The Spine Journal - (2013) -

Clinical Study

Similar outcome despite slight clinical differences between lumbar

radiculopathy induced by lateral versus medial disc herniations in patients
without previous foraminal stenosis: a prospective cohort study
with 1 year follow-up
Oriane A. M
erot, MD, Yves M. Maugars, MD, Jean-Marie M. Berthelot, MD*
Rheumatology Unit, Nantes University Hospital, CHU Nantes, Place Alexis Ricordeau, 44093 Nantes, France
Received 19 March 2013; revised 30 July 2013; accepted 19 September 2013

Abstract BACKGROUND CONTEXT: It has been claimed that lumbar radiculopathy induced by foram-
inal disc herniations had poorer outcome and different clinical features, including: 1-more progres-
sive onset, but shorter duration between the first sign and request of medical care; 2-more severe
radiculopathy; 3-less frequent/severe back pain; 4-less limitation of straight leg raising (SLR);
5-more frequent neurologic deficiencies; 6-poorer outcome.
PURPOSE: To check whether this still holds true when including only patients without other rea-
sons for foraminal stenosis, that is, whether patients with medial disc herniations had different fea-
tures and outcome than those with more lateral disc herniations.
STUDY DESIGN: All patients hospitalized to treat a lumbar radiculopathy within a 6-month pe-
riod in two French rheumatology units in 2012 were included in this prospective study each time
computed tomography scan or magnetic resonance imaging had already been performed and
showed clear disc bulging/herniation but no features of medial or lateral spinal stenosis.
PATIENT SAMPLE: Fifty-nine patients (31 males, 49 with sciatica only) were included: 31
(53%) had medial disc herniations and 28 (47%) had more lateral herniations (posterolateral in
3, foraminal in 20, and far lateral in 5).
OUTCOME MEASURES: Outcome was assessed by a phone call 1 year after the baseline assess-
ment using a standardized questionnaire. Patients were asked whether they experienced a relapse of
their radiculopathy after discharge from the hospital; whether they had been operated or not;
whether they felt it had improved or not; whether they felt cured or not; to assess their level of pain
radiating in the leg when standing on a 0 to 10 verbal scale; and how long they could walk.
METHODS: Features of patients with medial disc herniations were compared with patients with
more lateral herniations.
RESULTS: No significant differences according to the location of herniations were noticed for the
speed of radiculopathy onset, time elapsed since onset, back pain (both lying or standing), and leg
pain (both lying or standing), but slight significant differences (t test!0.05) were observed for other
items: the 28 patients with lateral herniations were 8 years older (53.4 615.8 vs. 45.2612.6), their
herniations involved discs from upper levels of the lumbar spine (above L4–L5: 7/28 vs. 3/31), mo-
tor weakness was more frequent (25% vs. 3%), SLR was less restricted (65.0 624.5 vs.
51.1 625.7 ), DN4 score of neuropathic pain was higher (4.462.1 vs. 3.261.8), anxiety level
was higher (10.364.1 vs. 7.963.2), length of hospital stay was longer (5.762.4 days vs.
4.561.4 days), and physician’s prognosis of a good outcome was poorer (6.662.2 vs. 8.061.6).
However, at the end of follow-up (12.263.3 months), outcome was similar: 37% (vs. 41% for me-
dial herniations) had transiently relapsed, 66% felt finally improved (vs. 63%), and walking

FDA device/drug status: Not applicable. * Corresponding author. H^otel-Dieu-CHU Nantes, Service de Rhuma-
Author disclosures: OAM: Nothing to disclose. YMM: Nothing to dis- tologie, 44093 Nantes Cedex 01, France. Tel.: (33) 240.08.48.22; fax: (33)
close. J-MMB: Nothing to disclose. 240.08.48.21.
