IMAGES IN CLINICAL MEDICINE. Resolution of Lumbar Disk Herniation without Surgery

Regression of a large prolapsed lumbar disc herniation achieved by conservative treatment: A case report and literature review

A common spinal condition known as lumbar disc herniation (LDH) can result in radicular and low back discomfort. A 27-year-old man was admitted to our hospital with a 6-year history of persistent low back pain, and his low back pain had recurred with radiation to his lower extremities over the last two months. An extensive right-sided paracentral disc herniation in the L5/S1 intervertebral region, which compressed the nerve root, was discovered by magnetic resonance imaging (MRI) of his lumbar spine. After receiving conservative treatment, the patient reported that his lower back discomfort and neurogenic claudication had gradually subsided after 4 months. After one year, a follow-up MRI showed that the massive, prolapsed disc herniation at the L5/S1 level had totally disappeared. The sagittal protrusion length of the L5/S1 intervertebral disc shrank from 12.35 mm to 3.49 mm. However, there remained a chance of vertebral height loss. During the course of treatment, the height of the L5/S1 intervertebral space was still slightly reduced. The intervertebral space height declined from 7.705 mm to 7.201 mm after one year of treatment. The current case and a review of the literature demonstrate that LDH can decrease with conservative therapy over a short period of time. We stress the effectiveness of conservative treatment in very select LDH cases that lack a clear surgical justification.

Reabsorption of intervertebral disc prolapse after conservative treatment with traditional Chinese medicine: A case report

BACKGROUND

Conservative treatments have been reported to diminish or resolve clinical symptoms of lumbar intervertebral disc herniation (LIDH) within a few weeks.

CASE SUMMARY

Computed tomography and magnetic resonance imaging (MRI) of the lumbar region of a 25-year-old male diagnosed with LIDH showed prolapse of the L5/S2 disc. The disc extended 1.0 cm beyond the vertebral edge and hung along the posterior vertebral edge. The patient elected a conservative treatment regimen that included traditional Chinese medicine (TCM), acupuncture, and massage. During a follow-up period of more than 12 mo, good improvement in pain was reported without complications. MRI of the lumbar region after 12 mo showed obvious reabsorption of the herniation.

CONCLUSION

A conservative treatment regimen of TCM, acupuncture, and massage promoted reabsorption of a prolapsed disc.

Non-surgical treatment of giant tumor-like lumbar disc herniation based on enhanced MRI: A case series

RATIONALE

In recent clinical follow-up, it has been vertified that resorption in lumbar disc herniation (LDH) could be of great curative effect in non-surgical treatment for LDH. However, reports of resorption in giant tumor-like LDH are rarely mentioned due to its risk of irreversible neurological damage which could be caused by long-term non-surgical treatment. In our clinical observations, we have found that enhanced MRI helps to distinguish LDH from intradural tumours and to predict the probability of resorption in LDH. We analyzed 8 patients with giant tumor-like LDH who underwent non-surgical treatment, and these patients had resorption during follow-up. All patients were examined with enhanced MRI before treatment, and the type of "bull's eye" sign classification was determined by images. The MRI protrusion volume(VP), resorption rate(HR%) and JOA score of patients at the first visit and the last follow-up were recorded.

PATIENT CONCERNS

8 patients of Han ethnicity were admitted to the department of orthopedic complaining of low back pain for 1week to 12months. They were diagnosed with giant tumor-like LDH by enhanced MRI.

DIAGNOSES

These patients were diagnosed with giant tumor-like LDH.

INTERVENTIONS

We adopted a non-surgical treatment plan for the patients, including taking oral non-steroidal anti-inflammatory agents and performing rehabilitation exercise. In consideration of the risk of irreversible neurological damage, patients were closely observed during treatment and follow-up. Once the following conditions occur, surgical treatment is required immediately: The symptoms are not signifcantly relieved after 3 to 6 months of non-surgical treatment; The symptoms are aggravated by non-surgica treatment; The clinical manifestations of cauda equina syndrome.

OUTCOMES

After treated with oral non-steroidal anti-inflammatory agents and rehabilitation exercise, the resorption was accompanied by clinical symptom relief. No neurological damage occurred in all patients, and the clinical symptoms did not recur in the subsequent follow-up.

