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Spontaneous regression of sequestrated lumbar


disc herniations: Literature review

Article in Clinical neurology and neurosurgery February 2014


DOI: 10.1016/j.clineuro.2014.02.013 Source: PubMed

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Clinical Neurology and Neurosurgery 120 (2014) 136141

Contents lists available at ScienceDirect

Clinical Neurology and Neurosurgery


journal homepage: www.elsevier.com/locate/clineuro

Review

Spontaneous regression of sequestrated lumbar disc herniations:


Literature review
Mohamed Macki a,b , Marta Hernandez-Hermann a,b , Mohamad Bydon a,b ,
Aaron Gokaslan b , Kelly McGovern b , Ali Bydon a,b,
a
Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, USA
b
Johns Hopkins Biomechanics and Surgical Outcomes Laboratory, Baltimore, USA

a r t i c l e i n f o a b s t r a c t

Article history: Lumbar disc herniations (LDH) may regress with conservative management; however, this phenomenon
Received 21 November 2013 is poorly understood for the sequestrated subtype of LDH. We present one of the rst comprehensive liter-
Received in revised form 2 January 2014 ature reviews specically addressing the spontaneous regression of sequestrated intervertebral discs. We
Accepted 17 February 2014
reviewed all publications with lumbar disc herniations, sequestrated subtype. Our results were then nar-
Available online 25 February 2014
rowed to patients who experienced spontaneous regression of the sequestration. Based on our literature
review of 53 cases, patients with sequestrated lumbar disc herniations experienced symptomatic resolu-
Keywords:
tion in a mean of 1.33 1.34 months and radiographic resolution in 9.27 13.32 months. Symptomatic
Disc
Herniation
patients with sequestrated discs present similarly to those with other types of lumbar disc herniations.
Lumbar Sequestrations may have the highest likelihood to radiographically regress in the shortest time frame in
Regression comparison to the remaining subtypes of LDH. The most likely mechanism for regression is an inam-
Sequestrated matory response elicited against the free fragment. Patients with disc sequestrations may be managed
conservatively, in the absence of intractable pain, inability to walk, weakness or symptoms suggestive of
cauda equina syndrome.
2014 Elsevier B.V. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
2. Case presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
3. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
4. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
5. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
6. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Conicts of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140

1. Introduction most common type of degenerative discogenic disease [2]. Cur-


rently, ve ordinal subtypes of LDH are described in the literature:
Lumbar disc herniations (LDH) are the most common cause bulging discs (mildest form), focal protrusions, broad-based pro-
of radicular pain, with an estimated annual incidence of 5 per trusions, extrusions, and sequestrations (severest form) (Fig. 1) [3].
1000 adults [1]. After annular tears and degeneration, LDH are the The severest form of LDH is the sequestrated disc. Also known
as free fragments, sequestrations are no longer attached to their
respective intervertebral disc [3]. Clinically, these patient present
Corresponding author at: Spine Center, Department of Neurosurgery, The Johns
similarly to any type of LDH; therefore, differentiating between
Hopkins Hospital, 600 North Wolfe Street, Meyer 7-109, Baltimore, 21287, USA.
the ve subtypes requires magnetic resonance imaging (MRI) for
Tel.: +1 443 722 2133. diagnostic identication [4]. According to the Spine Patient Out-
E-mail addresses: abydon1@jhmi.edu, mbydon1@jhmi.edu (A. Bydon). comes Research Trial (SPORT), out of 2720 patients with LDH, only

http://dx.doi.org/10.1016/j.clineuro.2014.02.013
0303-8467/ 2014 Elsevier B.V. All rights reserved.
M. Macki et al. / Clinical Neurology and Neurosurgery 120 (2014) 136141 137

Fig. 1. Classication of the ve subtypes of disc herniations in the lumbar spine.

