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Abstract

Giant lumbar disc herniation (GLDH) is common among adults aged 23-56 years who spend a significant amount of time seated or standing with heavy workloads. This case report discusses a 50-year-old male waiter with GLDH, leading to nerve root compression with neurological impairment. Initial magnetic resonance imaging (MRI) findings showed a differential diagnosis of GLDH and an epidural mass lesion. A follow-up MRI with contrast was performed to rule out more serious conditions, but it showed peripheral enhancement of the expansive process. The patient underwent surgical excision to alleviate symptoms and improve function. The diagnosis of GLDH can be difficult. The clinical presentation is hard to distinguish from other causes of lumbar canal stenosis, such as synovial cysts, epidural hematomas, metastases, and tumors.

Introduction

Giant lumbar disc herniation (GLDH) is an unusual spinal condition characterized by the displacement of intervertebral disc material beyond its normal anatomical boundaries. They represent 8%-22% of all lumbar disc herniation. In some cases, the herniated fragment may become sequestered [1]. Disc sequestration refers to the migration of herniated intervertebral disc fragments into the epidural space. Due to the anatomical configuration of the anterior epidural space, these fragments typically migrate in a lateral, cephalad, or caudal direction.

This atypical migration pattern may mimic the radiological appearance of spinal neoplasms, potentially leading to misdiagnosis [2]. The pathological migration of disc material can result in significant pain and functional impairment due to nerve root compression. Clinical manifestations commonly include localized lower back pain and radiculopathy, often accompanied by sensory deficits such as numbness or weakness along the affected dermatome. In severe cases, signs of cauda equina syndrome (CES) may be present, including perineal hypoesthesia and bladder or bowel dysfunction.

Magnetic resonance imaging (MRI) with gadolinium contrast remains the key diagnostic modality for differential diagnosis. Management strategies range from conservative approaches such as physical therapy, and pharmacological treatment to more invasive interventions like epidural steroid injections or surgical decompression, depending on the severity of symptoms and response to initial treatment [3].

We present the case of a patient whose preoperative imaging raised suspicion of a spinal tumor, but whose final diagnosis of GLDH was confirmed by histological analysis.

Case Presentation

A 50-year-old man with no significant past medical history reported a one-month history of progressive symptoms that initially manifested as intermittent neurogenic claudication associated with mild weakness in the left lower limb. Shortly thereafter, low back pain developed, typically triggered by prolonged standing and heavy lifting. Over the subsequent weeks, the symptoms gradually intensified, with the onset of left-sided lumbosciatica accompanied by a progressive sensation of heaviness in the left lower limb.

On general physical examination, the patient was alert and oriented, with no signs of systemic illness or fever. Neurological assessment revealed a steppage gait on the left side. A lumbar spinal syndrome was present, along with radicular symptoms following the left L5 distribution. A motor deficit consistent with L5 involvement (foot dorsiflexion) was 1/5 (Medical Research Council scale (MRC)). There were no sensory deficits or genitourinary sphincter disturbances. Laboratory work-up was...(More)

For more info please read, Giant Lumbar Disc Herniation Mimicking Spinal Tumor: A Case Report, by Cureus