Memoire Online - Clinical, radiological and therapeutic aspects of the lumbar disc herniation operated in central Africa (DRC/ Kinshasa)

CLINICAL, RADIOLOGICAL AND THERAPEUTIC ASPECTS OF THE LUMBAR DISC HERNIATION OPERATED IN CENTRAL AFRICA (DRC/ INSHASA)

Frederick Tshibasu Tshienda MD¹, Jean Mukaya Tshibola MD PhD¹, Emmanuel Ndoma Kabu MD PhD ¹, Michel Lelo Tshikwela MD PhD¹ , Jean Marie Mbuyi Muamba MD PhD².

1.¹Division of Diagnostic Imaging, University Hospital of Kinshasa, School of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo

2. Department of Internal Medicine, Division of Rheumatology, University Hospital of Kinshasa, School of Medicine, University of Kinshasa , Kinshasa, Democratic Republic of Congo

Corresponding author: Frederick Tshibasu Tshiendafredtshibasu@gmail.com

ABSTRACT

Objectives:Showing the clinical and radiological aspects of the lumbar disc herniation operated in hospital environments of Kinshasa then establishing the link between radiology and surgery results.

Materials and methods:Retrospective and documentary study of 160 cases of lumbar disc herniation operated in Biamba Marie Mutombo hospital over 4 years: from January, 2012 till December, 2016.Taking advantage of the fact that among 160 Computed Tomography Scans (CT scans) of the 160 patients, 48 patients have also effectuated Magnetic Resonance Imaging Scans (MRI scans), a data sheet allowed the collection of clinical, radiological and surgical data.

Results: The mean age of patients is 44, 7#177;12, 3 years. The most interesting age group range from 31 to 50 years (68, 8%). Females were the most affected with 55.6%. Housewives were more affected with 35.6%. Sciatica L5 was found in 28.8% of cases, sciatica S1 in 15.6% and left lateralization in 48, 1%. As for imaging results, the posterolateral type was the most common with 53.8% of cases.The disc level: L4-L5 was the most affected in 61.1% of cases.The single lumbar disc herniation was the most common. The discrepancy between imaging and surgery results was 6.3% for medial herniated discs and 24.4% for posterolateral disc herniation.

Conclusion: Lumbar disc herniation is a pathological reality in hospitals of Kinshasa. The aspects found mainly corroborate literature observations, except for some environment peculiarities. The discrepancy between imaging and surgery results was statistically insignificant.

Keywords: disc herniation- Sciatic- Magnetic Resonance Imaging- Computed Tomography scan

I. INTRODUCTION

Lumbar Disc Herniation (LDH) is a major public health issue around the world [1], whose disabling low back pain, whether associated or not with sciatica, is the clinical expression [2]. It is defined as an overflowing focal disc containing, in addition to the annulus fibrosus, the nucleus pulposus, migrated from its central position to the periphery, roughly associated with the cartilaginous elements of plateaus, marginal listella and inflammatory reaction tissue in the presence of nucleus pulposus [3]. According to the World Health Organization (WHO), LDH causes 15% of absenteeism in force workers [1]. In France, low back pain is the most common reason for consulting in rheumatology with around 26% of hospitalized patients and 30% of outpatients [4].In the US, 50 to 90% of Americans have low back pain that causes serious work disabilities and LDH is responsible for 1 to 30% of low back pain (or subjects or cases to avoid repetition) [5, 6].The incidence of LDH varies from one country to another. In Burkina Fasso and Mali, there are, respectively, 47% and 23.6% of cases [7, 8]. While in Ivory Coast and Tunisia, the rate is quite low at 10.3% [9] and 2.2% [10], respectively.In theDemocratic Republic of the Congo, observations made in Kinshasa by Mukuna in 1990 and Kutoloka in 2002 reported respectively 2.3 and 4.3 patients per year [11, 12]. Nzanzu in 2011 reported a rate of 26.4% [13]. It should be noted that until 2005, the only scanner available at University Clinics in Kinshasa presented some difficulties in terms of functioning [11, 12].LDH is certainly a reason for absenteeism from work and the alteration of quality of life because of the professional incapacity it provides. The WHO reports a rate of 15% of absenteeism from work among forced laborers, demonstrating its economic impact in terms of productivity [1, 2]. Its financial impact is dramatic in the industrialized countries, then all the more so in low-income countries such as the Democratic Republic of the Congo.In France, there are approximately 37000 surgical procedures per year for disc herniation [4, 14]. In England, the financial impact would be in the range of 16 to 50 billion U.S. dollars [15]. However, it should be noted that upstream of any surgical sanction, medical Imaging thrones, useful in the diagnostic confirmation. This is the opportunity to wonder about the regulatory role of surgical decisions, played by medical imaging? This is all the more relevant because, to the best of our knowledge, no prior study has so far defined the relevance of medical imaging in the management of lumbar disc herniation operated in hospitals in Kinshasa. In view of this impact, we propose to meet the following objectives:

Main objective: Describe the clinical, radiological and therapeutic aspects of LDH operated in hospitals in Kinshasa.

Specific objectives:To determine the sociodemographic characteristics of patients who undergone surgery forLDH, Describe the triggers of LDH, locate the most affected intervertebral discs, highlight the type and subtype of the operated LDH, analyze the biological profile in the operated LDH and compare the results of the imaging before the surgery to the intraoperative result of the LDH.

II.MATERIALS AND METHODS

It was a retrospective and documentary study conducted from January 2012 to June 2017, a period of four and a half years. The study was mono-centric and involved patients who received hernia treatment at Biamba Marie Mutombo Hospital (BMMH). The study population consisted of records of patients operated for Lumbar Disc Herniation, each having a sectional imaging examination (CT or MRI). The sample was exhaustive and included all patients undergoing Lumbar Disc Herniation.The study included any patients of Congolese nationality, male or female, aged at least 15 years, operated on for Lumbar Disc Herniation and with a medical record containing the desired variables of interest.This study does not include patients with incomplete medical records. Any patient operated on LDH outside the study period or in another hospital institution or any patient before surgery on LDH, was not included in this study.

