Diagnosis of Ruptured Intervertebral Disc without Contrast Myelography and Comment upon Recent Experience with Modified Hemilaminectomy for Their Removal *

The work of Mixter and Hampton published in 1934 indicated that nerve root compression by displaced intervertebral disc elements was a common lesion and a frequent cause of radiating low back pain and "sciatica." This prediction has been fully substantiated. In fact, the surgical relief of this condition now occupies a place of considerable importance in most neurosurgical clinics. At first it was desirable to demonstrate the defects due to a ruptured disc or a protruded nucleus pulposus, or, at times, an hypertrophied ligamentum flavum, by the use of iodized oil injected into the spinal subarachnoid space. This was necessary in order to convince the profession, the orthopedic surgeon and, last but not least, ourselves. This procedure is time consuming, expensive, and disagreeable. The lipiodol causes a constant but usually not serious reaction. It remains permanently in the subarachnoid space, enters the basal cisterns in certain positions, and eventually drifts along the nerve sheaths. Removal of the oil requires opening of the dura and arachnoid membranes, and even then all of the oil is not recovered. It is now certain that the great majority of ruptured discs and hypertrophied ligamenta flava causing symptoms occur in the fourth or fifth lumbar interspaces, and with growing familiarity with the clinical picture we thought it might be safe to eliminate the use of contrast myelography in the majority of cases. We have now operated upon 16 patients from clinical evidence alone. In all 16 cases ruptured discs were found and they were removed with the usual highly satisfactory results in all but one. Our impression up to the present is that only doubtful or com-