DOI: 10.33962/roneuro-2022-029 Lumbar disc herniation presenting with contralateral neuropathy. Case report D. Balasa, C. Popescu Romanian Neurosurgery (2022) XXXVI (2): pp. 161-163 DOI: 10.33962/roneuro-2022-029 www.journals.lapub.co.uk/index.php/roneurosurgery Lumbar disc herniation presenting with contralateral neuropathy. Case report D. Balasa1, C. Popescu2 1 Department of Neurosurgery, Clinical County Hospital Constanta, ROMANIA 2 Department of Orthopaedics, Clinical County Hospital Constanta, ROMANIA ABSTRACT We admitted a unique case of right lumbar disc herniation at L4L5 who presented with contralateral symptoms and was successfully treated with a right large L4/L5 fenestration and microdiscectomy. When the operation is considered, intervention only from the herniation side is sufficient. In the case presented, it is probable that Kernohan notch‑like phenomenon, venous engorgement and congestion at the contralateral side of the herniated lumbar disc and the contralateral migrated epidural fat are responsible for the emergence of contralateral symptoms. INTRODUCTION Lumbar disc herniation usually presents with varying degrees of pain, numbness and weakness in the distribution of the affected nerve root. CASE PRESENTATION A 46 year-old gentleman who performed intense physical work presented a 6 months old history of low back pain radiating down to his left buttock , posterior thigh, lateral and posterior leg (L5 and S1 dermatomas). Examination revealed intense algoparesthesias on the left L5 and S1 dermatomas (VAS 8/10), are refractory to conservative management and acupuncture, rotulian and achilian reflexes were absent bilaterally. Straight leg raise was positive at 30 degrees on the left side and 40 degrees on the right side. Anamnesis revealed L4-L5 disc hernia operated on the right side in 2020 with very good postoperative evolution. MRI of his lumbar spine showed a central and right-sided paracentral disc herniation at L4/L5 causing cauda equina compression ( blue arrow) rupture of fibrous ring and posterior longitudinal ligament in the midline (red arrow) - Figures 1,2) . Keywords herniated disc, intervertebral disc displacement, contralateral symptoms Corresponding author: D. Balasa Department of Neurosurgery, Clinical County Hospital Constanta, Romania balasadaniel100@yahoo.com Copyright and usage. This is an Open Access article, distributed under the terms of the Creative Commons Attribution Non–Commercial No Derivatives License (https://creativecommons .org/licenses/by-nc-nd/4.0/) which permits non- commercial re-use, distribution, and reproduction in any medium, provided the original work is unaltered and is properly cited. The written permission of the Romanian Society of Neurosurgery must be obtained for commercial re-use or in order to create a derivative work. ISSN online 2344-4959 © Romanian Society of Neurosurgery First published June 2022 by London Academic Publishing www.lapub.co.uk http://www.lapub.co.uk/ 162 D. Balasa, C. Popescu Figure 1. Sagittal cut of lumbar spine (T2) L4-L5 disc hernia, ruptured, huge, compressive on the cauda equina Figure 1. Axial cut at L4/L5 disc level, the right side (T2). central and right-sided paracentral disc herniation at L4/L5 causing cauda equina compression (blue arrow), rupture of fibrous ring and posterior longitudinal ligament in the midline (red arrow), operated (2020) L4-L5 fenestration (yellow arrow). The patient was emergently operated on (enlargment of fenestation L4-L5 on the right side, microsurgical discectomy). Postoperative results were very good with dissapearance of the pain and paresthesis. Postoperative follow-up period: 6 months. DISCUSSION There is no consensus about surgical approac; side or sides and the pathophysiology. Some authors like Choudhury et al1, Kornberg2 , Mirovsky and Halperin3 performed bilateral explorations not to miss a lesion. However, Sucu and Gelal4, Akdeniz et al5, and Karabekir et al6 performed the operative approach only on the lumbar disc herniated side and reported that exploration of the LDH side was