E-mail address: jeanmarie.berthelot@chu-nantes.fr (J.-M.M. Berthelot)

1529-9430/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.spinee.2013.09.020
2 O.A. M
erot et al. / The Spine Journal
capacity was nearly identical despite the fact that only 18% had to be operated (vs. 32% of those
with medial herniations).
CONCLUSIONS: Despite differences in clinical presentation, the outcome of radiculopathy in-
duced by the more lateral lumbar disc herniations was not worse than the outcome of patients with
only medial disc herniations. Previous claims of poorer outcome in foraminal herniations might be
explained by the inclusion of patients with associated foraminal stenosis. Ó 2013 Elsevier Inc. All
rights reserved.
Keywords: Disc; Herniation; Medial; Lateral; Foraminal; Radiculopathy; Sciatica; Outcome; Prognosis; Surgery
Introduction
Many spine surgeons and other physicians believe that
lumbar radiculopathy induced by lateral disc herniations
(ie, from posterolateral to foraminal and far lateral disc
herniations) has different clinical features from lumbar
radiculopathy induced by medial disc herniations. These
differences include more progressive onset and shorter du-
ration between the first sign and request of medical care
[1], more severe radiculopathy [2,3], less frequent/severe
back pain [2,4,5], less limitation of straight leg raising
(SLR) (in patients with sciatica) [2,4–6], more frequent
neurologic deficiencies [2,4–6], more frequent limping
[1], and older age [6]. Also, it has been claimed that pa-
tients with lateral (ie, from posterolateral to foraminal
and far lateral disc herniations [Figure]) might have poorer
outcome [1,7]. We sought to find out if this still holds true
when considering only patients without other causes of fo-
raminal stenosis. That is, we sought to study patients with-
out a history of either medial or lateral spinal stenosis. We
hypothesized that many of the abovementioned features,
ascribed to lateral disc herniations, are related more to
the worsening of preexisting foraminal stenosis than to
the disc herniation itself.
Participants and methods
Participants suffering from lumbar radiculopathy and
hospitalized from May 2011 to April 2012 in two rheuma-
tology units were evaluated for inclusion in this prospective
follow-up study. Inclusion criteria were definitive diagnosis
of lumbar radiculopathy with typical pain radiating below
the knee, associated either with neurologic signs (sensitiv-
ity, motor, and reflex) or with positive stretch signs (SLR
test, Lasegue sign, and femoral stretch test); clear, bulging
herniation of a single disc observed on a computed tomog-
raphy (CT) scan or magnetic resonance imaging (MRI) that
might account for the radiculopathy; exclusion of other
conditions, such as tumors or infections that could also in-
duce sciatica or femoral nerve pain; absence of either me-
dial or lateral spinal stenosis according to the Lee criteria
for foraminal stenosis [8]; and absence of anterolisthesis
or retrolisthesis [9].
Participants were asked on presentation to provide in-
formed consent, agree to complete baseline questionnaires,
- (2013) -
and be available later on for follow-up. The standard of care
for lumbar radiculopathy that included administering pain
relievers and one to three peridural injections of 5 ml of
a solution containing 125 mg of prednisolone acetate,
depending on easing of radiculopathy, remained unchanged
and was similar between the two units. All participants
benefited from education and physical therapy during their
initial stay in our medical units before discharge.
To prevent bias in choosing between medical and surgi-
cal management, participants were not informed that one
aim of the study was to compare the outcome of their rad-
iculopathy according to the location of their disc herniation,
and the surgeons remained unaware that participants had
previously completed the questionnaires. For each partici-
pant, the same rheumatology fellows in the two units
(OM) completed baseline questionnaires and recorded nu-
merous parameters on demographic information, descrip-
tion of the history of and the treatment for past and
present radiculopathies, magnitude of leg and back pain,
and results of neurologic and muscle tests (Table). Lasegue
test was defined as positive if the examiner observed pro-
duction of pain with a typically dermatomal pattern of dis-
tribution and pelvic muscle resistance during unilateral
provocative SLR below an angle of 60 . Crossed SLR
was defined as positive if the examiner observed the pro-
duction of pain with a typically dermatomal pattern of dis-
tribution and pelvic muscle resistance when the other leg
was raised below 90 . Last, patients fulfilled three scores:
the DN4 score of neuropathic pain [10], the French transla-
tion of Roland Disability Questionnaire adapted for radi-
culopathy (EIFEL score) [11], and the Hospital Anxiety
and Depression Scale [12]. Both physician and patients
expressed their prognosis on the ongoing radiculopathy
on a 0 (very poor prognosis) to 10 (very good prognosis
and no need for surgery) analog scale.
