Cauda equina syndrome due to intradural lumbar disc herniation

Cauda equina syndrome due to intradural lumbar disc herniation

Intradural lumbar disc herniation is rare, with an incidence of 0.3%-1%, but has been well reported in the literature. Transdural migration of the disc penetrating both ventral and dorsal dura is extremely rare, and there is a dearth of literature in the pathophysiology and surgical management of transdural herniation. Lack of knowledge on this type of presentation can cause intraoperative surprises and inadvertent cauda equina root injuries and lead to prolonged operative time. 1).

Diagnosis

Intradural disc prolapse remains a diagnostic dilemma as it is very difficult to diagnose all the cases preoperatively. The presence of MRI findings of mass effect in the form of displacement of the traversing nerve roots due to large central disc with crumble disc sign were suggestive of early evidence of intradural disc herniation. Y sign in ventral dura due to splitting of ventral dura and arachnoid mater by disc material was a good diagnostic sign to suspect intradural extra-arachnoid disc. The presence of hypointense structure inside the dura with no continuity with the adjacent intervertebral disc on MRI was highly suggestive of an intradural disc, in patients having the large central disc on MRI, especially at L4-L5 levels, should raise suspicion of intradural herniation of disc. 2).


Ducati et al. described five cases of this pathology and review the literature as well as some considerations about the difficulties in the preoperative diagnostic issues and the surgical technique.

They concluded that for intradural disc herniations the diagnosis is mainly intraoperative, and the surgical technique has some special aspects 3).


A female patient with lumbosciatic pain who developed an incomplete cauda equina syndrome. An asymmetric discopathy of the L2-L3 space and a gas bubble with disc material within the spinal canal was noticed in the radiologic explorations. The literature and the authors’ experience are reviewed with the aim of confirming the frequency of intradural herniation in association with gas in the spinal canal.

A laminoarthrectomy of the involved space was performed followed by direct intradural examination, which revealed a disc fragment that was excised. An instrumented L2-L3 arthrodesis was performed. Postoperative evolution was satisfactory. To date, the authors have found this association in 2% of the patients with intraspinal gas.

The potential presence of an intradural disc herniation must always be considered when performing an open discectomy on a patient whose CT scan study shows the presence of epidural gas. This association is particularly striking given the relative rarity of intradural herniations and intraspinal gas. In the event that no clear disc herniation was found, an intradural examination may be indicated to justify clinical signs and symptoms or previous radiologic studies 4).

Treatment

Intradural exploration and/or transdural sequestrectomy avoids traction on already compromised nerve roots and is often safer than extradural sequestrectomy. The onset of bladder paralysis is a most important indication for immediate surgery. The cases presented show that there is a highly significant difference in the outcome of those cases operated on within 24h of bladder paralysis compared to those operated on after this period 5).

Case series

Sharma et al. presented a case series of six cases of intradural disc herniation at L4-L5 level diagnosed on the basis of intraoperative findings.

All the cases, on preoperative magnetic resonance imaging (MRI) were reported as having diffuse annular bulge with large posterocentral extrusion. The study comprised patients in age group of 30-60 years. Four cases out of six presented with cauda equina syndrome. In three cases, cauda equina was associated with sudden deterioration in the power of lower limb muscle groups.

They suspected that intradural herniation of disc was synchronous with cauda equina syndrome in these cases, which was very well documented in one of the cases. On retrospective analysis, MRI findings of mass effect in the form of displacement of the traversing nerve roots due to large central disc with crumble disc sign were suggestive of early evidence of intradural disc herniation. Y sign in ventral dura due to splitting of ventral dura and arachnoid mater by disc material was a good diagnostic sign to suspect intradural extra-arachnoid disc. The presence of hypointense structure inside the dura with no continuity with the adjacent intervertebral disc on MRI was highly suggestive of an intradural disc.

