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KHIRURGIYA POZVONOCHNIKA (Russian journal of spine surgery) 2024;21(l):55-62 A.J. SANGINOV ET AL., 2024
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resorption of lumbar disc herniations:
a non-systematic literature review
A.J. Sanginov, I.D. Isakov, Sh.A. Akhmetyanov, A.V. Peleganchuk
Novosibirsk Research Institute of Traumatology and Orthopaedics n.a. Ya.L. Tsivyan, Novosibirsk, Russia
Objective. To analyze the information on spontaneous resorption of lumbar disc herniation.
Material and Methods. A non-systematic review of 37 publications on resorption of disc herniation was conducted. The data on the timing, mechanisms and predictors of regression of lumbar disc herniation were summarized. A clinical case is presented illustrating the resorption of a herniated L4—L5 intervertebral disc over 8 months.
Results. The frequency and timing of resorption of lumbar disc herniation vary depending on the number of patients, follow-up period, the type and nature of the hernial bulging, and other characteristics of patients. The results of meta-analyses indicate that the average period of spontaneous resorption of lumbar disc herniation is more than 6 months. The main theories of spontaneous resorption of lumbar disc herniation are the dehydration theory, the mechanical theory, and mechanisms associated with inflammatory processes and neovascularization. Currently, predictors of disc herniation resorption include the type and size of the hernia, follow-up period, Modic changes, etc. Existing data on the timing, mechanisms and predictors of resorption of lumbar disc herniation are insufficient to improve treatment tactics for this category of patients.
Conclusion. Herniated lumbar intervertebral discs tend to undergo spontaneous regression which, however, is not observed in all patients. The mechanisms of resorption can be different, and the fact of resorption itself can occur in different types of hernia with different frequencies. An analysis of large data sets is necessary to more accurately determine the timing and predictors of resorption of lumbar disc hernias. Key Words: lumbar disc herniation, resorption of the hernial fragment.
Please cite this paper as: Sanginov AJ, Isakov ID, Akhmetyanov ShA, Peleganchuk AV. Resorption of lumbar disc herniations: a non-systematic literature review. Russian Journal of Spine Surgery (Khirurgiya Pozvonochnika). 2024;21(1):55—62. In Russian.
DOI: http://dx.doi.org/10.14531/ss2024.1.55-62.
Lumbar disc herniations remain an acute challenge in modern vertebrolo-gy, as they are mainly found in working-age individuals and tend to increase the detection rate annually. The importance of surgery in the treatment of this pathology is high. Nowadays, the main attention is paid to minimally invasive surgeries [1]. Surgical treatment techniques are effective and fast ways to relieve radicular pain, prevent the development of neurological abnormalities, and allow an early return to work. According to the clinical guidelines of the Association of Neurosurgeons of Russia (2014), the indication for surgical treatment is the duration of radicular pain syndrome or pain in the lumbar spine for at least 4 weeks (in the absence of symptoms of loss of nerve function requiring immediate decompression). There is no defined duration of conservative therapy, including in foreign articles, and it ranges
from 6 weeks to 6 months, depending on the pain intensity and a treatment option [2-4].
With the development of new technologies in the fields of physiotherapy and neurology, non-surgical treatment options for patients with lumbar disc herniations are widely disseminated. This has led to an increase in the number of articles dedicated to this issue. Because of the development and prevalence of MRI, articles have appeared describing the spontaneous reduction or even disappearance of disc herniations over time. This phenomenon was called “resorption of disc herniation” that can be either partial or complete [5]. The first case of spontaneous regression of lumbar disc herniation was described in 1984 by Guinto et al. [6]. A systematic review of 37 studies showed that the incidence of this phenomenon ranged from 62 % to 66 % over a period of 6 to 12 months [7,
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8]. Nevertheless, there are still unstudied issues regarding the predictors and timing of regression of herniation.
Material and Methods
The analysis of PubMed and eLibrary databases was performed; 37 articles were selected in accordance with the keywords “lumbar disc herniation,” “resorption of herniation” and “regression of herniation.” This review provides the main issues discussed in the articles that are illustrated by our own clinical observation of the resorption of disc herniation at the L4-L5 level during 8 months.
Results and their Discussion
The timing and frequency of resorption of the herniatedfragment. According to the articles, the period of resorption of disc
KHIRURGIYA POZVONOCHNIKA (Russian journal of spine surgery) 2024;21(l):55-62 aj. sanginov et al. resorption of lumbar disc herniations
herniation ranges from 1.5 to 48 months, and the frequency of resorption ranges from 4.3 to 93.3 % (Table).