To carry out this work, the following materials were used: patient files, collection cards and data entry materials including statistical software. Each file included a consultation sheet containing the information sought.A pre-established data collection sheet was used to transcribe all data for each patient. It included the parameters or study variables. As for the data collection, it was carried out in two stages: the first stage consisted in the search of the cards and the second stage consisted in the data transcription on the card of collection of the data.A Dell computer equipped with software: Epidata 3.1, SPSS version 21, Excel and Word 2010 was used for data entry and analysis.The following variables were included in each data sheet: socio-demographic characteristics (age, sex and origin of the patient), clinical parameters (weight, height, hernia installation wayand trigger factor for Lumbar Disc Herniation),Para clinical parameters (laboratory tests, standard radiography, CT scan and MRI results), classification of lesions according to level, number, type and subtype of LDH.The intraoperative result as well as the intraoperative incidents and complications.Quantitative variables were expressed as mean, standard deviations or median with extremes and qualitative variables as a percentage. The Pearson chi-square test was used in the comparison of the qualitative variables. The materiality threshold was set at 0.05. The odd ratio (95% confidence interval) had studied the risk existing between the variables. The results are presented in the form of tables and figures.The principle of confidentiality was rigorously observed when collecting, entering and analyzing data using anonymity. No manifestation of any conflict of interest has been brought to our attention.

Ø Age was expressed in years, patients were grouped by 10-year age groups, conventionally.

Ø The body mass index (BMI) is the weight-to-height ratio squared (

), expressed in kilograms per square meter

Ø The admission delay was the period between the date on which the LDH diagnosis was made on imaging and the date on which the patient had undergone hernia repair. This period was divided into age groups: 1-7 months, 8-16 months and ? 16 months.

Ø Provenance, defined the various institutions of origin of the operated patients.

Ø "Paralyzing" and "paresiante" sciatica was defined as lumbar pain radiating to the lower limbs responsible for deficit of the levator or flexor foot.

Ø The hyperalgesic sciatica defined an intense radicular pain, causing insomniaand hardly relieved by morphine.

Ø Sciatica + having the cauda equine syndrome defined pain related to the compression of the other lumbosacral roots with sphincter disorders such as incontinence and anesthesia in saddle or hemi-saddle.

Ø Alternating sciatica and bilateral sciatica defined bilateral synchronous or successive radicular pains.

Ø L3 sciatica defined radiculalgiaon the anteromedial aspect of the thigh and then stopping at the inner side of the knee.

Ø L4 sciatica, defined the radicular pain on the anterior aspect of the thigh, the leg and which stops on the kick.

Ø L5 sciatica, defined the root pain on the posterolateral side of the thigh, external side of the leg, bypassing the external malleolus and stopping at the big toe.

Ø S1 sciatica defined the radicular pain in the posterior aspect of the buttock, thigh, leg, heel, and plantar surface of the foot which stops at the small toe.

Ø Disc herniation, defined as a focal discal overflow containing, in addition to the annulus fibrosus, nucleus pulposus, migrated from its central position towards the periphery associated with the cartilaginous elements of the plateau, the marginal listel and the inflammatory reaction tissue to the presence of the nucleus pulposus.

Ø Sub-ligamentous disc herniation: protrusion of disc material under LVCP. The sub-ligamentous migrated disc herniation: sliding of the disc material between the LVCP and the vertebral body, adopting a descending or ascending path.

Ø Extra ligamentous disc herniation: it is a protrusion of the disc material with rupture of the LVCP.

Ø Excluded disc herniation: defined by the presence of a disc material having lost all connection with the rest of the nucleus pulposus and migrated into the spinal canal at a distance from its floor (or level).

Ø The median disc herniation: protrusion of the disc material in the medial part of the vertebral canal or in zone A. It is less common (10%).

Ø Posterolateral disc herniation: protrusion of the disc material in the paramedian part of the vertebral canal or in zone B. It is the most common (80%).

Ø The foraminal disc herniation: it is a localization of the disc material within the foramen of conjugation. It is very rare.

Ø Extraforaminal disc herniation: it is a localization of the disc material outside the foramen of conjugation. It is very rare.

Ø The inflammatory balance sheet: divided into normal and disturbed, was considered as disrupted when one of the exams (VS, CRP)was elevated beyond normal values.

III. RESULTS

SOCIO-DEMOGRAPHIC CHARACTERISTICS OF PATIENTS

SEX OF PATIENTS

The sample in this study includes 160 patients' files, 89 of which are women (55.6%) and 71 are men (44.4%) with a sex ratio M/W of 0.8 (see figure 1).

The average age of our patients was 44.7 #177; 12.3 years with extremes ranging from 16 to 79 years. The youngest was 16 years old while the oldest was 79 years old.The table below illustrates comparative representation by sex and age group.

Table I: Distribution of patients by age and sex

Age group	Gendre				Total
	Male		Female		Total
	Number of patients	%	Number of patients	%	Number of patients	%
=30	3	4,2	5	5,6	8	5,0
31 - 40	26	36,6	29	32,6	55	34,4
41 - 50	19	26,8	36	40,4	55	34,4
51 - 60	11	15,5	11	12,4	22	13,8
61 - 70	10	14,1	7	7,9	17	10,6
=71	2	2,8	1	1,1	3	1,9
Total	71	100,0	89	100,0	160	100,0

This table indicates that age groups from 31 to 50 years were the most represented (68.8%).

The distribution by occupation indicated that there were employees, unemployed persons and persons practicing the liberal profession (see Table II).

Table II. Distribution of patients by profession

Profession	Number of patients	%
Household	57	35,6
Civil servants	44	27,5
Accountants	20	12,5
Tradespeople	15	9,4
Mechanics	14	8,8
Nurses Other (student)	9 1	5,6 0,625
Total	160	100,0

The distribution by occupation indicates that housewives were the most attacked by the disease.

ORIGIN

The study also focused on patient origins. The table below presents a summarization.

Origin	Numberof patients	%
National Electricity Company	53	33
University Clinics of Kinshasa	25	15,6
Commercial Banks of the Congo	23	14,4
Management Sciences for Health (MSH)	17	10,63
Biamba Marie Mutombo Hospital	15	9,4
Kinshasa Medical Center (CMK)	14	8,8
United Nations Observer Mission for the Stabilization of Congo (MONUSCO)	13	8,1
Total	160	100,0

The majority of patients come from the National Electricity Company with a percentage of 33%.