86 (3%) patients had sequestrated discs. However, patients with bilaterally. MRI at this time revealed complete resolution of the
symptomatic sequestrations comprised 7% of all surgical candi- sequestered disc fragment (Fig. 3). The only indication of a prior
dates (n = 1191) in the SPORT [5]. lesion at the L4-L5 disc space was a focal disc extrusion superim-
Sequestrations may undergo spontaneous regression and, even- posed on an annular disc bulge where T2 imaging suggests a small
tually, complete resolution both radiographically and clinically. annular tear. The patient was managed conservatively with non-
Veried with serial MRIs, this recently reported phenomenon has steroidal anti-inammatory drugs (NSAIDS). On follow-up clinic
been illustrated in 52 cases (12 publications) elsewhere in the lit- examination 6 weeks later, the patient remained asymptomatic
erature (Table 1) [1,616]. In this manuscript we present one of the with the exception of some back stiffness. Motor strength, sensa-
rst comprehensive literature reviews, in addition to a case pre- tion, reexes, and bowel and bladder function also remained intact.
sentation, on spontaneous regression of disc sequestrations. Our
analysis focuses on the clinical, radiographic, and pathophysiologi- 3. Methods
cal characteristics of patients undergoing spontaneous regression
of disc sequestrations. We reviewed all published case reports and case series of lumbar
disc herniations, sequestrated subtypes. From this body of litera-
2. Case presentation ture, we specically rened our results to patients who experienced
spontaneous regression of their sequestrated disc. Only cases mon-
A 35 year-old gentleman with a seven-year history of low back itored with serial MRIs were included in the literature review. All
pain presented to the outpatient clinic with back stiffness. Seven cases were attributed to degenerative changes to the spinal column.
years prior, the patient experienced back pain after attempting Patients with infectious, metabolic, neoplastic, and/or congenital
to lift a heavy box. At the time, lumbar X-ray had revealed mild causes of lumbar disc herniations were excluded. Fifty-two cases
lumbar spondylosis, and the patient was successfully treated with met the inclusion and exclusion criteria for this manuscript.
physical therapy. Upon presentation, the patient complained of Summary statistics are reported in order to describe num-
a one-month history of back stiffness in addition to left buttock ber of cases in each publication, average age in each publication,
and leg pain after a strenuous exercise maneuver at the gym. The location of sequestrated disc, symptoms, physical exam ndings,
patient expressed difculty walking along with severe pain. One average time to symptom resolution in each publication, average
month after the acute symptom onset, an MRI of the lumbar spine time to MRI resolution in each publication, and residual symptoms
revealed a large, left-sided L4-L5 sequestrated disc fragment with (Table 1). For comparative purposes, relative information from the
rostral migration, lying behind the L4 vertebral body. The frag- present case presentation was also included in Table 1.
ment compressed the thecal sac and the left L5 nerve root (Fig. 2).
The patient was managed conservatively with oral non-steroidal 4. Results
anti-inammatory medications.
Five months after presentation, the patients only complaint We carried out a literature review of 53 cases (including the
was back stiffness; the lower extremity symptoms had subsided. present case) of spontaneous regression of sequestrated discs
The patient denied leg pain, weakness, or bladder and bowel dif- (Table 1) [1,616]. On clinical examination, 37.7% of patients with
culties. Straight-leg test was negative. Muscle strength in the sequestrated discs in our literature review reported radiculopathy.
lower extremity muscle groups was 5/5 bilaterally. Sensation to Similarly on physical exam, the literature demonstrates positive
ne touch, proprioception, and pain of the lower extremities was straight leg tests in 41% of cases, hyporeexia in 7.5% of cases, weak-
grossly intact bilaterally. Patellar and Achilles reexes were 2/4 ness in 41.5% of cases, and sensory disturbances in 35.8% of cases
138
Table 1
Characteristics of 53 cases reporting spontaneous regression of sequestrated disc herniations in the lumbar spine.

Author (year) Number of Average age Disc (N = number of Symptoms (N = number Physical exam Average time to symptom Average time to MRI Residual symptoms
cases cases) of cases) (N = number of cases) resolution (months) resolution (months) (N = number of cases)

Ahn et al. [4] (2002) 11 46.4 Back pain (7) (+) straight leg raising 1.0 6.4 Sensory disturbance
test (11), sensory (3), weakness (3)

M. Macki et al. / Clinical Neurology and Neurosurgery 120 (2014) 136141


disturbance (8),
weakness (10)
Gelabert-Gonzlez 1 66 L4-L5 Back pain, (+) straight leg test, 7
et al. [6] (2007) radiculopathy weakness
Gezici et al. [7] (2009) 1 33 L4-L5 Back pain, (+) straight leg test 15
radiculopathy
Jensen et al. [8] (2006) 8 L3-L4 (1) Sciatica (8) Sciatica (1)
L4-L5 (5)
L5-S1 (2)
Keskil et al. [9] (2004) 2 40.5 L3-L4 Back pain (1), (+) straight leg test (1), 45.5 (+) straight leg test (1),
L4-L5 radiculopathy (2) weakness (2), sensory hyporeexia (1)
disturbance (2),
hyporeexia (2)
Nozawa et al. [10] 1 32 L4-L5 Back pain, weakness Sensory disturbance, 1 3
(2009) weakness
Orief et al. [11] (2012) 5 37.4 L4-L5 (3) Back pain (2), (+) straight leg test (5), 1.2 6.8 Sensory disturbance (1)
L5-S1 (2) radiculopathy (2) sensory disturbance
(5), weakness (2),
hyporeexia (1)
Sabuncuoglu et al. [12] 2 38.5 L1-L2 Back pain (2), (+) straight leg test (1), 11
(2008) L5-S1 radiculopathy (2) sensory disturbance
(1), hyporeexia (1)
Singh et al. [13] (1999) 1 43 L3-L4 Back pain, (+) straight leg test 4
radiculopathy
Slavin et al. [14] (2001) 1 23 L5-S1 Back pain, (+) straight leg test, 6.5 7
radiculopathy sensory disturbance
Ryu et al. [15] (2010) 1 53 L4-L5 Back pain, Sensory disturbance 6 Sensory disturbance
radiculopathy
Takada et al. [16] 18 Weakness (6) 0.75 6.75
(2001)
Current case 1 35 L4-L5 Back pain, Benign 1.5 5
radiculopathy
M. Macki et al. / Clinical Neurology and Neurosurgery 120 (2014) 136141 139

