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The results of non-operative treatment of ruptured lumbar discs
The Results of Non-operative Treatment of Ruptured Lumbar Discs Z. B. FRIEDENBERG, M.D., Diplomate,
American
Board of Orthopedic Surgery, Pennsylvania
AND
ROBERT C. SHOEMAKER, M.D., Philadelphia, From the Department
of Orthopedic Surgery, of Pennsylvania, Pbiladelpbia,
Hospital Pa.
of
with this degree of pain represent only the more severe fuIminating segment of a11 individuals suffering disc disease and the resuIts attained HE diagnosis of ruptured Iumbar disc conshouId be interpreted with this fact considered. tinues to be made with increasing freIt is not our poIicy to submit a11 suspected quency and is supplanting other diagnoses ruptured discs to myeIography. OnIy those paformerIy frequentIy made to expIain backache tients in whom the question of a surgica1 with or without radicuIar pain. It is apparent procedure was considered had myeIograms. that morphoIogic aIterations in the disc strucRoentgenograms of the spine in each patient ture can in themseIves cause symptoms indefaiIed to reveal any other cause for the papendent of any retropuIsion of the nucIeus tient’s symptoms and each individual’s history puIposus. AI1 intervertebra discs, and in and physical examination, as we11 as his subparticuIar those of the Iumbar area, undergo sequent clinica course, pointed to disc invoIvephysiologic changes with aging. BiochemicaI ment as a primary cause of his difTicuIties. studies show a gradua1 loss of the ffuid content UnquestionabIy many patients with rupof the nucIeus pulposus with concomitant Ioss tured discs were excIuded because of a negative of mucoid materia1. HistoIogicaIIy there is a myeIogram, yet it was believed that a criticaIIy steady increase in coIIagen fibers and a Ioss of seIected smaI1 series with a diagnosis beyond ceIIuIar eIements occurring as part of the aging question wouId shed more Iight than a Iarger process. diluted series. The precise reIationship between the physioThe group studied consisted of thirty-six Iogic and pathologic aIterations in the disc and patients, twenty-seven of whom were examined the roIe of trauma in the production of sympand nine evaluated by Ietter. There were tons is not yet known. The disc probIem, which twenty-five maIes and eIeven femaIes. formerIy was concerned simpIy with estabIishThe history of a patient with a Follow-up. ing whether or not a disc was dispIaced, has ruptured disc is characterized by numerous expanded to incIude a host of reIated and perattacks of disability interspaced between haps more basic probIems. variabIe periods of freedom or reIief from pain. The present study is confined to an assessTherefore, the vaIue of any study is directIy ment of the resuIts of non-operative treatment reIated to the Iength of the foIIow-up period. of definite lumbar disc ruptures. The current In this study the shortest foIIow-up period and broadened concept of disc disorder makes since hospitalization and myelography was a it more diffIcuIt to select a group of patients year and a haIf, the Iongest was ten years and with definite disc ruptures without benefit of the average foIIow-up four and a haIf years. operative confirmation. It is for this reason that The average time interva1 between the onset a critica selection of patients was empIoyed and of back pain and the foIIow-up visit was much myeIographic evidence of disc dispIacement was longer, being seven years. If we may consider considered essentia1 in addition to a definite that actua1 rupture occurred at the period the cIinica1 diagnosis. Selection of Patients. These patients reprepatient first experienced a severe attack of sciatica, the average period between this episent a seIected group. Each was so severeIy sode and the foIIow-up visit was five years. afflicted with Iow back pain and root radiation In most cases the decision to Treatment. that admission to the hospita1 for observation avoid surgery and treat the patient nonand treatment was recommended. IndividuaIs AmericanJournal of Surgery,Volume88, December, 19~4 933 tbe University
T
Ruptured
Lumbar
operativeIy was made because the patient showed an encouraging response to bedrest, and a further tria1 of such therapy seemed indicated. In the remaining, the patient refused surgery. Each patient was treated with a period of bedrest from one to three weeks and then was discharged with a back support which was worn for a varying period of time. PhysicaI therapy was seldom empIoyed. Each patient was instructed to limit his activities during the period of earIy treatment.