Intradural disc prolapse remains a diagnostic dilemma as it is very difficult to diagnose all the cases preoperatively. The presence of above-mentioned radiological signs on MRI in patients having the large central disc on MRI, especially at L4-L5 levels, should raise suspicion of intradural herniation of disc. 6).


Ducati et al. described five cases of this pathology and review the literature as well as some considerations about the difficulties in the preoperative diagnostic issues and the surgical technique.

They concluded that for intradural disc herniations the diagnosis is mainly intraoperative, and the surgical technique has some special aspects 7).

Case reports

Intradural lumbar disc herniation is rare, with an incidence of 0.3%-1%, but has been well reported in the literature. Transdural migration of the disc penetrating both ventral and dorsal dura is extremely rare, and there is a dearth of literature in the pathophysiology and surgical management of transdural herniation. Lack of knowledge on this type of presentation can cause intraoperative surprises and inadvertent cauda equina root injuries and lead to prolonged operative time. Pedaballe et al. reported 1 such case, described the surgical experience, and discussed the pathological mechanisms and signs.

A 30-year-old woman presented to outpatient clinic with chronic cauda equina syndrome due to massive L4-L5 disc herniation. L4-L5 decompression and transforaminal lumbar interbody fusion were planned. Unexpectedly, however, surgery revealed a transdural herniation, which was effectively managed with laminectomy, extension of durotomydiscectomy, repair of both dorsal and ventral dura, and interbody fusion, but at the expense of prolonged surgical time.

Transdural herniation of a lumbar disc is very rare presentation. It can be effectively managed with laminectomy, extension of durotomydiscectomy and repair of both dorsal and ventral dura. It can be diagnosed by magnetic resonance imaging preoperatively only if read with suspicion of such presentation. 8).


A 56-year-old man who developed cauda equina syndrome after several episodes of severe Valsalva maneuver.

The patient was found to have developed subacute urinary retention and leg weakness. Magnetic resonance imaging findings were concerning for an unusual-appearing lesion extending cranially at L2-3. Urgent decompression via an L2 laminectomy, exploration, and subsequent discectomy was performed. The patient recovered exceptionally well, regaining bladder function and ultimately being able to ambulate without assistance.

Cranially extending intrathecal disc herniations are a rare phenomenon and exceptionally uncommon above L3. The clinician should have a high level of suspicion for herniation when looking at the clinical and historical information consistent with such a diagnosis even in the presence of ambiguous imaging findings 9)


Nagaria et al. presented a case with intermittent symptoms and signs of cauda equina compression. They were unable to find in the literature, any previously described cases of intermittent cauda equina compression from a herniated intradural disc fragment leading to a “floppy disc syndrome” 10).


A 73-year-old male presented with a rare dorsally sequestrated lumbar disc herniation manifesting as severe radiating pain in both leg, progressively worsening weakness in both lower extremities, and urinary incontinence, suggesting cauda equina syndrome. Magnetic resonance imaging suggested the sequestrated disc fragment located in the extradural space at the L4-L5 level had surrounded and compressed the dural sac from the lateral to dorsal sides. A bilateral decompressive laminectomy was performed under an operating microscope. A large extruded disc was found to have migrated from the ventral aspect, around the thecal sac, and into the dorsal aspect, which compressed the sac to the right. After removal of the disc fragment, his sciatica was relieved and the patient felt strength of lower extremity improved 11).


Mailleux et al. described a case of anterior transdural L4-L5 disc herniation presenting as a partial cauda equina syndrome without related back pain or history of back pain. MRI allowed presurgical diagnosis showing an irregular intradural mass that did not enhance. That lack of enhancement could be related to the fact that the disc herniation was relatively recent 12).


A female patient with lumbosciatic pain who developed an incomplete cauda equina syndrome. An asymmetric discopathy of the L2-L3 space and a gas bubble with disc material within the spinal canal was noticed in the radiologic explorations. The literature and the authors’ experience are reviewed with the aim of confirming the frequency of intradural herniation in association with gas in the spinal canal.

