Lumbar disc herniation Management of free fragments Part 1 Vinod Naneria Consultant orthopaedic surgeon Choithram Hospital & Research Centre Indore, India

A piece of nucleus pulposus with annulus fribrosus & fragments of cartilagenous end-plate, lying loose in the spinal canal. It may migrate up or down a level or two, may migrate posterior to dura or perforate dura. Incidence - 9 to 15.5% Free fragment

A piece of nucleus pulposus with annulus fribrosus & fragments of cartilagenous end-plate, lying loose in the spinal canal.

It may migrate up or down a level or two, may migrate posterior to dura or perforate dura. Incidence - 9 to 15.5%

Types of Disk Disease Disk Bulge Disk bulges into anterior epidural space without any area of focal-ness or out-pouching Disk Herniation General term used to describe different degrees of 'eccentric out-pouching' of IV disk. Protrusion contained herniation or sub-ligamentous herniation Extrusion non-contained herniation, or trans-ligamentous herniation Sequestration free fragment

Free Fragments Free Fragments

Loose Fragments

Literature – Free Fragment Incidence - 9 to 15.5% Composition – N.P. / A.F. + fragments of end plate Lateral migration – cranial & caudal Posterior migration – cauda equina – mimic tumour Intra dural more than 60 cases reported-world literature Roof disc : central disc extrusion : contained by P.L.L.

Incidence - 9 to 15.5%

Composition – N.P. / A.F. + fragments of end plate

Lateral migration – cranial & caudal

Posterior migration – cauda equina – mimic tumour

Intra dural more than 60 cases reported-world literature

Roof disc : central disc extrusion : contained by P.L.L.

Migration Since it is impossible to predict on MRI, that a migrated fragment have some continuity with the parent disc or not - it should be considered as loose fragment. There is a real possibility of migration of the fragment and increase in the neuro-deficit. It is immaterial where the migration is. Migration may progress in the initial phase of extrusion, it may migrate one or two level – up or down.

Since it is impossible to predict on MRI, that a migrated fragment have some continuity with the parent disc or not - it should be considered as loose fragment.

There is a real possibility of migration of the fragment and increase in the neuro-deficit.

It is immaterial where the migration is.

Migration may progress in the initial phase of extrusion, it may migrate one or two level – up or down.

Composition of extruded material Nucleolus pulposus Annulus fibrosus Fragments of cartilage end plate .

Nucleolus pulposus

Annulus fibrosus

Fragments of cartilage end plate .

Pathophysiology of Absorption The disc formation takes place before the immune system develops in the embryonic life. The proteins in the nucleosus pulposus are foreign to immune system in adults. The free fragment is treated as foreign protein and a reactive granuloma forms, which absorbs the free fragment.

The disc formation takes place before the immune system develops in the embryonic life.

The proteins in the nucleosus pulposus are foreign to immune system in adults.

The free fragment is treated as foreign protein and a reactive granuloma forms, which absorbs the free fragment.

Absorption - Composition & Time Nucleolus Puplposus absorb by formation of granulation tissue possibly as an auto-immune reaction 3 months Annulus Fibrosus absorb by granulation tissue by vascular invasion 1 – 2 years Hyline cartilage of end-plate suppresses neo-vascularization resistant to absorb

Nucleolus Puplposus

absorb by formation of granulation tissue possibly as an auto-immune reaction

3 months

Annulus Fibrosus

absorb by granulation tissue by vascular invasion

1 – 2 years

Hyline cartilage of end-plate

suppresses neo-vascularization

resistant to absorb

The amount of hyaline cartilage, should be predictable on the basis of imaging data. Vertebral endplate marrow signal intensity changes are associated with fissures in the vertebral end-plate. Signal intensity changes may be regarded as osteo­cartilaginous fracture signs similar to other skeletal manifestations.

The amount of hyaline cartilage, should be predictable on the basis of imaging data.

Vertebral endplate marrow signal intensity changes are associated with fissures in the vertebral end-plate.

Signal intensity changes may be regarded as osteo­cartilaginous fracture signs similar to other skeletal manifestations.

MRI – showing End-plate lesion, marrow signals Indicating a portion of end-plate avulsion in the extruded disc & Will take long time to absorbed or reduction in size. Early surgery may be contemplated.

