Extruded Discs – Surgery or No Surgery?
CF 197: Extruded Discs – Surgery or No Surgery? Today we’re going to talk about extruded discs – surgery or no surgery? This one may surprise some of you. But first, here’s that sweet sweet bumper music
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OK, we are back and you have found the Chiropractic Forward Podcast where we are making evidence-based chiropractic fun, profitable, and accessible while we make you and your patients better all the way around. We’re the fun kind of research. Not the stuffy, high-brow kind of research. We’re research talk over a couple of beers. I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast. If you haven’t yet I have a few things you should do.
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You have found yourself smack dab in the middle of Episode #197 Now if you missed last week’s episode , we talked about How Car Wrecks Contribute To Future Neck and Back Pain. Make sure you don’t miss that info. Keep up with the class.
On the personal end of things…..
Alright, I’m feeling pretty good today. Last week was the very first time since February of 2020 that we hit the average weekly visit number that we were doing. I don’t know if that came out right. Before Rona, we were averaging 185 visits per week in 2019. Rona came along and the best we’ve been able to eke out was about 160. Maybe 165. With the rollercoaster ups and downs of the Rona outbreaks, that number has been down but since February of 2020, it’s never been any higher than that. Until last week. Last week, by myself, I hit 187. 23 of them were new patients. When you are evidence-based and patient-centered, you don’t hold on to patient unnecessarily for extended visits and treatment schedules so, unfortunately, you live and die by your new patient count.
Fortunately for me, I’m to a point that new patients aren’t a huge concern. I always have my eye on the count, but it doesn’t give me anxiety these days. We are pretty established here in my community and it tends to mostly take care of itself. Thank my good Lord. I don’t know if you’ve listened this long but back in February of 2020, the 14th to be exact, my wife and I took a trip to Key Largo. It was amazing.
I left a bustling, busy as hell practice to go on vacation. There was some concern about this COVID stuff but nothing crazy. In fact, I remember asking my wife on the way to Florida if we should take a mask just in case they told us we needed one. She told me if I brought a mask, that she’d punch me in the nose. Lol. Yes, I have that kind of a wifey. She’s a feisty Texas woman, ya know. After a week in The Keys, I came back to a ghost town. And then it got worse. I swore I’d never go on vacation again if it was going to tank my practice like that. Well, obviously, it was COVID. And it’s taken a year and a half to start to reclaim our lost business.
But, at 45 patients today as I type this and 5 of them being new patients, this week is looking good too. Here’s the best news about it all; this is in the midst of a BIG resurgence of COVID here in Amarillo locally. They are adding numbers at the rate they were adding them back in the worst of times. But people are done with it. They just are. I was one of the first group of providers to be vaccinated here locally. My friends and connections in the medical world here called me when it first came available. They recognized that we work in very close proximity with patients and reached out. Most of my staff and I accepted. I’ve been vaccinated since January 2021.
I just got the booster on August 26th. It’s a personal thing for each of us but, when you have had a hit on your business like I have, and you’ve had all of the ups and downs, and you’re just now getting back to where you left off after basically losing a year and a half…….well, I’m not about to take a chance on getting sick and being out for 2-4 weeks and watching my business go to crap again. Including me, I have 12 employees.
That includes 4 CA’s, 3 LMT’s, an NP, an acupuncturist, an esthetician, a billing pro, and I have an intern from Parker College here. These people have families, mortgages, bills, car payments, and gambling debts just to name a few things. The point is, when you’re the main provider and breadwinner, for me, it’s up to us to be as responsible as we can to make sure we are able to do our jobs. For example, here in Amarillo, TX, we are fairly close to the Colorado and New Mexico mountains. About 3 and a half hours to NM and about 5 or so to Colorado. Pretty close. We grew up going skiing in the mountains.
