Author: Li Yongchao Li Source: Spine Spine
In 1932, American doctors Barr and Mixter first proposed that lumbar disc herniation was the cause of low back and leg pain, and published the results in the famous New England Journal of Medicine (NEJM), since then, the study of low back and leg pain has entered the "era of intervertebral discs". The treatment of lumbar disc herniation is mainly conservative treatment, including drugs, physiotherapy, traction, massage, acupuncture and other methods, and only a few people need surgery, including traditional small windows, open decompression internal fixation and the gradual popularization of endoscopic and microscopic techniques.
Clinically, we often find that many patients with imaging manifestations of lumbar disc herniation have no obvious low back and leg pain, or only mild symptoms, while some patients have a very mild lumbar protrusion, but the symptoms of low back and leg pain are obvious, which seriously affects the quality of life. Studies have found that simple mechanical compression of nerve roots does not cause nerve root pain, and the protruding pulp nucleus can induce immune and inflammatory responses, indicating that the symptoms of lumbar disc herniation are closely related to inflammation. The immune response induced by herniation of the nucleus pulposus can promote the absorption of the nucleus pulposus, so clinically, the lumbar disc herniation, especially the prolapsed type (the nucleus pulposus is free from the spinal canal), has the possibility of self-absorption.
Spontaneous resorption/regression of disc herniation refers to the spontaneous disappearance or significant reduction of the nucleus pulposus in patients with herniated discs without surgical or invasive treatment. At present (2021.01.31), there are about 100 relevant English literature reports, mostly case reports or retrospective studies. Looking back at the literature, the most classic case of lumbar disc resorption should be the case published in the New England Journal of Medicine (NEJM) in 2016.
Classic lumbar spine case 1:
The patient, a 29-year-old female, presented with "pain and paresthesia in the right calf" and had normal bowel and urine. Initial LUM suggests lumbar 4-5 disc herniation and spinal stenosis with severe nerve root compression (left). She chose conservative treatment, and after 5 months, a review of the lumbar MAGNETIC resonance surprise found that the protruding disc was absorbed and the clinical symptoms were completely relieved.
Lumbar spine case 2:
Figure: A patient's onset, 1 month, and 8 months after a re-examination of the lumbar spine MRI suggests that the herniated disc is reabsorbed.
Lumbar spine case three:
Pictured: A 57-year-old male, due to low back pain with radiating pain in the left lower extremity for 6 months, lumbar MRI suggests lumbar 4-5 intervertebral disc herniation, after conservative treatment, the above symptoms disappear after 6 months, and the magnetic resonance imaging suggests that the herniated disc is absorbed. Axial and sagittal T2-weighted MRI images of the lumbar spine, (A) L4-L5 disc herniation (arrow), compression of the L5 nerve root on the left side, and (B) absorption of the previously protruding nucleus pulposus (arrow) at the time of Follow-up in June.
Lumbar spine case four:
The patient is a female, 56 years old. Outpatient clinic in June 2012 due to pain in the lower extremities radiating to both lower extremities in February. Physical examination: positive bilateral straight leg elevation test, normal sensation, movement, and reflexes of both lower extremities, and normal sensation in the saddle area. MRI shows a huge central herniation of the lumbar 4/5 disc with a spinal canal occupancy of about 3/4 (Figures 1 A, B). Diagnosed with lumbar 4/5 disc herniation, patients are recommended to be admitted to the hospital for percutaneous foramenoscopic lumbar disc nucleus extraction (PELD) surgery. The patient refused surgery and performed warm compresses, traction, and massage treatments at home, and the pain in the lower back and leg gradually decreased, leaving only the right hip pain. Outpatient review OF MRI in January 2014 showed spontaneous absorption of lumbar 4/5 herniated discs, and more than 90% of the protruding nucleus pulposus disappeared (Figures 1C, D).
Cervical Spine Case 1:
Patient, female, 40 years old. He was admitted to the hospital for 7 days due to aggravation of neck and shoulder discomfort for 4 years with walking instability. Onset cervical MRI: the left disc protrudes into the central tube, severe spinal cord compression (figure 1). The diagnosis of cervical spondylosis is recommended for hospitalization for anterior cervical disc removal cage bone graft fusion surgery. The patient refused surgery, requested non-surgical treatment, and was given oral NSAIDs, neurotrophics, and muscle relaxants, while the patients were self-directed and manually treated. After 3 months the patient's symptoms resolved. A review of the cervical MRI after 6 months shows spontaneous absorption of the C5-6 herniated discs and the disappearance of the protruding nucleus pulposus by 80% (Figure 2).
Cervical spine case 2:
The patient is a female, 72 years old, A and B are the initial MRI, and C and D are THE MRI followed up for 1 year.