Fig. 2. Sagittal (A) and axial (B and C) T2-weighted magnetic resonance images of a 31-year-old man, revealed a large left-sided sequestrated disc fragment at the L4-5 level
with upward migration, lying behind the L4 vertebral body and compressing the thecal sac and the left L5 nerve root.

Fig. 3. Sagittal (A) and axial (B and C) T2-weighted magnetic resonance images revealing complete resorption of disc fragment, residual small disc protrusion at L4-L5.

(Fig. 4). On radiographic studies, the spinal levels affected with connected to the parent disc [8]. These free fragments were once
sequestrations included L1-L2 (4.2%), L2-L3 (0%), L3-L4 (12.5%), L4- thought to represent benign intraspinal tumors, which were moni-
L5 level (58.3%), and L5-S1 (25%) (Fig. 5). tored radiographically [17]. However modern advances in imaging
The mean time from the rst diagnostic MRI of a sequestrated modalities have identied these structures as sequestrations [8].
disc herniation to radiographic resolution of the sequestrated disc Although they account for only 3% of all LDH, the sequestrated sub-
was 9.27 13.32 months (N = 35 cases reporting MRI intervals). type have now received increasing recognition in the literature
From the time of symptom onset, all 53 cases reported improve- by radiologists and spine surgeons alike. Nevertheless, our cur-
ment in clinical symptoms in a mean of 1.33 1.34 months (N = 19 rent understanding of this diagnosis remains limited [18]. Since the
cases specied a time interval). Back pain decreased by 100% identication of sequestrated discs, spontaneous regression (per
(n = 19), radiculopathy by 95% (19), weakness by 86% (19), sensory serial MRI images) has been documented in 12 publications rep-
disturbance by 68% (13), and hyporeexia by 75% (3) (Fig. 4). resenting 53 cases (including the present case), according to our
literature search (Table 1) [1,616].
5. Discussion Clinically, sequestrated discs present identically to other
subtypes of LDH. In a prospective study of 403 patients with all
A subtype of lumbar disc herniations, sequestrated discs are a types of LDH, Kortelainian et al. found a positive straight leg test
radiographic nding in which the herniated fragment is no longer in 42% of patients [19]. Hyporeexic responses were elicited in
7% of patients. Weakness was found in 45% of patients, and a
sensory level was appreciated in 38% of patients. On average, 47%
complained of radiculopathy (51% in the right leg and 43% in the
left leg). Of the lumbar intervertebral levels, the symptoms were

Fig. 5. The number of spontaneous regressions of disc sequestrations at each


Fig. 4. Signs, symptoms, and physical exam ndings of 53 cases reporting sponta- intervertebral level. N = 24 out of the 53 cases reporting a disc level where the
neous regression of sequestrated disc herniations in the lumbar spine. sequestration occurred.
140 M. Macki et al. / Clinical Neurology and Neurosurgery 120 (2014) 136141

most commonly attributed to the L4-L5 herniations accounted for Funding


56.8% of all cases. Similarly, we found the most commonly affected
level at L4-L5 (n = 14, 58.3%), which is the most common level for No funding has been contributed to this conception of this
all types of herniated discs (Fig. 5) [20]. manuscript. Ali Bydon is the recipient of a research grant from
In the present review of 53 cases, all patients were treated Depuy Spine. He serves on the clinical advisory board of MedIm-
conservatively with a combination of bed rest, oral analgesics, mune, LLC. The remaining authors do not have disclosures related
spinal anesthetic blocks, and/or physical therapy. Spinal anesthetic to the work in this manuscript.
blocks were primarily epidural spinal injections. Without regres-
sion of the discs, however, spontaneous symptomatic resolution Conicts of interest
may be the natural course of any intervertebral disc hernia-
tion [5,2123]. Several studies have reported similar outcomes The authors declare no conict of interest
in surgical versus conservative cohorts after long-term follow-up
[2427]. References
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