Download - Lumbar Disc Herniation Naneria Part 1
Lumbar disc herniationManagement of free fragments
Part 1
Vinod NaneriaConsultant orthopaedic surgeon
Choithram Hospital & Research CentreIndore, India
• A piece of nucleus pulposus with annulus fribrosus & fragments of cartilagenous end-plate, lying loose in the spinal canal.
• It may migrate up or down a level or two, may migrate posterior to dura or perforate dura. Incidence - 9 to 15.5%
Free fragment
Types of Disk Disease Disk Bulge
Disk bulges into anterior epidural space without any area of focal-ness or out-pouching
Disk HerniationGeneral term used to describe different degrees of 'eccentric out-pouching' of IV disk.
Protrusion
contained herniation or sub-ligamentous herniation
Extrusion
non-contained herniation, or trans-ligamentous herniation
Sequestration
free fragment
Free Fragments Free Fragments
Loose Fragments
Literature – Free Fragment
• Incidence - 9 to 15.5% • Composition – N.P. / A.F. + fragments of end plate• Lateral migration – cranial & caudal• Posterior migration – cauda equina – mimic tumour• Intra dural more than 60 cases reported-world
literature• Roof disc : central disc extrusion : contained by
P.L.L.
Migration
• Since it is impossible to predict on MRI, that a migrated fragment have some continuity with the parent disc or not - it should be considered as loose fragment.
• There is a real possibility of migration of the fragment and increase in the neuro-deficit.
• It is immaterial where the migration is.• Migration may progress in the initial phase of
extrusion, it may migrate one or two level – up or down.
Composition of extruded material
• Nucleolus pulposus
• Annulus fibrosus
• Fragments of cartilage end plate.
Pathophysiology of Absorption
• The disc formation takes place before the immune system develops in the embryonic life.
• The proteins in the nucleosus pulposus are foreign to immune system in adults.
• The free fragment is treated as foreign protein and a reactive granuloma forms, which absorbs the free fragment.
Absorption - Composition & Time
• Nucleolus Puplposus– absorb by formation of granulation tissue possibly as
an auto-immune reaction– 3 months
• Annulus Fibrosus– absorb by granulation tissue by vascular invasion– 1 – 2 years
• Hyline cartilage of end-plate– suppresses neo-vascularization– resistant to absorb
• The amount of hyaline cartilage, should be predictable on the basis of imaging data.
• Vertebral endplate marrow signal intensity changes are associated with fissures in the vertebral end-plate.
• Signal intensity changes may be regarded as osteo cartilaginous fracture signs similar to other skeletal manifestations.
MRI – showing End-plate lesion, marrow signalsIndicating a portion of end-plate avulsion in the extruded disc &Will take long time to absorbed or reduction in size.Early surgery may be contemplated.
Fate of Free Fragment – Complete absorption
• Sei A, Nakamura T et al 1994 • Coevoet V et al t.d. 1997• Westmark RM et al c.d. 1997• Miller S et al 1998• Singh P, Singh AP. 1998• Morandi X et al 1999• Kobayashi N et al c.d. 2003
More than 55% of absorption is clinically significantFollow up MRI – every 3 months for one year
Spontaneous changes on MRI & Clinical Correlation
- 42 cases treated conservatively.
Takada & Takahashi
• MRI changes Cases Excellent Good Poor
Disappearance 08 06 02 00
More 50% 29 11 18 00
No reduction 05 00 01 04
50% involution in 3 – 6 monthsJ.of Orthopaedic Surgery 2001, 9(1): 1–7
Upward behind body
Lateral Migration
Case history – 2 - Monoradiculopathy
L4 – L5 with loose fragment over L5 bodyEHL drop gr. 2
Complete relief 2 Yr FU
Downward Migration
Why conservative?
• Stable neurological deficit & Presented late > than one week.
• Bearable radicular pain with negative root stretching test (SLRT).
• No bladder or bowel dysfunction.
• Patient not willing for surgery but gave consent for surgery as & when needed. Kept under strict watchful supervision.
R.K.- Absorption one month
• A 25 M• Acute agonizing pain 5 days duration• Spinal flexion 50%, EHL lt weak gr3• No bladder – bowel dysfunction.• Pain minimal• MRI extruded disc at L5-S1 left• Repeat MRI after one month – extruded
fragment (N.P.)absorbed completely.
Jan2007 Feb
2007
Absorption within 3 months
• R.J. – 55 male,
• Backache sciatica rt., acute onset.
• Rt. Ankle jerk absent.
• MRI-June 07- extruded fragment L5-S1
• Conservative
• MRI – Aug 07- complete absorption
Completeabsorptionin threemonths.
N.K.- Complete absorption one year
• H/o backache sciatica 2005 – MRI degenerated discs at L4-L5, L5-S1.
• Extruded disc in 2006 – with no neurological deficit.
• Tx – conservatively with complete absorption of free fragment.
2005
2006
2006
2006
2007
Case history – U.S.
• 45 M,• Acute backache sciatica 15 days duration• Attended clinic as OPD patient.• L5 – S1 Rt. with loose fragment over L5 body• Measuring 2.4cm x 1.5cm• Full flexion spine and negative SLRT• Mild gr.4 weakness in EHL and Hypoasthesia in
L5 distribution.• Tx conservatively