Since the emergence of humans walking upright millions of years ago, we have not only been with us all the way to the top of the food chain, but also hemorrhoids and herniated discs. In the middle of the 20th century, Mixter and Barr reported that since the surgical treatment of lumbar intervertebral disc herniation, there has been no definite conclusion on the issue of "how to treat". It can be said that the benevolent sees benevolence, and the wise sees wisdom, but the general direction is nothing more than surgery or No surgery.
Commonly used procedures for disc herniation include nucleus pulposus removal, vertebral body fusion, internal fixation, etc., but all three have their drawbacks. Recurrence may occur after removal of the nucleus pulposus. After vertebral body fusion, there may be lesions of adjacent segments, stiffness of the lower back and even difficulty in wiping after stool. Internal fixation as an auxiliary measure often has metal foreign body reactions.
In the previous program, we talked about the issue of "self-absorption of compressive bone in the spinal canal of thoracolumbar fractures". Today we are also from the perspective of conservative treatment to explore whether the herniated disc can be absorbed by the cervical spine, The cases of thoracic and lumbar spine are presented.
Case number one
In 2003, Kobayashi reported a case of self-absorption of a herniated cervical disc on Spine. The patient was a 27-year-old male with neck pain and severe left upper limb pain for 3 days. He had no history of trauma. On examination, he had pain in the C6 plane on the left side, his muscle strength did not decrease, and his deep reflexes were normal. MRI on admission showed: C5/6 intervertebral disc herniation. (See below)
Note: On MRI, it is phase T1 and phase T2. The physiological lordosis of the cervical spine becomes straight, and C5/6 disc herniation can be seen
Kobayashi suggested that the patient undergo ACDF, but the patient refused and fixed it with a cervical collar. Interestingly, after 3 weeks, the patient's pain gradually disappeared, and MRI showed that the protrusion was partially absorbed (see figure below)
Note: After 3 weeks of treatment, the cervical 5/6 herniated intervertebral disc, partially absorbed
After 12 months, a re-examination of the MRI showed complete absorption. (See below)
Note: The protrusion is completely absorbed by itself after 12 months of treatment
In January 2016, Ahmad reported a case of spontaneous absorption of a herniated thoracic disc on BMJ. The patient was a 38-year-old woman who was diagnosed with thalassemia when she was 2 years old, and had multiple blood transfusions thereafter. In November 2010, she went to the doctor for chest and back pain. Physical examination of muscle strength, sensation, and tendon reflexes are normal. (See below)
Note: CT shows T6/7 intervertebral disc herniation and ossification, T7/8 ossification but no herniation
Ahmad originally planned to perform surgery on the patient, but while waiting for a decision, the patient's pain symptoms improved, so no surgery was performed. Then in September 2012, the patient had back pain again due to a fall, but no positive findings were found on the physical examination. MRI revealed that the original ossified and herniated T6/7 disc disappeared, and the T7/8 disc was newly herniated. (See below)
Note: A. After nearly 2 years, T6/7 intervertebral disc herniation and ossification and resorption, but degeneration still exists; T7/8 ossified intervertebral disc newly herniated, both T1 and T2 phases are low signal B. Transected position see T7 /8 Mild central disc protrusion
The follow-up was continued for 7 weeks, and MRI was performed for the third time. The resorption of the herniated and ossified T6/7 disc was confirmed again, but the newly herniated T7/8 disc had progressed. (See below)
Note: After 7 weeks, T7/8 ossified intervertebral disc herniation progresses, moderate ossification of central herniation
In view of the phenomenon of T6/7 intervertebral disc absorption, and the degree of spinal cord compression of this T7/8 intervertebral disc herniation is less than that of the previous T6/7 herniation, and the nerve function is intact, the author continues to choose conservative treatment. Regarding the follow-up situation of T7/8 intervertebral disc, the author has not yet published the latest article.
A 29-year-old female patient had pain in her right calf and paresthesias for more than 6 months, and her bowel movements were normal. MRI of the lumbar spine showed that L4/5 intervertebral disc herniation combined with spinal stenosis and severe nerve root compression (Figure A below). After the patient chose conservative treatment for 5 months, the lumbar MRI showed herniated absorption (Figure B).
Note: Picture A is at the beginning of the disease, and picture B is after 5 months
Seeing this, some comrades must have said: You are all cases, how can you embody a universal law? In fact, there are countless theories and studies supporting the self-absorption of intervertebral discs, which can be roughly divided into: immune immunity and autoimmunity theory, intervertebral protrusion re-regulation theory, intervertebral disc dehydration and dryness theory, cerebrospinal fluid pulsating pressure theory, epidural The role of the venous plexus.
It is worth mentioning the theory of immune immunity and autoimmunity. Due to the close surrounding of the annulus fibrosus and the upper and lower endplates, the nucleus pulposus of the intervertebral disc is physically isolated from the immune system, that is, immune immunity. Therefore, when various reasons cause the nucleus pulposus When the barrier of the nucleus pulposus is damaged, the nucleus pulposus will come into contact with the immune system and produce an autoimmune response, which forms the basis of the degeneration of the intervertebral disc. It is no wonder that pro-inflammatory factors such as IL-1, IL-6, and TNF-a can be detected in the area of degeneration of the intervertebral disc. But from another perspective, the inflammatory response at this time is also a manifestation of self-protection absorbed by the body.
to sum up
Regardless of whether the herniated disc is ossified or not, the body shows the powerful ability of natural absorption. Although the specific mechanism is currently unknown, we are alert to our spine surgeons: patients with herniated discs need to be cautious when choosing surgical treatment.