Free fragments in lumbar canal

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extruded disc fragments can usually be managed by conservative methods. Rational, Patho- physiology, duration of absorptions are discussed with literature support

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Free Fragments in Lumbar Canal: 

Free Fragments in Lumbar Canal Vinod Naneria Consultant, Orthopaedics Choithram Hospital & Research Centre Indore, MP, India

Free fragment: 

A piece of Nucleolus pulposus with Annulus Fribrosus & fragments of cartilagenous end-plate, lying loose in the spinal canal. It may migrate up or down a level or two, may migrate posterior to dura or perforate dura. Incidence - 9 to 15.5% Free fragment

Slide3: 

Types of Disk Disease Disk Bulge Disk bulges into anterior epidural space without any area of focal-ness or out-pouching Disk Herniation General term used to describe different degrees of 'eccentric out-pouching' of IV disk. Protrusion contained herniation or sub-ligamentous herniation Extrusion non-contained herniation, or trans-ligamentous herniation Sequestration free fragments

Slide4: 

Free Fragments Free Fragments

Slide5: 

Loose Fragments Loose Fragments

Literature – Free Fragment: 

Literature – Free Fragment Incidence - 9 to 15.5% Composition – N.P. / A.F. + fragments of end plate Lateral migration – cranial & caudal Posterior migration – cauda equina – mimic tumour Intra dural more than 60 cases reported-world literature Roof disc : central disc extrusion : contained by P.L.L.

Migration: 

Migration Since it is impossible to predict on MRI, that a migrated fragment have some continuity with the parent disc or not - it should be considered as loose fragment. There is a real possibility of migration of the fragment and increase in the neuro-deficit. It is immaterial where the migration is. Migration may progress in the initial phase of extrusion, it may migrate one or two level – up or down.

Composition of extruded material: 

Composition of extruded material Nucleolus pulposus Annulus fibrosus Fragments of Cartilage end plate.

Patho-physiology of Absorption: 

Patho-physiology of Absorption The disc formation takes place before the immune system develops in the embryonic life. The proteins in the nucleosus pulposus are foreign to immune system in adults. The free fragment is treated as foreign protein and a reactive granuloma forms, which absorbs the free fragment.

Absorption- composition & time: 

Absorption- composition & time Nucleolus Puplposus: absorb by formation of granulation tissue possibly as an auto-immune reaction. 3 months The Annulus Fibrosus: absorb by granulation tissue by vascular invasion. 1 – 2 years The Hyline cartilage of end-plate: suppresses neo-vascularization, resistant to absorb

Slide11: 

The amount of hyaline cartilage, should be predictable on the basis of imaging data. Vertebral endplate marrow signal intensity changes are associated with fissures in the vertebral end-plate. Signal intensity changes may be regarded as osteo­cartilaginous fracture signs similar to other skeletal manifestations.

Slide12: 

MRI – showing End-plate lesion, marrow signals Indicating a portion of end-plate avulsion in the extruded disc & Will take long time to absorbed or reduction in size. Early surgery may be contemplated.

Slide13: 

A 35 male, had acute disc extrusion at L4-L5 rt. With free fragment in the canal A follow up MRI after 2months Showing End-Plate edema L5. End-plate edema

Fate of Free Fragment –Complete absorption : 

Fate of Free Fragment –Complete absorption Sei A, Nakamura T et al 1994 Coevoet V et al t.d. 1997 Westmark RM et al c.d. 1997 Miller S et al 1998 Singh P, Singh AP. 1998 Morandi X et al 1999 Kobayashi N et al c.d. 2003 More than 55% of absorption is clinically significant Follow up MRI – every 3 months for one year

Spontaneous changes on MRI & Clinical Correlation - 42 cases treated conservatively. Takada & Takahashi : 

Spontaneous changes on MRI & Clinical Correlation - 42 cases treated conservatively. Takada & Takahashi MRI changes Cases Excellent Good Poor Disappearance 08 06 02 00 More  50% 29 11 18 00 No reduction 05 00 01 04 50% involution in 3 – 6 months J.of Orthopaedic Surgery 2001, 9(1): 1–7

Slide16: 

Number of cases 80 M / F same Age 20 – 70 Duration of symptoms 01 – 90 days No deficit 06 Mono-radiculopathy 59 Poly-radiculopathy 13 Delayed Cauda-equina 02 My experience

Why conservative?: 

Why conservative? Stable neurological deficit & Presented late > than one week. Bearable radicular pain with negative root stretching test (SLRT). No bladder or bowel dysfunction. Patient not willing for surgery but gave consent for surgery as & when needed. Kept under strict watchful supervision.

