Spontaneous regression of a lumbar disc herniation

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Krystyna Wójcik
7 lat temu
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1 CHAPTER XIII WELLNESS AND EDUCATION 1 Chair and Department of Neurosurgery and Pediatric Neurosurgery Medical University in Lublin, Poland Katedra i Klinika Neurochirurgii i Neurochirurgii Dziecięcej Uniwersytetu Medycznego w Lublinie KRZYSZTOF TUROWSKI, PAWEŁ SZMYGIN, ELŻBIETA BARTOŃ Spontaneous regression of a lumbar disc herniation Samoistne zmniejszenie się przepukliny dysku lędźwiowego Key words: lumbar disc extrusion, spontaneous regression, MRI Spontaneous regression of herniated lumbar disk was first reported by Guinto et al.in 1984 [1] and Teplick and Haksin in With the increased availability of magnetic resonance imaging, several specialists have reported this phenomenon [5, 6]. Usually, regression of the herniated disk coincided with the improvement of associated neurological symptoms [4]. CASE PRESENTATION In this paper we present one case with spontaneous regression of extruded lumbar disk documented by MRI studies. A healthy, white, nonsmoking 31 year old female with 20 years history of intermittent lower back and right leg pain and numbness. There was no sphincter dysfunction. The results of the neurologic examination, including motor and sensory function, reflexes and a straight leg raise test were normal. Because of persistent symptoms MR of the lumbar spine was obtained ( ) and showed a large intervertebral disc herniation in the right paracentral region of the spinal canal at the level L4-L5 consistent with the patient right radiculopathy. She refused surgical treatment.

2 WELLNESS AND EDUCATION Figure 1. Lumbar spine magnetic resonance images. Sagittal T2-weighted scan demonstrates a large central disc herniation at level L4-L5 146

3 Ewa Zienkiewicz, Krystyna Mitosek-Szewczyk, Tadeusz Zienkiewicz, Increasing of Lyme disease incidence in Poland and necessity of education Figure 2. Lumbar spine magnetic resonance images. Axial T2-weighted scan demonstrates a large right paracentral disc herniation with compromise at the canal The medical management was continued, which included intramuscular steroids followed by oral nonsteroidal anti-inflammatory medication. Over the next several weeks patient s pain has been significantly reduced. In December 2015, the patient experienced low back and left leg pain. The results of the neurologic examination, including motor and sensory function, reflexes and a sphincter function were normal. A straight leg raise test was not normal on the left side. MR of the lumbar spine was obtained ( ). The previously demonstrated disc herniation L4-L5 had completely resolved but showed a large intervertebral disc herniation in the left paracentral region of the spinal canal at the level L5-S1. 147

4 WELLNESS AND EDUCATION Figure 3. Lumbar spine magnetic resonance images. Sagittal T2-weighted scan demonstrates resolved disc at the level L4-L5 and a large central disc herniation at level L5-S1 148

5 Ewa Zienkiewicz, Krystyna Mitosek-Szewczyk, Tadeusz Zienkiewicz, Increasing of Lyme disease incidence in Poland and necessity of education Figure 4. Lumbar spine magnetic resonance images. Axial T2-weighted scan demonstrates demonstrates resolved disc at the level L4-L5 149

6 WELLNESS AND EDUCATION Figure 5. Lumbar spine magnetic resonance images. Axial T2-weighted scan a large central disc herniation at level L5-S1 Because of strong pain i low back and left leg patient decided for surgery and was operated ( ). By excision of left ligament L5-S1 herniated has been removed and decompression of the radicle has been performed. The pain was relieved. 150 DISCUSSION Number of studies examining the mechanism and factors affecting the resorption of herniated disc have evaluated the natural history of changes in disc morphology, size, shape, MR signal intensity. The exact mechanism underlying this process is unclear and number of hypotheses have been proposed. 1. Retraction due to posteriori longitudinal ligament tension 2. Regression via tear in the annulus 3. Dehydration and shrinkage