acterized principaIIy by pain occurring in an episodic manner. Thirty per cent of the patients showed atrophy of more than I cm., whiIe ten per cent showed changes in reflexes. Some patients had foIlow-up fiIms for comparison with those taken at the time of their hospitaIization, but no correIation couId be made between the changes encountered and the residua1 symptoms. It was also impossibIe to relate the size of the original myeIographic defect or the residual oi1 left after myeIography with the cIinica1 state of the patient. Capacity for Work. The degree of residua1 disabiIity may be evaluated aIso by determining how many individuaIs were abIe to resume their former types of work. Six of eIeven Iaborers (55 per cent) returned to Iaboring work. Of those engaged in a non-Iaboring capacity g4 per cent returned to their former work. Two individuaIs faiIed to return to any form of occupation. One such patient is sixtynine years of age and retired, whiIe the other is restricted by pain brought on by any exertion.
RESULTS
Pain-free. In this group are patients who have had no recurrence of either back pain or radicuIar pain. In spite of their apparent compIete recovery, many stiI1 favor their back and refuse to engage in strenuous pursuits. Seventeen patients (47 per cent) are in this group. One patient in this group has been pain-free for eight years foIIowing his myeIogram; the average foIIow-up period in this group is four years. Mild Residual Pain. In this category are patients who have miId backache or Ieg pain of a recurrent nature. They have reported no episodes of pain Severe enough to require Ioss of time from work or the care of a physician. In most instances they resort to a brace for reIief of symptoms. Eleven patients (31 per cent) are in this group. The average foIIow-up period for these patients was five years. Back pain aIone was noted in seven; four of these patients compIained of occasional duI1 pain in the back and Ieg. Severe Residual Pain. This group consists of individuaIs who have suffered severe pain intermittentIy or continuousIy in the spine or in combination with limb pain. This group aIso incIudes patients who have constant pain of a Iess severe nature not occurring in acute episodes. Eight patients (22 per cent) are cIassified in this group. The average foIIow-up period since myeIography is five years. ClinicaZ Findings
and Roentgenograms.
Discs
COMMENTS
In 1948 a simiIar survey was published and eIeven of the patients reviewed in this report were incIuded in the earIier study. Of this number seven remained unchanged, three were improved over their former status and one patient regressed. The resuIts in the present series, in which there is a Ionger foIIow-up, are better than those in the previous series. In 1948 twenty-eight patients were studied of whom 2g per cent were pain-free, 39 per cent suffered miId residua1 pain and 32 per cent were totaIIy dissatisfied with their results. In the present series 47 per cent were pain-free, 31 per cent had residua1 pain and 22 per cent had severe pain. The resuIts of conservative therapy reported by other authors in the treatment of dispIaced Iumbar discs show considerabIe Shinners and Hamby’O reviewed variation. cases with a history suggestive of a protruded disc and treated non-operativeIy, on the basis of a questionnaire. They found 30 per cent we11 and 70 per cent having some form of pain. HaIf of these patients had recurrent attacks of back and Ieg pain. The resuIts of operative therapy of ruptured Iumbar discs as reported by many authors seem to substantiate each other within certain limits. About 60 per cent are pain-free, 40 per cent showing some residua1 pain and approxi-
Each
of the twenty-seven patients reporting for foIIow-up had a compIete orthopedic examination, which in most instances was negative. This is UnderstandabIe as an individual subjected to examination during a remission of his disease wouId be expected to present few findings. This fact underIines the subjective nature of this or any report in a Iesion char934
Ruptured
Lumbar Discs patients with positive myelograms. J. Bone CY >oint Surg., 31A: 614-617, 1949. 1. DUNNING. H. S. Proenosis of so-calIed sciatic neuritis. Arch. Neuru~. Ed Psycbiat., 55: 573-577,
mateIy IO per cent of the Iatter figure are unimproved. It would appear from this study that individuaIs having a ruptured Iumbar disc with severe back pain associated with radicular findings and often with a background of many previous attacks will, in a substantia1 proportion of cases, have a fuII remission of symptoms over a period of years and return to their previous empIoyment without surgica1 recourse. The difficuIty confronting the surgeon is the selection of cases for operative and non-operative care. Most authors use as their criteria for operation the failure of conservative therapy or the deveIopment of increasing neurotogic signs or symptoms. Such standards, however, offer much Iatitude in interpretation. The duration of a conservative trial, the degree of cIinica1 improvement anticipated and what constitutes adequate conservative therapy are variousIy interpreted. It is beIieved that a series such as is reported herein may heIp crystaIIize this facet of the disc probIem.
