Lumbar disc extrusion –clinical relation with size

1. Lumbar disc Extrusion – an observational study Vinod Naneria Girish Yeotikar Arjun Wadhwani Choithram Hospital & Research centre, Indore, India Clinical & Disc Size Part 4

2. Hakan SABUNCUOGLU Clinical improvement of patients was demonstrated with radiological regression, it sometime does not correlate with morphological or radiological changes in different patients. Spontaneous Regression of Extruded Lumbar Disc Herniation : Report of Two Illustrative Case and Review of the Literature. Hakan SABUNCUOGLU, Selcuk OZDOGAN, Erdener T‹MURKAYNAK Turkish Neurosurgery 2008, Vol : 18, No: 4, 392-396

3. Saal JA, Saal JS In a retrospective cohort study, Saal and Saal demonstrated that lumbar disc herniation with radiculopathy can be successfully treated with nonoperative procedures resulting in “good to excellent ” outcomes for approximately 90% of patients. Saal JA, Saal JS: Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy . An outcome study. Spine 14(4):431-417, 1989. Saal JA, Saal JS, Herzog RJ: The natural history of lumbar intervertebral disc extrusions treated nonoperatively . Spine 15(7):668-683, 1990

4. Spontaneous regression from intervertebral disc herniation. Propos of a series of 37 cases Martínez-Quiñones JV, Aso-Escario J, Consolini F, Arregui-Calvo R.   Neurocirugia ( Astur ). 2010 Apr;21(2):108-17 . Disc herniation can regress, or even disappear, in a number of patients , rendering the radiological findings not to be taken as the only surgical indication criterium . The best treatment is the one relying on a good doctor-patient relationship, suspended in a balance between conservative and surgical treatment . The disc herniation conservative healing, both clinical as radiological , do exist, being a concept to widespread among clinicians and patients also .  

5. References Spontaneous regression of symptomatic lumbar disc herniation. Ribeiro RP, Matos RM, Vieira A, Costa JM, Proença R, Pinto R . Acta Reumatol Port. 2011 Oct-Dec;36(4):396-8. Portuguese. Spontaneous resorption of sequestrated intervertebral disc herniation . Orief T, Orz Y, Attia W, Almusrea K . World Neurosurg . 2012 Jan;77(1):146-52. Epub 2011 Nov 17 . Spontaneous regression of intervertebral disc herniation--case reports . Rapan S, Gulan G, Lovrić I, Jovanović S . Coll Antropol . 2011 Mar;35(1):211-5 .

6. References Transcript levels of major MMPs and ADAMTS-4 in relation to the clinicopathological profile of patients with lumbar disc herniation . Tsarouhas A, Soufla G, Katonis P, Pasku D, Vakis A, Spandidos DA . Eur Spine J. 2011 May;20(5):781-90. Epub 2010 Sep 22 . Spontaneous regression from intervertebral disc herniation. Propos of a series of 37 cases. Martínez-Quiñones JV, Aso-Escario J, Consolini F, Arregui-Calvo R. Neurocirugia ( Astur ). 2010 Apr;21(2):108-17. Spanish.

7. References Spontaneous regression of herniated cervical disc fragments and its clinical significance . Pan H, Xiao LW, Hu QF . Orthop Surg. 2010 Feb;2(1):77-9. doi : 10.1111/j.1757-7861.2009.00067.x. Spontaneous regression of lumbar herniated disc . Chang CW, Lai PH, Yip CM, Hsu SS . J Chin Med Assoc. 2009 Dec;72(12): 650-3 Spontaneous disappearance of lumbar disk herniation within 3 months. Nozawa S, Nozawa A, Kojima H, Shimizu K. Orthopedics . 2009 Nov;32(11):852. doi : .3928/01477447-20090922-21 .

8. References Ultrastructural analysis on lumbar disc herniation using surgical specimens: role of neovascularization and macrophages in hernias . Kobayashi S, Meir A, Kokubo Y, Uchida K, Takeno K, Miyazaki T, Yayama T, Kubota M, Nomura E, Mwaka E, Baba H . Spine ( Phila Pa 1976). 2009 Apr 1;34(7):655-62 . Spontaneous regression of extruded lumbar disc herniation: report of two illustrative case and review of the literature . Sabuncuoğlu H, Ozdoğan S, Timurkaynak E . Turk Neurosurg . 2008 Oct;18(4):392-6 .

