Spontaneous Disappearance of Lumbar Disk Herniation Within 3 Months

Abstract

Although spontaneous regression of disk herniation is a well-known phenomenon, the time taken for the condition to resolve has not been detailed in previous studies.

This article describes a case of vanishing lumbar disk herniation in a 33-year-old man. The patient experienced sudden severe lumbar pain while lifting a 240-kg weight while attempting a Donkey Calf Raise during muscle training. The pain persisted despite the use of a lumbar corset and nonsteroidal anti-inflammatory drugs. Twelve days after onset, sensory disturbance appeared in the right L5 dermatome, and a manual muscle test of the right anterior tibial muscle revealed level 3. The pain gradually spread over the right lower extremity and the indistinct lumbago changed to localized back pain at the L4/5 vertebral level. Magnetic resonance imaging (MRI) of the lumbar spine 12 days after onset revealed a large disk herniation at L4/5. T2-weighted images demonstrated the herniated disk with a sequestrated disk fragment, which compressed the right L5 nerve root. Over the following month, his pain gradually diminished and he was able to resume his muscle-building program. Follow-up MRI 3 months after the lumbar injury showed complete disappearance of the extruded disk material. This is the first reported case of disk herniation that disappeared within only 3 months, as previous reports have reported that a minimum 30-week period was needed. Clinical awareness of the possibility that disk herniation may resolve within a relatively short time may aid both correct informed consent and treatment.

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Although spontaneous regression of disk herniation is a well-known phenomenon, the time taken for the condition to resolve has not been detailed in previous studies. This article presents a case of vanishing lumbar disk herniation in a 33-year-old man. Clinical awareness of the possibility that disk herniation may resolve within a relatively short time may aid both correct informed consent and treatment.

Case Report

A 33-year-old man experienced sudden severe lumbar pain while lifting a 240-kg weight while attempting a Donkey Calf Raise during muscle training. He had a muscular physique and had been weight training regularly twice a week.

Because of this severe lumbago, he was unable to stand up and had difficulty sleeping. The pain persisted despite the use of a lumbar corset and nonsteroidal anti-inflammatory drugs. Twelve days after onset, sensory disturbance appeared in the right L5 dermatome, and a manual muscle test of the right anterior tibial muscle revealed level 3. The pain gradually spread over the right lower extremity and the indistinct lumbago changed to localized back pain at the L4/5 vertebral level.

Magnetic resonance imaging of the lumbar spine 12 days after onset revealed a large disk herniation at L4/5. T2-weighted images demonstrated the herniated disk with a sequestrated disk fragment (Figure A), which compressed the right L5 nerve root.

Surgery was recommended for removal of the herniated disk but the patient declined with the belief that the symptoms would eventually resolve spontaneously. Over the following month, his pain gradually diminished and he was able to resume his muscle-building program.

Follow-up MRI 3 months after the lumbar injury showed complete disappearance of the extruded disk material (Figure B).

Figure: MRIs at the time of injury (A) and showing spontaneous regression of the disk herniation after only 3 months (B).

Discussion

Spontaneous regression of a herniated lumbar disk was first reported by Guinto et al¹ in 1983. With the increased availability of MRI, several orthopedic specialists have reported this phenomenon at the cervical or lumbar level.

Although spontaneous regression of disk herniation is gradually becoming recognized by orthopedic surgeons and neurosurgeons, it is still a relatively unknown phenomenon to internists and general surgeons who may sometimes encounter patients with back pain. Surprisingly, the herniated disk in the present patient was found to disappear spontaneously and completely in only 3 months. This may be the fastest complete regression of a herniated lumbar disk reported thus far, as previous reports have reported that a minimum of at least 30 weeks was needed.^2-5

Previous studies examining the mechanism and factors affecting the resorption of herniated disk have evaluated the natural history of changes in disk morphology such as size and shape, and also the magnetic resonance signal intensity. Although the exact mechanism underlying this process remains unclear, a number of hypotheses have been proposed, including retraction due to posterior longitudinal ligament tension, dehydration, disk degeneration, resorption by macrophage phagocytosis, and immunological reaction.^6-10

Some researchers have also investigated the correlation with clinical outcome. Komori et al¹¹ reported that morphological changes basically corresponded to clinical outcome and that the further the herniated nucleus pulposus migrated, the greater the observed decrease in size.

Our literature review revealed that several authors have reported spontaneous regression of herniated disks, but few investigated their rate of disappearance. As a rule, nonsurgical care can be considered as an option for the treatment of patients with lumbar disk herniation, especially patients with large and extruded disks. For neurosurgeons who encounter patients with lumbago, it is useful to know that spontaneous regression can occur in a short period.

References

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Authors

Dr Nozawa (Satoshi) is from the Department of Orthopedic Surgery, Gifu Municipal Hospital, Dr Nozawa (Asae) is from the Department of Radiology, Gifu Prefectural General Medical Center, Gifu, Dr Kojima is from the Department of Orthopedic Surgery, Kojima Clinic, Kyoto, and Dr Shimizu is from the Department of Orthopedic Surgery, Gifu University, Gifu, Japan.

Drs Nozawa (Satoshi), Nozawa (Asae), Kojima, and Shimizu have no relevant financial relationships to disclose.

Correspondence should be addressed to: Satoshi Nozawa, MD, PhD, Department of Orthopedic Surgery, Gifu Municipal Hospital, 7-1 Shikano-cho Gifu city, Gifu, 500-8513, Japan (noza@tim.hi-ho.ne.jp).

doi: 10.3928/01477447-20090922-21