A laminoarthrectomy of the involved space was performed followed by direct intradural examination, which revealed a disc fragment that was excised. An instrumented L2-L3 arthrodesis was performed. Postoperative evolution was satisfactory. To date, the authors have found this association in 2% of the patients with intraspinal gas.

The potential presence of an intradural disc herniation must always be considered when performing an open discectomy on a patient whose CT scan study shows the presence of epidural gas. This association is particularly striking given the relative rarity of intradural herniations and intraspinal gas. In the event that no clear disc herniation was found, an intradural examination may be indicated to justify clinical signs and symptoms or previous radiologic studies 13).


A 59 year-old man with ILDH. It was the only case of ILDH among 960 patients surgically treated, during the period 1989-1996. Clinically the patient demonstrated an acute cauda equina syndrome. The diagnosis was established by radiculograms, which showed a total block at the L3-L4 level. There was a 3 days time interval between the diagnosed syndrome itself and the operation. At surgery the L3-L4 level was intact, whereas dense adhesions were found between the L4-L5 disc and the dura. Root retraction to expose the nucleus pulposus mass was impossible. A laminectomy of the L4 was undertaken. An incision was made in the dura and arachnoid, revealing an extruded discal mass, lying between the roots of the cauda equina. It was carefully removed. The state of the patient at follow-up 1 year after surgery was unsatisfactory. The patient has moderate flaccid paraparesis, bladder dysfunction improved. The prognosis appeared to be linked to the preoperative duration of symptoms 14)


One case of intradural lumbar disc herniation at the L3-L4 disc level with cauda equina syndrome is reported. Myelo-CT demonstrated an intradural tumor-like lesion with complete block. An intradural fragment of sequestrated disc material was found intraoperatively. Accurate preoperative diagnosis of the intradural nature of the disease and prompt surgical treatment resulted in a smooth recovery 15).


A case of intradural disk herniation at L4-5 observed in a patient with longstanding low back pain and sciatica due to a herniated disk. After having undergone various surgical procedures for this disorder, the patient developed a multiradicular syndrome of the cauda equina 16)

References

1) , 8)

Pedaballe AR, Mallepally AR, Tandon V, Sharma A, Chhabra HS. An Unusual Case of Transdural Herniation of a Lumbar Intervertebral Disc: Diagnostic and Surgical Challenges. World Neurosurg. 2019 Aug;128:385-389. doi: 10.1016/j.wneu.2019.05.103. Epub 2019 May 20. PubMed PMID: 31121367.
2) , 6)

Sharma A, Singh V, Sangondimath G, Kamble P. Intradural Disc a Diagnostic Dilemma: Case Series and Review of Literature. Asian J Neurosurg. 2018 Oct-Dec;13(4):1033-1036. doi: 10.4103/ajns.AJNS_55_17. PubMed PMID: 30459862; PubMed Central PMCID: PMC6208249.
3) , 7)

Ducati LG, Silva MV, Brandão MM, Romero FR, Zanini MA. Intradural lumbar disc herniation: report of five cases with literature review. Eur Spine J. 2013 May;22 Suppl 3:S404-8. doi: 10.1007/s00586-012-2516-4. Epub 2012 Sep 27. Review. PubMed PMID: 23014741; PubMed Central PMCID: PMC3641279.
4) , 13)

Hidalgo-Ovejero AM, García-Mata S, Gozzi-Vallejo S, Izco-Cabezón T, Martínez-Morentín J, Martínez-Grande M. Intradural disc herniation and epidural gas: something more than a casual association? Spine (Phila Pa 1976). 2004 Oct 15;29(20):E463-7. Review. PubMed PMID: 15480124.
5)

Dinning TA, Schaeffer HR. Discogenic compression of the cauda equina: a surgical emergency. Aust N Z J Surg. 1993 Dec;63(12):927-34. PubMed PMID: 8285904.
9)

