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      Spontaneous regression of extruded lumbar disc herniation: Correlation with clinical outcome

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          Abstract

          Objective:

          To evaluate the natural history of lumbar extruded disc with conservative treatment on MRI and to assess relation between the radiologic changes and clinical outcome.

          Methods:

          This prospective observational study was conducted at University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital between May 2015-June 2018. It included consecutive patients who were diagnosed as having lumbar symptomatic extruded disc as shown in MRI. After an average period of 17.0±7.2 months, repeat MRI was taken in 40 patients who received only conservative care during follow-up. Changes in the volume of herniated disc was measured. The patients were assigned into 3 groups as follow: (1) non-regression, (2) partial-regression, and (3) complete resolution. Numeric Rating Scale (NRS) pain score, the Oswestry Low Back Pain Disability Index (ODI) and muscle weakness were evaluated.

          Results:

          Based on disc volume of the T2-weighted MR images; four patients (10%) did not show any regression, six patients (15%) had a partial regression, and 30 patients (75%) had a complete resolution. Patients with complete resolution showed a significant improvement in the NRS pain score and the ODI score (p<0,001) over time. In patients with partial regression, only the ODI score improved significantly (p=0,043). Non-regression group did not show any improvement in any clinical outcome measure (p>0,05). Changes in the NRS scores over time were significantly higher in complete resolution group compared to non-regression group (p=0.016).

          Conclusion:

          The majority of the patients with extruded lumbar disc herniation might have reduction in size of herniated disc in the long run along with improvement in symptoms and function with conservative care.

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          Most cited references22

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          Recurrent disc herniation and long-term back pain after primary lumbar discectomy: review of outcomes reported for limited versus aggressive disc removal.

          Ghazala Datoo, Jean-Paul Wolinsky, Giannina Ambrossi … (2009)
          It remains unknown whether aggressive disc removal with curettage or limited removal of disc fragment alone with little disc invasion provides a better outcome for the treatment of lumbar disc herniation with radiculopathy. We reviewed the literature to determine whether outcomes reported after limited discectomy (LD) differed from those reported after aggressive discectomy (AD) with regard to long-term back pain or recurrent disc herniation. A systematic MEDLINE search was performed to identify all studies published between 1980 and 2007 reporting outcomes after AD or LD for a herniated lumbar disc with radiculopathy. The incidence of short- and long-term recurrent back or leg pain and recurrent disc herniation was assessed from each reported LD or AD cohort and the cumulative incidence compared. Fifty-four studies (60 discectomy cohorts) met the inclusion criteria, reporting the outcomes of 13 359 patients after lumbar discectomy (LD, 6135 patients; AD, 7224 patients). The reported incidence of short-term recurrent back or leg pain was similar after LD (mean, 14.5%; range, 7-16%) and AD (mean, 14.1%; range, 6-43%) (P < 0.01). However, more than 2 years after surgery, the reported incidence of recurrent back or leg pain was 2.5-fold less after LD (mean, 11.6%; range, 7-16%) compared with AD (mean, 27.8%; range, 19-37%) (P < 0.0001). The reported incidence of recurrent disc herniation after LD (mean, 7%; range, 2-18%) was greater than that reported after AD (mean, 3.5%; range, 0-9.5%) (P < 0.0001). Review of the literature demonstrates a greater reported incidence of long-term recurrent back and leg pain after AD but a greater reported incidence of recurrent disc herniation after LD. Prospective, randomized trials are needed to firmly assess this possible difference.
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            Failed back surgery syndrome: current perspectives

            Zafeer Baber, Michael Erdek (2016)
            The treatment of failed back surgery syndrome (FBSS) can be equally challenging to surgeons, pain specialists, and primary care providers alike. The onset of FBSS occurs when surgery fails to treat the patient’s lumbar spinal pain. Minimizing the likelihood of FBSS is dependent on determining a clear etiology of the patient’s pain, recognizing those who are at high risk, and exhausting conservative measures before deciding to go into a revision surgery. The workup of FBSS includes a thorough history and physical examination, diagnostic imaging, and procedures. After determining the cause of FBSS, a multidisciplinary approach is preferred. This includes pharmacologic management of pain, physical therapy, and behavioral modification and may include therapeutic procedures such as injections, radiofrequency ablation, lysis of adhesions, spinal cord stimulation, and even reoperations.
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              The natural history of herniated nucleus pulposus with radiculopathy.

