthmic spondylolisthesis of L5 are
also present. (C) and (0) Turbo spin-
echo T2-weighted and Tl-weighted
axial MR scans, respectively, revealing
extruded disc tissue in the right nerve-
root canal ofL3 (arrows). The patient
underwent laminotomy and
c D
discectomy with complete resolution of
the symptoms.
of postoperative low back pain was not different, on proximally and distally to the fusion area, to allow an
average, with respect to patients without retrolisthesis adequate muscular retraction to expose the transverse
(Fig. 20.2). In the only patient who showed a marked processes. Once the laminae have been cleared, the
worsening of retrolisthesis, as well as vertebral hyper- insertions of the longissimus thoracis muscle are sec-
mobility after surgery, a bilateral laminotomy and dis- tioned at the level of the lateral aspect of the articular
cectomy along with a wide facetectomy on one side had processes using the diathermy blade. At this stage
been performed. two arteries are found, one located laterally to the
pars interarticularis and the other at the intersection
between the superior border of the transverse process
Indication for fusion and the pedicle. Both arteries can be easily coagulated
using bayonet forceps. The lateral portion of the artic-
In patients with retrolisthesis and disc herniation, ular processes is then palpated with the index finger
fusion may be taken into consideration for two reasons: until the transverse process is identified. The transverse
1) to avoid an increase in the posterior slipping and/or process is then exposed subperiostally, taking care to
postoperative vertebral hypermobility when the avoid fracture.
herniation is located in the disc below the retrolisthetic Decortication of the fusion area can be performed
vertebra; 2) as a possible treatment of chronic low back either manually or by using a high speed burr. We
pain already present prior to the appearance of disc prefer the manual decortication, since the high speed
herniation, which may be located in the disc above or burr can cause thermic necrosis of the bone at the site
below the retrolisthetic vertebra. of the graft bed. The pars interarticularis and the lateral
The former should lead to perform fusion when, for aspect of the superior articular process can be de-
any reason, a bilateral laminoarthrectomy and discec- corticated with a curved osteotome or a large curette,
tomy have been carried out, whereas there is no motive whereas a bone rongeur should be used initially to
for carrying out fusion after a unilaterallaminoarthrec- interrupt the thin cortical wall of the transverse process
tomy, particularly when less than the medial one third to avoid causing its complete fracture. The decortica-
of the facet joint has been excised. The latter should tion is then extended to the entire transverse process
induce the surgeon to perform fusion in those rare cases with a small curette. The preparation of the bed graft is
in which preoperative flexion-extension radiographs completed when bleeding bone has been exposed
show hypermobility of the retrolisthetic vertebra. The throughout the fusion area and when soft tissues
presence of retrolisthesis only, does not justify fusion, which might interpose between the bone graft and the
even in the presence of chronic and severe low back decorticated bone have been carefully removed.
pain, since there are no proofs that posterior vertebral Small bone chips obtained from the iliac crest are
slipping may in itself be a cause of low back pain. placed in the bed graft, taking care to place a layer of
cancellous bone graft directly in contact with the decor-
ticated bone. Paraspinal muscles are then repositioned
over the bone graft, taking care to avoid displacement
Types of fusion of the bone chips into the spinal canal. To prevent this
from occurring, the dural sac should always be pro-
The most common techniques used for spinal fusion tected with hemostatic sponges prior to the positioning
will be described briefly, since they are extensively of the bone graft.
reported in numerous articles and books. If pedicle screw instrumentation has been planned,
the entry point for the screw insertion is located at
the intersection between a horizontal line located in the
Posterolateral fusion middle of the transverse process and a vertical line
(non-instrumented and instrumented) which may be located either at the inferolateral border
of the superior facet or slightly lateral to this point,
It may be carried out through the posterolateral depending on whether the screw is to be inserted
approach described by Wiltse (55) or the posterior with a sagittal or an inward orientation, respectively.
approach. The former allows a better exposure of the The advantage of positioning the screw with a sagittal
fusion area and reduces intraoperative bleeding. orientation is that a larger area for bone grafting is
Moreover, pedicular screw fixation is more easily per- available in the lateral portion of the articular process
formed with this approach. The posterior approach is and there is a lower risk of causing nerve injuries.
generally used when fusion is associated with decom- However, a lateral entry point associated with an
pression of the nervous structures. With this approach, inward screw orientation has the advantage of increas-
the skin incision should be extended one or two levels ing the stiffness of the spinal fixation and decreasing
- - - - - - - - - - - - - - 0 Spinal fusion and disc prosthesis at primary surgery 529 0
the risk of injuring both the neural structures and the ing the risk of bone collapse. It is advisable to leave a
abdominal vessels. A screw insertion at the middle bony edge of 2 mm along the posterior and posterolat-
point between the two techniques is the authors' pre- eral borders of the vertebral bodies in order to limit the
ferred method. Two further aspects should be taken chances of a posterior dislocation of the graft. The bone
into account: 1) the preservation of the cortical wall at graft should be thick enough to be inserted into the disc
the screw entry point increases the stiffness of the space with little resistance and as long as possible,
implant; 2) once the screw has been inserted into the considering that the anterior and posterior extremity
pedicle, it may be difficult to perform an accurate of the graft should be located 3-4 mm within the
decortication of the residual portion of the articular external border of the vertebral end-plates.
processes and the transverse process. Therefore, it The bone graft may be rectangular or cylindrical in
may be advisable to prepare the hole for the screw shape, or may consist of bone chips which are packed
first and then carry out the decortication, taking care to into the disc space. Usually, two to four rectangular
leave a small area of cortex around the hole. Once the bicortical or tricortical bone blocks are used. The
decortication has been completed, the pedicle screws advantage of using only two bone blocks, one on each
and bone graft are positioned. side, is that displacement of the graft is less likely to
In a historical cohort study including more than 2000 occur; however, they should be larger than when three
patients submitted to posterolateral fusion with pedicle or four bone blocks are used and, therefore, there is a
screw instrumentation, intraoperative complications higher risk of damaging the nervous structures during
have been recorded in 5% of cases (58). The most their insertion in the disc space or performing a total
frequent complication, i.e., pedicle fracture, occurred facetectomy. These risks are reduced by using three or
in 1.2% of patients. Nerve and vascular injuries were four bone blocks of a smaller size: once the first bone
found in 0.4% and 0.1% of cases, respectively. block has been positioned, it is shifted to the middle of
the disc space with a small osteotome and then a second
bone block is positioned laterally to the former.
Interbody fusion As an alternative, cylindrical or rectangular titanium
or carbon fibre cages filled with cancellous bone may
Posterior. The laminoarthrectomy should be extended be used. The use of such devices should allow a more
laterally and as much of the lateral and anterior annu- rapid functional recovery after surgery and eliminate
lus as possible should be removed. An interlaminar the risk of the bone graft collapsing (3, 39, 57). However,
retractor is positioned to achieve an adequate visualiza- it is often necessary to perform an extensive or even
tion of the disc space. The vertebral end-plates are total facetectomy to insert these devices with safety.
excised initially with an osteotome and subsequently This is more frequently the case at the upper lumbar
with a small curette until bleeding bone is exposed, but levels, where the facet joints show a sagittal orientation
without extending too deeply in the subchondral bone. and the emerging nerve root is less mobile. When a total
This reduces the bleeding in the disc space and pre- facetectomy has been performed, a spinal fixation with
serves the subchondral trabecular bone, thus decreas- pedicle screws should be associated (Fig. 20.3). If a total
allow the insertion of the 18 mm working cannula Among the possible intraoperative complications,
which is used for the removal of the disc and insertion a potentially immediate one is a iatrogenic injury to
of the cages. Using a special caliper, two marks, the abdominal aorta when inserting the cannula for the
equidistant from each other, are made on each side of distension of peritoneum. This is unlikely to happen if
the central pin to identify the ideal site for the insertion the procedure is carried out by an experienced laparo-
of the two cages. scopic surgeon. Vascular complications can occur when
The disc is then entered with an initial sharp tubesaw, inserting the cages and / or prepearing the disc, due to
which cuts a window into the anterior annulus. Under an insufficient retraction of the common iliac veins
laparoscopic vision, using specially-designed pituitary and/or an inadequate preparation of the mid sacral
and Kerrison rongeurs, the anterior annulus and nucle- vein and artery. When approaching the L4-L5 space,
us pulposus are removed prior to the insertion of spe- one has to be aware of the position of the ascending
cially-designed spacers. The procedure is repeated on lumbar vein, as in standard retroperitoneal open pro-
both sides prior to the insertion of the cages. Following cedures. At all stages, the surgeon has to be prepared to
subtotal excision of the intervertebral disc, the site for convert the laparoscopic procedure into an open one,
the cages is prepared using specially-designed burs, if warranted by excessive bleeding.
which cut a cylindrical groove into the end-plates of L5 Another potential complication may be caused by an
and 51. A tap is then employed and the threaded cage of inadequate clearance of the intervertebral disc with a
the selected length and width is inserted after having consequent posterior displacement of disc material
been filled with autogenous cancellous bone from the upon insertion of the implant. This may be compound-
iliac crest. ed by a lateral placement of the cage with secondary
The parietal peritoneum is sutured using a specially- nerve-root compression at the level of the intervertebral
devised instrument and the suprapubic portal is foramen. It is paramount, therefore, to carry out a
closed with interrupted reabsorbable sutures. Prior complete clearance of the disc prior to insertion of the
to the removal of the laparoscope, the abdomen is implants, to check the position of the cages on both the
deflated and the surgeon checks for any potential AP and lateral view, and to ensure that they are parallel
bleeding which may have been masked by the raised to each other and within the boundaries of the interver-
intra-abdominal pressure. tebral disc space proper. For the first few operations, it
Patients are allowed to stand up as soon as they is useful to perform a postoperative CT scan to confirm
regain trunk control and are able to roll in bed from the positioning of the cages, although this is not
side to side. A soft lumbar corset is used for the first 6 warranted on a routine basis.
weeks after surgery and, in most cases, after a standard Postoperative complications include deep infec-
one-level procedure, the patient is discharged between tions, displacement of the cages, ongoing instability
6 and 12 hours after the completion of surgery. AP and due to inadequate bone ingrowth into the implant,
lateral radiographs are taken prior to discharge and non-union, fibrous union and retrograde ejaculation. In
the patient is followed for 2 to 6 weeks after surgery the authors' experience, deep infections are rare with
with repeat radiographs (Fig. 20.4). titanium-threaded cages and their incidence is minim-
532.Chapter 20.-----------------------------------------------------
ized by the routine use of prophylactic antibiotics, a after a mean of 7.3 years, in patients in whom a pre-
meticulous surgical technique and careful postopera- operative discography had shown a normal disc at
tive monitoring (39, 58). Malpositioning of cylindrical the level adjacent to the area to be fused. In no patients
cages might lead to a rotation of the implants and were significant degenerative changes or instability
secondary instability. detected at the motion segments adjacent to fusion.
Cinotti et al. (9), analyzed 48 patients submitted to
posterolateral fusion after 7.4 years, on average; 14 of
these underwent CT or MRI. Of the latter, two patients
Effects of fusion on adjacent showed degenerative changes at the disc above the
vertebral motion segments fusion, and two other had stenosis and degenerative
spondylolisthesis, respectively.
Many studies indicate that fusion favours the occur- In a recent investigation, 110 patients who had
rence of several conditions such as disc degeneration, undergone posterolateral fusion were analysed after an
facet joint arthrosis, stenosis, segmental instability or average of 22.6 years and compared to a control group
spondylolisis, in the motion segments adjacent to of nonoperated patients (54). Narrowing of the disc
the fused area (4, 9, 19, 20, 27, 30, 34, 35, 37, 43, 45, 53). above the area of arthrodesis was found in 19% of cases
In a series of patients with degenerative conditions, and of the first non-adjacent disc in 21 %, whereas, in the
submitted to disc excision with or without fusion and control group, the incidence was 23% and 14%, respec-
followed-up 10 years after surgery (20), those who tively. Degenerative spondylolisthesis was found at the
had had fusion showed a significantly higher inci- level adjacent to an L4-S1 or an L5-Sl fusion in 11 % and
dence of asymptomatic degenerative changes in the 14% of cases, respectively, whilst in the control group
motion segments proximal to the fused area, including the incidence was 11% and 2%, respectively. Segmental
vertebral osteophytes, reduced disc height and verte- instability was observed in 9% of patients at the level
bral hypermobility. These changes were four times adjacent to the fused area and in 11% at the first non-
more frequent at L4-L5 level when fusion was per- adjacent level; similar rates were found in the control
formed at L5-Sl than at L3-L4level when the two lower group. The clinical outcomes did not appear to be relat-
lumbar levels were fused. Lehman et al. (34) analyzed ed to the radiographic findings. Penta et al. (41) carried
62 patients submitted to fusion, an average of 33 years out MRI studies in 52 patients who had been submitted
after surgery; moreover, 33 of these had radiographs or to interbody fusion 10 years before and who had under-
CT scan at the last evaluation. Of the latter, 45% showed gone discography before surgery. Degenerative changes
segmental instability at the level above the fusion and at the levels adjacent to the arthrodesis were observed
42% had stenosis, which was severe in one third of in 32% of patients, who also showed a significantly
cases. The incidence of stenosis was higher at the levels higher incidence of multiple disc degeneration in the
above than at those below the fusion. However, the lumbar spine compared with patients who had a normal
clinical results did not appear to be related to the radi- disc at the level adjacent to the fused area. This findings
ographic and CT findings, since the large majority of suggest that degenerative changes of the disc adjacent
patients were satisfied with the operation. It should to the fusion do not strictly depend on the increased
also be considered that these patients had undergone a mechanical stresses which occur at these levels, but they
posterior fusion, which is the type of arthrodesis that are probably related to a constitutional predisposition.
causes the largest mechanical stresses on the adjacent
non-fused levels compared with posterolateral or inter- Conclusions. The data available seem to indicate that in
body fusion (31). In a series of 19 patients who com- the first decades after spinal fusion only a small propor-
plained of new symptoms an average of 8.5 years after tion of patients develops degenerative changes at the
fusion (30), the most common conditions at the levels level or levels adjacent to the fused area, as a result of
adjacent to the fused area were facet joint arthrosis fusion. The most common changes are facet joint arthro-
(88% of cases) and stenosis (44%), whilst a marked disc sis, segmental instability and disc degeneration. These
degeneration was present in 27% of cases. However, in changes are probably more marked in patients who,
none of the patients of these series was the degree of before surgery, already have degeneration of discs
degeneration of the disc adjacent to the fusion evaluat- adjacent to the area to be fused. It is possible that in
ed by discography, nor were the dimensions of the patients who exhibit no degenerative changes at the
spinal canal assessed before surgery. Furthermore, in levels adjacent to the area to be fused, degenerative
none of the patients was the disc adjacent to the fused processes may occur due to aging or constitutional
area evaluated at follow-up by MRI or discography. predisposition rather than as a result of fusion. On the
A retrospective study (51) analyzed the results of other hand, in the majority of patients these degenera-
discectomy and posterolateral fusion at L4-L5 level tive changes are asymptomatic.
at °533
Instrumented fusion The latter has been eliminated with the use of spinal
instrumentation which, however, increases the mechan-
The occurrence of degenerative changes at the level ical stresses at the adjacent levels.
adjacent to the fused area is probably related to the These drawbacks might be overcome by using disc
amount of mechanical stresses which take place at prostheses. Such devices may improve low back symp-
these levels. The association of spinal instrumentation toms by removing the affected disc and, by preserving
decreases the rate of pseudarthrosis (56), but increases vertebral motion, may avoid abnormal mechanical
the stiffness of the fused area and, hence, the mechani- stresses at the adjacent levels. Moreover, disc prosthesis
cal stresses at the adjacent levels. This, in turn, should would allow the management of patients with multiple
increase the incidence and / or severity of degenerative disc degeneration without compromising spinal
changes at the motion segments adjacent to the fusion. mobility.
Moreover, the presence of stiff implants may cause a
decrease in the bone mineral density in the vertebrae
included in the fusion area due to a stress-shielding Models of artificial disc
phenomenon (23, 38). No study has analyzed, at long-
or very-long term, patients submitted to instrumented More than 20 models of artificial disc prostheses have
fusion compared with patients who underwent been designed, the majority of which have not been
noninstrumented fusion. In a study carried out at implanted in man. They are designed to replace the
medium term, however, it has been found that patients nucleus pulposus only or variable portion of the
with an instrumented fusion showed significantly whole disc.
earlier degenerative changes at the adjacent levels The first artificial disc implanted in man was the
than patients submitted to noninstrumented fusion spherical metal ball spacer designed by Fernstrom (17),
(28). a primitive model which should have allowed a wide
The disadvantages associated with an excessive stiff- mobility in each plane of motion. In the 50's and 60's,
ness of the fused area may be avoided by: removing the this prosthesiS was implanted in a large number of
instrumentation once a solid fusion has been achieved; patients. However, 4-7 years after surgery, the majority
using a unilateral instrumentation, which seems to pro- of the metal balls had migrated into the vertebral
vide a similar rate of solid fusion to bilateral instru- bodies with subsequent collapse of the disc space; the
mentation (8, 29); or using less rigid devices. However, author was then compelled by the medical authorities
even for these methods of spinal instrumentation, there to interrupt these operations. Thereafter, models which
are no data regarding the long-term effects of fusion on replace the nucleus pulposus with a remotely fillable
the adjacent segments. flexible bladder with end-plate anchoring pins (18),
with silicone fluid contained in a plastic tube (16), with
a silicone nucleus placed between two metallic plates
(12), or with semipermeable tubes filled with hygro-
Disc prosthesis scopic gel (44) were proposed. These prostheses, none
of which has been used in man, have the advantage
Rationale that they may be inserted through a posterior
approach. However, if the implant is not well fixed to
In the past, fusion was the only surgical option in treat- the annular tissue and vertebral end-plates, it might
ing severe degenerative conditions of peripheral joints. dislocate into the spinal canal. Very little data have been
In the last 20 years this procedure has been replaced, published so far on the biomechanical behavior of
with few exceptions, by artifical joint replacement. The these implants (22).
latter not only eliminates pain, but also allows recovery Prostheses which entail the replacement of the whole
of joint motion to a large extent, thus improving the disc have been tested and a few of these have been
functional result and avoiding a mechanical overload- implanted in man through an anterior transperitoneal
ing of the adjacent joints. or retroperitoneal approach.
The success of peripheral joint prosthesis has encour- Hedman et al. (26) have designed an artificial disc,
aged the design and use of devices to replace the inter- which should allow a similar vertebral mobility to that
vertebral disc. Spinal fusion, in fact, entails several of normal vertebral motion segments. The prosthesis
disadvantages: a solid fusion is not always achieved; consists of two metallic plates with an external porous
the mechanical stresses at the levels adjacent to fusion coating, linked with a posterior loose hinge. Two metal-
are increased; high rates of pseudarthrosis are reported lic springs are sited in the anterior half of the metallic
when fusion is performed at multiple levels; a pro- plates. A screw is used to augment the fixation to the
longed spinal immobilization is needed after surgery. vertebral body above and below. This prosthesis allows
534. Chapter 2 0 . - - - - - - - - - - - - - - - - - - - - - - - - - -
an angular motion of 15°-20° in the sagittal plane and clinical outcome was rated as very satisfactory in 47%
of 3°_6° in the coronal plane.There are many doubts of cases. An improvement of the preoperative symp-
regarding the mechanical strength of the metallic toms was obtained by 12% of patients, whereas 26%
springs, the tendency to produce metallic debris, and and 2% were unchanged or had worsened, respectively,
the possibility that soft tissue may penetrate within the compared to the preoperative status. A high proportion
springs, thus reducing the mobility of the prosthesis. of patients showed a subsidence of the implant in the
This device has only been implanted in animals so far. vertebral bodies (31 %) or a complete failure of the
The Steffee artificial disc (48) is made of a silicone metallic end-plates (5%) only a few months after
rubber disc and two titanium end-plates with an exter- surgery. The average vertebral motion at the operated
nal porous coating. On the external surface of each level was 8.8° before surgery and 5.2° at follow-up.
metallic end-plate are four cone-shaped posts to The results of the Steffee disc prosthesis have been
enhance mechanical fixation. Experimental tests have analysed in six patients (aged 33-75 years) a minimum
shown that the weak point of the prosthesis is the of 3 years after surgery (14). The preoperative diagnosis
rubber-titanium interface. However, in the six patients was disc degeneration, which involved a disc adjacent
who had this prosthesis implanted, the only mechani- to a fused area in four cases. The clinical result was
cal failure found was within the rubber core (14). rated as satisfactory in three patients.