At the beginning of the study, disc herniations noted on
a CT scan or on an MRI were classified either as medial,
posterolateral (subarticular), foraminal, or lateral (Figure)
according to classifications of Li et al. [13] and Lee et al.
[7]. A repeatability assessment was not performed by other
physicians, but all classifications were done by the same
person who trained with senior rheumatologist (J-MB) by
using the Figure, so as to be as consistent as possible.
For comparisons, participants were separated into two
groups: those with medial herniations and those with
 O.A. M
erot et al. / The Spine Journal
Figure. Transverse plane scan of L2 from a young man without hernia-
tions to show the classification of location of disc herniations in four
possible areas: A, medial (between white arrows); B, posterolateral (sub-
articular) (between white arrow and first grey arrow); C, foraminal
(between first and second grey arrows); D, far lateral (between second
and third grey arrows). Disc herniations in ‘‘B to D’’ areas (included)
were defined as lateral, and disc herniations in the ‘‘A’’ area were defined
as medial.
posterolateral (subarticular), foraminal, and lateral hernia-
tions, as already suggested [14].
A year after discharge from the hospital, participants
were reached by telephone to answer questions about hav-
ing had a surgery or not; relapse of radiculopathy, if any;
feeling pain; overall outcome; and walking (despite the lim-
itation of this parameter) [15] using a five-point scale: 1,
below 50 m; 2, 50 to 200 m; 3, 200 to 500 m; 4, 500 to 2
km; 5, more than 2 km.
Statistics
The t test for unpaired observations with unequal vari-
ances was used to compare mean values between partici-
pants who had or had not undergone surgery and between
- (2013) - 3
participants with lateral or medial disc herniations. Alpha
was set at 0.05. Data were analyzed with the SPSS 12.0
software (SPSS Inc., Chicago, IL, USA).
Results
Clinical features
In the two rheumatology units, 59 patients meeting the
inclusion criteria (37 males) agreed to participate (Table).
Although all participants had some features suggesting
sciatica, in 10 (17%) the main area of pain was in the L4
root dermatome. Accordingly, the 49 participants whose
radiculopathies were strictly limited to the L5 and S1 areas
were analyzed as a subset of participants who had sciatica
(L5 or S1 areas) only.
Location of hernia
Thirty-one patients (53%) had medial disc herniations
and 28 (47%) had lateral herniations (posterolateral in 3,
foraminal in 20, and far lateral in 5). Location of disc her-
niations in the 59 participants was observed by CT scan in
45 (76%) and by MRI in 18 (31%), which includes four
participants who underwent both procedures.
Comparison of baseline features of patients with central
and lateral disc herniations (Table)
Patients with lateral disc herniations significantly dif-
fered from those with medial disc herniations for several
items, such as they were older; their DN4 scores were
higher; their anxiety scores were higher; muscle weakness
was more frequently observed; the SLR angles were less
restricted and Lasegue test was less frequently positive;
the length of stay in hospital was greater; the prognosis
of the rheumatology fellows on the outcome of their radi-
culopathy was poorer.
