Lumbar disc Extrusion – an observational study                  Part 2                                   Vinod Naneria    ...
Reduction in size• More than 50% reduction in size on follow-up  MRI is clinically significant.• Bigger the size, better t...
Inui, Yoshihiro et al in Spine. 29(21):2365-2369,                    November 1, 2004.•    Fas-Ligand Expression on Nucleu...
Hypothesis of disc absorption• There are three proposed hypothesis for  absorption.• The first proposed hypothesis is the ...
Hypothesis of disc absorption• Third hypothesis - the recent studies asserted that  the spontaneous regression, to be a re...
Immunology• It has been made clear in the world literature  that the radicular pain from the compressed  nerve root is pri...
• This is the reason why fragments mainly  composed of nucleolus pulposus get absorbed  early. The annulus is absorbed by ...
Endplates at MR Imaging- Gebhard Schmid et al        published in “Radiology Vol 231 No.2• Findings in the current study s...
• Results confirm that there is cartilaginous material in a high  proportion of extruded disk herniations. The amount of  ...
Case summary - 1
comments•   Six years follow up.•   Marginal reduction in size.•   No neurological deficit.•   Persisting with backache.
Case Case summary - - 2                        summaryReduction in size of disc with complete recovery in clinical symptoms
Case summary - 3Reduction in size of disc with complete recovery in clinical symptoms
Case summary - 4Gr 4 EHL after 2 years with occasional backache
Case summary - 5Significant decrease in the size of the disc
Case summary - 6Marked reduction in size
Case summary - 7Marked reduction in size
May 2012
May 2012
Aug 2012
Aug 2012
Aug 2012
5/5/201230/8/2012
Case summary - 8Gradual absorption in process
Case summary - 9  Marked reduction in size
Case summary - 10 Marked regression
Case summary - 11   Regression in size
Case summary - 12Marked reduction in size
Case summary - 13Regression of extruded piece
March 2008
March 2008
Case summary - 14Regression of disc size
Case summary - 15 Significant regression of size
Case summary - 16      Case summary -Marked reduction in size
Case summary - 17Marked regression in size
Purpose of presentation• Conservative treatment is well accepted  method of treatment of PID.• There is no need to frighte...
Disclaimer• All photographs were taken with the consent of the all  patients.• Clinical photos were also put with due verb...
DISCLAIMERInformation contained and transmitted by this presentation isbased on personal experience and collection of case...
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
Lumbar disc extrusion –regression
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Lumbar disc extrusion –regression

  1. 1. Lumbar disc Extrusion – an observational study Part 2 Vinod Naneria Reduction in Size Girish Yeotikar Arjun Wadhwani Choithram Hospital & Research centre, Indore,
  2. 2. Reduction in size• More than 50% reduction in size on follow-up MRI is clinically significant.• Bigger the size, better the chances of reduction and better clinical outcome. Eiichi Takada and Masaya Takahashi - E Takada et al. Journal of Orthopaedic Surgery Vol. 9 No. 1, June 2001 - Natural history of lumbar disc hernia with radicular leg pain.
  3. 3. Inui, Yoshihiro et al in Spine. 29(21):2365-2369, November 1, 2004.• Fas-Ligand Expression on Nucleus Pulposus Begins in Developing Embryo. Expressed there views as - The present results demonstrated that Fas ligand expression is not detected in the notochord, but at the time of intervertebral disc formation, Fas ligand expression develops in the nucleus pulposus. These results indicate that the immune privilege of the intervertebral disc may begin in the very early stages of disc formation. Moreover, Fas ligand may play an important role in the formation of the intervertebral disc.
  4. 4. Hypothesis of disc absorption• There are three proposed hypothesis for absorption.• The first proposed hypothesis is the retraction back into the intervertebral space. If there is bulging or herniation into the annulus fibrosis, this situation can be encountered theoretically.• Second hypothesis is based on the concept of dehydration ( shrinkage with the loss of the water content of the herniated disc material), slowly.In journal of Neurological Sciences Volume 23, Number 4, Page(s) 339-343, 2006, MehmetŞENOĞLU, Kasım Zafer YÜKSEL, and Mürvet YÜKSEL reported two cases of spontaneousabsorption.
  5. 5. Hypothesis of disc absorption• Third hypothesis - the recent studies asserted that the spontaneous regression, to be a result of enzymatic degradation and phagocytosis against the extruded disc tissue in the epidural space with inflammatory reaction and neovacularization . There are some pathological and experimental studies supporting this situation.• There is also possibility that all 3 of these mechanisms take part in the spontaneous regression and disappearing of the disc material altogether.
