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Lumbar Herniated Nucleus Pulposus

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Minimally Invasive Spine Surgery

Abstract

This chapter will discuss the pathophysiology, exam, diagnosis, and management of lumbar disc herniation (LDH). In brief, LDH is a common pathology that affects a significant percentage of the population. The natural history of LDH is favorable, and excellent results have been obtained following conservative management. Anti-inflammatory medications, physical therapy, and epidural steroid injections make up the mainstay of nonoperative treatment. However, large-scale SPORT suggests that patients managed with discectomy may have a more favorable outcome when compared to conservative treatment. A “mini-open” technique is the most common modality of discectomy performed; however, minimally invasive approaches are gaining popularity. The use of a tubular retractor system typifies the modern minimally invasive approach. A number of randomized controlled trials comparing open discectomy to minimally invasive microdiscectomy have been performed, demonstrating that both techniques are equally effective at relieving pain and have comparable reherniation rates. Overall complication rates are similar between open and minimally invasive approaches; however, the number of incidental durotomies is higher with minimally invasive approaches, likely reflective of the learning curve. Minimally invasive approaches offer the potential benefit of less soft tissue trauma and faster recovery; however, they are technically demanding. Excellent results can be obtained with either a minimally invasive or open approach.

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Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA

    Philip K. Louie & Gregory D. Lopez

Authors
  1. Philip K. Louie
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  2. Gregory D. Lopez
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Corresponding author

Correspondence to Gregory D. Lopez .

Editor information

Editors and Affiliations

  1. Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA

    Frank M. Phillips

  2. Texas Back Institute Texas Health Presbyterian Hospital Plano Scoliosis and Spine Tumor Center, Plano, TX, USA

    Isador H. Lieberman

  3. Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA

    David W. Polly Jr.

  4. Department of Neurological Surgery, University of Miami/Jackson Memorial Hospital, Miami, FL, USA

    Michael Y. Wang

Appendices

Quiz Questions

  1. 1.

    A 43-year-old female presents to the clinic with a 4-week history of low back pain that radiates to the left lower extremity. On examination, she has mildly decreased sensation over the dorsum of the foot and positive straight leg raise on the left side. MRI reveals a left-sided paracentral disc herniation at L4–L5. Which of the following is true regarding this patient’s clinical presentation and treatment options?

    1. (a)

      Nonoperative management with NSAIDS and physical therapy is effective for 50% of patients.

    2. (b)

      Surgical treatment is indicated in patients with diminished sensation.

    3. (c)

      Surgical treatment is equivalent to nonoperative management in terms of pain and function.

    4. (d)

      Good surgical outcome is associated with mainly back complaints.

    5. (e)

      The size of disc herniations typically decreases over time without surgical intervention.

  2. 2.

    A 25-year-old male presents with a 12-week history of low back pain and right leg pain. He has failed to improve with conservative therapies that include anti-inflammatory medications, physical therapy, and selective nerve root corticosteroid injections. Leg pain and paresthesias are localized to his buttock, lateral and posterior calf, and the dorsal aspect of his foot. His strength testing is graded at 4/5 for plantar-flexion and 4+/5 to ankle dorsiflexion. On flexion and extension radiographs, there is no evidence of spondylolisthesis. Sagittal and axial T2-weighted MR imagings reveal a right-sided paracentral disc herniation. Which of the following treatment modalities will allow the greatest improvement of physical functioning?

    1. (a)

      Observation alone

    2. (b)

      Physical therapy

    3. (c)

      Medical management with GABA analogs

    4. (d)

      Discectomy

    5. (e)

      Discectomy and instrumented fusion

  3. 3.

    A 29-year-old female reports a 10-day history of acute lower back pain with radiation into the left lower extremity. She denies any history of trauma and there are no systemic signs. On exam, she has a positive straight leg test at 30 degrees on the left side. Strength testing demonstrates mild weakness of the gluteus medius and weakness of the extensor hallucis longus of 4/5. On sensory exam, she describes decreased sensation along the lateral aspect of the calf and dorsum of the foot. Knee and ankle reflexes are intact and symmetrical. No obvious abnormalities are observed on plain lumbar radiographs. MRI scans show a left-sided paracentral disc hernation, most likely at what level?

    1. (a)

      L1–L2

    2. (b)

      L2–L3

    3. (c)

      L3–L4

    4. (d)

      L4–L5

    5. (e)

      L5–S1

Answers

  1. 1.

    e

  2. 2.

    d

  3. 3.

    d

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Louie, P.K., Lopez, G.D. (2019). Lumbar Herniated Nucleus Pulposus. In: Phillips, F., Lieberman, I., Polly Jr., D., Wang, M. (eds) Minimally Invasive Spine Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-19007-1_34

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  • DOI: https://doi.org/10.1007/978-3-030-19007-1_34

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-19006-4

  • Online ISBN: 978-3-030-19007-1

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