Journal of Korean Society of Spine Surgery Loss of Disc Height after Spontaneous Regression of a Herniated Lumbar Disc - A Case Report - Hyoung Bok Kim, M.D., Hoon-Jae Chung, M.D. J Korean Soc Spine Surg 2018 Dec;25(4):175-179. Originally published online December 31, 2018; https://doi.org/10.4184/jkss.2018.25.4.175 Korean Society of Spine Surgery Asan Medical Center 88, Olympic-ro 43 Gil, Songpa-gu, Seoul, 05505, Korea Tel: +82-2-483-3413 Fax: +82-2-483-3414 Copyright 2017 Korean Society of Spine Surgery pissn 2093-4378 eissn 2093-4386 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.krspine.org/doix.php?id=10.4184/jkss.2018.25.4.175 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. www.krspine.org
Case Report J Korean Soc Spine Surg. 2018 Dec;25(4):175-179. https://doi.org/10.4184/jkss.2018.25.4.175 Loss of Disc Height after Spontaneous Regression of a Herniated Lumbar Disc - A Case Report - Hyoung Bok Kim, M.D., Hoon-Jae Chung, M.D. Department of Orthopedic Surgery, Bumin Hospital, Seoul, Korea Study Design: Case report. Objectives: We report 3 cases of loss of disc height after spontaneous regression of a herniated lumbar disc. Summary of Literature Review: Reports of spontaneous regression of a herniated lumbar disc were identified. Materials and Methods: We conservatively treated 3 patients who were diagnosed with a herniated lumbar disc. During outpatient follow-up, radiating pain improved in all patients, but they complained of chronic lower back pain. Magnetic resonance imaging (MRI) was performed for diagnostic purposes. Results: On MRI, spontaneous regression of the herniated lumbar discs was observed, but loss of disc height was also found. Conclusions: A herniated lumbar disc may be a risk factor for loss of disc height. It is important to recognize that a patient with a herniated lumbar disc can struggle with chronic lower back pain even if spontaneous regression of the herniated lumbar disc occurs. Key Words: Spontaneous regression, Herniated lumbar disc, Loss of disc height 요통과하지방사통을일으키는요추추간판탈출증은전체인구의 20~30% 에서발생하는흔한질환이다. 1) 1934년 Mixter 와 Barr가요추추간판탈출증에대한수술적처치를확립한이후과거에는이질환에대한대표적인치료법으로추간판절제술을시행하였지만, 수술적처치없이요추간판탈출증에의한요통과하지방사통이자연적으로호전되는경우가보고되었다. 2) 1984년 Guinto 등 3) 이 CT 영상을통해처음으로탈출된추간판이자연적으로소실되는것을보고한이후, 이같은현상에대한수많은증례가발표되었고, 이는추간판탈출증에대해보존적치료를시행하는근거가되고있다. 4) 본논문은요추추간판탈출증환자를추시하여, 탈출된요추추간판은자연적으로소실되었으나, 추간판간격이현저히감소된증례를문헌고찰과함께보고자한다. 나타났다. 신경학적이상소견은관찰되지않았다. 지속되는통증의원인을밝히기위해 MRI를시행하였고, 요추제 4-5번부위에서탈출된추간판이관찰되었다 (Fig. 1A). 환자에게보존적치료와수술적치료에대해설명하였고, 환자가보존적치료를원하여진통제와물리치료를유지하기로하였다. 2주뒤외래에내원하여증상이 VAS 8점에서 4점으로호전되어보존적치료를유지하기로하였다. 처음내원후 2개월뒤 VAS 2점으로증상호전되어, 경과추시를하기로하였다. 2년뒤본원외래에허리통증으로다시내원하였으며, 다시시행한 MRI 상탈출된추간판의자연소실이관찰되었으나, 추간판간격의감소및종판의 modic 변화가관찰되었다 (Fig. 1B). 증례보고 증례 1 38세여자환자는 3주전시작된 VAS 8점의우측하지방사통을주소로타병원에서물리치료를포함하는보존적치료를시행하였으나증상호전이없어본원외래내원하였다. 신체검사상우측하지방사통은요추 5번의신경피부분절부위에통증을호소하였으며, 하지직거상검사는 20도에서양성반응이 Received: September 16, 2018 Revised: October 18, 2018 Accepted: November 8, 2018 Published Online: December 31, 2018 Corresponding author: Hyoung Bok Kim, M.D. ORCID ID: Hyoung Bok Kim: https://orcid.org/0000-0001-6798-6386 Department of Orthopaedic Surgery, Bumin Hospital, 389, Gonghang-daero, Gangseo-gu, Seoul, 07590, Korea TEL: +82-2-2620-0003, FAX: +82-2-2620-0100 E-mail: esshappy@daum.net Copyright 2018 Korean Society of Spine Surgery Journal of Korean Society of Spine Surgery. www.krspine.org. pissn 2093-4378 eissn 2093-4386 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 175
