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Surgical management of giant lumbar disc herniation: Analysis of 154patients over

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Original article
Surgical management of giant lumbar disc herniation: Analysis of
154 patients over a decade
Prise en charge chirurgicale de la hernie discale lombaire gante : analyse dune
srie de 154patients sur une dcennie
A. Akhaddar
a,b,
, H. Belfquih
a
, M. Salami
a
, M. Boucetta
a
a
Department of neurosurgery, Mohammed V military teaching hospital, university of Mohammed V Souissi, Rabat, Morocco
b
Department of neurosurgery, Avicenne military hospital, Marrakech, Morocco
a r t i c l e i n f o
Article history:
Received 23 May 2013
Received in revised form8 January 2014
Accepted 22 February 2014
Available online xxx
Keywords:
Cauda equina syndrome
Classication
Giant
Lumbar disc herniation
Lumbar spine
Massive
a b s t r a c t
Background. We describe a decade of our experience in the surgical management of patients with giant
lumbar intervertebral disc herniation (GILID).
Methods. This is a case series of patients operated for a GILID between 2000 and 2009. Among 1334
patients eligible for the present study: 154 patients presented with GILID (study group) and1180 patients
without GILID (control group). Clinical symptoms and preoperative imaging results were obtained from
medical records. Complications and long-term results were assessed.
Results. This retrospective study documents the characteristic features between patients with and with-
out GILID. The difference in the incidence of female patients was statistically signicant between the study
group and the control group as was the mean duration of symptoms, hyperalgic radicular pain, bilateral-
ity of symptoms, preoperative motor decit, central location of lumbar disc herniation (LDH), contained
herniation and recurrence of LDH.
Conclusions. GILIDs are a distinct entity: they are distinctly uncommon compared with smaller her-
niations, patients were statistically more likely to be hyperalgic with bilateral radicular pain and often
associated with neurological decits. The majority of patients do not display a cauda equina syndrome
(CES). Low lumbar disc sites are mostly affected and disc fragments are more likely to be central-
uncontained. The recurrence rate is lower for GILIDs.
2014 Elsevier Masson SAS. All rights reserved.
Mots cls :
Syndrome de la queue de cheval
Classication
Gant
Hernie discale lombaire
Rachis lombaire
Massive
r s u m
Introduction. Nous dcrivons une dcennie de notre exprience dans la prise en charge de patients
affects par une hernie discale lombaire intervertbrale gante (HDLIG).
Mthodes. Cette srie de cas reprsente les patients oprs pour une HDLIG entre les annes 2000 et
2009. Parmi les 1334 patients oprs pour une hernie discale lombaire durant cette mme priode, 154
patients prsentaient une HDLIG (groupe dtude) et 1180 patients sans HDLIG (groupe tmoin). Les
symptmes cliniques et les rsultats de limagerie propratoire ont t obtenus des dossiers mdicaux
de chaque patient. Les complications et les rsultats long terme ont t valus.
Rsultats. Ce travail rtrospectif tudie les particularits des patients avec et sans HDLIG. La diffrence
de lincidence des patients de sexe fminin a t statistiquement signicative entre le groupe dtude et
celui de tmoin de mme que la moyenne de dure des symptmes, la bilatralit des symptmes, laspect
hyperalgique des douleurs radiculaires, la prsence dun dcit moteur en propratoire, la topographie
centrale de la hernie, laspect non rompu de la hernie et le caractre rcidivant de cette dernire.
Conclusions. Les HDLIGs prsentent certaines particularits : elles sont inhabituelles par comparaison
aux hernies moins volumineuses, les patients se prsentent souvent dans un tableau hyperalgique avec

Corresponding author. Bloc V2, appartement 5, avenue Kamal Zebdi, secteur 21, Hay Riyad, 10100 Rabat, Morocco.
E-mail address: akhaddar@hotmail.fr (A. Akhaddar).
http://dx.doi.org/10.1016/j.neuchi.2014.02.012
0028-3770/ 2014 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Akhaddar A, et al. Surgical management of giant lumbar disc herniation: Analysis of 154patients over
a decade. Neurochirurgie (2014), http://dx.doi.org/10.1016/j.neuchi.2014.02.012
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2 A. Akhaddar et al. / Neurochirurgie xxx (2014) xxxxxx
des radiculalgies bilatrales et dcitaires. Le syndrome de la queue de cheval nest pas habituel. Les
disques lombaires bas situs sont les plus concerns et le fragment discale est le plus souvent central et
rompu dans lespace pidural. Le taux de rcidive est moindre pour les HDLIGs.
2014 Elsevier Masson SAS. Tous droits rservs.
1. Introduction
Few reports have focused on the size of lumbar disc herniation
(LDH) [13]. Although large or massive LDH is often related
to cauda equina syndrome (CES) [411] scarce information can
be found in the literature regarding characteristics of voluminous
forms of LDH [2,1215].
