Lumbar disc herniationManagement of free fragments

Part 2

Vinod NaneriaConsultant orthopaedic surgeon

Choithram Hospital & Research CentreIndore, India

Reduction in size

• More than 50% reduction in size on follow-up MRI is clinically significant.

• Bigger the size, better the chances of reduction and better clinical outcome.

Fragment extruded between S1 root & card - Conservative Tx

Case report Mrs. W.

Before & after 6 months

Before & after 6 months

> 50% reduction in size

Patient when reported late

• It is usually for a second opinion.– For persisting pain– No improvement in neurological deficit.– It is stable neurology.– May be a case for surgical intervention.– Some times Epidural steroids works.

Reduction in size

• More than 50% reduction in size on follow-up MRI is clinically significant.

• Bigger the size, better the chances of reduction and better clinical outcome.

Case summary – Delayed reporting

Backache sciatica Lt 3 monthsHad localized pain around knee joint

Conservative treatment failed

• Six cases– Intractable radicular pain– Increase in neurological deficit due to

fragment migration– Increase in deficit due to central extrusion– Poor patient compliance– Surgery on demand

Case report – Operated for severe unbearable pain after 3 weeks of adequate treatment

Fragment had transfixed S1 root - Surgery

Migration two level down rupture of dura – deteriorated on conservative treatment.Operated fragments removed transdurally

Migration of fragment after one year

• Mr. M.L. 65 M.• Pain in the gluteal region with stiff back• No neurological deficit with – Ve SLRT.• MRI – free fragment in the sacral canal.• Conservatively.• Recurrence after 1 year. Some parasthesia in

gluteal region, bladder bowel dysfunction some times.

• Repeat MRI – fragment size same – mild displacement +.

• Tx – conservatively, asymptomatic

Central “Roof Disc Extrusion”Operated for developing bladder

symptom

Fragment mainly of end-plate

Management - Protocol

• All Tx conservative initially• Strict Bed Rest in position of comfort• No pelvic / limb traction• Sitting strictly prohibited• Supportive drugs Tx – steroids sos.• Frequent neurological examination• Bed rest cont… till SLRT become -ve

Management - Protocol

• Gradual Mobilization in the house• Exercises programme

– Straight leg raising– Knee bending to chest– Forward bending in sitting postion– Forward bending in standing – Back care ( jerk, weight lifting, bending,

sitting at work etc.Strict instructions regarding reporting of

neurological deterioration

Follow-up MRI

• At 3 months• At 6 months• At 12 months• Fragment mainly consist of NP will

absorbed in 3 months• Fragment mainly consisting of NP+AF will

take 6 months – one year• Fragment consist of end plate cartilage

take longer time – more than 2 years.

Favorable signs

• negative crossed straight-leg-raising test• absence of leg pain with spinal extension• absence of stenosis on imaging studies• favorable response to steroids• normal psychological profile• a motivated physically fit patient• more than twelve years of education• no Workers’ Compensation claim

Initial rest

• Extruded disc – acute onset

• Fragment is free in the canal and migrate any where.

• It is more likely to cause neurological deficit when it get trapped at narrow parts of spinal canal.

• It take roughly two weeks for the fragment to get fixed by the granulation tissue.

Traction

• Traction immobilize the patient is a fixed posture.

• Muscle spasm is basically protective and keep the patient in a posture which protect the compressed nerve root.

• An alteration in posture by forceful traction increases the chances of damage to nerve root.

• Traction should be avoided for acute pain.

Sitting posture to be avoided

• Maximum pressure on the damaged disc occur in sitting posture specially with forward bending.

• It increases the chances of further displacement or migration of the fragment.

Sitting posture increases intra-discal pressure

Management - Protocol• All Tx conservative initially

• Strict Bed Rest in position of comfort

• No pelvic / limb traction

• Sitting strictly prohibited

• Supportive drugs Tx – steroids sos.

• Frequent neurological examination

• Bed rest cont… till SLRT become -ve

Fragment mainly of end-plate

Types of Lumbar Herniated Disc and Clinical Course

SPINE Volume 26, Number 6, pp 648–651 ©2001, Lippincott Williams

& Wilkins, Inc.

Takui Ito, MD,* Yuichi Takano, MD,† and Nobuhiro Yuasa, MD†

• Conclusions. The authors believe that patients with noncontained lumbar disc herniation can be treated with out surgery, if these patients can tolerate the symptoms for the first 2 months.

Primary and revision lumbar discectomy A 16-YEAR REVIEW FROM ONE CENTRE

C. V. J. Morgan-Hough et al, England

• primary protrusions are almost three times as likely to require revision surgery as primary extrusions or sequestrations.

• We suggest that protrusion represents the beginning of a process of serial fragmentation of disc material, whereas extrusion and sequestration are an end-stage of this process

Saal JA, Saal JS, Herzog RJ: The natural history of lumbarintervertebral disc extrusions treated non-operatively. Spine 15: 683–686, 1990

• Patients with large compressive lesions are also generally believed to be more ideally suited to surgical intervention. These same patients, however, are those most likely to experience spontaneous regression of their lesions and they have a high rate of clinical improvement with noninvasive treatments.

Spangfort, - 2504 operationsSatisfactory results

• 99.5% results in complete or partial pain relief in cases of free fragments in the canal.

• 82% Incomplete herniation or extrusion of disc. • 63%, Excision of the bulging or protruding disc.• 38%, removal of the normal or minimally bulging

disc.• Failure to relieve sciatica was proportional to the

degree of herniation

Spangfort - 2504 operationsPersistent back pain

• 30% persistent back pain

• The incidence of persistent back pain after surgery was inversely proportional to the degree of herniation.

• In patients with complete extrusions the incidence was about 25%, but with minimal bulges or negative explorations the incidence rose to over 55%.

Natural history

• Protrusion – degenerated disc – decreased height – facetal joint degeneration – ligamentum flavum infolding – segmental canal stenosis

• Degenerative dynamic instability

• Osteoarthritis – osteophytes in an attempt to stabilize the spine.

• Surgery only relieve leg pain temporarily.

Radiculopathy and the Herniated Lumbar Disc. ControversiesRegarding Pathophysiology and Management

J. Bone Joint Surg. Am.John M. Rhee, Michael Schaufele and William A. Abdu, 88:2070-

2080, 2006.This information is current as of January 21, 2007

• Both the surgeon and the patient must realize that disc surgery is not a cure but may provide symptomatic relief.

• It neither stops the pathological processes that allowed the herniation to occur nor restores the back to a normal state

Recommendations

• Presence of Free fragment in the canal indicates auto-decompression of the nerve roots (SLRT –ve, Pain ↓ as nerve fired/ decompressed).

• Usually stable mono-radiculopathy – recovery is almost complete.

• Patients with gross / ↑ neurological deficit should be operated.

Think over it ???

?

Conservative

Thank U