R.K.- Absorption one month: 

R.K.- Absorption one month A 25 M Acute agonizing pain 5 days duration Spinal flexion 50%, EHL lt weak gr3 No bladder – bowel dysfunction. Pain minimal MRI extruded disc at L5-S1 left Repeat MRI after one month – extruded fragment (N.P.)absorbed completely.

Slide19: 

Jan 2 0 0 7 Feb 2 0 0 7

Absorption within 3 months: 

Absorption within 3 months R.J. – 55 male, Backache sciatica rt., acute onset. Rt. Ankle jerk absent. MRI-June 07- extruded fragment L5-S1 Conservative MRI – Aug 07- complete absorption

Slide22: 

Complete Absorption In three Months.

N.K.- Complete absorption one year: 

N.K.- Complete absorption one year H/o backache sciatica 2005 – MRI degenerated discs at L4-L5, L5-S1. Extruded disc in 2006 – with no neurological deficit. Tx – conservatively with complete absorption of free fragment.

Slide24: 

2 0 0 5 2006 2006

Slide25: 

2006

Slide26: 

2 0 0 7

Case history – U.S.: 

Case history – U.S. 45 M, Acute backache sciatica 15 days duration Attended clinic as OPD patient. L5 – S1 Rt. with loose fragment over L5 body Measuring 2.4cm x 1.5cm Full flexion spine and negative SLRT Mild gr.4 weakness in EHL and Hypoasthesia in L5 distribution. Tx conservatively

Reduction in size: 

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.

Slide33: 

fragment extruded beween S1 root & card - conservative Case report Mrs. W. Before & after 6 months

Slide34: 

Before & after 6 months > 50% reduction in size

Patient when reported late: 

Patient when reported late It is usually for a second opinion. For persisting pain No improvement in neurological deficit. It is stable neurology. May be a case for surgical intervention. Some times Epidural steroids works.

Slide36: 

Case summary – Delayed reporting Backache sciatica Lt 3 months Had localised pain around knee joint

Conservative treatment failed: 

Conservative treatment failed Six cases Intractable radicular pain Increase in neurological deficit due to fragment migration Increase in deficit due to central extrusion Poor patient compliance Surgery on demand

Slide39: 

Case report – Operated for severe unbearable pain after 3 weeks of adequate treatment Fragment had transfixed S1 root - Surgery

Central “Roof Disc extrusion” Operated for developing bladder symptom: 

Central “Roof Disc extrusion” Operated for developing bladder symptom

Slide41: 

Migration two level down Rupture of Dura – deteriorated on conservative treatment- Operated fragments removed transdurally

Migration of fragment after one year: 

Migration of fragment after one year Mr. M.L. 65 M. Pain in the gluteal region with stiff back No neurological deficit with – Ve SLRT. MRI – free fragment in the sacral canal. Conservatively. Recurrence after 1 year. Some parasthesia in gluteal region, bladder bowel dysfunction some times. Repeat MRI – fragment size same – mild displacement +. Tx – conservatively, asymptomatic

Fragment mainly of end-plate: 

Fragment mainly of end-plate

Fragment did not absorb even after one year, migrated minimally down: 

Fragment did not absorb even after one year, migrated minimally down

Management - Protocol: 

Management - Protocol All Tx conservative initially Strict Bed Rest in position of comfort No pelvic / limb traction Sitting strictly prohibited Supportive drugs Tx – steroids sos. Frequent neurological examination Bed rest cont… till SLRT become -ve

Management - Protocol: 

Management - Protocol Gradual Mobilization in the house Exercises programme Straight leg raising Knee bending to chest Forward bending in sitting postion Forward bending in standing Back care ( jerk, weight lifting, bending, sitting at work etc. Strict instructions regarding reporting of neurological deterioration

Follow-up MRI: 

Follow-up MRI At 3 months At 6 months At 12 months Fragment mainly consist of NP will absorbed in 3 months Fragment mainly consisting of NP+AF will take 6 months – one year Fragment consist of end plate cartilage take longer time – more than 2 years.

