Disc herniation: treatments process

Abstracts

A hérnia de disco é um processo em que ocorre a ruptura do anel fibroso, com subsequente deslocamento da massa central do disco nos espaços intervertebrais. É considerada uma patologia extremamente comum, que causa séria inabilidade em seus portadores. Estima-se que 2 a 3 % da população sejam acometidos desse processo, cuja prevalência é de 4,8% em homens e 2,5% em mulheres, acima de 35 anos. São fatores de risco, causas ambientais, posturais, desequilíbrios musculares e possivelmente, a influência genética. A terapia conservadora tem sido a preferida como a primeira escolha de tratamento, cujos objetivos são o alívio da dor, o aumento da capacidade funcional e o retardamento da progressão da doença. Nesta revisão, são abordadas as principais metodologias, de acordo com a literatura, dando ênfase ao uso de fármacos analgésicos e anti-inflamatórios, o uso de órteses, a acupuntura, o repouso e a adoção de um programa de exercícios adequados.

hérnia de disco; lombociatalgia; tratamentos

ARTIGO DE REVISÃO

Disc herniation: treatments process

Wilson Fábio Negrelli

Ortopedista e Traumatologista, Rua Otávio Tarquínio de Souza, 1046 - Campo Belo, São Paulo, SP - Brasil, CEP 04613-003

SUMMARY

The disc herniation is a process where the fibrous ring disrupts, with subsequent central disc mass dislocation. It is considered a extremely common pathology, which causes disability. It is estimated that 2 to 3% of the population have taken with this process whose prevalence is 4.8% in males and 2.5% in female, over 35 years old. Environmental causes, posture, muscular imbalance and possibly genetic influence have been considered as risk factors. The conservative therapy has been preferred as the first choice treatment, aiming pain relief, increase of functional capacity and avoidment of disease progression. In this review, it is approached the main methodologies, according to the literature, focusing on drugs prescriptions, orthesis indication, acupunture, rest and a suitable exercise program.

Key Words: disc herniation; low back pain, treatments

INTRODUCTION

Disc herniation is a frequent musculo-skeletal disorder responsible for low back pain. This expression is commonly used to describe a process where the fibrous ring disrupts, with subsequent central disc mass dislocation (Barros et al., 1995)⁷. The problems arising from that affection have been the most frequent reasons concerning work dismissal and disability compensation claims (Atlas et al., 2000)⁴.

This process occurs usually in patients between 30-50 years old, although it can be found in elderly people, teenagers and rarely in children (Garrido, 1993; Mayer et al., 1996; Obukhov et al., 1996; Bortolleto et al., 1998)^27;45;47;16 . The disc herniation is considered a common, serious disabling and non-fatal pathology and therefore a health problem worldwide (Long et al., 1996)³⁷. It has been estimated that 2 to 3 % of the entire population have taken with this process whose prevalence is 4.8% in males and 2.5% in female, over 35 years old. The mean age for the first attack is 37 years old approximately and 76% from all cases have a preceding low back crisis, 10 years before (Bell et al., 1984; Della-Giustina, 1999)^11;21.

A number of environmental risk factors have been suggested, such as lifting, driving and smoking besides the aging natural process (Urban & Roberts, 1995)⁵⁸. Nevertheless, in a retrospective study carried on by Battie et al.(1995b)¹⁰ these factors showed a modest effect which reinforced the ethiological theory for disc herniation based on genetic influences (Varlotta et al.,1991; Scarpinelli, 1993; Matsui et al.,1992; Battie et al., 1995 a;b; Urban & Roberts, 1995; Matsui et al.,1998; Sambrook et al, 1999)^{59;52;43;9;58;44;51}.