Tempel Z, Zhu X, McDowell MM, Agarwal N, Monaco EA 3rd. Severe Intradural Lumbar Disc Herniation with Cranially Oriented Free Fragment Migration. World Neurosurg. 2016 Aug;92:582.e1-582.e4. doi: 10.1016/j.wneu.2016.06.024. Epub 2016 Jun 16. PubMed PMID: 27318310.
10)

Nagaria J, Chan C, Kamel M, McEvoy L, Bolger C. Episodic cauda equina compression from an intradural lumbar herniated disc: a case of ‘floppy disc’. J Surg Case Rep. 2011 Sep 1;2011(9):6. doi: 10.1093/jscr/2011.9.6. PubMed PMID: 24950507; PubMed Central PMCID: PMC3649298.
11)

Kim JS, Lee SH, Arbatti NJ. Dorsal extradural lumbar disc herniation causing cauda equina syndrome : a case report and review of literature. J Korean Neurosurg Soc. 2010 Mar;47(3):217-20. doi: 10.3340/jkns.2010.47.3.217. Epub 2010 Mar 31. PubMed PMID: 20379476; PubMed Central PMCID: PMC2851086.
12)

Mailleux R, Redant C, Milbouw G. MR diagnosis of transdural disc herniation causing cauda equine syndrome. JBR-BTR. 2006 Nov-Dec;89(6):303-5. PubMed PMID: 17274584.
14)

Bayassi S. [Intradural lumbar disk herniation (ILDH). Case report and literature review]. Neurol Neurochir Pol. 1998 Sep-Oct;32(5):1295-301; discussion 1301-2. Polish. PubMed PMID: 10463243.
15)

Fang CM, Huang TJ, Chen WJ, Lee ST, Hsu RW. Intradural lumbar disc herniation–a case report. Changgeng Yi Xue Za Zhi. 1994 Sep;17(3):297-300. PubMed PMID: 7954013.
16)

Borgogno G, Fontanella C, La Camera V. [Herniated intradural lumbar disk: a clinical case]. Arch Putti Chir Organi Mov. 1991;39(1):87-91. Italian. PubMed PMID: 1842495.

Factors Related to the Primary Discectomy in Recurrent Lumbar Disc Herniation

Factors Related to the Primary Discectomy in Recurrent Lumbar Disc Herniation

The degree of disc removal did not influence the outcome or complication rate in Fountas et al., clinical series 1)

For Carragee et al., the more aggressive removal of remaining intervertebral disc material may decrease the risk of reherniation, but the overall outcome was less satisfactory, especially during the first year after surgery 2).

McGirt et al., found that larger annulus defects and smaller percentage of disc removed during primary surgery, rather than absolute volume as reported in previous studies, were associated with an increased risk of recurrent lumbar disc herniation while more aggressive removal contributed to accelerated disc height loss 3).

systematic review of the literature suggests that conservative discectomy may result in shorter operative time, quicker return to work, and a decreased incidence of long-term recurrent low back pain but with an increased incidence of recurrent disc herniation. Prospective randomized trails are needed to firmly assess this possible benefit. 4).

The question remains how to balance the desire for maintaining disc height with minimizing the risk for reherniation 5).

