Elsevier

World Neurosurgery

Volume 114, June 2018, Pages e1297-e1301
World Neurosurgery

Original Article
Lumbar Disc Herniations Causing Contralateral Radicular Symptoms: Can They Be Explained by Hypotenusal Theory?

https://doi.org/10.1016/j.wneu.2018.03.201Get rights and content

Highlights

  • •

    The top of the disk is responsible for the emergence of contralateral symptoms.

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    Specificity of SLRT and Lasegue sign findings is higher than that of other tests.

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    The SLRT and Lasegue sign increase side specificity for determination of the side to be operated.

  • •

    EMG is not effective when deciding on the surgical side.

  • •

    Root traction can be explained geometrically by a hypotenusal effect.

Objective

Cases presenting contralateral radicular symptoms are rarely encountered. It is difficult to decide on the correct side in cases where surgical intervention will be performed. The aim of the study is to explain the symptomatology in cases of lumbar disc herniations causing contralateral radicular symptoms by a hypotenusal effect.

Materials and Methods

In total, 27 cases were included in the study. Eight cases underwent surgical interventions performed on the side where disc herniation was radiologically detected. Nineteen cases were treated conservatively. Disc herniations were radiologically evaluated in 3 different groups, and the effect on the root on the symptomatic side was explained by a hypotenusal theory. Correlations among symptomatology, clinical findings, magnetic resonance imaging, and electromyography were discussed.

Results

Clinical improvement was observed in all cases that were operated on the side where disc herniation was detected radiologically. Neurologic examination findings in the postoperative period also revealed the correctness of the selected surgical approach. Electromyography is insufficient to explain clinical findings and to decide on the surgical side.

Conclusion

Lumbar disc herniations, which lead to contralateral radicular symptoms, should be operated from the side where the disc is radiologically detected. The top of the disc is responsible for symptomatology. Surgical excision of the top of the disc removes the contralateral root traction and root compression on the same side.

Introduction

Lumbar disc herniation (LDH) cases, which cause radicular symptoms on the opposite side, are challenging. In these cases, it is a dilemma for the surgeon to decide the side where the surgery will be applied. Although it is accepted in the traditional approach that the side to be operated is the symptomatic side, there are also studies supporting the opposite of this idea.1, 2, 3

In this study, 27 cases of LDH with radicular symptoms on the opposite side have been examined. Surgical interventions were performed on 8 of the cases. Preoperative neurologic examination and radiologic and electrophysiologic findings of all cases were evaluated. The importance of the straight leg raise test (SLRT) and Lasegue sign, which are critical neurologic examinations in LDH cases, was emphasized, and contralateral radicular symptoms were attempted to be explained by a hypotenusal effect.

Section snippets

Materials and Methods

Between 2013 and 2017, 27 LDH cases presenting radicular symptoms on the opposite side were evaluated in the study. Cases of lumbar stenosis, foraminal stenosis on the symptomatic side, multilevel disc herniations, and scoliosis were excluded from the study.

Surgery was performed in 8 out of 27 cases. All cases underwent microdiscectomy performed on the side where the disc was detected with radiography. In 1 case, partial medial facetectomy was applied together with discectomy and foraminotomy

Results

Clinical improvement was achieved in all operated cases. In 1 case, low-dose pregabalin treatment was administered due to a complaint of numbness. Nineteen patients were followed up with conservative treatment. Regarding the medication of cases in which conservative treatment was administered, nonsteroidal antiinflammatory drugs and thiocolchicoside, pregabalin or gabapentin, epidural steroid injection treatments were administered either alone or in combined form. Clinical results of the cases

Discussion

It is difficult for surgeons to choose the surgical side in cases where LDH causes radicular symptoms on the opposite side. Although surgical interventions are recommended to be performed on the symptomatic side according to the conventional approach, series in which surgery was administered on the side that the disc had been radiologically detected exist in the literature.1, 2, 3 There are also studies in the literature that advocate bilateral operation of these cases.4, 5, 6 Yang et al7 have

Conclusion

LDH cases resulting in contralateral symptoms are challenging. Bilateral surgical intervention is considered an aggressive intervention. Surgery done on the symptomatic side is unnecessary because there is no pathology requiring surgical intervention and it can indirectly lead to findings of relieved symptoms only because of a decrease in disc volume. The reason for the symptoms and the most critical factor leading to tension of the contralateral root is the top of the disc and its excision

Acknowledgments

The author would like to thank Omer Asan and Nurhale Asan for their help in the preparation and design of the manuscript and translator Irem Nur Onay.

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    Lumbar radiculopathy contralateral to upper lumbar disc herniation: report of 3 cases

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There are more references available in the full text version of this article.

Conflict of interest statement: No external funding was involved in the development of this study.

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