ANTHROPOMETRIC CHARACTERISTICS OF PATIENTS

The study of the body mass index gave rise to the results reported in the table below.

Table IV. Patient distribution according to BMI

CLINICAL PARAMETERS

Reading this figure indicates that in most cases, the triggering factor was unknown. However, the uplift effort was the main triggering factor in this study with 16.3%.

Table V below shows the various installation modes of lumbar disc herniation.

Table V. Distribution of patients according to the mode of installation of the herniated disc

The median time from diagnosis to actual patient hospitalization for hernia cure was 17.5 days. This period was divided into age groups: 1-7 months, 8-16 months and ? 16 months. Table VI below gives a summarization.

Table VI. Distribution of patients according to the admission delay

It can be seen from this table that 89.4% of patients were admitted within 1 to 7 months and 1.3% were more than 16 months old. The median admission time was 17.5 days.

*. RADICULAR PATH

The analysis of the various root paths is summarized in Table VII.

Table VII. Distribution of patients by root path

Root paths	Number of patients	%
L5
- Left	23	14,4
- right	15	9,4
- Bilateral	8	5,0
S1
- Left	12	7,5
- right	8	5,0
- Bilateral	5	3,1
Poorly systematized
- Left	35	21,9
- Right	20	12,5
- Bilateral	9	5,6
Truncated
- Left	7	4,4
- Right	3	1,9
- Bilateral	5	3,1
Cruralgia	10	6,3

Table VII indicates that the left side was the most affected. Poorly systematized lumbosciatica were the most common with 64 cases (40.0%), while 10 patients (6.3%) had cruralgia.

CLINICAL EXAMINATION

*. SPINAL SYNDROME

Limitation of spinal mobility

Table VIII. Distribution of patients according to spinal mobility

The following table shows that in 57.9% of patients, the hand-to-ground distance was limited to 51 cm and more.

Table IX below illustrates the distribution of patients according to the Lasègue's sign.

Table IX. Patient distribution according to the Lasègue sign

Lasègue's sigh	Number of patients	%
ipsilateral
<45	60	37,5
>45	50	31,25
contralateral	25	15,625
Absent	13	8,125
Bilateral	12	7,5

The sign of Lasègue was present in 66, 75%, absent in 8,125% and bilateral in 7, 5% of cases.

NEUROLOGICAL SYNDROM

Sensitivity balance sheet

Table X below shows the distribution of patients according to the sensitivity examination.

Table X. Distribution of patients by sensitivity examination

Variable	Number of patients	%
Normal	120	75,0
Hypoesthesia - L5 - S1
Hypoesthesia - L5 - S1	13 12	8,1 7,5
Anesthesia - L5 - S1	10	6,3
	5	3,1

The table above shows that sensitivity was normal in 75% of patients and disrupted in 25%.

Motricity (or traction) balance sheet (or records)

Table XI below reports the distribution of patients according to the motricity (or traction) examination.

.Table XI. Distribution of patients according to the examination of motricity

Table XI above shows that motor skills (motricity) were normal in 50.6% and disrupted in 49.4%.

COMMON SCIATICS AND LDH REBELS TO MEDICAL TREATMENT.

Table XII below illustrates the various clinical situations that may require a hernia cure. Among the 160 patients, there are 51 cases of hernias that are resistant to medical treatment. Table XII gives a distribution according to their clinical manifestations or etiological diagnosis.

Table XII. Distribution of patients according to clinical forms and LDH rebels to medical treatment

Clinical forms and LDH rebels to medical treatment	Number of patients	%
hyperalgic	80	50,0
paralytic	19	11,9
Cauda equina syndrome Herniated discs rebel to medical treatment	10 51	6,3 31,9

Table XII shows that the hyperalgic form was the most encountered in this series.

PARACLINIC FOCUS

*. INFLAMMATORY balance sheet (records) AND HEMOGRAM

All patients had performed the laboratory examinations mentioned above. The distribution of these various results is shown in Table XIII

Table XIII. Distribution of patients according to the results of the inflammatory balance sheet and the hemogram

	Number of patients	%
Inflammatory balance sheet Normal	130	81,3
disturbed
· Increased CRP	20	12,5
· Accelerated VS	10	6,2
Complete blood count
· Normal	155	96,9
· Disturbed	5	3,1

It can be seen from Table XIII above that no inflammatory marker is specific for LDH.

MEDICAL IMAGING

* Standard radiography

Standard X-rays were performed in all 160 patients, in whom there were 32 common X-rays. This is summarized in Table XIV below:

Table XIV. Patient distribution according to the results of standard radiography

X-ray	Number of patients	%
Normal	32	20,0
Disc pinching	95	59,4
Transitional anomalies
- Lombalization de SI	12	7,5
- Sacralization de L5	14	8,8
Lumbar spine rectitude	7	4,4

Table XIV shows that disc pinching was the most common anomaly with 59.3%.

*Computed tomography (CT)

The previous herniated disc was not found in any patient. All cases were of the posterior type as summarized in Table XV below.

Table XV. Distribution of patients by type and subtype of lumbar disc herniation at CT.

Imaging Diagnosis		Number of patients	%
Herniation type	Sub-type
Anterior hernia	-	-	-
Posterior hernia
	- Median hernia	80	50,0
	- Posterolateral hernia	85	53,1
	- Foraminal hernia	5	3,1
	- Extraforaminal hernia	5	3,1

This table shows that the median and posterolateral hernias were predominant in the proportions of 50% and 53.1%, respectively.

Among 160 patients, 48 (30.0%) patients had an MRI examination in addition to CT. Figure 2 below shows the distribution. Among these 48 patients, 47.9% had posterolateral DH, 33.3% had a median DH, and 18.8% had a foraminal hernia.

This figure confirms once again that the foraminal subtype is rare, as in the CT scan.

ANATOMICAL AND TOPOGRAPHIC DISTRIBUTION OF LESIONS

Table XVI below illustrates the distribution according to the number and disc level concerned.