Massive or giant disc herniationwas variably denedamong
different authors as occupying more than 8mm, 33%, 40%, 50% or
75%of theanterior-posterior diameter of thespinal canal or respon-
sible for a complete block on myelogram[2,8,10,14,1621]. In our
experience, we dene giant LDHs as those occupying more than
the half of the sagittal diameter of the lumbar spinal canal.
In our series of 1334 consecutive patients who underwent pri-
mary surgery at a single level for LDH (20002009), 154 patients
(11.54%) had a giant lumbar intervertebral disc herniation (GILID).
In this retrospective study, we describe the characteristics of
patients with GILID and compare demographic data, presenting
signs and symptoms, imaging features, surgical options, intraop-
erative ndings and clinical outcome in these patients with those
in patients with smaller LDH.
2. Clinical material and methods
Between 1999 and 2009, 1771 consecutive patients were oper-
ated on in the authors neurosurgical department for a LDH. The
medical records of all patients were reviewed and only 1334
patients were eligible for inclusioninthe present study. We dened
giant LDH as cases where herniated disc material occupied more
than the half of the anteroposterior diameter of the lumbar spinal
canal based on preoperative CT-scan, MRI or both. A total of
154 patients (11.54%) presented with a GILID and 1180 patients
(88.46%) without a GILID. The information was collected docu-
mented by the treating neurosurgeon. Exclusion criteria included
absent radicular symptoms, prior back surgery, signicant spinal
canal stenosis or spondylolysis, more than one herniated disc,
foraminal LDH as well as systematic diseases that affect bone and
joint.
The overall time to surgery from the onset of symptoms was
calculated. All patients were investigated by CT-scan and/or MRI
of the lumbar spine. The anatomical location of the herniated frag-
ment was classied based on CT-scan or MR imaging as central or
posterolateral. The size of herniated mass was estimated fromthe
axial images on CT-scan, MRI or both.
Surgical treatment was indicated when patients had cauda
equinasyndrome(CES), progressivemotor weakness, or intolerable
symptoms. Surgery aimed at removal of herniated disc fragments
with decompression of the nerve root and dural sac as well as
removal of as muchdisc material as possibleof theintradiscal space.
From the intraoperative ndings, the herniation morphology was
classied as contained or non-contained.
The operative records were reviewed to determine occur-
rence of any intraoperative complication. Long-termoutcome was
dened as the need for a repeat lumbar microdiscectomy or addi-
tional lumbar surgery.
Surgical results were graded as excellent when there was no
pain and no limitation of activity; as good when back pain or
leg pain on major activity was reported only occasionally, as fair
when the symptoms improved after operation, but recurrent or
residual pain led to restriction of activities; and as poor when the
symptoms did not improve or worsened after the operation [22].
Statistical analysis was performed by Students t-test for contin-
uous variables and Chi
2
test for categorical variables. Signicance
was dened as a P<0.05. All calculations were performed using
SPSS statistical software version 14.0 (SPSS Inc, Chicago, IL).
3. Results
Pertinent patient characteristics in the study group (GILID) and
the control group (without GILID) are displayed in Table 1. The
majority of the study population was male (107 cases or 69.78%).
Seventeen patients (11.04%) complained of bilateral radicu-
lar symptoms and hyperalgic radicular pain was observed in 33
patients (21.43%).
The preoperative neurological examination was normal for
lower-extremity motor weakness in 114 patients (74.06%), 29
patients (18.83%) had a motor radicular decit and only 11 cases
(7.14%) had a CES. A scoliotic list (scoliotic attitude) was observed
in 16 patients (10.39%) as the result of the patient leaning away
from the side of disc herniation to decompress the exiting nerve
root.
The mean time to surgical intervention after the development
of pain was 7.80months (5.77months).
Disc herniation was located laterally in 121 patients (78.57%)
(Fig. 1), among them the left side was predominantly involved in
71patients (46.10%). Thirty-threepatients (21.43%) hadcentral disc
herniation (Fig. 2).
Surgical treatment consisted of unilateral interlaminar
approach in 101 patients (65.58%), bilateral approach in 2
patients (1.30%) and full laminectomy in 51 patients (33.12%).
Lumbar fusion was never used. A contained LDH was found in
82 patients (53.25%) and 72 patients (46.75%) had non-contained
LDH.
The difference in the incidence of female patients was statisti-
callysignicant (P=0.012) betweenthestudygroupandthecontrol
group, as was the average duration of symptoms (P=0.031), hyper-
algic radicular pain (P=0.021), bilaterality of radicular symptoms
(P=0.010), preoperative motor decit (P<0.0001), central location
of LDH (P<0.0001), type of surgical approach (P=0.001), herni-
ation morphology (P<0.0001) and with a lower recurrence rate
for GILIDs (P=0.038). In terms of average age, smoking status,
incidence of scoliotic list, level of LDH and concomitant congen-
ital lumbosacral malformation there was no statistical difference
between the groups. Similarly, there was no difference in surgical
complications and clinical outcomes between patients with GILID
and those with smaller formof LDH.
