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MRI-documented regression of a herniated cervical nucleus pulposus: A case report
Surg Neurol 1992;37:457-9
457
MRI-Documented Regression of a Herniated Cervical Nucleus Pulposus: A Case Report Abbott J. Krieger, M.D., and Allen H. Maniker, M.D. Section of Neurological Surgery, The University of Medicine and Dentistry of New Jersey, The New Jersey Medical School, Newark, New Jersey
Krieger AJ, Maniker AH. MRI-documented regression of a herniated cervical nucleus pulposus: a case report. Surg Neurol 1992;37:457-9.
An MRI-documented case of regression of a herniated cervical nucleus pulposus in a neurologically intact patient is presented. KEY WORDS: Cervical disk disease; MRI
The case presented is that of a patient involved in a motor vehicle accident with a chief complaint of neck pain, who presented with normal neurological exam findings but with a large MRI-demonstrated herniated cervical nucleus pulposus with associated spinal cord compression. The patient was treated conservatively; the serial magnetic resonance imaging (MRI) studies that demonstrated a regression of the herniated cervical nucleus pulposus are presented.
Case R e p o r t This 38-year-old man presented in May 1990 after involvement in a rear-end collision 1 month previously. Immediately after the accident he experienced neck pain, and a "whiplash" injury was diagnosed in the emergency room. H e then obtained chiropractic manipulations, which offered some relief, but because of persistent pain an MRI was obtained. As seen in the MRI from April 1990 (Figure 1), a significantly herniated nucleus pulposus that crosses the midline is demonstrated at the C5-C6 level. The patient was then referred to a neurosurgeon, who recommended surgery as a prophylactic measure against the potential of quadriplegia in the event o f further trauma. For a second opinion the
Address reprint requests." Allen Maniker, M.D., University of Medicine and Dentistry of New Jersey, The New Jersey Medical School, Section of Neurological Surgery, 185 South Orange Avenue Room H-592, Newark, New Jersey 07103-2757. Received August 29, 1991; accepted December 3, 1991. © 1992 by Elsevier Science Publishing Co., Inc.
patient was seen by another neurosurgeon, who felt that surgery was not indicated. H e was then referred to our institution for a third opinion. Upon presentation at this institution the patient stated that his neck pain had resolved. H e exhibited no muscle weakness and his sensory examination was intact to pin prick and light touch. The deep tendon reflexes were + 2 bilaterally. N o Babinski sign was present and his gait was normal with good heel and toe walking. We agreed with the second surgeon's recommendation of a nonoperative approach to the patient and performed serial MRI scans as follow-up. The patient remained neurologically intact with complaints of occasional pain in his right upper extremity. Follow-up scans were performed in October 1990 (Figure 2), and again in March 1991 (Figure 3). By March 1991 he was entirely pain-free. While no scans, when reviewed retrospectively, can be aligned exactly, these figures are the most representative of the midline cuts available. Furthermore, when viewed in conjunction with the axial sections, they leave no doubt as to the regression of the lesion. In Figure 3 there may also be a question whether the lesion included a bony bar; however, the spinal cord compression due to the soft tissue component has resolved. Discussion Herniations of the cervical nucleus pulposus typically present with a symptom complex of radiculopathy, myelopathy, or both. Radiographic evidence in the form of a myelogram and/or MRI is then obtained to confirm the presence and the level of the herniation [5]. In the majority o f patients presenting with radiculopathy alone, the problem, when given a trial of conservative therapy, tends to resolve [ 1]. Conservative measures of treatment can include bed rest, heat application, massage, physical therapy, soft cervical collars, analgesics, and muscle relaxants. In the event of continued pain, although many no longer advocate such therapy, a period of cervical traction may be justified [4]. In the patient presenting with myelopathic signs alone 0090-3019/92/$5.00
Figure 1. MRl from April 1990. sagittal and axial sections, demonstrating ,i .~igniflcant/y herniated nucleus pulposus at the C5-C6 let'el and as.*ociated spinal cord compression.
Figure 2. MRI from October 1990. sagittal and axial sections, showing a reduction in the size of the pret4ously demonstrated herniated nucleus p~lposus.
