Extruded Lumbar Disc Herniation with Spontaneous Reabsorption: Case Report and Review

Abstract

Disc herniation is a common condition in the population and has a direct impact on the quality of life in patients, also causing functional limitations in the work place. Treatment protocols include conservative management and/or various surgical interventions. This paper reports on a case of symptomatic large extruded disc herniation, together with spontaneous clinical regression and total re-absorption. We show here conservative management, and a literature review of the main pathophysiological hypotheses for such an unusual evolution.

Resumo

Hérnia discal é condição comum na população e tem impacto direto na qualidade de vida dos pacientes, assim como causa limitações funcionais em seu ambiente de trabalho. Protocolos de tratamento incluem manejo conservador e/ou diversos tipos de intervenção cirúrgica. Este artigo relata o caso de uma extensa hérnia extrusa sintomática, juntamente a sua regressão clínica espontânea e sua total reabsorção. Descrevemos também seu manejo conservador e uma revisão da literatura para a principal hipótese diagnóstica nesta evolução incomum.

Keywords

disc herniation - spontaneous regression - disc reabsorption

Palavras-chave

hérnia discal - regressão espontânea - reabsorção discal

Introduction

The herniated disc of the lumbar spine occurs more frequently in discs L4-L5 and L5-S1 transitionally. It is estimated that 2–3% of the population may be affected, with prevalence of 4.8% in men and 2.5% in women aged over 35 years.[1] All patients present changes in their performance at work due to pain, including the inability to work.[2]

Although surgical intervention for the treatment of this disease has existed for over 60 years, and the literature describes many different techniques, conservative treatment is an alternative to surgery that may reverse the symptoms completely or partially, including partial reduction in the size of the hernia.

The authors present the case of a patient with a large extruded lumbar disc herniation and severe sciatic symptoms with spontaneous reabsorption of the disc and discuss the clinical aspects of this disease.

Case Report

A 31-year-old man, with morbid obesity, complains of intense lumbar and sciatic pain experienced for about two months and reports a worsening after physiotherapy. Magnetic resonance imaging (MRI) of the lumbar spine revealed a voluminous posterior median disc protrusion L5-S1, migrating cranial to the posterior portion of the L5 vertebral body ([Fig. 1]). We considered surgical treatment, following a period of nutritional treatment. After 40 days, the patient had returned showing a weight loss of 29kg and controlled pain (score 1 on a scale of 1 to 10), after using a nonsteroidal anti-inflammatory. A new MRI showed a spontaneous resolution of the herniated lumbar disc ∼5 months after onset ([Figs. 1] and [2]). In twelve months, the patient no longer complained of sciatic pain.

Fig. 1 Left: sagittal MRI with L5-S1extruded disc herniation with upward dislocation; Right: sagittal MRI 5 months later with spontaneous disc herniation reabsorption.

Fig. 2 Left: axial MRI with right disc herniation; Right: axial MRI presenting the spontaneous disc reabsorption.

Discussion

Teplick and Haskin[3] first documented spontaneous regression of a herniated disc after confirmation via a follow-up of computed tomography (CT) scans on 11 patients. Since then, reports of this phenomenon have surfaced randomly.

The literature describes cases of spontaneous resolution of the lumbar disc herniation in different clinical situations, including the presence of severe radiculopathy.[4] [5] [6] [7] [8] Three mechanisms were proposed to explain this phenomenon. The first defends that the herniated disc retracts, returning into the intervertebral space again. The second emphasizes that dehydration followed by shrinkage of the herniated disc occur. The last mechanism advocates enzymatic degradation and phagocytosis, due to an inflammatory reaction and neovascularization, which are responsible for such reabsorption.[8] [9] Hernias in the epidural space would be recognized by the immune system as foreign bodies, therefore, programming an inflammatory answer against trying to remove this invasive tissue. This reaction would lead to neovascularization, enzymatic degradation, and phagocytosis.[10] [11] [12] [13] [14] [15] Haroet et al, in a study designed with animal subjects, demonstrated that the induction of a condrocytic enzyme (metaloproteinase-3), through the macrophages, plays an essential role in the spontaneous re-absorption of the herniated tissue.[13]

The literature offers other pathologic processes. Burke et al[16] stated that the intervertebral disc is able to produce cytokines (MCP-1 and IL-8), responsible for the macrophage chemotaxis and capillarization, which culminate in the synthesis of a granulation tissue that precedes the hernia reabsorption. Hirabayashi et al[11] showed that epidural fat vessels infiltrate the herniated disc, and are followed by granulation tissue, with possible transformation into scar tissue. Carreon et al[17] showed evidence of the different reactions between the fibrous annulus, which induce neovascularization and propitiate spontaneous reabsorption, including of the cartilage endplate. This presence reduces the neovascular response and prevents the degradation of the herniated tissue and reabsorption.

In a clinical study, Minamide et al[18] demonstrated the presence of neovascularization and the increase in inflammatory cell numbers, which facilitated the reabsorption of the disc herniation in a group treated with fibroblastic growing factor.

The clinical impact of this spontaneous hernia resolution reflects a gradual change in management protocols, prioritizing the initial conservative treatment. Weber's study[19] estimated that in one year of evolution, 25% of the patients initially managed conservatively would require surgery. In a larger study,[20] only 15% of the patients managed conservatively needed the surgery within 3 months. This shows the importance of initially trying the conservative approach.

In a retrospective cohort study, Saal and Saal[21] demonstrated that the conservative management of lumbar disc herniation with radiculopathy was considered efficacious in 90% of patients. In another study, Takada and Takahashi[22] advocated that the average time for spontaneous regression of more than 50% of the herniated mass varied from between 3 and 12 months.

In this context of initial conservative treatment, it is important to consider the predictive factors of hernia disc reabsorption known. Ahn et al[23] elucidated that sequestrated disc herniation regresses faster than protuse herniation. Gadolinium contrasted MR studies demonstrated that sequestrated hernias tend to present rim enhancement, a sign of spontaneous regression or considerable mass reduction, in 75% of cases.[24] [25] Komori et al[24] showed that the more pronounced the rim enhancement, the greater the tendency of regression.

Buttermann et al[26] concluded that the larger the size of the herniated disc – specifically sequestrated and extruse types –, the greater the percentage of regression in size. They observed that patients who responded positively to the conservative management in the first six weeks exhibited faster hernia regression, with concomitant decrease in inflammation and pain.

Radicular pain can be explained either by the nervous compression by the hernia or by radicular inflammation and blood congestion. Radicular pain relief is justifiable in some cases before the reduction in size of the hernia, as a result of the improvement of secondary inflammatory responses. Pain usually reduces in 3–6 weeks, while hernia reabsorption takes 4–9 months.[27]

Rothoerl et al[28] analyzed the time of the onset of symptoms in a surgically treated group, comparing with the postoperative outcomes, to define when to indicate surgery to obtain the best possible results. The conclusion was that the conservative treatment should be tried before 2 months, during which time the pain should have already presented a regression. After this period, surgery should be considered.

Conclusion

The possibility of spontaneous disc reabsorption should be considered in cases of lumbar disc herniation, even in large and extruded ones. In cases where there are no emergency criteria for radicular decompression, conservative management should be a reasonable option for the initial treatment of these patients.

• References

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