Herniated discs: when is surgery necessary?

In all levels of disc herniations the absolute surgical indications include deteriorating neurological deficits with myelopathy or cauda equina syndrome. However, this review summarized the relative indications for surgery in each level. In cervical disc herniation (CDH), the indications for surgery consist of six months of persisting symptoms, not responding to conservative treatment. However, high-quality studies are lacking, and a randomized controlled trial is now underway to clarify the indications. In thoracic disc herniation (TDH), the indications for surgery comprise failure of conservative measures and/or worsening neurological symptoms. Moreover, giant calcified thoracic disc herniations or myelopathy signs on magnetic resonance imaging, even in the absence of neurological symptoms, may benefit from surgical treatment as a preventive measure. In lumbar disc herniation (LDH), the indications for surgery include imaging confirmation of LDH, consistent with clinical findings, and failure to improve after six weeks of conservative care. Cite this article: EFORT Open Rev 2021;6:526-530. DOI: 10.1302/2058-5241.6.210020

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Spontaneous and rapid resolution of a massive lumbar disc herniation

Surgical Neurology International ◽

10.25259/sni_491_2021 ◽

2021 ◽

Vol 12 ◽

pp. 352

Author(s):

Dinesh Naidoo

Keyword(s):

Lumbar Disc Herniation ◽

Disc Herniation ◽

Spontaneous Recovery ◽

Surgical Intervention ◽

Nonoperative Management ◽

Lumbar Disc ◽

Cauda Equina ◽

Neurological Deficits ◽

Lumbar Surgery ◽

Disc Herniations

Background: Most lumbar disc herniations can be successfully treated conservatively. However, massive lumbar disc herniations are often treated surgically to avoid permanent cauda equina syndromes/neurological deficits and potential litigation. Nevertheless, here, we present a 51-year-old female who refused lumbar surgery due to coronavirus disease 2019 (COVID-19) and sustained a full spontaneous recovery without surgical intervention. Case Description: A 51-year-old female presented with a massive lumbar disc herniation at the L5S1 level. Despite refusing surgery for fear of getting COVID-19, she spontaneously neurologically improved without any residual neurological or radiographic sequelae. Conclusion: Although the vast majority of patients with massive lumbar disc herniations are managed surgically, there are rare instances in which nonoperative management may be successful.

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Caudal Lumbar Disc Herniations Are More Likely to Require Surgery for Symptom Resolution

Global Spine Journal ◽

10.1177/2192568220905849 ◽

2020 ◽

pp. 219256822090584

Author(s):

Anmol Gupta ◽

Shivam Upadhyaya ◽

Caleb M. Yeung ◽

Peter J. Ostergaard ◽

Harold A. Fogel ◽

...

Keyword(s):

Lumbar Disc Herniation ◽

Disc Herniation ◽

Nonoperative Management ◽

Lumbar Disc ◽

Strong Association ◽

Cauda Equina ◽

Radicular Pain ◽

Motor Deficits ◽

Disc Herniations ◽

The Impact

Study Design: Retrospective study. Objectives: We examined the impact that location of a lumbar disc herniation has on the likelihood that a patient will require surgery after at least 6 weeks of nonoperative management. Methods: Using ICD-10 codes M51.26 and M51.27, we identified patients at a single academic institution from 2015 to 2016 who received a diagnosis of primary lumbar radicular pain, had magnetic resonance imaging confirming a lumbar disc herniation, and underwent at least 6 weeks of nonoperative management. Patients experiencing symptoms suggesting cauda equina syndrome or progressive motor deficits were excluded. Results: Five hundred patients met inclusion/exclusion criteria. Twenty-nine (5.8%) had L3-L4 herniations, 245 (49.0%) had L4-L5 herniations, and 226 (45.2%) had L5-S1 herniations. Overall, 451 (90.2%) patients did not undergo surgery within 1 year of diagnosis. Nonsurgical patients had an average herniation size occupying 31.2% of the canal, compared with 31.5% in patients who underwent surgery. While herniation size, age, sex, and race failed to demonstrate a statistical association with the likelihood for surgery, location of disc herniation demonstrated a strong association. L3-L4 and L4-L5 herniations had odds ratios of 0.19 and 0.45, respectively, relative to L5-S1 herniations ( P = .0047). Patients were more than twice as likely to require a surgery on an L5-S1 herniation in comparison with an L4-L5 herniation ( P < .05). L3-L4 herniations rarely required surgery. Conclusions: Patients with caudal lumbar disc herniations were more likely to require surgery after at least 6 weeks of conservative management than those with disc herniations in the mid-lumbar spine.

