Conservative Treatment of Lumbar Disc Herniation - A Prospective Study of Disc Herniation Encroaching More than One-third of Spinal Canal -

Byung-Joon Shin; Jae Chul Lee; Ho-Hyoung Lee; Hae-Dong Jang

doi:10.4184/jkss.2011.18.3.123

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Shin, Lee, Lee, and Jang: Conservative Treatment of Lumbar Disc Herniation - A Prospective Study of Disc Herniation Encroaching More than One-third of Spinal Canal -

Original Article

Journal of Korean Spine Surg 2011;18(3):123-131.

Published online: 21 September 2011

DOI: https://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

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: jlee@schmc.ac.kr

Received 17 February 2011 Revised 21 July 2011 Accepted 21 July 2011

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.

Abstract

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 followup 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 followups 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 followup 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 followup, conversion to surgery during followup, 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.

Keywords: Lumbar Disc Herniation, Conservative Treatment, MRI, Spinal Canal Encroachment

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Figures and Tables%

Fig. 1.

Spinal canal area and herniated disc size were measured on MRI axial images.

Fig. 2.

VAS score at initial visit and the final followup

Fig. 3.

Clinical outcome at the final followup (four patients who converted to surgery were defined as “poor”)

Fig. 4.

Thirty five year old male patient suffering from bilateral buttock and right leg pain showed canal encroachment about 53% on MRI axial image at the first visit(A). After conservative treatment for 17 months, pain subsided and herniated disc material was absorbed at the final follow up(B).

Table. 1.

Kim & Kim's criteria of clinical outcome

	Complete relief of pain in back and lower limbs
Excellent	No limitation of physical activity
Excellent	Analgesics not used
	Able to squat on the floor
	Relief of most pain in back and lower limbs
	Able to return to accustomed employment
Good	Physical activities slightly limited
	Analgesics used only infrequently
	Able to squat on the floor
	Partial relief of pain in back and lower limbs
Fair	Able to return to accustomed employment with limitation, or return to lighter work
Fair	Physical activities definitely limited
	Mild analgesic medication used frequently
	Mild limitation to squat on the floor
	Little or no relief of pain in back and lower limbs
	Physical activities greatly limited
Poor	Unable to return to accustomed employment
	Analgesic medication used regularly
	Unable to squat on the floor without support

Table 2.

Summary of cases

No	^Sex	Age	Level	Type	Canal encroachment (%)	F/U period (yr)	Neurologic deficits		VAS(LBP)		VAS(RP)		Clinical outcome	Conversion to Surgery(m)
No	^Sex	Age	Level	Type	Canal encroachment (%)	F/U period (yr)	Initial	Last	Initial	Last	Initial	Last	Clinical outcome	Conversion to Surgery(m)
1	F	47	5-1	Extruded	33.9	3.2	N	N	0	2	5	1	2	N
2	F	49	5-1	Extruded	40.8	1.1	Y	N	0	0	8	0	1	N
3	M	28	4-5	Extruded	59.7	1.8	Y	N	0	0	3	0	1	N
4	M	54	4-5	Extruded	42.0	1.1	N	N	0	2	9	0	2	N
5	F	75	4-5	Extruded	51.5	1.2	N	N	0	0	5	0	1	N
6	M	58	5-1	Extruded	46.8	1.4	N	N	0	0	7	0	1	N
7	F	32	5-1	Extruded	50.2	3.5	N	N	3	0	3	0	1	N
8	M	33	4-5	Sequestrated	42.6	3.2	Y	N	0	2	2	0	2	N
9	M	45	5-1	Extruded	42.9	1.8	N	N	0	0	5	1	1	N
10	M	47	4-5	Extruded	44.4	2.2	N	N	3	0	4	1	1	N
11	M	42	5-1	Extruded	60.6	3.2	Y	N	0	0	3	1	1	recurred at 19m
12	M	62	4-5	Extruded	65.0	1.1	Y	N	0	0	5	0	1	N
13	M	33	4-5	Extruded	53.1	2.4	N	N	5	0	3	0	1	N
14	M	37	5-1	Extruded	75.0	3.5	N	N	6	0	7	0	1	N
15	F	44	4-5	Extruded	44.9	3.3	N	N	3	0	7	0	1	N
16	M	40	4-5	Sequestrated	42.9	3.8	Y	Y	3	0	7	0	1	N
17	M	31	4-5	Extruded	73.7	1.5	N	N	0	0	6	0	1	recurred at 24m
18	M	37	5-1	Extruded	34.3	2.1	Y	N	0	0	4	0	1	N
19	M	29	3-4	Sequestrated	52.4	1.9	Y	N	0	0	10	0	1	N
20	F	69	1-2	Extruded	33.4	1.3	Y	Y	0	0	3	0	1	N
21	M	70	4-5	Sequestrated	49.0	2.6	Y	N	0	0	6	0	1	N
22	F	67	4-5	Extruded	57.1	2.3	Y	N	6	0	9	0	1	N
23	F	29	4-5	Extruded	45.3	1.4	Y	N	3	0	7	0	1	N
24	F	27	4-5	Extruded	37.9	1.2	N	N	0	0	8	0	1	persistent pain for 2m
25	F	47	5-1	Extruded	52.9	1.5	N	N	5	2	6	7	3	N
26	M	31	5-1	Extruded	73.1	3.4	N	N	5	0	7	0	1	N
27	F	12	5-1	Extruded	45.7	2.4	N	N	0	0	4	0	1	N
28	M	43	4-5	Extruded	38.3	2.2	N	N	5	6	4	0	3	N
29	M	17	5-1	Extruded	52.9	3.1	N	N	3	0	5	0	1	N
30	M	76	5-1	Extruded	45.2	3.3	N	N	0	0	3	0	1	N
31	F	41	4-5	Extruded	78.6	2.1	N	N	8	0	5	0	1	N
32	F	26	4-5	Extruded	44.7	2.5	Y	Y	5	0	5	2	2	N
33	M	46	4-5	Extruded	57.1	1.6	N	N	2	0	5	0	1	N
34	F	60	5-1	Extruded	44.2	1.6	N	N	0	0	6	0	1	persistent pain for 8m
35	M	32	5-1	Extruded	69.6	3.2	N	N	4	3	6	0	2	N
36	M	37	3-4	Extruded	44.4	2.3	N	N	7	0	5	2	2	N
37	M	31	4-5	Extruded	40.6	1.3	N	N	8	0	9	0	1	N
38	M	50	5-1	Extruded	35.5	2.2	Y	N	6	0	6	0	1	N
39	M	29	5-1	Extruded	35.7	1.6	N	N	0	0	4	0	1	N

F, female; M, Male; F/U:follow up; yr, year; VAS, visual analogue scale; LBP, low back pain; RP, radiating pain; m, month; Gr, grade; Y, yes; N, no

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