In the past, it was believed that once a patient acquired a
herniated disc,
it was permanent. However, recent research with MRI and CT outcome studies has
documented that this is fallacy. Herniated discs in the cervical and lumbar
spine have been shown to not only reduce in size after a period of conservative
care, but in many cases regress and disappear upon reimaging.
Numerous medical studies and some chiropractic studies have been performed
and published. In recent studies by Mochida et al., both cervical (CDH) and
lumbar (LDH) disc herniations were studied in pre- and post-MR imaging conditions.
In CDH cases, they demonstrated that in 40% of the time, there was a reduction
in size or regression. In LDH cases, they demonstrated about a 60% reduction
or regression in the size of the herniation. They also found that the larger
the extrusion or sequestration, the better the rate of regression. They concluded
that disc regression or resorption depended upon size, location and the phase
of the injury. Discs tended to reduce in size early on after onset, and more
so in the lateral or sequestered type of herniation than smaller or subligamentous
herniations. It is interesting to note that most patients in Mochida's study
did well clinically with conservative care regardless of the MRI outcome.
In a different study, Mochida found that there is a large percentage of macrophages
in excised herniated disc material, as well as evidence of neovascularization.
As such, the reduction in size is most likely due to phagocytic or macrophagic
digestion, since the body attacks the disc fragment as a foreign protein, much
like any other antigen. Immunohistochemistry studies are being conducted at
this time to elucidate the pathophysiology of disc herniation and regression.
In a similar study of LDH outcome by Bozzao et al., 63% of the patients treated
nonsurgically with epidurals, medication, etc., demonstrated disc resorption
upon repeat imaging. In a prospective study of patients with LDH, Ellenberg
et al. documented that patients with CT evidence of herniated discs and EMG
evidence of radiculopathy had a 78% rate of disc reduction. Matsubara found
in a similar study that medical care involving medication, physiotherapy, traction
and epidural steroid injections resulted in disc regression in 60% of the cases.
In another prospective study, Bush et al. showed disc regression in 12 of the
13 cases studied. The period of care averaged six months, with a range of 2-12
months for good clinical and anatomical MRI outcome.
In one of the few chiropractic care MRI studies, I published a prospective
case series of 27 patients with either CDH or LDH. I obtained pre- and post-chiropractic
care MRIs and found that in 63% of the cases, there was either a reduction in
size, or the disc herniation resorbed completely. I also found that 80% of the
cases had good clinical outcomes, and 78% of the patients returned to their
preinjury occupations. Chiropractic care was shown to be amenable to the clinical
management of the disc herniation not only on a clinical level, but on an anatomical
level as well. In a study by Cassidy et al. on the effects of side posture manipulation
on CT-documented herniated discs, the authors found that 13 of 14 patients had
good clinical results. Of those, about half had a decrease in the size of the
herniation on repeat CT followups.
Case Report
In a recent case that I treated, a 48-year-old female patient presented
with acute low back and associated leg/extremity pain into the foot. She had
evidence of radiculopathy with diminished sensation at the L4/5 dermatomes,
and positive root tension signs with a positive straight leg raise at 35 degrees
on the left and 45 degrees on the right. DTRs were within normal limits, and
there was no significant motor weakness. An MRI of the lumbar spine revealed
a large focal disc herniation centrally and to the left.
The patient began treatment on a three times per week schedule and was treated
with lumbar flexion/distraction, interferential current and microcurrent delivered
by pads and probes. Microcurrent therapy was combined with regular interferential
therapy and helped reduce pain and increase circulation to enhance the healing
process. Microcurrent was then delivered to the LS spine and lower extremity
by probes, stimulating the acupuncture points of the bladder meridian as well
as stimulation along the affected dermatome.
The microcurrent therapy helped afford the patient pain management and reduced
the healing period. The patient improved significantly with the above mode of
care, and repeat MRI imaging showed a reduction in the size of the herniation.
References
1.BenEliyahu DJ. MRI and clinical followup study of 27 patients receiving
chiropractic care for cervical and lumbar disc herniation. JMPT 1996;19(9):597-606.
2.Bush K. Pathomorphologic changes that accompany the resolution of cervical
radiculopathy. Spine 1997;22(2):183-187.
3.Matsubara Y. Serial changes on MRI in lumbar disc herniations. Neuroradiology
1995;37:378-383.
4.Komori H. Natural history of herniated nucleus pulposus with radiculopathy.
Spine 1996;21(2):225-229.
5.Saal J. Nonoperative management of cervical herniated disc with radiculopathy.
Spine 1996;21(16):1877-83.
6.Mochida K. Regression of cervical disc herniation observed on MRI. Spine
1998;23(9):990-997.
7.Ellenberg MR. Prospective evaluation of the course of disc herniations in
patients with radiculopathy. Arch Phys Med Rehab 74; Jan 1993, p. 3.
8.Bozzao A. Lumbar disc herniation: MR imaging assessment of natural history
in patients treated without surgery. Radiology 1992;185:135-141.
9.Maigne JY. CT followup study of 21 cases of nonoperatively treated cervical
soft disc herniation. Spine 1994;19(2):189-191.
Last Updated: 09/12/2008