Same trends were also noticed for the subset of 49
patients with sciatica only, although differences less often
reached signification because of the lower number of pa-
tients. Patients (with sciatica only) with lateral disc hernia-
tions as compared with those with medial disc herniations:
1-were older; 2-their DN4 scores were higher; 3-their anx-
iety scores were higher; 4-muscle weakness was more fre-
quently observed as well as dermatome anesthesia; 5-the
SLR angles were less restricted and Lasegue test was less
frequently positive; 6-the length of stay in hospital was
greater; 7-the prognosis of the rheumatology fellows on
the outcome of their radiculopathy was poorer (data not
shown).
Outcome and surgery
All the patients responded to a questionnaire by phone
call 12.263.3 months after baseline. Fifteen of 59 (25%)
had been readmitted, but in a surgery unit, and operated 1
4 O.A. M
erot et al. / The Spine Journal - (2013) -

Table
Comparison of baseline features and outcome of participants with lateral and medial disc herniations
Location of disc herniation (n559)
Lateral (n528; 47%);
Posterolateral, 3;
Variables Foraminal, 20; Far lateral, 5 Medial (n531; 53%) p
1. Age, y (mean [SD]) 53.4 (15.8) 45.2 (12.6) !.05
2. Sex (M/F) 10 M 12 M
18 F 19 F
3. Weeks elapsed since onset of radiculopathy (mean [SD]) 22 (24) 21 (17) .83
4. Speed of onset of radiculopathy (n [%])
Very quickly (1 d to reach maximal pain) 5 (18) 8 (26)
Quickly (1 wk) 12 (43) 7 (23)
Slowly (between 1 wk and a month) 10 (36) 9 (29)
Very slowly (several months) 1 (4) 7 (23)
5. Predominant dermatomal pattern of distribution (n [%])
L4 7 (25) 3 (10)
L5 14 (50) 10 (32)
S1 7 (25) 18 (58)
6. Leg pain at rest (mean [SD]) 2.8 (1.8) 3.7 (2.4) .12
7. Leg pain when standing (mean [SD]) 5.3 (2.1) 5.4 (2.0) .85
8. Back pain at rest (mean [SD]) 2.6 (2.1) 2.3 (2.6) .68
9. Back pain when standing (mean [SD]) 4.0 (2.3) 3.9 (2.9) .89
10. Limping (n [%]) 12 (43) 13 (42) .94
11. Tingling (n [%]) 19 (68) 17 (55) .31
12. Dermatome anesthesia (%) (n[%]) 9 (32) 3 (10) !.05
13. Muscle weakness (n [%]) 7 (25) 1 (3) !.05
14. Decreased deep tendon reflexes in the knees or ankles (n [%]) 12 (43) 12 (39) .75
15. Positive Lasegue test (n [%]) 57 80 !.05
16. Femoral stretch test (n [%]) 4 (14) 5 (16) .85
17. SLR angle (  ) (mean [SD]) 65 (25) 51 (26) !.05
18. Positive contralateral SLR (n [%]) 2 (7) 5 (16) .29
19. DN4 score (mean [SD]) 4.4 (2.1) 3.2 (1.8) !.05
20. Rolland and Morris (mean [SD]) 17 (3) 16 (4) .52
21. HAD anxiety score (mean [SD]) 10 (4) 8 (3) !.05
22. HAD depression score (mean [SD]) 7.6 (3.2) 6.3 (3.9) .21
23. Rheumatology fellow’s prognosis 6.6 (2.2) 8.0 (1.6) !.02
24. Participant’s prognosis (mean [SD]) 5.3 (2.8) 6.4 (3.0) .14
25. Length (d) of hospital stay (mean [SD]) 5.7 (2.4) 4.5 (1.4) !.05
26. Status at 1-y follow-up
Underwent surgery (n [%]) 5 (18) 10 (32) .21
Achieved final cure with or without surgery (n [%]) 12 (42) 16 (52) .71
Pain in those not undergoing surgery (mean [SD]) 4.1 (3.1) 3.6 (3.3) .34
Walking ability (mean [SD]) 3.7 (1.8) 4.1 (1.6) .49
SD, standard deviation; SLR, straight leg raising; DN4, neuropathic score; HAD, hospital anxiety and depression scale.
