1. Lumbar disc Extrusion –
an observational study Part 2
Vinod Naneria
Reduction in Size Girish Yeotikar
Arjun Wadhwani
Choithram Hospital & Research centre, Indore,

2. Reduction in size
• More than 50% reduction in size on follow-up
MRI is clinically significant.
• Bigger the size, better the chances of
reduction and better clinical outcome.
Eiichi Takada and Masaya Takahashi - E Takada
et al. Journal of Orthopaedic Surgery Vol. 9 No. 1,
June 2001 - Natural history of lumbar disc hernia
with radicular leg pain.

3. Inui, Yoshihiro et al in Spine. 29(21):2365-2369,
November 1, 2004.
•
Fas-Ligand Expression on Nucleus Pulposus
Begins in Developing Embryo. Expressed there
views as - The present results demonstrated that
Fas ligand expression is not detected in the
notochord, but at the time of intervertebral disc
formation, Fas ligand expression develops in the
nucleus pulposus. These results indicate that the
immune privilege of the intervertebral disc may
begin in the very early stages of disc formation.
Moreover, Fas ligand may play an important role
in the formation of the intervertebral disc.

4. Hypothesis of disc absorption
• There are three proposed hypothesis for
absorption.
• The first proposed hypothesis is the retraction
back into the intervertebral space. If there is
bulging or herniation into the annulus fibrosis,
this situation can be encountered theoretically.
• Second hypothesis is based on the concept of
dehydration ( shrinkage with the loss of the
water content of the herniated disc material),
slowly.
In journal of Neurological Sciences Volume 23, Number 4, Page(s) 339-343, 2006, Mehmet
ŞENOĞLU, Kasım Zafer YÜKSEL, and Mürvet YÜKSEL reported two cases of spontaneous
absorption.

5. Hypothesis of disc absorption
• Third hypothesis - the recent studies asserted that
the spontaneous regression, to be a result of
enzymatic degradation and phagocytosis against
the extruded disc tissue in the epidural space with
inflammatory reaction and neovacularization .
There are some pathological and experimental
studies supporting this situation.
• There is also possibility that all 3 of these
mechanisms take part in the spontaneous
regression and disappearing of the disc material
altogether.

6. Immunology
• It has been made clear in the world literature
that the radicular pain from the compressed
nerve root is primarily due to sensitization of
the nerve root as a result of inflammation
induced by antigen – antibody reaction. This is
the reason for a quick response to cortisone
therapy in acute prolapse.

7. • This is the reason why fragments mainly
composed of nucleolus pulposus get absorbed
early. The annulus is absorbed by granulation
formation.
• A disc fragment contain more of end plate
cartilage take long time to absorb.

8. Endplates at MR Imaging- Gebhard Schmid et al
published in “Radiology Vol 231 No.2
• Findings in the current study show that avulsion-
type disk herniation with hyaline cartilage
material occurs frequently (in nearly 50% of
patients). The amount of cartilage may be as
much as 50% of the extruded material, and bone
fragments were observed in five patients.
• Lumbar Disk Herniation:Correlation of Histologic Findings with
Marrow Signal Intensity Changes in Vertebral Gebhard Schmid, MD:

9. • Results confirm that there is cartilaginous material in a high
proportion of extruded disk herniations. The amount of
cartilage in the herniation material is usually less than 10%,
but it can be as much as 50%. The association of the
amount of cartilaginous material with endplate
abnormalities supports the theory that avulsion of the
vertebral endplate is one source of disk herniation.
• The good correlation of marrow signal intensity changes in
the middle third of the endplate with cartilaginous material
in the disk herniation further supports the histopathologic
findings by Tanaka et al that most avulsions occur in the inner
or transitional zone of the annulus end plate interface.
Carreon LY, Ito T, Yamada M, Uchiyama S, Takahashi HE.
Neovascularization induced by annulus and its inhibition by cartilage
endplate: its role in disc absorption. Spine 1997; 22:1429–1434.

10. Case summary - 1

18. comments
• Six years follow up.
• Marginal reduction in size.
• No neurological deficit.
• Persisting with backache.

19. Case Case summary - - 2
summary
Reduction in size of disc with complete recovery in clinical symptoms

25. Case summary - 3
Reduction in size of disc with complete recovery in clinical symptoms

28. Case summary - 4
Gr 4 EHL after 2 years with occasional backache

33. Case summary - 5
Significant decrease in the size of the disc

36. Case summary - 6
Marked reduction in size

41. Case summary - 7
Marked reduction in size

43. May 2012

44. May 2012

46. Aug 2012

47. Aug 2012

48. Aug 2012

49. 5/5/2012
30/8/2012

50. Case summary - 8
Gradual absorption in process

53. Case summary - 9
Marked reduction in size

58. Case summary - 10
Marked regression

61. Case summary - 11
Regression in size

68. Case summary - 12
Marked reduction in size

71. Case summary - 13
Regression of extruded piece

73. March 2008

74. March 2008

77. Case summary - 14
Regression of disc size

80. Case summary - 15
Significant regression of size

86. Case summary - 16
Case summary -
Marked reduction in size

89. Case summary - 17
Marked regression in size

93. Purpose of presentation
• Conservative treatment is well accepted
method of treatment of PID.
• There is no need to frighten the patient for
possible hypothetical complications.
• In our experience, a mono radiculopathy
never deteriorates to poly neuropathy.
• Poly neuropathy is a separate incident in the
cases of pre-existing disc pathology.

94. Disclaimer
• All photographs were taken with the consent of the all
patients.
• Clinical photos were also put with due verbal
permission.
• This presentation strictly for students of orthopedics
with the sole idea of propagating knowledge.
• Any objection as for photographs or x-rays, please
inform naneria@yahoo.com for prompt deletion.
• Material is collected from C.H.& R.C., Indore and from
private clinics of the authors.

95. DISCLAIMER
Information contained and transmitted by this presentation is
based on personal experience and collection of cases at
Choithram Hospital & Research centre, Indore, India, during
last 25 years. It is intended for use only by the students of
orthopaedic surgery. Views and opinion expressed in this
presentation are personal opinion. Depending upon the x-
rays and clinical presentations viewers can make their own
opinion. For any confusion please contact the sole author for
clarification. Every body is allowed to copy or download and
use the material best suited to him. I am not responsible for
any controversies arise out of this presentation. For any
correction or suggestion please contact naneria@yahoo.com