The Charite SB prosthesis is the artifical disc most A multicentric study has evaluated the results of 234
widely used in man so far. The SB III Charite is the evo- patients with an age ranging between 25 and 59 years in
lution of two previous models (6). It is made up of two whom a Charite disc prosthesis was implanted (46). In
CrCoMo metallic end-plates with a smooth external 19% of patients intraoperative or postoperative compli-
surface, presenting small teeth to anchor the implant cations occurred, including injuries to iliac vessels
to the vertebral end-plates. The polyethylene core has repaired intraoperatively, thrombosis of the iliac veins,
a convex surface above and below, which slides on the temporary sexual dysfunction, and temporary bladder
concave surface of the metallic end-plates. This device and bowel disturbances. The clinical result was rated as
should provide a range of motion of 12°-14° in flexion- satisfactory in 73% of cases. A marked subsidence of the
extension and unlimited motion in axial rotation. The prosthesis in the vertebral bodies and an anterior
latter may cause a functional overloading of the facet dislocation of the implant was found in eight and nine
joints. Further concerns are related to the wear of the patients, respectively; however, these complications did
polyethylene core and the production of wear debris. not influence the surgical outcome. In six cases a partial
Lee et al. (32) have designed an artificial disc, the bio- intervertebral ossification was noted. Eight patients
mechanical characteristics of which should reproduce underwent fusion due to persistent pain. In no case did
those of the human disc. This model includes three a failure of the polyethylene core occur, and none of the
components corresponding to the nucleus pulposus, removed implants were found to be cracked or worn.
the annulus fibrosus and the vertebral end-plates, all Postacchini and Cinotti (7, 42) analysed 46 patients in
made of urethane elastomers, but with a progressively whom a CharM SB III disc prosthesis was implanted
higher stiffness in the three components. The annulus by Thierry David. There were 21 men and 25 women,
fibrosus is reinforced by fibers of urethans and dacron with an average age of 36 years (range 27-44 years) at
with a spatial orientation similar to that of annular
fibers.
Clinical results
the time of surgery. The preoperative diagnosis was best candidates for disc prosthesis. The cases of disc
low back pain due to disc degeneration or a previous herniation in which fusion is indicated may represent
discectomy. The artificial disc was implanted at one a further indication for disc prosthesis.
level in 36 cases and at two levels in 10. The patients When deciding whether a disc replacement may be
underwent clinical and radiographic evaluations on indicated or not, a careful preoperative evaluation of
average 3.2 years after surgery (range 2.1-5.3 years). the vertebral structures which will be directly or in-
The clinical result was rated as excellent or good in 63% directly affected by the presence of the artificial disc
of cases, fair in 30% and poor in 7%. Of the eight should be carried out. The presence of osteoporosis
patients who obtained unsatisfactory results, all but contraindicates artificial disc replacement, due to the
one underwent spinal fusion without removing the risk of subsidence or dislocation of the implant.
prosthesis. The clinical results were satisfactory in 69% Likewise, arthrotic changes of the facet joints may
of patients who had the disc prosthesis at one level and contraindicate surgery, since they may be a cause of
in only 40% of those who had the prosthesis at two residual pain, particularly when the vertebral motion
levels. Satisfactory results were obtained by 48% of segment regains part of its mobility. The height of the
patients who had previous failed back surgeries and by disc space does not appear to influence the surgical out-
78% of those who had not. The vertebral motion at the come; however, it may be advisable to avoid implan-
operated level as seen on flexion-extension radio- ting a disc prosthesis in a disc space which is markedly
graphs was, on average, 8.2°. The better results were decreased and thus responsible for a severe reduction
obtained in patients in whom a prosthesis larger than in the vertebral motion. A disc prosthesis is also con-
80% of the sagittal length of the adjacent vertebral traindicated in the presence of segmental instability,
bodies was positioned at the middle of the disc space both because it may persist along with back pain after
(Fig. 20.5). In no patient was a dislocation of the implant surgery and because the abnormal mechanical stresses
observed. A subsidence of the implant into the verte- at the affected motion segment increase the chances
bral body above or below was found in four patients in of mechanical failures of the prosthesis (dislocations,
whom an undersized prosthesis was inserted. In seven subsidence, wear or failure of the polyethylene core).
patients an annular ossification or a spontaneous Young adults with an isolated disc degeneration
fusion was found (Fig. 20.6). These poor radiographic appear to be the best candidates for disc prosthesis.
outcomes, however, did not influence the clinical On the other hand, artificial discs are not indicated in
results. elderly patients, due to the high chances that they
may have severe degenerative changes of the facet
joints and vertebral osteoporosis.
Indications It should be taken into account, however, that disc
prosthesis is still a procedure in a phase of clinical
Patients with a disc degeneration unresponsive to testing which has been performed in a limited number
prolonged conservative treatments should be the of patients and that few data are available on the
536.Chapter 20.---------------------------------------------------
clinical results obtained. In particular, the long-term 17. Fernstrom U.: Arthroplasty with intercorporal endopros-
results of disc prosthesis are entirely unknown. The thesis in herniated disc and in painful disc. Acta Chir.
Scand. Suppl. 357: 154-159, 1966.
experience with hip arthroplasty has shown that the
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son of radiographic findings in fusion and non-fusion
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43. Prothero S. R, Parkes J. c., Stinchfield E E.: Complications 53. Whitecloud T. S., Davis J. M., Olive P. M.: Operative treat-
after low-back fusion in 1000 patients. J. Bone Joint Surg. ment of the degenerated segment adjacent to a lumbar
48-A: 57-65, 1966. fusion. Spine 19: 531-536,1994.
44. Ray C. D.: The artificial disc. Introduction, history, and 54. Wiltse L. L., Hambly M. E: Degenerative changes in the first
socioeconomics. In: Clinical efficacy and outcome in the two segments above a lumbosacral fusion: a 22.6 year
diagnosis and treatment of low back pain. Weinstein J. N. (average) follow-up. In: Instrumented spinal fusion.
Ed., Raven Press, 1992. Preoperative evaluation, indications and techniques.
45. Rothman R H., Booth R: Failure of spinal fusion. Orthop. Wittenberg R H. Ed., G. Thieme Verlag, Stuttgart-New
Clin. NorthAm. 6: 299-304, 1975. York,1994.
46. Schellnack K., Lemaire J. P., Buttner-Janz K. et al.: The inter- 55. Wiltse L. L., Spencer C. W.: New uses and refinements of the
vertebral disc endoprosthesis SB Charite. First Congress of paraspinal approach to the lumbar spine. Spine 13: 696-706,
EFORT, Paris, 1993. 1988.
47. Simmons J. W: Posterior lumbar interbody fusion (PLIF). 56. Wood G. W., Boyd R J., Carothers T. A. et al.: The effect of
In: The adult spine. Principles and practice. Frymoyer J. W pedicle screw / plate fixation on lumbar / lumbosacral auto-
Editor-in- chief, Raven Press, New York, 1991. genous bone graft fusions in patients with degenerative
48. Steffee A. D.: The Steffee artificial disc. In: Clinical efficacy disc disease. Spine 20: 819-830, 1995.
and outcome in the diagnosis and treatment of low back 57. Yuan H. A., Dowdle J. A., Griffith S. L. et al.: Prospective
pain. WeinsteinJ. N. Ed., Raven Press, 1992. multi-center clinical trial of BAK interbody fusion system.
49. Suzuki T., Pearcy M. J., Tibrewal S. B. et al.: Posterior inter- Spinetech, USA, 1996.
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ography. Int. Orthop. 9: 11-17, 1985. cohort study of pedicle screw. fixation in thoracic, lumbar,
50. Turner P. L.: Neurological complications of posterior lum- and sacral spinal fusions. Spine 19, 20 S: 2279 S-2296 S,
bar interbody fusion. Proc. Annual Meeting of the Spine 1994.
Society of Australia, Melbourne, 1994.
------·CHAPTER 21·------
DISC HERNIATION
ASSOCIATED TO OTHER
CONDITIONS
F. Postacchini, G. Cinotti
Lumbar stenosis side, and are not relieved by rest; different types of
intermittent claudication may be present; and the
nerve-root tension tests are slightly positive.
Clinical presentation
Isolated nerve-root canal stenosis often becomes
symptomatic in the presence of annular bulging or a
The clinical presentation of central stenosis associated
herniated disc. The symptoms of also this form of
with marked annular bulging or disc herniation is
stenosis can be variable. Usually, however, the clinical
extremely variable. In some cases, signs and symptoms
presentation is that typical of pure stenosis in the pres-
differ from those typical of lumbar stenosis: chronic
ence of annular bulging, and that observed in patients
symptoms with a predominance of radicular distur-
with a herniated disc when the latter is present. In the
bances with respect to low back pain; bilateral radicular
former case, the patients report long-standing radicular
symptoms, even if often predominant on one side; no
symptoms, which worsen or appear during walking,
symptoms at rest; sensory, astenic or, less commonly,
painful intermittent claudication; and negative nerve- the nerve-root tension tests are negative or slightly
positive, and the motor deficits are of mild severity.
root tension tests. A clinical presentation typical of
stenosis is usually observed when the disc condition is In the latter case, even a small herniated disc may cause
a clinical picture of acute nerve-root compression,
represented by slight annular bulging. In the presence
usually associated with mild low back pain.
of a herniated disc, signs and symptoms are more often
those typical of disc herniation: recent onset or exacer- In stenosis of the intervertebral foramen associated
with a pathologic disc condition, the clinical presenta-
bation of symptoms; predominance of radicular pain
tion is similar to that of radicular canal stenosis.
with respect to sensory and motor dysfunction; unilat-
eral radicular symptoms; pain at rest; no or essentially
painful intermittent claudication; and positive nerve-
root tension tests. The latter, however, tend to be slight- Surgical treatment
ly positive, particularly in elderly patients, who are
those most frequently presenting stenosis. A third type Spinal stenosis
of clinical picture is a combined presentation, in which
either the typical symptoms of stenosis or those of disc Constitutional stenosis
herniation may prevail. In these cases, the patients
usually complain of chronic radicular disturbances of In this type of stenosis, the disc often plays a relevant
mild entity, which have recently exacerbated; radicular role in the compression of the neural structures. The
symptoms are bilateral, however predominant on one disc condition usually consists in annular bulging into
540.Chapter 2 1 . - - - - - - - - - - - - - - - - - - - - - - - - - - -
the spinal canal (Fig. 21.1); when bulging is marked, it holds particularly when bilateral laminotomy, which is
may be hardly distinguishable from a midline disc her- the treatment of choice in most constitutional stenoses,
niation. Occasionally, a midline herniation with con- is carried out (75). Laminotomy, in fact, preserves
comitant bulging of the posterolateral portions of the spinal stability to a large extent, even if bilateral discec-
annulus fibrosus is present. A lateral or posterolateral tomy is performed, provided that the motion segment
disc herniation is rarely associated with constitutional is preoperatively stable. If the disc is not excised, the
stenosis (Fig 21.2). preservation of the midportion of the posterior arch
A classic concept in the surgical treatment of lumbar exposes to the risk of persistent compression of the
stenosis is that disc excision is not needed in the pres- thecal sac by the disc or, when this is soft, of possible
ence of annular bulging (3, 24, 26, 63, 79, 88). In effect, formation of true herniation subsequently (74).
this is true only for mild bulging, when the disc is hard Discectomy should be performed bilaterally when
in consistency. If marked bulging is present, the disc has radicular symptoms are bilateral and/ or when, after
to be excised, particularly when it is soft (69, 68). This disc excision on one side, marked annular bulging
A B c
Fig. 21.2. Constitutional canal stenosis of the spinal canal and disc herniation. (A) and (B) Spin-echo T2-weighted sagittal MR images revealing
moderate stenosis at L2-L3 and L4-L5 levels and marked stenosis at L3-L4 level. (C) Spin-echo Tl-weighted axial MR image at L3-L4 level showing
disc herniation on the left.
- - - - - - - - - - - - - - - - - . Disc h erniation associated to o th er conditions· 541
persists on the opposite side. In patients with two-level root compression. In these forms, as in constitutional
or three-level constitutional stenosis, a marked disc stenosis, a true disc herniation is rarely present.
bulging is usually present at one level, very often where Discectomy should generally be avoided, particular-
stenosis is most pronounced, whereas less severe ly when annular bulging is mild and the disc is of hard
bulging may be found at the adjacent levels. In these consistency. On the other hand, if central laminectomy;
cases, discectomy should usually be performed only at which is often necessary in these cases (75), is carried
the level where annular bulging is most marked. out, a large space is created for the nervous structures,
When disc herniation is present, it is usually suf- which may easily escape the mild compression exerted
ficient to perform discectomy on the side of herniation. by the disc when the posterior arch is intact. However,
Usually, in the presence of a midline disc herniation, the disc excision should be performed in the presence of a
herniated tissue may be adequately removed through a marked disc bulging, to avoid any persistent compres-
unilateral approach. sion of the nervous structures after surgery. Discectomy
is even more indicated when bilateral laminotomy is
performed or the disc is soft in consistency.
Degenerative and combined stenosis Disc excision should always be performed in the
presence of disc herniation. If severe stenosis is present
In these forms of stenosis, disc bulging is often mild and at the level of the herniated disc, and centrallaminec-
plays a secondary role in the pathomechanism of nerve- tomy has been planned, discectomy should be carried
out after bone decompression (94). Disc excision in a
stenotic spinal canal, in fact, may expose to the risk of
injuring the neural structures.
At times, preoperative imaging studies reveal both
disc herniation and a moderate spinal canal stenosis of
the degenerative or combined type. In these cases, the
patient should generally be treated as if the spinal canal
were of normal size, particularly when radicular symp-
toms are unilateral. Removal of the disc on only one
side, in fact, may lead to adequate decompression of the
nervous structures also on the opposite side (Figs. 21.3
and 21.4).
A B
emerging nerve root. The use of an operating micro- Stenosis of the intervertebral foramen
scope may be useful both to decompress the nerve root
without removing too extensively the facet joint and Stenosis of the intervertebral foramen, i.e., a narrow-
to visualize and excise the herniated disc more easily ness responsible for nerve-root compression, is a rare
(73,99). condition, and even less common is the coexistence of a
to °543
herniated disc at the same level. Annular bulging is tomy, but also indicate that a concomitant unilateral
more frequently observed, but it rarely contributes discectomy has little influence on spinal stability. Iida
significantly to compress the nerve root running in the et al. (44) found postoperative instability in 11% of 35
neuroforamen. CT and MRI studies often suggest patients who had undergone laminotomy, and 27% of
foraminal stenosis, but most patients have only consti- the 11 who had had central laminectomy. However, in
tutional or degenerative narrowing of the neuro- none of the patients was spinal stability assessed before
foramen, causing no compression of the nerve root. surgery. In our experience, whether discectomy has
Usually this type of stenosis can only be diagnosed at been performed or not, the effects of surgical decom-
surgery, by evaluating, with a Frazier probe, the space pression are directly related to the degree of preopera-
around the nerve root along its intraforaminal course. tive spinal stability (68).
In the presence of a contained or extruded herniation, When the motion segment is preoperatively stable,
or a disc fragment migrated proximally to the disc, central laminectomy with partial or complete discecto-
surgical treatment is similar to that performed for a my does not significantly impair spinal stability. This
herniated disc not associated with foraminal stenosis. holds when at least the outer one third of the facet joint
When the latter is suspected, an interlaminar, rather is preserved. However, if subtotal or total arthrectomy
than an extravertebral, approach should be carried out, is performed, there are high chances of causing post-
particularly when concomitant radicular canal stenosis operative instability. Bilateral discectomy significantly
is present or suspected. Laminoarthrectomy may be increases the risk of instability. Bilateral laminotomy,
performed, as usually done, at the level of the herniated which preserves the medial portion of the ligamentum
disc (L4-L5 interlaminar space for disc herniation at flavum, as well as the interspinous and supraspinous
this level) or at the level above. In the former case, ligaments, does not reduce stability even if a bilateral
after removal of the herniation, one moves cranially to discectomy is carried out. In this case, care should be
expose the nerve root above and performs a partial taken to preserve the midportion of the annulus fibro-
athrectomy in a mediolateral direction, until the root is sus and the posterior longitudinal ligament. Complete
entirely decompressed. In the latter case, starting from unilateral arthrectomy with ipsilateral discectomy
the interlaminar space above, the distal lamina and the decreases spinal stability, however at medium and
articular processes compressing the nerve root are long term it is not generally associated with significant
excised and, then, the herniation at the level below is low back pain. Vertebral body osteophytes may pro-
removed. The former procedure, which is less invasive, duce spontaneous vertebral fusion, as often occurs in
should be preferred when the herniated disc is thought degenerative stenosis; this allows a wide decompres-
to be the primary or the only cause of nerve-root com- sion to be carried out with no significant compromise
pression, or when concomitant radicular canal stenosis of spinal stability.
is present at the same level as the herniated disc. The When the motion segment is potentially unstable,
second approach may be more appropriate when laminoarthrectomy with concomitant discectomy may
nerve-root compression is thought to be mainly caused reduce spinal stability to a critical extent. This is parti-
by the osteoligamentous structures and / or in the pres- cularly true if discectomy is performed bilaterally or
ence of radicular canal stenosis at the level above that central laminectomy or complete unilateral arthrecto-
of herniation. In both cases, the use of an operating my are carried out. Likewise, when the motion segment
microscope may facilitate the decompression of the is preoperatively unstable, any decompressive pro-
nerve root and decreases the risk of performing an cedures tend to decrease spinal stability, particularly if
unnecessary total facetectomy. associated with discectomy. Although the latter does
not necessarily imply that low back pain wiJI increase
after surgery, there are high chances that this will occur.
Indications for fusion after discectomy Arthrodesis is usually not indicated in patients with
preoperatively stable motion segments, unless bilateral
In vitro biomechanical studies (1, 35) indicate that arthrectomy has been performed. However, there may
laminotomy with partial facetectomy, performed uni- be an indication for fusion when central laminectomy
laterally or bilaterally, does not significantly affect with subtotal arthrectomy and bilateral discectomy has
spinal stability. However, spinal stability may be signi- been carried out. Another possible exception is repre-
ficantly impaired by even unilateral total arthrectomy sented by patients with one-level or two-level stenosis,
or central laminectomy with partial arthrectomy. Disc disc degeneration in the stenotic area and a chronic
excision, particularly if radical, significantly increases history of low back pain. In these cases, if no patholog-
vertebral motion at the operated level (34). Clinical ic conditions are present proximally or distally to the
studies (44, 75) confirm that laminotomy preserves stenotic area, arthrodesis may be performed to relief
spinal stability to a greater extent than centrallaminec- chronic low back pain.
