1) Lumbar disc herniation can involve free fragments, consisting of nucleus pulposus, annulus fibrosus, and cartilage endplate fragments that have migrated outside of the disc space. 2) Free fragments can migrate laterally or posteriorly over time and cause increasing neurological deficits. They are difficult to predict based on MRI alone. 3) Free fragments are gradually absorbed over time through formation of granulation tissue, with nucleus pulposus absorbing within 3 months, annulus fibrosus within 1-2 years, and cartilage endplate fragments resisting absorption due to lack of vascularization.

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

3. 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

4. Free Fragments Free Fragments

5. Loose Fragments

12. 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.

15. Upward behind body

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

17. Downward Migration

20. Jan 2 0 0 7 Feb 2 0 0 7

23. Complete absorption in three months.

25. 2 0 0 5 2006 2006

26. 2006

27. 2 0 0 7