Favorable signs:: 

Favorable signs: negative crossed straight-leg-raising test, absence of leg pain with spinal extension, absence of stenosis on imaging studies, favorable response to steroids, normal psychological profile, a motivated physically fit patient, more than twelve years of education, no Workers’ Compensation claim.

Initial rest: 

Initial rest Extruded disc – acute onset Fragment is free in the canal and migrate any where. It is more likely to cause neurological deficit when it get trapped at narrow parts of spinal canal. It take roughly two weeks for the fragment to get fixed by the granulation tissue.

Traction: 

Traction Traction immobilize the patient is a fixed posture. Muscle spasm is basically protective and keep the patient in a posture which protect the compressed nerve root. An alteration in posture by forceful traction increases the chances of damage to nerve root. Traction should be avoided for acute pain.

Sitting posture to be avoided: 

Sitting posture to be avoided Maximum pressure on the damaged disc occur in sitting posture specially with forward bending. It increases the chances of further displacement or migration of the fragment.

Slide52: 

Sitting posture increases intra-discal pressure

Types of Lumbar Herniated Disc and Clinical Course SPINE Volume 26, Number 6, pp 648–651 ©2001, Lippincott Williams & Wilkins, Inc. Takui Ito, MD,* Yuichi Takano, MD,† and Nobuhiro Yuasa, MD† : 

Types of Lumbar Herniated Disc and Clinical Course SPINE Volume 26, Number 6, pp 648–651 ©2001, Lippincott Williams & Wilkins, Inc. Takui Ito, MD,* Yuichi Takano, MD,† and Nobuhiro Yuasa, MD† Conclusions. The authors believe that patients with noncontained lumbar disc herniation can be treated with­out surgery, if these patients can tolerate the symptoms for the first 2 months.

Slide54: 

Primary and revision lumbar discectomy A 16-YEAR REVIEW FROM ONE CENTRE C. V. J. Morgan-Hough et al, England primary protrusions are almost three times as likely to require revision surgery as primary extrusions or sequestrations. We suggest that protrusion represents the beginning of a process of serial fragmentation of disc material, whereas extrusion and sequestration are an end-stage of this process

Saal JA, Saal JS, Herzog RJ: The natural history of lumbar intervertebral disc extrusions treated non-operatively. Spine 15: 683–686, 1990: 

Saal JA, Saal JS, Herzog RJ: The natural history of lumbar intervertebral disc extrusions treated non-operatively. Spine 15: 683–686, 1990 Patients with large compressive lesions are also generally believed to be more ideally suited to surgical intervention. These same patients, however, are those most likely to experience spontaneous regression of their lesions and they have a high rate of clinical improvement with noninvasive treatments.

Spangfort, - 2504 operations Satisfactory results: 

Spangfort, - 2504 operations Satisfactory results 99.5% results in complete or partial pain relief in cases of free fragments in the canal. 82% Incomplete herniation or extrusion of disc. 63%, Excision of the bulging or protruding disc. 38%, removal of the normal or minimally bulging disc. Failure to relieve sciatica was proportional to the degree of herniation

Spangfort, - 2504 operations persisted back pain: 

Spangfort, - 2504 operations persisted back pain 30% persisted back pain The incidence of persistent back pain after surgery was inversely proportional to the degree of herniation. In patients with complete extrusions the incidence was about 25%, but with minimal bulges or negative explorations the incidence rose to over 55%.

Natural history: 

Natural history Protrusion – degenerated disc – decreased height – facetal joint degeneration – ligamentum flavum infolding – segmental canal stenosis Degenerative dynamic instability Osteoarthritis – osteophytes in an attempt to stabilize the spine. Surgery only relieve leg pain temporarily.

Slide59: 

Radiculopathy and the Herniated Lumbar Disc. Controversies Regarding Pathophysiology and Management J. Bone Joint Surg. Am. John M. Rhee, Michael Schaufele and William A. Abdu, 88:2070-2080, 2006. This information is current as of January 21, 2007

Slide60: 

Both the surgeon and the patient must realize that disc surgery is not a cure but may provide symptomatic relief. It neither stops the pathological processes that allowed the herniation to occur nor restores the back to a normal state

Recommendations: 

Recommendations Presence of Free fragment in the canal indicates auto-decompression of the nerve roots (SLRT –ve, Pain ↓ as nerve fired/ decompressed). Usually stable mono-radiculopathy – recovery is almost complete. Patients with gross / ↑ neurological deficit should be operated.

Slide62: 

Think over it ??? ? Conservative Thank U