But it dawned on my during my last trip a few years ago; they call them accidents for a reason. If I fall and break a wrist or twist a knee up, I could be out of a job for up to 6 weeks or more. Well hell, in most cases, that’s more time out than COVID would take you out. I’m the major provider at this time for this clinic. I can’t allow that. So, I gave up snow skiing. It’s not worth it to me. Why should the pandemic be looked at any differently? For me, it shouldn’t be. Anyway, I got a little sidetracked there.
Things are going well. I’m hoping business is back to normal and stays normal. For me and for you. We have all fought hard and deserve it. Now, let’s get some folks to feeling better shall we? Let’s hop into research having to do with large extruded discs. Once upon a time, I would send them straight to a Neurosurgeon. Not so quickly these days. Knowledge and clinical experience tell me to think twice. Especially in the absence of progressive neurological deficits.
Item #1
Item one is called “Spontaneous Regression of a Large Lumbar Disc Extrusion” by Ryu et. Al (Ryu Sung-Joo 2010) and published in the Journal of Korean Neurosurgical Society back in 2010. It’s got a little dust on it but not a ton.
Why They Did It
They say that Although the spontaneous disappearance or decrease in size of a herniated disc is well known, that of a large extruded disc has rarely been reported. This paper reports a case of spontaneous regression of large lumbar disc extrusion. The disc regressed spontaneously with clinical improvement and was documented on a follow-up MRI study 6 months later.
How They Did It
- It’s a case report so it’s not incredibly impactful but still helpful for something like this. You can see it on one MRI and then 6 months later, it’s gone. 2+2=4 so I’m OK with a case report on something like this here.
- A 53-year-old woman was referred to our clinic with a 6-month history of low-back and left lateral leg pain with numbness. Six months earlier, her symptoms had developed suddenly as severe left lateral leg pain.
- A neurological examination showed no neurological deficits. The straight leg raise test was negative bilaterally. The lumbar spine MRI performed 6 months earlier revealed a left posterolateral herniated nucleus pulposus which was migrated caudally and compressed the left L5 root
- She received conservative treatment including pain-relieving medication, physical therapy and spinal anesthetic block therapy due to her poor medical conditions
What They Found
- After conservative treatment, her clinical symptoms subsided gradually but the numbness of her left lateral leg still remained. A second MRI study performed approximately 6 months after the prior examination reveal almost complete disappearance of the extruded fragment that had been located posterolateral to the L5 vertebral body, and no evidence of compression or displacement of the dural sac or nerve root
- The height of the L4/5 disc space remained decreased compared to the other levels and was unchanged from the previous MRI examination.
Wrap It Up
- The precise mechanisms of disc regression are unclear. Three hypotheses have been proposed to explain the process of disc regression.
- The first hypothesis, “retraction of a herniated disc”, proposes that the herniated disc retracts back into the intervertebral space17). Theoretically, this can occur if there is a disc bulge or if the disc material protrudes through the anulus fibrosus but is not separated from it6). However, it would be unlikely in cases of completely extruded or migrated fragments.
- The second explanation, “dehydration of herniated disc”, states that the herniated fragment would disappear due to gradual dehydration and shrinkage16).
- The third hypothesis, “inflammatory reaction and neovascularization”, which is the most compelling and studied hypothesis, states that extruded disc material into the epidural vascular space of spine is recognized as a “foreign body” and induces an inflammatory reaction by the autoimmune system. This would cause neovascularization of the cartilaginous tissue along with infiltration by inflammatory cells, such as macrophages, granulocytes, and lymphocytes7,8,10,11,15). Several histopathology studies from surgical specimens and experimental animal research support this theory
- Nevertheless, it is possible that all 3 mechanisms play a role in the regression and disappearance of herniated disc tissue.
