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The Results of Nonoperative Treatment of Ruptured Lumbar Disks
The Results of Nonoperative Treatment of Ruptured Lumbar Disks Z. B. FRIEDENBERG, M.D., F.A.C.S.*
RECENT investigations have made it clear that the pathology of the lumbar intervertebral disk is far more complicated than originally conceived.l, 6 It is inadequate to think only in terms of a ruptured or a nonruptured disk. The disk structure is subject to both physiologic and pathologic degeneration, the clinical evidences of which are poorly understood. As long as the nucleus pulposus maintains its fluid consistency and the annulus fibrosus is intact, pressure is distributed evenly in all directions according to hydrostatic principles. Progressive changes occur in the nucleus beginning at an early age, morphologic alterations as well as a gradual decrease in the fluid content having been noted. This decomposition of the nucleus is a continual process in all intervertebral disks, particularly in the lumbar area. There is a gradual decrease in the cellular elements with loss of mucoid material and replacement by collagen fibers, and these changes alter the pressure stresses and may predispose to disk protrusion. Narrowed disks with osteophytosis and changes in vertebral body alignment often seen on roentgenograms may be related to disk degeneration independent of gross rupture and root preS5Ure. Many of the diagnoses made in patients with acute or chronic back pain are not easily subjected to laboratory, roentgenographic or pathologic verification. Such diagnoses as chronic lumbosacral or postural strain, myositis or osteoarthrosis should be re-examined in the light of the varied and progressive changes that occur in the movable weightbearing elements of the spinal axis, the intervertebral spaces. The concepts of treatment of the various stages of disk rupture or
From the Department of Orthopaedic Surgery, Hospital of University of Pennsylvania, Philadelphia.
* Associate, University of Pennsylvania School of Medicine; Attending Staff, University of Pennsylvania and Presbyterian Hospitals, Philadelphia; Consultant, Chester County Hospital, West Chester, Pa. 1545
1546
Z. B. Friedenberg
degeneration also are in need of clarification. This clinic will consider only the simpler aspect of this problem, disk rupture with root pressure. When rupture of the intervertebral disk was first described by Mixter and Barr, the therapeutic emphasis was on operative removal of the offending mass. S It was a common observation, however, that many patients with clinical evidence of a protruded disk responded to nonoperative treatment. The conservative treatment of disk rupture is accepted generally for patients suffering mild symptoms. The use of conservative therapy in those patients with intense pain in the back and leg of a prolonged or recurrent nature and with a definite diagnosis of disk rupture is of greater interest. This study is an attempt to find out how much relief patients with definite lumbar disk protrusions causing severe pain and disability experienced over a long follow-up period. Some of the patients reported in tre series were reviewed in 1949. 2 In order to eliminate as many patients as possible whose diagnoses might be subject to question, it was decided to include only those patients who were hospitalized for severe back and radicular pain. Each patient presented a history strongly suggestive of disk protrusion and on physical examination showed supportive evidence. In addition, routine roentgenograms of the lumbar spine revealed no evidence of any abnormalities sufficient to account for the symptoms, and in each case an oil myelogram was done which indicated a filling defect typical of disk protrusion. The conservative or non operative therapy of disk rupture is based on the relief of symptoms and improvement in physical findings noted following a period of recumbency. Most of tl~~se patients had leg or pelvic traction applied during their hospital stay and were discharged with a back support and instructions to restrict their activities for several months. It is not known whether the relief experienced by such patients is due to movement of the offending disk mass in relation to the nerve root or whether it is a result of subsidence of edema and other superimposed inflammatory changes in the region of the displaced disk. Most of the patients were re-examined, and a few replied to a questionnaire. The average period between the hospital stay and the follow-up examination was four years. The longest follow-up period was ten years, and all patients who were followed less than two years were excluded. In order to evaluate results each patient was placed in one of three categories. A patient was placed in group one if he had experienced no further episodes of root or back pain of any magnitude. Such patients are working and lose no time from work because of their disk ailment. They are well satisfied with their status, although they may on occasions experience mild backache. Many favor their back and avoid strenuous activity.