544.Chapter 2 1 . - - - - - - - - - - - - - - - - - - - - - - - - - -
When lamina arthrectomy and discectomy are per- tently degenerated and often decreased in height.
formed in a potentially unstable spine, the possibility Usually the disc shows mild, if any, annular bulging,
of performing a fusion should be carefully considered. whilst a herniated disc is rarely present; the latter is
Arthrodesis is generally indicated when central more likely to occur in discs showing a normal, or
laminectomy, bilateral laminotomy and discectomy, or moderately decreased, height (Fig. 21.6). Disc hernia-
unilateral total facetectomy are performed. tion may be central, posterolateral, or more rarely,
Fusion should routinely be performed when the lateral and is usually contained or extruded. We have
motion segment submitted to decompression and never observed a tissue fragment migrated from the
discectomy is preoperatively unstable. The only excep- disc below a vertebra presenting degenerative spon-
tions may be the patients with no history of chronic dylolisthesis.
low back pain, in whom a unilateral laminotomy with As in disc herniation associated with stenosis in the
minimal arthrectomy and discectomy are carried out. absence of spondylolisthesis, the clinical presentation
may be that typical of patients with disc herniation or
stenosis, or mixed features may be present. Usually, the
Degenerative spondylolisthesis clinical picture resembles that of disc herniation when
no stenosis is present, whilst it shows mixed features in
The disc below a spondylolisthetic vertebra is consis- the presence of a stenotic spinal canal.
A
Fig. 21.6. Degenerative
spondylolisthesis and disc herniation.
(A) Lateral radiograph showing mild
degenerative spondylolisthesis of L4.
(B) Spin-echo T2-weighted MR
sagittal image revealing compression
of the nervous structures due to
olisthesis ofL4 and disc herniation at
L4-L5Ievel. (C) Axial CT scan at L4-
L5 level showing a small posterolateral
herniation on the right (arrow). (D)
Anteroposterior radiograph obtained
after laminotomy and discectomy on
. •
the right. Laminotomy extends
.
:r-' .
cranially until the distal third of L4
vertebral body and caudally to the
c O distal portion of L5 pedicle
(arrowheads).
- - - - - - - - - - - - - - - - - . Disc herniation associated to other conditions· 545
Surgical treatment no stenotic compression of the neural structures. In
these patients, it is usually sufficient to perform a con-
In patients with disc herniation and degenerative ventionallaminotomy and discectomy or microdiscec-
spondylolisthesis, the two decisions that should be tomy, without arthrodesis (Fig. 21.6). After discectomy,
made in the planning of surgical treatment are: the type olisthesis may increase, but this does not usually cause
of surgical decompression, i.e., unilateral or bilateral significant low back pain, nor stenosis, or symptomatic
laminotomy versus central laminectomy; and whether stenosis, on the contralateral side, at least for several
fusion should be associated to decompression. Few years after surgery. However, the patient should be
studies (17, 72, 75, 76) have compared the results of informed that this surgical option involves the risk that
bilateral or unilateral laminotomy with those of central central, or contralateral, decompression and/ or fusion
laminectomy in degenerative spondylolisthesis, and no may be needed in the following years. The advantages
study has electively analyzed patients with a concomi- of this surgical strategy are the reduced morbidity and
tant disc herniation. Postacchini et al. (72,75) found rapid functional recovery associated with discectomy
that in patients with stenosis and mild spondylolis- alone, and the low chances of developing symptomatic
thesis, bilateral laminotomy may allow adequate de- degenerative changes at the adjacent levels.
compression of the neural structures. However, in the At the opposite extreme, there are the patients with
presence of severe olisthesis (25% or more) or marked or without a history of chronic low back pain, who
stenosis, an adequate surgical decompression may be show marked olisthesis, vertebral hypermobility, severe
achieved only by central laminectomy. stenosis of the spinal canal, and bilateral radicular
There are conflicting opinions on the need for spinal symptoms. In these patients, central laminectomy or
fusion in patients with degenerative spondylolisthesis. bilateral laminotomy and fusion should be carried out.
Although several authors have reported satisfactory In the intermediate situations, there are various
results after decompression alone (23, 28, 43, 61, 76), options: 1) Unilateral laminotomy and discectomy,
other investigators have stressed the risk of an increase associated with fusion, may be preferred in patients
in olisthesis and vertebral hypermobility following with chronic low back pain or hypermobility of the
decompression (42, 46, 52, 84, 88). This has led, in the olisthetic vertebra, but no significant stenosis or radi-
last 20 years, to perform fusion more and more often in cular symptoms on the side opposite the herniation.
association with decompression (12, 17, 18, 30, 31, 39, 2) Bilateral laminotomy with unilateral or bilateral dis-
49, 50). Nevertheless, few studies have compared cectomy and fusion may be indicated in the presence of
patients who had, or had not, undergone spinal fusion. stenosis on the side opposite the herniated disc or of
In a study (53), satisfactory results were obtained by midline or bilateral herniation. In these cases, however,
80% of patients submitted to central laminectomy and central laminectomy is usually preferable in order to
90% of those who had had no fusion. Herkowitz and achieve a more effective decompression of the neural
Kurz (42), in a prospective study comparing 25 fused structures, at least in the presence of central stenosis
and 25 unfused patients, found the results to be (75). This holds particularly if pedicle screw fixation,
satisfactory in 44% and 90% of cases, respectively. which increases short-term spinal stability, is carried
out. 3) Bilateral laminotomy and unilateral discectomy
without fusion may be carried out in patients with
Surgical options no chronic low back pain, who show moderate central
stenosis or radicular canal stenosis on the side opposite
Different surgical procedures may be performed in the herniation, mild olisthesis without vertebral hyper-
patients with degenerative spondylolisthesis, particu- mobility, decreased height of the herniated disc, and / or
larly when a concomitant disc herniation is present. marked degenerative changes or annular bulging in
The choice depends on several factors: type and severi- one of the discs adjacent to the herniation.
ty of stenosis; presence of unilateral or bilateral radicu- In patients with herniation of an adjacent disc to that
lar symptoms; severity of low back pain before the below the olisthetic vertebra, the decision to extend the
clinical manifestation of disc herniation; degree of olis- surgical procedure to the olisthetic level (decompres-
thesis; degree of mobility of the olisthetic vertebra on sion, arthrodesis or both) is based on the evaluation of
preoperative flexion-extension radiographs; and pres- the same factors as in patients with disc herniation
ence of degenerative changes in the discs adjacent to immediately below the olisthesis. In these cases, the
the herniation. most important element in choosing the surgical proce-
At one extreme, there are the patients with signs and dure is the severity of stenosis and its possible effect on
symptoms typical of disc herniation: no history of radicular symptoms over time. If an arthrodesis is
chronic low back pain, mild olisthesis with no vertebral performed, this usually includes the level where disc
hypermobility on flexion-extension radiographs, and herniation is located.
546.Chapter 21.---------------------------------------------------
Type and extension of fusion laminotomy and discectomy are performed (Fig. 21.7).
The advantage of using unilateral instrumentation is
The type of fusion depends, to a large extent, on the a decreased stiffness of the fused area, whereby the
surgeon's preference. We prefer bilateral intertransverse chances of degenerative changes at the adjacent
arthrodesis with autologous bone graft augmented motion segments will be reduced (20, 47, 70).
with pedicle screw fixation. The main goal of internal Bilateral instrumentation should be preferred in the
fixation is to avoid any postoperative rigid immobiliza- presence of severe olisthesis or hypermobility of the
tion. Instrumented fusion allows a similar proportion olisthetic vertebra, particularly if central laminectomy
of solid fusions to be obtained compared with non- is performed (Fig. 21.8).
instrumented arthrodesis and prolonged rigid post- The alternative to posterolateral arthrodesis is poste-
operative immobilization. In the majority of studies, rior interbody fusion, using autologous iliac bone graft,
the percentage of solid fusions ranges from 91 % to bone fragments obtained from the excised portion of
100% after noninstrumented arthrodesis (30, 31, 53,72) the posterior vertebral arch or allograft (10, 13, 21, 85).
and from 87% to 100% after arthrodesis using pedicular Unilateral or bilateral pedicle screw fixation may be
fixation and autologous bone graft (12, 18, 19,47). associated to interbody fusion (14, 48, 86). The latter
Internal fixation with pedicle screws can be per- may also be carried out by packing bone graft into tita-
formed on one or both sides. Unilateral fixation may be nium or carbon fiber cages, implanted into the inter-
sufficient in patients with mild olisthesis and no verte- vertebral space.
bral hypermobility who undergo arthrodesis at a single Anterior discectomy with interbody fusion (90) is
vertebral level (19); this holds particularly if unilateral justified only in the absence of stenosis or when this is
A B c
Fig. 21.10. Disc herniation and isthmic spondylolisthesis. (A) and (B) Turbo spin-echo Tl-weighted sagittal MR images showing an intraforaminal
disc herniation and Grade 1 spondylolisthesis ofL5. (C) Spin-echo Tl-weighted axial MR image at L5-S1level revealing an intraforaminal herniation
on the left (arrow).
55°' 21.---------------------------------------------------
radicular symptoms may persist in the presence of disc radiographs; height of the disc where herniation has
herniation and a concomitant spondylolisthesis. developed; and presence of degenerative changes in the
intervertebral discs adjacent to the slipped vertebra.
Usually, arthrodesis is not indicated in patients with
Management no history of low back pain or a history of occasional,
mild pain. This holds particularly when: 1) The olisthe-
Percutaneous procedures tic vertebra is L5; this vertebra is intrinsically more
stable than an L4 olisthetic vertebra (37) and is less
A few authors (25, 26, 64) have performed chymopa- likely to become unstable after discectomy. 2) The
pain injection in patients with a herniated disc below a preoperative flexion-extension radiographs reveal no
spondylolisthetic vertebra (Grade I or II); the propor- hypermobility of the slipped vertebra. 3) The disc
tion of satisfactory results was found to be similar to where herniation has occurred shows a marked
that in patients without spondylolisthesis, and only in decrease in height; in this instance, there is little proba-
few cases was an increased olisthesis observed after bility that the slipping will significantly increase after
the procedure. In our experience, a true herniation discectomy, since, in adulthood, the spontaneous
rarely develops in the disc below the olisthetic verte- increase in olisthesis over time parallels the decrease in
bra. In some of the patients submitted to nucleolysis, height of the disc below and terminates when the disc is
the satisfactory outcome might be attributed to the completely resorbed (55, 66, 69, 93). 4) Preoperative
natural evolution of an irritative radicular syndrome, MRI demonstrates degenerative disc changes at the
produced by bulging of the annulus fibrosus or the level above or below the herniation. After arthrodesis,
pseudarthrosis tissue. However, in the presence of in fact, the increased mechanical stresses on the degen-
a true herniation, there may be an indication for erated disc tend to aggravate the degenerative changes;
chemonucleolysis, particularly when radicular pain is this may be avoided by extending the arthrodesis to the
the only or main patient's complaint. When the disc adjacent level(s), however an extended arthrodesis
below the spondylolytic or spondylolisthetic vertebra may not be desirable, particularly in young patients or
shows a normal or slightly decreased height, it should those with mild low back pain.
be taken into account that olisthesis or vertebral mobil- Arthrodesis is generally indicated in patients who
ity may increase following chemonucleolysis. have been complaining of intermittent low back pain
In the presence of a herniated disc above the olisthet- for years or decades. This holds particularly when: the
ic vertebra, the indications for chemonucleolysis or disc where herniation is located shows a slight decrease
other percutaneous procedures are similar to those in in height; flexion-extension radiographs demonstrate
patients without spondylolisthesis. hypermobility of the olisthetic vertebra; and no degen-
erative changes are present in the disc(s) adjacent to the
slipped vertebra. The risk, if fusion is not performed, is
Surgical treatment
that discectomy may lead to an exacerbation of low
back pain due to the occurrence of, or an increase in,
When spinal fusion is performed along with discecto-
spinal instability.
my, laminoarthectomy may be even very wide Of, in
Arthrodesis is generally indicated in patients with a
patients in whom radicular symptoms are attributable
long history of frequent or continuous low back pain.
to the spondylolisthesis, the entire posterior vertebral
The procedure is contraindicated when multiple-level
arch may be excised. If no fusion has been planned,
disc degeneration makes it difficult to determine the
laminoarthrectomy should be of limited extent to reduce
role played by the spondylolisthesis in the etiology of
the risk of causing or accentuating spinal instability. In
chronic low back pain. In these cases, discography may
these cases, it is preferable to use the operating micro-
be carried out to establish whether a degenerated disc
scope, since it may allow disc excision through a smaller
adjacent to the spondylolisthesis is symptomatic; in
laminoarthrectomy than that performed with the naked
addition, the pars defect may be injected with local anes-
eye. As in patients with herniation and no spondylolis-
thetic to assess the role of pseudarthrosis tissue in the
thesis, a complete discectomy should be preferred.
origin of low back symptoms (9, 87). However, the pres-
ence of disc herniation makes these diagnostic tests of
Indications for fusion
uncertain interpretation and, thus, of little usefulness.
Disc herniation below spondylolisthesis. To evaluate Disc herniation above spondylolisthesis. This con-
whether fusion may be needed, the following factors dition usually consists in a herniation at L4-L5 level,
should be taken into account: severity and duration of in the presence of a spondylolisthesis of L5. In these
low back pain; level of the olisthetic vertebra; degree of cases, arthrodesis is rarely indicated. The indication
mobility of the slipped vertebra on flexion-extension essentially depends on the presence (or absence) and
to other conditions· 551
severity of chronic low back pain, since excision of the be associated more frequently with lumbar stenosis
herniation does not affect the stability of the olisthetic (2,27,38,54).
vertebra, unless a subtotal or total L5-S1 foraminec- In patients with idiopathic scoliosis and disc hernia-
tomy is performed. Hence, the indication for fusion is, tion, the clinical presentation does not differ from that
to a large extent, independent of the herniation and of patients without scoliosis, although scoliotic patients
should be evaluated using the same criteria adopted are more likely to report a history of chronic low back
in patients who have spondylolisthesis and no disc pain. More often, patients with degenerative scoliosis
herniation. If fusion is carried out, it should usually be present a clinical picture which is typical of stenosis.
extended to L4. The coexistence of severe degenerative Percutaneous treatments may be indicated in young
changes of the L3-L4 disc may represent a contraindica- patients with a spinal curve of less than 20°. In the pres-
tion for arthrodesis, due to the increase in mechanical ence of more severe scoliosis, narrowing of the radic-
stress on this level following fusion. ular canal may be present, which increases the chances
of failure after percutaneous treatments. Moreover, if
chemonucleolysis is performed, the reduced disc
Types of arthrodesis
height occurring after chymopapain injection may
cause further narrowing of the intervertebral foramen,
A posterolateral arthrodesis, an anterior or posterior
and lead to compression of the emerging nerve root.
interbody fusion, or a circumferential arthrodesis, with
Furthermore the decreased disc height might decom-
or without instrumentation, can be performed; further-
pensate the scoliotic curve.
more, an in situ fusion may be carried out, or the olis-
Although in these cases discectomy is not technically
thesis may be reduced preoperatively or intraoperatively
different from that performed in subjects without
(8,41,55, 60). Posterolateral in situ fusion with pedicle
scoliosis, care should be taken to avoid an excessively
screw fixation is the authors' preferred method in adult
wide arthrectomy, which might compromise spinal
patients with Grade I-III spondylolisthesis. It is still
stability to a greater extent than in non-scoliotic patients.
unclear whether pedicle screw fixation significantly
Therefore, microdiscectomy seems to be particularly
increases the proportion of solid fusions in patients
indicated in these patients, since it may allow excision
with isthmic spondylolisthesis; pedicle screw fixation
of the herniated disc through a more limited facetecto-
led to a higher rate of fusions in one comparative study
my. There is no indication for fusing the operated level,
(101), but not in another investigation (58). However,
unless a complete arthrectomy has been performed.
the use of internal fixation decreases the immediate post-
In the presence of severe scoliosis, a single-level fusion
operative back pain and, thus, the hospitalization time
exposes to the risk of increasing the spinal curve
and, above all, avoids prolonged rigid postoperative
and! or causing rotatory instability of the motion
immobilization. Intraoperative reduction of the olisthe-
segments adjacent to the arthrodesis.
sis associated with circumferential arthrodesis may be
In adults with severe and progressive scoliosis, who
considered in patients with Grade IV spondylolisthesis
complain of intense low back pain prior to the appear-
or in adolescents with Grade III or IV slipping.
ance of lumboradicular symptoms caused by the
herniated disc, correction of the deformity and fusion
Isthmic repair should be associated to discectomy. If posterior instru-
mentation is used to correct the deformity, a segmental
This procedure is indicated in patients with Grade I fixation with pedicular screws may be advisable (54).
spondylolisthesis. However, as in patients with spond- With pedicle screw instrumentation one may obtain
ylolysis, the resolution of chronic low back pain a better correction of the lumbar kyphosis, which is
may not be the main goal of the procedure, when pain often responsible for the low back symptoms com-
is due to degeneration of the disc below the slipped plained of by the patients who have lumbar scoliosis.
vertebra. Isthmic repair may be useful in patients with In the presence of a marked and rigid kyphoscoliosis,
disc herniation below the slipped vertebra when fusion an anterior, or combined, procedure may be indicated.
is not indicated, in order to avoid the progression of
olisthesis and the possibile occurrence of postoperative Cervical and thoracic disc herniations
instability.
Cervical and lumbar herniations rarely occur simulta-
Lumbar scoliosis neously. Even more rarely are a lumbar and a thoracic
herniation found together, since the latter condition is
The prevalence of disc herniation does not seem to be uncommon in itself. The presence of disc herniations
affected by the presence of idiopathic lumbar scoliosis. in different areas of the spine entails diagnostic and
This is also true for degenerative scoliosis, which may therapeutic problems.
552.Chapter 21.-----------------------------------------------------
Diagnosis useful when doubts persist as to whether the lumbar
disc herniation is asymptomatic or responsible for the
Diagnostic problems may arise in the presence of spinal patient's symptoms.
cord compression causing symptoms which mimic The role of these investigations in the diagnostic path
those of a lumbar disc herniation, at least when the is demonstrated by the following cases.
symptoms in the lower limbs are vague and bilateral,
and sensory and motor impairment prevails on pain. Case 1. A 38-year-old female complained, for several
This may occur, for instance, in the presence of a low months, of sensory loss and paresthesias in the posterior
thoracic herniation and a lumbar disc herniation locat- aspect of the left thi:;?h, and less frequently, the left Ie:;?, alan:;?
ed in the midline or associated with lumbar spinal with frequent pain in the posterior aspect of the limb and a
stenosis. sensation of asthenia and "difficulty in controllin:;?" the
Spinal cord compression shown by CT or MRI may lower limb. Physical examination revealed a moderate
be asymptomatic or symptomatic (Fig. 21.11). In the increase in reflex activity in both lower limbs, a negative
former case, the patient presents only the clinical signs Babinski's sign, and decreased abdominal reflexes on the left
and symptoms caused by lumbar herniation. In the side. MRI showed a midline herniated disc at T9- T1D level
latter, some or all of the typical signs of the various and a small disc herniation at LS-S1 level, on the left. SEPs
cervical or thoracic cord compression syndromes may showed an increase in the central sensory conduction veloci-
be present. The correct diagnosis of the origin of the ty. EMC revealed normal function of the S1 nerve root.
patient's signs and symptoms may be made from Discography provoked no low back or radicular pain. The
the evaluation of disturbances in the lower limbs. The herniation at LS-S11evel was, thus, thought to be most prob-
presence of pain, particularly if it shows a derma to mal ably asymptomatic and T9-TID discectomy was carried out
distribution, and monoradicular motor loss suggest with complete and lasting relief of symptoms.
a lumbar pathologic condition. This holds also for
depression of the reflex activity on only one side. Case 2. A 62 -year-old male had been complaining, for sever-
However, in the presence of asthenic intermittent clau- al months, of low back pain, as well as pain and mild hypos-
dication, it may be impossible to determine whether thesia along the posterolateral aspect of the thi:;?h and the
this is caused by compression of the caudal nerve posterior aspect of the leg, on the left. Similar symptoms,
roots or the spinal cord. however less severe, were present on the right side. The pain
Sensory and/ or motor evoked potentials can be use- in the left Ie:;? considerably increased during walking, where-
ful in determining whether a subclinical myelopathy is by the patient could walk only a few dozen meters. Physical
present or evaluating the severity of a clinically overt examination revealed a marked symmetrical hyperreflexia on
myelopathy. EMG sudies may document the presence both lower limbs, a negative Babinski's sign, normal abdomi-
and severity of lumbar nerve-root compression. nal reflexes, absence of motor deficits in the lower limbs, a
Discography or anesthetic nerve-root block may be negative straight leg raising test, and a slightly positive
femoral nerve stretch test, on the left side. Radiographs of the
lumbar spine showed degenerative spondylolisthesis of L3.