Hyoung Bok Kim et al Volume 25 Number 4 December 31 2018 A Fig. 1. Magnetic resonance imaging (MRI) findings. (A) Initial MRI, showing a large area of disc extrusion at the L4/5 disc space. (B) MRI taken 2 years after the initial MRI, showing spontaneous regression of the herniated lumbar disc and loss of disc height. 증례 2 35 세여자환자는 1 개월전시작된 VAS 8 점의우측하지방사 통을주소로본원에내원하였다. 신체검사상우측하지방사통 은요추 5 번의신경피부분절부위에통증을호소하였으며, 하 지직거상검사는 30 도에서양성반응이나타났다. 신경학적검 사상우측무지신전이근력검사상 5 점만점중 4 점으로감소된 소견외에다른이상소견은관찰되지않았다. 시행한 MRI 영 상상요추제 4-5 번부위에중심부로탈출된요추추간판이관 찰되었다 (Fig. 2A). 2 달간진통제와물리치료를시행하였으며, 이전에관찰되었던방사통이호전되어, 외래추시하기로하였 다. 초기증상발생후 3 년뒤본원외래다시내원하였으며, 이 전에있었던방사통은호전되었으나, VAS 2 점의만성요통이 지속되어 MRI 를시행하였다. 이전에관찰되었던탈출된추간 판은자연소실되었으나, 추간판간격의감소및종판의 modic 변화가관찰되었다 (Fig. 2B). 증례 3 44 세남자환자는 2 주전시작된 VAS 8 점의우측하지방사 통을주소로본원에내원하였다. 신체검사상우측하지방사통 은요추 4 번의신경피부분절부위에통증을호소하였으며, 하 지직거상검사는음성반응이나타났다. 신경학적검사상우측 족관절의신전이근력검사상 5 점만점중 4 점으로감소된소견 외에다른이상소견은관찰되지않았다. 본원에서시행한 MRI B A Fig. 2. Magnetic resonance imaging (MRI) findings. (A) Initial MRI, showing a large area of disc extrusion at the L4/5 disc space. (B) MRI taken 3 years after the initial MRI, showing spontaneous regression of the herniated lumbar disc and loss of disc height. A Fig. 3. Magnetic resonance imaging (MRI) findings. (A) Initial MRI, showing a large area of disc extrusion at the L4/5 foraminal area. (B) MRI taken 2 years after the initial MRI, showing spontaneous regression of the herniated lumbar disc and loss of disc height. 영상상요추제 4-5 번부위에우측추간공부위로탈출되어상 방으로이동한추간판이관찰되었다 (Fig. 3A). 6 주간신경차단 B B 176 www.krspine.org
Journal of Korean Society of Spine Surgery Loss of Disc Height 술, 약물치료및물리치료를유지하였으며, 처음내원시관찰되었던우측하지의방사통은호전되어, 외래추시하기로하였다. 이후 2년뒤방사통은호전되었으나, VAS 3점의만성적인요통이관찰되어 MRI를시행하였고, 이전에관찰되었던탈출된추간판은자연소실되었으나, 추간판간격의감소가관찰되었다 (Fig. 3B). 본논문은본원 IRB 승인 (201809-BM-002) 을받은이후진행되었다. 고찰 지난수년간탈출된추간판의자연소실에대한여러기전이보고되었으나, 아직추간판자연소실에대한정확한기전은알려지지않고있다. 5) 문헌고찰을해보면세가지의가설이인지도가높다. 첫번째가설은탈출된추간판이건강한후종인대에의해다시추간판공간으로되돌아간다는것이고, 6) 두번째가설은점차적인탈수와수축에의해서추간판의크기가작아진다는것이다. 7) 마지막가설은추간판탈출에의해면역반응과혈관신생이일어나이로인해연골조직의 phagocytosis 와 enzymatic degradation 이일어난다는것이다. 8) 이중최근에가장주목을받는자연소실에대한가설은면역반응과혈관신생에의해추간판조직이흡수되어자연소실된다는것이며, 이는 Gadoliium enhanced MRI 상 Rim enhancement 가관찰되는것으로미뤄짐작할수있어, 9) 이런환자들에초기치료로보존적치료를권유할수있겠다. 본증례보고에서도수술적처치를시행하지않고, 보존적치료만을통해서방사통이호전되었으며 MRI 상탈출된추간판의자연소실이관찰되었다. 적절한기간의보존적치료에도불구하고지속되는통증이있거나, 신경학적증상이발생한경우수술적처치를고려해볼수있다. 수술이요추추간판탈출증증상의극적인회복에도움이될수있지만, 수술후실패혹은합병증의발생율이 5~10% 로보고되고있다. 추간판제거술로인해추간판간격의감소, Modic 변화가수술후추간판내의퇴행성변화를가속화시켜요통을발생시킬수있다는보고가있다. 10) 그러나, 본증례에서는수술적처치를하지않았음에도불구하고, 추간판간격의감소및 Modic 변화로인해환자에게만성요통이발생한것을관찰할수있었다. 이를보면위에서설명한건강한후종인대에의해다시탈출된추간판이추간판공간으로되돌아간다는가설은설득력이떨어질수있다고할수있으며, 수술적처치와같은침습적인치료를하지않더라도, 요추추간판탈출증이발생한환자에서는추간판내퇴행성변화가가속될수있음을짐작할수있다. 요추추간판탈출증의치료에있어서보존적치료가탈출된추간판의자연소실을기대할수있는효과적인치료법이라할지라도, 요추추간판탈출증자체를추간판간격의소실과함께 modic 변화를발생시킬수있는위험인자로인식하는것이필요할것으로생각된다. 