الفهرس 
Anatomy of the lumbar SpineOnly 14 pages are availabe for public view
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Abstract
The lumbar vertebrae are the lowest five of the vertebral column. Because the lumbar vertebrae are subjected to the greatest loads in the spinal column, they are relatively massive structures.
Each vertebra is attached to its neighbours by the intervertebral disc, variety of spinal ligaments, and the articular facet joints. The intervertebral disc acts as an articulation between the vertebrae and as a shock absorber or a cushion between vertebrae.
Lumbar disc disease progresses as a series of pathophysiological events, beginning with asymptomatic fissuring and fragmentation within the disc. The decrease in water content within the disc leads to degeneration of the annulus fibrosus resulting in radial tears through which the posteriorly migrated nucleus pulposus herniates, followed by herniation of the disc into the spinal canal or the neural foramen.
Lumbar disc herniation may cause a variety of clinical problems but, in addition, disc protrusion may often be found on magnetic resonance imaging (MRI) in asymptomatic patients.
Manifestations of lumbar disc herniation include, low-back pain, radiculopathy; which is pain or paresthesia or both in the distribution of a nerve root, tenderness over the lumbar spine with paraspinal muscle spasm and limitation of movement, motor weakness (of the muscle supplied by the compressed nerve root), and/or diminished sensation (in the area of skin supplied by the compressed nerve root).
The radiological evaluation of patients with suspected lumbar disc disease begins with plain radiographs, Magnetic resonance imaging (MRI), computed topography (CT). MRI has become the method of choice for further radiographic evaluation.
Treatment options for lumber disc herniation include conservative non-operative treatment which is routinely recommend for at least 6-8 weeks after initial onset of symptoms. Medical Therapy generally consists of the use of non-steroidal anti-inflammatory drugs, muscle relaxants, physical therapy.
Only patients that do not respond to a trial of non-operative therapy are considered for surgical intervention. However, if a neurological deficit is present, as may be observed in a patient with a foot drop, early intervention may be entertained. It is to be noted that if a cauda equina syndrome exists, urgent surgical intervention is recommended.
The goal of surgery in degenerative disc herniation is decompression of neural structures. There must be a strong correlation between clinical symptoms and radiological compression of nerve root. Under these conditions, the results of lumbar disc surgery are very favorable.
There are various options in surgical treatment including standard discectomy and minimally invasive techniques which include microdiscectomy, endoscopic discectomy, automated percutaneous discectomy, laser discectomy, Chemonucleolysis, Intradiscal Electrothermal Therapy.
Conventional discectomy is still the golden option to which any new modality of treatment is compared. Its scope includes the bilateral laminectomy, hemilaminectomy, laminotomy, and the interlaminar techniques.
The main intraoperative complication of conventional discectomy is bleeding from epidural veins and the major postoperative complication is disc space infection, but it is fortunately rare. Recurrent prolapse with sciatica is more common and may require revision decompression surgery.
The complete laminectomy and transdural approach to herniated lumbar discs was long ago replaced by strategies to reduce blood loss, incision length, and intraoperative morbidity.
Minimally techniques have several theoretical advantages over open procedures as Less collateral damage to the back muscles, Shorter hospital stay, Less scar formation, less blood loss, improved visualization, less postoperative pain and good cosmetic result.
Minimally invasive surgery requires advanced technical expertise and may require specialized equipment and navigation systems and involve increased intra operative exposure to radiation. Complications of minimally invasive spinal surgery can be related to anesthesia, patient positioning, and surgical technique.
The gold standard for surgery is an open or microsurgical discectomy. In the last 10 to 15 years the microdiscectomy surgery has been modified to allow for a relatively small incision and less soft tissue dissection, which provide for significantly less postoperative discomfort and quicker healing Endoscopic Lumbar discectomy was introduced as a less invasive alternative. Another surgical option as Chymopapain injections not used nowadays due their complication whereas Laser discectomy and Intra-Discal Electro-Thermal Therapy used in limited circumstance.
Evolving technological sophistication has resulted in ongoing modifications of traditional surgical approaches to correct disorders of the spinal axis. Advances in instrumentation and pre- and intraoperative imaging have fueled a move toward minimally invasive, minimal access spine surgery.