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Group two consists of patients who suffer occasional backache or radicular pain or both. At intervals this is sufficiently severe to cause them loss of working time, but they do not usually consult a physician. Between such episodes, which occur from twice a year to once every few years, they are pain-free or have occasional mild back pain. They are satisfied with their status and do not regard their complaints sufficiently disabling to consider surgery. In group three are patients who have either continuous disabling back or leg pain or are subject to frequent attacks of severe back or root pain or both. Each of these patients suffered at least one attack of back pain with root radiation of such severity that surgery was contemplated. Disk removal in most cases was decided against because the patient showed some early definite relief on bed rest. In other CMeS the patient refused surgery or presented medical complications which made conservative therapy the treatment of choice. It does not seem unreasonable to presume that many patients with frank disk ruptures may never experience symptoms of such magnitude. Thus this group of nonoperative cases represents the severe form of this malady. It would be profitable to compare these patients with a group treated by disk removal. A study of operative results in 95 cases of disk removal was published in 1949. The results of this latter study compare favorably with other published results after disk removal and will be used as a background to assess the nonoperative results." 9.10 No direct comparison of the nonoperative results with the results following disk removal and spine fusion is made. Published reports indicate a small but definite improvement in results in patients having the combined operation over those subjected to disk removal alone. 9 In group one in the nonoperative cases there were 17 patients (61 per cent) who had suffered no further disabling pain. The average time since hospitalization and myelography was four years. In the operative group 60 per cent were in this category. In group two, 9 patients (32 per cent) continued to be subjected to occasional severe pain in the nonoperative group. The average follow-up period was seven years. In the operative series 28 per cent were in this group. In group three, 2 patients (7 per cent) continued to suffer frequent disabling pain in the nonoperative group, one for a period of six years and the other for a period of two years. In the operative series 12 per cent were classified in this group. Few studies of the results of conservative therapy in the treatment of intervertebral disks have been published. In 1949 the author assisted in a similar study, but with a shorter follow-up period of 2,7 years. These patients also were selected to include only those with severe pain and myelographic corroboration. In that series 29 per cent were in group
z.
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B. Friedenberg
one, 39 per cent in group two and 32 per cent in group three. 2 Kirstein reported a group of nonoperative cases followed up for six months to three years in which the results were also poor, with 12.5 per cent of his patients pain-free. 6 Dunning studied a group of patients with a clinical diagnosis of ruptured disk not supported by myelography. He reported 54 per cent of his patients to be in a comparable state to group one in this series.3 Kuhns reported 449 cases of sciatic pain in which 79.5 per cent obtained relief by conservative means. 7 It is difficult to reconcile the wide divergenee of these figures. Unquestionably some of the difficulty lies in the size of the groups reported which lack full statistical reliability. The difficulty of establishing an accurate diagnosis even with myelography is recognized. Further~ore, the disk syndrome encompasses a wide range of pathologic changes; some patients present the full symptom complex in all its intensity, while others never attain this degree of disability. A degenerative disk may minimally bulge posteriorly through a fissured area of the annulus fibrosus, or it may bulge far into the canal under a thin, stretched annulus before it extrudes. Some tentative conclusions may, however, be drawn. CONCLUSIONS
Gross rupture of a lumbar disk may lead to recurrent episodes of disability extending over many years and frequently causes the patient to limit his activities sharply. The average time in this series between the onset of back pain and the myelogram was over five years. N onoperative treatment can result in relief of pain and prevention or amelioration of future attacks even in the long-standing, most severe forms of this disease. Since 40 per cent of patients in whom disk removal is done will suffer occasional residual or recurrent pain and becau~e many of the patients who are postoperatively pain-free restrict their activities and do not regard their back as normal, there is a definite sphere for nonoperative treatment even in patients with a recurrent history of severe backache and radicular pain. The selection of cases for operative and nonoperative care remains an interesting problem. REFERENCES 1. Bengt, S.: On the Biology of Nucleus Pulposus. Acta orthop. Scandinav., 20: 257-74, 1951. 2. Colonna, P. C., and Friedenberg, Z. B.: The Disc Syndrome. Results of the Conservative Care of Patients with Positive Myelograms. J. Bone & Joint Surg., 31A: 614-17, 1949. 3. Dunning, H. S.: Prognosis of So-Called Sciatic Neuritis. Arch. Neurol. & Psych., 55: 573-77, 1946. 4. Grant, F. C., Austin, G., Friedenberg, Z. B., and Hansen, A.: A Correlation
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of Neurologic, Orthopedic and Roentgenogra.phic Findings in Displaced Intervertebral Discs. Surg., Gynec. & Obst., 87: 561--68, 1948. 5. Hirsch, C.: Studies on the Mechanism of Low Back Pain. Acta orthop. Scandinav., 20: 261-74, 1951. 6. Kirstein, L.: An Mter-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 Low Back Disability. J. Bone & Joint Surg., 23: 43H7, 1941. 8. Mixter, W. J., and Barr, J. S.: Rupture of the Intervertebral Disc with Involvement of the Spinal Canal. New Eng. J. Med., 211: 210--15, 1934. 9. Nachlas, W. I., and Simpson, J. E.: End Result Study of the Treatment of Herniated Nucleus Pulposus by Excision with Fusion and without Fusion. J. Bone & Joint Surg., 64A: 981-88, 1952. 10. White, J. C., and Peterson, T. H.: Lumbar Herniation of Intervertebral Discs. Occup. Med., 1: 145-50, 1946. 133 South Thirty-sixth Street Philadelphia 4, Pa.
