Cauda equina syndrom
This syndrome was noted in 10 patients (6.3%) of this series.
It translates a compression of the roots of the Cauda equina by a bulging
hernia, often in a postero median position. This syndrome is rare both in
literature and in our series. Our observations are close to Pierron's data [35]
which reported a frequency of 5.4%. As for Rafik [36], he reported a frequency
of 2.7%.
Forms depending on the age
Operated LDH remains rare in the elderly. Our series
identified 3 patients (1.9%) aged 71 years or older, including 2 men and one
woman. This could be explained by the fact that neurosurgeons and
anesthesiologists avoid taking risks because surgery and anesthesia at this age
remains very delicate. In children and adolescents, LDH was also rare. Our
series had noted a single case operated at the age of 16 years. Our results are
close to those of Rafik [36] and Mrabet [37] who reported respectively 1.1% and
3%.
PARACLINIC EXAMINATIONS
Biology
? Inflammatory balance sheet and hemogram
Our study shows that of the 160 patients, 130 patients
(81.3%) had a normal inflammatory balance sheets. Thirty patients (18.7%) had a
disturbed inflammatory balance, of which 12.5 with increased CRP and 6.2% with
accelerated VS. Note also that the blood count was disrupted in 3.1% of
cases.
A relationship has been sought between the inflammatory
balance and the different types of LDH. It follows that of the 80 cases of
median DH, 10 cases (5.7%) had a disturbed inflammatory balance. Similarly, of
the 85 cases of postero-lateral DH, 15 cases (8.6%) had a disturbed
inflammatory balance, whereas 5 out of 5 cases of foraminale DH had a disturbed
inflammatory balance. The study found a statistically significant relationship
between imaging diagnoses and inflammatory outcome (p = 0.001).
However, it should be noted that LDH is a degenerative
affection that does not positively influence the rate of sedimentation [34,
37]. It should be noted that accelerated VS and elevated CRP in some patients
in our study may be due to other conditions that were not likely to be
investigated or reported in the charts. Some authors also found high levels of
CRP in LDH [38]. According to the latter, the disc pathology is marked by a
systemic inflammatory response related to the degree of progression of the
herniated mass.
MEDICAL IMAGING
· Standard radiography
The results of standard radiography in this study had shown an
overall pinch of the disc in 95 patients (59.4%). The examination was normal in
32 patients (20%). Transitional abnormalities were found in 26 patients
(16.2%), whereas spinal rectitude was seen in 7 patients (4.4%). The standard
radiography is the first examination to realize before the failure of the
medical treatment. El Azhari [32] and Czorny [39] had also noted a global disc
narrowing respectively in 32% and 25% of cases.
· Computed tomography (CT)
Posterior LDH was found in 100% of patients in our series. The
median DH was observed in 80 patients (50.0%), posterolateral DH in 85 patients
(53.1%), foraminal DH in 5 patients (3.1%) and finally the extra foraminal
hernia also in 5 patients (3.1%).In our series, single disc herniation's were
frequently found in 90 cases (56.3%). Disc level L4 - L5 was the most highly
affected in 55 cases (34.4%). These results corroborate the work of Suk, Rompe,
Porchet, Kimn and Kutoloka [40]. The predominance of impairment at the L4-L5
level may be due to the fact that this disk is probably more constrained than
the L5-S1 stage.Double disc herniation's were found in 55 cases (34.4%) with a
predominance of discs L4 - L5 and L5 - S1 in 45 cases (28.1%). These last two
discs are the most mobile of the lumbosacral hinge, hence the predominance of
the attack on their levels. Triple disc herniation's were found in 15 cases
(9.4%) in L3 - L4, L4 - L5 and L5 - S1. Our results are consistent with those
of the literature for both disc stages and topography of lesions. In Destandau
[41], the stages (L3-L4, L4-L5 and L5-S1) were concerned in 15%, 51% and 25% of
cases, respectively. This confirms that the L4-L5 and L5-S1 disks are the most
affected because of the importance of the stresses and pressures exerted there
[42].Note that the first two disks: L1-L2 and L2-L3 were not affected in our
series.
· Magnetic resonance imaging (MRI)
In our series, 48 patients had benefited from the CT-lumbar
MRI pair, i.e. 30% of cases. We did not notice a discrepancy of results between
these two techniques. This can be explained by a small number of patients who
have done both exams at the same time. Which makes it impossible to draw
realistic conclusions.
ASSOCIATED PATHOLOGIES
Our series shows that hypertrophy of the yellow ligament was
the spinal pathology most commonly associated with lumbar disc herniation's in
62.5% of cases, followed by narrow lumbar canal in 21.9% of cases. Transitional
abnormalities and retrolisthesis were the least recovered in 6.2% of cases.A
statistically significant link was noted between the three subtypes of
posterior LDH and hypertrophy of the yellow ligament with p values 0.022
(median LDH), 0.001 (posterolateral LDH) and 0.003 (extraforaminal LDH),
respectively.The narrow lumbar canal can be primary or secondary. It seems that
fibrosis occurring during any herniated disc is at the origin of the formation
of osteophytes and hypertrophy of the facet joints, causing the compression of
bone structures still called primary structures. This is called the primary
narrow lumbar canal [2].The hypertrophy of the yellow ligament concerns only
the ligamentous structures of the rachis still called secondary structures.
Hence its name narrow secondary lumbar canal.Lumbar osteoarthritis is the most
common degenerative pathology. It constitutes more than a quarter of the
etiologies of lumbosciaticaaccording to the literature. This hypothesis has not
been confirmed in this series. Moreover, these three pathologies are
degenerative pathologies of the spine like herniated discs. This is why their
association is frequent. In addition, the transitional anomalies of the lumbar
hinge had a negligible percentage.
CONFRONTATION BETWEEN THE ADMISSION DELAY AND THE
SURGICAL ACT.
The surgical treatment of LDH had to be well qualified in some
cases. In this study, the notion of admission delay and its comparison with
literature data allowed us to identify three operative indication groups:
| 