Table XVI. Distribution of patients by number and level of disc level affected

Number of discfloors	Level of disc floors	Number of patients	%
Unique	L4 - L5	55	34,4
	L5 - S1	35	21,9
	Total	90	56,3
Double	L3 - L4, L4 - L5	10	6,3
	L4 - L5, L5 - S1	45	28,1
	Total	55	34,4
Triple	L3 - L4, L4 - L5, L5 - S1	15	9,4

Table XVI shows that multiple localization is quite common in our environment.

ASSOCIATED PATHOLOGIES

Figure 3 below shows the pathologies associated with hernia in this study.

Figure 3. Pathologies associated with operated lumbar disc herniation.

Figure 3 indicates that hypertrophy of the yellow ligament was frequently associated with lumbar disc herniation (62.5%).

STATISTICAL ANALYSIS

* RELATIONSHIP BETWEEN THE SUB-TYPES OF HERNIA AND SEX

Table XVII represents a comparative study of the subtypes of the encountered LDH and sex.

Table XVII. Cross representation between subtypes of hernia and sex

Hernia sub type	Sex		P	OR (IC à 95%)
Hernia sub type	Male	Female	P	OR (IC à 95%)
Median hernia
Yes No	37 (52, 1%) 34 (37, 9%)	43 (48, 3%) 46 (51, 7%)	0,633	0,859 (0,460 - 1,604)
Posterolateral hernia
Yes No	41 (57, 74%) 30 (42, 3%)	44 (49, 4%) 45 (50, 6%)	0,295	0,715 (0,382 - 1,381)
Foraminal hernia
Yes No	1 (1, 4%) 70 (98, 6%)	4 (4, 5%) 85 (95, 5%)	0,265	3,294 (0,360 - 30,149)
Extraforaminal hernia
yes No	2 (2, 8%) 69 (97, 2%)	3 (3, 4%) 86 (96, 6%)	0,841	1,203 (0,196 - 7,406)

Table XVII reveals that there was no statistically significant relationship between subtypes and sex. In contrast, the risk was 3 times higher in women with foraminal hernias and 1 time higher in men with extra foraminal hernias.RELATIONSHIP BETWEEN THE SUBTYPES OF LDH AND THE LIFTING EFFORT AS A TRIGGER FACTOR.

The notion of lifting force as a triggering factor was found in 16.3% of the patients. Below is the distribution of these cases according to this triggering factor.

Table XVIII. Relationship between the subtypes of the hernia and the effort of uplift.

Hernia subtype	Uplifting effort
Hernia subtype	Yes	No	P	OR (IC à 95%)
Median hernia
Yes No	14 (53, 8%) 12 (46, 2%)	66 (49, 3%) 68 (50, 7%)	0,668	1,202 (0,518 - 2,790)
Posterolateral hernia
Yes No	14 (53, 8%) 12 (46, 2%)	71 (53, 0%) 63 (47, 0%)	0,936	1,035 (0,446 - 2,444)
Foraminal hernia
Yes No	25 (96, 2%) 1 (3, 8%)	130 (97, 0%) 4 (3, 0%)	0,817	1,300 (0,139 - 12,123)
Extraforaminal hernia
yes No	0 (0, 0%) 26 (100, 0%)	129 (96, 3%) 5 (3, 7%)	0,317	0,963 (0,931 - 0,995)

Table XVIII indicates that there was no statistically significant relationship between the subtypes and the lifting effort. However, the risk was multiplied by 1.202 for median DH, 1.035 for posterolateral DH, and 1.300 for foraminal DH, respectively.

RELATIONSHIP BETWEEN THE SUBTYPES OF LDH AND TRAUMATISM AS A TRIGGERING FACTOR.

The concept of trauma as a triggering factor was found in 11.9% of patients in our study. The table below summarizes its distribution.

Hernia subtype	Trauma		P	OR (IC à 95%)
Hernia subtype	Yes	No	P	OR (IC à 95%)
Median hernia
Yes No	4 (21, 1%) 15 (78, 9%)	76 (53, 9%) 65 (46, 1%)	0,255	1,901 (0,648 - 5,007)
Posterolateral hernia
Yes No	10 (52, 6%) 9 (47, 4%)	75 (53, 2%) 66 (46, 8%)	0,963	0,978 (0,375 - 2,552)
Foraminal hernia
Yes No	1 (96, 2%) 4 (3, 8%)	18 (97, 0%) 137 (3, 0%)	0,568	1,903 (0,201 - 17,976)
Extraforaminal hernia
yes No	1 (96, 2%) 4 (3, 8%)	18 (97, 0%) 137 (3, 0%)	0,568	1,903 (0,201 - 17,976)

There is no statistically significant link between subtypes of hernia and trauma. However, it should be noted that the risk was multiplied by 1.901 for the medial hernia, 1.903 for the foraminal hernia and 1.903 for the extra foraminal hernia (Table XIX).

The concept of sport as a triggering factor was only found in 5.6% of the cases on our entire workforce. The table below summarizes its distribution.

Hernia subtype	Sport
Hernia subtype	Yes	No	p	OR (IC à 95%)
Median hernia
Yes No	0 (0, 0%) 9 (100, 0%)	80 (53, 0%) 71 (47, 0%)	0,002	0,470 (0,397 - 0,557)
Posterolateral hernia
Yes No	8 (88, 9%) 1 (11, 1%)	77 (41, 0%) 74 (51, 0%)	0,027	7,688 (0,938 - 62,935)
Foraminal hernia
Yes No	0 (0, 0%) 9 (100, 0%)	5 (3, 3%) 146 (96, 7%)	0,579	0,967 (0,939 - 0,996)
Extraforaminal hernia
yes No	0 (0, 0%) 9 (100, 0%)	5 (3, 3%) 146 (96, 7%)	0,579	0,967 (0,939 - 0,996)

The median and posterolateral DH had a statistically significant relationship with the sport with p = 0.002 and p = 0.027, respectively. The risk was multiplied by 7.688 in the posterolateral hernia (Table XX).

RELATIONSHIP BETWEEN THE SUBTYPES OF LDH AND HYPERTROPHY OF YELLOW LIGAMENT AS AN ASSOCIATED PATHOLOGY.