References

 
1) 
Fountas KN, Kapsalaki EZ, Feltes CH, et al. Correlation of the amount of disc removed in a lumbar microdiscectomy with long-term outcome. Spine (Phila Pa 1976). 2004;29:2521–2526.
2) 
Carragee EJ, Spinnickie AO, Alamin TF, Paragioudakis S. A prospective controlled study of limited versus subtotal posterior discectomy: short-term outcomes in patients with herniated lumber intervertebral discs and large posterior anular defect. Spine (Phila Pa 1976). 2006;31:653–657.
3) 
McGirt MJ, Eustacchio S, Varga P, et al. A prospective cohort study of close interval computed tomography and magnetic resonance imaging after primary lumbar discectomy: factors associated with recurrent disc herniation and disc height loss. Spine (Phila Pa 1976). 2009;34:2044–2051.
4) 
Walters WC, 3rd, McGirt MJ. An evidence-based review of the literature on the consequences of conservative versus aggressive discectomy for the treatment of primary disc herniation with radiculopathy. Spine J. 2009;9:240–257.
5) 
Shepard N, Cho W. Recurrent Lumbar Disc Herniation: A Review. Global Spine J. 2019 Apr;9(2):202-209. doi: 10.1177/2192568217745063. Epub 2017 Dec 18. Review. PubMed PMID: 30984501; PubMed Central PMCID: PMC6448208.

Thoracolumbar disc herniation

Thoracolumbar disc herniation

Thoracolumbar disc herniation (TLDH) is a rare and progressively disabling disorder occurring T10/T11 T11/T12T12/L1L1/L2 levels. It constitute about 0.25% to 5% of all lumbar degeneration diseases 1).

see also Upper Lumbar Disc Herniation.

Upper lumbar discs have been reported as only L1L2 and L2L3 by some authors, and by others as T12L1L1L2, and L2L3.

Most previous studies of upper lumbar disc herniations included the L1-L2, L2-L3, and L3-L4 levels. Upper lumbar disc herniations have been reported to occur with a frequency of less than 5% of all disc herniations.

Clinical features

It may cause various symptoms attributable to the polytropic neuromechanism in different levels.

Treatment

Posterior decompressive laminectomy was the most common operation of TLDH before.

Anterolateral retroperitoneal approachanterior transthoracic approach, posterolateral, and lateral approaches are performed in discectomy with or without fusion and internal fixation. However, patients who have undergone any operation at these levels are predisposed to postoperative recurrence, neurological aggravation, and adjacent segment degeneration, and the outcomes are inferior than those in lower lumbar spine 2) 3).

Posterior approach operation is an ideal surgical technique for treatment of TLDH; the operative time, blood loss, hospitalization duration, and symptomatic improvement are favorable 4).

Complications

Surgical procedures predispose the subjects to high incidence of complications including recurrence, neurological aggravation, and adjacent segment degeneration.

Case series

Ten patients with TLDH underwent posterior approach operation in the Department of Orthopaedics, General Hospital of Jinan Military Region, from January, 2006 to December, 2015. The mean preoperative duration of clinical symptoms was 16.5 months. The clinical data including operative timeblood loss, and hospitalization duration were investigated. Furthermore, pre and postoperative neurological status was evaluated by the Modified Japanese Orthopaedic Association scale and pain by visual analog scale (VAS) scoring system.The mean operative time was 176.50 ± 20.55 minutes, the mean blood loss was 435.00 ± 89.58 mL, and the mean hospitalization length was 13.30 ± 2.97 days. All patients were followed with a mean period of 35.1 months. The mean JOA score of all patients before operation, at discharge, 3 months after operation, and at last follow-up was 6.50 ± 1.28, 7.60 ± 1.22, 8.90 ± 0.99, and 9.00 ± 0.92, respectively. The differences between the pre and postoperative JOA and VAS scores were significant (P < .05). However, the differences of JOA and VAS scores at postoperative 3 months and final follow-up were not statistically significant.Posterior approach operation is an ideal surgical technique for treatment of TLDH; the operative time, blood loss, hospitalization duration, and symptomatic improvement are favorable 5).


A retrospective analysis of 33 patients with single level TLJ disc herniations undergoing operations was performed. Medical records, operative findings, and radiologic data were assessed. TLJ was defined as the level from T11-12 to L2-3. The mean follow-up period was 21.8 months.

