Many studies have indicated that the immune cells, which infiltrate around the degenerated disc, could impact the situation. While these immunocytes can cause damage such as inflammation, can they also clean the herniated nucleus pulposus and reduce nerve root stress? At least to some degree?
I agree that the treatment of symtomatic disc herniation is mainly conservative. As far as spontaneous absorption of nucleus pulposus is concerned it occurs rarely. Usually it is attempted to reduce the volume of nucleus pulposus by percutaneous instillation of proteolytic enzymes (chemonucleolysis with papain, etc.). This procedure was very popular in some countries some 25-30 years ago, but some colleagues reported allergic reactions which made the chemonucleolysis less popular.
As far as the surgical treatment in extruded disc herniations is concerned, in my opinion there are three absolute indications: 1. Intensive back pain with/without schiatica resistant to systematic conservative treatment for 6 weeks; 2. Acute neurologic deficit corresponding to the level of herniation; 3. Appearance of cauda equina syndrome.
There are newer percutaneous devices and injectables, such as Discogel, percutaneous decompressor, laser, coblation etc..
Yes, Dr. Kelekis, you are right. But the fact that so many new methods are introduced without break shows that something is wrong with that treatment. I can only count upon RCTs on the efficiency of these methods. Please, redirect me to some if you can. Thank you for your efforts in advance.
Comparative Prospective Randomized Study Comparing Conservative Treatment and Percutaneous Disk Decompression for Treatment of Intervertebral Disk Herniation
http://www.ncbi.nlm.nih.gov/pubmed/21613439
Hey, Dr. Ignacio
Thank you for your joining. You recommended articles are really interesting and inspiring. I think this issue is need to be studied and the absortion of herniated nucleus pulposus might contribute to it. However, more evidence is needed. I hope this hypothesis will be finally proved, whether correct or not. The long-term outcomes of patients with herniated disc comparing diskektomy Vs medical treatment will be pratical.
Thnaks
Zhen Sun
Dr Alexios Kelekis and Dr Panayot Tanchev,
The issue between conservative and surgery treatment remains open to this disease, which is thought to be mainly based on particular case. Although mang new methods have been introduced in this field, no breakthrough has been reported untill now. A conservative option is always a better objective for many patients. This hypothesis at least shows some possibility in the conservative aspect. I think its clarification will help to advance the treatment options, "old" or "new"....
Thanks
Zhen Sun
Hi everyone,
I don't want to be misunderstood...Primary treatment is conventional medication and physio (for symptomatic herniation without motor deficit). For sciatalgia without motor deficit after medication failure, percutaneous approach is an alternative to surgery for small to moderate herniation without sequestration
QUALITY ASSURANCE GUIDELINES FOR PERCUTANEOUS TREATMENTS OF INTERVERTEBRAL DISCS
http://www.cirse.org/files/files/SOP/2010/SOP_CIRSE_2010_PERCUTANEOUS%20TREATMENTS%20OF%20INTERVERTEBRAL%20DISCS.pdf
Dr. Duntsch,
You present a valuable collection of studies which contributes to the understanding of damaged NP. Anyway, pro duomo suo (spinal surgery), I would say that a massive extruded or sequestered NP prolapse causing acute neurologic deficit corresponding to the niveau of the prolapse is an absolute indication for surgical decompression with or without restoration of NP (nucleoplasty or similar).
Hello Sun,
Yes, of course it can, because nucleus tissue is mainly made of proteoglycans and has the ability to bind with water ( tissue fluids), especially after disc herniation nucleus tissue can swell and lose its proteoglycan contents, the herniated disc then becomes a collagen rich and proteoglycan poor mass, such changes facilitates specific changes in the nucleus and annulus tissue that is characterised by ingrowth of blood vessels and nerves and inflammatory cells.
If interested please read my paper on "Do intervertebral disc degenerate before they herniate, or after?"
Thank U,
Polly
Yes, in my practice ( more than 20 yrs) I have seen some cases that herniated disc dissapeared. I wonder how many discs also were cleaned in patients that were treated conservatively with good result. Most of them had no control MRI . I completely agree with dr Tanchev regarding indications. Regarding some "new fancy" procedures like Discogel, PLDD or similar I always citate professor Claudius Thome form Insbruck, Austria :"Do not destroy nucleus". Best regards.
Dear Sun,
It is well known if herniated disc contact epidural fat tissue, it is removed by fagocytes for a while. The problem is herniation occured among the annullar layers. Because of poor vascularisation of annulus, fagocytes can not easly reach to death nuclear material among the annullar layers . Most of the patient who were operated due the disc herniation have this kind of herniation( Carrage classification type III, IV). Rarely it is seen spontenous regression in these type of hernations. In my opinion in these rare cases, paravertebral muscle support is very important. If the patient has enough muscle support, spontenous regression incidance is increased. We notticed this reality after transpedicular dynamic stabilisation of the spine.We have a lot of such cases. Briefly in my opinion , there is strong relationship between the stabil spine( muscle support or enstrumantation) and spontaneous regression of a disc herniation.
Ali Fahir Ozer
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