1946. 4. GRANT, F. C., AUSTIN, G., FRIEDENBERG,Z. B. and HANSEN, A. A correIation of neurologic, orthopedic and roentgenographic findings in disptaced intervertebra discs. Surg., Gynec. & Obst., 87: 561-568, 1948. ,in. HERSCH. C. Studies on the mechanics of low back pain. kta orthop. Scandinav., 20: 261-274, 195 I. 6. KIRSTEIN, L. An after-examination of operated and non-operated cases with clinical symptoms of herniated discs. Acta med. Scandinav., 120: 93-106, 1945. 7. KUHNS, J. G. Conservative treatment of sciatic pain in Iow back disability. J. Bone 0 Joint Surg., 23: 435-447. 1941. 8. MIXTER, W. J. and BARR, J. S. Rupture of the intervertebra disc with involvement of the spinal canaL New England J. Med., 21 I: 210-215, 1934. g. NACHLAS, W. 1. and SIMPSON, J. E. End rest& study of the treatment of herniated nucleus pulposus by excision with fusion and without fusion. J. Bone Ed Joint Surg., 34A: 98x988, 1952. IO. SHINNERS, B. M. and HAMBY, W. B. Protruded lumbar intervertebral disc. J. Neurosurg., 6: 450-457. 1949. I 1. WHITE. J. C. and PETERSON. T. H. Lumbar herniation of intervertebral discs. Occup. Med., I: r45-150, 1946.
REFERENCES I. BENGT, S.
On
the
biology
of
nucteus
puIposus.
Acta chop. Scandinav., 20: 257-274, 195 I. 2. COLONNA. P. C. and FRIEDENBERG. Z. B. The disc syndrome. Results of the conservative care of
935
American
Board of Orthopedic Surgery, Pennsylvania
AND
ROBERT C. SHOEMAKER, M.D., Philadelphia, From the Department
of Orthopedic Surgery, of Pennsylvania, Pbiladelpbia,
Hospital Pa.
of
with this degree of pain represent only the more severe fuIminating segment of a11 individuals suffering disc disease and the resuIts attained HE diagnosis of ruptured Iumbar disc conshouId be interpreted with this fact considered. tinues to be made with increasing freIt is not our poIicy to submit a11 suspected quency and is supplanting other diagnoses ruptured discs to myeIography. OnIy those paformerIy frequentIy made to expIain backache tients in whom the question of a surgica1 with or without radicuIar pain. It is apparent procedure was considered had myeIograms. that morphoIogic aIterations in the disc strucRoentgenograms of the spine in each patient ture can in themseIves cause symptoms indefaiIed to reveal any other cause for the papendent of any retropuIsion of the nucIeus tient’s symptoms and each individual’s history puIposus. AI1 intervertebra discs, and in and physical examination, as we11 as his subparticuIar those of the Iumbar area, undergo sequent clinica course, pointed to disc invoIvephysiologic changes with aging. BiochemicaI ment as a primary cause of his difTicuIties. studies show a gradua1 loss of the ffuid content UnquestionabIy many patients with rupof the nucIeus pulposus with concomitant Ioss tured discs were excIuded because of a negative of mucoid materia1. HistoIogicaIIy there is a myeIogram, yet it was believed that a criticaIIy steady increase in coIIagen fibers and a Ioss of seIected smaI1 series with a diagnosis beyond ceIIuIar eIements occurring as part of the aging question wouId shed more Iight than a Iarger process. diluted series. The precise reIationship between the physioThe group studied consisted of thirty-six Iogic and pathologic aIterations in the disc and patients, twenty-seven of whom were examined the roIe of trauma in the production of sympand nine evaluated by Ietter. There were tons is not yet known. The disc probIem, which twenty-five maIes and eIeven femaIes. formerIy was concerned simpIy with estabIishThe history of a patient with a Follow-up. ing whether or not a disc was dispIaced, has ruptured disc is characterized by numerous expanded to incIude a host of reIated and perattacks of disability interspaced between haps more basic probIems. variabIe periods of freedom or reIief from pain. The present study is confined to an assessTherefore, the vaIue of any study is directIy ment of the resuIts of non-operative treatment reIated to the Iength of the foIIow-up period. of definite lumbar disc ruptures. The current In this study the shortest foIIow-up period