7 Ewa Zienkiewicz, Krystyna Mitosek-Szewczyk, Tadeusz Zienkiewicz, Increasing of Lyme disease incidence in Poland and necessity of education 4. Disc degeneration 5. Enzymatic degradation 6. Resorption by macrophage phagocytosis 7. Inflammatory reaction 8. Neovascularisation of disk herniation Nozawa et al. [2] reported spontaneous and complete disappearance herniated lumbar disk in only three months, Chiriac at al. in eight months [3]. Patients who improved during the first 6 weeks may experience more rapid regression of their disc herniation with concomitant decrease in nerve root inflammation and pain [7]. Spontaneous regression of herniated disc is seen occasionally. Therefore, nonsurgical treatment can be an another therapeutic option, when the patient refused surgical treatment. REFERENCES 1. Guinto F.C. Jr, Hashim H., Stumer M.: CT demonstration of disk regression aftyer conservative therapy. AJNR Am J Neuroradiol. 1984, 5 (5), Nozawa S., Nozawa A., Kojima H., Shimizu K.: Spontaneous disappearance of lumbar disk herniation within 3 months. Orthopedics. 2009, 32,11 3. Chiriac A., Ion G., Faiyad Z., Poeta I.: Spontaneous regression of lumbar herniated disc. Case presentation. Romneu 2015, 29,4, Reyentovich A., Abdu A.W.: Multiple Independent, sequential and spontaneously resolving lumbar intervertebral disc herniations. Spine, 2012, 27,5, Kim G. S., Yang C.J., Kim W.T., Park K.H.: Spontaneous regression of extruded lumbar disc herniation: three cases report Korean J. Spine, 20113,10,2, Sabuncuoglu H., Ozdogan S., Timurkayak E.: Spontaneous regression of extruded lumbar disc herniation: report of two illustrative case and review of the literature, Turkish Neurosurgery, 2008, 19, 4, Buttermann G. R.: Lumbar disc herniation regression after successful epidural steroid injection J. Spinal Disord Tech., 2002, 15,6, ABSTRACT Most patients suffering from radiculopathy caused by intervertebral disc herniation heal spontaneously without surgical intervention. Since Guinto et al. first presented a case of spontaneous regression of a lumbar herniated disc using computed tomography (CT) in 1984, an increasing number of studies have described this phenomenon. Nevertheless, a case of spontaneous regression of large extruded lumbar disc is rare. This paper presents a case of lumbar radiculopathy caused by a large herniated disc at the L4/5 level in which clinical improvement was associated with a significant decrease in the size of the extruded disc fragment, which was document- 151

8 WELLNESS AND EDUCATION ed on the serial MRI scans. Possible explanations for disc spontaneous regression are also discussed. STRESZCZENIE Większość pacjentów cierpiących z powodu bólu kręgosłupa lędźwiowego promieniującego do kończyny dolnej wywołanego przepukliną dysku zdrowieje bez interwencji chirurgicznej. Guinto i wsp. w 1984 roku pierwsi opisali samoistne zmniejszenie przepukliny dysku lędźwiowego w komputerowej tomografii. Dotychczas niewielu autorów opisało samoistne ustąpienie znacznych przepuklin dysków lędźwiowych. Ten artykuł przedstawia przypadek lędźwiowej radikulopatii wywołanej przepukliną dysku L4/5, która zmniejszyła się po leczeniu nie operacyjnym z przepukliną dysku L5/S1, która wymagała leczenia operacyjnego. Zmiany przepukliny dyskowej zostały udokumentowane obrazami rezonansu magnetycznego. Przedstawiono także możliwe wyjaśnienia samoistnego zmniejszenia się przepukliny dysku lędźwiowego. Artykuł zawiera znaków ze spacjami (6991 znaków + 611cm 2 grafiki) 152

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