Far lateral lumbar disc herniation part 1: Imaging, neurophysiology and clinical features.

Far lateral lumbar disc herniations (FLLDH) represent a separate category of disc pathology which includes both intraforaminal and extraforaminal lumbar disc herniations, that are characterized by a peculiar clinical presentation, diagnostic and treatment modalities as compared to the more frequent median and paramedian disc hernias. Surgical treatment often represents the only effective weapon for the cure of this disease and over the years different approaches have been developed that can reach the region of the foramen or external to it, with different degrees of invasiveness. The diagnosis is more demanding and still underestimated as it requires a more detailed knowledge in the spine anatomy and dedicated radiological studies. Computerized tomography and in particular magnetic resonance imaging are the appropriate tools for the diagnosis of FLLDH. Despite the widespread use of these diagnostic tests, many cases of FLLDH are overlooked due to insufficiently detailed radiological examinations or due to the execution of exams not focused to the foraminal or the extraforaminal region. Neurophysiological studies represent a valid aid in the diagnostic classification of this pathology and in some cases they can facilitate the differential diagnosis with other types of radiculopathies. In the present study, a comprehensive review of the clinical presentation, epidemiology, radiological study and the neurophysiological aspects is presented.

Degenerative Lumbar Stenosis Surgery: Predictive Factors of Clinical Outcome-Experience with 1001 Patients.

BACKGROUND: Degenerative lumbar spinal stenosis (DLSS) carries a high risk of morbidity and represents a financial burden to society. A late diagnosis can lead to severe disability. Although lumbar decompressive surgery has been widely used worldwide, the proper preoperative factors to define the ideal candidates for decompression are missing. METHODS: A total of 1001 patients who had undergone decompressive surgery from 2012 to 2019 for DLSS were screened for the presence of 9 clinical and radiological parameters. For all cases, the differences between the baseline and postoperative Oswestry disability index were calculated and the results categorized as 5 different classes (ranging from very poor outcomes to excellent outcomes) according to the specific scores. Generalized ordinal logistic regression was then used to analyze the significance of the 9 parameters (coded as dummy variables) in predicting the outcome as measured by Oswestry disability index improvement after surgery. RESULTS: Of the 9 parameters, 8 were found to be significant predictors. The radiological grade of compression was the strongest, followed by polyneuropathy, obesity, symptom duration, gait autonomy, radicular deficits, American Society of Anesthesiologists score, and level of surgery. In contrast, previous back surgery was not predictive of the outcome. CONCLUSIONS: Our findings have indicated that the ideal candidate for surgery will have the following preoperative characteristics: Schizas grade D, no signs of peripheral polyneuropathy, body mass index <30 kg/m2, symptom duration of <2 years, gait autonomy <100 m, no radicular deficits, 1 level of stenosis, and an American Society of Anesthesiologists score of 1, 2, or 3.