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Disc herniation at T1–2

Journal of Neurosurgery ◽

10.3171/jns.1998.88.1.0148 ◽

1998 ◽

Vol 88 (1) ◽

pp. 148-150 ◽

Cited By ~ 40

Author(s):

Howard Morgan ◽

Christopher Abood

Keyword(s):

Disc Herniation ◽

Clinical Signs ◽

Cervical Disc ◽

Motor Deficit ◽

Thoracic Disc Herniation ◽

Content Type ◽

Disc Herniations ◽

Muscles Of The Hand ◽

Thoracic Disc ◽

Intrinsic Muscles

✓ In preparing this paper, the authors reviewed their experiences with four cases of T1–2 disc herniation as well as the medical literature on the subject. Intervertebral thoracic disc herniations are uncommon and high thoracic disc herniations are rare. In the upper third of the thoracic spine, T1–2 is the most common level for disc ruptures. Four cases of disc herniation at T1–2 that caused T-1 radiculopathy are reported in this paper. In reviewing the literature on thoracic disc herniation, the authors found 27 cases at the T1–2 level, 23 of which were lateral disc herniations that produced radiculopathy and four of which were central disc herniations that caused myelopathy. The clinical signs and symptoms of T-1 radiculopathy are similar to those of C-8 radiculopathy; however, distinguishing features can frequently be found on neurological examination. The T-1 radiculopathy usually involves weakness of the intrinsic muscles of the hand. The motor deficit of C-8 radiculopathy involves the intrinsic muscles of the hand and most of the flexors and extensors of the fingers and wrist. The T-1 radiculopathy may produce Horner's syndrome (oculosympathetic paralysis) and diminished sensation in the axilla, which are not found with C-8 radiculopathy. In clinical presentation as well as in treatment, the lateral T1–2 disc herniation resembles a cervical disc herniation, whereas the central T1–2 disc herniation displays the usual appearance of a thoracic disc herniation.

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Is Open Lumbar Micro- Discectomy Safe at Periphery of Nepal?

Nepal Journal of Neuroscience ◽

10.3126/njn.v13i1.15909 ◽

2016 ◽

Vol 13 (1) ◽

pp. 30-34

Author(s):

Bal K Thapa

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Disc Herniation ◽

Economic Status ◽

Lumbar Disc ◽

Low Back ◽

Indications For Surgery ◽

Nerve Roots ◽

Disc Herniations

Lumbar disc surgery is performed exclusively for disc herniation. Either low back pain, or sciatica or both are common presentations depending upon the levels of compressed nerve roots. Indications for surgery and MRI needs to be carefully judged upon keeping the economic status of our patients into consideration. Open lumbar (micro) discectomy is safe and successful method for lumbar disc herniations at periphery. Results in these hundred thirteen initial cases with minimum follow up of 5 years indicate that this is not only feasible but safe in these 57 males and 56 female patients aged between 12 and 93. Redo surgeries were not that difficult in this series and were safe. There were 18 cases with Multiple and 95 single levels. Of the single levels it gradually increased as the level gradually decreased in terms of the vertebral counts. L3/4: 3 cases, L4/5: 28 cases and L5/S1 : 64 cases . There were 18 cases of more than one level discs. There were 96 (Micro) discectomies, 11 Laminotomies and 6 Laminectomies.Nepal Journal of Neuroscience 13:30-34, 2016

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Effect of Thunder-Fire Moxibustion for Lumbar Disc Herniation: Study Protocol for a Randomized Controlled Trial

10.21203/rs.3.rs-350200/v1 ◽

2021 ◽

Author(s):

Jiale Zhang ◽

Xu Zhai ◽

Xue Wang ◽

Liuqing Wang ◽

Hongxuan Tong ◽

...

Keyword(s):

