Journal of Korean Society of
Spine Surgery Conservative Treatment of Lumbar Disc Herniation - A Prospective Study of Disc Herniation Encroaching More than One-third of Spinal Canal Byung-Joon Shin, M.D., Jae Chul Lee, M.D., Ho-Hyoung Lee, M.D., Hae-Dong Jang, M.D. J Korean Soc Spine Surg 2011 Sep;18(3):123-131. Originally published online September 30, 2011;
http://dx.doi.org/10.4184/jkss.2011.18.3.123 Korean Society of Spine Surgery Department of Orthopedic Surgery, Inha University School of Medicine #7-206, 3rd ST. Sinheung-Dong, Jung-Gu, Incheon, 400-711, Korea Tel: 82-32-890-3044 Fax: 82-32-890-3467
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Original Article
J Korean Soc Spine Surg. 2011 Sep;18(3):123-131.
pISSN 2093-4378 eISSN 2093-4386
http://dx.doi.org/10.4184/jkss.2011.18.3.123
Conservative Treatment of Lumbar Disc Herniation - A Prospective Study of Disc Herniation Encroaching More than One-third of Spinal Canal Byung-Joon Shin, M.D., Jae Chul Lee, M.D., Ho-Hyoung Lee, M.D., Hae-Dong Jang, M.D. Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Seoul, Korea
Study Design: Prospective study. Objectives: To investigate the clinical results of conservative treatment for mid-to-large lumbar disc herniation diagnosed via magnetic resonance imaging (MRI) and the factors influencing treatment. Summary of Literature Review: There is limited information regarding the clinical results of conservative treatment for lumbar disc herniation. The recent studies using MRI have suggested favorable treatment results. Materials and Methods: The study subjects were 39 cases of herniated disc patients with over a 1/3 spinal canal encroachment -- based on MRI -- that were followed up for at least 1 year. The average age was 42.6-years-old (range of 12-76 years-old), and the average follow-up period was 28 months. The neurological deficit and the visual analogue scale (VAS) of back pain and radiating pain at the time of initial diagnoses and final follow-ups were compared, and the clinical results were evaluated based Kim & Kim’s criteria. Results: Although 4 of the 39 patients needed to undergo surgery during the follow-up period, 33 of the remaining 35 patients showed satisfactory (excellent and good ratings) results: 27 excellent, 6 good, 2 fair, i.e., a 85% (33 out of 39) satisfactory results. Of the 14 cases that had neurological defect at the initial diagnosis, only 1 case needed surgery, thereby resulting in a 93% (13 out of 14) satisfactory result. There were no statistically significant correlations among the degree of spinal canal encroachment and other factors such as age, sex, herniation type, and neurological deficit at initial diagnosis, and the clinical results at the final follow-up, conversion to surgery during follow-up, and remaining pains. Conclusions: The clinical results of conservative treatment in lumbar disc herniation were satisfactory even in cases of high degree of spinal canal encroachment. Therefore, conservative treatment of lumbar disc herniation should be considered first before resorting to surgical treatment. Key Words: Lumbar Disc Herniation, Conservative Treatment, MRI, Spinal Canal Encroachment
INTRODUCTION Lumbar disc herniation is a common disease in the spine area and it occurs in 1%-2% of the total population1) in the 2)
U.S. about 200,000 diskectomies are performed annually.
Recently, as MRI is used widely in diagnosing disc herniation, a great number of patients are being diagnosed with lumbar disc herniation and they are being treated - other than the surgical methods using microscope, endoscope, and laser - with a variety of treatment methods and rehabilitations. However, there is a considerable amount of controversy in regard to the pathophysiology and treatment guidelines for lumbar disc herniation. After the study by Hakelius et al.3) on the natural progress of patients with radiating pain, although
Received: January 17, 2011 Revised: July 21, 2011 Accepted: July 21, 2011 Published Online: September 30, 2011 Corresponding author: Jae Chul Lee, M.D. Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, 657, Hannam-dong, Yongsan-gu, Seoul, Korea TEL: 82-2-709-9808, FAX: 82-2-794-9414 E-mail:
[email protected]
“This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.”
many reports about the sound natural progress of herniated disc patients along with surgery and conservative treatment have been
© Copyright 2011 Korean Society of Spine Surgery
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Byung-Joon Shin et al
published, there have been significant disagreements regarding
Volume 18 • Number 3 • September 2011
2. Study Methods
the results. This is believed to be attributable to the differences in diagnostic methods which, importantly, caused the study subject
1) Analysis of Clinical Factors and Results
groups to be different. However, according to the existing
At the time of the initial and final follow-up, the patients’
studies on the diagnoses of disc herniation were based on various
back pain and radiating pain were recorded using VAS (Visual
methods ranging from using the symptoms of radiating pain as
Analogue Scale), and Kim & Kim’s criteria (Table 1) was used to
basis to myelogram and computed tomography. Some studies
evaluate the clinical results, and cases that required surgery were
have used MRI, and, particularly, a small number of studies
classified as “bad”. In addition, the prognostic factors such as the
have used MRI for confirmation of all their cases.
