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BACKGROUND: One-hole split endoscope technique has been widely used in the treatment of lumbar degenerative diseases, but there is no relevant literature on the safety analysis of this technique in the treatment of upper lumbar disc herniation.OBJECTIVE:To observe the position relationship of nerve roots, intervertebral space and bone landmarks in the upper lumbar spine by three-dimensional lumbar CT reconstruction technology, and to provide a basis for the clinical ope ration of one-hole split endoscope surgery. METHODS: Twenty-six patients with upper lumbar disc herniation underwent a lumbar CT scan.Mimics 17.0 software was imported to measure the related imaging paramete rs of L1/2 to L3/4 segments: (1) Measurement of vertical distance:In coronal view, the distance (a) from the intersection point of the medial facet of the superior articular process and the superior endplate (N) to the apex of the articular process (S); in the coronal view, the distance (b) from the sagittal intersection (M) of N and the inferior endplate to the apex of the inferior articular process (X). (2) Measured horizontal distance: the distance (c)between the cross-section of N and the lower edge of the outlet nerve root (N2);distance (d) between the cross-section of N and the intersection point of neural tissue (N1);N1 to N2 distance (e); distance (f) between the cross-section of M and the lateral edge of the nerve tissue (M1); M to M cross-section and exit nerve root intersection (M2) distance (g); distance (h) from M1 to M2;distance (i) from M2 to N1; distance (j) from the posterior edge of the articular surface (R)to M2 in sagittal view of the superior articular process.RESULTS AND CONCLUSION: (1) With the decrease of the segment, the distances a and b gradually increased, and the distance j gradually decreased. There was no significant difference between L1/2 and L2/3 segments (P＞ 0.05). (2) With the decrease of the segment, distance d first decreased and then increased; distance f gradually decreased;distances c, e, g, h and i gradually increased;and there was no significant difference between L2/3 and L3/4 segments (P＞ 0.05). (3) Distance i was the shortest distance without pulling nerve roots in the natural state, and the area of the safety zone was between four points M1, M2, N1, and N2. The bone was removed to the upper and lower endplates by biting the bone downward and upward through S and X, respectively, to expose the intervertebral space, and the window of distance g to M2 could be opened outward to avoid injury of the outlet nerve roots. (4) In conclusion, the upper lumbar vertebrae have unique anatomical characteristics. Based on the relevant measurements of nerve roots, spinal dura and intervertebral space, the parameters of the one-hole split endoscope technique are more accurate and safe during operation. [ABSTRACT FROM AUTHOR]

Background Data: Upper lumbar disc herniation involving D12/L1, L1/L2, and L2/L3 levels is less prevalent than lower lumbar discs. In terms of clinical characteristics and surgical managements, they are different from those at the lower levels of the lumbar spine. Spinal canals are narrower than those of the lower levels, which may compromise multiple spinal nerve roots or conus medullaris with higher complication rate with surgical intervention. Purpose: To investigate the clinical features and surgical outcomes of patients operated on for upper lumbar disc herniations. Study Design: Retrospective clinical cohort study. Patients and Methods: This study included 20 patients diagnosed with herniated disc at upper levels (T12-L1, L1-L2, and L2-L3). Patients were operated on during the period between June 2015 to March 2017. All patients were operated on via transfacet approach with pedicle screw fixation. Postoperative data including clinical and neurological outcomes and radiographic imaging have been collected. Postoperative follow-up evaluation included immediate postoperative medical records and a postoperative visit to the outpatient clinic until 18 months postoperatively. Patients’ outcomes were assessed using Visual Analogue Scale of radicular and back pain and Oswestry Disability Index (ODI) as functional score. Results: Over a mean follow-up period of 13±2.5 months, there was significant improvement in radicular pain (P = 0.0026) and back pain (P = 0.049) and myelopathy and statistically significant improvement in Oswestry Disability Index (ODI) (P = 0.0032) compared to the preoperative value. No postoperative complications were detected in this series. Conclusion: This approach offers a safe technique for decompression and stabilization at lower thoracic and upper lumbar region. (2019ESJ178)

