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Abstract
Objectives
The coronal MR images were carefully evaluated to document the efficacy of diagnosing foraminal and extraforaminal disc herniations.
Summary of the Literature Review
Extraforaminal disc herniations constitute 1~11.7% of all disc herniations. The diagnosis of it demands great caution because it must be distinguished from intraspinal canal disc herniation. Diagnosing extraforaminal disc herniations can be neglected with using ordinary diagnostic methods.
Materials and Methods
A retrospective analysis was performed on 24 patients, (26 cases) that underwent lumbar spine MRI, with the T2 coronal images, for the evaluation of disc herniations from March 2006 to March 2007. Every MRI image of each patient who had foraminal or extraforaminal disc herniations was graded according to the Pfirrmann's classification of diagnostic efficacy by two spinal surgery specialists and two radiology specialists.
Results
There were 13 cases of foraminal disc herniation and 13 cases of extraforaminal disc herniation in all 26 cases that were diagnosed by MRI. The coronal and axial images were more effective than the sagittal images for the discrimination of a compressed root. Especially, for the extraforaminal disc herniation, all of the coronal images were graded as grade 3; on the other hand, all of the sagittal images were not helpful for the assessment and the axial images were graded as grade 2 for 38.5% of the and as grade 3 for 61.5%. So, the coronal images were most effective for making the diagnosis of extraforaminal disc herniation and this was statistically significant (p<0.05).
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Fig. 2.
MR images of a patient shows foraminal disc herniation of L4~5. (A) T2 sagittal image shows compression of Rt. L4 exiting nerve root by disc material (grade 3) (yellow arrow) (B) T2 axial image shows compression of Rt. L4 exiting nerve root by disc material (grade 3) (yellow arrow). (C) T2 Coronal image shows compression of Rt. L4 exiting nerve root by disc material (grade 3) (yellow arrow).
Fig. 3.
MR images of a patient shows extraforaminal disc herniation of L4~5. (A) T2 axial image shows compression of Rt. L4 exiting nerve root by disc material (grade 3) (yellow arrow). (B) T2 Coronal image shows compression of Rt. L4 exiting L4 nerve root by disc material (grade 3) (yellow arrow).
Fig. 4.
MR images of a patient shows extraforaminal disc herniation of L4~L5. (A) T2 axial image shows deviation of Rt. L4 exiting nerve root by disc material (grade 2) (yellow arrow). (B) T2 Coronal image shows compression of Rt. L4 exiting nerve root by disc material (grade 3) (yellow arrows).
Fig. 1.
Diagram show a system for grading lumbar nerve root compromise in coronal plane (A) No compromise of the nerve root. (B) Contact of disc material (red arrowheads) with the right exiting nerve root (yellow arrow). The nerve root is in the normal position and is not dorsally deviated. (C) Dorsal deviation of the right exiting nerve root (yellow arrow) caused by contact with disc material (red arrowheads). (D) Compression of the right exiting nerve root (yellow arrow) between disc material (red arrowheads) and surrounding structure.
Table 1.
Physical Exmamination and treatment method in Foraminal and Extraforaminal Disc Herniation
| No. | Age | Sex | Level | P/E∗ | Motor | Sensory | Procedure | ||
|---|---|---|---|---|---|---|---|---|---|
| FST® | KJ® | ||||||||
| EF® | 1 | 53 | F | L4~5 | +# | -∗∗ | ↓ | ↓ | TLIF¶¶ |
| 2 | 60 | F | L4~5 | +# | -∗∗ | ↓ | Normal | SRB## | |
| 3 | 83 | M | L4~5 | U®® | n.c®® | Normal | Normal | SRB## | |
| 4 | 68 | M | L4~5 | +# | -∗∗ | Normal | Normal | SRB## | |
| 5 | 57 | F | L4~5 | +# | -∗∗ | ↓ | ↓ | SRB## | |
| 6 | 43 | M | L4~5 | U®® | -∗∗ | Normal | Normal | SRB## | |
| 7 | 54 | M | L3~4 | +# | +# | ↓ | ↓ | TLIF¶¶ | |
| 8 | 72 | F | L3~4 | -∗∗ | +# | ↓ | ↓ | TLIF¶¶ | |
| 9 | 73 | M | L4~5 | U®® | -∗∗ | Normal | Normal | SRB## | |
| 10 | 64 | M | L5~S1 | ∙ | ∙ | ↓ | ↓ | OLM∗∗∗ | |
| 11 | 69 | F | L4~5 | U®® | n.c®® | Normal | Normal | SRB## | |
| 12 | 60 | F | L4~5 | +# | +# | ↓ | ↓ | TLIF¶¶ | |
| 13 | 63 | F | L4~5 | +# | -∗∗ | ↓ | Normal | TLIF¶¶ | |
| F¶ | 1 | 55 | F | L3~4 | -∗∗ | -∗∗ | Normal | Normal | SRB## |
| 2 | 54 | M | L5~S1 | ∙ | ∙ | ↓ | ↓ | SRB## | |
| 3 | 72 | F | L4~5 | -∗∗ | -∗∗ | ↓ | ↓ | SRB## | |
| 4 | 55 | M | L4~5 | U®® | -∗∗ | Normal | Normal | SRB## | |
| 5 | 60 | F | L5~S1 | ∙ | ∙ | Normal | Normal | TLIF¶¶ | |
| 6 | 65 | F | L4~5 | +# | n.c®® | ↓ | ↓ | SRB## | |
| 7 | 70 | F | L4~5 | +# | -∗∗ | Normal | Normal | SRB## | |
| 8 | 54 | F | L5~S1 | ∙ | ∙ | Normal | Normal | SRB## | |
| 9 | 65 | F | L2~3 | ∙ | ∙ | ↓ | ↓ | SRB## | |
| 100 | L3~4 | +# | +# | SRB## | |||||
| 110 | 69 | F | L5~S1 | ∙ | ∙ | Normal | Normal | TLIF¶¶ | |
| 120 | L3~4 | -∗∗ | +# | TLIF¶¶ | |||||
| 130 | 66 | F | L5~S1 | ∙ | ∙ | ↓ | ↓ | TLIF¶¶ | |
Table 2.