MRI revealed stenosis of the spinal canal and a left paramedi-
an disc herniation at L3-L4 level, as well as a left paramedi-
an herniation at TlO-T11 level. SEPs were normal, whilst
EMC studies showed slight impairment of the LS nerve
root on the left. The thoracic herniation was thought to be
asymptomatic. Central laminectomy and left discectomy, as
well as instrumented posterolateral fusion, were performed at
L3-L41evel, with complete relief of symptoms.
Management
I
F. Postacchini, G. Cinotti
Definition and classification toms. On the other hand, patients with surgical failures
cannot be considered as only those undergoing reoper-
A failure in surgical treatment should be distinguished ation. This parameter is well-defined but too restric-
from a complication. The latter term - as currently used tive, since a patient with a surgical failure may refuse
in medicine - includes extraordinary events, often further surgery. Failures should be considered as all
unpredictable and sometimes correctable intraopera- those cases in which surgery did not lead to a signifi-
tively, which render abnormal the operative or post- cant improvement or caused worsening of the pre-
operative course; however, complications do not operative clinical status. These cases correspond to
necessarily affect the surgical outcome. A failure occurs those with outcomes that are usually rated as poor.
when the expected result has not been achieved, due to The failure may be due to persistence of low back or
events which may normally cause a deviation from the radicular pain (Table 22.1). Radicular pain may persist
usual course. Failures may be the result of factors inher- unchanged or decrease only slightly after surgery, or it
ent to the treated condition, related to other conditions, may recur after a symptom-free period. This distinction
or due to intraoperative or postoperative complica- is important, since, in the first case, surgery may have
tions. The distinction between complications and fail- failed in decompressing adequately the neural struc-
ures is often difficult and at times arbitrary. However, tures, whilst in the second, the failure is usually due to
it is important not only for taxonomic reasons, but a pathologic condition which developed after the pri-
also for the different therapeutic and legal implications mary operation. Severe postoperative low back pain
that are involved in the two situations. In this chapter, may be due to a preexisting vertebral instability or be
we analyze the failures which are not related to caused by surgery. However, in most cases, the causes
surgical complications. may not be clearly defined and sometimes may be
Recurrent herniations and new symptomatic hernia- several. We refer to this type of low back pain as
tions are generally reported as surgical failures (3, 8,24, idiopathic, to underline that the etiology can often be
25). This is certainly not appropriate for new hernia- suspected, but not proven.
tions, which represent a pathologic condition that was
not present at the time of the primary discectomy.
However, it is not even appropriate for recurrent herni- Persistent radiculopathy
ations, which, in the majority of cases, are due to factors
for the most part unknown, rather than to a wrong Wrong surgical indication
planning or execution of surgery. Thus, we have not
included these conditions among the surgical failures. This represents a frequent, if not the most frequent,
Failures in surgical treatment should not be identi- cause of surgical failure. The error usually consists in a
fied with unsatisfactory outcomes. The latter, in fact, too enlarged indication for surgery. This essentially
usually include the fair results, characterized by a mod- occurs in three situations: in the presence of a slight
erate improvement in the preoperative clinical symp- compression of the neural structures responsible for
558.Chapter 22.-----------------------------------------------------
Table 22.1. Classification of surgical failures. The presence of psychologic disorders, such as
Persistent radiculopathy depression, anxiety, hysteria and hypochondriasis,
may considerably affect the surgical result (48, 58, 66,
Wrong surgical indication 72). The same is true for legal controversies directed at
- Mild radicular compression
- Psychogenic pain obtaining financial compensation or work disability.
- Long-standing neurologic deficits Certainly, even patients with disorders in their emo-
Wrong preoperative diagnosis tional profile may present entirely organic conditions,
- Stenosis which resolve with surgery (54). However, in the pres-
-Tumors ence of behavioral or clearly psychotic disorders, the
- Thoracic disc hernia tion
- Other pathologic conditions indication for surgery should be carefully evaluated
Wrong surgical planning and psychologic tests performed prior to surgery. This
- Concomitant herniation at another level is particularly true when diagnostic studies show a less
- Unilateral discectomy for bilateral herniation severe pathologic condition than expected from the
- Concomitant stenosis patient's complaints.
- Concomitant isthmic spondylolisthesis
Errors in detecting herniation Radicular motor or sensory deficits, lasting for sever-
- Surgery at wrong level al months or years, have little possibility of recovering
- Surgery on wrong side after nerve-root decompression. If the only reason for
Defective surgical treatment surgery is the improvement of neurolog~c deficits, there
- Incomplete removal of contained or extruded herniation are high chances of failure. In these cases, the operative
- No or incomplete removal of migrated disc fragment
- Extrusion of residual disc fragment treatment is justified only if radicular pain or lumbo-
- Persistent nerve-root canal stenosis radicular intermittent claudication is present, and the
- Nerve-root injury primary aim is the resolution of these symptoms, rather
Recurrent radiculopathy after a pain-free interval
than of the motor deficits.
Epidural fibrosis
Arachnoiditis
Stenosis Wrong preoperative diagnosis
Postoperative low back pain Approximately one fifth of asymptomatic subjects have
Spinal instability a herniated disc in the lumbar spine. The presence of
Discogenic low back pain herniation may lead to ascribe the lumboradicular
Facet joint osteoarthrosis symptoms to this condition, whereas the cause of pain
Pseudarthrosis
Psychogenic low back pain is another condition, such as stenosis or tumor, located
at a different vertebral level from that of herniation.
A stenotic condition can be missed when the diagno-
mild radicular symptoms; when pain is mainly sis is based only on clinical data, or when CT examina-
psychogenic in nature or a legal contention exists; and tion is not extended to the uppermost lumbar levels.
in the presence of long-standing neurologic deficits After surgery, the radicular symptoms and neurologic
associated with no or mild radicular symptoms. deficits remain unchanged or may worsen in the pres-
Unsatisfactory results are likely to be obtained in ence of severe compression of the neural structures at
patients with annular bulging or a small contained or the stenotic level. A wrong diagnosis should be suspect-
extruded herniation, who complain of mild radicular ed when preoperative CT shows a narrow spinal canal
symptoms and/ or symptoms limited to the proximal or marked osteoarthrotic changes of the facet joints.
portion of the lower limb, and show negative or slight- All intraspinal or vertebral tumors in the lower
ly positive nerve-root tension tests and no neurologic thoracic or lumbosacral spine may mimic the clinical
deficits. In these cases, pain is often relieved only slight- presentation of a lumbar herniated disc. The most
ly or persists unchanged after surgery, particularly in frequently unrecognized tumors are cauda equina
the short term. The cause of surgical failure in these neurinomas (Fig. 22.1) and ependymomas of the lower
patients is unknown. However, in many conditions in thoracic or upper lumbar spine, whilst primary or sec-
which pain is the main symptom, the quality of the sur- ondary bone tumors are rarely a cause of diagnostic
gical outcome is known to be related to the severity of errors. When preoperative signs and symptoms are
the preoperative pathologic condition. Possibly, these caused by the tumor, rather than the herniated disc, the
patients have an abnormally low pain threshold, due to clinical picture remains unchanged or may worsen
an insufficient production of endogenous opiates or after discectomy. The deterioration can vary from a
other unknown causes, leading to an abnormal percep- mild worsening of the preoperative neurologic deficits
tion of pain before and after surgery. to complete paraplegia. In these cases, MRI studies of
-----.- 8
Fig. 22.1. MR images of a patient with neurinoma at L2 and concomitant disc herniation at L4-L5
level, on the left side. The spin-echo T2-weighted sagittal image (A), Tl-weighted sagittal image (B)
and Tl-weighted axial image (e) show an expanding, intraspinal, extradural lesion on the left at L2
level, which causes erosion of the posterior aspect of L2 vertebral body and enlargement of the spinal
canal and intervertebral foramen. The spin-echo T2-weighted sagittal image (D) reveals an extrud-
ed disc herniation at L4-L5level (arrow) and an expanding lesion at L2 (arrowheads). D
the thoracic and lumbosacral spine usually lead to tic errors (Fig. 22.2). These conditions should be taken
detection of the tumor. The subsequent treatment will into consideration when CT and / or MRI of the lumbar
vary according to the type and spread of the tumor, and spine reveal no pathologic conditions which can
the severity of the neurologic deficits. account for the patient's complaints.
Disc herniation in the lower thoracic spine may cause
lumboradicular symptoms similar to those produced
by a lumbar herniated disc. The condition may be Wrong surgical planning
missed if neurologic examination reveals no signs of
spinal cord compression, or these are not recognized by Wrong planning of surgery is due to inadequate evalu-
the examiner, and MRI studies are limited to the lumbar ation of the clinical data or diagnostic tests. This may
spine. After surgery, the clinical picture remains lead to the clinical signs and symptoms of a different
unchanged or may worsen due to spinal cord edema or pathologic condition from that responsible for the
ischemia, as a result of the patient positioning during patient's complaints, or to the role played by a given
surgery or intraoperative hypotension. condition in the etiology of radicular pain, being under-
Many other vertebral or extravertebral conditions - estimated. The result is an error in the surgical strategy
such as synovial cysts of the facet joints or aneurysms of and partial or no decompression of the involved neural
the abdominal aorta - may be responsible for diagnos- structures.
560. Chapter 22 . - - - - - - - - - - - - - - - - - - - - - - - - - - -
Concomitant herniation at another level similar to, those present preoperatively. In the former
case, it is advisable to carry out conservative treatment
Two situations may be identified: symptomatic disc for several weeks before considering repeat surgery.
herniation at two levels; and symptomatic herniation at This holds particularly when the unexcised herniation is
one level with concomitant asymptomatic herniation at small and responsible for mild radicular symptoms. In
another interspace. The second condition is analyzed in these cases, in fact, not only may the residual symptoms
the chapter dealing with recurrent herniation. gradually disappear, as occurs in patients who undergo
It is extremely rare that a symptomatic herniated disc successful conservative management, but there is also
is simultaneously present at two levels. On the other the risk that persistent symptoms may result from post-
hand, it may be difficult to determine preoperatively operative irritation of the decompressed nerve root
whether bothherniated discs are responsible for radicu- rather than from the residual herniation and, thus, that
lar symptoms, or which herniation is symptomatic. further surgery is unnecessary. However, when severe
When only one of two symptomatic herniated discs, or symptoms persist unchanged for 2 weeks after surgery,
only the asymptomatic herniation, is excised, the repeat surgery should be planned, if postoperative MRI
patient continues to complain of lumboradicular symp- excludes other conditions or reveals an insufficient
toms, which may be, respectively, less severe than, or decompression of the neural structures at the operated
___________________________ 0 Surgical failures 0561
level (Fig. 22.3). Only in the latter case may re-explo- Concomitant stenosis
ration of the operated level be indicated.
The removal of only the herniated disc, in the presence
of symptomatic stenosis at another level, may leave
Unilateral discectomy for bilateral herniation the lumboradicular symptoms caused by stenosis
unchanged. Similarly, when stenosis is present at the
Bilateral herniation rarely causes compression of the level of discectomy, the patient may continue to com-
nerve structures on both sides, particularly in the plain of radicular symptoms due to persistent compres-
absence of nerve-root canal stenosis. sion of the neural structures. In effect, this rarely occurs
Wrong surgical planning may occur when: the con- when, prior to operation, radicular symptoms are pre-
tralateral herniation is not diagnosed preoperatively, sent only on the operated side, since the decompression
and the radicular symptoms on the opposite side are of the neural structures that laminotomy implies usual-
felt to be caused by the midline or paramedian location ly resolves the leg symptoms. However, in these cases,
of the herniation; or it is felt that the herniation on the the patient may begin to complain of contralateral
opposite side can be removed by disc excision on the radicular symptoms, after an initial period of pain relief.
more symptomatic side. In both cases, after surgery, the The opposite mistake is to overestimate the clinical
patient continues to complain of radicular symptoms significance of a narrow or stenotic spinal canal. This
on the side opposite that operated on. In the majority of may lead to unnecessary decompression, causing
patients with bilateral herniation, the preoperative radicular symptoms, generally transitory, due to the
symptoms are predominant on one side, and the mild effect of surgical trauma on preoperatively asympto-
radicular pain which may persist postoperatively on matic nerve roots.
the opposite side is usually well-tolerated and tends to
disappear in a few weeks or months. This holds partic-
ularly when the contralateral herniation was identified Concomitant isthmic spondylolisthesis
preoperatively and accurate, radical disc excision was
carried out. In these cases, prolonged conservative In a patient with disc herniation and isthmic spondy-
management should be carried out, before considering lolisthesis, the radicular symptoms may persist after
repeat surgery on the opposite side. In the presence of surgery if the role played by the spondylolisthesis in
severe leg pain, which usually occurs in patients with the patient's complaints was not determined preopera-
nerve-root canal stenosis, reoperation should be tively. The condition most frequently encountered is
planned after a short period of conservative therapy. spondylolisthesis of L5 and concomitant herniation, or
22.-------------------------------------------------------
annular bulging, at L4-L5 level. Excision of the L4-L5 Surgery on wrong side
disc may only decrease or leave unchanged the radicu-
lar pain if this is partly, or entirely, due to spondylolis- To perform disc excision on the side opposite the her-
thesis. This possibility should not lead to indiscriminate niation, and not to recognize the error during surgery, is
decompression and / or fusion of the olisthetic vertebra an extremely rare event: 0.8% in a series of 116 surgical
in addition to disc excision, particularly when spondy- failures analyzed by Zerbi et al. (74). In the presence of
lolisthesis is long-standing, whilst radicular symptoms a contained, or a sub ligamentous or transligamentous
are recent in onset, and the patient reports no chronic extruded, herniation, the herniated tissue may even be
history of low back pain. removed from the opposite side, provided a complete
or radical disc excision is carried out. Surgery on the
wrong side, therefore, may occasionally be associated
Errors in detecting disc herniation with the resolution of radicular symptoms. However,
this does not occur when the herniation is extruded
Surgery at wrong level behind the posterior longitudinal ligament or a migrat-
ed disc fragment is present. Furthermore, in all these
This is one of the most common mistakes in lumbar cases, transitory nerve-root impairment on the operat-
disc surgery. In the vast majority of cases, the error is ed side may occur, due to manipulation of a pre-
recognized and corrected intraoperatively. Otherwise, operatively asymptomatic nerve root. The treatment
after surgery, the patient continues to complain of required is an immediate reoperation.
the same symptoms as those present preoperatively.
Occasionally, the symptoms improve for a few days
after the operation due to a surgery-related placebo
Defective surgical treatment
effect or the anti-inflammatory medication adminis-
Many patients complain of persistent radicular pain
tered during the postoperative period. In a few cases,
both pain and neurologic deficits are more severe after surgery, particularly when no anti-inflammatory
immediately after surgery. This may be related to an drugs are administered in the first postoperative days.
Usually, pain is less severe than preoperatively and
increase in nerve-root compression due to the patient's
position during surgery or to intraoperative bleeding, gradually disappears over several days or weeks. This
persistent pain should not be considered as pathologic
when the explored disc is adjacent to the herniated one.
and the patient has to be reassured that it will gradual-
Wrong level exploration at initial surgery has been
reported in 2% to 9% of patients submitted to reopera- ly disappear.
The persistence of radicular pain as severe as, or only
tion for surgical failure (13, 24, 26, 29, 61). Usually, the
mistake can easily be detected postoperatively on an slightly less severe than, the preoperative pain, should
suggest that a wrong surgical treatment has been car-
anteroposterior radiograph of the lumbar spine. The
ried out. The distinction between normal and abnormal
radiograph may not permit diagnosis or may leave
postoperative pain is based on the evaluation of sever-
doubts when only flavectomy, or an extremely limited
al factors, such as the patient's psychologic profile, the
laminoarthrectomy, has been performed. In these
degree of positivity of nerve-root tension tests and,
cases, the diagnostic doubt is easily resolved by MRI,
particularly, the correlation between the surgical find-
which shows the changes in the epidural tissue and
ings and the condition diagnosed preoperatively.
paraspinal muscles produced by the surgical approach.
MRI should usually be given preference over CT, due to
its greater ability in excluding errors in preoperative Incomplete removal of contained or extruded
diagnosis. herniation
If surgery at a wrong level is diagnosed after the
operation, the patient should be immediately informed This cause of failure has been detected in 2.5% of 116
and reoperated on. patients with persistent radicular pain after discectomy
To avoid this error, some surgeons routinely perform (74). An incomplete removal of the herniation should
an intraoperative lateral radiograph of the lumbar be suspected when the preoperative neuroradiologic
spine at the end of discectomy, placing a blunt dissector studies reveal no migrated disc fragment or nerve-root
into the disc space. In our opinion, this procedure is canal stenosis, or when the amount of disc tissue
useful if there is any doubt, even minimal, that a wrong excised at surgery was less than expected. In these
level has been explored; however, it should be avoided, cases, radicular pain generally decreases after surgery,
because of the time loss and radiation exposure, when but only slightly.
the surgical findings leave no doubts that the patholog- There are two possible options when an incomplete
ic disc has been operated on. removal of herniation is suspected: to carry out a
neuroradiologic study aimed at demonstrating the when the excised fragment is smaller than suggested by
possible persistence of the herniation and reoperate on the preoperative imaging studies and/ or the fragment
the patient; or to obtain plain radiographs of the lumbar has been removed in small pieces.
spine to exclude that surgery was performed at a wrong When the entire migrated fragment has been left
level and carry out a prolonged conservative therapy behind, the patient complains of radicular symptoms of
before considering further surgery. a similar severity to those present preoperatively.
The first choice is more appropriate when radicular Occasionally, in the first few days, pain and neurologic
pain is severe. Usually, however, it is advisable to wait deficits may be even more severe, due to the additional
at least 1-2 weeks after surgery, during which bed rest trauma to the nerve root caused by the surgical maneu-
is advised and anti-inflammatory medication, possibly vers and intraoperative bleeding. When only a portion
corticosteroids, is administered. If severe symptoms of the fragment was removed, radicular symptoms may
persist, repeat surgery should be planned, once a con- be less severe after surgery, but in the first few weeks
dition requiring surgery has been detected on CT or they are often unchanged. There are no clinical data
MRI. CT may be sufficient when MRI was performed which may lead to the suspicion of a missed migrated
preoperatively, whereas the latter should be performed fragment, even if this possibility should always be
when the preoperative diagnosis was made by CT; taken into account in the presence of a partial or com-
computerized tomography, in fact, may fail to detect plete failure in relieving preoperative radicular symp-
non-discal conditions or pathologies located at the toms. CT and, particularly, MRI usually demonstrate,
upper lumbar levels, which may be the true cause of even in the immediate postoperative period, the pres-
the persisting symptoms. However, if only a disc condi- ence of a medium-sized or large migrated fragment not
tion is detected at the operated level, the therapeutic excised at surgery. However, a small fragment, or the
decision should be based on the clinical presentation, residual portion of an incompletely removed fragment,
since CT or MRI findings may be difficult to interpret may not be clearly shown by imaging studies.
in the early postoperative period. Failure to remove a migrated fragment usually
The second choice is justified when the postoperative requires an immediate reoperation. The same is true for
symptoms are of a moderate severity and/ or the sur- an incomplete removal of a migrated fragment, if the
geon feels that the neural structures were adequately residual portion is large. However, if only a small por-
decompressed. In these cases, it is advisable to perform tion of the original fragment (less than one fourth of the
an intensive conservative treatment, based on anti- original size) was left in place, the evolution of symp-
inflammatory medication and physiotherapy, for 3-5 toms should be carefully monitored during the follow-
weeks, avoiding postoperative exercise therapy during ing 3-6 weeks, before considering repeat surgery,
this period. When radicular symptoms do not improve particularly when operative treatment has consider-
significantly, CT or MRI should be carried out accord- ably relieved the radicular symptoms. In fact, resorp-
ing to the criteria previously outlined. If imaging stud- tion of the residual fragment may gradually occur, with
ies reveal a persistent disc herniation which may be a complete resolution of symptoms.
responsible for nerve-root compression, it is usually If a reoperation is performed, the neural structures
advisable to reoperate on the patient. To prolong wait- should be exposed more widely than at initial surgery,
ing, in fact, not only may not lead to a sufficient pain especially if microdiscectomy was carried out.
relief, but may cause a long sick-leave as well as reduce However, the use of the operating microscope may
the probability of a satisfactory outcome, if surgery is facilitate the visualization of migrated disc fragments.
delayed excessively.
