Pneumatic nerve root compression: epidural gas in association with lateral disc herniation

Report of two cases

Restricted access

✓ Extreme lateral disc herniations are increasingly recognized as a cause of lumbar nerve root compression syndromes. This disorder often presents major diagnostic and therapeutic challenges, especially in the presence of multiple degenerative changes and chronic back pain in elderly patients. The authors describe two patients with presentations and findings that have not been previously described in the literature. Both patients had histories of upper lumbar back and leg pain. Degenerative spine disease, gaseous degeneration of the intervertebral discs, and epidural gas in the lateral recesses were noted on imaging studies. However, because both patients had undergone prior epidural diagnostic and therapeutic procedures, the epidural gas in the lateral recesses could be attributed either to gaseous disc degeneration or to the previous intraspinal procedures. One patient was found to have a large, far lateral extruded disc fragment that contained air. The nerve root in the second patient was impaled by an unusual combination of a small extruded disc fragment as well as an air-filled sac that was surrounded by the walled-off fragment's capsule and which freely communicated with the gaseous degenerated disc space. The suspected mechanism of root compression is illustrated and discussed. The possibility of disc herniation should be seriously considered in cases of nerve root compression in which epidural gas is present, especially those associated with gaseous degenerated discs.

Article Information

Address reprint requests to: Theresa M. Cheng, M.D., Ph.D., Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota 55905.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Case 1. Computerized tomography scan, axial view, showing gaseous degeneration of the L-2 disc space and degenerative changes with hypertrophy of the facet joints and ligamentum flavum causing moderate central canal stenosis. Epidural gas (arrow) can be seen within a far lateral disc herniation at the L-2 interspace on the left side, migrating superiorly from the disc space.

  • View in gallery

    Case 1. Magnetic resonance T1-weighted (left) and T2-weighted (right) images at the L-2 level. A large area of soft-tissue density (arrows) is seen lateral to the pedicle with extension into the neural foramen on the left, consistent with a far-lateral disc extrusion.

  • View in gallery

    Case 2. Magnetic resonance image at the L-3 level showing degenerative, spondylotic changes consisting of a diffusely bulging anulus and hypertrophic facet joints that caused mild stenosis of the spinal canal and narrowing of the right lateral recess. Gaseous degeneration of the disc space is visible. A well-encapsulated low density air-filled sac can be seen compressing the right L-3 nerve root as it exits the foramen (arrows). Otherwise, there was no clear evidence of focal disc protrusion.

  • View in gallery

    Case 2. Iopamidol myelograms, anteroposterior view (left pair) and oblique view (right pair) of the right side showing slight kinking and blunting of the L-3 nerve root as it exits the neural foramina on the right (arrows). Gaseous degeneration of the intervertebral disc is clearly evident.

  • View in gallery

    Case 2. Postmyelography computerized tomography scans, axial view, at the L-3 level demonstrating moderate spondylotic changes of the lumbar spine with hypertrophic changes of the ligamentum flavum and facet joints, and mild end-plate osteophyte formation. Left: A well-circumscribed bubble of air can be seen (arrow), consistent with epidural gas in the lateral recess. Right: The right L-3 nerve root is obscured by ill-defined soft tissue and tiny bubbles of air (arrow).

  • View in gallery

    Artist's drawings demonstrating the mechanism of nerve root compression in Case 2. Left: The piston-like pneumatic compression of the L-3 vertebral body upon the gaseous degenerated disc causes air to be squeezed out into a well-encapsulated connective tissue-lined sac generated by the extruded fragment's capsule, impaling the nerve root that exits at that level. Right: Improvement of symptoms occurred when the patient was supine and the vertebral body compression was removed, allowing air to return into the disc space, deflating the air-filled sac, and relieving pressure on the root(s).

References

  • 1.

    Abdullah AFDitto EW IIIByrd EBet al: Extreme-lateral lumbar disc herniations. Clinical syndrome and special problems of diagnosis. J Neurosurg 41:2292341974Abdullah AF Ditto EW III Byrd EB et al: Extreme-lateral lumbar disc herniations. Clinical syndrome and special problems of diagnosis. J Neurosurg 41:229–234 1974

    • Search Google Scholar
    • Export Citation
  • 2.