  6. 6. Immunology• It has been made clear in the world literature that the radicular pain from the compressed nerve root is primarily due to sensitization of the nerve root as a result of inflammation induced by antigen – antibody reaction. This is the reason for a quick response to cortisone therapy in acute prolapse.
  7. 7. • This is the reason why fragments mainly composed of nucleolus pulposus get absorbed early. The annulus is absorbed by granulation formation.• A disc fragment contain more of end plate cartilage take long time to absorb.
  8. 8. Endplates at MR Imaging- Gebhard Schmid et al published in “Radiology Vol 231 No.2• Findings in the current study show that avulsion- type disk herniation with hyaline cartilage material occurs frequently (in nearly 50% of patients). The amount of cartilage may be as much as 50% of the extruded material, and bone fragments were observed in five patients.• Lumbar Disk Herniation:Correlation of Histologic Findings with Marrow Signal Intensity Changes in Vertebral Gebhard Schmid, MD:
  9. 9. • Results confirm that there is cartilaginous material in a high proportion of extruded disk herniations. The amount of cartilage in the herniation material is usually less than 10%, but it can be as much as 50%. The association of the amount of cartilaginous material with endplate abnormalities supports the theory that avulsion of the vertebral endplate is one source of disk herniation.• The good correlation of marrow signal intensity changes in the middle third of the endplate with cartilaginous material in the disk herniation further supports the histopathologic findings by Tanaka et al that most avulsions occur in the inner or transitional zone of the annulus end plate interface. Carreon LY, Ito T, Yamada M, Uchiyama S, Takahashi HE. Neovascularization induced by annulus and its inhibition by cartilage endplate: its role in disc absorption. Spine 1997; 22:1429–1434.
  10. 10. Case summary - 1
  11. 11. comments• Six years follow up.• Marginal reduction in size.• No neurological deficit.• Persisting with backache.
  12. 12. Case Case summary - - 2 summaryReduction in size of disc with complete recovery in clinical symptoms
  13. 13. Case summary - 3Reduction in size of disc with complete recovery in clinical symptoms
  14. 14. Case summary - 4Gr 4 EHL after 2 years with occasional backache
  15. 15. Case summary - 5Significant decrease in the size of the disc
  16. 16. Case summary - 6Marked reduction in size
  17. 17. Case summary - 7Marked reduction in size
  18. 18. May 2012
  19. 19. May 2012
  20. 20. Aug 2012
  21. 21. Aug 2012
  22. 22. Aug 2012
  23. 23. 5/5/201230/8/2012
  24. 24. Case summary - 8Gradual absorption in process
  25. 25. Case summary - 9 Marked reduction in size
  26. 26. Case summary - 10 Marked regression
  27. 27. Case summary - 11 Regression in size
  28. 28. Case summary - 12Marked reduction in size
  29. 29. Case summary - 13Regression of extruded piece
  30. 30. March 2008
  31. 31. March 2008
  32. 32. Case summary - 14Regression of disc size
  33. 33. Case summary - 15 Significant regression of size
  34. 34. Case summary - 16 Case summary -Marked reduction in size
  35. 35. Case summary - 17Marked regression in size
  36. 36. Purpose of presentation• Conservative treatment is well accepted method of treatment of PID.• There is no need to frighten the patient for possible hypothetical complications.• In our experience, a mono radiculopathy never deteriorates to poly neuropathy.• Poly neuropathy is a separate incident in the cases of pre-existing disc pathology.
  37. 37. Disclaimer• All photographs were taken with the consent of the all patients.• Clinical photos were also put with due verbal permission.• This presentation strictly for students of orthopedics with the sole idea of propagating knowledge.• Any objection as for photographs or x-rays, please inform naneria@yahoo.com for prompt deletion.• Material is collected from C.H.& R.C., Indore and from private clinics of the authors.
  38. 38. DISCLAIMERInformation contained and transmitted by this presentation isbased on personal experience and collection of cases atChoithram Hospital & Research centre, Indore, India, duringlast 25 years. It is intended for use only by the students oforthopaedic surgery. Views and opinion expressed in thispresentation are personal opinion. Depending upon the x-rays and clinical presentations viewers can make their ownopinion. For any confusion please contact the sole author forclarification. Every body is allowed to copy or download anduse the material best suited to him. I am not responsible forany controversies arise out of this presentation. For anycorrection or suggestion please contact naneria@yahoo.com

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