Volume 27, Issue 2 , Pages 123-128, February 2004
Far-Lateral disk herniation: case report, review of the literature, and a description of nonsurgical management
Article Outline
Abstract
Objective
To review the history and examination of a far-lateral lumbar intervertebral disk herniation (FLLIDH), as well as the treatment and outcomes of a nonsurgical approach.
Clinical features
A 60-year-old healthy male subject had a 3-week history of right buttock and calf pain. He initially had a left lateral list and asymmetrical pelvic landmarks. Range of motion (ROM) of the lumbar spine revealed full and pain-free lumbar flexion, right-sided pain with lumbar extension and left side bending, and painful and restricted left side bending. Neurologic examination was unremarkable.
Intervention and outcome
The patient was treated with a lumbar epidural and nerve root injection, as well as manipulation. Physical therapy consisted of deweighting treadmill, autotraction, and strengthening exercises. Outcomes were measured by using the Modified Oswestry Questionnaire, as well as a numerical pain rating scale. His initial Oswestry was 73%, pain 9/10 at presentation. Upon discharge, the Oswestry was 0% and pain was rated as 0/10.
Conclusion
A significant decrease was noted in both the Oswestry Questionnaire, as well as the pain rate. The patient returned to running on alternate days for a minimum of 30 minutes, which was his primary goal. This case demonstrated a positive outcome using a multidisciplinary approach in a patient diagnosed with a FLLIDH. He obtained his goals and his function was fully restored.
Keywords: Disk Herniation, Lumbar Vertebrae, Chiropractic Manipulation, Traction, Exercise
Introduction
The anatomy of the lumbar intervertebral disk is such that herniation may occur in any direction. Examples include cephalad and caudad herniations into the vertebral end plates and anterior herniation. Posterior, posterolateral, and lateral intervertebral disk herniations may cause conus, cauda equine, or nerve root compromise, resulting in pain, decreased sensation, weakness, or reduction in bladder, bowel, or sexual function.1
There are 3 categories for herniated disks2:
Traditionally, most health care practitioners treat nonemergent symptoms such as pain due to intervertebral disk herniation with nonsurgical treatment modalities, including physical therapy, bed rest, steroids taken orally or via epidural injection, oral anti-inflammatory medicines, or no specific treatment. Nonsurgical therapies result in symptom improvement or resolution in 70% to 90% of patients to the degree that surgical treatment is not necessary.
A specific type of disk rupture, the “far-lateral” or “extreme-lateral” intervertebral disk herniation, is felt to be less responsive to nonsurgical therapies than the more typical posterior or posterolateral disk herniations.3 Far-lateral lumbar intervertebral disk herniation (FLLIDH) is a well-recognized clinical and radiographic entity which is generally thought to be a rare occurrence, accounting for less than 1% of all intervertebral disk herniations up to 12% of herniations.4 The patient's symptoms and signs usually correlate well with the root(s) being compressed or irritated by the herniation. Although a number of studies have reported excellent results with excision of the disk fragment, few studies have examined the outcomes of nonsurgical management. Rust and Olivero4 did a retrospective study on 16 patients, which showed that 71% responded to conservative treatment with good long-term outcome. Conservative management included physical therapy, medications, and epidural steroid injections. The purpose of this case report is to review the history, relevant neurologic examination, and radiographic studies associated with FLLIDH, as well as the interventions and outcome of nonsurgical treatment techniques in this specific case.
Case report
The patient was first seen in the Spine Specialty Center 15 months prior to the onset of the episode to be discussed. The patient presented with a long history of recurrent low back pain, which had been dormant for the previous 3 years until 1 month prior to presentation. On examination, the patient was asymptomatic and was placed on a preventive low back exercise routine. This 60-year-old male patient was a very busy, physically active, fit individual who was compliant with his exercise program and was asymptomatic for 15 months, at which time he presented to the Spine Specialty Center with onset of symptoms 3 weeks previously after taking up golf, followed by extensive sitting in travel by both plane and automobile. The pain became so severe that he was unable to stand erect. He scored 73 out of a possible 100 on the Oswestry Low Back Questionnaire (Fig 1); the Numerical Pain Rating Scale indicated current pain as 9 out of 10, worst in the past 24 hours as 10 out of 10, and best in the previous 24 hours as 6 out of 10. The Body Pain Map showed right buttock and right calf pain (Fig 2). There was no complaint of bladder, bowel, or sexual dysfunction.