    Abdullah AFWolber PGHWarfield JRet al: Surgical management of extreme lateral lumbar disc herniations: review of 138 cases. Neurosurgery 22:6486531988Abdullah AF Wolber PGH Warfield JR et al: Surgical management of extreme lateral lumbar disc herniations: review of 138 cases. Neurosurgery 22:648–653 1988

    • Search Google Scholar
    • Export Citation
  • 3.

    Angtuaco EJCHolder JCBoop WCet al: Computed tomographic discography in the evaluation of extreme lateral disc herniation. Neurosurgery 14:3503521984Angtuaco EJC Holder JC Boop WC et al: Computed tomographic discography in the evaluation of extreme lateral disc herniation. Neurosurgery 14:350–352 1984

    • Search Google Scholar
    • Export Citation
  • 4.

    Aronson HADunsmore RH: Herniated upper lumbar discs. J Bone Joint Surg (Am) 45:3113171963Aronson HA Dunsmore RH: Herniated upper lumbar discs. J Bone Joint Surg (Am) 45:311–317 1963

    • Search Google Scholar
    • Export Citation
  • 5.

    Brown HAPont ME: Disease of lumbar discs. Ten years of surgical treatment. J Neurosurg 20:4104171963Brown HA Pont ME: Disease of lumbar discs. Ten years of surgical treatment. J Neurosurg 20:410–417 1963

    • Search Google Scholar
    • Export Citation
  • 6.

    Brown LJ: Definitive diagnosis of extreme lateral lumbar disc herniation. Surg Neurol 27:3733761987Brown LJ: Definitive diagnosis of extreme lateral lumbar disc herniation. Surg Neurol 27:373–376 1987

    • Search Google Scholar
    • Export Citation
  • 7.

    DePalma ARothman R: Clinical Manifestations of Lumbar Disc Syndrome. Philadelphia: WB Saunders1970 pp 203248DePalma A Rothman R: Clinical Manifestations of Lumbar Disc Syndrome. Philadelphia: WB Saunders 1970 pp 203–248

    • Search Google Scholar
    • Export Citation
  • 8.

    Dickman CAMamourian ADrayer BPet al: MR imaging of lateral disc herniation. J Neurosurg 73:6426431990 (Letter)Dickman CA Mamourian A Drayer BP et al: MR imaging of lateral disc herniation. J Neurosurg 73:642–643 1990 (Letter)

    • Search Google Scholar
    • Export Citation
  • 9.

    Epstein NEEpstein JACarras Ret al: Far lateral lumbar disc herniations and associated structural abnormalities. An evaluation in 60 patients of the comparative value of CT, MRI, and myelo-CT in diagnosis and management. Spine 15:5345391990Epstein NE Epstein JA Carras R et al: Far lateral lumbar disc herniations and associated structural abnormalities. An evaluation in 60 patients of the comparative value of CT MRI and myelo-CT in diagnosis and management. Spine 15:534–539 1990

    • Search Google Scholar
    • Export Citation
  • 10.

    Falconer MAMcGeorge MBegg AC: Observations on the cause and mechanisms of symptom-production in sciatica and low-back pain. J Neurol Neurosurg Psychiatry 11:13261948Falconer MA McGeorge M Begg AC: Observations on the cause and mechanisms of symptom-production in sciatica and low-back pain. J Neurol Neurosurg Psychiatry 11:13–26 1948

    • Search Google Scholar
    • Export Citation
  • 11.

    Gado MPatel JHodges FJ III: Lateral disc herniation into the lumbar intervertebral foramen: differential diagnosis. AJNR 4:5986001983Gado M Patel J Hodges FJ III: Lateral disc herniation into the lumbar intervertebral foramen: differential diagnosis. AJNR 4:598–600 1983

    • Search Google Scholar
    • Export Citation
  • 12.

    Godersky JCErickson DLSeljeskog EL: Extreme lateral disc herniation: diagnosis by computed tomographic scanning. Neurosurgery 14:5495521984Godersky JC Erickson DL Seljeskog EL: Extreme lateral disc herniation: diagnosis by computed tomographic scanning. Neurosurgery 14:549–552 1984

    • Search Google Scholar
    • Export Citation
  • 13.

    Gurdjian ESOstrowski AZHardy WGet al: Results of operative treatment of protruded and ruptured lumbar discs. Based on 1176 operative cases with 82 per cent follow-up of 3 to 13 years. J Neurosurg 18:7837911961Gurdjian ES Ostrowski AZ Hardy WG et al: Results of operative treatment of protruded and ruptured lumbar discs. Based on 1176 operative cases with 82 per cent follow-up of 3 to 13 years. J Neurosurg 18:783–791 1961

    • Search Google Scholar
    • Export Citation
  • 14.

