Choi Jeong-Wook, Lee Jung-Kil, Moon Kyung-Sub, Hur Hyuk, Kim Yeon-Seong, Kim Soo-Han
Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Republic of Korea.
J Neurosurg Spine. 2007 Sep;7(3):370-4. doi: 10.3171/SPI-07/09/370.
Disc herniations of the upper lumbar spine (L1-2 and L2-3) have a frequency of 1 to 2% of all disc herniations. During posterior discectomy after laminectomy, significant manipulation of the exiting nerve root is unavoidable because of the narrow lamina and the difficulty in mobilizing the nerve root. The authors adopted a transdural approach in patients with calcified central disc herniation at the L1-2 level to reduce the risk of nerve root injury. Four patients suffering from radiating pain together with back pain were treated using the transdural approach. Preoperative neuroimaging studies revealed severe central disc herniation with calcification at the L1-2 level. After laminectomy or laminotomy, the incised dura mater was tacked, and the cauda equina rootlets were gently retracted. An intentional durotomy was performed over its maximal bulging of the ventral dura. After meticulous dissection of dense adhesions between the disc herniation and the dural sac, adequate decompression with removal of calcified disc fragments and osteophytes was accomplished. Clinical symptoms improved in all patients. Postoperative permanent cerebrospinal fluid leakage and pseudomeningocele were not observed, and no patient had a progressive lumbar deformity at an average follow-up of 53 months. Transient mild motor weakness and sensory change were observed in two patients postoperatively; however, these symptoms resolved completely within 1 week. The posterior transdural approach offers an alternative in central calcified upper lumbar disc herniation when root retraction is dangerous.
上腰椎（L1 - 2和L2 - 3）椎间盘突出症占所有椎间盘突出症的比例为1%至2%。在椎板切除术后进行后路椎间盘切除术时，由于椎板狭窄且神经根难以游离，不可避免地要对穿出神经根进行显著的操作。作者对L1 - 2水平钙化中央型椎间盘突出症患者采用经硬膜入路，以降低神经根损伤风险。4例伴有背痛和放射性疼痛的患者采用经硬膜入路进行治疗。术前神经影像学检查显示L1 - 2水平存在严重的中央型椎间盘突出伴钙化。椎板切除或椎板切开术后，将切开的硬脑膜固定，马尾神经根轻轻牵开。在腹侧硬脑膜最大膨出处进行故意的硬脑膜切开。在仔细解剖椎间盘突出与硬脊膜囊之间的致密粘连后，通过去除钙化的椎间盘碎片和骨赘实现了充分减压。所有患者的临床症状均有改善。术后未观察到永久性脑脊液漏和假性脑脊膜膨出，平均随访53个月时，无患者出现进行性腰椎畸形。术后有2例患者出现短暂性轻度运动无力和感觉改变；然而，这些症状在1周内完全消失。当神经根牵拉危险时，后路经硬膜入路为中央钙化型上腰椎间盘突出症提供了一种替代方法。