Mean age was 47.3 years. Affected disc levels were T11-T12 in 5 patients, T12-L1 in 2 patients, L1-L2 in 6 patients, and L2-L3 in 20 patients. Soft disc herniations were detected in 24 patients, while the remainder showed hard disc herniations such as a bony spur or calcification. Thirty-one patients presented with pain as their chief complaint and radicular pain was the most common symptom(n=14). Various neurologic deficits including upper motor neuron syndromelower motor neuron syndrome, and radiculopathy were observed in 27 patients and were not related to the affected levels. Twenty-four patients with lateral disc herniations or central soft disc herniations underwent partial hemilaminectomy and facetectomy, and the remaining patients(n=9) with central disc herniations or severely calcified disc herniations underwent total facetectomy and subsequent posterior fusion. There were 7 cases with complications including dural tear, mild motor and sensory deficits, and bladder and bowel dysfunction without permanent morbidities. TLJ disc herniation shows variable symptoms and signs due to its unique anatomy. It can be safely managed by the correct surgical approach as determined by the location and type of disc herniation 6).


A cohort of 63 patients with symptomatic TLDH, who had surgery was investigated. Incidences of associated Scheuermann’s disease (SD) and four radiographic signs of SD that were Schmorl’s node, irregular vertebral end plate, posterior bony avulsion of the vertebra and wedge-shaped vertebra, average thoracolumbar kyphotic angle and incidences of disc herniation at segments with and without radiographic signs of SD were examined. Data from the TLDH group were compared with 57 patients undergoing surgery for lower lumbar disc herniation (LDH, L3/4-L5/S1) in the same period.

The incidences of the four radiographic signs of SD and the incidence of associated SD were all significantly higher in the TLDH group than in the LDH group. 95.2 % of the patients in the TLDH group were diagnosed with SD (either classical SD or its atypical form). The average thoracolumbar kyphotic angle of the TLDH group was 16.9°, while that of the LDH group was 7.6° (P = 0.000). In the TLDH group, the incidences of disc herniation at segments with radiographic signs of SD were all significantly higher than at segments where no sign of SD was found.

The high proportion of associated SD and the tendency of SD’s signs to promote disc herniation in symptomatic TLDH patients suggest a close relationship between these two disorders. Symptomatic TLDH should be seen as a truly different surgical entity, that is, a special form of SD rather than just an indicator of a failing back 7).


Reports concerning MIS-TLIF at the thoracolumbar junction are rare. Thus, Wang et al., performed a retrospective analysis of the clinical outcomes of 10 patients with thoracolumbar junction disc herniation treated by MIS-TLIF between December 2007 and October 2010. The purpose of the study was to investigate the efficacy and safety of MIS-TLIF for disc herniation in the thoracolumbar junction. Clinical and radiological data were collected and analyzed. Fusion levels included T12-L1 (two patients), L1-L2 (four patients) and L2-L3 (four patients). Clinical outcome was assessed using the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI). The average follow-up period was 39.2 months, with a minimum of 24 months. The mean ± standard error of the mean of the operative time, intraoperative blood loss, and x-ray exposure were 128 ± 36 minutes, 204 ± 35 mL, and 43 ± 12 seconds, respectively. The VAS for back and leg pain decreased significantly postoperatively from 6.4 ± 2.7 to 1.5 ± 0.6 (p<0.01), and from 7.1 ± 2.4 to 1.3 ± 0.4 (p<0.01) respectively, as did the ODI from 39.3 ± 11.2 to 16.5 ± 4.7 (p<0.01). Bone fusion was observed in eight patients. There were no other major complications at last follow-up. MIS-TIF is a safe and effective procedure for disc herniation in the thoracolumbar junction. Occurrence of non-union is relatively high compared to previous findings 8).


The clinical features of 26 patients who had undergone operations for single disc herniations at T10-T11 through L2-L3 were investigated. Affected levels were as follows: 2 patients with disc herniation at T10-T11 disc, 4 patients at T11-T12, 3 patients at T12-L1, 6 patients at L1-L2, and 11 patients at L2-L3. The level of disc space of interest was confirmed with whole-spine plain roentgenograms. The caudal end of the cord was judged by magnetic resonance imaging and computed tomographic myelogram.