Fig 1.
Flowsheet data.
Fig 2.
Body Map diagram.
Physical examination revealed a 60-year-old man who was in acute distress, had difficulty transitioning from sitting to standing, and ambulated with an antalgic gait, unable to assume the erect position, and with an observable lateral list to the left. Static pelvic landmarks were markedly asymmetric, with the right iliac crest 4° high posteriorly and 2° high anteriorly in the standing position. Pain was produced in both lateral bendings and backward bending, all felt on the right side; however, only the right lateral bending was markedly restricted due to the presence of the frontal plane deformity, and flexion was full range without enhancement of symptoms. Deep tendon reflexes were equal and symmetrical, and the patient could heel and toe walk with no loss of sensation.
On the initial visit, the patient was treated with manipulation and Auto Trac,5 a hydraulic table that performs mechanically facilitated passive movements combined with active involvement of the patient. After correction on the table, gradual reloading is obtained with the tilt table component. Following this treatment, the patient was instructed in self-correction exercises (Fig 3). Two days later on the second visit, he was treated with Auto Trac to full correction, with pain returning on weight bearing. The patient was fitted with a CASH brace (Ballert Orthopedic, Chicago, Ill.). Four days later, on the third visit, the patient was again treated with manipulation and returned to work part-time. Request for magnetic resonance imaging (MRI) and neurosurgical consultation regarding further treatment was made at the fourth visit. The lumbar MRI demonstrated a far-lateral L5, S1 disk rupture with L5 nerve root impingement on the right (Fig 4). In light of the patient's improvement with nonsurgical treatment, surgery was deferred. At this point, the patient was no longer exhibiting a lateral list. He was back to work, and his primary complaint was sitting intolerance. Consultation was obtained from one of us (BL), who recommended lumbar epidural and nerve root injection, because our subject's lumbar MRI indicated a far-lateral disk herniation that was compressing the right L5 nerve root (Fig 4). He underwent computed tomography (CT)-guided transforaminal epidural injection after an epidurogram reproduced his leg symptoms. This was performed 1 week later, which was nearly 1 month after the initial visit. Three days later, the patient was seen again, and the injection had accomplished the desired effect of reducing the leg pain and thus improving sleep. The patient was working and driving but was suffering fatigue by midafternoon. The patient was then referred to physical therapy for a course of deweighting and rehabilitation. The patient attained a 0 on the Numeric Pain Rating Scale and 2 out of 100 on the Oswestry Low Back Questionnaire in 4 weeks of physical therapy. The patient was seen 6 weeks later, at which time all scores were 0. The next visit was made 6 weeks following that visit, and again the patient had no complaint of pain, had a 0 on the Oswestry Low Back Questionnaire, and was running or alternatively using a stair climbing machine on alternate days for a minimum of a half hour and continuing his stabilization exercises. At 1-year follow-up, the patient remains asymptomatic.
Fig 3.
The Doorway Hula (left). Stand in the doorway with your palms placed against the door jams, as shown. Without allowing your arms or shoulders to move, shift your pelvis from one direction to the other. Your clinician will instruct you as to which direction should be emphasized. The Doorway Hula Bending Backwards (right). After shifting your pelvis in the restricted direction, bend backwards gently from the shifted position. Return to the erect position and attempt to shift the pelvis again in the same direction. When both directions are equal, you have achieved the goal.
Fig 4.
Axial scans demonstrating far-lateral disk herniation causing compression of nerve root.
Discussion
Studies regarding the use of epidural steroid injections as treatment for herniated disk symptoms have been mixed.2 Carette et al6 published in the New England Journal of Medicine in 1997 a randomized, double-blind trial using 158 subjects studying the long-term effects of epidural injections versus placebo for treatment of radiculopathy and back pain from disk herniation. They found only short-term leg pain relief and sensory deficit improvement compared with the control group. However, the study did not distinguish far-lateral disk herniation within the subjects. Schmid et al7 showed short-term and long-term improvements in the 32 subjects that were administered CT-guided epidural steroid injections.
Zennaro et al8 published a study in February 1998 in the American Journal of Neuroradiology which demonstrated in a cohort of 41 subjects with radiculopathy that 71% responded well with periganglionic foraminal CT-guided steroid injections. Twenty-six of the patients had long-term relief. The subjects had either foraminal narrowing due to degeneration or herniated disks. They found the degeneration group to be more responsive. However, once again, it was not specified whether the herniated disk subjects contained far-lateral disks.
