Disclosures: Jasmin Harounian, MD: No financial relationships or conflicts of interest

Case Description: A 62-year-old male presents with severe left lateral shin pain, ankle dorsiflexor weakness, and minimal low back pain. A 58-year-old postal worker presents with sudden-onset, severe left anterior thigh pain and limited mobility.

Setting: Academic outpatient physiatry clinic

Patient: 62-year-old male and 58-year-old male Assessment/

Results: Initial non-contrast MRI of the lumbar spine in both cases were negative for disc herniation. In case one, an electrodiagnostic study was performed to assess for another etiology of the foot drop, such as peroneal nerve palsy, and was consistent with an acute left L5 radiculopathy. A repeat MRI with gadolinium was obtained and revealed a circumferentially enhancing signal within the left neural foramen at L5-S1, consistent with a fragmented disc herniation. In case two, contrast MRI showed a fragmented extruded disc herniation in the outlet of left neural foramen at L2-L3. Both patients underwent epidural injections and subsequently reported improvement with regards to both pain and motor strength.

Discussion: Foraminal and far lateral disc herniations (FLDH) are uncommon, but they can be a significant cause of intractable leg pain. Although MRI has radically improved the detection of FLDHs, non-contrast studies can be still inconclusive. Gadolinium enhances the peripheral border of free fragments and is useful in diagnosis and treatment planning. Although contrast MRI use has been reported for paracentral herniations, there are no reports in the literature, to our knowledge, of contrast MRI use for detection of fragmented FLDH.

Conclusion: Contrast-enhanced MRI is not commonly utilized for evaluation of the lumbar spine unless infection or tumor are suspected. However, it can be a valuable modality in the diagnosis of foraminal and far lateral fragmented disc herniations, ultimately expediting treatment in patients with FLDH and unremitting pain.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/utility-of-contrast-enhanced-mri-in-diagnosis-of-foraminal-and-far-lateral-fragmented-disc-herniations-two-case-reports/