    Haughton VMEldevik OPMagnaes Bet al: A prospective comparison of computed tomography and myelography in the diagnosis of herniated lumbar discs. Radiology 142:1031101982Haughton VM Eldevik OP Magnaes B et al: A prospective comparison of computed tomography and myelography in the diagnosis of herniated lumbar discs. Radiology 142:103–110 1982

    • Search Google Scholar
    • Export Citation
  • 15.

    Jackson RPGlah JJ: Foraminal and extraforaminal lumbar disc herniation: diagnosis and treatment. Spine 12:5775851987Jackson RP Glah JJ: Foraminal and extraforaminal lumbar disc herniation: diagnosis and treatment. Spine 12:577–585 1987

    • Search Google Scholar
    • Export Citation
  • 16.

    Johansen JG: Computed tomography in assessment of myelographic nerve root compression in the lateral recess. Spine 11:4924951986Johansen JG: Computed tomography in assessment of myelographic nerve root compression in the lateral recess. Spine 11:492–495 1986

    • Search Google Scholar
    • Export Citation
  • 17.

    Kornberg M: Extreme lateral lumbar disc herniations: clinical syndrome and computed tomography recognition. Spine 12:5865891987Kornberg M: Extreme lateral lumbar disc herniations: clinical syndrome and computed tomography recognition. Spine 12:586–589 1987

    • Search Google Scholar
    • Export Citation
  • 18.

    Kurobane YTakahashi TTajima Tet al: Extraforaminal disc herniation. Spine 11:2602681986Kurobane Y Takahashi T Tajima T et al: Extraforaminal disc herniation. Spine 11:260–268 1986

    • Search Google Scholar
    • Export Citation
  • 19.

    Leonardi MBiasizzo EFabris Get al: CT evaluation of the lumbosacral spine. AJNR 4:8468471983Leonardi M Biasizzo E Fabris G et al: CT evaluation of the lumbosacral spine. AJNR 4:846–847 1983

    • Search Google Scholar
    • Export Citation
  • 20.

    Macnab I: Negative disc exploration. An analysis of the causes of nerve-root involvement in sixty-eight patients. J Bone Joint Surg (Am) 53:8919031971Macnab I: Negative disc exploration. An analysis of the causes of nerve-root involvement in sixty-eight patients. J Bone Joint Surg (Am) 53:891–903 1971

    • Search Google Scholar
    • Export Citation
  • 21.

    Maroon JCKopitnik TASchulhof LAet al: Diagnosis and microsurgical approach to far-lateral disc herniation in the lumbar spine. J Neurosurg 72:3783821990Maroon JC Kopitnik TA Schulhof LA et al: Diagnosis and microsurgical approach to far-lateral disc herniation in the lumbar spine. J Neurosurg 72:378–382 1990

    • Search Google Scholar
    • Export Citation
  • 22.

    Mikhael MA: High resolution computed tomography in the diagnosis of laterally herniated lumbar discs. Comput Radiol 7:1611661983Mikhael MA: High resolution computed tomography in the diagnosis of laterally herniated lumbar discs. Comput Radiol 7:161–166 1983

    • Search Google Scholar
    • Export Citation
  • 23.

    Mikhael MACiric ITarkington JAet al: Neuroradiological evaluation of lateral recess syndrome. Radiology 140:971071981Mikhael MA Ciric I Tarkington JA et al: Neuroradiological evaluation of lateral recess syndrome. Radiology 140:97–107 1981

    • Search Google Scholar
    • Export Citation
  • 24.

    Motateanu MFankhauser HMansouri Bet al: La hernie discale lombaire extrêmement latérale. A propos d'une série de 25 cas. Neurochirurgie 32:74801986Motateanu M Fankhauser H Mansouri B et al: La hernie discale lombaire extrêmement latérale. A propos d'une série de 25 cas. Neurochirurgie 32:74–80 1986

    • Search Google Scholar
    • Export Citation
  • 25.