enough for the recovery of the contralateral symptoms. Radiculopathy from lumbar disc herniation can be a result of mechanical compression7 , ischaemia7 or inflammatory irritation8 of the nerve root. The mechanism for lumbar disc herniation presenting with contralateral leg symptoms is poorly understood. Kornberg et al2 proposed that inconsistent dural attachments to the posterior longitudinal ligaments holds the lumbar nerve roots at certain levels resulting in a more symptomatic traction of the contralateral nerve root A radicular pain contralateral to the herniated side is an unusual finding rarely reported in the literature(Safdarian9). Safdarian hypothesized that the reason for patients’ symptoms contralateral to the apparent compression on imaging studies involves a Kernohan notch-like phenomenon. Sucu and Gelal4 presented five patients with lumbar disk herniations and contralateral. The authors observed that the shape of disk herniations in imaging studies was quite similar in these patients. Almost all of them had a broad posterior central-paracentral herniated disk with the apex deviated away from the side of the symptoms. Kalemci et al10 reported a case of painless contralateral neurological deficit due to venous engorgement and congestion at the contralateral side of the herniated lumbar disc . Karabekir et al6. concluded that a hypertrophied ligamentum flavum was the likely etiology of contralateral sciatica comparing five patients with only contralateral symptoms, with 200 disc herniated patients with ipsilateral symptoms According to Jun-Song Yang11 the migrated epidural fat plays a significant role in the pain mechanism of LDH with contralateral radiculopathy. Only via a surgical approach ipsilateral to the herniated side, could clinical improvement be obtained postoperatively. 163 Lumbar disc herniation presenting with contralateral neuropathy CONCLUSIONS Patients with lumbar disc herniation may present with radicular symptoms involving the contralateral leg. In the case presented, the mechanism of contralateral symptoms was Kernohan notch-like phenomenon, venous engorgement and congestion at the contralateral side of the herniated lumbar disc and the contralateral migrated epidural fat. The operative approach (enlarged fenestration, operative approach of the contralateral disc hernia ) was mandatory for a very good postoperative evolution. REFERENCES 1. Choudhury AR, Taylor JC, Worthington BS, Whitaker R. Lumbar radiculopathy contralateral to upper lumbar disc herniation: report of 3 cases. Br J Surg. 1978;65:842-4. 2. Kornberg M. Sciatica contralateral to lumbar disk herniation. Orthopedics 1994;17:362-4. [PubMed] 3. Mirovsky Y, Halperin N. Eccentric compression of the spinal canal causing dominantly contralateral-side symptoms. J Spinal Disord. 2000;13(2):174-7 4. Sucu HK, Gelal F. Lumbar disk herniation with contralateral symptoms. Eur Spine J 2006;15:570-4. [Crossref] [PubMed 5. Akdeniz T, Kaner T, Tutkan I,Ozer AF. Unilateral surgical approach for lumbar disc herniation with contraletaral symptoms. J Neurosurg Spine. 2012;17:124-7 6. .Karabekir H. S. , Izhan A Y ,Atar E K ,YaycIoglu S, Gocmen- Mas N, Yazici C. Effect of ligamenta flava hypertrophy on lumbar disc herniation with contralateral symptoms and signs: a clinical and morphometric study 7. Garfin SR, Rydevik B, Lind B, et al. Spinal nerve root compression. Spine (Phila Pa 1976) 1995;20:1810-20. [Crossref] [PubMed] 8. Takahashi H, Wada A, Iida Y, et al. Antimicrobial prophylaxis for spinal surgery. J Orthop Sci 2009;14:40-4. [Crossref] [PubMed] 9. Safdarian M, Farzaneh F, Rahimi-Movaghar V. Contralateral radiculopathy: A kernohan–woltman notch-like phenomenon. Asian J Neurosurg 2018;13:165- 7. 10. Kalemci O, Kizmazoglu C, Ozer E, Arda MN. Lumbar disc herniation associated with contralateral neurological deficit: Can venous congestion be the cause? Asian Spine J 2013;7:60-2. [PUBMED] 11. Jun-Song Yang, MD, Dong-Jie Zhang, MS, and Ding-Jun Hao. Lumbar Disc Herniation with Contralateral Radiculopathy: Do We Neglect the Epidural Fat?