Note: Walking ability was assessed on a five-point scale: 1, below 50 m; 2, 50 to 200 m; 3, 200 to 500 m; 4, 500 to 2 km; 5, more than 2 km.

to 6 months after hospital’s discharge from the medical
units (mean6standard deviation timeframe after discharge
from the medical unit: 3.162.0 months).
Only 2 of the 40 characteristics recorded at baseline (the
28 listed in the Table plus 12 minor items on past hospital-
izations or treatments for the ongoing episode) were signif-
icantly associated with the need of surgery to treat the
radiculopathy at the end of the follow-up: angle of SLR
(43.3 629.7 in those later operated vs. 66.7 621.7 in
those only treated conservatively [p5.01]) and positivity
of Lasegue test (73.3% in those later operated vs. 61.1%
in those only treated conservatively [p5.05]). This conclu-
sion also stands for the subgroup of 49 patients who only
suffered from sciatica (pain strictly restricted to the derma-
tome areas of L5 and S1 roots): angle of SLR (36.2 624.9
in those later operated vs. 60.0 620.1 in those treated con-
servatively [p5.01]).
Neither patients’ prognosis nor physician’s prognosis at
the baseline were able to predict which patients will be
operated. Indeed, patients’ prognosis were very similar in
the 15 patients later operated versus the 44 who were not
(5.362.7 vs. 5.863.2 [not significant]), and rheumatology
fellow’s prognosis, although more optimistic than patients’
prognosis, was worse for those who were finally not oper-
ated (7.962.1 vs. 7.162.1 [not significant]).
Of the 15 patients operated, 13 were quite immediately
relieved from their radiculopathy (average of leg pain for
this whole group being 0.661.3). This was significantly
lower than the mean pain in the group of 44 patients who
had only been treated conservatively (3.863.2) (p!.001).
 O.A. M
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Outcome of patients with medial and lateral disc
herniations (Table)
After more than 1-year follow-up, only 18% of patients
with lateral disc herniations had to be operated versus 32%
of those with medial herniations. Other outcome features
were very similar and not statistically different in the two
groups; indeed, 27% (lateral disc herniations) versus 22%
(medial disc herniations) felt cured without surgery and
42% (lateral disc herniations) versus 52% (medial disc her-
niations) felt cured with or without surgery. Walking capac-
ity was similar, overall resting pain was rather similar, and
muscle weakness was absent in all (Table). Similarly, only
37% (vs. 41% for median herniations) had transiently re-
lapsed after discharge from hospital and 66% felt finally
much improved (vs. 63% for those with median disc herni-
ations). Once again, this also applies to the subgroup of 49
patients with sciatica only; only 23% of patients with lat-
eral disc herniations had to be operated versus 37% of
those with medial herniations and other outcome features
were very similar; indeed, 27% (lateral disc herniations)
versus 37% (medial disc hernations) felt cured without
surgery (p5.54), walking capacity was quite identical
(3.961.7 vs. 4.261.6 on the 1–5 scale described in the
methods section) (p5.51), overall resting pain was rather
similar (3.263.0 vs. 2.263.0 [p5.27]), and muscle weak-
ness was absent in all. Similarly, 47% (vs. 42% for medial
herniations) had transiently relapsed (p5.74) and 71% felt
much improved (vs. 67% for medial disc herniations)
(p5.8).
Discussion
Knowing whether a lateral disc herniation needs more
surgery than medial disc herniation is a relevant question
given the large number of worldwide patients with dis-
abling radiculopathy lasting for months without spontane-
ous cure and the possibility that removal of lateral disc
herniation might favor further foraminal stenosis [16].