Hypertrophy of the yellow ligament was the most predominant associated pathology at 62.5%. Table XXI summarizes its relationship with the various subtypes.

Table XXI. Relationship between subtypes of hernia and hypertrophy of ligament.

Hernia subtypes	Hypertrophy of the yellow ligament				P
	No		Yes
	Number of patients	%	Number of patients	%
Median Yes No	7	61,7	43	43,0	0,022
	23	38,3	57	57,0	0,022
Posterolateral hernia
Yes No	15	25,0	60	60,0	?0,001
	45	75,0	40	40,0	?0,001
Foraminal hernia
Yes No	60	100,0	95	95,0	0,078
	0	0,0	5	5,0	0,078
Extraforaminal hernia
yes No	55	91,7	100	100,0	0,003
	5	8,3	0	0,0

Table XXI shows that three subtypes of posterior LDH had a statistically significant relationship with hypertrophy of the yellow ligament: p = 0.022 (median DH), p = 0.001 (posterolateral DH), p = 0.003 (extraforaminal DH).RELATIONSHIP BETWEEN THE SUB-TYPES AND LOMBARTHROSIS AS ASSOCIATED PATHOLOGY

The study sought to establish the link between subtypes of LDH and lumbar spondylosis, which was present in 34.4% of the cases. This is well illustrated in the table below.

Table XXII. Relationship between subtypes of hernia and associated pathologies (lumbar spondylosis)

Hernia subtypes	LOMBARTHROSIS				P
	No		Yes		P
	Number of patients	%	Number of patients	%
Median hernia Yes No	62	59,0%	18	32,7%	0,002
	43	41,0%	37	67,3%	0,002
Posterolateral hernia
Yes No	45	42,9%	30	54,5%	0,159
	60	57,1%	25	45,5%	0,159
Foraminal hernia
Yes No	100	95,2%	55	100,0%	0,100
	5	4,8%	0	0,0%	0,100
Extraforaminal hernia
yes No	100	95,2%	55	100,0%	0,100
	5	4,8%	0	0,0%

Table XXII shows that there is a statistically significant relationship between the posteromedial subtype and lumbar spondylitis with a value of P equals to 0.002.

RELATIONSHIP BETWEEN THE SUB-TYPES AND THE Lumbar spinal stenosis AS ASSOCIATED PATHOLOGY

The Lumbar spinal stenosiswas found as an associated pathology in 21.9% of cases. Table XXIII below illustrates the relationship with the various subtypes.

Table XXIII. Relationship between the subtypes of the hernia and the Lumbar spinal stenosis

Hernia subtypes	Lumbar spinal stenosis				P
	No		yes		P
	Number of patients	%	Number of patients	%
Median hernia
Yes No	61	48,8	19	54,3	0,566
	64	51,2	16	45,7	0,566
Posterolateral hernia
Yes No	60	48,0	15	42,9	0,590
	65	52,0	20	57,1	0,590
Foraminal hernia
Yes No	120	96,0	35	100,0	0,229
	5	4,0	0	0,0	0,229
Extraforaminal hernia
yes No	120	96,0	35	100,0	0,229
	5	4,0	0	0,0

We conclude from the table XXIII that there is no statistically significant link between the Lumbar spinal stenosis and the different subtypes.

RELATIONSHIP BETWEEN DIAGNOSIS OF MEDICAL IMAGING AND INFLAMMATORY BALANCE SHEET

A relationship between the result of the inflammatory balance sheet and the various subtypes of LDH has been sought. Table XIV below generates a summarization.

Table XXIV. Imaging diagnosis and results of inflammatory balance sheet

Imaging diagnosis	Inflammatory balance sheet				Total		P
	disturbed		Normal
	Number of patients	%	Number of patients	%	Number of patients	%
Median hernia	10	5,7	70	40,0	80	45,7	?0,001
Posterolateral hernia	15	8,6	70	40,0	85	48,6
Foraminal hernia	5	2,8	0	0,0	5	2,8
Extraforaminal hernia	0	0,0	5	2,8	5	2,8
Total	30	17,1	145	82,9	175	100,0

Table XXIV indicates that the inflammatory balance was only disturbed in 30 of the 160 patients. A statistically significant link was noted between the result of the imaging and the result of the inflammatory balance sheet (p = 0.001).

All 160 patients underwent laminectomy with hernia repair. Table XXV below reports the concordances and discrepancies found between the diagnosis of imaging and the intraoperative results.

Table XXV. Comparative illustration between the diagnosis of imaging and the intraoperative results.

diagnosis of imaging	intraoperative diagnosis	n/%	P
Median hernia	Posterolateral hernia under ligament	5 (6,3)	<0,001
	Medial hernia under ligament	75 (93,7)
	Total	80 (100,0)
Posterolateral hernia	Bony outgrowth compressing the roots	1 (1,2)	<0,001
	Ejected posterolateral hernia	5 (5,8)
	Posterolateral hernia under ligament	60 (69,8)
	Ejected median hernia	10 (11,6)
	Median hernia under ligament	10 (11,6)
	Total	85 (100,0)
Foraminal hernia	Foraminal hernia	5 (100,0)	<0,001
	Total	5 (100,0)	<0,001
Extraforaminal hernia	Extraforaminal hernia	5 (100,0)	<0,001
	Total	5 (100,0)

Table XXV shows that the discrepancies between the imaging results and the intraoperative results were of the order of 6.3 and 24.4% concerning the medial and posterolateral disc hernias respectively. A statistically significant link was noted between subtypes of LDH and intraoperative diagnosis (p?0.001).

DISCUSSION

The clinical and para clinical profile of the Congolese from Kinshasa suffering from lumbar disc herniation is that of a female individual (55.6%), aged on average 44.7 #177; 12.3 years, obese (39.4%), complaining mainly of lumbosciatic L5 (28.8%), more lateralized on the left (14.4%), triggered by the lifting effort and whose neurological disorders were marked by hypoesthesia and anesthesia respectively at (8, 1 et 7, 5%), associated with motor disorders (49.4%).Conventional X-ray was pathological in 80.0%, CT in 100% and MRI in 30.0% of operated patients.The analysis of the results revealed statistically significant links (69.3%) respectively between the medical imaging results and the intraoperative results, then (82.9%) between the LDH subtypes and the results of the inflammatory balance sheet. This led us to point out some peculiarities of the environment, even if the study corroborates the observations of the literature globally.

