Clinical and surgical outcomes of upper lumbar disc herniations: a retrospective study

Turkish Journal of Medical Sciences http://journals.tubitak.gov.tr/medical/ Research Article Turk J Med Sci (2017) 47: 1157-1160 © TÜBİTAK doi:10.3906/sag-1604-113 Clinical and surgical outcomes of upper lumbar disc herniations: a retrospective study Burak KARAASLAN*, Ayfer ASLAN, Alp Özgün BÖRCEK, Memduh KAYMAZ Department of Neurosurgery, Faculty of Medicine, Gazi University, Ankara, Turkey Received: 23.04.2016 Accepted/Published Online: 22.04.2017 Final Version: 23.08.2017 Background/aim: Upper lumbar disc herniation (LDH), generally involving L1–L2 and L2–L3 level herniation, is less common than lower LDH and, in this retrospective study, the clinical and radiological findings of patients who suffered from upper LDH and were operated on due to this pathology were reviewed. Materials and methods: Data regarding neurological and radiological findings of patients operated on between January 2005 and December 2013 were retrospectively collected. During this period, 3494 patients had surgery for LDH, and 129 of these patients had disc herniation at the upper levels. Seventy-eight patients with proper follow-up and data were included in the study. Results: There were 39 males and 39 females enrolled in the study. Twenty-one patients (0.6%) were operated on due to L1–L2 disc herniation and 45 (1.2%) had L2–L3 disc herniation. Twelve (0.3%) patients had disc pathologies at both levels. The mean age of the population was 59.9 years old, and this was significantly higher than lower LDH averages previously described in the literature (42 years old). Cauda equina signs and urinary disturbances were frequently seen, in addition to symptoms related to back and leg pain, neurologic claudication, and weakness in lower extremities. Conclusion: Upper LDHs requiring surgical therapy are extremely rare, more so than other LDHs. They are more frequent among older patients and are often present along with signs of cauda equina and urinary dysfunction. Key words: Upper lumbar disc herniation, microdiscectomy, cauda equina syndrome, lumbar radiculopathy 1. Introduction Lumbar disc herniation (LDH) is a prolapse of the nucleus pulposus from a defect in the annulus fibrosus forming the circumferential rim of the disc. This condition may generally occur secondary to degeneration of the intervertebral disc that comes with aging. Trauma is another common etiological factor and one of its many causes. LDHs frequently occur at the posterolateral parts of the spinal canal due to the longitudinal ligament lying at the posterior central part of the vertebral corpus (1–3). Various studies have indicated that the lifetime prevalence of low back pain is between 60% and 80% (1). However, in the United States, the National Health and Nutrition Examination Survey (NHANES II) showed that the prevalence of low back pain lasting at least 2 weeks was 13.8% (3). Between 15% and 77% of low back pain is associated with LDHs seen in radiological imaging. Only 1%–2% of those cases require surgical intervention (1,3,4). The majority of low back pain improves with resting, medical treatment, and physical therapy. LDHs are mostly seen in the 3rd and 4th decades of life and are more frequent in males (72%) than in females (28%) (2). * Correspondence: Iwasaki et al. reported on the predilection of herniated disc levels as follows: L5–S1 (51%), L4–L5 (41%), L3–L4 (5%), L2–L3 (2%), and L1–L2 (0.7%), respectively (2, 5). However, other studies suggested that the L4–L5 level is the most frequently affected level, followed by L5–S1 (6). While these prevalences are affected by variations such as age, race, region, or educational status, current statistics show that the most commonly affected sites are L4–L5 and L5–S1 (95%) among all lumbar disc herniations (3,7). L1–L2 and L2–L3 disc herniations, which constitute upper LDHs, are very rare. Upper LDHs may have different clinical signs and surgical outcomes than lower lumbar disc herniations. Besides low back pain and radicular leg pain, there is an increased risk of neural compression and cauda equina syndrome in upper LDHs, which are both challenges in terms of surgical decision-making (2,8,9). In our study, we retrospectively searched the clinical records of patients who underwent microdiscectomy due to L1–L2 and/or L2–L3 disc herniation in our clinic between January 2005 and December 2013 and compared these results with the literature. 1157 KARAASLAN et al. / Turk J Med Sci 2. Materials and methods We retrospectively analyzed patients who underwent lumbar microdiscectomy performed by different surgeons for any lumbar disc level at our institute between January 2005 and December 2013. Patients with L1–L2 and L2– L3 disc herniation were included in our study. L3–L4, L4–L5, and L5–S1 disc herniation, as well as previously operated cases, were excluded. We collected data on age, sex, the duration and characteristics of pain, the presence or absence of trauma, comorbidities, the presence of neurologic claudication, neurological examination findings, radiological patterns of disc herniation, and surgical outcomes and complications. The patients’ preoperative and postoperative neurological examinations and assessments were made by scoring them with the Modified Japanese Orthopedic Association (mJOA) scale (10). Using this scale, upper and lower extremity motor dysfunctions and sensation and sphincter dysfunctions were analyzed by grading them between 0 and 18 points. All surgeries were performed under microscope, and the patients who underwent only laminectomy without discectomy were also excluded. had some type of systemic problem, such as diabetes mellitus, hypertension, coronary artery disease, goiter, or pulmonary disease. Furthermore, 64% (50 patients) never tried physical therapy in their preoperative period, 24% (19 patients) had but did not experience any improvement of symptoms, and 12% (9 patients) experienced temporary benefits. Magnetic resonance imaging-based patterns of LDHs were as follows: there were posteriorly migrated herniations in 82% (64 patients), inferiorly in 10% (8 patients), and superiorly in 8% (6 patients). For surgical outcomes, preoperative and postoperative mJOA scores were compared, and postoperative mJOA points increased in 88% (69 patients), while they did not change or got worse in 12% (9 patients). In 85% (66 patients), no complications occurred during the postoperative period. In 15% (12 patients), we experienced some complications. There were perioperative dural tears in 3 patients (3.8%), postoperative wound infections in 5 patients (6.4%), recurrence of disc herniation in 4 patients (4.1%), and increased weakness in a lower extremity in 1 patient (1.2%). 3. Results The number of patients who had lumbar microdiscectomy at any level was 3494 during this time period. Of these cases, 78 of them (2.2%) were at upper lumbar levels (L1–L2 and/ or L2–L3). Of these, 21 (0.6%) patients underwent L1–L2 discectomy, 45 (1.3%) underwent L (...truncated)