In this prospective cohort of patients with no spinal ste-
nosis and a single disc herniation, significant differences
have been found between patients with lateral and medial
disc herniations. This confirms some of the previous con-
clusions, or beliefs, that patients with lateral disc hernia-
tions are older, their SLR angle is less restricted, and
muscle weakness is more frequently observed. Other slight
differences, less previously emphasized, have also been no-
ticed including higher neuropathic and anxiety scores, per-
haps explaining their slightly longer stay in hospital.
Conversely, we could not confirm some previous state-
ments because radiculopathy was not more severe and its
onset was not more progressive in patients with lateral her-
niations. Similarly, we could not find differences in the
baseline back pain intensity and limping. Last but not least,
although the prognosis on the outcome of the radiculopathy
was poorer, there was in fact no difference in the outcome
- (2013) - 5
because patients with lateral herniation were even less often
operated and their mean status after more than 1 year
follow-up was quite similar to those of patients with medial
herniations.
This could suggest that previous associations with back
pain, limping, and radiculopathy severity might have been
linked to the combination of lateral disc herniations with
preexisting spinal stenosis (mostly foraminal stenosis),
leading to nearly complete obliteration of foramen and root
impingement. Another confounding factor might be the ra-
diographic location of dorsal root ganglion. Although Oh-
mori et al. [17] also found no significant differences
between the location of dorsal root ganglion and the preop-
erative sensory or motor disturbance and surgical outcomes,
preoperative leg pain was higher (despite a lower limitation
on the SLR) in their patients with extraforaminal location
of dorsal root ganglion.
Accordingly, to avoid self-prophecy effect leading to
premature surgery, physicians should not be pessimistic
when facing patients with lateral disc herniations but no
spinal stenosis; moreover, as the angles of SLR are higher
in those patients, lower angles of SLR was the only param-
eter predictive of further surgery as observed in nearly all
prospective studies devoted to the outcome of patients with
sciatica [18–20].
There are probably several explanations to the counter-
intuitive observation that patients with medial disc her-
niations have more restricted SLR than patients with
lateral disc herniations. First, an increase in the size of
the medial disc bulging because of lumbar kyphosis in-
duced by the SLR maneuver could induce further traction
on the root before entering the foramen. Second, kyphosis
should enlarge the volume of foramen and reduce the
entrapment of nerve root in patients with lateral disc her-
niation. Third, small-volume medial disc herniation may
cause more significant impingement of a neighboring ven-
trally located preneural lumbar nerve root because root
sleeves exiting from the ventrolateral angles of the thecal
sac are tigthened to it and cannot avoid the medial disc
herniation [21]. Fourth, the most important veins in fora-
men (radicular veins) are less susceptible to crush than
veins from the anterior epidural space, thanks to their spe-
cific arteriovenous anastomoses that raise their flow [22].
This hypothesis would be in line with the per-surgery
demonstration by Kobayashi et al. [23] that during SLR
maneuver, the intraradicular flow decreased by a mean
of 70% before hernia removal. Medial disc herniations
might indeed be a greater barrier to venous flow than lat-
eral herniations.
The strength of this study is its prospective design. Its
main shortcomings are the rather low number of patients
(N559), the mix of radiculopathies from L4 to S1 roots
(although results were roughly similar for the subset of
49 patients with sciatica only), and the method used for
long-term assessment (participants reached by telephone
to answer a questionnaire).
6 O.A. M
erot et al. / The Spine Journal
To better demonstrate that the prognosis of radiculop-
athy is more associated with the degree of foraminal ste-
nosis than with the location of disc herniation (lateral vs.
medial), another prospective study including a large num-
ber of patients with and without spinal (foraminal) steno-
sis would be welcome. Those patients should ideally
benefit at the baseline from a standardized MRI, with
the study of disc herniation and dorsal root ganglia loca-
tion and evaluation of foramen size including measures of
perineural fat obliteration around dorsal root ganglia [8]
although these are imperfect substitutes to the pressures
around and within it [24].
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