This study shows that 110 out of 160 patients (68.8%) were aged between 31 and 50 years old. The mean age was 44.7 #177; 12.3 years with extremes ranging from 16-79 years. LDH was overwhelmingly a pathology of young adults. The latter would generally be exposed to heavy work, incriminated in the pathogenesis of LDH. Our results are very close to those found in the literature. Indeed, LDH lumbosciatica occur most often in young adults aged 30 to 50 years [16]. Some small variations were noted according to the series, but most often, the age of the patients at the time of the diagnosis is 50 % of the times between 36 and 55 years [17-18]. At CNHU Hubert Maga of Cotonou, Tononhi studies showed an average age of 44.9 years [16]. Tchuindjang found that the most affected age groups were between the ages of 31 and 60, with the prevalence of the 41 to 50 age group and a median age of 45.6 years. Ouattara had found a median age of 43.5 years with a predominant attack between 40 and 49 years. Kutoloka, in his series, found an average age of 48.4 years [12, 19].

The sex

In this study the female predominance was found in 110 cases (55.6%) out of a total of 160 patients, with a sex ratio of 0.8 in favor of the woman. We believe that it is possible that the large participation of Congolese women in the activities of survival pushes them to exert activities of effort thus overloading their lumbar spine. The high number of maternity could also play a role in lumbar spine imbalance.Our results would be close to those of Bamako study in 2005 that found a female predominance with a sex ratio of 1.95.Unlike the study conducted in Burkina Faso where the sex ratio was 1.9 in favor of men [8, 9].Our results are, on the other hand, in contradiction with some data of the literature which are unanimous on the male predominance of the herniated disc as well in Mali, in Africa or even in the world with a sex ratio oscillating between 1.4 according to Diarra M and 1.9 according to Tchuintdjang K [8, 20].

Profession

This study indicates that 57 out of 160 patients (35.6%) were housewives. This category of the population is exposed to a sedentary life, predisposing to develop obesity which is incriminated in the imbalance of spinal biomechanics, because of the overload it imposes. Our observations corroborate the data in the literature. Davis reports a higher prevalence of LDH among sedentary people, without providing any application.This could be explained either by obesity or by the accentuation of the early degeneration of the disc by repeated trauma and micro trauma [22].It should be noted that professional activity is criminalized in 36.6% of cases of forced or manual workers and 26.7% of those in sedentary jobs [17, 23, and 24].Nevertheless, it should be noted that, according to De Korvin et al, lumbosciatica affects all professional sectors, that they make use of the muscles (20% of the handlers, 40% of the building workers and 40% of the caregivers) or that they are sedentary (30% of women and 40% of men clerks) [4].

The origin

The majority of patients in the series, 53 patients or 33.1% came from the National Society of Electricity. This can be explained by several reasons: notably by an offer of care more granted to the National Society of Electricity agents and their family members, the heavy work that some agents face, not to mention the large number of the National Society of Electricity agents who attend the hospital as part of their agreement with Biamba Marie Mutombo Hospital.

Uplifting effort was the most criminalized factor with 16.3% of cases. It is a risk factor for both lumbosciaticaand lumbosciaticaon LDH [17], concomitantly with other factors such as sports, trauma, prolonged standing, cold, obesity and driving. . No statistically significant link was noted between the subtype of the hernia and the lifting effort.

On the other hand, the risk was multiplied by 1,202 for the medial hernia, 1,035 for the posterolateral hernia and 1,300 for the foraminal hernia.The high incidence of this factor could also be explained by the fact that the majority of patients in this series consisted of housewives who are exposed to muscular efforts to provide for their families. Our data are close to those of the literature: Deshayes and Mandour had also incriminated the lifting effort in their series with respectively 38% and 49.1% of cases [25, 26]. This difference in percentages could be explained by the fact that in this series the triggering factor was not specified in 66.3% of cases.

In this series, obesity was found in 39.4% of cases. The housewives were the most frequent professional category. This category of people is subject to a sedentary life, exposing them to obesity that is one of the triggers of the LDH [21]. Another reason is that the abdominal musculature counterbalances the powerful action of the extensors. Its deficiency, its distension in obese or pregnant women, as well as its inefficiency accentuate lumbar lordosis, which, in turn, accelerates disc degeneration [21].

This study showed that 71 patients (44.4%) had a progressive mode of LDH installation. This could be explained by a high rate of self-medication with analgesics and anti-inflammatories in our environment.It should be noted that LDH sciatica are installed in two modalities: acute and progressive. In the first, pains occur from the start in lightning, associated with a more or less marked functional impotence. As for the second, it spreads in a few days and follows a history of low back pain or lumbago.In this series, acute onset was noted in 25% of cases. This is in accordance with the results generated by Mandour and Lazorthes with 27.5% and 28% respectively [26, 27]. On the other hand, the progressive start of the 44.4% recorded in this series was far lower than the observations of Mandour and Deshayes, who reported respectively 58.8% and 60% [25, 26]. This difference was probably due to the fact that the installation method was not specified in our series in 49 patients (30.6%).

The admission delay in this series ranged from 1-7 months in 143 patients (89.4%). This delay corresponds to the time elapsed between the date when the diagnosis of disk herniation was made in imaging and the hospitalization for a surgical cure for LDH. During this period, patients consulted several doctors and received various therapeutics. The median admission delay was 17.5 days in this series. This is probably due to the terror that the surgical procedure caused in many people. In the different series of the literature, the admission period ranges from one week to 10 years with a maximum frequency between 1 month and 1 year [23]. Our results are close to those of the literature on this point.

This study showed that 50.6% of patients were admitted to the hospital in emergency, against 49.4% of patients admitted to hospital by appointment. This is explained by the fact that the majority of patients operated on (68.2%) had symptomatic forms of LDH hernia (the hyperalgic, paralyzing, and Cauda equina syndromes), which were found in 50%, 11.9% and 6.3% of cases respectively, while the LDH rebels to medical treatment were found in only 31.9% of cases.