Herniated Cervical Nucleus Pulposus
Surg Neurol 1992;37:457-9
459
Figure 3. MRI from March 1991, sagittal and axia/ sections, demonstra-
ting the complete regression of the herniated nucleus pu/posus at the C5-C6 level
or in conjunction with radicular signs, although some find a limited role for conservative therapy [3], most would agree that operative intervention is indicated. Surgical therapy then becomes appropriate in patients with radiographically demonstrated disk herniations with myelopathic signs and in patients with intractable pain or a persistent radicular deficit after a failure of conservative therapy. In patients whose symptoms resolve, neurosurgical as well as continued radiographic follow-up is rarely required. However, in this particular patient, owing to the large size of the disk herniation and the demonstrated cervical cord compression, radiographic follow-up was deemed necessary. The advent of MRI with its imaging of soft tissues, particularly those in the midline sagittal plane, allows a superior demonstration of the herniated cervical nucleus pulposus. It is therefore an ideal way of documenting the progression of a disk herniation for the patient being treated conservatively. This patient showed an ongoing regression of the herniated nucleus pulposus with progressively lessening spinal cord compression, as documented by the serial MRI scans. Although Fager [2] has shown the spontaneous regression of a herniated lumbar disk in a case documented by CT scans, this is the first such MRI-documented case of regression in the cervical spine. Although only speculative, this regression of a devitalized fragment of disk probably occurs through mechanisms of dehydration followed by phagocytosis and local tissue reaction, and it is no doubt not uncommon. However, with the use of MRI, we now have the capability of following these patients and documenting this occurrence in an easily obtained, noninvasive way.
References 1. Ehni B, Ehni G, Patterson RH. Extradural spinal cord and nerve root compression from benign lesions of the cervical area. In: Youmans JR, ed. Neurological surgery. Book 4, 3rd ed. Philadelphia: W.B. Saunders Company, 1990:2881. 2. Fager CA. Neurosurgical management of lumbar spine disease. N Dev Med 1988;3:18-9. 3. HoffJT: Surgical approaches to diseases of the anterior cervical spine. Contemp Neurosurg 1984;6:1-6. 4. Murphy F, Simmons JCH, Brunson B: Ruptured cervical discs, 1939-1972. Clin Neurosurg 1973;20:9-17. 5. Simon JE, Lukin RR: Diskogenic disease of the cervical spine. Semin Roentgenol 1988;23(2):118-24.
457
MRI-Documented Regression of a Herniated Cervical Nucleus Pulposus: A Case Report Abbott J. Krieger, M.D., and Allen H. Maniker, M.D. Section of Neurological Surgery, The University of Medicine and Dentistry of New Jersey, The New Jersey Medical School, Newark, New Jersey
Krieger AJ, Maniker AH. MRI-documented regression of a herniated cervical nucleus pulposus: a case report. Surg Neurol 1992;37:457-9.
An MRI-documented case of regression of a herniated cervical nucleus pulposus in a neurologically intact patient is presented. KEY WORDS: Cervical disk disease; MRI
The case presented is that of a patient involved in a motor vehicle accident with a chief complaint of neck pain, who presented with normal neurological exam findings but with a large MRI-demonstrated herniated cervical nucleus pulposus with associated spinal cord compression. The patient was treated conservatively; the serial magnetic resonance imaging (MRI) studies that demonstrated a regression of the herniated cervical nucleus pulposus are presented.
Case R e p o r t This 38-year-old man presented in May 1990 after involvement in a rear-end collision 1 month previously. Immediately after the accident he experienced neck pain, and a "whiplash" injury was diagnosed in the emergency room. H e then obtained chiropractic manipulations, which offered some relief, but because of persistent pain an MRI was obtained. As seen in the MRI from April 1990 (Figure 1), a significantly herniated nucleus pulposus that crosses the midline is demonstrated at the C5-C6 level. The patient was then referred to a neurosurgeon, who recommended surgery as a prophylactic measure against the potential of quadriplegia in the event o f further trauma. For a second opinion the
Address reprint requests." Allen Maniker, M.D., University of Medicine and Dentistry of New Jersey, The New Jersey Medical School, Section of Neurological Surgery, 185 South Orange Avenue Room H-592, Newark, New Jersey 07103-2757. Received August 29, 1991; accepted December 3, 1991. © 1992 by Elsevier Science Publishing Co., Inc.