According to the retrospective analysis of 37 cases performed by Martinez-Quinones et al. [9], it was found that the timing of herniation regression is at least 1 year. After the review of the data of 53 patients with sequestered disc herniations, Macki et al. [45] reported that resorption of the herniated fragment occurs after an average of 9.3 ± 13.3 months (according to MRI findings). According to other authors [45, 46], the mean time between MRI scans, which state the fact of spontaneous regression of a herniated fragment, ranges from 5.54 to 9.27 months.
The incidence of resorption varies depending on the type of herniation and the duration of follow-up. After the review of 42 patients, Takada et al. [38] concluded that the period of regression depends on the type of hernial bulging. According to their data, sequestered herniations usually regress after 9 months, extrusion herniations - after 12 months. Protrusion herniations regress very slowly, because this type is often detected in young patients whose nucleus pulposus is enriched with collagen fibers and chondrocytes. According to the retrospective analysis of 48 patients with lumbar disc herniation performed by Kurilina et al. [21], regression was recorded after 12 months in patients with extrusion and sequestered hernias in all cases, whereas it was in 25.0 % in patients with protrusion-type herniations. Ahn et al. [26], based on an MRI examination, found that 25 (69.4 %) out of 36 patients had resorption; meanwhile, the rate of resorption in sequestered herniations was 100 %. Seo et al. [20] analysed the data from 43 patients with lumbar disc herniation using MRI to estimate the volume of the herniation. They found that there was a decrease in the volume in 62.5 % of cases, with a mean reduction of 310.73 ± 743.60 mm3. Yu et al. [32] followed up on 102 patients with lumbar disc herniation over a two-year period. Out of them, 83 (81.4 %) showed a partial or complete response to treatment. Surgery was recommended
for the remaining 19 patients (18.5 %). The volume of the herniated disc during conservative treatment decreased from 1,433.89 ± 525.49 mm3 to 1,002.01 ± 592.95 mm3 (p < 0.01). In 20 patients (24.1%), the volume of resorption exceeded 50 %; no decrease in the herniation was found in 63 patients during the MRI scan. Nevertheless, there has been a clinical improvement. According to the results of a meta-analysis performed by Zhong et al. [47], the incidence of disc herniation resorption was 66.66 % (95 % CI 55.12-78.21 %).
Wang et al. [48] found that the mean incidence of lumbar disc herniation is 63 %. Meanwhile, the highest rate of resorption (96 %) was recorded by Lee et al. [13], with a mean follow-up period of 12 months. Three articles report the lack of resorption with a follow-up period of 45 days [49], 20 days [50], and a median of 5 days (3-7 days) [51], which suggests that disc herniation resorption should not be expected for 1.5 months. According to Ahn et al. [26], the rate of disc herniation resorption was 69 % after
8.5 months, Delauche-Cavallier et al. [24]: 67 % after 12.5 months, Bozzao et al. [22]: 63 % after 12.5 months, Matsubara et al. [19]: 62 % after 11 months, Komori et al. [8]: 64 % after 8.7 months, Bush [23]: 64 % after 12 months, and Iwabuchi [18]: 62 % after 4.1 months. The timing of resorption in the other six articles, with a resorption rate of approximately 63 %, ranged from 8.5 to 12.9 months, mean
10.5 months. Four studies reported longterm follow-up data with a mean duration of more than 24 months. Fagerlund et al. [27] reported resorption of 73 % of the hernias after a 24-month followup, Yukawa et al. [15]: 57 % after a mean follow-up of 30 months, Shin et al. [16]: 58 % after follow-up of 3 years, Ilkko et al. [34]: 83 % after a mean follow-up of 5.2 years.
One of the latest is a meta-analysis performed by Zou et al. [52], which included 31 studies involving 2,233 patients with lumbar disc herniations who received conservative treatment. According to this study, the cumulative incidence of disc herniation resorption was 70.39 %: 87.77 % for sequestered
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hernias; 66.91 % for extruded hernias and 37.53 % for protruded ones. It is interesting that the rate of resorption varies in different countries: 66.98 % in Japan, 61.66 % in the USA, 83.52 % in Korea, 60.68 % in China, 78.30 % in the UK, 56.70 % in Italy, and 83.68 % in Turkey. The analysis showed that there was no statistically significant difference in the rate of resorption between prospective, retrospective and randomized controlled studies (p = 0.77). Similarly, there was no difference between qualitative and quantitative methods for estimating the volume of disc herniations (p = 0.05). The mean period of regression was more than 6 months.
