Lumbar Disc Reabsorption
Original Editor - Matt Huey
Top Contributors - Matt Huey, Rachael Lowe, Carina Therese Magtibay, Vidya Acharya and Mohit Chand
Introduction
One cause of both lumbar pain and radiculopathy is the presence of a disc herniation. This is when the nucleus pulposus of the lumbar disc has protruded into the annulus fibrosus of the disc which leads to the compression of the spinal nerves. Many people believe that once this has occurred it cannot be reversed and must require surgical intervention. There is evidence that the lumbar disc can reabsorb with conservative treatment or spontaneously. It has been found that within 6 months of starting a conservative treatment, that between 66.66-70.39% of people with a disc herniation have a spontaneous reabsorption of the disc material[1][2].
Features of Reabsorption
Lumbar disc herniations have 4 separate classifications based upon where the nucleus of the disc is located. These are:
- Bulging. The disc extends beyond the vertebral endplates
- Protrusion. The nucleus is pressing onto the anulus fibrosus with the posterior longitudinal ligament remaining intact.
- Extrusion. The nucleus has broken through the anulus fibrosis with the posterior longitudinal ligament remaining intact.
- Sequestration. The nucleus has broken through the anulus fibrosis but the posterior longitudinal ligament is disrupted.
It has been found that discs that are classified as an extrusion or sequestration are more likely to have a higher rate of resorption than bulging or protrusion[3]. This is believed to be due to an extrusion or sequestration having a higher composition of the nucleus. If there are Modic changes of the disc herniation, meaning more hyaline cartilage from the vertebral endplate and less of the nucleus, the lower the likelihood of reabsorption[4].
When to consider conservative treatment vs surgery
Surgical intervention for any sort of disc herniation is still considered the primary treatment by surgeons and the public. There are considerations to be accounted for when making a decision for surgery vs conservative care.
The presences of red flag symptoms is very important in the screening of these patients. Patients who present with cauda equina symptoms, worsening neurological symptoms, and ataxia do warrant imaging and surgical consideration. Likewise, if patients do not improve with 3-6 months of conservative care or their symptoms are worsened with conservative care, surgical intervention can be the next step.
In terms of a decision for surgery based upon imaging, several areas must be considered. The size of the herniation should not be considered unless red flag symptoms are present. Imaging can at times see the make up of the herniation. Herniations that are seen to be primarily made up of the nucleus pulposus and water are more likely to be reabsorbed[3].
References
- ↑ Zou, T., Liu, X. Y., Wang, P. C., Chen, H., Wu, P. G., Feng, X. M., & Sun, H. H. (2024). Incidence of Spontaneous Resorption of Lumbar Disc Herniation: A Meta-analysis. Clinical spine surgery, 37(6), 256–269. https://doi.org/10.1097/BSD.0000000000001490
- ↑ Zhong, M., Liu, J. T., Jiang, H., Mo, W., Yu, P. F., Li, X. C., & Xue, R. R. (2017). Incidence of Spontaneous Resorption of Lumbar Disc Herniation: A Meta-Analysis. Pain physician, 20(1), E45–E52.
- ↑ 3.0 3.1 Yu, P., Mao, F., Chen, J., Ma, X., Dai, Y., Liu, G., Dai, F., & Liu, J. (2022). Characteristics and mechanisms of resorption in lumbar disc herniation. Arthritis research & therapy, 24(1), 205. https://doi.org/10.1186/s13075-022-02894-8
- ↑ Shan, Z., Fan, S., Xie, Q., Suyou, L., Liu, J., Wang, C., & Zhao, F. (2014). Spontaneous resorption of lumbar disc herniation is less likely when modic changes are present. Spine, 39(9), 736–744. https://doi.org/10.1097/BRS.0000000000000259