Review Question - QID 218816

The patients clinical presentation and imaging studies are consistent with a L5 radiculopathy caused by a right paracentral disc herniation at L4/5 which is compressing the L5 nerve root. Because she has failed nonoperative management a laminotomy and diskectomy would be the most appropriate treatment.

A L4/5 paracentral disc involves the L5 nerve root. The muscles innervated by L5 nerve root include EHL and tibialis anterior, and therefore these patients may present with a "foot drop". While EHL is usually innervated by L5 alone, tibialis anterior has variable innervation by L4 and L5.

Weinstein et al. (SPORT 2 year results) showed as-treated analysis (prospective nonrandomized), discectomy was favorable with quicker improvement in symptoms for patients with surgery. They warn that the SPORT intent-to-treat analysis (prospective randomized) showed no statistical difference between those who had diskectomy vs. those who did not, but this data was disrupted by a very high crossover rate, and therefore most consider the as-treated analysis as a more accurate representation of the true clinical effect of treatment.

Weinstein et al (SPORT 4 year results) showed in the as-treated analysis that patients treated surgically for intervertebral disc herniation showed significantly greater improvement in pain, function, satisfaction, and self-rated progress over 4 years compared to patients treated non-operatively. They found at four years there was no significant difference in work status between the surgical and nonsurgical group.

Weber et al. look at a cohort that was randomized into surgical and non-surgical treatment for lumbar disc herniations. They found the controlled trial showed a statistically significant better result in the surgically treated group at the one-year follow-up examination. After four years the operated patients still showed better results, but the difference was no longer statistically significant.

Illustration A shows the lower extremity dermatomes. Illustration B shows how a laminotomy is used to access the disc and how an paracentral disc will affect the descending nerve root. Illustration C shows the difference between a laminotomy, hemilaminectomy, and laminectomy.