recurrences after conservative treatment,

1. Lumbar disc Extrusion –
an observational study Part 3
Vinod Naneria
Recurrences on MRI Girish Yeotikar
Arjun Wadhwani
Choithram Hospital & Research centre, Indore,

2. 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.

3. Recurrence – after surgery
• Recurrence has been noted to occur in 5 to 15% of
cases surgically treated for primary lumbar disc
herniation.
• Recurrence after surgery for recurrence increased to
27%.
• Incidence of recurrence is very high in cases operated
for annular tear and is lowest when there is extruded
disc fragment.

4. Recurrent lumbar disc herniation after discectomy: outcome of
repeat discectomy.
Dai LY, Zhou Q, Yao WF, Shen L. Surg Neurol. 2005
Sep;64(3):226-31;
No factors such as age, sex, traumatic events, times
of prior surgery, level of herniation, side of
recurrence, pain-free interval, duration of recurrence
symptoms, walking capacity, the preoperative JOA
score, associated spinal stenosis, procedures of
revision surgery, and dural tear were found to be of
predictive value for a prognosis of revision surgery
for recurrent disc herniation.

5. Surgery -complications
• Discectomy-related complications occur in 15
to 30% of cases and include haemorrhage,
soft-tissue infection, nerve root injury, dural
tear, recurrent or residual disc herniation,
epidural scar formation, discitis, arachnoiditis,
pseudomeningocele, facet joint fracture
(iatrogenic or stress related), spinal stenosis,
and epidural hematoma, mechanical
instability.

6. Reference
• Carragee, et al., prospectively evaluated disc herniation
types, rate of re-herniation, and rate of reoperation.
They divided disc herniations into four shape-based
groups:
• 1) fragment–fissure herniations (disc fragment and
small anular defect);
• 2) fragment–defect herniations (large disc fragment
with massive posterior annular tear);
• 3) fragment contained discs (incomplete anular tear);
• 4) absence of fragment-contained herniations (annular
prolapse).

7. Reference
• Of the four groups, the fragment–fissure type
herniations were associated with the best
outcomes, lowest rate of re-herniation (1%),
and required the fewest re-operative
procedures (1%).
• Those with annular prolapse were associated
with the worst outcomes, with 38% of
patients experiencing recurrent or persistent
symptoms.

8. Case summary - 1

16. Feb. 2011
Sept. 2011

17. Comments
• First attack in 2007 – with a large disc protrusion
with EHL weakness.
• Improved clinically
• Recurrence in Feb 2011 without any deficit.
• Finally – disc extrusion occur in Sept 2011
without any deficit.
• Off duty for a month in Feb 2011 and another
month in Sept 2011.
• Last follow up – Sept 2012 - Happy

18. Case summary - 2

22. comments
• Three years follow up
• First follow up MRI showed reduction in size
and absorption a large piece of extruded disc
in three months time.
• Recurrence of back pain and further extrusion
at same level in Jan 2011.
• Some reduction in size in April 2011.
• Recurrence can occur at the same level.

23. Gourav Kapoor
Case summary - 3
• 26/M
• Acute on chronic PID L4 – L5 rt.
• EHL – N
• Ankle jerk – N
• MRI – Feb. – 2005 contended disc
• Tx – conservative
• Recurrence in July 2007
• EHL – weak
• Ankle jerk - N
• MRI – extruded disc at L4 – L5
• Tx – conservative
• Last follow up – Sept 2012 - improved

27. Case summary - 4

32. Case summary - 5

41. Case summary - 6

47. Case summary - 7
Suresh Neema
• 60/M
• Acute PID rt L4 – L5>2wks
• EHL – weak
• Ankle jerk – N
• MRI – Feb 2009
• Tx – Conservative
• Follow up MRI – June 2010
• Recurrence
• No neurological deficit
• MRI – Aug 2012 – extrusion at L2 – L3

55. Case summary - 8
Sept 2012, Tx – Conservative +epidural

65. Comments
• PID L4 – L5 on left side in Feb 2005
• Follow up MRI Sept 2005 showed disc
absorption.
• Recurrence of PID in July 2011 on right side
same level.
• Recurrence of PID in Sept 2012 on right side at
same level.

66. Case summary - 9

67. July 2008

68. July 2008

70. Nov 2011

71. Nov 2011

72. Nov 2011

73. Nov 2011

74. May 2012

75. May 2012

76. May 2012

77. May 2012

78. comments
• Initial MRI just had a contended disc at L5 – S1 in 2008.
• Recurrence with multiple level disc in Nov – 2011. No
neurological deficit.
• Recurrence in May 2012 with extrusion of L5 – S1 disc
and quadaequina with temporary loss of bladder
control.
• Prompt surgery with removal of loose piece from L5 –
S1 space and discoidectomy at L4 – L5 relieved her.
• Improving neurological status at last follow up Sept
2012.

79. Case summary 10
• 42/M
• Acute on chronic PID L2 – L3<1wk
• Quad – N
• EHL – N
• Ankle jerk – N
• MRI – extruded disc
• Tx – conservative with epidural + nerve block

80. Case summary conti…
• H/o Acute PID – April 1999.
• MRI – multiple level discs – L3 – L4, L4 – L5,
L5 – S1.
• Recurrence in July 2005
• MRI – L5 – S1 disc prolapse left
• Tx – Conservative with epidurals
• Recurrence in Aug 2012
• MRI – extruded disc at L2 – L3

81. April 1999

82. July 2005

83. Aug 2012

84. Aug 2012

85. April 1999
July 2005
Aug 2012

86. 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 collected from C.H.& R.C., Indore and from
private clinics of the authors.

87. 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