As shown in the table, the number of patients in 31 of the 37 articles was less than 100; the follow-up period exceeded 12 months in 16 papers; and the incidence of resorption was more than 70 % in 18 papers. The incidence and time of lumbar disc herniation resorption differ depending on the number of patients, follow-up duration, the type and nature of the hernia bulging, and other features of the patients. In compliance with the results of the conducted meta-analyses, the mean period of spontaneous resorption of lumbar disc herniation is more than 6 months.
Mechanisms of resorption of lumbar disc herniation. Various theories of the mechanisms of spontaneous resorption of disc herniation have been offered, including those confirmed by in vitro and in vivo animal studies [53-55]:
- according to the theory of dehydration, a herniated nucleus pulposus can compress back into a fibrous ring as a result of gradual dehydration;
- if disc herniation bulges through the ring without damaging it, it can pull back (the so-called protrusion types of herniation);
- lumbar disc herniation triggers sterile inflammation and neovascularization in the epidural space with gradual cartilage resorption through enzymatic degradation and phagocytosis.
Lama et al. [56] proposed that fragments of hyaline cartilage present in the disc herniation tissue have a slight swelling or loss of proteoglycan and can be
KHIRURGIYA POZVONOCHNIKA (Russian journal of spine surgery) 2024;21(l):55-62 a.j. sanginov et al. resorption of lumbar disc herniations
Table
Follow-up periods and incidence of resorption of lumbar disc herniation (according to literature data)
Authors Patients, n Follow-up period, months Incidence of resorption, %
Komori et al. [8] 77 8.7 64.00
Martinez-Quinones et al. [9] 37 1.5 4.30
Kamanli et al. [10] 26 1.5 19.20
Teplick, Haskin [11] 55 5.0-36.0 20.00
Modic et al. [12] 16 6.0 25.00
Lee et al. [13] 505 12.0 43.50
Jensen et al. [14] 139 14.0 46.70
Yukawa et al. [15] 30 30.0 56.60
Shin et al. [16] 128 36.0 58.00
Ма et al. [17] 409 12.0 59.06
Iwabuchi et al. [18] 34 6.0 62.00
Matsubara et al. [19] 31 9.7 62.00
Seo et al. [20] 43 6.3 62.50
Kurilina et al. [21] 48 12.0 62.50
Bozzao et al. [22] 65 12.5 63.00
Bush et al. [23] 165 12.0 64.00
Delauche-Cavallier et al. [24] 21 12.5 67.00
Ahn et al. [25] 36 6.9 69.40
Ahn et al. [26] 36 8.5 69.40
Fagerlund et al. [27] 30 24.0 73.00
Galucci et al. [28] 15 4.0 73.30
Ellenberg et al. [29] 14 30.0 78.50
Shan et al. [30] 30 6.0 80.00
Maigne et al. [31] 48 48.0 81.20
Yu et al. [32] 102 24.0 81.37
Saal et al. [33] 11 25.0 81.80
Ilkko et al. [34] 18 62.4 83.00
Hong et al. [35] 28 8.8 85.70
Benson et al. [37] 32 23.2 87.50
Takada et al. [38] 42 3.0-12.0 88.00 (>50 % reduction in herniation size)
Buttermann [39] 58 36.0 89.60
Demirel et al. [40] 20 3.0 90.00
Kesikburun et al. [41] 40 17.0 90.00
El Barzouhi et al. [42] 95 12.0 92.60
Autio et al. [43] 55 12.0 92.70
Cribb et al. [44] 15 24.0 93.30
Komori et al. [59] 22 6.0 86.30
slowly resorbed, which accumulates the risk of persistent sciatic nerve pain.
Predictors of spontaneous regression of a herniated fragment. The following criteria for spontaneous regression of disc herniation are described in the literature: the type and size of the herniated fragment, MRI parameters, and a transient enlargement in the size of hernia bulging [18, 48]. Ahn et al. [26] believe the integrity of the posterior longitudinal
ligament to be the main predictor of herniation regression: the regression rate of subligamentous, transligamentous, and sequestered herniations is 17 %, 48 % and 82 %, respectively. The high incidence of resorption of extruded and sequestered herniations is explained by the fact that when a fragment of the nucleus pulpo-sus penetrates through the fibrous ring and posterior longitudinal ligament into the epidural space and is exposed to the
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systemic circulation [7, 45]. This causes an autoimmune response, including the infiltration of inflammatory cells and neovascularization. According to Chiu et al. [7], the incidence of regression of protrusion-type herniations is 30.0 %, and that of extrusion and sequestration-type herniations is 76.9 %.