    Nelson MJGold LH: CT evaluation of intervertebral foramina lesions with normal or non-diagnostic myelograms. Report of ten cases. Comput Radiol 7:1551601983Nelson MJ Gold LH: CT evaluation of intervertebral foramina lesions with normal or non-diagnostic myelograms. Report of ten cases. Comput Radiol 7:155–160 1983

    • Search Google Scholar
    • Export Citation
  • 26.

    Novetsky GJBerlin LEpstein AJet al: The extraforaminal herniated disk: detection by computed tomography. AJNR 3:6536551982Novetsky GJ Berlin L Epstein AJ et al: The extraforaminal herniated disk: detection by computed tomography. AJNR 3:653–655 1982

    • Search Google Scholar
    • Export Citation
  • 27.

    O'Connell JE: Protrusions of the lumbar intervertebral discs. A clinical review based on five hundred cases treated by excision of the protrusion. J Bone Joint Surg (Br) 33:8301951O'Connell JE: Protrusions of the lumbar intervertebral discs. A clinical review based on five hundred cases treated by excision of the protrusion. J Bone Joint Surg (Br) 33:8–30 1951

    • Search Google Scholar
    • Export Citation
  • 28.

    Osborn AGHood RSSherry RGet al: CT/MR spectrum of far lateral and anterior lumbosacral disk herniations. AJNR 9:7757781988Osborn AG Hood RS Sherry RG et al: CT/MR spectrum of far lateral and anterior lumbosacral disk herniations. AJNR 9:775–778 1988

    • Search Google Scholar
    • Export Citation
  • 29.

    Patrick BS: Extreme lateral ruptures of lumbar intervertebral discs. Surg Neurol 3:3013041975Patrick BS: Extreme lateral ruptures of lumbar intervertebral discs. Surg Neurol 3:301–304 1975

    • Search Google Scholar
    • Export Citation
  • 30.

    Postacchini FMontanaro A: Extreme lateral herniations of lumbar discs. Clin Orthop 138:2222271979Postacchini F Montanaro A: Extreme lateral herniations of lumbar discs. Clin Orthop 138:222–227 1979

    • Search Google Scholar
    • Export Citation
  • 31.

    Raaf J: Some observations regarding 905 patients operated upon for protruded lumbar intervertebral disc. Am J Surg 97:3883991959Raaf J: Some observations regarding 905 patients operated upon for protruded lumbar intervertebral disc. Am J Surg 97:388–399 1959

    • Search Google Scholar
    • Export Citation
  • 32.

    Raskin SPKeating JW: Recognition of lumbar disk disease: comparison of myelography and computed tomography. AJR 139:3493551982Raskin SP Keating JW: Recognition of lumbar disk disease: comparison of myelography and computed tomography. AJR 139:349–355 1982

    • Search Google Scholar
    • Export Citation
  • 33.

    Semmes RE: Ruptures of the Lumbar Intervertebral Disc. Their Mechanism Diagnosis and Treatment. Springfield, Ill: Charles C Thomas1964Semmes RE: Ruptures of the Lumbar Intervertebral Disc. Their Mechanism Diagnosis and Treatment. Springfield Ill: Charles C Thomas 1964

    • Search Google Scholar
    • Export Citation
  • 34.

    Spanu GRodriguez y Baena RRainoldi F: Reliability of clinical examination and computed tomography in the diagnosis of extreme lateral disc herniation. Neurochirurgia 30:1121141987Spanu G Rodriguez y Baena R Rainoldi F: Reliability of clinical examination and computed tomography in the diagnosis of extreme lateral disc herniation. Neurochirurgia 30:112–114 1987

    • Search Google Scholar
    • Export Citation
  • 35.

    Williams ALHaughton VMDaniels DLet al: CT recognition of lateral lumbar disk herniation. AJR 139:3453471982Williams AL Haughton VM Daniels DL et al: CT recognition of lateral lumbar disk herniation. AJR 139:345–347 1982

    • Search Google Scholar
    • Export Citation
  • 36.

    Winter DDBMunk PLHelms CAet al: CT and MR of lateral disc herniation: typical appearance and pitfalls of interpretation. Can Assoc Radiol J 40:2562591989Winter DDB Munk PL Helms CA et al: CT and MR of lateral disc herniation: typical appearance and pitfalls of interpretation. Can Assoc Radiol J 40:256–259 1989

    • Search Google Scholar
    • Export Citation

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 144 144 18
Full Text Views 161 161 1
PDF Downloads 95 95 1
EPUB Downloads 0 0 0

PubMed

Google Scholar