Epidural injections can be performed via the caudal or lumbar approach. The caudal approach is technically easier and avoids thecal puncture, but a larger volume of medication has to be used. The lumbar approach needs less medication because it is closer to the target. Like manipulation, the epidural approaches and efficacies are dependent on the physician's skill and experience. Most often, the procedure is administered in an outpatient setting without CT or fluoroscopy. Stitz and Sommer9 showed in Spine in 1999 that 25.9% of the caudal injections were placed incorrectly when performed by a physician experienced in the procedure. It is thought that the dorsal root ganglion, which lies in the neural foramina, is involved in pain transmission via the cell bodies of C fibers. Some other authors have demonstrated that chemical radiculitis occurs without direct pressure on a nerve root.8 Targeting the dorsal root ganglion in a transforaminal epidural injection would address the inflammatory and pain process.
FLLIDH is common in the sixth decade of life and most commonly occurs at the L4-5, L5-S1. Long-term follow-up following diskectomy shows that approximately 70% to 80% of patients have good to excellent results,10, 11, 12, 13 and nonsurgical treatments must be compared with these results. This single case, along with the Rust and Olivero4 retrospective analysis of 16 cases, indicates the potential for good outcomes in this patient population with no surgical treatment. It must be emphasized in this case that the patient was fit, motivated, and compliant with the program. Moreover, the outcome in this specific case is indicative of the benefits of interdisciplinary interventions. Initially, when the patient was in the acute stage with a frontal plane deformity, the Auto Trac (Fig 5) was beneficial in correcting the deformity and returning the patient back to limited activity. The manipulation corrected the pelvic malalignment. When the patient plateaued, the epidural and nerve root injection was effective in relieving the lower extremity symptoms, which helped the patient with sleeping and mitigated his passage from a passive to an active approach in physical therapy, where exercise and a deweighted treadmill not only helped to improve function but also in decreasing symptoms. Surgical intervention would have been available had the conservative measures failed.
Fig 5.
Auto Trac.
Conclusion
Our case study demonstrated the possibility of success with conservative management of FLLIDH in an active 60-year-old male. His symptoms resolved completely and his function was fully restored.
A prospective study on subjects with FLLIDH will need to be done to demonstrate long-term efficacy.
References
- . Foraminal and extraforaminal disc herniation (diagnosis and treatment). Spine. 1987;12:577–585
- . Randomized controlled trials in industrial low back pain relating to return to work. Part 2. Diskogenic low back pain. Arch Phys Med Rehabil. 1996;77:1189–1197
- . Surgical management of extreme lateral lumbar disc herniations (review of 138 cases). Neurosurgery. 1988;22:648–653
- . Far-lateral disc herniations; the result of conservative management. J Spinal Disord. 1999;12:138–140
- Natchev E. A manual on auto-traction treatment for low back pain. Stockholm: Tryckeribolaget i Sundsvall AB; 1984. p. 1-308
- Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J Med. 1997;336:1634–1640
- . CT-guided epidural/perineural injections in painful disorders of the lumbar spine (short and extended-term results). Cardiovasc Intervent Radiol. 1999;22:493–498
- Periganglionic foraminal steroid injections performed under CT control. Am J Neuroradiol. 1998;19:349–352
- . Accuracy of blind versus fluoroscopically guided caudal epidural injection. Spine. 1999;24:1371–1383
- . Surgical treatment for the far lateral herniated lumbar disc. Spine. 1993;18:1263–1267
- . Long-term follow up of patients surgically treated by the far-lateral approach for foraminal and extraforaminal lumbar disc herniations. J Neurosurg. 1999;90:59–66
- . Evaluation of varied surgical approaches used in the management of 170 far-lateral lumbar disc herniations (indications and results). J Neurosurg. 1995;83:648–656
- . Far lateral disc herniations treated by microscopic fragment resection (techniques and results). Spine. 1995;20:1500–1505
PII: S0161-4754(03)00229-X
doi:10.1016/j.jmpt.2003.12.007
© 2004 National University of Health Sciences. Published by Elsevier Inc. All rights reserved.
Volume 27, Issue 2 , Pages 123-128, February 2004
