0:00

We've just discussed the differentiation between

0:04

protrusions and extrusions and sequestrated

0:07

or free fragments.

0:10

I went to the four neurosurgeons that operate on

0:14

discs at Johns Hopkins and asked them what does it

0:19

mean to them when we use the term

0:21

protrusion or extrusion?

0:23

I didn't even mention sequestrated fragment.

0:26

And the first neurosurgeon said,

0:28

"Well, when it's an extrusion, I have to incise

0:31

the annulus and take the fragment out."

0:35

The next neurosurgeon said,

0:37

"Well, you know, the extrusion is a free fragment,

0:41

and so, that's a difference than a contained disc."

0:47

The third neurosurgeon said, "I, myself have

0:50

been confused about this, but bottom line is

0:53

protrusions and extrusions are herniation which

0:55

means I operate. If it's a bulge, I don't operate.

0:58

But I also look at the degree of stenosis."

1:02

And the final neurosurgeon said,

1:04

"Well, a herniation is anything through the annulus,

1:07

whereas an extrusion is still in continuity

1:10

with the parent disc,

1:11

whereas a sequestration is a free fragment."

1:15

So you can see that there is a lot of ambiguity,

1:19

if not, total confusion, about what the terms mean.

1:24

In the nomenclature that was accepted by the ASNR,

1:28

the ASSR and the North American Spine Surgery Society,

1:33

the description of protrusion extrusion

1:36

is purely based on shape.

1:39

It does not imply anything about,

1:42

through and through, the annulus,

1:44

or through and through,

1:45

the posterior ligamentous complex.

1:48

And so, again, there still is non-uniformity

1:51

in the understanding of what it means.

1:53

That's why, if we go from the neurosurgery take to the

2:00

Yousem take, I don't emphasize as much.

2:03

I sometimes will just use the term herniation,

2:05

not even talk about protrusion extrusion.

2:08

But my emphasis is,

2:10

what's it doing to the spinal canal,

2:13

to the thecal sac, to the nerve roots?

2:15

So again, for the Yousemisms, if you will,

2:18

you're going to use the term non-compressive.

2:21

That means it's unlikely to be symptomatic as far

2:24

as a radicular problem, abutting.

2:27

This is in that Gray zone,

2:29

perhaps when you have axial loading of

2:32

the spine or in the upright position,

2:34

it would be hitting that nerve root and causing

2:36

pain, versus those that are compressing or

2:39

displacing implies that it's already irritating or

2:44

injuring that nerve root.

2:46

The next thing that I try to do in my dictation is talk

2:50

about where the nerve root is being compressed,

2:55

and the terms I use are intrathecal.

2:58

That means that the nerve root

3:00

has not left the thecal sac.

3:02

Sometimes the disc herniation is irritating the

3:05

nerve root as it is leaving the thecal sac.

3:07

And so, I'll say the L5-S1 large disc herniation

3:11

is compressing the nerve root as it exits the thecal sac.

3:15

The third location is the lateral recess.

3:18

So from the exit of the thecal sac,

3:21

it's going to go into that lateral

3:22

recess at the pedicle level.

3:24

And I'll describe that that is the location at

3:26

which the disc herniation is

3:29

compressing the nerve root.

3:30

Or is it compressing the nerve root in the foramen

3:34

or in the extra foraminal compartment?

3:36

So by doing so,

3:37

I'm trying to allow the surgeon to understand

3:42

where he's going to find that disc and remove

3:45

it from the irritating the nerve root.

3:48

In some cases,

3:49

the surgeon is just going to decompress the spinal

3:52

canal and do a laminectomy and not even worry

3:55

about doing a "discectomy."

3:58

However, in most cases, they're

4:00

going to want to remove the offending disc,

4:03

and I'm trying to tell them,

4:05

this is where you're going to find the nerve root

4:07

being irritated by this disc herniation.

4:10

As I mentioned, we use the term mild, moderate,

4:12

and severe, or mild, moderate

4:14

and marked for the size of the disc

4:17

herniations as small, medium, or large,

4:20

or the degree of stenosis as mild,

4:22

less than one-third of the spinal canal,

4:25

moderate, one-third to two-thirds,

4:27

or marked, or severe, greater than two-thirds.

4:30

This is also the terminology that I use

4:33

for describing foraminal stenosis.

4:36

So if the foramen is narrowed by either facet

4:40

joint disease or disc disease or osteophytes,

4:44

I will characterize it in these same terms.

4:46

And sometimes I'll hedge and say it's mild to

4:48

moderate severity, or moderate to severe, et cetera.

4:52

But we're using those terms because they were

4:54

defined in the nomenclature as the terms that

4:57

we should use for describing less than one-third, mild,

5:00

one-third or two-thirds, moderate,

5:02

and greater than two-thirds, marked or severed.

5:04

And finally, I will also,

5:06

in the impression, talk about what I believe is the

5:12

major pathology that's doing the

5:14

damage to the nerve root.

5:16

We've been emphasizing the disc herniation but

5:20

sometimes I will say this is predominantly due to

5:23

osteophyte and this might be the

5:25

case in the cervical spine.

5:27

Or there is compression of the L5 nerve root

5:31

predominantly due to a synovial cyst compressing

5:36

it from posteriorly, as opposed to

5:38

the anterior disc herniation.

5:41

Or potentially you might be using the

5:44

same thing for ligamentum flavum,

5:46

ossification, or calcification, might be the

5:50

predominant pathology that's compressing the nerve

5:54

root, as opposed to the disc herniation

5:57

or the osteophyte, or the disc bulge.

6:00

So I'm trying to say you want to go after this

6:04

ligamentum flavum or you want to go after this

6:07

disc herniation, or you want to

6:08

go after the synovial cyst.

6:10

So that's part of the impression.

6:12

So you might hear me say, there is an L5-S1 disc herniation

6:20

protrusion extrusion that is compressing the

6:24

left L5 nerve root as it leaves the thecal sac with the

6:29

disc materially predominantly in the lateral

6:32

recess, causing moderate central canal stenosis.

6:37

And that is the predominant cause of the

6:41

nerve root irritation or compression.