Lumbar disc Extrusion – an observational study                  Part 4                                   Vinod Naneria    ...
Hakan SABUNCUOGLU• Clinical improvement of patients was  demonstrated with radiological regression, it  sometime does not ...
Saal JA, Saal JS• In a retrospective cohort study, Saal and Saal  demonstrated that lumbar disc herniation  with radiculop...
Spontaneous regression from intervertebral disc herniation.               Propos of a series of 37 cases      Martínez-Qui...
References• Spontaneous regression of symptomatic lumbar disc  herniation. Ribeiro RP, Matos RM, Vieira A, Costa JM,  Proe...
References• Transcript levels of major MMPs and ADAMTS-4 in  relation to the clinicopathological profile of patients  with...
References• Spontaneous regression of herniated cervical disc fragments  and its clinical significance. Pan H, Xiao LW, Hu...
References• Ultrastructural analysis on lumbar disc herniation using  surgical specimens: role of neovascularization and  ...
References• Disc herniation-induced sciatica: medical or surgical  treatment? Legrand E, Hoppé E, Bouvard B, Masson C,  Au...
Case summary - 1Six years follow up. Marginal reduction in size.No neurological deficit. Persisting with backache.
Case summary - 2Persistence of same size, backache, no new deficit since 2004
Oct 2004
Oct 2004
Dec 2008
Dec 2008
Oct 2010
Oct 2010
Oct 2010
Case summary - 3 No changes in 3 years
Sept 2007
Sept 2007
May 2010
May 2010
Case summary - 4No relationship between size of disc and functions
Comments• In spite of huge disc size, there is no  neurological deficit.• There is limited straight leg raising on left si...
Case summary - 5Yet another example of relationship of size of disc and clinical status
Case summary - 6Contended disc – No appreciable changes in 7 years
Case summary - 7
Case summary - 8
Case summary - 9
Case summary - 10
Case summary - 11
Case summary - 12
Feb 2010
Case summary - 13
Case summary - 14      No change in size , clinically OK
March 2002
March 2002
May 2007
May 2007
Case summary - 15
Inferences• Extruded disc – disappears completely.• Extruded fragment – complete absorption.• Extruded disc – reduce in si...
Inferences• Extrusion of disc – genetic predisposing.• Extrusion of disc – more with multiple level  disc bulges.• Extrude...
Inferences• Contended disc remains same for long time.• There is no co-relation between size of  prolapse/extrusion with a...
Inferences• EHL – improve to gr 3- 5 power depends on  initial damage.• Ankle jerks – do not come back• Functional recover...
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 –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
Lumbar disc extrusion –clinical relation with size
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Lumbar disc extrusion –clinical relation with size

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  • The management of weakness caused by lumbar and lumbosacral nerve root compression:
    H. Sharma, MS(Orth), MCh(Orth), FRCS(Tr&Orth), Consultant Orthopaedic Spinal Surgeon1 ;
    S. W. J. Lee, BSc, Medical Student 2; and
    A. A. Cole, FRCS(Tr&Orth), Consultant Orthopaedic Spinal Surgeon3


    The main indication for surgical treatment in the management of patients with lumbosacral nerve root compression should be pain rather than weakness..
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Lumbar disc extrusion –clinical relation with size

