Observations on spontaneous recovery from intervertebral disc herniation.

Spontaneous recovery from disc herniation is well known and is an important aspect of treatment strategy. Computed imaging studies have provided further insight into the possible mechanisms of recovery.

Identification and management of radiculopathy.

Proper identification of compressive radiculopathy is essential before any treatment can be undertaken. The differential recognition of different pain patterns, sensory symptoms, and neurologic deficits provides the clinical guide to specific nerve root involvement. Appropriate radiology and imaging must correlate with symptoms and signs. Management includes surgical intervention when indicated for relief of radicular pain and restoration of function.

Role of laminectomy in lumbar disk herniation.

A personal view of the role of laminectomy in lumbar disk herniation is presented. The phenomena of the true herniated nucleus pulposus and the asymptomatic bulging degenerative disk are discussed in relation to clinical presentation, neuroradiologic studies, and surgical findings. Microscopic technique and so-called less invasive procedures are also evaluated.

Lumbar microdiscectomy: a contrary opinion.

Successful operation for ruptured lumbar disc is directly related to appropriate selection of patients and an operative approach designed for the particular size and location of the compressed fragment of disc. Lumbar microdiscectomy provides no advantage when operation is clearly indicated and adds the additional risks that have always accompanied inadequate exposure and incomplete decompression.

Professional liability and potential liability.

Operations on the nervous system continue to result in claims that rank among the most costly. A retrospective review of 300 cases of alleged or potential liability referred for opinion over an 11-year period is reported to catalog areas of vulnerability for the neurosurgeon and to alert younger practitioners in particular. Spinal surgery produced the largest single group of neurosurgical malpractice cases, 136 of the 300; among these, 71 came from operations on the lumbar spine. Cerebral and spinal trauma accounted for 54 cases, the next largest group. Subgroups were studied in detail and provide individual features of some importance. Other conclusions are that 37% of all cases reviewed were found to have some merit in favor of the claimant; plaintiffs and their attorneys can be dissuaded from legal pursuit if the deficit is not serious; many defensible cases are settled or lost on the basis of disability rather than merit; and some type of reform of the present system is clearly needed.

Ruptured median and paramedian lumbar disk. A review of 243 cases.

Ruptured median and paramedian lumbar disks present special problems for the surgeon, not the least of which is adequate laminectomy to provide satisfactory decompression and release of the disk fragment without trauma to the cauda equina. The surgical technique described was used over a 10-year period in a series of 243 patients and emphasized the principles of sufficient removal of bone and posterolateral approach. Although 72% of patients had complete or partial myelographic block, unilateral symptoms and neurologic signs predominated. Full recovery with minimal or no neurologic deficit was recorded in 85% of patients, with a recurrence rate of 6%. In no patient was neurologic deficit greater than before operation.