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Objective: the authors presented a extremely rare case of severe foraminal stenosis combined with huge lateral lumbar disc herniation
Case presentation: The authors presented a 74 – year old, male with type II chronic diabetes, had severe pain of the dermatomal distribution of L5, S1 nerve roots, and foot-drop of the right lower limb. When we evaluated the patient’s MRI, the huge paramedian disc herniation of the right L5-S1 level was seen and the right L5-S1 laminotomy and discetomy were planned for the treatment of the patient. However, the clinical symptoms were not completely correlated with that MRI findings so that, we re-checked the MRI, particularly at the lumbosacral region, and the right severe foraminal stenosis of L5-S1 level was found. The patient underwent surgery with facetectomy, transforaminal interbody fusion, and pedicle screw fixation. After the operation, the patient has quickly reduced radiating pain of the right lower extremity, although the foot-drop was not improved. Because of the huge lateral lumbar disc herniation impression, that could affect the assessing the patient’s injury correctly, leaded consequences of a missing diagnosis of foraminal stenosis and inadequate surgery method.
Conclusion: It is essential to detail examination of the clinical manifestations and thorough assessment of MRI for evaluation of the correlation between the physical examination and MRI findings before making the decision of surgical method.
Frymoyer JW, Pope MH, Clements JH, Wilder DG, MacPherson B, Ashikaga T. Risk factors in low-back pain. An epidemiological survey. J Bone Joint Surg Am. 1983 Feb;65(2):213–8.
Postacchini F, Postacchini R. Operative management of lumbar disc herniation : the evolution of knowledge and surgical techniques in the last century. Acta Neurochir Suppl. 2011;108:17–21.
Pouriesa M, Fouladi RF, Mesbahi S. Disproportion of end plates and the lumbar intervertebral disc herniation. Spine J. 2013 Apr;13(4):402–7.
Jenis LG, An HS. Spine update. Lumbar foraminal stenosis. Spine (Phila Pa 1976). 2000 Feb;25(3):389–94.
Kunogi J, Hasue M. Diagnosis and operative treatment of intraforaminal and extraforaminal nerve root compression. Spine (Phila Pa 1976). 1991 Nov;16(11):1312–20.
Wiltse LL, Guyer RD, Spencer CW, Glenn WV, Porter IS. Alar transverse process impingement of the L5 spinal nerve: the far-out syndrome. Spine (Phila Pa 1976). 1984;9(1):31–41.
Yamada K, Aota Y, Higashi T, Ishida K, Nimura T, Konno T, et al. Lumbar foraminal stenosis causes leg pain at rest. Eur Spine J. 2014 Mar;23(3):504–7.
Orita S, Inage K, Eguchi Y, Kubota G, Aoki Y, Nakamura J, et al. Lumbar foraminal stenosis, the hidden stenosis including at L5/S1. Eur J Orthop Surg Traumatol. 2016;26(7):685–93.
Humphreys SC, Eck JC. Clinical evaluation and treatment options for herniated lumbar disc. Am Fam Physician. 1999 Feb;59(3):575-582,587-588.
Amin RM, Andrade NS, Neuman BJ. Lumbar Disc Herniation. Curr Rev Musculoskelet Med [Internet]. 2017 Dec;10(4):507–16. Available from: https://pubmed.ncbi.nlm.nih.gov/28980275
Lee CK, Rauschning W, Glenn W. Lateral lumbar spinal canal stenosis: classification, pathologic anatomy and surgical decompression. Spine (Phila Pa 1976). 1988 Mar;13(3):313–20.
Macnab I. Negative disc exploration. An analysis of the causes of nerve-root involvement in sixty-eight patients. J Bone Joint Surg Am. 1971 Jul;53(5):891–903.
Herron LD. Selective nerve root block in patient selection for lumbar surgery: surgical results. J Spinal Disord. 1989 Jun;2(2):75–9.
Burton C V, Kirkaldy-Willis WH, Yong-Hing K, Heithoff KB. Causes of failure of surgery on the lumbar spine. Clin Orthop Relat Res. 1981 Jun;(157):191–9.
Eguchi Y, Ohtori S, Suzuki M, Oikawa Y, Yamanaka H, Tamai H, et al. Diagnosis of Lumbar Foraminal Stenosis using Diffusion Tensor Imaging. Asian Spine J [Internet]. 2016/02/16. 2016 Feb;10(1):164–9. Available from: https://pubmed.ncbi.nlm.nih.gov/26949473
Lee S, Lee JW, Yeom JS, Kim K-J, Kim H-J, Chung SK, et al. A practical MRI grading system for lumbar foraminal stenosis. AJR Am J Roentgenol. 2010 Apr;194(4):1095–8.