LESSONS

Clinicians should fully consider the possibility of resorption prior to surgical treatment in patients with giant LDH. We can predict the probability of resorption in patients with giant LDH based on enhanced MRI. For patients with a high probability of resorption, we can choose non-surgical treatment in the absence of progressive neurological impairment and cauda equina syndrome.

Tuina combined with Adjuvant therapy for lumbar disc herniation: A network meta-analysis

OBJECTIVE

To directly or indirectly compare the effectiveness and pain relief of TN combined with different treatments for lumbar disc herniation (LDH).

METHODS

The Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure (CNKI), Wanfang data, Chinese Biomedical Literature database (CBM), Chinese Scientific Journal Database (VIP), PubMed, Embase, Cochrane library, and Web of Science were searched from inception to July 2020. Only full texts of randomized controlled trials (RCTs) that make comparisons between Tuina and Tuina combined with other methods were included. We extracted trial data and assessed the risk of bias by two reviewers independently. We pooled continuous data in standard mean differences (SMDs) and binary data in risk ratios (RRs), and provided 95% confidence intervals. The primary outcomes were the effectiveness rate. The secondary outcome was pain measurements including visual analog scale (VAS) scores.

RESULTS

Forty-four trials which included 4741 participants and 16 kinds of interventions were selected in our study. Tuina combined with Acupuncture was the most frequently investigated intervention. Five (31%) kindnesces (SMDs) and binary data in risk ratios (RRs), and provided 95% confidence intervals. The primary outcomes were the effectiveness rate. The secondary outcome was pain measurements including visual analog scale (VAS) scores.

RESULTS

Forty-four trials of treatments among 15 increased the healing rate more significantly compared with Tuina(TN), including Tuian combined with Traction and formula(TN + TRA + FM), Tuina combined with formula(TN + FM), Tuina combined with Traction and Acupuncture(ACU + TN + TRA), Tuian combined with Traction(TN + TRA), Tuina combined with Electroacupuncture(EA + TN), Tuina combined with the warm needle(TN + WN), Tuina combined with Acupuncture(ACU + TN). Seven treatments including Tuina combined with Electroacupuncture(EA + TN), Tuian combined with Traction and formula(TN + TRA + FM), Tuina combined with Acupuncture(ACU + TN), Tuina combined with formula(TN + FM), Acupuncture(ACU), Tuian combined with Traction(TN + TRA), Tuina combined with the warm needle(TN + WN) had better effects in reducing pain intensity compared with Tuina, range from 0.01 (95%Crl 0-0.08) for EA + TN to 0.30 (95%Crl 0.20-0.45) for TN + WN.

CONCLUSIONS

According to the comprehensive review, Tuina combined with Traction and formula(TN + TRA + FM) seemed to be the most recommendable treatment which is more affordable and effective. However, all the available evidence was of low quality, so more high-quality studies are expected to confirm the effectiveness.

REGISTRATION NUMBER

PROSPERO CRD42020193068.

Pediatric lumbar disc herniation: a report of two cases and review of the literature

BACKGROUND

Lumbar disc herniation (LDH) is not a common condition in children. Most reports on pediatric LDH concern the outcomes of surgeries performed in children in whom nonsurgical treatment failed while the outcome of nonsurgical treatment of LDH in children was rarely reported.

CASES PRESENTATION

Case 1: a 10-year-old girl presented with back pain and sciatica in her left leg for over 3 months. The physical examination revealed exacerbation of back pain by waist extension or flexion, and a positive Lasegue's sign was revealed in her left leg. Magnetic resonance imaging (MRI) revealed lumbar disc herniation at the L5/S1 level. She was diagnosed with LDH. After receiving nonsurgical treatment of traditional Chinese medicine (TCM) for 30 days, the girl had mild low back pain and sciatica and the symptoms had resolved completely at the 3-month follow-up. There was no recurrence within the following 2 years. MRI performed 30 months later revealed that the herniated disc did not shrink significantly. However, she was totally asymptomatic at the follow-up performed 30 months later. Case 2: a 13-year-old boy presented with sciatica in his left leg for over 3 months. The physical examination revealed that Lasegue's sign was positive in the left leg, the level of muscle strength in the left ankle plantar flexors was grade 4. MRI revealed a lumbar disc herniation at the L5/S1 level. He was diagnosed with LDH. The boy underwent 2 weeks of TCM treatment, and exhibited a favorable outcome: only mild pain was noticed in his left buttocks after walking for more than 15 min. He was asymptomatic at the 3-month follow-up and there was no recurrence within the next 3 years. MRI scan performed at 40 months later showed no significant resorption of the herniated disc. However, he was totally asymptomatic at the follow-up performed 40 months later.