Intradural disc herniation (IDH) in the upper lumbar spine is rare. Preoperative radiologic diagnosis can be difficult, making operative planning challenging. We report on a 74-year-old female patient who was diagnosed with an L1-L2 IDH intraoperatively. This case report aims to highlight and discuss the radiological features of IDH and operative challenges when approaching IDH. A 74-year-old female patient presented to outpatient clinic with a 3-month history of significant intermittent neurological claudication and severe lumbar back pain. Her examination was unremarkable apart from a positive left-sided femoral stretch test. Magnetic resonance imaging (MRI) revealed a large central L1/L2 disc herniation causing significant compression of the thecal sac and proximal cauda equina nerve roots. She underwent an elective posterior L1/L2 lumbar exploration. Intraoperatively, identification of the disc was difficult, which led to inadvertent cerebrospinal fluid leak after incision of what was thought to be a disc bulge. Further exploration revealed an intradural disc that was removed via durotomy. The thecal sac was repaired with sutures and TISSEEL (Baxter, Deerfield, Illinois, USA). Postoperatively, the patient complained of weak left lower limb; MRI revealed residual disc remnants causing compression of the cauda equina. She successfully underwent an urgent revision decompression procedure. She was discharged to rehabilitation on postoperative day 14 with weakness in left knee flexion and extension (MRC grade 4/5) and left ankle plantar- and dorsiflexion (MRC grade 2/5). Upper lumbar IDH represent a surgical challenge. Intraoperative considerations include identification of the disc, intentional or incidental durotomy, intradural discectomy, and anatomical restrictions of operating at the level proximal to the cauda equina. [ABSTRACT FROM AUTHOR]

Objective The conventional microsurgical interlaminar approach for upper lumbar disc herniation (LDH) can increase the risk of postoperative spinal instability due to excessive laminectomy and/or facetectomy. The authors present a key-hole laminotomy (microsurgical translaminar approach) for upper LDH, which allows less destructive laminotomy, and review the results of this surgical technique. Methods Between 2007 and 2014, 20 patients underwent single level discectomy in the upper lumbar spine (L1-2 or L2-3) using a microsurgical translaminar approach. Mean patient age was 58.0±12.0 years and minimum follow-up was 1.0 years. A retrospective review of clinical and radiological data was conducted. Results Back pain and leg pain were improved from an average of 4.9±1.1 and 8.3±0.9 to 0.9±0.7 and 0.9±1.6 at 1-year postoperatively (p

Background: Upper lumbar disc herniation (ULDH) is easy to be misdiagnosed due to its special anatomical and atypical clinical features. Few studies have identified the relationship between ULDH and adjacent wedge-shaped vertebrae (WSV)., Hypothesis: WSV may have some indicative relations withULDH., Patients and Methods: Between January 2003 and October 2013, 47 patients (27 males and 20 females; mean age, 41.2 years) with single-level ULDH (as study group) and 47 sex- and age-matched healthy volunteers (as control group) were studied by radiograph. The two groups were compared with respect to age, sexual proportion, body mass index (BMI), kyphotic angle, and the proportion of WSV. Also, correlative analyses were conducted in the study group to investigate the relation between the kyphotic angle of target vertebrae and other factors including age, BMI, Cobb angle, JOA score and bone mineral density (BMD)., Results: The average kyphotic angle in the study group was 11° (4°-22°), while the average kyphotic angle in the control group was 2° (0°-7°). Obviously, the mean kyphotic angle in the study group was statistically larger than that in the control group (t=13.797, P<0.001). The proportion of WSV in the study group was significantly larger than that in the control group (x(2)=36.380, P<0.0001). The correlations between kyphotic angles and other items (i.e., age, BMI, BMD, Cobb angle and JOA score) in the study group and the control group were low or uncorrelated., Conclusions: WSV are indicatively associated with adjacent ULDH. Thus, ULDH should be alerted when WSV are first found in radiograph and accompanied by clinical symptoms.