and broadened concept of disc disorder makes since hospitalization and myelography was a it more diffIcuIt to select a group of patients year and a haIf, the Iongest was ten years and with definite disc ruptures without benefit of the average foIIow-up four and a haIf years. operative confirmation. It is for this reason that The average time interva1 between the onset a critica selection of patients was empIoyed and of back pain and the foIIow-up visit was much myeIographic evidence of disc dispIacement was longer, being seven years. If we may consider considered essentia1 in addition to a definite that actua1 rupture occurred at the period the cIinica1 diagnosis. Selection of Patients. These patients reprepatient first experienced a severe attack of sciatica, the average period between this episent a seIected group. Each was so severeIy sode and the foIIow-up visit was five years. afflicted with Iow back pain and root radiation In most cases the decision to Treatment. that admission to the hospita1 for observation avoid surgery and treat the patient nonand treatment was recommended. IndividuaIs AmericanJournal of Surgery,Volume88, December, 19~4 933 tbe University
T
Ruptured
Lumbar
operativeIy was made because the patient showed an encouraging response to bedrest, and a further tria1 of such therapy seemed indicated. In the remaining, the patient refused surgery. Each patient was treated with a period of bedrest from one to three weeks and then was discharged with a back support which was worn for a varying period of time. PhysicaI therapy was seldom empIoyed. Each patient was instructed to limit his activities during the period of earIy treatment.
acterized principaIIy by pain occurring in an episodic manner. Thirty per cent of the patients showed atrophy of more than I cm., whiIe ten per cent showed changes in reflexes. Some patients had foIlow-up fiIms for comparison with those taken at the time of their hospitaIization, but no correIation couId be made between the changes encountered and the residua1 symptoms. It was also impossibIe to relate the size of the original myeIographic defect or the residual oi1 left after myeIography with the cIinica1 state of the patient. Capacity for Work. The degree of residua1 disabiIity may be evaluated aIso by determining how many individuaIs were abIe to resume their former types of work. Six of eIeven Iaborers (55 per cent) returned to Iaboring work. Of those engaged in a non-Iaboring capacity g4 per cent returned to their former work. Two individuaIs faiIed to return to any form of occupation. One such patient is sixtynine years of age and retired, whiIe the other is restricted by pain brought on by any exertion.
RESULTS
Pain-free. In this group are patients who have had no recurrence of either back pain or radicuIar pain. In spite of their apparent compIete recovery, many stiI1 favor their back and refuse to engage in strenuous pursuits. Seventeen patients (47 per cent) are in this group. One patient in this group has been pain-free for eight years foIIowing his myeIogram; the average foIIow-up period in this group is four years. Mild Residual Pain. In this category are patients who have miId backache or Ieg pain of a recurrent nature. They have reported no episodes of pain Severe enough to require Ioss of time from work or the care of a physician. In most instances they resort to a brace for reIief of symptoms. Eleven patients (31 per cent) are in this group. The average foIIow-up period for these patients was five years. Back pain aIone was noted in seven; four of these patients compIained of occasional duI1 pain in the back and Ieg. Severe Residual Pain. This group consists of individuaIs who have suffered severe pain intermittentIy or continuousIy in the spine or in combination with limb pain. This group aIso incIudes patients who have constant pain of a Iess severe nature not occurring in acute episodes. Eight patients (22 per cent) are cIassified in this group. The average foIIow-up period since myeIography is five years. ClinicaZ Findings
and Roentgenograms.