CONCLUSIONS

For the nonsurgical treatment of pediatric LDH, resorption of herniated discs is not necessary for favorable long-term outcomes, and children with symptomatic LDH may become asymptomatic without resorption.

Volumetric Changes in Cervical Disc Herniation: Comparison of Cervical Expansive Open-door Laminoplasty and Cervical Microendoscopic Laminoplasty

STUDY DESIGN

Retrospective study on 185 patients with 490 cervical disc herniation (CDH).

OBJECTIVE

The aim of this study was to compare the changes in volumes of CDH in patients with degenerative cervical myelopathy (DCM) surgically treated by expansive open-door laminoplasty (EOLP) or cervical microendoscopic laminoplasty (CMEL).

SUMMARY OF BACKGROUND DATA

Spontaneous resorption of CDH was shown in patients with DCM after conservation treatment, but very few in surgically treated patients. Our previous study identified the clinical efficiency of CMEL to treat DCM but how CDH sized postoperatively, as well as comparing to EOLP, was unknown.

METHODS

Consecutive patients with DCM from December 2015 to December 2019, who underwent MRI evaluation, receiving CMEL or EOLP, and repeat MRI in follow-up were included. The volume of CDH were monitored using the picture archiving and communication system, further calculating the incidence of CDH with volume regression and the percentage changes of CDH volume. The correlations of possible determines with CDH volume changes were analyzed by Spearman rank correlation coefficient.

RESULTS

A total of 89 patients (215 CDHs, EOLP-group) and 96 patients (275 CDHs, CMEL-group) was surveyed, respectively. Resultantly, volume of CDH was decreased postoperatively in both EOLP and CMEL cases. But this CDH volume regression was more profound in CMEL groups (incidence of 81.2% from 223/275, median volume change ratio of -26.7%, occurring from 1 month after CMEL), statistically different from EOLP group (50.2% from 108/215, median volume change ratio of -5.4%, none-appearance within 1 month). Patients information as sex, age, and follow-up time, not CDH significant, was significantly correlated with CDH volume changes.

CONCLUSION

Patients who underwent CMEL developed a postoperative reduction of CDH volume, with more popularity, greater degree and earlier-staged than EOLP-patients. Young females with longer follow-up time were more likely occur.Level of Evidence: 4.

Spontaneous regression of a large sequestered lumbar disc herniation: a case report and literature review

Lumbar disc herniation is a common disorder in adults that is accompanied by lower back and radicular pain. A 32-year-old man visited our clinic with 1-week history of persistent lower back pain and weakness in his right big toe. Magnetic resonance imaging (MRI) of his lumbar spine revealed herniated discs at L3/L4, L5/S1 and L4/L5, where a right-sided intraspinal mass lesion deep to the L4 vertebral body was causing compression of the nerve root. The patient underwent conservative treatment and reported no symptoms referrable to his back or leg 4 months later. Follow-up MRI showed no herniation of the nucleus pulposus at the L4/L5 level or lesion deep to the vertebral body of L4, whereas no changes had occurred to the status of the herniated L3/L4 and L5/S1 discs. The present case and a literature review show that a sequestered lumbar disc herniation can regress within a relatively short timeframe without surgery. The authors emphasise the utility of conservative therapy for patients who do not have a definitive surgical indication.

Short-Term Resolution of Herniated Disk Mimicking Tumor

We report a middle-aged man with a history of back pain and right-sided sciatica. Magnetic resonance imaging revealed an atypical disk fragment with radiologic characteristics of a spinal tumor. Follow-up imaging shows resolution of the lesion. Clinical symptoms resolved simultaneously. Clinical and radiologic characteristics cannot distinguish atypical disk herniation from tumors. While no imaging method allows distinguishing between these 2 entities, resolution of a disk herniation is not uncommon. In the absence of muscle weakness, follow-up imaging rather than surgery is advised in order to clarify its true entity.