- Motor and sensory deficits are present in 50-90% of patients with a herniated lumbar disc18). Surgery can be carried out as an emergency when bladder symptoms or progressive motor weakness are present. In the absence of these symptoms, 75-90% of patients with acute sciatica due to a protruded lumbar disc experience a resolution of symptoms without surgery
- Conservative treatment should be considered when cauda equina syndrome or progressive motor weakness are absent in the acute stage of the lumbar herniated disc. Surgical intervention should be considered in cases with neurological deficits or intractable low back and leg pain despite the initial conservative treatment
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Item #2
Our last one is called “Spontaneously disappearing large herniated lumbar disc fragment”’ by Reddy et. al. (Reddy UV 2014) and published in the Journal of Orthopaedics and Allied Sciences in 2014. As impactful as this information is, why do you think there aren’t more studies on it that are recent? Could it because it suggests they shouldn’t be doing surgery on these large extruded discs?
Why They Did It There are reports of spontaneous regression of large extruded disc; however, the exact underlying mechanism and management of such cases remains controversial. We report a 40-year-old female who opted for conservative management for a large extruded lumbar disc. Follow-up magnetic resonance imaging (MRI) showed complete disappearance of the disc fragment; however, there were degenerative changes in the upper and lower adjacent margins of the vertebral body. Herniated lumbar disc is one of the common causes of low back pain and smaller disc herniations tend to regress over a period of time; and thus, the pain is known to improve with conservative management.
How They Did It
| A 40-year-old female presented with low back pain of 2 year duration. The pain was radiating to lower limbs more to the left side. There was no history of motor or sensory deficits. There was no history of bowel or bladder dysfunction. She was investigated for the similar problem with an MRI 6 months back and it showed a large disc protrusion [Figure 1]. However, she opted for conservative management. On examination, there were no focal motor or sensory deficits. Deep tendon reflexes were normal except bilateral sluggish ankle jerks. Planters were flexor. As the patient was complaining in the severity of the pain with numbness and a repeat magnetic resonance imaging (MRI) was performed. Follow-up MRI showed complete disappearance of the disc fragment; |
What They Found
The exact timing for spontaneous regression of the protruded disc material is not known; however, it ranges from few weeks to months. The fastest regression of the fragmented disc material was reported in 2 months.
Wrap It Up
| Present case illustrates that a conservative approach can be adopted for a large extruded lumbar disc as it can resolve in a selective group of patients. [24],[38],[39] Spine surgeons should be aware of spontaneous regression of the disc phenomenon as a patient with a large extruded disc who opted for the conservative management initially can have persistence pain, but there may not be an underlying protruded disc. It is important to perform a repeat imaging of the spine to assess the degree and severity of the disc protrusion before making a plan for surgery or any further conservative management. |
Alright, that’s it. Keep on keepin’ on. Keep changing our profession from your corner of the world. The world needs evidence-based, patient-centered practitioners driving the bus so get active, get involved, and make it happen. Let’s get to the message. Same as it is every week.
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The Message
I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is primarily a movement-related pain and typically responds better to movement-related treatment rather than chemical treatments like pills and shots. When compared to the traditional medical model, research and clinical experience show us patients can get good to excellent results for headaches, neck pain, back pain, and joint pain to name just a few. It’s safe and cost-effective can decrease surgeries & disability and we do it through conservative, non-surgical means with minimal hassle to the patient. And, if the patient treats preventatively after initial recovery, we can usually keep it that way while raising the overall level of health!
Key Point:
At the end of the day, patients should have the guarantee of having the best treatment that offers the least harm. When it comes to non-complicated musculoskeletal complaints…. That’s Chiropractic!
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About the Author & Host Dr. Jeff Williams – Fellow of the International Academy of Neuromusculoskeletal Medicine – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger
Bibliography
- Reddy UV, A. A., Hegde KV, Suneetha P, Rao MG, (2014). “Spontaneously disappearing large herniated lumbar disc fragment.” J Orthop Allied Sci 2: 26-28.
- Ryu Sung-Joo (2010). “Spontaneous Regression of a Large Lumbar Disc Extrusion.” J Korean Neurosurg Soc. 48(3): 285-287.
What They Found![[Figure 1]](https://www.joas.in/viewimage.asp?img=JOrthopAlliedSci_2014_2_1_26_134208_u1.jpg){kind=link}