B
Fig. 22.4. Extrusion of a residual disc fragment
after discectomy. The preoperative MRI (A) of
this 67-year-old female showed an extruded
herniation at L4-L5 level on the left and a small
asymptomatic herniation at L3-L4. The patient
underwent an L4-L5 discectomy on the left with
complete relief of radicular symptoms. Eleven
days after surgery she experienced a sudden
recurrence of radicular pain on the left.
Postoperative MRI, (B) and (C), revealed, at the
site of surgery, a tissue of uncertain origin
(arrowhead). After gadolinium injection (D), the
tissue showed a peripheral increase in signal
intensity, whilst the central portion remained
hypointense (arrowhead). The arrow in (B)
indicates the hyperintense tissue present at the
site of the surgical approach. o
- - - - - - - - - - - - - - - - - - - - - - - - - - · S u r g i c a l failures' 565
the patient experiences an immediate pain relief, Furthermore, the latter develops ventrally to the thecal
which, however, does not progress to a complete disap- sac and the emerging nerve root, particularly in the area
pearance of the symptoms during the weeks following adjacent to the disc, where it forms adhesions between
surgery. Radicular pain may be present even at rest or the residual annulus and the neural structures.
appear only during walking. Pain on walking may Studies aimed at determining the origin of epidural
indicate persistent stenosis. In these cases, CT has a fibrosis indicate that the connective tissue cells of the
greater diagnostic ability than MRI, since it allows bet- deep layer of the paraspinal muscles are the main source
ter visualization of the bony structures. It should be of epidural scar tissue (42). Within a few weeks, fibrob-
noted, however, that it may be difficult to determine lasts form a fibrous membrane which fills the surgical
whether nerve-root compression due to radicular canal defect (laminectomy or laminotomy) and penetrates
stenosis is present at an operated level, except when into the spinal canal, where it adheres to the thecal sac
stenosis is severe. and emerging nerve roots. When discectomy is per-
When imaging studies reveal, or strongly suggest, a formed, even the anterior portion of the spinal canal is
persistent nerve-root canal stenosis, repeat surgery invaded by fibrous tissue (36, 65). The latter might also
should be planned, if conservative management for at originate from cells of the annulus fibrosus, since the
least 3 months has not relieved the radicular symp- exploration of the spinal canal, with no lesion to the
toms. If a definite condition has not been diagnosed, a annulus fibrosus, does not seem to stimulate the forma-
reoperation may be justified when the patient com- tion of scar tissue in the ventral region of the canal (42).
plains of the typical symptoms of stenosis, and these Epidural bleeding seems to play an important role
are severe and not relieved by conservative treatment in the development of scar tissue. In an experimental
prolonged for at least 6 months. study (1), the epidural scar tissue which developed in
the animals in whom profuse bleeding had occurred
during surgery, was more resistent to tensile stresses
Traumas to the emerging nerve root
than that formed in animals with normal bleeding. It is
still unclear, however, whether the formation of scar
Excessive retraction or traumatic manipulation of the
tissue is related to other factors, such as the entity of
nerve root in the extrathecal course may cause root
trauma to the epidural tissue during surgical maneu-
edema or ischemia, responsible for persistent radicu-
vers, the extent of the opening created in the annulus
lopathy after surgery. Usually, the symptoms consist
fibrosus or the individual tendency to form scar tissue.
in sensory disturbances (hypoesthesia, paresthesias,
dysesthesia), at times associated with a mild worsen-
ing of the preoperative motor deficit; even persistent
Clinical relevance
postoperative radicular pain may be due to a battered
root. The radicular symptoms usually regress over sev-
Epidural fibrosis is often considered as a possible
eral weeks, but they may also persist in the long term
cause of surgical failure, responsible for the recurrence
(3). It is unclear whether traumatic manipulation may
of radicular symptoms several weeks or months after
cause arachnoiditis of the nerve root in the extrathecal
surgery (25, 29, 74). The asymptomatic interval would
course, as a result of meningeal inflammatory reaction.
correspond to the time necessary for the scar tissue to
This possibility, however, seems to be realistic and
become dense and retracted enough to cause patholog-
might explain the persistence of radiculopathy in
ic effects. A pure epidural fibrosis, however, has been
patients with no apparent reason for surgical failure.
found at reoperation even in patients with no pain-free
interval after primary discectomy (34). The fibrous tis-
sue might provoke: 1) Traction of the emerging nerve
Recurrent radicular pain root, causing nutritional disturbances and impairment
after a pain-free interval of nerve conduction and, thus, radicular pain (1).
2) Decreased mobility of the nerve root, resulting
Epidural fibrosis in a greater vulnerability of the root to compressive
agents, such as recurrent herniation or stenosis (I, 40).
Origin 3) Constriction of the nerve root, which would be as
enfolded in a rigid sleeve; in the presence of inflamma-
Any surgery entailing the violation of the spinal canal tory processes of the nerve root, this rigid sleeve would
produces epidural fibrosis. After laminotomy and dis- cause root compression or ischemia of the neural tissue.
cectomy, the area originally occupied by the ligamen- In effect, the clinical significance of epidural fibrosis
tum flavum and the portion of the laminae and facet remains to be elucidated. In particular, it is unclear
joint excised at surgery is filled with scar tissue. whether epidural fibrosis may, in itself, determine
s66.Chapter 22.-----------------------------------------------------
traction-compression effects on the nerve root and annular constriction and a central patent zone; in
whether these effects are related to the amount of scar Type III, the thecal sac is completely obstructed (35).
tissue. Several findings suggest that the scar tissue, Arachnoiditis may involve one or more vertebral lev-
even when abundant, does not in itself cause patholog- els. Usually, it affects the entire terminal portion of the
ic effects. There is, in fact, no correlation between the thecal sac. In long-standing cases, areas of calcification
clinical results of the operation and the factors that may or ossification of the arachnoid may be observed.
favor the formation of scar tissue: patients presenting
profuse intraoperative bleeding or a tendency to form
keloid scars, have similar chances of obtaining an Etiology and clinical presentation
excellent surgical result as those with little bleeding and
no tendency to form hypertrophic scars; postoperative Lumbar arachnoiditis is usually attributed either to the
CT and MRI show that, in patients with no radicular contrast media employed for myelography or to
symptoms, the amount of epidural scar can vary surgery; other causes may be traumas, subarachnoid
considerably (2,10). hemorrhages, infections, tumors or unknown causes
Scar tissue is likely to favor the onset or persistence of responsible for spontaneous arachnoiditis (4, 27, 28, 30,
radicular symptoms only when marked bulging of the 31,35,57,71). A role may be played by an intradural or
annulus fibrosus persists after surgery or even a small systemic decrease in fibrinolytic activity (11).
recurrent herniation occurs. Fibrous tissue decreases Numerous experimental and clinical studies indicate
the nerve-root mobility, thus favoring compression of that not only lipiodol, but also the hydrosoluble
the root by the discal pathologic condition. contrast media (at least the less recent ones) can cause
arachnoiditis, particularly when blood penetrates into
the thecal sac or several myelographies are carried
Treatment out. With the advent of CT and MRI, this cause of
arachnoiditis has almost disappeared, since myelogra-
In patients with postoperative radicular pain in whom phy is now rarely performed. Surgery may cause arach-
the imaging studies show only epidural fibrosis at the noiditis as a result of the operative trauma to the
operated level, management should usually be conser- thecal sac or the emerging nerve roots. Predisposing
vative. Numerous studies indicate that, in these factors to the development of the condition may be: a
patients, reoperation often provides unsatisfactory midline disc herniation, responsible for severe com-
results; the percentage of failure ranges from 33% to pression of the neural structures; central laminectomy
92% (15, 19, 20, 22, 34, 44, 59), usually being around or multiple-level surgery; intraoperative dural tears;
50%. The proportion of unsatisfactory results is not and multiple operations (35, 58, 63, 71). In effect, the
decreased by the use of the operating microscope. In a role played by surgery in causing arachnoiditis remains
few patients, the clinical picture improves in the first unclear. In many cases, postoperative arachnoiditis is
few weeks or months after reoperation, but then it likely to be caused by idiopathic factors, the surgical
worsens, becoming the same as, or at times even worse trauma being only a favoring or aggravating factor.
than, before surgery. Hence, before planning a reopera- On the other hand, in patients submitted to discectomy
tion, it is extremely important to determine whether and no previous myelographic studies, adhesive arach-
epidural fibrosis is the only demonstrable pathologic noiditis is exceedingly rare: 1.6% and 3% of cases in
condition. If this is the case, when severe radicular pain two series of patients who underwent postoperative
persists after prolonged conservative management, MRI (21, 32).
repeat surgery may be justified, however only when This condition develops and progresses over 6-18
imaging studies do not exclude the possible presence of months (70). It may cause low back pain and radicular
a concomitant recurrent disc herniation or nerve-root dysfunction including mono- and multiradicular
canal stenosis. pain, sensory disorders (paresthesias, hypoesthesia,
dysesthesia), motor loss and, in rare instances, sphinc-
ter disorders. The condition, however, may be entirely
Adhesive arachnoiditis asymptomatic - 50% of cases in Fitt and Stevens's
series (21) - or the symptoms may gradually dis-
In this condition, there is an inflammatory process of appear with no specific therapy (71). Therefore, one
the arachnoid and pia mater, which leads to thickening should be very cautious in attributing recurrent lumbo-
of these membranes and adhesions of the nerve roots radicular symptoms occurring a few months after
to each other and / or the arachnoid. Three types of decompressive surgery to arachnoiditis; diagnosis of
arachnoiditis have been identified: in Type I, only the arachnoiditis can be made only when all other demon-
area where a single nerve root emerges from the thecal strable causes of radicular compression have been
sac is affected; in Type II, the thecal sac presents an excluded.
- - - - - - - - - - - - - - - - - - - - - - - - - - - · S u r g i c a l failures· 567
Treatment have severe pain and progressive neurologic deficits.
This is especially true in the absence of other patholog-
In the vast majority of cases, management should be ic conditions. When a dis cal or stenotic condition co-
conservative: anti-inflammatory and anti-depressive exists, surgery may be more indicated and give better
medication, physiotherapy, acupuncture, functional re- results (7). In these cases, it is generally advisable
education, low back school. The use of dorsal column to treat the associated condition without performing
stimulators placed subcutaneously or epidurally may neurolysis.
be indicated when pain has not been sufficiently
relieved by non-invasive treatments (56).
Surgical treatment consists in intrathecal neurolysis Lumbar stenosis
performed with the operating microscope; sensory rhi-
zotomy may be carried out in association with, or An untreated, or inadequately treated, lumbar stenosis
instead of, neurolysis. Controversial results have been in a patient submitted to discectomy may be responsi-
reported following neurolysis. In the majority of surgi- ble for recurrent lumboradicular symptoms (Fig. 22.5).
cal series, the percentage of patients who had a signifi- However, if stenosis has developed subsequently to
cant relief of symptoms does not exceed 50% (33,35, 63, disc excision, it cannot be considered as a surgical
70); by comparison, conservative treatment led to satis- failure, since it could not have been treated at the time
factory results in a similar or slightly lower proportion of primary surgery. Stenosis may involve, at a single
of cases (33, 63). Since symptoms may become even level, the entire spinal canal or only the radicular canal,
worse after neurolysis, and rhizotomy does not seem to on one or both sides. Moreover, the condition may be
be any more effective (70), surgical treatment should be present at the level of the previous discectomy and I or
considered only in extremely selected patients, who at a different level.
A B c
Fig. 22.5. MRI scans and myelogram of a patient with lumbar stenosis who had inadequate surgical decompression. (A) Preoperative spin-echo T2-
weighted sagittal image showing stenosis at multiple levels, between Ll and L5, and concomitant disc herniation at L3-L41wel. Bilateral laminotomy
was performed at L2-L3, L3-L4 and L4-L5Ievels, along with discectomy at L3-L4. (B) Turbo spin-echo T2-weighted sagittal image performed 11 months
after surgery, showing compression of the nervous structures at Ll-L2 level (arrowhead), due to stenosis of the spinal canal and disc herniation which
were already present, although producing a less severe neural compression, prior to surgery. (C) Myelogram showing a complete block of the contrast
medium at Ll-L2 level.
568.Chapter 2 2 . - - - - - - - - - - - - - - - - - - - - - - - - - -
Incidence and clinical presentation plain of intermittent or continuous low back pain, gen-
erally of a mild entity. Pain is almost invariably present
The incidence of spinal stenosis responsible for delayed upon awakening in the morning and is increased by
surgical failure has been reported to vary from 41% to physical efforts, whilst it often improves or disappears
71% (9, 34, 37); in two series, the ratio of spinal canal with exercise therapy. Low back pain is more frequent
stenosis to radicular canal stenosis was 1:1 (34) and 6:1 in middle-aged, than in young or elderly, patients.
(8), respectively. However, no studies report whether From the third month after discectomy, approximately
stenosis was present at the time of primary surgery or half of the patients complain of low back pain, usually
whether it developed subsequently. mild and discontinuous. After the sixth month, most
In our experience, a preoperatively asymptomatic patients do not suffer from low back pain or complain
stenosis rarely becomes symptomatic after surgery. of occasional discomfort in the low back, which does
This probably occurs in less than 15% of surgical fail- not limit daily activities nor require any treatment. Low
ures after discectomy, and the rate of spinal canal steno- back pain is much more frequent in patients who have
sis to isolated radicular canal stenosis is approximately complained of back pain for years or decades before
1:1. The frequency observed by us is comparable to that surgery than in those with a short history of pain. Rare
reported by Finnegan et al. (20) and Ebeling et al. (15), episodes of acute low back pain, generally of a short
who found stenosis to be the cause of surgical failure in duration, may occur either during or after the first post-
2% and 19% of cases, respectively. operative year.
After discectomy, the asymptomatic interval or the Up until the third month after surgery, low back pain
period of clinical improvement ranges from a few should be considered as physiologic, even when it is
months to many years, but it generally lasts a few years. persistent or frequent, but mild or moderate. Between
The clinical picture is usually characterized by a pre- the third and sixth month, mild and discontinuous low
dominance of radicular pain over low back pain. The back pain requiring occasional medication should still
radicular signs and symptoms are generally unilateral be considered as normal. After the sixth month, low
and involve more frequently the previously sympto- back pain is pathologic if it is mild but continuous, or
matic side. They can have the typical features either of when it is occasional but severe enough to limit daily
disc herniation or spinal stenosis. activities or it requires treatment.
Pseudarthrosis
Facet joint osteoarthrosis
Frequency
Clinical relevance
Pseudarthrosis after an unsuccessful fusion is one of
Chronic postoperative low back pain may be due to the most frequent causes of failure in low back surgery.
degenerative changes of the facet joints of the operated In patients with disc herniation, however, this is a rare
motion segment and/or the adjacent segments. A cause of failure, since fusion is not usually associated
decrease in disc height is known to expose the posterior with discectomy. This is particularly true of patients
joints to abnormal mechanical stresses (14, 73), which with simple disc herniation and of those who have had
may cause, or increase the severity of, degenerative only one previous failed back operation. In the pres-
changes of the facets. This may also occur as a result of ence of associated conditions or in patients submitted
- - - - - - - - - - - - - - - - - - - - - - - - - - - · S u r g i c a l failures· 571
to multiple spinal operations, fusion is often per- compensation claims who had undergone one or more
formed. In these cases, pseudarthrosis is more likely to previous back operations. However, in the individual
be a cause of surgical failure, even if pseudarthrosis patient, it may be extremely difficult to determine
may not be associated with any clinical symptoms (12, whether the psychologic disorders were pre-existent
23, 60). The rate of failures in back surgery attributable to the operation and the surgical failure is due to
to pseudarthrosis ranges from 6% to 16% (5,20,37,45). the prevalence of the psychologic condition over the
The studies in the literature, however, do not usually organic disease, or whether the psychic disorders
report the initial diagnosis in patients submitted to depend, to a large extent, on the surgical failure and
reoperation due to pseudarthrosis and it is, thus, not can be corrected by curing the spinal condition. In both
possible to determine the role of pseudarthrosis cases, it is important to detect the psychologic disorder
as a cause of failure in patients initially operated on and assess its severity, even when a clear-cut organic
for disc herniation, either isolated or associated with condition is present, since the therapeutic planning, as
other conditions. well as the results of treatment, may be considerably
affected by the patient's psychosocial features.
Pseudarthrosis can be responsible for low back pain, or In some cases, the presence of psychologic or psychoso-
even radicular symptoms, in the presence of spinal cial dysfuntions is clearly demonstrated by the
instability. Low back pain shows no peculiar feature, patient's behavior. In other cases, psychogenicpain is
except in patients with spinal instability, whose symp- difficult to suspect or diagnose. In both situations, it is
toms may be those typical of this condition. useful to perform psychometric tests, which may allow
Usually pseudarthrosis is clearly evident on plain the psychologic dysfunction to be detected and/or
radiographs and the persistent vertebral motion in the quantified. Psychologic dysfunctions, in fact, signifi-
fused area may be demonstrated by flexion-extension cantly increase the probability of failure of any organic
radiographs. If the diagnosis is uncertain, biplanar or treatment, particularly if surgical. On the other hand, a
multiplanar CT may be a useful diagnostic tool (41). further failed back surgery entails a high risk of wors-
The diagnosis of pseudarthrosis cannot generally be ening the psychologic disorders and increasing the
made earlier than 6-8 months from surgery. A trial psychogenic component of pain.
plaster jacket or an external fixator may sometimes be In patients with overt psychologic disorders, the
indicated, as in patients with spinal instability. decision to perfom surgery must be taken with extreme
Several clinical studies indicate that in the presence of caution and only in the presence of a clear-cut, severe
symptomatic pseudarthrosis, re-arthrodesis has high organic condition. The same holds when the clinical
chances of significantly improving the clinical symp- examination reveals no significant psychologic dys-
toms, if a solid fusion is obtained (20,37,39). By contrast, function, but the psychometric tests are considerably
Waddell et al. (68) observed unsatisfactory results in altered. In the vast majority of these patients, the
most patients with working compensation claims who therapeutic strategy should be aimed at improving the
had undergone a successful or unsuccessful re- psychologic disorder, returning the patient to a social
arthrodesis. The percentage of solid fusion after re- and productive context, and reducing the organic
arthrodesis varies between 55% and 100% (20,37,43,55). component of pain with various forms of conservative
treatment.