Regression of lumbar disc herniation with non-surgical treatment: a case report

To date, only a few reports have described the regression of lumbar disc herniation, which may be because of a failure to follow up patients treated conservatively. We report a case of a 25-year-old man who presented with a 2-month history of pain and soreness owing to lumbar disc herniation. He was managed conservatively, and his presenting symptoms and scoliosis gradually decreased over approximately 5 months. Two years later, he returned unexpectedly and was advised to undergo magnetic resonance imaging, which revealed regression of the disc herniation; the patient also confirmed that the pain had not recurred. After 8 months, he underwent repeat magnetic resonance imaging, and the findings pertaining to disc herniation were normal. Our findings suggest that previous cases should be retrospectively studied to establish a prediction model for the outcomes of conservative treatment in patients with lumbar disc herniation. We also emphasize the significance of selecting suitable patients for conservative treatment to obtain the best therapeutic outcomes. The CARE guidelines have been followed in the reporting of this case.

Current Approaches to the Management of Acute Thoracolumbar Disc Extrusion in Dogs

Intervertebral disc extrusion (IVDE) is one of the most common neurologic problems encountered in veterinary clinical practice. The purpose of this manuscript is to provide an overview of the literature related to treatment of acute canine thoracolumbar IVDE to help construct a framework for standard care of acute canine thoracolumbar IVDE where sufficient evidence exists and to highlight opportunities for future prospective veterinary clinical research useful to strengthen care recommendations in areas where evidence is low or non-existent. While there exist a number of gaps in the veterinary literature with respect to standards of care for dogs with acute thoracolumbar IVDE, recommendations for standard care can be made in some areas, particularly with respect to surgical decompression where the currently available evidence supports that surgery should be recommended for dogs with nonambulatory paraparesis or worse. While additional information is needed about the influence on timing of decompression on outcome in dogs that are deep pain negative for longer than 48 h duration, there is no evidence to support treatment of the 48 h time point as a cut off beyond which it becomes impossible for dogs to achieve locomotor recovery. Surgical decompression is best accomplished by either hemilaminectomy or mini-hemilaminectomy and fenestration of, at a minimum, the acutely ruptured disc. Adjacent discs easily accessed by way of the same approach should be considered for fenestration given the evidence that this substantially reduces future herniation at fenestrated sites. Currently available neuroprotective strategies such as high does MPSS and PEG are not recommended due to lack of demonstrated treatment effect in randomized controlled trials, although the role of anti-inflammatory steroids as a protective strategy against progressive myelomalacia and the question of whether anti-inflammatory steroids or NSAIDs provide superior medical therapy require further evaluation.

The incidence of regression after the non-surgical treatment of symptomatic lumbar disc herniation: a systematic review and meta-analysis

BACKGROUND

Although the regression of symptomatic lumbar disc herniation (SLDH) has been widely reported, little data exist regarding the generalized incidence of regression (IR). We aimed to review the varying IRs and to synthesize the pooled IR of non-surgically-treated SLDH.

METHODS

Four electronic databases were searched for relevant studies pertaining to the regression of SLDH after non-surgical treatment and for potential studies that may have reported morphological changes in lumbar disc herniation in the follow-up results of SLDH patients treated non-surgically. The main outcome was the regression of SLDH. A random effects model was used to determine the pooled IR of SLDH.

RESULTS

We identified 13,672 articles, 38 of which were eligible for analysis. Our analysis included 2219 non-surgically treated SLDH patients, 1425 of whom presented regression. The pooled IR was 63% (95% CI 0.49-0.77). In subgroup analyses, studies that quantitatively measured the regression of SLDH yielded statistically higher pooled IRs than those that used qualitative methods. The pooled IRs gradually increased in randomized controlled trials and prospective and retrospective studies. The pooled IR varied from 62 to 66% after the sequential omission of any single study. Meta-regression showed that study types, herniation levels and regression measurements caused heterogeneity.

CONCLUSIONS

We report an overall IR of 63% among non-surgically treated SLDH patients, thus providing clinical decision makers with quantitative evidence of IR. Based on our systematic review, we suggest a follow-up timeline with time points 4 and 10.5 months after onset when deciding whether to perform surgery for SLDH.