MRI∗ Gradings and other radiologic findings in Foraminal and Extraforaminal Disc Herniation
| No. | Age | Sex | Level | Pfirrmann's grade | Scoliotic | angle | Associated disorder | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Sagittal | Axial | Coronal | focal | L1~L5 | ||||||||
| T1 | T2 | T1 | T2 | T2 | ||||||||
| EF® | 1 | 53 | F | L4~5 | NA® | NA® | 2 | 2 | 3 | 0 | 2 | Spondylolisthesis |
| 2 | 60 | F | L4~5 | NA® | NA® | 3 | 3 | 3 | 1 | 1 | ∙ | |
| 3 | 83 | M | L4~5 | NA® | NA® | 3 | 3 | 3 | 3 | 4 | stenosis | |
| 4 | 68 | M | L4~5 | NA® | NA® | 3 | 3 | 3 | 4 | 5 | stenosis | |
| 5 | 57 | F | L4~5 | NA® | NA® | 2 | 2 | 3 | 0 | 2 | ∙ | |
| 6 | 43 | M | L4~5 | NA® | NA® | 2 | 2 | 3 | 2 | 1 | ∙ | |
| 7 | 54 | M | L3~4 | NA® | NA® | 2 | 2 | 3 | 3 | 8 | ∙ | |
| 8 | 72 | F | L3~4 | NA® | NA® | 3 | 3 | 3 | 2 | 8 | stenosis | |
| 9 | 73 | M | L4~5 | NA® | NA® | 3 | 3 | 3 | 1 | 2 | ∙ | |
| 10 | 64 | M | L5~S1 | NA® | NA® | 2 | 2 | 3 | 1 | 2 | ∙ | |
| 11 | 69 | F | L4~5 | NA® | NA® | 3 | 3 | 3 | 2 | 4 | stenosis | |
| 12 | 60 | F | L4~5 | NA® | NA® | 3 | 3 | 3 | 0 | 4 | Spondylolisthesis | |
| 13 | 63 | F | L4~5 | NA® | NA® | 3 | 3 | 3 | 6 | 3 | ∙ | |
| F® | 1 | 55 | F | L3~4 | 1 | 1 | NA® | NA® | 2 | 0 | 2 | ∙ |
| 2 | 54 | M | L5~S1 | 3 | 3 | 2 | 2 | 3 | 2 | 3 | ∙ | |
| 3 | 72 | F | L4~5 | 3 | 3 | 3 | 3 | 3 | 0 | 0 | stenosis | |
| 4 | 55 | M | L4~5 | 2 | 2 | 3 | 3 | 3 | 0 | 0 | ∙ | |
| 5 | 60 | F | L5~S1 | 3 | 3 | 3 | 3 | 3 | 1 | 0 | stenosis | |
| 6 | 65 | F | L4~5 | 3 | 3 | 3 | 3 | 3 | 7 | 7 | stenosis | |
| 7 | 70 | F | L4~5 | 2 | 2 | 3 | 3 | 3 | 3 | 1 | stenosis | |
| 8 | 54 | F | L5~S1 | 3 | 3 | 3 | 3 | 3 | 0 | 5 | stenosis | |
| 9 | 65 | F | L2~3 | 3 | 3 | 3 | 3 | 3 | 1 | 3 | stenosis | |
| 10 | L3~4 | 3 | 3 | 2 | 2 | 3 | 2 | 3 | stenosis | |||
| 11 | 69 | F | L5~S1 | 3 | 3 | 3 | 3 | 3 | 5 | 3 | stenosis | |
| 12 | L3~4 | 3 | 3 | 3 | 3 | 3 | 4 | 3 | stenosis | |||
| 13 | 66 | F | L5~S1 | NA® | 3 | 3 | 3 | 3 | 0 | 4 | stenosis | |
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