9. References Disc herniation-induced sciatica: medical or surgical treatment ? Legrand E, Hoppé E, Bouvard B, Masson C, Audran M . Rev Prat . 2008 Feb 15;58(3):285-93. French. Spontaneous regression of a huge subligamentous extruded disc herniation: short report of an illustrative case. Gezici AR, Ergün R. Acta Neurochir (Wien). 2009 Oct;151(10):1299-300 . Spontaneous regression of a lumbar disk herniation. Monument MJ, Salo PT. CMAJ. 2011 Apr 19;183(7):823. Epub 2011 Jan 31.

10. Case summary - 1 Six years follow up . Marginal reduction in size. No neurological deficit . Persisting with backache .

11. Persistence of same size, backache, no new deficit since 2004 Case summary - 2

12. Oct 2004

13. Oct 2004

14. Dec 2008

15. Dec 2008

16. Oct 2010

17. Oct 2010

18. Oct 2010

19. No changes in 3 years Case summary - 3

20. Sept 2007

21. Sept 2007

22. May 2010

23. May 2010

24. No relationship between size of disc and functions Case summary - 4

25. Comments In spite of huge disc size, there is no neurological deficit. There is limited straight leg raising on left side after 2 months of acute attack. Patient can still stand on his left toes indicating the power in the Gastrosoleus muscles.

26. Yet another example of relationship of size of disc and clinical status Case summary - 5

27. Contended disc – No appreciable changes in 7 years Case summary - 6

28. Case summary - 7

29. Case summary - 8

30. Case summary - 9

31. Case summary - 10

32. Case summary - 11

33. Case summary - 12

34. Feb 2010

35. Case summary - 13

36. No change in size , clinically OK Case summary - 14

37. March 2002

38. March 2002

39. May 2007

40. May 2007

41. Case summary - 15

42. Inferences Extruded disc – disappears completely. Extruded fragment – complete absorption. Extruded disc – reduce in size. Extruded disc – can recur at same level, same side or other side. Extrusion of disc – can occur at other site.

43. Inferences Extrusion of disc – genetic predisposing. Extrusion of disc – more with multiple level disc bulges. Extruded disc – may not reduce in size. Extruded disc – mostly with single root radiculopathy . Extrusion of disc – usually acute onset – last for few hours and pain decreases with some neurological deficit with in 24 hours.

44. Inferences Contended disc remains same for long time. There is no co-relation between size of prolapse /extrusion with amount of pain or neurological deficit. Foraminal disc – protrusion/extrusion causes severe pain and compressive radiculopathy . Neurological status never deteriorate after initial insult(damage at the time of extrusion)

45. Inferences EHL – improve to gr 3- 5 power depends on initial damage. Ankle jerks – do not come back Functional recovery – complete Back pain – remain Patients own assessment – Happy Extrusion – may be considered as final stage in disc pathology.

46. Purpose of presentation Conservative treatment is well accepted method of treatment of PID. There is no need to frighten the patient for possible hypothetical complications. In our experience, a mono radiculopathy never deteriorates to poly neuropathy. Poly neuropathy is a separate incident in the cases of pre-existing disc pathology.

47. Disclaimer All photographs were taken with the consent of the all patients. Clinical photos were also put with due verbal permission. This presentation strictly for students of orthopedics with the sole idea of propagating knowledge. Any objection as for photographs or x-rays, please inform [email protected] for prompt deletion. Material is collected from C.H.& R.C., Indore and from private clinics of the authors.

48. DISCLAIMER Information contained and transmitted by this presentation is based on personal experience and collection of cases at Choithram Hospital & Research centre, Indore, India, during last 25 years. It is intended for use only by the students of orthopaedic surgery. Views and opinion expressed in this presentation are personal opinion. Depending upon the x-rays and clinical presentations viewers can make their own opinion. For any confusion please contact the sole author for clarification. Every body is allowed to copy or download and use the material best suited to him. I am not responsible for any controversies arise out of this presentation. For any correction or suggestion please contact [email protected]