UPPER LUMBAR DISC HERNIATIONS

This study reviews the presentation, diagnosis, and outcomes of upper lumbar disc herniations (L1-2, L2-3, L3-4). One hundred forty-one pati ents operated upon at three centers between 1980 and 1990 were analyze d (102 men, 39 women; 3 LI-2, 21 L2-3, 117 L3-4; average age 51.6 year s; 10.4% of all lumbar discectomies performed). Preoperative signs and symptoms were highly variable. Sensory, motor, and reflex testing was variable and potentially misleading in suggesting a level of herniati on. In analyzing radiographic studies (noncontrast CT, myelography, MR I) individually and using other radiographic studies and operative fin dings as a standard for comparison, a high false-negative rate was fou nd for all studies when considered individually, especially at the hig her L2-3 level. Intraoperative radiographs were employed with increasi ng frequency as the level of herniation ascended. Six operative compli cations (4.3%) were identified, all of which were treated and were res olving at the time of discharge. Follow-up obtained at an average of 2 .2 years in 87% of patients by chart review showed no reoperations or late complications. Noncompensation patients had a significantly highe r percentage of good/excellent results (86%) than those with compensat ion or legal claims pending (45% good/excellent results). Based upon t hese data, we recommend myelogram with postmyelogram CT and/or MRI in the workup of these patients and intraoperative radiographs in all cas es when decompressing an upper lumbar disc herniation. Patients with c ompensation/legal claims should be approached cautiously, because thei r subjective results are significantly worse than those of noncompensa tion patients. Finally, consider the differential possibilities of ret roperitoneal tumor or hemorrhage, abdominal aortic aneurysm, diabetic femoral neuropathy, or lumbar plexopathy in the workup of patients wit h signs and symptoms similar to those reported here.