4. Discussion
In this retrospective clinical study, we reviewed our experience
over the past decade regarding the surgical treatment of GILID.
This study represents the largest series to date and documents the
successful surgical management of this unusual subgroup of LDH.
Giant lumbar disc herniations are distinctly uncommon compared
with smaller herniations, patients were more likely to have hyper-
algic and bilateral radicular pain, their symptomatology is often
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Table 1
Sociodemographic data, clinical characteristics, imaging features, surgical ndings and outcome of the patients.
Donnes sociodmographiques, cliniques, radiologiques, chirurgicales et volutives des patients.
Giant LDH
Study group
(n=154)
No giant LDH
Control group
(n=1180)
Overall P value
Age (mean in years) 41.669.32 42.108.65 0.556
Sex of patients 0.012
Men 69.48% (107) 78.47% (926)
Women 30.52% (47) 21.53% (254)
Smokers 13.63% (21) 13.81% (163) 0.797
Mean duration of symptoms (months) 7.805.77 11.1310.16 0.031
Hyperalgic radicular pain 21.43% (33) 14.23% (168) 0.021
Preoperative radicular symptoms 0.01
Unilateral symptoms 88.96% (137) 95.60% (1128)
Bilateral symptoms 11.04% (17) 4.40% (52)
Patients with scoliotic list 10.39% (16) 7.20% (85) 0.173
Preoperative neurological decit <0.0001
Without motor decit 74.06% (114) 88.31% (1042)
With motor decit 18.83% (29) 10.42% (123)
Cauda equina syndrome 7.14% (11) 1.27% (15)
Levels of disc herniation 0.861
L4-L5 55.19% (85) 55.68% (657)
L5-S1 38.96% (60) 39.49% (466)
High level 5.85% (9) 4.83% (57)
Anatomical location of LDH <0.0001
Posterolateral right 32.47% (50) 41.95% (495)
Posterolateral left 46.10% (71) 50.76% (599)
Central 21.43% (33) 7.29% (86)
Surgical approach 0.001
Unilateral interlaminar 65.58% (101) 77.88% (919)
Laminectomy 33.12% (51) 20.93% (247)
Herniation morphology <0.0001
Contained 53.25% (82) 79.07% (933)
Non-contained 46.75% (72) 20.93% (247)
Congenital malformation 0.695
Transitional vertebrae 14.29% (22) 16.10% (190)
Spina bida 3.90% (6) 3.47% (41)
Complications 3.89% (6) 3.39% (40) 0.871
Dural tear 2.60% (4) 1.95% (23)
Supercial wound infection 0.65% (1) 0.68% (8)
Deep wound infection 0.65% (1) 0.42% (5)
Spondylodiscitis 0 0.26% (3)
Iliac artery injury 0 0.09% (1)
Recurrent LDH 1.94% (3) 5.93% (72) 0.038
Outcomes 0.431
Excellent 70.13% (108) 67.97% (802)
Good 21.43% (33) 25.17% (297)
Fair 5.84% (9) 4.91% (58)
Poor 2.60% (4) 1.95% (23)
associated with neurological decits but not always, disc fragment
was more likely to be central and non-contained and outcome after
surgery is not so different fromthose with smaller LDHs.
The true incidence of GILID is not known with certainty. In only
a few large series, the size of the LDH and their relationship to the
spinal canal were reported [13]. Some of these discs were likely
giant, but data in this subgroup were rarely analyzed. The reported
incidence of GILIDvaries from8to22%[2,14,17,23], andwas 11.54%
in the present study. However, in series of CES secondary to LDH
the incidence of giant LDH varies between 45 and 60% [8,13], and
was 42.30% in our study.
We know that the nerves in the lumbosacral area are struc-
turally, vascularly, and metabolically unique regions of the nervous
system. Rydevik et al. demonstrated that even minor compression
creates edema formation because of the vulnerable venous system,
and eventually leads to intraneural inammation and hypersen-
sitivity, making the nerve root highly mechanosensitive in terms
of inducing pain and neurologic decits [24]. This implies that a
combinationof mechanical pressure andabnormal chemical events
may be the source of nerve root symptoms. It also has been sug-
gested that the presence of endogenous chemicals released from
non-neural tissue may increase the nerve hyper-excitability and
induce a susceptibility to compression by a herniated disc [25,26].
On the contrary, as reported in the literature and seen in our prac-
tice, some cases with major compression did not routinely induce
neurologic decits [2,26].
