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Vol. 21. Issue 2.
Pages 108-117 (January 2010)
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Vol. 21. Issue 2.
Pages 108-117 (January 2010)
Regresión espontánea de hernias discales intervertebrales. A propósito de una serie de 37 casos
Spontaneous regression from intervertebral disc herniation. Propos of a series of 37 cases
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J.V. Martínez-Quiñones
Corresponding author
jvmartinez@maz.es

Correspondencia: C/María de Oviedo 1; portal 1°, 7° B. 50008-Zaragoza.
, J. Aso-Escario, F. Consolini, R. Arregui-Calvo
Servicio de Neurocirugía. Hospital MAZ. Zaragoza
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Resumen
Introducción

La enfermedad discal intervertebral (EDI) es uno de los trastornos musculoesqueléticos más comunes, que induce tanto una elevada proporción de discapacidad laboral como un gran coste sanitario. Dentro de la EDI cabría considerar dos modalidades, la enfermedad discal de origen degenerativo (EDD) y la de origen traumático (hernias discales traumáticas - HDT). Con respecto a las HDT no se ha podido determinar, a día de hoy, qué pacientes son susceptibles de mejorar espontáneamente y cuales lo harán si se someten a tratamiento quirúrgico. Algunos estudios han determinado, que hasta el 85% de los pacientes con una hernia discal lumbar aguda y hasta el 90% con una hernia discal cervical aguda, mejorarán en el plazo medio de 6 semanas.

Material y método

Durante el bienio 2006–2007, realizamos un estudio observacional, prospectivo en 858 pacientes diagnosticados clínica y radiológicamente de HDT, que no cumplimentaban los criterios de una cirugía urgente -síndrome de la cola de caballo, déficit motor progresivo/grave, o dolor incoercible-. Un grupo de pacientes evolucionaron de forma progresiva a la remisión espontánea de la clínica que motivara su asistencia médica. Se solicitó, en aquellos pacientes que así lo aceptaron, un nuevo estudio de neuroimagen.

Resultados

. Se ha apreciado una regresión espontánea de la herniación en 33 casos a nivel lumbar (29 varones y 4 mujeres), en 3 casos a nivel cervical (1 varón y 2 mujeres) y en 1 caso a nivel dorsal (1 varón).

Discusión

. Se lleva acabo una revisión de otras series publicadas y se analizan los distintos factores que pueden intervenir en la regresión espontánea de las mismas: a) el realojo del disco herniado en el espacio intervertebral; b) la desaparición del fragmento herniado por mecanismos de deshidratación y retracción; c) la progresiva resorción del tejido herniado por fagocitosis y degradación enzimática inducida por una reacción inflamatoria provocada por el material discal al actuar como cuerpo extraño, y d) la pulsión del líquido céfalo-raquídeo.

Conclusiones

. Consideramos que el mejor tratamiento es el que descansa en la decisión emanada de una adecuada relación médico-paciente, debiéndose buscar un equilibrio entre el tratamiento conservador a toda costa, que superaría el tiempo estimado a partir del cual el resultado quirúrgico no resultaría satisfactorio y el quirúrgico de entrada, salvo situaciones de necesidad obligada como la existencia de un síndrome de la cola de caballo, un déficit motor grave o un dolor intratable.

Palabras clave:
Hernia de disco
Regresión espontánea
Historia natural
Abreviaturas:
DI
EDD
EDI
HD
HDT
RM
Summary
Introduction

. The intervertebral disc disease (IDD) is one of the most common muscle-skeletic disorders, causing both high work disability and elevated healthcare costs. There are two specific origins of disk disease that should be kept in mind: degenerative (DDD) and traumatic (TDD). Concerning the TDD, nowadays it has not been determined which patients could gradually improve and which ones will requiere surgery. Some studies indicate that about 85% of lumbar and 90% cervical acute disc herniation will get better in an average of 6 weeks.

Materials and methods

. We conducted an observational, prospective study, over a group of 858 patients, with the following inclusion criteria: 1. MRI imaging indicating TDD, 2. No signs or symptons requiring urgent surgical treatment (cauda equina syndrome, progressive or serious motor deficit or unbearable pain) and 3. Development of progressively spontaneous symptoms remission.

All of the patients included in our study were treated in our Department of Neurosurgery from 2006 to 2007. Patients were tested for disc herniation regression with a second MRI study.

Results

A spontaneous regression of their hernia was appreciated as follow: 33 cases of lumbar hernia (29 male, 4 female), 3 cervical hernia (1 male, 2 female) and 1 dorsal hernia (male).

Discussion

Research about other reported series was done, and the different factors that could take place in disc spontaneous regression were analyzed: a) lodgement of the herniated disc back into the intervertebral space; b) disappearance of the herniated fragment due to dehydration and retraction mechanisms; c) gradual resorption of the herniated tissue by phagocytosis and enzymatic degradation induced by an inflammatory reaction that appeared as the disc (acting the extrusion itself as an foreign body) and, d) pulsion of cephalorhachidian liquid againts the herniated portion.

Conclusions

Disc herniation can regress, or even disappear, in a number of patients, rendering the radiological findings not to be taken as the only surgical indication criterium. We consider that the best treatment is the one relying on a good doctor-patient relationship, sustented in a balance between conservative and surgical treatment. According to clinical data, the first one (conservative) should not exceed the estimated time beyond which the surgical result would be insatisfactory. The seconde one (operative), excepting “need-tooperate” situations (such as cauda equina compression, progressive or serious motor déficit, or unbearable pain), should be prudently supedited to MRI regresión control, in particular in patients in which a clinical improvement is observed. Thus, the disc herniation conservative healing, both clinical as radiological, do exist, being a concept to widespread among clinicians and patients also.

Key words:
Intervertebral disc
Spontaneous regression
Natural history

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