In order to study the predictors of lumbar disc herniation resorption, Rashed et al. [58] performed a system-
KHIRURGIYA POZVONOCHNIKA (Russian journal of spine surgery) 2024;21(l):55-62 aj. sanginov et al. resorption of lumbar disc herniations
atic review and meta-analysis, which included 16 articles describing 360 cases. The mean time period between MRI scans was 11.5 months. The probability of spontaneous regression in protruded, extruded and sequestered disc herniations was 52.5 %, 70.4 % and 93.0 %, respectively (x2 = 126.01; p < 0.001). Extruded and sequestered herniations also had a considerably higher probability of complete resorption. Other predictors of resorption were a larger initial herniation volume (1,260.16 versus 1,006.71 mm3; p < 0.002), a transligamentous herniation (x2 = 13.321; p < 0.001), and the third type of disc herniation according to the Komori classification (sequestered herniation with disc fragment migration; x2 = 14.5132; p < 0.001). The authors also detected similar patterns in qualitative data and confirmed that the improvement in symptoms is associated with the resorption of disc herniation.
The composition of hernial bulging is of great significance in its resorption [61-63]. The presence of parts of the endplate and changes in the Modic classification prevent the infiltration of macrophages and the initiation of neovascularization processes, thereby preventing the onset of spontaneous resorption of disc herniation. Yu et al. [32] highlighted the decisive influence of autoimmune responses in spontaneous resorption of herniation, including inflammatory responses mediated by infiltration of macrophages interacting with the disc, enzymatic degradation reactions, and angiogenesis.
Shan et al. [30] performed a retrospective analysis of 85 cases of disc herniations to study the effect of Modic changes on herniation resorption in two treatment groups: conservative and surgical. In the conservative treatment group, patients with no Modic type changes at the endplate were more likely to experience the disc herniation resorption, as shown by MRI findings. The authors found a reduced herniation volume in 67 % (10 out of 15) of patients in the group with Modic changes compared with 93 % (14 out of 15) in the group without Modic changes (criteri-
on x’; p = 0.169). In the surgical treatment group, a histological examination of the disc tissue was conducted, and different proportions of the pulpous nucleus, fibrous ring and hyaline cartilage in the hernial mass were detected in patients with and without Modic changes (p < 0.05). The disc herniation tissues in the Modic changes group had more hyaline cartilage and less nucleus pulposus than in the Modic unchanged group, although the content of the fibrous ring was similar. More capillaries were revealed in herniation samples from patients without Modic changes. Macrophages were more widespread in samples from patients without changes in the Modic classification. In this regard, Modic changes in patients with lumbar disc herniations are associated with a cartilaginous herniation, which resolves worse than a more typical hernia. Conservative treatment is less likely to be efficient in patients with lumbar disc herniation with Modic changes. Summarizing the above data, it can be concluded that currently the type and size of herniation, follow-up period, Modic changes, etc. are considered predictors of the resorption of a herniated disc. In our opinion, the existing data on the time, mechanisms and predictors of resorption of lumbar disc herniation are insufficient to improve the treatment strategy for this category of patients. Given that the duration of conservative treatment for herniations varies from 6 weeks to 6 months in patients without neurological deficits, and the duration of herniation resorption is often more than 6 months, it is important to determine which patients should be referred for surgery after 6-8 weeks and which patients can be treated conservatively with the expectation of herniated fragment resorption.
For exemplificatory purposes, here is an example from our practice.