  1. 1. Lumbar disc Extrusion – an observational study Part 4 Vinod Naneria Clinical & Disc Size Girish Yeotikar Arjun Wadhwani Choithram Hospital & Research centre, Indore,
  2. 2. Hakan SABUNCUOGLU• Clinical improvement of patients was demonstrated with radiological regression, it sometime does not correlate with morphological or radiological changes in different patients. Spontaneous Regression of Extruded Lumbar Disc Herniation: Report of Two Illustrative Case and Review of the Literature. Hakan SABUNCUOGLU, Selcuk OZDOGAN, Erdener T‹MURKAYNAK Turkish Neurosurgery 2008, Vol: 18, No: 4, 392-396
  3. 3. Saal JA, Saal JS• In a retrospective cohort study, Saal and Saal demonstrated that lumbar disc herniation with radiculopathy can be successfully treated with nonoperative procedures resulting in “good to excellent” outcomes for approximately 90% of patients. Saal JA, Saal JS: Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy. An outcome study. Spine 14(4):431-417, 1989. Saal JA, Saal JS, Herzog RJ: The natural history of lumbar intervertebral disc extrusions treated nonoperatively. Spine 15(7):668-683, 1990
  4. 4. Spontaneous regression from intervertebral disc herniation. Propos of a series of 37 cases Martínez-Quiñones JV, Aso-Escario J, Consolini F, Arregui-Calvo R. Neurocirugia (Astur). 2010 Apr;21(2):108-17.• Disc herniation can regress, or even disappear, in a number of patients, rendering the radiological findings not to be taken as the only surgical indication criterium. The best treatment is the one relying on a good doctor-patient relationship, suspended in a balance between conservative and surgical treatment.• The disc herniation conservative healing, both clinical as radiological, do exist, being a concept to widespread among clinicians and patients also.
  5. 5. References• Spontaneous regression of symptomatic lumbar disc herniation. Ribeiro RP, Matos RM, Vieira A, Costa JM, Proença R, Pinto R. Acta Reumatol Port. 2011 Oct- Dec;36(4):396-8. Portuguese.• Spontaneous resorption of sequestrated intervertebral disc herniation. Orief T, Orz Y, Attia W, Almusrea K. World Neurosurg. 2012 Jan;77(1):146-52. Epub 2011 Nov 17.• Spontaneous regression of intervertebral disc herniation-- case reports. Rapan S, Gulan G, Lovrid I, Jovanovid S. Coll Antropol. 2011 Mar;35(1):211-5.
  6. 6. References• Transcript levels of major MMPs and ADAMTS-4 in relation to the clinicopathological profile of patients with lumbar disc herniation. Tsarouhas A, Soufla G, Katonis P, Pasku D, Vakis A, Spandidos DA. Eur Spine J. 2011 May;20(5):781-90. Epub 2010 Sep 22.• Spontaneous regression from intervertebral disc herniation. Propos of a series of 37 cases. Martínez- Quiñones JV, Aso-Escario J, Consolini F, Arregui- Calvo R. Neurocirugia (Astur). 2010 Apr;21(2):108- 17. Spanish.
  7. 7. References• Spontaneous regression of herniated cervical disc fragments and its clinical significance. Pan H, Xiao LW, Hu QF. Orthop Surg. 2010 Feb;2(1):77-9. doi: 10.1111/j.1757-7861.2009.00067.x.• Spontaneous regression of lumbar herniated disc. Chang CW, Lai PH, Yip CM, Hsu SS. J Chin Med Assoc. 2009 Dec;72(12):650- 3• Spontaneous disappearance of lumbar disk herniation within 3 months. Nozawa S, Nozawa A, Kojima H, Shimizu K. Orthopedics. 2009 Nov;32(11):852. doi: .3928/01477447- 20090922-21.
  8. 8. References• Ultrastructural analysis on lumbar disc herniation using surgical specimens: role of neovascularization and macrophages in hernias. Kobayashi S, Meir A, Kokubo Y, Uchida K, Takeno K, Miyazaki T, Yayama T, Kubota M, Nomura E, Mwaka E, Baba H. Spine (Phila Pa 1976). 2009 Apr 1;34(7):655-62.• Spontaneous regression of extruded lumbar disc herniation: report of two illustrative case and review of the literature. Sabuncuoğlu H, Ozdoğan S, Timurkaynak E. Turk Neurosurg. 2008 Oct;18(4):392-6.
  9. 9. References• Disc herniation-induced sciatica: medical or surgical treatment? Legrand E, Hoppé E, Bouvard B, Masson C, Audran M. Rev Prat. 2008 Feb 15;58(3):285-93. French.• Spontaneous regression of a huge subligamentous extruded disc herniation: short report of an illustrative case. Gezici AR, Ergün R. Acta Neurochir (Wien). 2009 Oct;151(10):1299-300.• Spontaneous regression of a lumbar disk herniation. Monument MJ, Salo PT. CMAJ. 2011 Apr 19;183(7):823. Epub 2011 Jan 31.
  10. 10. Case summary - 1Six years follow up. Marginal reduction in size.No neurological deficit. Persisting with backache.
  11. 11. Case summary - 2Persistence of same size, backache, no new deficit since 2004
  12. 12. Oct 2004
  13. 13. Oct 2004
  14. 14. Dec 2008
  15. 15. Dec 2008
  16. 16. Oct 2010
  17. 17. Oct 2010
  18. 18. Oct 2010
  19. 19. Case summary - 3 No changes in 3 years
  20. 20. Sept 2007
  21. 21. Sept 2007
  22. 22. May 2010
  23. 23. May 2010
  24. 24. Case summary - 4No relationship between size of disc and functions
  25. 25. Comments• In spite of huge disc size, there is no neurological deficit.• There is limited straight leg raising on left side after 2 months of acute attack.• Patient can still stand on his left toes indicating the power in the Gastrosoleus muscles.
  26. 26. Case summary - 5Yet another example of relationship of size of disc and clinical status
  27. 27. Case summary - 6Contended disc – No appreciable changes in 7 years
  28. 28. Case summary - 7
  29. 29. Case summary - 8
  30. 30. Case summary - 9
  31. 31. Case summary - 10
  32. 32. Case summary - 11
  33. 33. Case summary - 12
  34. 34. Feb 2010
  35. 35. Case summary - 13
  36. 36. Case summary - 14 No change in size , clinically OK
  37. 37. March 2002
  38. 38. March 2002
  39. 39. May 2007
  40. 40. May 2007
  41. 41. Case summary - 15
  42. 42. Inferences• Extruded disc – disappears completely.• Extruded fragment – complete absorption.• Extruded disc – reduce in size.• Extruded disc – can recur at same level, same side or other side.• Extrusion of disc – can occur at other site.
  43. 43. Inferences• Extrusion of disc – genetic predisposing.• Extrusion of disc – more with multiple level disc bulges.• Extruded disc – may not reduce in size.• Extruded disc – mostly with single root radiculopathy.• Extrusion of disc – usually acute onset – last for few hours and pain decreases with some neurological deficit with in 24 hours.
  44. 44. Inferences• Contended disc remains same for long time.• There is no co-relation between size of prolapse/extrusion with amount of pain or neurological deficit.• Foraminal disc – protrusion/extrusion causes severe pain and compressive radiculopathy.• Neurological status never deteriorate after initial insult(damage at the time of extrusion)
  45. 45. Inferences• EHL – improve to gr 3- 5 power depends on initial damage.• Ankle jerks – do not come back• Functional recovery – complete• Back pain – remain• Patients own assessment – Happy• Extrusion – may be considered as final stage in disc pathology.
  46. 46. 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.
  47. 47. 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.
  48. 48. 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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