Randomized Controlled Trial ◽

Lumbar Disc Herniation ◽

Disc Herniation ◽

Controlled Trial ◽

Lumbar Disc ◽

Japanese Orthopaedic Association ◽

Cauda Equina ◽

Lower Limbs ◽

Randomized Controlled ◽

Moxibustion Group

Abstract BackgroundLumbar disc herniation (LDH) is one of the common diseases in orthopedics and traumatology, which is caused by nucleus pulposus herniation stimulating cauda equina nerve, nerve root and intervertebral disc degeneration. Its clinical manifestations are low back pain, radiation pain of lower limbs and cauda equina symptoms, which seriously affect the quality of life of patients. At present, oral analgesics are commonly used in clinical non drug therapy for LDH, but oral analgesics will produce gastrointestinal reactions and other side effects. Thunder-fire moxibustion is one kind of moxibustion method, which has been applied widely for treating pain syndromes in China. The aim of our research is to design a randomized controlled trial of thunder-fire moxibustion in the treatment of lumbar disc herniation to explore whether it is safer and more effective than oral analgesic drugs.Methods90 patients will be randomly divided into thunder-fire moxibustion group and acetaminophen group. The intervention included 10 days as a course of treatment, lasting for 20 days. The acetaminophen group took two acetaminophen sustained-release tablets every other day, while the thunder fire moxibustion group will be treated with thunder fire moxibustion once every other time for 30 minutes. Japanese Orthopaedic Association (JOA) score, visual analogue scale (VAS) and oswestry disability index (ODI) will be used as the main the observation indexes. Meanwhile, the occurrence of adverse events (AES) will also be recorded. The assessment will be conducted at baseline and at the end of the first and second course of treatment.DiscussionThe aim of this study is to determine whether thunder-fire moxibustion is more effective than acetaminophen in the treatment of patients with LDH.Trial registrationChinese Clinical Trial Registry (http://www.chictr.org.cn), ChiCTR2000036079. Registered on 21 August 2020.

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Transdural approach for calcified central disc herniations of the upper lumbar spine

Journal of Neurosurgery Spine ◽

10.3171/spi-07/09/370 ◽

2007 ◽

Vol 7 (3) ◽

pp. 370-374 ◽

Cited By ~ 15

Author(s):

Jeong-Wook Choi ◽

Jung-Kil Lee ◽

Kyung-Sub Moon ◽

Hyuk Hur ◽

Yeon-Seong Kim ◽

...

Keyword(s):

Lumbar Spine ◽

Disc Herniation ◽

Nerve Root ◽

Lumbar Disc ◽

Cauda Equina ◽

Cerebrospinal Fluid Leakage ◽

Nerve Root Injury ◽

Central Disc ◽

Disc Herniations ◽

Transdural Approach

✓Disc herniations of the upper lumbar spine (L1–2 and L2–3) have a frequency of 1 to 2% of all disc herniations. During posterior discectomy after laminectomy, significant manipulation of the exiting nerve root is unavoidable because of the narrow lamina and the difficulty in mobilizing the nerve root. The authors adopted a transdural approach in patients with calcified central disc herniation at the L1–2 level to reduce the risk of nerve root injury. Four patients suffering from radiating pain together with back pain were treated using the transdural approach. Pre-operative neuroimaging studies revealed severe central disc herniation with calcification at the L1–2 level. After laminectomy or laminotomy, the incised dura mater was tacked, and the cauda equina rootlets were gently retracted. An intentional durotomy was performed over its maximal bulging of the ventral dura. After meticulous dissection of dense adhesions between the disc herniation and the dural sac, adequate decompression with removal of calcified disc fragments and osteophytes was accomplished. Clinical symptoms improved in all patients. Postoperative permanent cerebrospinal fluid leakage and pseudomeningocele were not observed, and no patient had a progressive lumbar deformity at an average follow-up of 53 months. Transient mild motor weakness and sensory change were observed in two patients postoperatively; however, these symptoms resolved completely within 1 week. The posterior transdural approach offers an alternative in central calcified upper lumbar disc herniation when root retraction is dangerous.

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Magnetic resonance imaging findings in intervertebral disc herniation: Comparison of canal compromise and canal size in patients with and without cauda equina syndrome

Surgical Neurology International ◽

10.25259/sni_242_2020 ◽

2020 ◽

Vol 11 ◽

pp. 171

Author(s):

Kalyan Kumar Varma Kalidindi ◽

Sulaiman Sath ◽

Gayatri Vishwakarma ◽

Harvinder Singh Chhabra

Keyword(s):

Magnetic Resonance ◽

Disc Herniation ◽

Clinical Evidence ◽

Lumbar Disc ◽

Cauda Equina ◽

Intervertebral Disc Herniation ◽

Imaging Findings ◽

Resonance Imaging ◽

Disc Herniations ◽

The Mean

Background: Surgical decompressions are typically warranted in patients with magnetic resonance (MR) and clinical evidence of cauda equina syndromes (CESs). However, it is still unclear what MR findings best correlate with such CES. Here, we compared MR-documented canal size and level/extent of compromise in 52 patients with and 56 others without CES attributed to lumbar disc herniation. Methods: This was a retrospective study of 52 patients with and 56 patients without CES attributed to MR- documented lumbar disc herniations (IDHs). The anteroposterior diameters of the spinal canal and the levels of maximal compression were documented and compared utilizing MR scans from both groups. Results: The 52 patients with CES had more extensive narrowing of the canal diameters at the L4-L5 and L5- S1 levels and higher mean canal compression ratios versus 56 patients without CES. The mean percentage of compression in the CES group at L4-L5 and L5-S1 levels (70% and 67.5%, respectively) was less versus L2-L3 and L3-L4 levels (89.7% and 81.8%, respectively). Conclusion: The 52 patients with CES due to IDH had greater canal compromise versus 56 without CES. Further, the percentage of canal compromise was less at L4-L5 and L5-S1 levels compared to other levels in patients with CES.