There are other indicative contribution to confirm the genetic inheritance as a important component in the ethiopathogenesis of disc herniation. Recently, a lot of effort has been undertaken aiming the identification of genes that play a relevant role in the development and evolution of this pathology (Battie et al., 1995 a)⁹. Amongst them, it seems to participate the vitamin D receptor gene, VDR (Jones et al., 1998; Videman et al., 1998)^31;60, the gene that codifies for one of polipeptidic collagen chain, COL9A2 (Annunen et al., 1999)³ and the human aggregan gene, a major component of articular cartilage and supports the biomechanical function of this tissue (Doege et al., 1997; Horton et al., 1998; Kawaguchi et al.,1999)^23;30;33.

The pain that characterizes disc herniation is caused by disc herniation and degeneration and by spinal canal stenosis, as well (Magnaes, 1999)⁴⁰. However, they are not on their own responsible for the process, therefore it has to be account for the mechanical compression and the inflammatory changes around the disc and the nerve root (Cortet & Bourgeois, 1992)²⁰.

The musculo-skeletal disorders are one of the commonest condition where the patient seeks after relief (Borenstein, 1993; Bullock et al.,1999)^14;18 and the western medicine offers the conservative treatment as the first choice in the majority of cases (Deyo, 1983; Bell & Rothman, 1984; Revel, 1994; Komori et al., 1996;1998; Zentner et al., 1997)^{22;11;500;35;34;69}, although the treatment option relies an open question still (Herno et al., 1996)²⁸. Three are the objectives of the conservative treatment, i.e., the pain relief, the function capacity improvement and the disease progress delay (Borenstein, 1997)¹⁵.

The conservative treatment meaning is to impose to the patient relative or complete low back immobilization associated with different auxiliary methodologies such as belts and corsets, manipulation, physical activities program, traction, criotherapy, pain killer prescription and acupunture.

In 1956, after studying different features of conservative method, Söderberg affirmed that the real therapeutically value of this treatment is the absolute rest in conjunction with corset use. Afterwards, this assumption was correlated by Armnstrong in 1965 that postulated different degrees for immobilization, ranging from relative to rigorous rest where the patient is forbidden to sit aiming to avoid movements that can generate dorsal tension (Ref. em Kakelius, 1970)³².

Besides those data, there is sufficient information electing this practice as a safe method leading good results, once the horizontal position relieves the radiated pain in a lot of patients (Palazzo & Kahn, 1992; Christensen et al., 1993; Weber, 1994; Zentner et al., 1997)^48;19;65;69.

Despite the rest indication it has to be point out that there is no conclusive results concerning its benefits. The rest length has to be just sufficient to provide reduction of the inflammatory process (Vroomen et al., 1999)⁶², according to the side effects arose from the inability. Therefore, one week after rest onset it has to be set the mobility return (Ernst & Fialka, 1993a)²⁴. The corset and belt indication is recommended as a partial inability in specific pain due to its uncertain utility (Ernst & Fialka, 1993b)²⁵.

The manipulation is faced with caution once there is no improvement demonstration regarding disease shortening or morbidity reduction neither (Young et al., 1997)⁶⁸. The manipulation mechanism action is not well understood, however current theories propose that pain is due to a unbalanced muscle activity that manipulation can relieve through a reflexive action (Fiechtner & Brodeur, 2000)²⁶. Although it remain doubts around the adoption of manipulation as a auxiliary therapy, its indication is accepted before deciding for the surgery (Bergmann & Jongeward, 1998)¹².

The principle and benefit of appropriate physical activities are well known and usually the patient motivation for it is better during or two or three weeks after the inability period. If any recurrence occurs the program must be discontinued to be reinitiated after the remission symptoms. The physical program should include flexibility and stretching exercises with gradual increase in its execution (AAOS, 1996; Ulreich & Kullich, 1999)^1;57. The therapy effect does not seem to be due to the physical inability reversion but to a central effect involving a perception adjustment regarding inability and pain (Mannion et al., 1999)⁴².

Concerning the traction application there is no conclusive result focused on pain relief, spine mobility or neurological signs. However, the self-traction, where the patient executes the traction by itself has shown more suitable results compared to the rest and corset employment.