Spontaneous reabsorption has been reported, including cervical, thoracic, and lumbar disc herniation, with the largest number of cases of spontaneous resorption of lumbar disc herniation. In the lumbar spine, lumbar 2/3, lumbar 3/4, lumbar 4/5 and lumbar 5/sacral 1 disc have been reported. The reabsorption time is the longest 2 years, the shortest is 2 months. Types of lumbar disc resorption have been reported, including free, transligamental, inferior dural detachment, and recurrent free. Due to the low incidence of lumbar disc herniation resorption, there were no statistical reports, and only two authors did clinical studies. Autio et al. observed that most lumbar spine patients are reabsorbed within 1 year, and reabsorption is most likely to occur in people aged 41 to 50 years, and the clinical symptoms gradually decrease as resorption occurs. Ahn et al. found that the free type is most prone to reabsorption, believing that the nucleus pulposus is caused by free entry into the epidural space and contact with blood circulation. The larger the nucleus pulposus, the farther away it is, the larger the area of contact with the blood supply, and the greater the likelihood of reabsorption.
In 1998, the team of Professor Jiang Hong of Suzhou Hospital of Traditional Chinese Medicine published the article "Natural Resorption after Lumbar Disc Herniation and Its Clinical Significance" in the Chinese Journal of Orthopedics, which was also the first article in China to systematically report on reabsorption after lumbar disc herniation. They believe that the protrusion after the rupture of the posterior longitudinal ligament can contact the epidural blood circulation and is more likely to reabsorb the phenomenon; The larger the volume of the protrusion (the protrusion rate >50%), the more likely it is to reabsorption; The higher the degree of displacement of the protrusion and the farther away the nucleus pulposus, the more likely it is to reabsorb. The first 6 months after the onset of lumbar disc herniation are active periods of resorption, and the time span can be 2-12 months or more.
However, some scholars maintain a cautious attitude towards spontaneous reabsorption of lumbar disc herniation, and Professor Hou Lisheng of the Domestic Naval General Hospital reviewed the literature and pointed out that the traditional lumbar disc herniation that needs to be actively considered for surgical treatment is of large, ruptured and free reabsorption, and there is a possibility of symptom relief due to resorption. For the first onset of these types of disc herniation, if the patient is not severe symptoms, or the symptoms are tolerated and there is sufficient time for recuperation, conservative treatment may be tried. However, conservative treatment should not be too long, and if unbearable pain, aggravation of neurological symptoms or cauda equina syndrome occur, surgery should be actively considered. Lumbar disc resorption can occur as shortly as 2 months, and the imaging data based on surgery should not exceed this period of time from the time of surgery.
The mechanism of reabsorption of lumbar disc herniation is not fully understood, and it is generally believed to be related to the two effects of inflammatory response and autoimmune response. The inflammatory response is caused by the exposure of the nucleus pulposus to the blood supply environment, and the infiltration of inflammatory cells such as monocytes. The inflammatory response manifests itself in two ways, one is that the inflammatory cells directly engulf and absorb the nucleus pulposus; Second, inflammatory cells produce a variety of inflammatory mediators, activating autolysible metal matrix proteases in the nucleus pulposus tissue and causing spontaneous absorption.
However, the literature that has reported spontaneous reabsorption of lumbar disc herniation in the past literature is mostly reported as cases, and from the perspective of evidence level, it is low-level evidence, and the relative reference credibility is low (to give an inappropriate example, just like the weather forecast will not rain tomorrow?). The credibility of CCTV forecasts is relatively high, but the credibility of county-level weather prevention is lower, and the level of evidence reported in the literature on spontaneous reabsorption of lumbar disc herniation belongs to the county-level weather forecast level).
In addition, from another point of view, the incidence of lumbar disc herniation resorption is very low, that is, most of the lumbar process does not undergo reabsorption, so we cannot put all bets on the small probability of "reabsorption".
Clinically, except for patients with severe or progressive neurological dysfunction who need emergency surgery, the rest of the lumbar protrusion patients, doctors will recommend strict conservative treatment for 3 months, if conservative treatment is ineffective for three months, surgery will be recommended. Because the natural history of lumbar disc herniation tends to improve. Studies have found that without surgical intervention, about 87% of patients have less pain within 3 months. However, many patients with lumbar protrusion can not stand the slow recovery of conservative treatment, do not have sufficient time for recuperation, are in a hurry, and often require domestic doctors to quickly and thoroughly solve the symptoms of lumbar protrusion, therefore, the specific treatment plan requires doctors to point out the advantages and disadvantages of various treatment methods, and doctors and patients make decisions together.
In summary, lumbar disc herniation may occur spontaneous reabsorption, but the probability is very low, and the level of evidence reported in the literature is low, which needs to be treated with caution. For the initial onset of a large, ruptured, or free disc herniation, conservative treatment may be tried if the patient is not severe, or if the symptoms are tolerated and there is sufficient time for recuperation. However, the conservative treatment time should not be too long, and if there is unbearable pain, aggravation of neurological symptoms or cauda equina syndrome, surgery needs to be actively considered and cannot be delayed.
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