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The Effectiveness of Moxibustion for Treating of Lumbar Disc Herniation(LDH): A Protocol for Systematic Review and Meta-ananlysis

10.21203/rs.3.rs-60111/v1 ◽

2020 ◽

Author(s):

Zenan Wu ◽

Jun Xiong ◽

Guixing Xu ◽

Zhengyun Zuo ◽

Yi Yang ◽

...

Keyword(s):

Systematic Review ◽

Lumbar Disc Herniation ◽

Disc Herniation ◽

Clinical Symptoms ◽

Lumbar Disc ◽

Cauda Equina ◽

The Body ◽

Lumbar Pain ◽

Cochrane Library ◽

Disc Herniations

Abstract Background: Lumbar disc herniation (LDH) refers to lumbar disc degeneration or external pressure, resulting in annulus fibrosus rupture, nucleus pulposus protrusion or bulging, compression of nerve roots, cauda equina nerve, and then some clinical symptoms of a clinical syndrome, clinical symptoms are often manifested as unilateral or bilateral lumbar pain, leg numbness. L3/L4,L4/L5, and L5/S1 intervertebral disc herniations are common in the lesion sites of lumbar disc herniations, and the incidence rate is as high as 90%. Typical manifestations are tenderness at the corresponding surface of the body. This disease is a common and frequently-occurring disease in the department of rehabilitation and acupuncture of the hospital, and is a common cause of lumbago and leg pain. At present, the common external treatment for LDH includes many methods,mostly acupuncture and moxibustionMethods: We're going to use systematic electronic search, including PubMed,MEDLINE, Cochrane library, SinoMed,CNKI,WF,VIPand checked references of retrieved articles. Randomized controlled trials (RCTs) on acupotomy treatment in LDH patients will be searched for independently by 2 reviewers in the databases from their inception to August 2020. We will combine data from clinically homogenous studies in a fixed effect meta-analysis using RevManV.5.3.5, and the evidence level will be assessed by using the method for Grading of Recommendations Assessment, Development, and Evaluation (GRADE).Discussion: The results of this review will provide reliable evidence for effectiveness and safety of moxibustion for treating LDH.Systematic review registration: CRD42020187626

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Case of the week: Updating a cervical MR scan avoided unnecessary cervical surgery

Surgical Neurology International ◽

10.25259/sni_931_2020 ◽

2021 ◽

Vol 12 ◽

pp. 134

Author(s):

Nancy E. Epstein

Keyword(s):

Disc Herniation ◽

Surgical Intervention ◽

Lumbar Disc ◽

Mr Studies ◽

Cervical Disc ◽

Focal Neurological Deficit ◽

Full Resolution ◽

Cervical Surgery ◽

Disc Herniations

Background: As spinal surgeons, we have all likely seen cases in which lumbar disc herniations regressed/resolved on successive MR studies. Here, we present a patient whose original cervical MR showed a large C4-C5 cervical disc herniation that completely resolved on the follow-up MR obtained 9 months later, thus avoiding cervical surgery. Case Description: A young patient (e.g. <30 years old) sustained multiple prior traumatic events over the past 3 years. The last episode 9 months ago resulted in the performance of an MR scan that demonstrated a significant central C4-C5 disc herniation with cord/root compression. Despite pain and mild radiculopathy, the patient had no focal neurological deficit, and did not undergo surgery. When the patient recently consulted multiple spinal orthopedists and neurosurgeons, the uniform recommendation was for a C4-C5 anterior cervical discectomy/ fusion (ACDF). However, a telemedicine consultation with a spinal neurosurgeon resulted in a follow-up cervical MR scan that demonstrated cervical disc resorption, and, therefore, no need for cervical surgical intervention. When the new study showed full resolution of the C4-C5 disc, the telemedicine and local neurosurgeon agreed that cervical surgery was unnecessary. Conclusion: The spinal literature shows that predominantly lumbar disc herniations (LDH) spontaneously regress on MR studies 34.7–95% of the time over 6–17 month intervals, with full resolution being seen in 43–75% of cases. As cervical disc herniations likely demonstrate similar resorption/resolution on successive MR studies, old cervical MR examinations should probably be updated/repeated in patients who are being considered for cervical surgical intervention. If/when cervical discs have resorbed, cervical surgery may be avoided.

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