RRENT NEW
F. Postacchini, C. Cinotti
(Fig. 23.2 A). In both cases, the fragment may increase time intervals from primary surgery, remains to be elu-
in size after primary discectomy due to the regenerative cidated. Two hypotheses may be advanced:
processes occurring at the operated site. 1) In the majority of patients, the newly formed tissue
2) A large free fragment of nucleus pulposus may is mainly fibrous tissue which, in itself, shows little ten-
remain within the disc after discectomy and then dency to dislocate and herniate. However, in a few
move to the innermost annulus, i.e., the portion of the patients, most of, or all, the tissue replacing the nucleus
annulus fibrosus which likely fails to heal after disc pulposus tends to acquire fibrocartilaginous features.
incision. The free fragment may remain for a long peri- This tendency might be related to the type and magni-
od of time, or even forever, at this site without causing tude of the mechanical load exerted upon the operated
clinical symptoms; alternatively, it may exert pressure vertebral motion segment in the first few months or
on the fibrous tissue filling the defect of the outer annu- years after discectomy. Like the degenerated nuclear
lus fibrosus, and thus lead to a contained herniation tissue, the fibrocartilaginous tissue might have a greater
or, having perforated the outermost annulus, to an tendency, compared with fibrous tissue, to penetrate
extruded fragment (Fig. 23.2 B). into old or newly-formed annular fissures and be
Early recurrent herniations occurring 6 to 8 months extruded at the site of the previous surgical fenestration
after surgery are much more frequent than very early or at a different site. The variability in the time interval
ones. They are probably due to a different mechanism between primary discectomy and recurrence might be
rather than to incomplete removal of the primary herni- related to a different rate with which subjects form
ation. In these cases, the pathogenetic mechanism is like- fibrocartilaginous tissue after the primary operation.
ly to be similar to that occurring in the late recurrences. 2) In a few patients, exuberant reparative processes,
leading to the formation of abundant regenerated tis-
sue after discectomy, might occur. Due to the abnormal
Late recurrent herniation amount of newly-formed tissue, this may likely herni-
ate into the weakest zone of the annulus fibrosus, i.e.,
These are probably formed by fibrous and/ or fibrocar- at the site of the previous surgical fenestration (Fig.
tilaginous tissue replacing the nucleus pulposus after 23.2 C). This pathogenetic mechanism could explain
primary discectomy. The reason why a minority of why, in many cases, the recurrences are larger than the
patients develop a late recurrent herniation, at different primary herniations.
s80.Chapter 23.-----------------------------------------------------
However, even for recurrent herniation, alternative The terms "contained" or "extruded" are improperly
pathogenetic mechanisms to that of herniation of the used in patients with recurrent herniation, at least when
nucleus pulposus through the annulus fibrosus cannot the latter occurs at the same site as the primary disc pro-
be excluded (page 163). As with primary herniation, lapse, since they refer to that portion of the annulus
it may be hypothesized that, in specific circumstances, fibrosus which has been excised at primary discectomy.
a portion of the annulus fibrosus, or the fibrous tissue However, use of these terms may be justified by the
filling the site of the surgical fenestration, might be analogy between the surgical findings observed in pri-
extruded from the annulus. mary and recurrent herniations. In some patients, in
fact, the herniation appears like a protrusion of the pos-
terior annulus, which resembles a contained primary
Pathology herniation; very often, in these cases, the posterior
annulus is of relatively hard consistency and its incision
Three types of recurrent herniation may be identified: does not cause a spontaneous extrusion of tissue from
small protrusion, medium or large herniation located at the disc space. In other patients, the herniated tissue is
the level of the disc, and migrated herniation. located within the spinal canal, but is still connected to
A B
B c o
Fig. 23.4. CT and MRI scans of a patient with recurrent herniation. (A) Preoperative axialCT scan at L5-S1level revealing a left disc herniation locat-
ed, in part, posterolaterally and, in part, within the neuroforamen (arrows). (B) Sagittal MR image obtained 20 months after primary discectomy, show-
ing a large recurrent herniation (arrows) at L5-S1 level. (e) and (D) Axial MR images showing the disc fragment extruded cranially (arrows); the
recurrence appears to be larger than primary herniation.
the disc (Fig. 23.3). In some of these cases, the herniated the dural sac can occur more frequently than in pri-
tissue may be excised without violating the disc space, mary herniations.
which frequently contains little, if any tissue. Like the tissue contained within the disc, the extrud-
Usually, small herniations are contained and large ed fragment is usually of fibrous or fibrocartilaginous
herniations are extruded. Disc prolapse is usually locat- consistency. Sometimes, it may have intermediate
ed posterolaterally or centrolaterally. A frequent feature characteristics between the latter and the fibrogelati-
of recurrent herniations, particularly of the extruded nous tissue typical of primary herniation. This tends to
type, is that their dimensions are clearly larger than occur more easily in early recurrent herniation, even if
primary herniations (Figs. 23.4 and 23.5). there is no strict correlation between the macroscopic
Migrated herniations rarely occur. They are usually features of the herniated tissue and the time interval
formed by a small fragment of fibrocartilaginous tissue from primary discectomy.
or by fragments consisting entirely, or to a large The scar tissue may adhere to the disc, the thecal sac
extent, of cartilaginous or osteocartilaginous tissue. and the emerging nerve root. The residual ligamentum
Like in primary herniation, the fragment may migrate flavum is often a fibrous laminar structure surrounded
cranially or caudally (Fig. 23.6); rarely is a migrated by scar tissue. There is no epidural fat in the spinal canal
fragment found intraforaminally. Since recurrent herni- and the dura mater is covered by a thin layer of fibrous
ations are often of large size, and due to the presence of tissue and may, thus, be difficult to identify. The nervous
epidural scar, penetration of the herniated tissue within structures can be retracted only when the thin adhesions
- - - - - - - - - - - - - - - - - - - - - - - . Recurrent and new herniations· 583
connecting the disc, and often the posterior aspect of the
vertebral bodies, to the dural sheath, have been divided.
The amount of scar tissue varies, particularly in the
zone located posterolaterally to the neural structures,
i.e., at the site of the previous laminotomy. Instead, the
amount of scar tissue located ventrally to the nervous
structures does not appear to vary between subjects.
In patients submitted to microdiscectomy, the
epidural scar tissue may be less abundant than in those
undergoing standard discectomy, although the differ-
ence is slight and not consistent. When autogenous fat
graft has been placed over the laminar defect, a thin
layer of fibroadipose tissue may be observed, separat-
ing the scar tissue of the muscular layer from that cov-
ering the neural structures. Fig. 23.7. Histologic appearance of recurrent disc herniation. The tissue
consists offew chondrocyte-like cells and intercellular matrix formed, to
a large extent, by fibrous tissue (hematoxylin-eosin).
Microscopic features
fibrous intercellular matrix (Fig. 23.7). Chondrocytes,
A recurrent herniation consists of few chondrocytes either isolated or in clones, exhibit similar histologic
and rare cells with intermediate features between and ultrastructural features to those observed in pri-
chondrocytes and fibrocytes, scattered in an abundant mary herniation. They are surrounded by a pericellular
lacuna containing a dense network of thin fibrils and The intercellular matrix is formed by bundles of col-
proteoglycan granules (Fig. 23.8 A). The fibrochondro- lagen fibers orientated in various directions and little
cytes are elongated cells with no definite pericellular amount of amorphous ground substance, in which pro-
lacuna, showing a scallopped cell membrane and short teo glycan granules are scattered (Fig. 23.9). Aggregates
cytoplasmic projections similar to those of chondro- of electron-dense granular material may be found, at
cytes. In some cells the cytoplasm is entirely replaced times in large amount (Fig. 23.10). The collagen fibers
by filaments (Fig. 23.8 B). Many cells are necrotic or vary considerably in thickness, but many have large
disintegrating. diameters. Collagen fibers are intermingled with thin
fibrils, which often appear to be more numerous in
proximity to the cells and where the ground substance
is more abundant. Granulation tissue may be observed
in some areas (48).
The main difference between primary and recurrent
herniation is that, in the latter, the intercellular matrix
contains a larger number of collagen fibers and a small-
est amount of amorphous ground substance (48, 64).
Hence, recurrent herniation consists of a more fibrous
tissue compared with primary herniation. The morpho-
logic features of early and late recurrent herniations
are similar, even if, in the latter, the intercellular matrix
tends to be more fibrous, the proteoglycan granules
are less numerous and the electron-dense granular
material less is abundant.
Conservative treatment
Imaging studies
The natural history of recurrent disc herniation is
In the presence of recurrent lumboradicular pain, the entirely unknown. Likewise, very little is known
first step in decision-making is to establish whether to regarding the effectiveness of conservative manage-
perform a neuroradiologic investigation or to wait for ment. Hakelius (31) and Naylor (56) reported that 5%
the results of conservative treatments. In patients with and 8%, respectively, of their operated patients had
moderate radicular pain of few weeks' duration and complained of recurrent radicular pain which had
mild clinical signs of nerve-root compression, it is gen- resolved with conservative treatments. However, in
erally preferable to postpone the neuroradiologic stud- both series, the diagnosis was based exclusively on the
ies, since in many cases a gradual regression of clinical evaluation.
symptoms occurs spontaneously. In contrast, in the In our experience, patients with a small recurrent
presence of severe radicular pain lasting 1 month or herniation tend to have a spontaneous resolution of
586.Chapter 2 3 . - - - - - - - - - - - - - - - - - - - - - - - - - -
A 8
Fig. 23.11. MRI scans of a patient with recurrent herniation at L4-LS level, which developed 13 months after the removal of a herniation migrated cau-
dally to the L4-LS disc on the right. (A) Spin-echo Tl-weighted axial image before gadolinium injection, showing tissue of uncertain origin in the
epidural space (arrow) at the site of primary discectomy. (B) Spin-echo T1-weighted axial image after gadolinium, in which the abnormal tissue in the
epidural space shows an increased signal intensity compared with pre-contrast image, except for a small fragment of tissue displacing the thecal sac
posteriorly, (arrowheads). These images suggest the presence of an extruded disc fragment surrounded by abundant epidural scar tissue. This diagnosis
was confirmed at surgery.
lumboradicular symptoms, which may be hastened by those patients who have obtained a satisfactory result
conservative treatments. Hence, conservative manage- after primary discectomy and this has been followed by
ment should be carried out for 3-6 months before oper- a long painless period, since these factors considerably
ative treatment is taken into account, also because in increase the chances of a satisfactory outcome after
these patients the result of surgery is unpredictable. In reoperation.
contrast, in patients with a medium or large recurrent The modalities of conservative treatment are samilar
herniation causing severe nerve-root compression, a to those carried out in patients with primary herniation.
complete resolution of the radicular pain is less likely to
occur compared to patients with primary herniation.
This is due to the intrinsic characteristics of the her- Surgical treatment
niated tissue, which shows little tendency to decrease
in size as a result of dehydration processes, and to the Conventional surgery
presence of epidural fibrosis, which reduces the mobil-
ity of the affected nerve root and, thus, the possibility Exposure of interlaminar space
that the root can escape compression by the herniation.
In these patients, if lumboradicular symptoms remain A slightly longer skin incision than that performed for
unchanged after 1-2 months, conservative treatment a primary discectomy is carried out, in order to expose
should be discontinued. This holds particularly for a larger portion of the proximal and distal laminae;
- - - - - - - - - - - - - - - - - - - - - - - - 0 Recurrent and new herniations 0587
this usually entails an incision 8-10 em long. The When, at the previous operation, a total laminectomy
thoracolumbar fascia is divided close to the spinous (cranial or caudal) or a central laminectomy has been
processes using the diathermy blade. This may be carried out, detachment of the muscle layer has to be
accomplished with no risks until a depth of 3 em is deepened until the posterior border of the articular
reached. The paravertebral muscles are then detached processes can be palpated. The latter need to be clearly
with a periosteal elevator from the residual portion of exposed, since they represent the only bony structure of
the proximal and distal laminae. If any difficulty is reference to determine the depth at which the spinal
encountered in identifying the laminae, the dissection canal is located.
should be extended at a greater distance from the inter-
laminar space; sometimes, it may be necessary to begin
the dissection from one of the adjacent interlaminar Laminoarthrectomy
spaces and then proceed towards that exposed at the
primary discectomy by following the laminar surface. It is usually advisable to widen the previous laminoto-
Exposure of the residual laminae is essential, because my proximally and distally before starting arthrectomy.
they represent an anatomic structure of reference by However, in some cases, it may be preferable to start
which to identify the interlaminar space corresponding with the arthrectomy and then proceed with the
to the herniated disc and to determine the depth at laminotomy. This holds particularly when the lamina is
which the division of the paravertebral muscles can be thick or shows an abnormally ventral direction, or
safely performed using the diathermy blade or the when it is difficult to detach the scar tissue from the
periosteal elevator. We prefer the use of the periosteal anterior border of" the lamina. Usually, laminotomy
elevator in the deep portion of the muscle layer to and, particularly, arthrectomy, are initiated with a small
reduce the risk of injury to the nervous structures. Kerrison rounger and then continued with a medium or
While exposing the inter laminar space, the muscle large rongeur, until an adequate space has been created
layer is detached from the lamina opposite that already between the bony surface and the scar tissue filling the
exposed (proximal lamina, if the distal lamina has been interlaminar defect. Arthrectomy should be performed
exposed); alternatively, the lamina is identified, and very carefully, since, having already excised the medial
exposure of the interlaminar space is then started. portion of the facet joint at primary discectomy, total
Detachment of the muscle layer, which may be more arthrectomy is more likely to occur inadvertently. On
or less fibrotic, should be extended to the articular the other hand, disc excision cannot usually be per-
processes. formed without removing at least one fourth or one
Once the laminae and articular processes have third of the residual facets. Only in this case, in fact, can
been identified and partially exposed, a self-retaining the vertebral canal be entered laterally to the nervous
retractor is positioned. We use a large Taylor retractor. structures and at a zone where the scar tissue is less
Exposure of the laminae and articular processes is com- abundant and, thus, the disc more easily identifiable.
pleted with a periosteal elevator and! or a large curette, One of the most common errors in this phase is to
by scraping off as much scar tissue as possible from the start the arthrectomy too far laterally and superficially;
bone surface. Close to the previoulsy excised laminar this may occur due to the fear of injuring the thecal sac
edge, the fibrous tissue is detached with a small curette, or when the superior articular process has been mistak-
which is then inserted ventrally to the laminar border en for the proximal lamina. Such a mistake may consid-
to excise the scar tissue from the anterior aspect of the erably prolong surgery and lead to a too wide, or even
lamina. total, arthrectomy. The error may be avoided by wider
The more abundant and dense the fibrous tissue fill- exposure of the laminae and articular processes, reach-
ing the inter laminar defect after primary discectomy, ing, if necessary, their outer border. Conversely, this
the more demanding the exposure of the interlaminar mistake is likely to occur when lamina arthrectomy is
space. The longitudinal extent of the previous exposure started before adequate exposure and identification of
is important in this regard, since a wide exposure the bony structures.
implies that scar tissue is present also in the interlami-
nar spaces adjacent to that exposed at primary discec-
tomy. This makes more difficult the identification of Discectomy
the laminae delimiting the inter laminar space to be
explored and increases the risk of operating at a wrong Once the laminoarthrectomy has been widened, the
level. The level where the scar tissue is more abundant soft tissues present in the interlaminar space are retract-
and adherent to the bone is likely to be the previously ed medially. Usually, the nervous structures are not rec-
explored level. However, if any doubt persists, a ognizable, since they are covered by scar tissue and the
fluoroscopic control should be carried out. residues of the ligamentum flavum. In this phase, it is
s88.Chapter 23.-----------------------------------------------------
not essential to identify the emerging nerve root or the for a primary microdiscectomy. The operation is carried
thecal sac, but it is sufficient to medially retract the out with the same modalities as repeat surgery with the
tissue until the intervertebral disc has been exposed. As naked eye.
at primary discectomy, retraction of the neural struc-
tures has to be made at the proximal portion of the
inter laminar space, since the disc is usually located at Arthrodesis
this site. Retraction should be rather vigorous to dissect
the scar tissue from the ventral aspect of the vertebral Some surgeons often perform spinal fusion in patients
canal. On the other hand, there is no great risk of dam- operated on for recurrent herniation and almost invari-
aging the nervous structures since these are protected ably in those with a second recurrent herniation. Other
by the scar tissue. surgeons never carry out fusion. The rationale of spinal
Identification of the intervertebral disc is more fusion is to eliminate the risk of another recurrence and
demanding compared with primary discectomy due to relieve low back pain, which tends to be more severe
the presence of adhesions covering the disc and the after a reoperation than following primary discectomy.
adjacent vertebrae. Dissection should be gentle and We rarely perform a fusion, since the incidence of
careful to avoid injuries to the dural sac or the dural a second or third recurrence is extremely low. On the
sleeve of the radicular nerve, which frequently occur at other hand, fusion may facilitate or accelerate degener-
this phase. The intervertebral disc may be identified by ative changes, and thus even a new herniation, in the
its soft consistency with respect to the adjacent verte- discs adjacent to the fused area. Moreover, after reoper-
brae. To confirm this, a ventral pressure may be exerted ation, the majority of patients complain of mild low
with a thin dissector, until the disc space is entered. back pain, which usually does not require any specific
Subsequently, an adequate portion of the disc is treament. The lower morbidity and the more rapid
exposed until the posterior annulus fibrosus can be functional recovery after discectomy alone versus dis-
incised with a scalpel or a tenotome. Usually, it is advis- cectomy plus fusion should also be taken into consider-
able to penetrate into the disc with a small pituitary ation in this decision-making.
rounger to widen the annular fenestration, thus allow- Spinal arthrodesis may be indicated in patients com-
ing use of a medium-sized pituitary rounger later. plaining of severe low back pain before primary discec-
Once the disc tissue has been removed, a Frazier probe tomy and / or reoperation. In these cases, MRI should be
is introduced between the thecal sac and the posterior carried out before repeat surgery. If the disc above
aspect of the annulus fibrosus in order to weaken, and and / or below the recurrent herniation show no degen-
then remove, disc fragments located in the midline. erative changes, there are no contraindications to
After complete discectomy has been carried out, perform a fusion; however, if this is not the case, the
migrated fragments are sought if they had not already usefulness of extending the fused area to an adjacent
been removed before disc excision. degenerated level should be carefully evaluated. When
MRI shows degenerative changes of more than one of
the adjacent discs, fusion is usually contraindicated.
Microdiscectomy
A 8 c
Fig. 23.13. Contralateral herniation at the operated level. MRI sequences obtained 4 years after primary discectomy. (A) Spin-echo T2-weighted sagit-
tal image showing an extruded herniation at L4-L5 level. (B) Spin-echo Tl-weighted axial image, which reveals the previous laminotomy on the right
side (arrow) and tissue occupying the radicular canal on both sides (arrowheads). (C) Spin-echo T2-weighted axial image showing, in the left radicular
canal, abnormal tissue (arrowhead), with a signal intensity similar to that of the disc. The arrow indicates the previous laminotomy.
discectomy should be avoided, unless strictly neces- the presence of degenerative changes at the adjacent
sary, in order to limit the risk of increasing postopera- vertebral levels, and the affected vertebral level (chapter
tive instability, since a reoperation on the operated 20). If, as usually occurs, fusion is not planned, care
side implies widening of the previous arthrectomy. should be taken to avoid an extensive arthrectomy on
The indication for fusion may be absolute or relative. the side of new herniation.
The indication is absolute in the presence of segmental Some authors (16, 23) found satisfactory outcomes in
hypermobility on flexion-extension radiographs. Rela- all patients submitted to discectomy for contralateral
tive indications are: a wide arthrectomy on the side of herniation, whilst others obtained unsatisfactory
previous disc excision; a potential instability (spon- results in patients undergoing bilateral disc excision
dylolysis, spondylolisthesis, scoliosis) of the affected (49). In the authors' experience, the surgical results are
vertebral motion segment; and severe low back pain. comparable to those achieved by patients undergoing
In these cases, the decision should be based on the primary discectomy, provided no postoperative
evaluation of various factors, such as the patients's age, instability has been produced.
- - - - - - - - - - - - - - - - - - - - - - - - - o H . e c u r r e n t and new herniations 0591
lumbar disc surgery: results in 130 cases. Acta Neurochir. nerve roots. A prospective two-year evaluation. J. Bone Joint
(Wien) 122: 102-104, 1993. Surg. 75-B: 894-897, 1993.