RECENT investigations have made it clear that the pathology of the lumbar intervertebral disk is far more complicated than originally conceived.l, 6 It is inadequate to think only in terms of a ruptured or a nonruptured disk. The disk structure is subject to both physiologic and pathologic degeneration, the clinical evidences of which are poorly understood. As long as the nucleus pulposus maintains its fluid consistency and the annulus fibrosus is intact, pressure is distributed evenly in all directions according to hydrostatic principles. Progressive changes occur in the nucleus beginning at an early age, morphologic alterations as well as a gradual decrease in the fluid content having been noted. This decomposition of the nucleus is a continual process in all intervertebral disks, particularly in the lumbar area. There is a gradual decrease in the cellular elements with loss of mucoid material and replacement by collagen fibers, and these changes alter the pressure stresses and may predispose to disk protrusion. Narrowed disks with osteophytosis and changes in vertebral body alignment often seen on roentgenograms may be related to disk degeneration independent of gross rupture and root preS5Ure. Many of the diagnoses made in patients with acute or chronic back pain are not easily subjected to laboratory, roentgenographic or pathologic verification. Such diagnoses as chronic lumbosacral or postural strain, myositis or osteoarthrosis should be re-examined in the light of the varied and progressive changes that occur in the movable weightbearing elements of the spinal axis, the intervertebral spaces. The concepts of treatment of the various stages of disk rupture or
From the Department of Orthopaedic Surgery, Hospital of University of Pennsylvania, Philadelphia.
* Associate, University of Pennsylvania School of Medicine; Attending Staff, University of Pennsylvania and Presbyterian Hospitals, Philadelphia; Consultant, Chester County Hospital, West Chester, Pa. 1545
1546
Z. B. Friedenberg
degeneration also are in need of clarification. This clinic will consider only the simpler aspect of this problem, disk rupture with root pressure. When rupture of the intervertebral disk was first described by Mixter and Barr, the therapeutic emphasis was on operative removal of the offending mass. S It was a common observation, however, that many patients with clinical evidence of a protruded disk responded to nonoperative treatment. The conservative treatment of disk rupture is accepted generally for patients suffering mild symptoms. The use of conservative therapy in those patients with intense pain in the back and leg of a prolonged or recurrent nature and with a definite diagnosis of disk rupture is of greater interest. This study is an attempt to find out how much relief patients with definite lumbar disk protrusions causing severe pain and disability experienced over a long follow-up period. Some of the patients reported in tre series were reviewed in 1949. 2 In order to eliminate as many patients as possible whose diagnoses might be subject to question, it was decided to include only those patients who were hospitalized for severe back and radicular pain. Each patient presented a history strongly suggestive of disk protrusion and on physical examination showed supportive evidence. In addition, routine roentgenograms of the lumbar spine revealed no evidence of any abnormalities sufficient to account for the symptoms, and in each case an oil myelogram was done which indicated a filling defect typical of disk protrusion. The conservative or non operative therapy of disk rupture is based on the relief of symptoms and improvement in physical findings noted following a period of recumbency. Most of tl~~se patients had leg or pelvic traction applied during their hospital stay and were discharged with a back support and instructions to restrict their activities for several months. It is not known whether the relief experienced by such patients is due to movement of the offending disk mass in relation to the nerve root or whether it is a result of subsidence of edema and other superimposed inflammatory changes in the region of the displaced disk. Most of the patients were re-examined, and a few replied to a questionnaire. The average period between the hospital stay and the follow-up examination was four years. The longest follow-up period was ten years, and all patients who were followed less than two years were excluded. In order to evaluate results each patient was placed in one of three categories. A patient was placed in group one if he had experienced no further episodes of root or back pain of any magnitude. Such patients are working and lose no time from work because of their disk ailment. They are well satisfied with their status, although they may on occasions experience mild backache. Many favor their back and avoid strenuous activity.