The criotherapy seems to have some effect on muscular spasm, once the ice-elicited vasoconstriction reduces hyperemia, promoting a reflexive compensatory peripheral vasodilatation. The heat is a physical auxiliary approach in the treatment of pain as well and it can be superficial, applied through heating bag or with the employment of short waves and ultra sound. Nevertheless, it has to be aware concerning burns caused by local anesthesia and hypo-anesthesia. The use of deep heat is refuted in patients with tumors, metallic implants, in pregnant women, children, in infection process and gonad organs.

Regarding pain killer prescription, they are necessary once the rapid relief of peripheral pain is able to prevent the evolution to the chronic status, besides being an adjuvant to maintain the patient in rest (Ernst & Fialka, 1993b)²⁵. The muscle relaxants are prescribed and they are useful for patients with severe paravertebral muscle spasm. The morphine and related drugs should be avoided, although its usefulness in very severe symptoms. They can be replaced by psychoactive drugs that are indicatives for patients presenting chronic pain complicated by an anxious and depressive component. The anesthetic drugs has shown good results, as well (Medrick- Goldberg et al., 1999)⁴⁶.

The disc herniation is a neuropathic pain syndrome caused by spinal root compression or inflammation and its treatment demands the prescription of non- hormonal anti-inflammatory drugs at the first instance

(Viton et al., 1998; Bratton, 1999)^64;17. When this prescription is not well succeeded it can be replaced by the hormone ones. On the other hand, the epidural steroid application and the peripheral radicular infiltration are recommended by some researchers, despite the conflicting literature data (Hopayian & Mugford, 1999)²⁹.

The acupuncture has been presenting good results and its benefit is related with neurological signal that inhibit or excite the synapses (Yamamura et al., 1995)⁶⁷, providing significant symptoms enhancement in a short period of time (Bullock et al., 1999)¹⁸. In according of that, there is a suggestion to inquire more about this method (Longworth & Mc Carthy, 1997)³⁸. Other alternative proposal of conservative treatment has emerged, despite the lack of scientific research which generates a slow improvement of this area of expertise. The clinic trial execution is difficult due to the extreme ability, honesty and neutral performance of the researcher.

A lot of drawbacks must be solved having in mind as a ultimate goal to carry on the research in the most adequate way, in order to generate dependable information. For instance, it can be cited how to select homogeneous material, how to perceive the morphological and pathological conditions, how to register the pain and how to effectuate the acceptable protocols concerning the match among the individuals belonging to the study (Bessette et al., 1996)¹³. At the same time, the knowledge of psycho-social conditions are fundamental, seeking for the participants cooperation in order to better execute the research and to elucidate the results (Waddell, 1992; Bach, 1998)^63;6.

The ethical aspect regarding intentionally placebo use has to be considered, since its effect will be involved in the treatment of the patients, whether approved or not.

The surgery practice is another available option for the disc herniation treatment, although its indication occurs when the natural course of the disease worsens after the employment of non- aggressive measures. The exact point when it can be concluded that the conservative treatment failed is controversial and it varies from one individual to another, depending on the symptoms severity, the social and economic circumstances of the patients and on the relationship between the patient and the physician as well (Schiltenwolf, 1999)⁵³. This point detection is considered a challenge for the knowledge and experience of the medical profession. In cases that are not clear, it has to do further investigations, such as the spine fluid protein content and the fibrinolitic activity to clarify and conduct to a better decision. Definitive surgery indication are the cauda equina syndrome, unbearable pain and progressive muscle weakening. In other cases, the indication is relative and depends essentially on the duration of symptoms; the vertebral foramen or canal stenosis and the quality or severity of symptoms. The motor or sensorial deficit do not account for surgery because the chances of recovery are similar either applying the conservative or surgical treatment as well.

There are no much data comparing the efficacy between conservative and surgical treatments. One of the reason is due to the lack of study standardization regarding patient samples, experimental design and criteria patterns that can measure the results. The appropriated patient selection and the combination of a clear affected nerve root diagnosis allied with a correspondent pathologic findings as well seem to be the most important condition leading to the surgery success (Magnaes, 1999)⁴⁰. Patients who demonstrate good expectation at the surgery option moment present a more rapid recovery (Lutz et al., 1999)³⁹, reason why the surgery has to be decided both for the patient and the physician.