Although the etiopathogenic mechanism of GILID remains
unclear, unusual movements of the patient (heavy labor, traction,
spinal manipulation and conditions of hypermobility) may pre-
dispose to this voluminous disc herniation. Age and congenital
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Fig. 1. Lumbar MRI on T2-WI. Axial (left) and sagittal (right) viewshowing a giant left posterolateral lumbar disc herniation at L5-S1 level migrated down.
IRMlombaire en squences pondres T2. Coupe axiale (gauche) et sagittale (droite) montrant une hernie discale gante postrolatrale gauche en L5-S1 et migre vers le bas.
malformation are not factors in the pathogenesis of GILID. The
mean age of patients with GILIDin our series was 42years, which is
the same as the overall population with disc herniations. However,
compared with patients with smaller LDH, disc herniation appears
to more likely occur in women.
The signs and symptoms of GILID are somewhat different from
that of smaller LDH especially for neurologic symptoms related
to root compression. These symptoms are likely to be hyper-
algic with a mean duration shorter than the population with
smaller LDH (7.80months vs. 11.13months). Bilateral sciatica,
lower-extremities weakness and CES were also more frequent with
GILID. However, giant LDH does not always induce CES, and only
7.14% of our patients presented with a CES. As seen above it is
clear that the severity of the neurologic decits appeared not to
be strongly dependent on the size of disc fragment.
High resolution CT-scan usually demonstrates the disc herni-
ation. However, the interpretation of the voluminous lesion by
CT-scan sometimes is difcult and may be confused by the cal
sac [17,27,28]. Interestingly, in two of our patients a central GILID
was misdiagnosed when the CT-scan was initially interpreted on
the radiologist report. This phenomenon was previously reported
by Flak and Li: because the protruding discs were considerably
larger, the compressed dural sacs may be overlooked and the large
discs mistaken for dural sacs [28]. The diagnosis is aided by careful
observationfor anyasymmetryinthe surroundingepidural fat. MRI
is more sensitive and always showed the disc herniation especially
in the sagittal plane. Intravenous gadolinium injection is rarely
used because disc fragment is rarely confused with other anterior
epidural space-occupying lesions [29]. As showed in patients with
smaller LDH, most cases with GILID occur at L4-5 and L5-S1 levels
but disc fragment was more likely to be central (21.43%) comparing
with those of patients without GILID (7.29%, P<0.0001).
Generally, the treatment of GILID is early surgical removal of
the compressive lesion through an interlaminar approach or via a
laminectomy depending on the size and the location of the lum-
bar disc fragment. For some authors, a laminectomy is more useful
for giant and some migrated fragment to decompress before gen-
tle retraction and discectomy [7,10,30]. Narrow exposition need
excessive manipulation during lumbar discectomy and may cause
permanent paralysis as previously reported by McLaren [31]. For
Shapiro, a microdiscectomyvia hemisemilaminotomyfor this volu-
minous type of disc herniation is not advocated [10]. The disc
fragment usually has no adhesions to the dura and can be removed
without difculty. But when the lesion was adherent to the the-
cal sac, progressive dissection is essential to prevent dural tear or
further root injury.
As seen in our study and others [3,23], surgical results of GILID
are encouraging. More than 90% of the cases reviewed (141 out of
154 patients) had a good improvement to full recovery fromtheir
lomboradicular pain, inferior leg weakness and/or sphincter distur-
bance. These rates are signicantly the same compared with those
reportedfromthegroupof patients withsmaller LDHwitha follow-
up period of at least 12months. Another peculiarity of the GILIDs
is that they were associated with a low recurrence rate compared
with smaller LDH [8]. Only 3 of our patients (1.95%) needed sur-
gical revision for herniation recurrence. This phenomenon can be
explained by the larger disc curettage or a lower amount of remain-
ing disc.
Fig. 2. Lumbar MRI. Sagittal (left) and axial (right) T2-WI showing a huge central L4-L5 disc herniation with overwhelming cauda equina roots.
IRMlombaire. Coupe sagittale (gauche) et axiale (droite) en squences pondres T2 visualisant une hernie discale gante centrale en L4-L5 crasant les racines de la queue de cheval.
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5. Conclusions
Giant lumbar disc herniations are a distint entity in a number of
ways: they are distinctly uncommon compared with smaller her-
niations, patients were more likely to be hyperalgic with bilateral
radicular pain and often, but not always, associated with neuro-
logical decits. Interestingly, few patients developed a CES. Low
lumbar disc sites are the level mostly affected and disc fragments
are more likely to be central and non-contained. This condition
may require more extensive surgical exposure without necessar-
ily a supplementary spinal fusion. The occurrence of GILID is not
associated with high rate of recurrence or poor results. Finally this
subgroup of LDH may be more benign than previously thought.
Disclosure of interest
The authors declare that they have no conicts of interest con-
cerning this article.
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