Ruptured Lumbar Disks
15J,.7
Group two consists of patients who suffer occasional backache or radicular pain or both. At intervals this is sufficiently severe to cause them loss of working time, but they do not usually consult a physician. Between such episodes, which occur from twice a year to once every few years, they are pain-free or have occasional mild back pain. They are satisfied with their status and do not regard their complaints sufficiently disabling to consider surgery. In group three are patients who have either continuous disabling back or leg pain or are subject to frequent attacks of severe back or root pain or both. Each of these patients suffered at least one attack of back pain with root radiation of such severity that surgery was contemplated. Disk removal in most cases was decided against because the patient showed some early definite relief on bed rest. In other CMeS the patient refused surgery or presented medical complications which made conservative therapy the treatment of choice. It does not seem unreasonable to presume that many patients with frank disk ruptures may never experience symptoms of such magnitude. Thus this group of nonoperative cases represents the severe form of this malady. It would be profitable to compare these patients with a group treated by disk removal. A study of operative results in 95 cases of disk removal was published in 1949. The results of this latter study compare favorably with other published results after disk removal and will be used as a background to assess the nonoperative results." 9.10 No direct comparison of the nonoperative results with the results following disk removal and spine fusion is made. Published reports indicate a small but definite improvement in results in patients having the combined operation over those subjected to disk removal alone. 9 In group one in the nonoperative cases there were 17 patients (61 per cent) who had suffered no further disabling pain. The average time since hospitalization and myelography was four years. In the operative group 60 per cent were in this category. In group two, 9 patients (32 per cent) continued to be subjected to occasional severe pain in the nonoperative group. The average follow-up period was seven years. In the operative series 28 per cent were in this group. In group three, 2 patients (7 per cent) continued to suffer frequent disabling pain in the nonoperative group, one for a period of six years and the other for a period of two years. In the operative series 12 per cent were classified in this group. Few studies of the results of conservative therapy in the treatment of intervertebral disks have been published. In 1949 the author assisted in a similar study, but with a shorter follow-up period of 2,7 years. These patients also were selected to include only those with severe pain and myelographic corroboration. In that series 29 per cent were in group
z.
1548
B. Friedenberg
one, 39 per cent in group two and 32 per cent in group three. 2 Kirstein reported a group of nonoperative cases followed up for six months to three years in which the results were also poor, with 12.5 per cent of his patients pain-free. 6 Dunning studied a group of patients with a clinical diagnosis of ruptured disk not supported by myelography. He reported 54 per cent of his patients to be in a comparable state to group one in this series.3 Kuhns reported 449 cases of sciatic pain in which 79.5 per cent obtained relief by conservative means. 7 It is difficult to reconcile the wide divergenee of these figures. Unquestionably some of the difficulty lies in the size of the groups reported which lack full statistical reliability. The difficulty of establishing an accurate diagnosis even with myelography is recognized. Further~ore, the disk syndrome encompasses a wide range of pathologic changes; some patients present the full symptom complex in all its intensity, while others never attain this degree of disability. A degenerative disk may minimally bulge posteriorly through a fissured area of the annulus fibrosus, or it may bulge far into the canal under a thin, stretched annulus before it extrudes. Some tentative conclusions may, however, be drawn. CONCLUSIONS
Gross rupture of a lumbar disk may lead to recurrent episodes of disability extending over many years and frequently causes the patient to limit his activities sharply. The average time in this series between the onset of back pain and the myelogram was over five years. N onoperative treatment can result in relief of pain and prevention or amelioration of future attacks even in the long-standing, most severe forms of this disease. Since 40 per cent of patients in whom disk removal is done will suffer occasional residual or recurrent pain and becau~e many of the patients who are postoperatively pain-free restrict their activities and do not regard their back as normal, there is a definite sphere for nonoperative treatment even in patients with a recurrent history of severe backache and radicular pain. The selection of cases for operative and nonoperative care remains an interesting problem. REFERENCES 1. Bengt, S.: On the Biology of Nucleus Pulposus. Acta orthop. Scandinav., 20: 257-74, 1951. 2. Colonna, P. C., and Friedenberg, Z. B.: The Disc Syndrome. Results of the Conservative Care of Patients with Positive Myelograms. J. Bone & Joint Surg., 31A: 614-17, 1949. 3. Dunning, H. S.: Prognosis of So-Called Sciatic Neuritis. Arch. Neurol. & Psych., 55: 573-77, 1946. 4. Grant, F. C., Austin, G., Friedenberg, Z. B., and Hansen, A.: A Correlation
Ruptured Lumbar Disks
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of Neurologic, Orthopedic and Roentgenogra.phic Findings in Displaced Intervertebral Discs. Surg., Gynec. & Obst., 87: 561--68, 1948. 5. Hirsch, C.: Studies on the Mechanism of Low Back Pain. Acta orthop. Scandinav., 20: 261-74, 1951. 6. Kirstein, L.: An Mter-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 Low Back Disability. J. Bone & Joint Surg., 23: 43H7, 1941. 8. Mixter, W. J., and Barr, J. S.: Rupture of the Intervertebral Disc with Involvement of the Spinal Canal. New Eng. J. Med., 211: 210--15, 1934. 9. Nachlas, W. I., and Simpson, J. E.: End Result Study of the Treatment of Herniated Nucleus Pulposus by Excision with Fusion and without Fusion. J. Bone & Joint Surg., 64A: 981-88, 1952. 10. White, J. C., and Peterson, T. H.: Lumbar Herniation of Intervertebral Discs. Occup. Med., 1: 145-50, 1946. 133 South Thirty-sixth Street Philadelphia 4, Pa.