Amongst the comparative studies performed, Kakelius (1970)³² followed up patients treated in a conservative and surgical way during 7 years and 4 month. At the first beginning, the best results were encountered among the patients that underwent surgery, however 6 months later no significant difference was observed between both groups. Those data suggest a transitory condition for disc herniation and the solution is independent of the applied methodology. Similar results were found by Weber (1983)⁶⁴ that showed a significant recovery after one year in patients that underwent surgery. Nevertheless, this significance becomes similar comparing to conservative treatment after 4 years and no difference was observed after 10 years.

The benefits confront between conservative and surgical treatment was approached in a prospective study conducted by Atlas et al.(1996)⁵. Although the symptoms overlap between conservative and surgical treatment, the patient treated by the last method reported significant enhancement after one year. However, effects concerning compensatory employment and work were similar in both groups. No difference was observed among patients that underwent surgery and those presenting mild symptoms treated in a conservative way.

Overall, the comparative studies keep unaltered the conservative treatment efficacy (Zentner et al. 1997; Simotas et al., 2000)^69;54, besides it can be extended over 8 weeks, due to denoted patient progressive recovery. This decision places the conservative treatment as an allied in the surgery postponement. Therefore, the surgery has to be considered when the conservative treatment does not demonstrate efficacy anymore (Kurth et al., 1996; Postacchini, 1996; Stevens et al., 1997)^36;49;56.

Complete disc herniation absorption data (Basile et al., 1993; Song et al., 1999)^8;55 reinforce the indication of conservative treatment. At the same time, there are positive results (Ahn et al., 2000)² of conservative treatment concerning decrease in size of transligamentous herniations (posterior longitudinal ligament).

Nowadays, facing the new scenario involving health insurance plan, all the high cost elective surgery has to be revised, being the disc herniation surgery a proper example of that (Stevens et al., 1997)⁵⁶. According to Malter & Weinstein (1996)⁴¹ the study results from cost-benefit are inconsistent, although if the long term benefit are considered, the surgery does not demonstrate to be more effective than the conservative treatment.

The variety of expert opinions and the lack of a systematic methodology hamper the development of reliable clinical guides to be used promptly. There is also the need of elaborating standardized protocols in order to quantify, to compare and to summarize different expert judgements about the best treatment to be adopted (Wietlisbach et al., 1999)⁶⁶.