Two patients with T10-T11 disc herniation showed moderate lower extremity weakness, increased patellar tendon reflex, and sensory disturbance of the entire lower extremities. Three of four patients with T11-T12 disc herniation experienced lower extremity weakness, and three patients had accentuated patellar tendon reflex. Sensory disturbance was observed in the anterolateral aspect of the thigh in one patient and on the entire leg in three patients. Bowel and bladder dysfunction was noted in three patients. In the T12-L1 disc herniation group (n = 3), muscle weakness and atrophy below the leg were advanced, and bowel and bladder dysfunction were also noted. Two of these three patients had bilateral drop foot, and one patient had unilateral drop foot; sensory disturbance was noted in the sole or foot and around the circumference of the anus, and the patellar tendon reflex and Achilles tendon reflex were absent. All six patients with L1-L2 disc herniation showed severe thigh pain and sensory disturbance at the anterior aspect or lateral aspect of the thigh. On the other hand, there were no clear signs of lower extremity weakness, muscle atrophy, deep tendon reflex, or bowel and bladder dysfunction in these patients. In the L2-L3 disc herniation group (n = 11), all patients had severe thigh pain and sensory disturbance of the anterior aspect or the lateral aspect of the thigh. Weakness in the quadriceps was noted in five patients and weakness in the tibialis anterior in two patients. Decreased or absence of patellar tendon reflex was observed in nine patients. Five patients had positive straight leg raising test results, and eight patients showed positive femoral nerve stretch test results.

Among thoracolumbar junction disc herniations, T10-T11 and T11-T12 disc herniations were considered upper neuron disorders, T12-L1 disc herniations were considered lower neuron disorders, L1-L2 disc herniations were considered mild disorders of the cauda equina and radiculopathy, and L2-L3 disc herniations were considered radiculopathy. These findings had relatively distinct differences among herniated disc levels 9).

References

1)

Albert TJ, Balderston RA, Heller JG, et al. Upper lumbar disc herniations. J Spinal Disord 1993;6:351–9.
2)

Sanderson SP, Houten J, Errico T, et al. The unique characteristics of “upper” lumbar disc herniations. Neurosurgery 2004;55:385–9.
3)

Ido K, Shimizu K, Tada H, et al. Considerations for surgical treatment of patients with upper lumbar disc herniations. J Spinal Disord 1998;11:75–9.
4) , 5)

Kang J, Chang Z, Huang W, Yu X. The posterior approach operation to treat thoracolumbar disc herniation: A minimal 2-year follow-up study. Medicine (Baltimore). 2018 Apr;97(16):e0458. doi: 10.1097/MD.0000000000010458. PubMed PMID: 29668617; PubMed Central PMCID: PMC5916692.
7)

Liu N, Chen Z, Qi Q, Shi Z. The relationship of symptomatic thoracolumbar disc herniation and Scheuermann’s disease. Eur Spine J. 2014 May;23(5):1059-66. doi: 10.1007/s00586-013-3108-7. Epub 2013 Nov 17. PubMed PMID: 24241014.
8)

Wang J, Zhou Y, Zhang ZF, Li CQ, Zheng WJ, Huang B. Disc herniation in the thoracolumbar junction treated by minimally invasive transforaminal interbody fusion surgery. J Clin Neurosci. 2014 Mar;21(3):431-5. doi: 10.1016/j.jocn.2013.04.029. Epub 2013 Nov 10. PubMed PMID: 24225365.
9)

Tokuhashi Y, Matsuzaki H, Uematsu Y, Oda H. Symptoms of thoracolumbar junction disc herniation. Spine (Phila Pa 1976). 2001 Nov 15;26(22):E512-8. PubMed PMID: 11707722.
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