patients’ age, sex, herniated region, herniation type, neurologi-
In addition, there is a pattern of more recommendation for surgery when MRI shows greater degrees of disc herniation;
cal deficits at initial diagnosis, back pain and radiating pain were measured.
as such, this study attempted to investigate about the clinical results of conservative treatment and the factors that influence
2) Radiographic Analysis
the results of patients who were clearly diagnosed with herniated
The degree of spinal canal encroachment was measured in the
discs with over 1/3 canal encroachment shown on MRI and
most encroached region from the axial view of the MRI image
corroborating clinical symptoms such as radiating pain.
by using digital measurement tools (Fig. 1). The degree of spinal canal encroachment was on the average 49.7% (range of 33.4%
RESEARCH SUBJECTS AND METHODS
-78.6%). On the MRIs, the types of herniation were classified into these categories according to the criteria of Costello et al.;
1. Study Subjects
protruded, extruded, and sequestrated.4) In this study, since only
The study subjects were comprised of, among the patients who
the degrees of herniation of 1/3 or more were used as study
visited our hospital from April 2006 to March 2009, the cases
subjects, the protruded types were excluded.
with -- either 1) the first symptoms occurred within 6 weeks, or 2) symptoms were older than 6 weeks but symptoms showing
3) Statistical Analysis
improving trend -- of the patients diagnosed through MRI with
Statistically in the univariate analysis t-tests and cross analysis
disc herniation of more than 1/3 spinal canal encroachment and with radiating pain in the associated dermatome. The cases where the muscle strength was below grade 2 and there were severe neurological deficits or progressing neurological deficit, cauda equina syndrome, symptoms occurred more than 6 weeks before but no sign of improvement were recommended for surgery and were excluded as study subjects. Also excluded were the patients, during this period, who had a previous history of discectomy in the same region, spinal stenosis, foraminal and extraforaminal types. This was a prospective study using the 44 cases that met the above criteria. Conservative treatments included analgesics, antiinflammatory drug therapy, and spinal rehabilitation education. Among the 44 patients, 39 patients who could be followed up for more than 1 year were studied; the average age was 42.6 years old (range of 12-76 years old), 25 male cases, 14 female cases, and the average follow-up period was 28 months.
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Fig. 1. Spinal canal area and herniated disc size were measured on MRI axial images.
Journal of Korean Society of Spine Surgery
Conservative Treatment of Lumbar Disc Herniation
Table.1. Kim & Kim’s criteria of clinical outcome
Excellent
Good
Fair
Poor
Complete relief of pain in back and lower limbs No limitation of physical activity Analgesics not used Able to squat on the floor
1. Radiographic Analysis of the Results
The occurrence region was most frequent at Lumbar 4-5 (L4-L5) with 19 cases, next was Lumbar 5 – Sacral 1 (L5-
Relief of most pain in back and lower limbs Able to return to accustomed employment Physical activities slightly limited Analgesics used only infrequently Able to squat on the floor
S1) with 17 cases, next Lumbar 3-4 (L3-L4) with 2 cases, and
Partial relief of pain in back and lower limbs Able to return to accustomed employment with limitation, or return to lighter work Physical activities definitely limited Mild analgesic medication used frequently Mild limitation to squat on the floor
MRI image was on 49.7% (range of 33.4%-78.6%)(Table 2).
Little or no relief of pain in back and lower limbs Physical activities greatly limited Unable to return to accustomed employment Analgesic medication used regularly Unable to squat on the floor without support
the follow-up period; the remaining 35 cases showed VAS at
then Lumbar 1-2 (L1-L2) with 1 case. Extruded type was in 35 cases, sequestrated type was in 4 cases; the highest degree of spinal canal encroachment measured from the axial view of the
2. Pain and Clinical Results
Of the 39 cases, 4 cases had to be converted to surgery due to the failure of conservative treatment or recurrence during the time of initial diagnosis of on average 2.3 (0-8) and at the time of final follow-up 0.5 (0-6), VAS for radiating pain was on average 5.5 (3-10) and at the time of final follow-up 0.4 (0-7). (Fig. 2) The clinical results were, of the 35 cases that did
were used to determine the correlation between the clinical result
not require surgery: 27 cases of “excellent”, 6 cases of “good”,
scores at the time of the final follow-up and other factors that
2 cases of “fair” at the time of the final follow-up; i.e., without
were expressed as non-continuous variables; Pearson correlation
surgery 85% (33 out of 39) of all the cases showed satisfactory
was used to determine the correlation between the clinical result
results(Fig. 3).
scores at the time of the final follow-up and other factors that were expressed as continuous variables. Statistical test defined as significant when p