The study of radicular path in our series showed a predominance of poorly systematized lombosciatalgia in 46 cases (28.8%), followed by L5 locations in 46 cases (28.8%) and S1 in 25 cases (15.6%). This large number of poorly systematized lumbosciatalgia could be explained by the fact that the neurological examinations were probably brief, carried out by the general practitioners. The frequent attack of the L5 root could be explained by the vulnerability of the root L5 with respect to the root S1, whose lesion can evolve slowly for a long time before manifesting itself. Our data are in agreement with the results of Mandour and Lazorthes [26, 28].The predominance of lateralization on the left was noted in this series in 77 cases (48.1%) compared to 46 cases (28.8%) in the right side. We have no explanation to give in this regard.Bilateral sciatica was found in our series in 19.3% of cases. We do not have a particular reason to provide against this observation. Nevertheless, our data are close to the results of Gandin who reported 16% of cases [29].

Low lumbar stiffness was assessed by hand-to-ground distance in all patients,among which 116 patients (82.9%) had a distance greater than 30 cm. This rate was slightly higher than that reported by Mandour, accounting for 53.2% of cases [26].Lasègue's maneuver was the most explored gesture in the neurological examination. It was noted in 147 patients (91.9%), 68.75% of these patients are noted with an ipsilateral positive Lasegus, 15.625% with a contralateral positive Lassec and 7.5% with a bilateral positive Lassec. Indeed, following its impact on the nerve root, disc herniation, in most cases, reduces the normal amplitude of root slip in the inter-disco-apophyseal parade [30]. This is why it shows correlations with the degree of progression of LDH [31]. For Klat M and Mbuyi M, the first degrees of the sign of Lasègue are the most determining for the diagnosis of sciatica of disc origin [31]. A Lasègue sign below 25 ° -30 ° indicates severe sciatica. When the sciatic pain of the patient is reproduced by the elevation of the contralateral lower limb, it is a contralateral Lasègue. At Gandin and El Azhari the sign of Lasègue was positive in 75% and 87% respectively [29, 32].

In this series, these disorders were investigated in all patients, 120 of these patients (75%) had normal sensitivity, 25 patients (15.6%) had hypoesthesia, while anesthesia was found in 15 patients (9,4%).Sensitivity disorders generally consisted of hypoesthesia, see, superficial anesthesia in the L5 or SI territory (on the antero-external part of the leg, the back of the foot and the big toe in case of L5 involvement and On the Achilles' tendon, the heel, the sole of the foot when suffering from SI).These sensitivity disorders were also found by Deshayes in 25% of cases and by El Azhari in 42% of cases [25, 32].

Segmental motricity function was evaluated in all patients in this series. Eighty-one patients (50.6%) had no motor deficit, 35 patients (21.9%) had paresis and 34 patients (21.3%) had complete paralysis. Our results are in agreement with the observations of Dheshayes who reported paralytic sciatica in 9.1% and paresiant sciatica in 23.9% [25]. Similarly Guieu reported paralyzing sciatic in 10% and paresiant in 14% [33]. As for Brement, he had reported 5.8% of paralytic sciatica and 10.8% of parasiant sciatica [34].

It prohibits any spinal mobilization. The pain is excruciating, not relieved by the decubitus. After radiological assessment and when this pain does not give way under medical treatment, it can impose a surgical intervention. In our series, hyperalgic sciatica was found in 80 patients (50% of all patients). Our results are close to those of the study of Davis who found in his series 76% of hyperalgic forms [21].Nevertheless, our observations were in contradiction with the data of Brement which had found a frequency of 24, 16% [34]. Barhourhe, on a sample of 266patients? , found a frequency of 25.93% [24]. This high rate of the hyperalgesic form explained why nearly 50% of patients had an admission time of around 17.5 days.

This form was observed in 19 patients (11.9%) of this series. In general, paralytic sciatica presents itself first as a common or hyperalgic sciatica and then, the pain disappears, leaving room for a brutal or sub-acute motor deficit. This most often concerns the antero-external compartment of the leg. In some cases, electromyography can quantify the motor impairment and follow its evolution. Our observations are consistent with those of Guieu [33] and Deshayes [34] who reported a frequency of 10% and 9.1% respectively. Barhoure [24] had a frequency of 14.27%.

Cauda equina syndrom

This syndrome was noted in 10 patients (6.3%) of this series. It translates a compression of the roots of the Cauda equina by a bulging hernia, often in a postero median position. This syndrome is rare both in literature and in our series. Our observations are close to Pierron's data [35] which reported a frequency of 5.4%. As for Rafik [36], he reported a frequency of 2.7%.

Operated LDH remains rare in the elderly. Our series identified 3 patients (1.9%) aged 71 years or older, including 2 men and one woman. This could be explained by the fact that neurosurgeons and anesthesiologists avoid taking risks because surgery and anesthesia at this age remains very delicate. In children and adolescents, LDH was also rare. Our series had noted a single case operated at the age of 16 years. Our results are close to those of Rafik [36] and Mrabet [37] who reported respectively 1.1% and 3%.

PARACLINIC EXAMINATIONS

Biology

? Inflammatory balance sheet and hemogram

Our study shows that of the 160 patients, 130 patients (81.3%) had a normal inflammatory balance sheets. Thirty patients (18.7%) had a disturbed inflammatory balance, of which 12.5 with increased CRP and 6.2% with accelerated VS. Note also that the blood count was disrupted in 3.1% of cases.

A relationship has been sought between the inflammatory balance and the different types of LDH. It follows that of the 80 cases of median DH, 10 cases (5.7%) had a disturbed inflammatory balance. Similarly, of the 85 cases of postero-lateral DH, 15 cases (8.6%) had a disturbed inflammatory balance, whereas 5 out of 5 cases of foraminale DH had a disturbed inflammatory balance. The study found a statistically significant relationship between imaging diagnoses and inflammatory outcome (p = 0.001).

However, it should be noted that LDH is a degenerative affection that does not positively influence the rate of sedimentation [34, 37]. It should be noted that accelerated VS and elevated CRP in some patients in our study may be due to other conditions that were not likely to be investigated or reported in the charts. Some authors also found high levels of CRP in LDH [38]. According to the latter, the disc pathology is marked by a systemic inflammatory response related to the degree of progression of the herniated mass.