요추추간판탈출증에대해보존적치료를받는환자에게탈출된요추추간판이자연소실될수있다는설명뿐아니라, 추간판내퇴행성변화로인해만성요통이발생할수있음을외래추시시설명하는것이필요하다고생각한다. 하지만, 요추추간판탈출증의어떤인자가추간판의퇴행성변화에관여하는지에대해서는추가적인연구가필요할것으로생각된다. REFERENCES 1. Boden SD, McCowin PR, Davis DO, et al. Abnormal magnetic-resonance scans of the cervical spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990 Sep;72(8):1178-84. DOI: 10.2106/00004623-199072080-00008. 2. Sabuncuoglu H, Ozdogan S, Timurkaynak E. Spontaneous regression of extruded lumbar disc herniation: report of two illustrative case and review of the literature. Turk Neurosurg. 2008 Oct;18(4):392-6. 3. Guinto FC, Jr., Hashim H, Stumer M. CT demonstration of disk regression after conservative therapy. AJNR Am J Neuroradiol. 1984 Sep-Oct;5(5):632-3. 4. Benoist M. The natural history of lumbar disc herniation and radiculopathy. Joint Bone Spine. 2002 Mar;69(2):155-60. DOI: 10.1016/S1297-319X(02)00385-8. 5. Komori H, Shinomiya K, Nakai O, et al. The natural history of herniated nucleus pulposus with radiculopathy. Spine (Phila Pa 1976). 1996 Jan;21(2):225-9. DOI: 10.1097/00007632-199601150-00013. 6. Teplick JG, Haskin ME. Spontaneous regression of herniated nucleus pulposus. AJR Am J Roentgenol. 1985 Aug;145(2):371-5. DOI: 10.2214/ajr.145.2.371. 7. Slavin KV, Raja A, Thornton J, et al. Spontaneous regression of a large lumbar disc herniation : report of an illustrative case. Surg Neurol. 2001 Nov;56(5):333-6. DOI: 10.1016/S0090-3019(01)00607-3. 8. Henmi T, Sairyo K, Nakano S, et al. Natural history of extruded lumbar intervertebral disc herniation. J Med Invest. 2002 Feb;49(1-2):40-3. www.krspine.org 177
Hyoung Bok Kim et al Volume 25 Number 4 December 31 2018 9. Autio RA, Karppinen J, Niinimäki J, et al. Determinants of spontaneous resorption of intervertebral disc herniations. Spine (Phila Pa 1976). 2006 May;31(11):1247-52. DOI: 10.1097/01.brs.0000217681.83524.4a. 10. Barth M, Diepers M, Weiss C, et al. Two-year outcome after lumbar microdiscectomy versus microscopic sequestrectomy: part 2: radiographic evaluation and correlation with clinical outcome. Spine (Phila Pa 1976). 2008 Feb;33(3):273-9. DOI: 10.1097/BRS.0b013e31816201a6. 178 www.krspine.org
Case Report J Korean Soc Spine Surg. 2018 Dec;25(4):175-179. https://doi.org/10.4184/jkss.2018.25.4.179 탈출된요추추간판자연소실후발생한추간판간격감소 - 증례보고 - 김형복 정훈재서울부민병원정형외과연구계획 : 증례보고목적 : 탈출된요추추간판이자연소실된이후추간판간격이감소된증례를보고하고자한다. 선행문헌의요약 : 보존적치료를통한탈출된요추추간판의자연소실이보고되었다. 대상및방법 : 요추추간판탈출증으로진단된 3명의환자를외래추시를통해보존적치료를시행하였다. 내원당시에관찰되었던방사통은호전되었으나, 만성적인요통을호소하였다. 원인파악을위해 MRI 촬영을다시시행하였다. 결과 : 보존적치료로탈출된요추추간판이자연소실되었지만, 추간판간격의현저한감소가관찰되었다. 결론 : 요추추간판탈출증이추간판간격감소의위험요인중하나일수있다. 요추추간판탈출증을진단받은환자의경우탈출된요추추간판이자연소실되더라도만성요통이발생할수있음을인지하는것이중요하다. 색인단어 : 자연소실, 요추추간판탈출증, 추간판간격감소 약칭제목 : 추간판간격감소 접수일 : 2018년 9월 16일 수정일 : 2018년 10월 18일 게재확정일 : 2018년 11월 8일 교신저자 : 김형복 서울특별시강서구공항대로 389 서울부민병원정형외과 TEL: 02-2620-0003 FAX: 02-2620-0100 E-mail: esshappy@daum.net Copyright 2018 Korean Society of Spine Surgery Journal of Korean Society of Spine Surgery. www.krspine.org. pissn 2093-4378 eissn 2093-4386 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 179