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Lumbar disc prolapse is a common condition which can cause lumbar nerve root compression and result in lower limb radiculopathy.
Everyone develops degenerative disc disease over the course of their life, with the lower lumbar discs generally being effected earlier than the upper lumbar discs. The vast majority develop a degenerative broad based bulge that does not cause any neural compression. However, some people will develop a focal prolapse or herniation which can cause nerve compression. The most common location for a disc herniation is paracentral, which is located within the spinal canal, and causes compression of the traversing nerve root in the lateral recess. Less common locations for disc herniation include central, foraminal, and far lateral.
The incidence of lumbar disc herniation is between 0.5% and 2% and is most common in people in their fourth and fifth decades of life. It can sometimes be related to a specific incident involving heavy lifting or bending, but there is often no specific causative factor.
The lower limb radiculopathy caused by the neural compression can be severe and tends to be felt in the dermatomal area of the compressed nerve. The vast majority of disc prolapses do resolve spontaneously over time and this can generally take between 3 and 12 months. As such, most patients will be able to follow a non-operative course of treatment using analgesia and activity modification. Steroid injections around the nerve may help with pain relief during this time.
For those patients who cannot tolerate the pain despite non-operative measures or those who have a progressive neurological deficit, surgery may be beneficial.
Lumbar microdiscectomy is one of the most common spinal procedures performed and doctors managing spinal patients should be familiar with the management of lumbar disc herniation, the treatment options available, and the principles of a lumbar microdiscectomy.
Acknowledgement and thanks to Mr Simon Hughes FRCS (Tr & Orth) for providing a number of the images of this surgical technique.
Author:Mr Stephen Morris FRCS (Tr & Orth).
Institution: The Avon Orthopaedic centre, Southmead hospital, Bristol, UK.
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Question 1 of 15
Which one of the following describes the proportion of patients with acute disc herniation who find their symptoms resolve spontaneously?CorrectIncorrect
Question 2 of 15
Lumbar disc herniation can be anatomically described as which one of the following?CorrectIncorrect
Question 3 of 15
Which one nerve root will be compressed by a left L5/S1 paracentral disc herniation?CorrectIncorrect
Question 4 of 15
The majority of patients with acute disc herniation have significant improvement in their symptoms over which one of the following time periods?CorrectIncorrect
Question 5 of 15
On the MRC grading of muscle power, which one of the following numbers represents normal power?CorrectIncorrect
Question 6 of 15
The Lasegue test reproduces neuropathic pain due to tension of which one of the following nerves?CorrectIncorrect
Question 7 of 15
In the absence of contra-indications, which one of the following imaging modalities is considered the gold standard for assessing neural compression related to a disc herniation?CorrectIncorrect
Question 8 of 15
Which one of the following joints should be extended when positioning a patient for a lumbar microdiscectomy?CorrectIncorrect
Question 9 of 15
When looking at spinal surface anatomy, which one of the following levels lies between the posterior superior iliac spines?CorrectIncorrect
Question 10 of 15
Once the exposure of the posterior aspect of the spine for an L5/S1 microdiscectomy is complete, which one of the following structures should now be visible?CorrectIncorrect
Question 11 of 15
Once the posterior elements are exposed for an L5/S1 microdiscectomy, which one of the following should be performed prior to entering the spinal canal?CorrectIncorrect
Question 12 of 15
Which one of the following structures need to be resected to allow visualisation of the dura and nerve root for a left L5/S1 microdiscectomy?CorrectIncorrect
Question 13 of 15
Which one structure needs to be carefully retracted and protected whilst the loose disc fragments are being removed from an L5/S1 paracentral disc prolapse?CorrectIncorrect
Question 14 of 15
Following an uncomplicated lumbar microdiscectomy, which one of the following describes after how long post-operatively should a patient start to mobilise?CorrectIncorrect
Question 15 of 15
Following a lumbar microdiscectomy, which answer describes when a patient likely to be discharged home?CorrectIncorrect