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111-124,1966. 47. LaMont R. 1., Morawa 1. G., Pederson H. E.: Comparison
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Clin. Orthop. 134: 196-201, 1978. 49. Law J. D., Lehman R A. W., Kirsch W. M.: Reoperation after
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Catania, 1966. 50. Lewis P. J., Weir B. K A., Broad R W. et a!.: Long-term
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29. Grenier N., Vital J. M., Greselle J. F. et al.: CT-diskography pain after laminectomy for lumbar disc lesions. New Zeal.
in the evaluation of the postoperative lumbar spine. Med. J. 91: 206-208, 1980.
Preliminary results. Neuroradiology 30: 232-238, 1988. 53. Mattmann E.: Das Problem der Rezidive nach Operation
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laminectomy in lumbar disc prolapse. Acta Orthop. Scand. Psychiat. 108: 39 -44, 1971.
48: 41-46, 1977. 54. Meyer J. D., Latchaw R E., Roppolo H. M. et al.: Computed
31. Hakelius A.: Prognosis in sciatica. Acta Orthop. Scand. tomography and myelography of the postoperative lumbar
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32. Hampton D., Laros G., McCarron Ret a!.: Healing potential 55. Miyamoto M., Takemitsu Y., Harada Y. et al.: A case of recur-
of the annulus fibrosus. Spine 14: 398-401,1989. rent extraforaminallaterallumbar disc herniation occurring
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Lumbar disc disease. Hardy R W. Jr. Ed., Raven Press, 996-997,1991.
New York, 1982. 56. Naylor A.: The late results of laminectomy for lumbar disc
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1988. 58. O'Connell J. E. A.: Intervertebral disc protrusions in child-
36. Irstam 1.: Differential diagnosis of recurrent lumbar disc hood and adolescence. Br. J. Surg. 47: 611-616, 1960.
herniation and postoperative deformation by myelography. 59. Oldenkott P., Roost D.V.: Traitment microchirurgical de la
An impossible task. Spine 9: 759-763, 1984. hernie discale lombaire. Neurochirurgie 26: 229-234, 1980.
37. Jacchia G. E., Bardelli M., Barile 1. et al.: Casistica, risultati e 60. O'Sullivan M. G., Connolly A. E., Buckley T. F.: Recurrent
cause di insuccessi di ernie discali operate. Giorn. Ita!. lumbar disc protrusion. Br. J. Neurosurg. 4: 319-326, 1990.
Ortop. Traumat. Supp!. Vol. 6: 5-23, 1980. 61. Ott A.: Pathologisch-histologische Untersuchungen der
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for lumbar disc excision. J. Bone Joint Surg. 53-B: 609-616, operierten Patienten. Z. Orthop. 87: 378-383,1956.
1971. 62. Pace N., Pace P., Morici D.: Clinical valutation of late results
39. Jackson R P., Cain J. E., Jacobs R. R. et al.: The neuroradi- of surgical therapy for protruded lumbar intervertebral
agraphic diagnosis of lumbar herniated nucleus pulposus. 1. disc. Arch. Orthop. Traumat. Surg. 96: 91-94, 1980.
A comparison of computed tomography (CT), myelogra- 63. Pappas C. T. E., Harrington T., Sonntag V. K H.: Outcome
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40. Jonsson B., Stromquist B.: Repeat decompression of lumbar 64. Postacchini F., Bellocci M., Ricciardi-Pollini P. T. et al.: An
594.Chapter 23.-----------------------------------------------------
ultrastructural study of recurrent disc herniation. A prelim- 75. Spengler D. M.: Low back pain. Grune and Stratton, New
inary report. Spine 7: 492-497, 1982. York,1982.
65. Postacchini E, Cinotti G., Perugia D.: Microdiscectomy in 76. Stolke D., Sollmann w.-P., Seifert V.: Intra- and post-opera-
treatment of herniated lumbar disc. Ital. J. Orthop. tive complications in lumbar disc surgery. Spine 14: 56-59,
Traumatol. 18: 5-16, 1992. 1989.
66. Reith c., Lausberg G.: Risk factors of recurrent disc hernia- 77. Teplik J. G., Haskin M. E.: Computed tomography of the
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67. Rogers 1. A: Experience with limited versus extensive disc 78. Teplik J. G., Haskin M. E.: Intravenous contrast-enhanced
removal in patients undergoing microsurgical operations CT of the postoperative lumbar spine: improved identifica-
for ruptured lumbar discs. Neurosurgery 22: 82-85, 1988. tion of recurrent disk herniation, scar, arachnoiditis, and
68. Ruggieri E, Specchia 1., Sabalat S. et al.: Lumbar disc herni- diskitis. AJR 143: 845-855, 1984.
ation: diagnosis, surgical treatment recurrence - A review of 79. Thomalske G., Galow W., Ploke G.: Critical comments on a
872 operated cases. Ital. J. Orthop. Traumatol. 15: 210-216, comparison of two series (1000 patients each) of lumbar disc
1988. surgery. Adv. Neurosurg. 4: 22-27, 1977.
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intervertebral disc in children anal adolescents. Long-term tion. Acta Chir. Scand. 103: 213-221, 1952.
follow-up of 101 cases treated by surgery. Ital. J. Orthop. 81. Tullberg T., Isacson J., Weidenhielm 1.: Does microscopic
Traumatol. 17: 505-511, 1991. removal of lumbar disc herniation lead to better results than
70. Schramm J., Oppel E, Umbach W. et al.: Komplizierte the standard procedure? Results of one-year randomized
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71. Schubiger 0., Valavanis A: CT differentiation between vanile. Arch. Putti 13: 11-22, 1983.
recurrent disc herniation and postoperative scar formation: 83. Waddell G., Kummel E. G., Lotto W. N.: Failed lumbar disc
the value of contrast enhancement. Neuroradiology 22: surgery and repeat surgery following industrial injury.
251-254,1982. J. Bone Joint Surg. 61-A: 20]-207, 1979.
72. Shannon N., Paul E. A: L4/5 and L5/S1 disc protrusions: 84. Williams R. W.: Microlumbar discectomy: a conservative
analysis of 323 cases operated on over 12 years. J. Neurol. surgical approach to the virgin herniated lumbar disc. Spine
Neurosurg. Psychiat. 42: 804-809, 1979. 3: 175-]82, 1978.
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CT. AJNR 10: 639-643, 1989. Ortop. Traumat. Suppl. Vol. 6: 25-34,1980.
------·CHAPTER 24·------
PROFESSIONAL LIABILITY
IN TREATMENT
F. Postacchini, G. Martini
Diagnostic evaluation nostic value, simple execution and low cost. MRI is
often more diagnostic than CT, but it also has limita-
tions, which may provide it with a lower diagnostic
Clinical data
ability than CT or myelography. CT and MRI are
currently the examinations of choice in the diagnosis of
Clinical evaluation of patients with a lumboradicular
lumbar conditions, and at least one of the two should be
syndrome is based on the analysis of the site, severity
carried out in patients with a herniated disc requiring
and duration of symptoms and of neurologic deficits.
surgical treatment.
The inductive procedure which, by means of these
elements, allows identification of the pathologic chan- Myelography, being an invasive procedure, should
be carried out when CT and/ or MRI provide ambigu-
ges is definitely an essential factor in the cultural pre-
ous findings. This investigation, however, is of high
paration of a specialist. The most frequent cause of
diagnostic value and, with the hydrosoluble contrast
diagnostic errors is a defect in the inductive procedure
media currently used, does not expose the patient to a
or failure to detect the alterations which lead to a patho-
significant risk of complications. From a medicolegal
logic condition different from that suspected. While
viewpoint, therefore, its use is completely justified,
collecting the clinical history, skill and caution should
even as a substitute to CT or MRI, if the clinician con-
be employed not to underestimate apparently insignif-
siders the test necessary and the patient is informed of
icant details and to search for their significance with
the possible side effects caused by the contrast media.
clinical examination and diagnostic investigations,
Electromyography may document functional impair-
which may require consulting other specialists. Various
ment of the nerve roots compressed by disc herniation
conditions, in fact, may simulate or aggravate a lumbo-
or related pathologic conditions. However, this test
radicular syndrome and lead to errors entailing negli-
gence, which is in proportion to the severity of clinical may be of little value in the diagnosis of a herniated
disc, because either an accurate clinical examination
consequences. Request for expert advise is a useful
complement to avoid diagnostic errors in the presence frequently provides adequate information on nerve-
of clinical syndromes of uncertain interpretation. root function or the test does not allow diagnosis of the
nature, and often the anatomic site, of the condition
responsible for radiculopathy. Electromyography is
Diagnostic tests particularly useful to differentiate radiculopathy from
peripheral neuropathy. Furthermore, it may be useful,
These provide necessary confirmation to diagnosis in the presence of severe radicular impairment, to doc-
based on the clinical features or confirm the diagnostic ument what has been found on clinical examination.
suspicion emerging from the clinical data. The number Blood tests are usually of little or no usefulness in the
of cj.iagnostic tests which should be carried out is a fre- diagnostic evaluation of patients with a suspect herni-
quent subject of discussion in legal medicine, since ated disc. These tests may be useful or necessary in the
their role is often emphasized with respect to the clini- differential diagnosis with inflammatory, neoplastic or
cal data. In actual fact, clinical features should deter- infectious conditions, which may simulate a herniated
mine the indication for diagnostic tests, which should disc syndrome.
have a precise aim and a clinically logical sequence. All Numerous other tests may be considered useful or
tests may be theoretically useful or indispensable in necessary by the surgeon or his consultants in order to
patients with suspected disc herniation. However, a reach an accurate diagnosis. However, all examina-
few examinations have precedence over others due to tions, in particular invasive procedures must be carried
their diagnostic abilities, simplicity of execution or out on the basis of a well-founded clinical suspicion.
availability of equipment. In consideration of the increasing number of diagnos-
Plain radiographs are of limited diagnostic value, but tic tests provided by medical science to the clinician, a
may be useful in the choice of subsequent investiga- legitimate question arises: which examinations should
tions. A radiographic examination should be carried be considered necessary and sufficient from a medicole-
out when CT and MRI are not completely in keeping gal viewpoint? There is no answer to this question, since
with the clinical features. Furthermore, it should pre- the multitude of clinical situations does not allow us to
cede other imaging studies in patients who have establish a basic protocol, which may exempt the physi-
already undergone surgery for lumbar conditions, cian from the accusation of failure to diagnose or incor-
since the correct interpretation of these studies may be rect diagnosis. In the identification of the causes of
influenced by the radiographic findings. clinical signs and symptoms, it is the physician's duty to
CT has become a currently used test in patients with reach a level of reasonable certainty, which is closely
suspected disc herniation on account of its high diag- related to the diagnostic difficulties in each single case.
Failed or incorrect diagnosis nostic equipment where the patient is hospitalized may
not be used as an excuse in the presence of a sound
These generally stem from defective or erroneous inter- clinical suspicion, since, in this case, the physician
pretation of the clinical findings and / or diagnostic must transfer the patient to another hospital where the
tests. necessary examinations can be carried out.
A clinician may make an incorrect or incomplete 4. The physician does not detect a pathologic con-
diagnosis due to inadequate cultural or technical dition (such as spondylolisthesis) associated to disc
preparation, lack of updating, negligence in patient herniation and treatment leads to worsening of the
evaluation or an incorrect interpretation of clinical and associated pathology. The clinician is liable for damage
laboratory findings. Both the patient and the specialist if the concomitant disease, even if of mild severity, was
who carries out the laboratory tests may have a respon- apparent from diagnostic examinations carried out
sibility in the diagnostic error. The former may report prior to surgery. On the other hand, the physician is not
an incorrect, incomplete or confusing medical history. liable if the associated condition was detected, but not
The latter may draw up an incorrect or inadequate treated concomitantly with the herniation; in this case,
report, due to omissions or partial information, which however, the physician must have previously informed
may lead astray or be insufficient to answer the the patient on the reasons, albeit questionable, which
question raised. In this case, the error must also be led to the decision of partial abstention from treatment.
attributed to the specialist who carried out the diag- 5. The diagnostic error is derived from an incorrect
nostic tests. However, the clinician is required to have or inadequate interpretation of diagnostic tests by
the necessary cultural preparation to interpret and the specialist (radiologist or other specialists) and the
evaluate himself currently used tests such as plain clinician did not detect the incorrect interpretation.
radiographs, CT, MRI or myelography. The clinician, The specialist is liable for damage to the patient on
therefore, may not be excused, or may be only partially account of inexpertness and negligence. However, the
excused, when his/her mistake derives from an incor- clinician is also liable if examinations were those cur-
rect interpretation, by the specialist, of currently used rently used, since he / she should be able to interpret
investigations. them correctly.
A diagnostic error may have considerable medicole-
gal consequences if it leads to biological and/ or finan-
Professional liability cial damage to the patient. This error is due to
inexpertness; very often, however, it may be attributed
In the event of a diagnostic error, various important sit- to negligence and the medicolegal relevance is propor-
uations may occur as far as professional liability is tionate to the severity of the consequences to the
concerned: patient.
1. Prior to surgery, examinations currently consid-
ered sufficient for diagnostic purposes, have been car-
ried out; diagnosis was orientated towards a pathologic Case reports
condition, which justified signs and symptoms, but
subsequently was seen not to be responsible for the Case 1. A 38-year-old male with thoracic spine pain, recur-
clinical picture. The clinician is not liable for damage if rent low back pain and completely negative radiographic
the clinical picture did not generate any definite suspi- findings, presented improvement of his pain after medical
cion that diagnosis was erroneous. Likewise, if the and physical therapies carried out during a period of hospi-
pathologic condition presented a particular and atypi- talization. A few days after discharge, sudden monolateral
cal diagnostic difficulty, the error may be due to the lim- lumboradicular pain appeared, for which an L4-L5 hemil-
itations of current scientific knowledge, rather than the aminectomy was performed. Surgery revealed a bulging
actions of the physician. degenerated disc, and discectomy was carried out. The day
2. Diagnosis is made intraoperatively and treatment after surgery, paraplegia occurred on account of a giant cell
led to a significant, but not total, improvement to the tumor of the posterior arch ofT11. Decompressive surgery at
patient. In this case, there is no professional error, since this levelled to no improvement in the clinical picture.
the patient did not experience any damage. The surgeon who had carried out the discectomy was held
3. Erroneous or incomplete diagnosis is due to the liable for failing to diagnose the tumor at T11 level, despite
fact that the necessary diagnostic tests were not carried the fact that thoracic symptomatology was occasional, vague
out. The physician is liable, due to negligence, if he / she and much less severe than the lumboradicular symptoms,
did not use the available diagnostic procedures or and radiographic examinations repeatedly carried out (before
ignored or underestimated the indication to carry out the advent ofCT and MRI) had revealed no suspect findings
further tests. The non-availability of adequate diag- in the thoracic spine.
liability in treatment· 599
Case 2. A 24-year-old male with unilateral low back and intraoperative or postoperative complications may
anterior thigh pain on the right side underwent surgery at justify the decision to abstain.
L4-LS level, which revealed mild disc bulging. Symptoms
remained unchanged following discectomy. A more accurate
evaluation of the preoperative radiographs led to the detection Professional liability
of an osteosclerotic area in the ipsilateral iliac bone, in prox-
imity to the sacroiliac joint. CT revealed a suspect osteoid A physician who decides to carry out conservative
osteoma, which was excised with complete resolution of treatment might be accused of favoring deterioration of
symptoms. Both the radiologist, who did not detect the the clinical conditions or prolonging the period of
osteosclerotic image in the iliac bone, and the surgeon, who inability, but he can usually easily defend himself/her-
did not correctly interpret the clinical picture and did not pay self maintaining his right to decide the method of
sufficient attention to the radiographic findings, were held treatment. The physician may be liable if he / she
professionally liable and the case ended in a decision for the unjustifiably delays surgery, for days or weeks, in the
defense. presence of a cauda equina syndrome or a demon-
strated progressive increase in radicular deficit.
Case 3. A 26-year-old male had severe radicular pain and
showed marked motor and sensory deficits of the left Sl root.
The report by the radiologist who had carried out CT exami- Case report
nation only mentioned an LS-Sl disc protrusion on the left.
At operation, a small contained LS-S1 disc herniation was A 42-year-old female with chronic lumboradicular symptoms
found and excised; based on the radiologist's report, the sur- presented a relapse of severe pain in the right leg and slight
geon did not search for migrated disc fragments. Following motor deficit of the right triceps surae. An orthopaedic sur-
surgery, radicular pain persisted and motor loss was found to geon, following careful evaluation of the pathologic condi-
be increased. On a subsequent examination of the preopera- tion, represented by a small LS-S1 disc herniation, and
tive CT scans, another physician unequivocally detected a adequate information to the patient, opted for medical and
large fragment of disc, migrated at a distance from the LS-S1 physical therapy and application of a corset. A few weeks
intervertebral space. A second operation led to resolution of later, immediate excision of disc herniation was proposed by a
pain and partial improvement of motor deficit. Both the radi- neurosurgeon, who threw serious doubt on the correctness of
ologist and the physician who had carried out the first opera- the therapeutic decision of his colleague. Surgery was carried
tion were held liable for inexperience and negligence; the out with a good result. The first physician was not held liable
former for failure to detect the migrated fragment on CT for advising conservative treatment. The second physician
scans, and the latter for not having searched for migrated cannot be censured from a professional point of view, howev-
fragments or other causes of nerve-root compression in the er definitely from an ethical and deontological point of view
presence ofa clinical picture not justified only by the mild LS- for damaging the professional reputation of his colleague.
Sl disc protrusion.
Surgical treatment
Conservative treatment
Defective approach
In the presence of a lumboradicular syndrome due to a
herniated disc, the physician may decide to carry out Surgery for disc herniation and associated conditions
conservative treatment for various reasons: mildness of should satisfy two opposite requisites: to carry out a
nerve-root signs and symptoms or distinct prevalence sufficiently wide opening of the vertebral canal in
of low back pain compared with radicular symptoms, order to allow adequate disc excision and removal
short duration of the disease, small size of the herniated of possible migrated disc fragments without risk of
disc or poor psychologic stability of the patient. Not damaging the neural structures; and to preserve, as far
only is the decision to continue conservative treatment as possible, the osteoligamentous structures responsi-
usually justified, but, in some cases, execution of ble for vertebral stability in order to avoid post-
surgery may imply an excess of indication. Surgery operative instability of the motion segment. Either
should be carried out rapidly, and often in an emer- insufficient opening of the spinal canal, which may
gency, only in the presence of progressive worsening of make surgery ineffective, or decrease in vertebral
neurologic deficits or a cauda equina syndrome. Also in stability may represent a defective approach.
these cases, poor general conditions or concomitant Interlaminar flavectomy alone, which entirely
diseases exposing the patient to the risk of severe preserves vertebral stability, may make excision of
6oo.Chapter 24.-----------------------------------------------------
extruded or migrated fragments difficult or impossible ularly when instability is entirely produced or consid-
and may expose the neural structures to the risk of trau- erably increased by the operation. On the other hand, if
mas during removal of the herniation. Laminotomy (or postoperative instability may be foreseen prior to
interlaminar fenestration or hemilaminoarthrectomy), surgery, it is the surgeon's duty to plan a possible spinal
more or less enlarged in a longitudinal direction, gener- fusion to be carried out concomitantly with decompres-
ally allows excision also of fragments migrated into the sion or to inform the patient on the reasons for not
intervertebral foramen, after removal of at least the performing an arthrodesis.
medial one third of the articular processes. Percutaneous access may not be indicated, as in the
Hemilaminoarthrectomy with total resection of the case of migrated herniation, or may be carried out
facet joint permits a wide access also to extraforaminal erroneously from a technical point of view due to lack
herniated disks, but decreases vertebral stability. This of experience of the surgeon or inadequacy of the fluo-
reduction in stability may be of little clinical impor- roscopic equipment. The fault may be attributed, in the
tance when the spine is preoperatively stable, whilst it former case, to inexpertness or imprudence in the inter-
may increase, to a critical extent, a pre-existing real or pretation of clinical data or preoperative investigations
potential instability. and, in the latter, to inexpertness or negligence.
