Lumbar disc extrusion – recurrence


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recurrences after conservative treatment,

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Lumbar disc extrusion – recurrence

  1. 1. Lumbar disc Extrusion – an observational study Part 3 Vinod Naneria Recurrences on MRI Girish Yeotikar Arjun Wadhwani Choithram Hospital & Research centre, Indore,
  2. 2. 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.
  3. 3. Recurrence – after surgery• Recurrence has been noted to occur in 5 to 15% of cases surgically treated for primary lumbar disc herniation.• Recurrence after surgery for recurrence increased to 27%.• Incidence of recurrence is very high in cases operated for annular tear and is lowest when there is extruded disc fragment.
  4. 4. Recurrent lumbar disc herniation after discectomy: outcome of repeat discectomy. Dai LY, Zhou Q, Yao WF, Shen L. Surg Neurol. 2005 Sep;64(3):226-31;No factors such as age, sex, traumatic events, timesof prior surgery, level of herniation, side ofrecurrence, pain-free interval, duration of recurrencesymptoms, walking capacity, the preoperative JOAscore, associated spinal stenosis, procedures ofrevision surgery, and dural tear were found to be ofpredictive value for a prognosis of revision surgeryfor recurrent disc herniation.
  5. 5. Surgery -complications• Discectomy-related complications occur in 15 to 30% of cases and include haemorrhage, soft-tissue infection, nerve root injury, dural tear, recurrent or residual disc herniation, epidural scar formation, discitis, arachnoiditis, pseudomeningocele, facet joint fracture (iatrogenic or stress related), spinal stenosis, and epidural hematoma, mechanical instability.
  6. 6. Reference• Carragee, et al., prospectively evaluated disc herniation types, rate of re-herniation, and rate of reoperation. They divided disc herniations into four shape-based groups:• 1) fragment–fissure herniations (disc fragment and small anular defect);• 2) fragment–defect herniations (large disc fragment with massive posterior annular tear);• 3) fragment contained discs (incomplete anular tear);• 4) absence of fragment-contained herniations (annular prolapse).
  7. 7. Reference• Of the four groups, the fragment–fissure type herniations were associated with the best outcomes, lowest rate of re-herniation (1%), and required the fewest re-operative procedures (1%).• Those with annular prolapse were associated with the worst outcomes, with 38% of patients experiencing recurrent or persistent symptoms.
  8. 8. Case summary - 1
  9. 9. Feb. 2011Sept. 2011
  10. 10. Comments• First attack in 2007 – with a large disc protrusion with EHL weakness.• Improved clinically• Recurrence in Feb 2011 without any deficit.• Finally – disc extrusion occur in Sept 2011 without any deficit.• Off duty for a month in Feb 2011 and another month in Sept 2011.• Last follow up – Sept 2012 - Happy
  11. 11. Case summary - 2
  12. 12. comments• Three years follow up• First follow up MRI showed reduction in size and absorption a large piece of extruded disc in three months time.• Recurrence of back pain and further extrusion at same level in Jan 2011.• Some reduction in size in April 2011.• Recurrence can occur at the same level.
  13. 13. Gourav Kapoor Case summary - 3• 26/M• Acute on chronic PID L4 – L5 rt.• EHL – N• Ankle jerk – N• MRI – Feb. – 2005 contended disc• Tx – conservative• Recurrence in July 2007• EHL – weak• Ankle jerk - N• MRI – extruded disc at L4 – L5• Tx – conservative• Last follow up – Sept 2012 - improved
  14. 14. Case summary - 4
  15. 15. Case summary - 5
  16. 16. Case summary - 6
  17. 17. Case summary - 7 Suresh Neema• 60/M• Acute PID rt L4 – L5>2wks• EHL – weak• Ankle jerk – N• MRI – Feb 2009• Tx – Conservative• Follow up MRI – June 2010• Recurrence• No neurological deficit• MRI – Aug 2012 – extrusion at L2 – L3
  18. 18. Case summary - 8 Sept 2012, Tx – Conservative +epidural
  19. 19. Comments• PID L4 – L5 on left side in Feb 2005• Follow up MRI Sept 2005 showed disc absorption.• Recurrence of PID in July 2011 on right side same level.• Recurrence of PID in Sept 2012 on right side at same level.
  20. 20. Case summary - 9
  21. 21. July 2008
  22. 22. July 2008
  23. 23. Nov 2011
  24. 24. Nov 2011
  25. 25. Nov 2011
  26. 26. Nov 2011
  27. 27. May 2012
  28. 28. May 2012
  29. 29. May 2012
  30. 30. May 2012
  31. 31. comments• Initial MRI just had a contended disc at L5 – S1 in 2008.• Recurrence with multiple level disc in Nov – 2011. No neurological deficit.• Recurrence in May 2012 with extrusion of L5 – S1 disc and quadaequina with temporary loss of bladder control.• Prompt surgery with removal of loose piece from L5 – S1 space and discoidectomy at L4 – L5 relieved her.• Improving neurological status at last follow up Sept 2012.
  32. 32. Case summary 10• 42/M• Acute on chronic PID L2 – L3<1wk• Quad – N• EHL – N• Ankle jerk – N• MRI – extruded disc• Tx – conservative with epidural + nerve block
  33. 33. Case summary conti…• H/o Acute PID – April 1999.• MRI – multiple level discs – L3 – L4, L4 – L5, L5 – S1.• Recurrence in July 2005• MRI – L5 – S1 disc prolapse left• Tx – Conservative with epidurals• Recurrence in Aug 2012• MRI – extruded disc at L2 – L3
  34. 34. April 1999
  35. 35. July 2005
  36. 36. Aug 2012
  37. 37. Aug 2012
  38. 38. April 1999July 2005Aug 2012
  39. 39. 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 for prompt deletion.• Material collected from C.H.& R.C., Indore and from private clinics of the authors.
  40. 40. 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