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The risk of contralateral versus ipsilateral recurrence was significantly increased with a risk ratio of 1.6 (95% confidence interval 1.4-1.9) in a time to event model.

Herniated lumbar disc may be asymptomatic or associated with lower limb radiculopathy. Most spinal surgeons would offer surgery following a period of conservative measures if the radiological and clinical findings correlate. However, the existing dictum that lumbar radiculopathy should correlate with ipsilateral lumbar disc herniation may not be accurate as it can rarely present with contralateral sciatica. Literature regarding this phenomenon is scarce. Therefore, we report a patient with herniated lumbar disc presenting with predominantly contralateral motor weakness radiculopathy, which resolved after discectomy. Discussion Herniated lumbar disc is a common entity with an estimated incidence of 1–2% per annum. MRI studies showed that nerve root compressions are often asymptomatic.

Boden et al reported that 20% of those aged less than 60 years and 36% of those above 60 years old with no history of radicular pain, have HLD on MRI. Spinal surgeons base their decision to operate if MRI and clinical findings correlate.

There have been several reports suggesting a phenomenon whereby an HLD resulted in contralateral radiculopathy, similar to Kernohan's phenomenon in the brainstem. Various pathophysiological mechanisms have been suggested in the literature to explain this clinical syndrome. Anatomical factors are the most common reported causative factors that explain this syndrome. Significant spondylotic changes in lumbar facet joints and ligamentum flavum hypertrophy leading to lateral recess stenosis may render the traversing nerve roots susceptible to even the mildest lateral displacement. This may be bilateral or unilateral, resulting in contralateral radiculopathies from a large HLD. Anatomical anomalies of the ipsilateral nerve root with a high or low take-off may be protective against compressive forces. Conversely, anomalies of the contralateral nerve root, such as a conjoint origin or shorter lateral recess course, may render it more susceptible to compressive or tractional forces akin to the aetiology of the cervical C5 nerve root syndrome.

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Abnormalities of the dural attachments of the posterior longitudinal ligaments (Hoffman ligaments) have also been proposed in the mechanisms of this syndrome. Kornberg proposed that the absence of Hoffman's ligaments may allow posterior displacement of the ipsilateral nerve root without compression but lateral shift of the contralateral nerve root into a tight lateral recess. In contrast, Akdeniz et al suggested that it was entrapment of the contralateral nerve root in the lateral recess by the presence of Hoffman's ligaments that was the causative factor. Our patient had radiculopathy initially on the left, which resolved before developing an acute right-sided foot drop suggestive of an L5 nerve lesion.

This may be caused by a migrating disc fragment as reported by Mobbs and Steel; however, a subsequent MRI showed only a large left-sided paracentral HLD at L3/4 with a normal disc and canal dimensions at L4/5. We believe that due to the size of the disc prolapse, our patient's symptoms were attributable to direct lateral shift and compression of the traversing fibres of the contralateral nerve roots against the contralateral pedicle and facet joint in the lateral recess, or potentially acute tethering and stretch of the traversing nerve root fibres. Alternatively, overlap in myotomal distribution may explain the foot drop without an L4/5 lesion. Owing to the severity of his weakness, a decision was made for bilateral decompression and left-sided discectomy. Sucu and Gelal and Akdeniz et al have suggested in their case series that discectomy on the side of the disc extrusion would be sufficient for resolution of the contralateral symptomatology, and this will be considered in future practices. Herniated lumbar disc can rarely present with radiculopathy on the contralateral side.

Spinal surgeons should be aware of this phenomenon and decompressive surgery indicated in certain situations. Unilateral discectomy on the side of the disc herniation may be sufficient for resolution of the contralateral radiculopathy; however, this should be considered on a case-by-case basis.

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Download Presentation PowerPoint Slideshow about 'Regione Emilia Romagna Azienda Ospedaliera di Bologna Policlinico S. Orsola-Malpighi' - stevie An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. Braccio A Chemioterapia preoperatoria M P/A1 M P/A1 ------------------------- Chirurgia 0 1 4 5 settimane Chemioterapia postoperatoria A M M P A M M P A M M P M M --------------------------------------------------------- 9 12 13 14 17 20 21 22 25 28 29 30 33 34 settimane ≥90% A I M M P A I M M P A I M M P M M -------------------------------------------------------------------- 9 12 15 16 17 20 23 26 27 28 31 34 37 38 39 42 43 sett. STATO POST IMMUNO PAZIENTE STATO ATTUALE II°CE HDCT TERAPIA IL-2 (interrotta BD PR PR VIVO-SD (15 mesi) per PD -9 mesi-) GF PD (2 mesi) / / DOD (7 mesi) VA PD (2 mesi) / / DOD (8 mesi) PR SD PD (3 mesi) / DOD (18 mesi) BS PD (2 mesi) / / DOD (4 mesi) IL-2 CS PR PR VIVO-RC (19 mesi) (12 cicli) PR SD TMO DOD (14 mesi) CM IL-2 MM SD SD (interrotta DOD (8 mesi) per PD) CMI PD (2 mesi) / / DOD (5 mesi) CG PD (2 mesi) / / VIVO-PR (16 mesi) IL-2 CMA PR SD VIVO-SD (10 mesi) (10 cicli) IL-2 SD RC RC VIVO-RC (7 mesi) (9 cicli) chirurgia. • EWS-FLI1 t(11;22)(q24;q12) nel 90-95% dei casi EWS-ERG t(21;22)(q22;q12) nel 5-10% dei casi EWS-ETV1 t(7;22)(q22;q12). DIAGNOSI Indagine anamnestica Esame obiettivo con misurazione delle lesioni tumorali Esami di laboratorio: non esistono marker specifici Immunoistochimica: CD99, Vimentina, Citocheratina, S-100, NSE, b-2 microglobulina Genetica: -RT-PCR e/o FISH per prodotto di traslocazione su SP, MO e tumore primitivo Esami radiologici Tumore primitivo: Radiografia standard, TAC, RMN Metastasi: - Rx e TAC del torace - Scintigrafia ossea - Aspirato/biopsia midollare Esplorazione chirurgica Asportazione completa o biopsia incisionale.