The natural history of a lumbar hernia of the nucleus pulposus (HNP) is not fully known and clear indications for operative intervention cannot be established from the literature. Several studies have shown that the largest discs appear to have the greatest tendency to resolve. The aim of this study was to investigate whether massive prolapsed discs can be safely managed conservatively once clinical improvement has occurred.
PATIENTS AND METHODS:
Thirty-seven patients were studied by clinical assessments and serial magnetic resonance imaging (MRI) over 2 years. Patients had severe sciatica at first, but began to show clinical improvement despite the large disc herniations. Clinical assessment included the Lasegue test and neurological appraisal. The Oswestry Disability Index was used to measure function and changes in function. Serial MRI studies allowed measurement of volume changes of the herniated disc material over a period of time.
Initial follow-up at an average of 23.2 months revealed that 83% had a complete and sustained recovery at the initial follow-up. Only four patients required a discectomy. The average Oswestry disability index improved from 58% to 15%. Volumetric analysis of serial MRI scans found an average reduction of 64% in disc size. There was a poor correlation between clinical improvement and the extent of disc resolution.
A massive disc herniation can pursue a favourable clinical course. If early progress is shown, the long-term prognosis is very good and even massive disc herniations can be treated conservatively.
The entire article above is worth reading, and fortunately a free full text is available. I have a read a lot of case reports and observations of both cervical and lumbar disc herniations (prolapsed discs) healing or reabsorbing on their own and thought it would be good to know both how often and to what extent this was occurring. This paper with its 7 year follow up was the best one I found and it fits with my experience pretty well with low back pain patients showing or reporting poor looking MRIs but still progressing very well with their exercise program, often with a full resolution of symptoms with strength, endurance and function returning to better than they were pre-injury.
Interesting factoids and comments from the paper were as follows:
- Massive herniated discs were defined as those for which the extruded disc material occupied 50% or more of the anteroposterior diameter of the spinal canal. I’d agree that’s big.
- 83% of the 37 patients reported complete and sustained recovery 7 years after the injury.
- The average reduction in the size of the disc prolapse was 64% most of which occurred in the first 6 months after the initial scan at which point they were only one third of their original size. They slightly better at 6-12 months after which point reduction volume was relatively unchanged.
- They cited another paper that found that with herniated disc larger than 6 mm, that that on average they improved 36% in 6 weeks, and 60% at 6 months, which closely agrees with the 6 month outcome of this study.
- Four of the 37 patients went on to have surgery and their average volume reduction was less at 47%.
- Seven years later 90% of the conservatively treated patients were satisfied with their outcome, while with only 50% of those having surgery being satisfied, though the difference was not statistically significant.
- In the discussion they cited other research that surprisingly found the worst discs had greatest ability to improve (on a percent of initial injury) over time, speculating that it was due to increased immune/inflammatory response with macrophages and neovascularization playing a role.
- They cited two additional studies indicating similar outcomes with herniated discs in the cervical spine, aka, neck.
- The noted the degree of disc resorption was not always correlated with symptoms as they cited several papers where patients showed considerable improvement in symptoms even when MRI changes were minimal.
- They thought, and I agree, that patients with sciatica should be initially treated with conservative treatment and that early access to surgeons and diagnostic can result in unnecessary surgery.
The authors said that only four of the patients had surgery. However there was no mention regarding what types of therapy, exercises, postural advice, etc, was or wasn’t utilized as part of the conservative course of treatment. Also there was no mention as to what caused the herniated discs, which seem often the case from the point of view from a lot of practitioners. Often a person will complain of severe back or neck pain, go to their doctor, get an MRI, see a herniated disc, and there’s the cause. However physical therapists who want to more effectively treat spine pain, need to look further back than that.
I’ve read a fair number of philosophy books and it seems there are very few uncaused events, and vertebral discs don’t herniate by magic. While there often isn’t a specific injury, it is known that most disc bulges and herniations are caused by repeated spine flexion, which is exacerbated by sustained flexion loads, with rotational stresses not doing the discs a lot of good either. So sufferers of back pain (and neck too) should keep this in mind, and should probably avoid a lot of spine stretching, and sustained poor postures, or else what happened to the disc in question will likely happen to neighboring discs either above or below. As many pain sufferers can tell you, a good number of spine injuries result in recurrent and chronic pain, then is only eliminated when bad habits are eliminated and strength increased. Still the good news from this study is that even with the worst of herniated discs generally respond very well to treatment without the need of surgery.
As always, if you have any further questions or need for clarifications, please don’t hesitate to ask. Being aware that some of my blog ideas are contentious and occasionally a bit out of the field of my expertise, I encourage my readers to come forth with any questions/comments that are of interest or concern. Your comments are valued and welcomed.
Chad Reilly is a licensed physical therapist, located in North Phoenix, practicing science based medicine with treatment protocols unique and effective enough to proudly serve patients from Phoenix, Scottsdale, Mesa, Chandler, Tempe, Peoria, and Glendale.