Patient K., 48 years old, applied to the Consulting Unit of the Novosibirsk Research Institute of Traumatology and Orthopaedics n.a. Y.L. Tsivyan with complaints of lumbar spine pain (3 points according to VAS) and in
_______________58_______________
the left leg along the posterior surface of the thigh and lower leg (6 points according to VAS) and temporary numbness in the left foot along the outer surface. Motor status: no paresis. According to the medical history, the pain appeared 3 months ago on the background of physical activity. Conservative treatment was almost ineffective. The patient was diagnosed with degenerative spine disease of the lumbar spine, L4-L5 disc herniation, grade 1 polysegmental spondy-loarthrosis, compression L5 root syndrome on the left, and low back pain. According to the MRI of the lumbar spine, sequestered herniation of the L4-L5 intervertebral disc with caudal migration of the fragment was detected (Fig. 1). There was no instability in the spinal motion segment, according to the results of functional radiography. The patient was referred for elective surgical treatment. Nevertheless, he consulted a neurosurgeon again only after 8 months to resolve the issue of the appropriateness of surgical treatment. During this period, on his own initiative, he was followed on an outpatient basis and received two courses of conservative treatment, including drug therapy, therapeutic blockades, and physiotherapy procedures. At the time of admission to the hospital, he presented with lumbar spine pain (3 points according to VAS), intermittent moderate pain in his left leg up to the knee (2 points according to VAS), and complete regression of numbness in his left foot. According to the MRI scan of the lumbar spine, complete resorption of the hernial fragment was found (Fig. 2).
Resorption of L4-L5 disc herniation, grade 1 polysegmental spondyloarthrosis, left-sided residual compression L5 root syndrome, and low back pain were established. Intermittent pain in the left leg up to the knee was regarded as a left-sided residual compression L5 root syndrome. Considering the relief of radicular symptoms with resorption of the herniated fragment (according to MRI findings), we decided to refuse surgical treatment of the patient, and he was discharged for
KHIRURGIYA POZVONOCHNIKA (Russian journal of spine surgery) 2024;21(1):55-62 a.j. sanginov et al. resorption of lumbar disc herniations
Fig. 1
MRI scan of the lumbar spine of patient K. at initial visit
Fig. 2
MRI scan of the lumbar spine of patient K. 9 months after initial visit
outpatient supervision by a neurologist at his place of residence.
Conclusion
Lumbar disc herniations often undergo spontaneous regression, although this is not always the case for all patients. The mechanisms behind this resorption process can vary, and the frequency of resorption may differ depending on the type of herniation. To more accurately determine the timing and predictors of resorption of lumbar disc herniations, analysis of large data sets is required.
The study had no sponsors. The authors declare that they have no conflict of interest.
The study was approved by the local ethics committee of the institution. All authors contributed significantly to the research and preparation of the article, read and approved the final version before publication.
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KHIRURGIYA POZVONOCHNIKA (Russian journal of spine surgery) 2024;21(l):55-62 aj. sanginov et al. resorption of lumbar disc herniations
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KHIRURGIYA POZVONOCHNIKA (Russian journal of spine surgery) 2024;21(l):55-62 aj. sanginov et al. resorption of lumbar disc herniations
Address correspondence to:
Sanginov Abdugafur Jabborovich
Novosibirsk Research Institute of Traumatology and Orthopaedics n.a. Ya.L. Tsivyan,
17 Frunze str., Novosibirsk, 630091, Russia, Dr.sanginov@gmail.com
Received 02.02.2024 Review completed 12.02.2024 Passed for printing 19.02.2024
Abdugafur Jabborovich Sanginov, MD, PhD, researcher, Research Department of Neurovertebrology, Novosibirsk Research Institute of Traumatology and Orthopaedics n.a. Ya.L. Tsivyan, 17Frunze str., Novosibirsk, 630091, Russia, ORCID: 0000-0002-4744-4077, Dr.sanginov@gmail.com;
Ilya Dmitrievich Isakov, junior researcher, Research Department of Neurovertebrology, Novosibirsk Research Institute of Traumatology and Orthopaedics n.a. Ya.L. Tsivyan, 17Frunze str., Novosibirsk, 630091, Russia, ORCID: 0000-0002-9228-3241, doctorisakov@mail.ru;
Shamil Alfirovich Akhmetyanov, MD, PhD, researcher, Research Department of Neurovertebrology, Novosibirsk Research Institute of Traumatology and Orthopaedics n.a. Ya.L. Tsivyan, 17Frunze str., Novosibirsk, 630091, Russia, ORCID: 0000-0003-0505-8319, sh.ahmetyanov@yandex.ru;
Aleksey Vladimirovich Peleganchuk, MD, PhD, researcher, Research Department of Neurovertebrology, Head of the Department of Neurosurgery No. 2, Novosibirsk Research Institute of Traumatology and Orthopaedics n.a. Ya.L. Tsivyan, 17 Frunze str., Novosibirsk, 630091, Russia, ORCID: 0000-0002-4588-428X, apeleganchuk@mail.ru.
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