REFERÊNCIAS

Trabalho recebido em 06/06/2000. Aprovado em 20/11/2000

• 1. AAOS. American Academy of Orthopaedic Surgeons. Public Information. 1996.
• 2. Ahn, S. H.; Ahn, M. W.; Byun, W. M. Effect of transligamentous extension of lumbar disc herniations on their regression and the clinical outcome of sciatica. Spine, 25 (4): 475-480, 2000.
• 3. Annunen, S., Paassilta, P., Lohiniva, J., Perala, M., Pihlayamaa, T., Karppinen, J., Tervonen, O., Kroger, H., Lahde, S., Vanharanta, H., Ryhanen, L., Goring, H.H., Ott, J., Prockop, D.J., Ala-Kokko, L. An allele of COL9A2 associated with intervertebral disc disease. Science 285: 409-412, 1999.
• 4. Atlas, S.J., Chang, Y., Kammann, E., Keller, R.B., Deyo, R.A., Singer, D.E. Long term disability and return to work among patients who have a herniated lumbar disc: the effect of disability compensation. J Bone Joint Surg Am 82: 4-15, 2000.
• 5. Atlas, S.J., Deyo, R.A., Keller, R.B., Chapin, A.M., Patrick, D.L., Long, J.M., Singer, D.E. The main lumbar spine study, part II. 1-year outcomes of surgical and non-surgical management of sciatica. Spine 21:1777-1786, 1996.
• 6. Bach, M. Psychosomatic aspects of chronic low back pain. Anathesiol Intensivmed Notfallmed Schmerzther 33: 802-806, 1998.
• 7. Barros Fş, T. & Basile Jr., R. Coluna vertebral. Diagnóstico e Tatamento das Principais Patologias. Sarvier Editora, São Paulo, 1995, p.59-75.
• 8. Basile Jr.,R.; Rosemberg, L.; Barros Fş, T. & Bonetti, C. Absorção da hérnia do núcleo pulposo lombar. Acta Ortop. Bras1:127-130, 1993.
• 9. Battie, M.C., Haynor, D.R., Fisher, L.D., Gill, K., Gibbons, L.E., Videman, T. Similarities in degenerative findings on magnetic resonance images of the lumbar spines of identical twins. J Bone Joint Surg Am 77: 1662-1670, 1995 a .
• 10. Battie, M.C., Videman, T., Gibbons, L.E., Fisher, L.D., Manninen, H., Gill, K. 1995 Volvo Award in Clinical Sciences. Determinants of lumbar disc degeneration. A study relating lifetime exposures and magnetic resonance findings in identical twins. Spine 20: 2601-2612, 1995b.
• 11. Bell, G. & Rothman, R. The conservative treatment of sciatica. Spine9: 54-56, 1984.
• 12. Bergmann, T. F. & Jongeward, B. V. Manipulative therapy in lower back pain with leg pain and neurologic deficit. J Manipulative Physiol Ther 21: 288-294, 1998.
• 13. Bessette, L., Liang, M. H., Lew, R. A ., Weinstein, J. N. Classics in spine. Surgery literature revisited. Spine 21: 259-263, 1996.
• 14. Borenstein, D. G. Medical therapy of low back pain. Orthop Rev 22: 20-25, 1993.
• 15. Borenstein, D. G. A clinician's approach to acute low back pain. Am J Med 102: 16S- 22S, 1997.
• 16. Bortoletto, A.; Prata, S. & Bonfim dos Santos, G. Hérnia discal em crianças e adolescentes: relato de cinco casos. Rev. Bras. Orto 33: 811-814, 1998.
• 17. Bratton, R. L. Assessment and management of acute low back pain. Am Fam Physician 60: 2299-2308, 1999.
• 18. Bullock, M.L., Pheley. A .M., Lenz, S.K., Culliton, P.D. Short-term outcomes of treatment for musculo-skeletal disorders in a hospital-based alternative and complementary medicine clinic. J Altern Complement Med 5: 253-260, 1999.
• 19. Christensen, T.H.; Bhiddal, H.; Hansen, S. E.; Jensen, H.; Jensen, R. & Bay, H. Severe low-back pain. Scand J. Rheumatol. 22: 25-29, 1993.
• 20. Cortet, B. & Bourgeois, P. Causes and mechanisms of sciatica pains. Ver Prat 42: 539-543, 1992.
• 21. Della- Giustina, D. A. Emergency department evaluation and treatment of back pain. Emerg Med Clin North Am 17: 877-893, 1999.
• 22. Deyo, R. Conservative therapy for low back pain. JAMA 250: 1057-1062, 1983.
• 23. Doege, K.J., Coulter, S. N., Meek, L. M., Maslen, K., Wood, J. G. A human-specific polymorphism in the codon region of the aggrecan gene. J Biol Chem 272: 13974-13979, 1997.