Clinical research for whether the Traditional Chinese medicine could promote the resorption of lumbar disc herniation: a randomized controlled trial

Lumbar disc herniation (LDH) is a common, disabling musculoskeletal disorder. Magnetic resonance imaging has clarified the natural history of lumbar disc lesions and has documented that disc lesions can become smaller and can even be completely resorbed. Previous studies have confirmed that some traditional Chinese medicine (TCM) therapies can promote resorption of the protrusion. However, high-quality research evidence is needed to support the effectiveness of the protocol.

OBJECTIVE

This clinical trial aims to establish whether TCM can promote the resorption of LDH and to assess the efficacy of such therapy for LDH, thereby evaluating its clinical effect.

METHODS

The present study design is for a single-center, 2-arm, open-label randomized controlled trial. A total of 150 eligible LDH patients will be randomly assigned to either a TCM treatment group or a control group in a 1:1 ratio. Patients in the TCM group will be administered a TCM decoction for 4 weeks. Patients in the conventional drug control group will be instructed to take a specific daily dose of celecoxib. The primary outcome measure is the change from baseline in the volume of the protrusion, as assessed using MR images. Secondary outcome measures include visual analog scale pain scores and Japanese Orthopaedic Association scores assessed at 3 and 6 months.

DISCUSSION

The design and methodological rigor of this trial will allow evaluation of the basic clinical efficacy and safety data for TCM in the treatment of patients with LDH. The trial will also assess whether TCM can promote the resorption of LDH. This research will therefore help provide a solid foundation for the clinical treatment of LDH and for future research in TCM therapy.

TRIAL REGISTRATION

ChiCTR1900022377.

[New possibilities of treatment of low back pain]

Low back pain (LBP) is a syndrome caused by degenerative spine diseases and a common reason for referral for medical care. LBP is mostly often caused by osteoarthritis (OA) that needs long-term treatment with nonsteroidal anti-inflammatory drugs. The treatment is associated with a risk of side-effects. The authors consider the possibility of using slow-acting drugs for symptomatic treatment of OA (SYSADOA) in patients with LBP and present the data on anti-inflammatory effects of chondroitin sulfate on the chondral tissue in OA. The results of the studies on the use of SYSADOA in LBP are analyzed.

Comprehensive comparison of therapeutic efficacy of radiofrequency target disc decompression and nucleoplasty for lumbar disc herniation: a five year follow-up

PURPOSE

To compare the therapeutic efficacy of radiofrequency target disc decompression(TDD) and nucleoplasty for lumbar disc herniation.

METHODS

Two hundred sixty patients with lumbar disc herniation were divided into two groups: target disc decompression group (group T, n = 147) and nucleoplasty group (group N, n = 113). Visual analogue scale (VAS) and functional rating index (FRI) were measured at one, three, six, 12, 24, and 60 months after the surgery. Hospitalization time, operation time, complications, and recurrence/invalid were compared between the two groups.

RESULTS

Compared with the pre-operation, the VAS and FRI in both groups were significantly decreased in post-operation(P < 0.01). The VAS and FRI in group T have no significant difference compared to those in group N. The hospitalization and operation time of group T were significantly longer than those in group N. There was no significant difference of the occurrence of complications and disease recurrence/invalid during the follow-up between the two groups. Logstic regression analysis showed that operation time was an independent factor in the prognosis. Operation time affects the treatment effect. Shorter operation time leads to better therapeutic efficacy, and longer operation time leads to poor therapeutic efficacy.

CONCLUSIONS

Both TDD and nucleoplasty can reduce pain in patients with lumbar disc herniation and improve quality of life. Group N had shorter hospitalization and operation time than group T.

The Role of Fenestration in Management of Type I Thoracolumbar Disk Degeneration

Fenestration offers the advantages of prophylaxis without the need for specialized instrumentation and imaging. Currently there is a lack of equipoise regarding the efficacy of fenestration relative to decompression for treatment of acute canine intervertebral disk herniation; most veterinary spinal surgeons do not consider the 2 procedures equivalently efficacious. Therapeutic fenestration should perhaps be given greater consideration, especially if advanced imaging shows only mild to moderate spinal cord compression or there are restrictions on the duration of surgery, when it might be better to spend the time on fenestration rather than decompression.