The results of standard radiography in this study had shown an overall pinch of the disc in 95 patients (59.4%). The examination was normal in 32 patients (20%). Transitional abnormalities were found in 26 patients (16.2%), whereas spinal rectitude was seen in 7 patients (4.4%). The standard radiography is the first examination to realize before the failure of the medical treatment. El Azhari [32] and Czorny [39] had also noted a global disc narrowing respectively in 32% and 25% of cases.

Posterior LDH was found in 100% of patients in our series. The median DH was observed in 80 patients (50.0%), posterolateral DH in 85 patients (53.1%), foraminal DH in 5 patients (3.1%) and finally the extra foraminal hernia also in 5 patients (3.1%).In our series, single disc herniation's were frequently found in 90 cases (56.3%). Disc level L4 - L5 was the most highly affected in 55 cases (34.4%). These results corroborate the work of Suk, Rompe, Porchet, Kimn and Kutoloka [40]. The predominance of impairment at the L4-L5 level may be due to the fact that this disk is probably more constrained than the L5-S1 stage.Double disc herniation's were found in 55 cases (34.4%) with a predominance of discs L4 - L5 and L5 - S1 in 45 cases (28.1%). These last two discs are the most mobile of the lumbosacral hinge, hence the predominance of the attack on their levels. Triple disc herniation's were found in 15 cases (9.4%) in L3 - L4, L4 - L5 and L5 - S1. Our results are consistent with those of the literature for both disc stages and topography of lesions. In Destandau [41], the stages (L3-L4, L4-L5 and L5-S1) were concerned in 15%, 51% and 25% of cases, respectively. This confirms that the L4-L5 and L5-S1 disks are the most affected because of the importance of the stresses and pressures exerted there [42].Note that the first two disks: L1-L2 and L2-L3 were not affected in our series.

In our series, 48 patients had benefited from the CT-lumbar MRI pair, i.e. 30% of cases. We did not notice a discrepancy of results between these two techniques. This can be explained by a small number of patients who have done both exams at the same time. Which makes it impossible to draw realistic conclusions.

Our series shows that hypertrophy of the yellow ligament was the spinal pathology most commonly associated with lumbar disc herniation's in 62.5% of cases, followed by narrow lumbar canal in 21.9% of cases. Transitional abnormalities and retrolisthesis were the least recovered in 6.2% of cases.A statistically significant link was noted between the three subtypes of posterior LDH and hypertrophy of the yellow ligament with p values 0.022 (median LDH), 0.001 (posterolateral LDH) and 0.003 (extraforaminal LDH), respectively.The narrow lumbar canal can be primary or secondary. It seems that fibrosis occurring during any herniated disc is at the origin of the formation of osteophytes and hypertrophy of the facet joints, causing the compression of bone structures still called primary structures. This is called the primary narrow lumbar canal [2].The hypertrophy of the yellow ligament concerns only the ligamentous structures of the rachis still called secondary structures. Hence its name narrow secondary lumbar canal.Lumbar osteoarthritis is the most common degenerative pathology. It constitutes more than a quarter of the etiologies of lumbosciaticaaccording to the literature. This hypothesis has not been confirmed in this series. Moreover, these three pathologies are degenerative pathologies of the spine like herniated discs. This is why their association is frequent. In addition, the transitional anomalies of the lumbar hinge had a negligible percentage.

The surgical treatment of LDH had to be well qualified in some cases. In this study, the notion of admission delay and its comparison with literature data allowed us to identify three operative indication groups:

· A delay of less than or equal to 7 months: 89.4% of patients operated on for surgical emergencies, including hyperalgic sciatica, paresis, paralyzing sciatica and Cauda equina syndrome. Our observations are consistent with those in the literature, which report an admission period ranging from one week to 10 years with a maximum frequency between 1 month and 1 year [23].

· Delay between 8-16 months: 9.4% of patients operated on tramp sciatica who were resistant to medical treatment.

· A delay greater than or equal to 16 months: 1.3% of patients operated for sciatics not amenable to medical treatment.

- The confrontation of the results of the medical imaging (CT-MRI) with those of the surgery of the LDH operated allowed to create the following:

- With respect to median hernias, out of 80 cases, the study found a discrepancy in results in 5 patients (6.3%).

- Regarding postero-lateral lumbar disc herniation, out of 85 operated cases, there was a discrepancy in 21 patients (24.4%).

- As for foraminal and extraforaminal hernias, the results were confirmed by intraoperative imaging.

- The other point of disagreement was due to the fact that the CT scanner was silent with the lumbar disc herniation ejected, which became anxious intraoperatively.

The significant rate of discordance in posterolateral lumbar disc herniation could be attributed to an error in the evaluation of the various disc zones by the radiologist or simply to the following regression of hernia volume in patients who received medical treatment based anti-inflammatory before surgery. Note a statistically significant statistical link established between the results of the imaging and the results per operation with a value (p?0.001).

To the best of our knowledge, this study is the first to be conducted in a hospital in Kinshasa and to set the stage for a confrontation between the radiological and intraoperative results of the LDH operated. This would avoid unjustified surgical indications and insufficient diagnoses in terms of imaging in our environment. However, we recognize that it has some weaknesses including:

· The absence of a prospective study allowing the re-reading of certain images of examinations carried out with a view to a diagnostic requalification.

The present study revealed the clinical, radiological and therapeutic aspects of LDH operated in hospitals in Kinshasa. It allowed us to compare the results of medical imaging with those of surgery.It turned out that, LDH is the prerogative of young patients, 110 patients(68.8%) with a peak between the age groups of 31 to 50 years.

A slight female predominance was observed in 89 cases, i.e. 55.6% with a sex ratio of 80 men per 100 women.The effort of uprising was more incriminated as the triggerof the pathology disc. Sciatica L5 was more common with lateralization preferentially on the left.Floors L4-L5 and L5-S1 were the most affected. Posterolateral LDH was the most common subtype with 53.1%.The discrepancy between the results of the imaging and those of the surgery was statistically insignificant(6.3%) for median LDH and 24.4% for posterolateral LDH.

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