Posterior epidural migration of thoracic and lumbar disc material: a comprehensive 63-year systematic review with anatomical perspectives

Abstract

This study aims to thoroughly investigate the clinical presentation, duration of symptoms, radiological aspects of posterior epidural migration of disc fragments (PEMDF), and assess various treatment options and their impacts on patient functionality. A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We conducted a comprehensive search in PubMed, Web of Science, and Scopus from inception to March 2024. Patient demographic and clinical outcomes data were extracted from articles that met the inclusion criteria. The extracted data included patients' age, sex, duration of symptoms (months), clinical presentation, diagnostic imaging, PEMDF spinal level, surgical technique used, and functional outcome and clinical improvement with follow-up (months). The primary outcomes of interest were total recovery (complete resolution of neurological deficits), partial recovery (clinical improvement with residual neurologic deficits), stable status (no change from the patient's baseline), and worst outcome (new symptoms or neurological deficits appearing post-surgical treatment). This review examined 105 studies on the pathology of posterior epidural migration of disc fragments, including 29 case series and the remainder as case reports, involving a total of 175 patients. The median age of the cohort was 54 years (range, 19-95), with 75.61% male and 24.39% female. Symptoms lasted a median of 0.5 months (range, 0.1-120 months), with cauda equina syndrome (45.7%) as the most common presenting symptom, followed by radiculopathy (34.3%) and lower back pain (21.1%). A history of heavy lifting was reported in 10.7% of patients. In terms of treatment, 5 patients (2.9%) were managed conservatively, while 162 (92.6%) underwent laminectomy. Additional interventions included minimally invasive interlaminar surgery (3 patients, 1.7%), transforaminal lumbar interbody fusion (2 patients, 1.1%), interlaminar lumbar interbody fusion (1 patient, 0.6%), and endoscopic spine surgery (2 patients, 1.1%). Functional outcomes showed symptomatic improvement in 173 patients (98.9%), with one patient remaining stable and one experiencing worsening symptoms. Partial recovery occurred in 42 patients (24%), while 131 patients (74.9%) achieved total recovery. Our study highlights the rarity and diagnostic complexity of posterior epidural migration of disc fragments. Prompt and precise diagnosis is crucial to prevent further neurological decline. Surgical intervention to remove sequestered disc fragments has demonstrated excellent functional and clinical outcomes.

Keywords: Clinical outcomes; Clinical presentation; Disc material; Posterior epidural migration.