              Agnes Takeda, K Shinomiya, O Nakai … (1996)
              The present study retrospectively investigated the morphologic changes that occurred during conservative treatment of patients with unilateral leg pain resulting from herniated nucleus pulposus without significant lumbar canal stenosis. The results were correlated with clinical outcomes and extruding forms to determine which type of herniated nucleus pulposus had the greatest capacity for spontaneous regression and how rapidly such regression might occur. The study population consisted of 77 patients with radiculopathy. All patients complained primarily of unilateral leg pain, and 94% had positive tension signs. Additionally, 32% exhibited muscle weakness corresponding to the symptomatic nerve root. All patients were studied more than twice using magnetic resonance imaging during conservative therapy at a mean interval of 150 days. Morphologic changes on magnetic resonance imaging fell into four categories, with herniated nucleus pulposus classified into three types using T1-weighted sagittal views. Each patient was reexamined on the same scanner; 53 patients were examined twice, and 24 patients were examined more than three times. Morphologic changes, with the exception of 13 false-negative cases, basically corresponded to clinical outcome. In half of the cases that showed some improvement at follow-up evaluation, improvement of clinical findings were seen before those observed on magnetic resonance imaging. Migrating herniated nucleus pulposus frequently presented an obvious decrease in size, and even disappearance in seven cases. The further the herniated nucleus pulposus migrated, the more decrease in size could be observed. The cases apparently corresponding to "protrusion" showed little or no change on follow-up magnetic resonance imaging. Regarding the mechanism of herniated nucleus pulposus disappearance, exposure to the vascular supply undoubtedly took a part, although many factors were suspected to have some influence. Morphologic changes on magnetic resonance imaging mainly corresponded to clinical outcomes but tended to lag behind improvement of leg pain. Disappearance of herniate nucleus pulposus was seen frequently in the cases of migrating disc herniation, and it was presumed that exposure to the vascular supply had a lot to do with this phenomenon.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Pak J Med Sci
                Journal ID (iso-abbrev): Pak J Med Sci
                Title: Pakistan Journal of Medical Sciences
                Publisher: Professional Medical Publications (Pakistan )
                ISSN (Print): 1682-024X
                ISSN (Electronic): 1681-715X
                Publication date (Print): Jul-Aug 2019
                Volume: 35
                Issue: 4
                Pages: 974-980
                Affiliations
                [1 ]Bilge Kesikburun, MD, University of Health Sciences, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Department of Physical Medicine and Rehabilitation, Ankara, Turkey
                [2 ]Emel Eksioglu, MD, Associate Professor, University of Health Sciences, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Department of Physical Medicine and Rehabilitation, Ankara, Turkey
                [3 ]Aynur Turan, MD, Associate Professor, Department of Radiology, University of Health Sciences, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Department of Radiology, Ankara, Turkey
                [4 ]Emre Adiguzel, MD, Associate Professor, University of Health Sciences, Gulhane School of Medicine, Department of Physical Medicine and Rehabilitation, Gaziler Physical Therapy and Rehabilitation Training and Research Hospital, Ankara, Turkey
                [5 ]Serdar Kesikburun, MD, Associate Professor, University of Health Sciences, Gulhane School of Medicine, Department of Physical Medicine and Rehabilitation, Gaziler Physical Therapy and Rehabilitation Training and Research Hospital, Ankara, Turkey
                [6 ]Aytul Cakci, MD, University of Health Sciences, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Department of Physical Medicine and Rehabilitation, Ankara, Turkey
                Author notes
                Correspondence: Dr. Bilge Kesikburun, MD, Department of Physical Medicine and Rehabilitation, Diskapi Yildirim Beyazit Training and Research Hospital, Kazim Karabekir Boulevard, Aslanbey Street, Iskitler, Ankara, Turkey. Email: drbilgekb@ 123456gmail.com
                Article
                Publisher ID: PJMS-35-974
                DOI: 10.12669/pjms.35.4.346
                PMC ID: 6659070
                PubMed ID: 31372127
                SO-VID: 09badc91-d1fe-421c-9315-98c737094a54
                Copyright © Copyright: © Pakistan Journal of Medical Sciences
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 09 January 2019
                Date revision received : 14 January 2019
                Date revision received : 24 April 2019
                Date accepted : 05 May 2019
                Categories
                Subject: Original Article

                Keywords: low back pain,lumbar disc herniation,pain,spine,spontaneous regression
                Data availability:
                Keywords: low back pain, lumbar disc herniation, pain, spine, spontaneous regression

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