Central laminectomy can be necessary in the pres- Professional liability for a defective surgical approach
ence of marked stenosis of the spinal canal, however it should be considered more severe if the physician
is not generally indicated in patients with a herniated is particularly expert and qualified in spinal surgery.
disc alone. It does not, in fact, facilitate access to the Another element which may aggravate the offence is
intervertebral disc or migrated disc fragments and may the underestimation, for negligence, of the possibility
reduce vertebral stability, although usually not signifi- of causing an injury when it is well known that aware-
cantly, if at least the outer half of the articular processes ness of this possibility must be part of the common
are preserved. cultural patrimony of the physician carrying out the
The need to reach a compromise between preserva- surgical procedure.
tion of the anatomic structures and decompression of
the caudal nerve roots justifies the need for an accurate
preoperative analysis of the pathologic characteristics
of the herniation and the degree of stability of the Case reports
motion segment involved.
In percutaneous procedures, a defective approach Case 1. A 39-year-old female with recurrence of L4-L5 disc
may consist in failure to penetrate in the disc space herniation, following open discectomy performed at the same
(or more specifically in the nucleus pulposus) or to level and on the same side two years before, underwent auto-
invade the vertebral canal with surgical instruments mated percutaneous nucleotomy with no relief of symptoms.
(7,22,26). This is usually due to technical errors, occa- The surgeon who had carried out nucleotomy was not held
sionally favored by congenital or acquired vertebral liable due to lack of damage to the patient, even if the indica-
anomalies. tion for percutaneous nucleotomy in the case of a recurrent
herniation, is debatable.
Failure to decompress or defective defective result for which it may be difficult to deter-
decompression mine whether professional liability exists. This occurs
only when preoperative signs and symptoms remain
The most frequent defect in decompression of the neur- unchanged following surgery and insufficient decom-
al structures consists in no or incomplete excision of a pression of the neural structures is related to serious
disc fragment extruded in the midline, or incomplete omissions during surgery. There is no responsibility,
disc excision leaving behind a marked annular bulging therefore, when new disc herniation occurs at a vari-
or a disc protrusion, albeit small in size. The latter inci- ably long time interval after surgery, at the same level as
dent may occur more easily when partial discectomy is the primary herniation or in different discs from that
carried out, or in young subjects in whom complete dis- operated on.
cectomy may be difficult on account of mild degenera- A poor surgical outcome is, at times, related to a
tive changes of disc tissue. In these cases, if the annulus behavioral defect of the physician, as occurs when a
fibrosus bulges markedly, it may still compress the large extruded or migrated disc fragment is not detect-
neural structures even after removal of the nucleus ed and removed at surgery due to negligence and / or
pulposus. lack of expertise. In other cases, however, the defective
Another fairly frequent cause of defective decom- decompression may be only partially foreseen and
pression (4, 6) is the lack of detection and removal of a avoided. For instance, persistence of annular bulging in
migrated disc fragment. This may occur especially in a young patient with mild disc degeneration may
migrated intraforaminal herniations, in which the sometimes be avoided only by performing bilateral
migrated fragment may not be sought, or inadequately discectomy, which, however, may also lead to a
searched for, if its existence and location are not clearly decrease in vertebral stability, or by means of concomi-
demonstrated by preoperative imaging studies. In tant spinal fusion, which is generally not recommended
these cases, it may be necessary to carry out a wide in young subjects. Likewise, in a patient with severe
laminoarthrectomy to expose the compressed nerve stenosis, partial compression of the neural structures
root and / or the migrated fragment. If the surgeon is may sometimes persist on account of the difficulty or
only slightly in doubt concerning the presence of a impossibility of completely eliminating the osteoliga-
migrated fragment, he / she may decide not to enlarge mentous cause of compression, due to the risk of
the laminoarthrectomy in order not to compromize causing, or accentuating the pre-existing, neurologic
vertebral stability, particularly when the presence of a deficits.
disc protrusion apparently justifies the clinical picture In the medicolegal evaluation, the simple detection
and exploration of the vertebral canal failed to reveal "a posteriori" of a defective decompression may not
migrated disc fragments. allow formulation of an impartial judgement or may
Concomitant stenosis of the spinal canal may be the even give rise to an erroneous evaluation and, thus, an
cause of persistent radicular symptoms. This may occur incorrect motivation in a possible verdict for the plain-
when stenosis is at the same level as, or even at a differ- tiff. On the other hand, it must be underlined that CT
ent level from, the herniation. and MRI findings may be partially misleading in the
The persistence of radicular symptoms due to isth- first few months following discectomy, since they may
mic spondylolisthesis at an adjacent level to that of reveal a persistent disc protrusion even in patients with
discectomyor at the same level, is a rare occurrence. In an excellent surgical outcome.
the latter case, disc excision may lead to an increase in The expert called to ascertain a possible professional
olisthesis, or to vertebral instability responsible for liability of the surgeon should retrace the same induc-
persistence of nerve-root compression on the same side tive and deductive path followed by the surgeon, bear-
as discectomy or for onset of radicular symptoms on ing in mind the difficulties involved in vertebral surgery.
the opposite side.
Patients undergoing chcmonucleolysis or percuta-
neous nucleotomy often experience persistence of, or Case report
even an increase in, radicular symptoms. In these cases,
however, the defect is often in the indication for the A 67-year-old female with a lumboradicular syndrome
procedure rather than in the execution. caused by a right in traforaminal L3-L4 disc herniation, diag-
nosed by CT, underwent surgery with no relief of low back
and radicular pain. CT carried out 8 months later revealed
Professional liability the presence, in the intervertebral foramen, of afree fragment
of disc showing the same shape and size, as well as the same
Incomplete excision of disc tissue, responsible for per- location, as that present preoperatively. The surgeon was
sistent compression of neural structures, leads to a considered negligent and the case was settled.
602.Chapter 24.-------------------------------------------------------
Error in identifying the pathologic level logic level was, objectively, extremely difficult. This
holds also for the third situation, particularly if surgery
This is one of the most common mistakes in surgery for led to considerable improvement in clinical symptoms
a herniated disc (13,14,27). It may be responsible for a and neurologic impairment.
defective decompression and! or approach. The more
cranial the affected disc and the more decreased the
inter laminar and interspinous spaces, the greater the
frequency of this error; furthermore, it is more frequent Intraoperative injuries
when the skin incision is limited to the interlaminar
space involved, as in the case of microdiscectomy These may be accidentally produced or favored by the
(18,24). surgeon during laminoarthrectomy, retraction or
Three situations may be identified: a) the surgeon ini- decompression of the neural structures, or excision of
tially operates on a wrong level, but detects the error disc herniation. The main discriminating elements
before or after discectomy and, upon identification from a medicolegal point of view are the severity of
of the correct level, performs the planned operation; the damage that they involve and the possibility, or
b) the surgeon does not detect the error and carries not, of making intraoperative diagnosis and carrying
out laminotomy and discectomy only at the wrong out immediate treatment.
level; c) the error in identification of the affected level
is not detected during surgery, but the posterior arch Nerve-root injuries. Contusion, or partial or total tear,
is partially or entirely resected also at the involved of a nerve root may generally be attributed to errors in
intervertebral level, where, however, discectomy is surgical maneuvers, occasionally facilitated by particu-
not carried out. In the former case, the early post- lar anatomic conditions, such as nerve-root anomalies,
operative backache may be more severe than expected, periradicular fibrosis, adhesion of the root to the herni-
but the probability of relieving radicular symptoms is ated disc or the walls of the spinal canal, or lumbar
no different from that in cases with no error in level stenosis (25). Profuse intraoperative bleeding due to
identification. In the second case, preoperative symp- epidural varicosities or coagulation disorders may
toms remain unchanged or occasionally increase in favor nerve-root injury on account of the difficulties in
severity. In the latter case, preoperative symptomatol- adequately visualizing the anatomic structures.
ogy may improve or disappear on account of the
partial decompression of the neural structures resulting Dural tear. This is the most frequent injury during
from bone resection. surgery for lumbar disc herniation. The injury assumes
a medicolegal relevance when it remains undetected
during operation or it is inadequately treated, thus
leading to development of a CSF fistula or a
Professional liability pseudomenigocele. In both cases, the surgeon may be
accused of failed diagnosis, inexpertness, or negligence
In general, the surgeon's liability decreases parallel for not performing effective treatment.
with the objective increase in the difficulty of preopera-
tive and intraoperative detection of the pathologic Cauda equina syndrome. This is one of the most
level. Responsibility, therefore, may be very slight, or dreaded complications in lumbar surgery due to the
even non-existent, when error in level identification is severity and often irreversibility of the neurologic
very easy due to the site of the herniation or the objec- damage. The latter may be caused by surgical trauma
tively considerable difficulty in identifying the patho- to the neural structures or postoperative epidural
logic level during surgery. This holds particularly if hematoma (11, 17, 19). Surgical trauma may be favored
numerous fluoroscopic or radiographic cheks have by a defective approach (e.g., posterior rather than lat-
been carried out preoperatively or intraoperatively to eral approach for 11-L2 herniation), or specific anatom-
identify the pathologic level. ic and! or clinical conditions (intradural herniation,
In the first of the three aforementioned situations, the large herniated disc in a patient with marked stenosis
surgeon is generally not liable, since laminotomy (with and! or severe pluriradicular preoperative deficits).
or without discectomy) at an unaffected level does not In both cases, often the surgeon does not realize,
usually produce significant damage to the patient. In during surgery, that he has produced severe nerve-root
the second situation, the surgeon is liable due to a impairment. A postoperative hematoma may be
defective approach and failure to decompress the neur- favored by having maintained intraoperative con-
al structures; professional liability, however, may be trolled hypotension until the complete closure of the
slight, or even absent, when identification of the patho- thoracolumbar fascia. This may hinder the surgeon
---------------------0 Professional liability in treatment 0603
from detecting profuse epidural bleeding and thus Favoring conditions. Pathologic changes related to
realizing the need for carrying out accurate hemostasis the quality, severity and duration of the disease are
and/ or applying a drain. often the main, if not the only, causes responsible for
intraoperative injury. The surgical act which actually
Injuries to abdominal structures. Vascular injuries produces the injury may imply no liability of the
causing hemoperitoneum are potentially the most surgeon if he / she was prudent and skilful; the sur-
severe complications in lumbar disc surgery, since they geon's action, in this case, may only be a precipita-
involve a high mortality rate (3, 5, 29). These lesions ting factor, or a concause, in a pathologic condition
may more easily occur in the presence of marked disc which intrinsically possesses a high potential of risk.
degeneration, responsible for a decrease in the mechan- For example, a mild surgical trauma related to the nor-
ical resistance of the anterior portion of the annulus mal execution of surgery, in a patient with a severe
fibrosus (28). The diagnostic suspicion should arise in radicular deficit, may lead to an increase in nerve-root
the anesthetist when marked hypovolemic shock impairment: the surgeon is not specifically liable, if
occurs during, or immediately after, surgery, and in the his/her conduct did not deviate from the rules of
surgeon in the presence of profuse hemorrhage from vertebral surgery.
the disc space. Diagnosis of an arteriovenous fistula At times, the risk of intraoperative injuries is very
is more difficult and generally delayed, however this high, or causing a lesion is almost inevitable on
complication requires less urgent treatment. account of the nature of the disease. In these cases, it
Injuries to abdominal organs, which are exceedingly is of paramount importance to evaluate the benefits
rare, are favored by the same predisposing conditions to be derived from surgery with respect to the severity
involved in vascular lesions. of the consequences of a possible surgical injury.
The decision of running a high risk may be justified
Peripheral nerve injuries. These may involve the if this is done in the interest of the patient, who must
upper or lower limb. The former are caused by incor- give his consent after having received exhaustive
rect positioning of the limb when the patient is placed information.
in the prone position. The latter are usually caused by
incorrect positioning of the patient on the operating Diagnosis. Diagnosis may be intraoperative or postop-
table by the surgeon. erative, and direct or indirect.
Diagnosis is immediate and direct when abnormal
situations occur with respect to the normal course of the
Professional liability operation, such as leakage of CSF from the thecal sac or
massive hemorrhage from inside the disc, which are
The medicolegal relevance of these injuries should be clear signs of injury to the thecal sac or abdominal ves-
evaluated taking into account that the damage to the sels, respectively. In these cases, the lesion should be
patient represents, compared with the primary disease, treated immediately due to its intrinsic severity and, if
a new impairment, which is not derived from a compli- necessary, treatment of the primary disease should be
cation of routine treatment, and thus unforeseen or interrupted or witheld. Failure to diagnose the injury, in
unavoidable, but from a specific surgical risk, which, contrast with clear-cut surgical findings, or their under-
having been described and therefore known, must be estimation, implies lack of expertise and negligence of
foreseen and avoided or, in the event that it occurs, the surgeon and his collaborators.
must be treated rapidly and correctly. At times, the liability for damage deriving from
An intraoperative injury usually involves profes- an injury should not be attributed to the surgeon, but
sional liability; in a series of 109 cases of lumbar to other specialists if they omitted to inform or
surgery for which surgeons in the United States were delayed providing the surgeon with details of clinical
prosecuted for professional liability; complications findings suggesting the injury. For instance, an injury
were represented by a dural injury in 20 cases, cauda to abdominal vessels may not be apparent to the sur-
equina syndrome in 20 and nerve-root injury in 14 geon during the operation, but the anesthetist may be
(12). However, this is not always the case: liability is able to suspect it on account of the occurrence of
strictly related to the behavior of the surgeon rather hypovolemic shock. In this case, the anesthesist is
than to injury outcome, even if this is considerably responsible for the consequences which may derive
poor. It is very important, therefore, to establish from a delayed or omitted diagnosis. It is his/her
whether the damaging action by the surgeon was responsibility; in fact, to diagnose hypovolemic shock
favored by pre-existing pathologic conditions and during anesthesia or the early postoperative period and
whether diagnosis, treatment or information concern- to immediately inform the surgeon of the abnormal
ing the injury were defective. clinical findings.
604.Chapter 24.-----------------------------------------------------
A nerve-root or cord injury is clinically evident only appeared. Nineteen days after surgery, another physician
after surgery, since it is asymptomatic under anesthe- prescribed MRI, which revealed a pseudomeningocele caused
sia. Diligence of the surgeon always requires immedi- by intraoperative dural injury, and successfully repaired the
ate postoperative monitoring of neurologic functions to lesion. A verdict against the first physician was passed, since
establish the presence, site and severity of an injury as he had not adequately diagnosed and treated the patient when
soon as possible; delayed detection may, in fact, repre- pseudomeningocele had become clinically evident.
sent a negligent omission of action.
Case 2. A 68-year-old male underwent surgery for left L4-L5
Treatment. Treatment concerns all physicians involved disc herniation. During surgery, a tear of the left iliac artery
in the surgical procedure. The anesthetist is responsible occurred, with consequent retroperitoneal hemorrhage.
for the general conditions of the patient. The surgeon Diagnosis of hemorrhage was made intraoperatively.
and his team must do all they can to reduce or remedy Surgery was interrupted and the intervention was requested
the consequences of damage. This may require imme- of a vascular surgeon, who attempted to repair the vascular
diate intervention of other specialists, such as an lesion without success on account of the large size of the tear.
abdominal or vascular surgeon, as well as the use of an The patient died during surgery. A verdict in favor of the sur-
intensive care unit. geon who carried out the spinal operation was passed, since it
The possibility of immediate and effective treatment was considered that the vascular injury had been favored by
entails timely availability of adequate diagnostic and the severe degeneration of the annulus fibrosus and anterior
therapeutic equipment, and qualified medical person- longitudinal ligament, and that behavior, as far as concerns
nel. A lack of these may entail the liability of those diagnosis and treatment of the complication, had been entire-
who did not prudently and diligently foresee all the ly correct.
necessary means for carrying out surgery or treating
possible complications. This does not mean, for Case 3. A 38-year-old female, while undergoing excision of a
instance, that, on account of the possible occurrence right L4-L5 herniated disc, sustained a tear of the right iliac
of abdominal vascular injuries, a vascular surgeon artery, of which the surgeon was not aware. Hemorrhagic
should be present in the hospital during surgery for shock was initially attributed to cardiac causes. Three hours
lumbar disc herniation. However, in the event of after surgery, the hypovolemic nature of the shock was recog-
suspect or ascertained vascular injury which puts the nized and the patient was transferred to another hospital
patient in immediate danger, the surgical team is where she died. The behavior both of the surgeons and the
obliged to require the intervention of the specialist as anesthetist was considered negligent and inexperienced,
rapidly as possible. since they had not diagnosed the complication and immedi-
ately performed adequate therapy.
Information concerning the injury. Members of staff
involved in treatment should report in detail the nature Case 4. A 39-year-old man, submitted to surgery for
and severity of the injury and its causes on the hospital recurrent lumbar disc herniation, sustained laceration of an
chart. They must also inform the patient of these iliac artery, which was diagnosed by the orthopedic surgeon
aspects and of the consequences of the injury. This intraoperatively. After a relatively long interval (90 min-
information is not only an ethical and legal obligation, utes), the patient was transferred to a hospital in another
but also assures the patient of the straightforward town, in which there was a department of vascular surgery.
behavior of the treating physicians. Lack of information Repair of the vascular tear was carried out 5 hours after
or reticent information is probably the most frequent spinal surgery, however the patient died afew days later also
cause of claims from patients who are usually willing on account of incomplete closure of the tear, as revealed
to understand a difficulty or an error, but not to be by autopsy.
cheated. A verdict for the plaintiff was rendered due to the delay in
diagnosis and treatment of the vascular injury.
In the appellate lawsuit, a verdict for the defense occurred
Case reports on account of the impossibility of determining the "time
required" to diagnose an abdominal vascular lesion and of
Case 1. A 47-year-old female underwent excision of an L3- the lack of evidence concerning the actual efficacy of a more
L4 herniated disc. Eight days after surgery, the patient noted timely vascular operation.
a soft subcutaneous swelling in the area of the surgical A Supreme Court trial lawsuit ended with a verdict for the
wound. Over the next few days, swelling reached the size of a plaintiff because "". there is always a causal link between
chicken's egg. Ten days after surgery, the surgeon applied a inexpert, negligent or imprudent behavior of the physician
compressive bandage and advised the patient to stay in bed. who did not endeavor to carry out extremely urgent surgical
The swelling remained unchanged, but headache and fever intervention and the subsequent fatal event, when such an
- - - - - - - - - - - - - - - - - - - - - . Professional liability in treatment .605
intervention, even though its use in saving the patient's life tis is not mandatory, also considering that the proce-
was not certain, might have had considerable probabilities of dure is invasive.
reaching that aim N.
Case report
Infections
A 27-year-old male underwent removal ofL4-L5 disc hernia-
Infections occurring during surgery are usually caused tion with immediate resolution of the symptoms. Ten days
by bacteria from the external environment. Sources and after surgery, severe low back pain associated with fever
vehicles are numerous and often unknown and not appeared. Spondylodiscitis was suspected and then demon-
avoidable: patient's skin, non-sterile surgical instru- strated, and adequate antibiotic therapy was carried out. The
ments, structural discontinuities or tears in surgical patient had been hospitalized, before and after surgery, in the
gloves, fine dust from the environment or from same room as a patient with a severe open infection. The ver-
surgeons (hat, glasses, forehead) during accidental dict for the plaintiffwas based on the assumption that the sur-
reciprocal contact, and surgeon's breath. General and geon had been imprudent and negligent in underestimating
immunological conditions of the patient are also the possibility of transmission of the infection from one
important, since they may favor the development of patient to the other.
infection and affect its resistance to treatment.
Henrv. V. Crock
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Journal of Neurosurgery
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