patient was seen by another neurosurgeon, who felt that surgery was not indicated. H e was then referred to our institution for a third opinion. Upon presentation at this institution the patient stated that his neck pain had resolved. H e exhibited no muscle weakness and his sensory examination was intact to pin prick and light touch. The deep tendon reflexes were + 2 bilaterally. N o Babinski sign was present and his gait was normal with good heel and toe walking. We agreed with the second surgeon's recommendation of a nonoperative approach to the patient and performed serial MRI scans as follow-up. The patient remained neurologically intact with complaints of occasional pain in his right upper extremity. Follow-up scans were performed in October 1990 (Figure 2), and again in March 1991 (Figure 3). By March 1991 he was entirely pain-free. While no scans, when reviewed retrospectively, can be aligned exactly, these figures are the most representative of the midline cuts available. Furthermore, when viewed in conjunction with the axial sections, they leave no doubt as to the regression of the lesion. In Figure 3 there may also be a question whether the lesion included a bony bar; however, the spinal cord compression due to the soft tissue component has resolved. Discussion Herniations of the cervical nucleus pulposus typically present with a symptom complex of radiculopathy, myelopathy, or both. Radiographic evidence in the form of a myelogram and/or MRI is then obtained to confirm the presence and the level of the herniation [5]. In the majority o f patients presenting with radiculopathy alone, the problem, when given a trial of conservative therapy, tends to resolve [ 1]. Conservative measures of treatment can include bed rest, heat application, massage, physical therapy, soft cervical collars, analgesics, and muscle relaxants. In the event of continued pain, although many no longer advocate such therapy, a period of cervical traction may be justified [4]. In the patient presenting with myelopathic signs alone 0090-3019/92/$5.00
Figure 1. MRl from April 1990. sagittal and axial sections, demonstrating ,i .~igniflcant/y herniated nucleus pulposus at the C5-C6 let'el and as.*ociated spinal cord compression.
Figure 2. MRI from October 1990. sagittal and axial sections, showing a reduction in the size of the pret4ously demonstrated herniated nucleus p~lposus.
Herniated Cervical Nucleus Pulposus
Surg Neurol 1992;37:457-9
459
Figure 3. MRI from March 1991, sagittal and axia/ sections, demonstra-
ting the complete regression of the herniated nucleus pu/posus at the C5-C6 level
or in conjunction with radicular signs, although some find a limited role for conservative therapy [3], most would agree that operative intervention is indicated. Surgical therapy then becomes appropriate in patients with radiographically demonstrated disk herniations with myelopathic signs and in patients with intractable pain or a persistent radicular deficit after a failure of conservative therapy. In patients whose symptoms resolve, neurosurgical as well as continued radiographic follow-up is rarely required. However, in this particular patient, owing to the large size of the disk herniation and the demonstrated cervical cord compression, radiographic follow-up was deemed necessary. The advent of MRI with its imaging of soft tissues, particularly those in the midline sagittal plane, allows a superior demonstration of the herniated cervical nucleus pulposus. It is therefore an ideal way of documenting the progression of a disk herniation for the patient being treated conservatively. This patient showed an ongoing regression of the herniated nucleus pulposus with progressively lessening spinal cord compression, as documented by the serial MRI scans. Although Fager [2] has shown the spontaneous regression of a herniated lumbar disk in a case documented by CT scans, this is the first such MRI-documented case of regression in the cervical spine. Although only speculative, this regression of a devitalized fragment of disk probably occurs through mechanisms of dehydration followed by phagocytosis and local tissue reaction, and it is no doubt not uncommon. However, with the use of MRI, we now have the capability of following these patients and documenting this occurrence in an easily obtained, noninvasive way.
References 1. Ehni B, Ehni G, Patterson RH. Extradural spinal cord and nerve root compression from benign lesions of the cervical area. In: Youmans JR, ed. Neurological surgery. Book 4, 3rd ed. Philadelphia: W.B. Saunders Company, 1990:2881. 2. Fager CA. Neurosurgical management of lumbar spine disease. N Dev Med 1988;3:18-9. 3. HoffJT: Surgical approaches to diseases of the anterior cervical spine. Contemp Neurosurg 1984;6:1-6. 4. Murphy F, Simmons JCH, Brunson B: Ruptured cervical discs, 1939-1972. Clin Neurosurg 1973;20:9-17. 5. Simon JE, Lukin RR: Diskogenic disease of the cervical spine. Semin Roentgenol 1988;23(2):118-24.