Fate of Free Fragment – Complete absorption Sei A, Nakamura T et al 1994 Coevoet V et al t.d. 1997 Westmark RM et al c.d. 1997 Miller S et al 1998 Singh P, Singh AP. 1998 Morandi X et al 1999 Kobayashi N et al c.d. 2003 More than 55% of absorption is clinically significant Follow up MRI – every 3 months for one year

Sei A, Nakamura T et al 1994

Coevoet V et al t.d. 1997

Westmark RM et al c.d. 1997

Miller S et al 1998

Singh P, Singh AP. 1998

Morandi X et al 1999

Kobayashi N et al c.d. 2003

Spontaneous changes on MRI & Clinical Correlation - 42 cases treated conservatively. Takada & Takahashi MRI changes Cases Excellent Good Poor Disappearance 08 06 02 00 More  50% 29 11 18 00 No reduction 05 00 01 04 50% involution in 3 – 6 months J.of Orthopaedic Surgery 2001, 9(1): 1–7

MRI changes Cases Excellent Good Poor

Disappearance 08 06 02 00

More  50% 29 11 18 00

No reduction 05 00 01 04

Upward behind body

Lateral Migration Case history – 2 - Monoradiculopathy L4 – L5 with loose fragment over L5 body EHL drop gr. 2 Complete relief 2 Yr FU

Downward Migration

Why conservative? Stable neurological deficit & Presented late > than one week. Bearable radicular pain with negative root stretching test (SLRT). No bladder or bowel dysfunction. Patient not willing for surgery but gave consent for surgery as & when needed. Kept under strict watchful supervision.

Stable neurological deficit & Presented late > than one week.

Bearable radicular pain with negative root stretching test (SLRT).

No bladder or bowel dysfunction.

Patient not willing for surgery but gave consent for surgery as & when needed. Kept under strict watchful supervision.

R.K.- Absorption one month A 25 M Acute agonizing pain 5 days duration Spinal flexion 50%, EHL lt weak gr3 No bladder – bowel dysfunction. Pain minimal MRI extruded disc at L5-S1 left Repeat MRI after one month – extruded fragment (N.P.)absorbed completely.

A 25 M

Acute agonizing pain 5 days duration

Spinal flexion 50%, EHL lt weak gr3

No bladder – bowel dysfunction.

Pain minimal

MRI extruded disc at L5-S1 left

Repeat MRI after one month – extruded fragment (N.P.)absorbed completely.

Jan 2 0 0 7 Feb 2 0 0 7

Absorption within 3 months R.J. – 55 male, Backache sciatica rt., acute onset. Rt. Ankle jerk absent. MRI-June 07- extruded fragment L5-S1 Conservative MRI – Aug 07- complete absorption

R.J. – 55 male,

Backache sciatica rt., acute onset.

Rt. Ankle jerk absent.

MRI-June 07- extruded fragment L5-S1

Conservative

MRI – Aug 07- complete absorption

Complete absorption in three months.

N.K.- Complete absorption one year H/o backache sciatica 2005 – MRI degenerated discs at L4-L5, L5-S1. Extruded disc in 2006 – with no neurological deficit. Tx – conservatively with complete absorption of free fragment.

H/o backache sciatica 2005 – MRI degenerated discs at L4-L5, L5-S1.

Extruded disc in 2006 – with no neurological deficit.

Tx – conservatively with complete absorption of free fragment.

2 0 0 5 2006 2006

2006

2 0 0 7

Case history – U.S. 45 M, Acute backache sciatica 15 days duration Attended clinic as OPD patient. L5 – S1 Rt. with loose fragment over L5 body Measuring 2.4cm x 1.5cm Full flexion spine and negative SLRT Mild gr.4 weakness in EHL and Hypoasthesia in L5 distribution. Tx conservatively

45 M,

Acute backache sciatica 15 days duration

Attended clinic as OPD patient.

L5 – S1 Rt. with loose fragment over L5 body

Measuring 2.4cm x 1.5cm

Full flexion spine and negative SLRT

Mild gr.4 weakness in EHL and Hypoasthesia in L5 distribution.

Tx conservatively