Discs
COMMENTS
In 1948 a simiIar survey was published and eIeven of the patients reviewed in this report were incIuded in the earIier study. Of this number seven remained unchanged, three were improved over their former status and one patient regressed. The resuIts in the present series, in which there is a Ionger foIIow-up, are better than those in the previous series. In 1948 twenty-eight patients were studied of whom 2g per cent were pain-free, 39 per cent suffered miId residua1 pain and 32 per cent were totaIIy dissatisfied with their results. In the present series 47 per cent were pain-free, 31 per cent had residua1 pain and 22 per cent had severe pain. The resuIts of conservative therapy reported by other authors in the treatment of dispIaced Iumbar discs show considerabIe Shinners and Hamby’O reviewed variation. cases with a history suggestive of a protruded disc and treated non-operativeIy, on the basis of a questionnaire. They found 30 per cent we11 and 70 per cent having some form of pain. HaIf of these patients had recurrent attacks of back and Ieg pain. The resuIts of operative therapy of ruptured Iumbar discs as reported by many authors seem to substantiate each other within certain limits. About 60 per cent are pain-free, 40 per cent showing some residua1 pain and approxi-
Each
of the twenty-seven patients reporting for foIIow-up had a compIete orthopedic examination, which in most instances was negative. This is UnderstandabIe as an individual subjected to examination during a remission of his disease wouId be expected to present few findings. This fact underIines the subjective nature of this or any report in a Iesion char934
Ruptured
Lumbar Discs patients with positive myelograms. J. Bone CY >oint Surg., 31A: 614-617, 1949. 1. DUNNING. H. S. Proenosis of so-calIed sciatic neuritis. Arch. Neuru~. Ed Psycbiat., 55: 573-577,
mateIy IO per cent of the Iatter figure are unimproved. It would appear from this study that individuaIs having a ruptured Iumbar disc with severe back pain associated with radicular findings and often with a background of many previous attacks will, in a substantia1 proportion of cases, have a fuII remission of symptoms over a period of years and return to their previous empIoyment without surgica1 recourse. The difficuIty confronting the surgeon is the selection of cases for operative and non-operative care. Most authors use as their criteria for operation the failure of conservative therapy or the deveIopment of increasing neurotogic signs or symptoms. Such standards, however, offer much Iatitude in interpretation. The duration of a conservative trial, the degree of cIinica1 improvement anticipated and what constitutes adequate conservative therapy are variousIy interpreted. It is beIieved that a series such as is reported herein may heIp crystaIIize this facet of the disc probIem.
1946. 4. GRANT, F. C., AUSTIN, G., FRIEDENBERG,Z. B. and HANSEN, A. A correIation of neurologic, orthopedic and roentgenographic findings in disptaced intervertebra discs. Surg., Gynec. & Obst., 87: 561-568, 1948. ,in. HERSCH. C. Studies on the mechanics of low back pain. kta orthop. Scandinav., 20: 261-274, 195 I. 6. KIRSTEIN, L. An after-examination of operated and non-operated cases with clinical symptoms of herniated discs. Acta med. Scandinav., 120: 93-106, 1945. 7. KUHNS, J. G. Conservative treatment of sciatic pain in Iow back disability. J. Bone 0 Joint Surg., 23: 435-447. 1941. 8. MIXTER, W. J. and BARR, J. S. Rupture of the intervertebra disc with involvement of the spinal canaL New England J. Med., 21 I: 210-215, 1934. g. NACHLAS, W. 1. and SIMPSON, J. E. End rest& study of the treatment of herniated nucleus pulposus by excision with fusion and without fusion. J. Bone Ed Joint Surg., 34A: 98x988, 1952. IO. SHINNERS, B. M. and HAMBY, W. B. Protruded lumbar intervertebral disc. J. Neurosurg., 6: 450-457. 1949. I 1. WHITE. J. C. and PETERSON. T. H. Lumbar herniation of intervertebral discs. Occup. Med., I: r45-150, 1946.
REFERENCES I. BENGT, S.
On
the
biology
of
nucteus
puIposus.
Acta chop. Scandinav., 20: 257-274, 195 I. 2. COLONNA. P. C. and FRIEDENBERG. Z. B. The disc syndrome. Results of the conservative care of
935