• 24. Ernst, E., Fialka, V. Conservative therapy of low back pain. Part 1: Immobilization. Fortschr Med 111: 311-312, 1993a.
• 25. Ernst, E., Fialka, V. Conservative therapy of low back pain. Part 2: Drug therapy of low back pain. Fortschr Med 111: 329-331, 1993b.
• 26. Fiechtner, J. J. & Brodeur, R. R. Manual and manipulation techniques for rheumatic disease. Rheum Dis Clin North Am 26: 83-96, 2000.
• 27. Garrido, E. Lumbar disc herniation in the pediatric patient. Neurosurg Clin N Am 4:149-152, 1993.
• 28. Herno, A ., Airaksinen, O ., Saari, T., Luukkonen, M. Lumbar spinal stenosis: a matched-pair study of operated and non-operated patients. Br J Neurosurg 10: 461-465, 1996.
• 29. Hopayian, K., Mygford, M. Conflicting conclusions from two systematic reviews of epidural injections for sciatica : which evidence should general practitioners heed? Br J Gen Pract 49: 57-61, 1999.
• 30. Horton, W. E., Lethbridge-Cejku, M., Hochberg, M. C., Balakir, R., Precht, P., Tobin, J. D., Meek, L., Doege, K. An association between an aggrecan gene polymorphic allele and bilateral hand osteoarthritis in elderly white men: data from the Baltimore Longitudinal Study of Aging (BLSA). Osteoarthritis Cartilage 6: 245-251, 1998.
• 31. Jones, G., White, C., Sambrook, P., Eisman, J. Allelic variation in the vitamin D receptor, lifestyle factors and lumbar spinal degenerative disease. Ann Rheum Dis 57: 94-99, 1998.
• 32. Kakelius, A. Prognosis in sciatica. A clinical follow-up of surgical and non-surgical treatment. Acta Orthopaedica Scandinavica, Suppl. 129, 1970, 76p.
• 33. Kawaguchi, Y., Osada, R., Kanamori, M., Ishihara, H., Ohmori, K., Matsui, H., Kimura, T. Association between an aggrecan gene polymorphism and lumbar disc degeneration. Spine 24: 2456-2460, 1999.
• 34. Komori, H., Otaiva, A; Haro, H. & Shinomiya, K. Contrast-enhanced magnetic resonance imaging in conservative management of lumbar disc herniation. Spine 23: 67-73, 1998.
• 35. Komori, H.; Shinomiya, K.; Nakai, O.; Yamaura, I. & Furuya, K. The natural history of herniated nucleus pulposus with radiculopathy. Spine 21: 225-229, 1996.
• 36. Kurth, A . A ., Rau, S., Wang, C., Schmitt, E. Treatment of lumbar disc herniation in the second decade of life. Eur Spine J 5: 220-224, 1996.
• 37. Long, D. M., BenDebba, M., Torgerson, W.S, Boyd, R.J., Dawson, E.G., Hardy, R.W., Robertson, J.T., Sypert, G.W., Watts, C. Persistent back pain and sciatica in the United States: patient characteristics. J Spinal Disord 9: 40-58, 1996.
• 38. Longworth, W., Mc Carthy, P. W. A review of research on acupunture for the treatment of lumbar disk protrusions and associated neurological symptomatology. J Altern Complement Med 3: 55-76, 1997.
• 39. Lutz, G.K., Butzlaff, M.E., Atlas, S.J., Keller, R.B., Singer, D.E., Deyo, R.A. The relation between expectations and outcomes in surgery for sciatica. J Gen Intern Med 14: 740-744, 1999.
• 40. Magnaes, B. Surgical treatment of low back pain. Tidsskr Nor Laegeforen 119: 1773-1777, 1999.
• 41. Malter, A.D., Weintein, J. Cost-effectiveness of lumbar discectomy. Spine 21: 69S-74S, 1996.
• 42. Mannion, A . F., Muntener, M. Taimela, S., Dvorak, J. A randomized clinical trial of three active therapies for chronic low back pain. Spine 24: 2435-2438, 1999.
• 43. Matsui, H, Terahata, N., Tsuji, H., Hirano, N., Naruse, Y. Familial predisposition and clustering for juvenile lumbar disc herniation. Spine 17: 1323-1328, 1992.
• 44. Matsui, H., Kanamori, M., Ishihara, H., Yudoh, K. Naruse, Y. Isuji, H. Familial predisposition for lumbar degenerative disc disease. Spine 23: 1029-1034, 1998.
• 45. Mayer, H.M., Mellerowicz, H., Dihlmann, S.W. Endoscopic discectomy in pediatric and juvenile lumbar disc herniations. J Pediatr Orthop B 5: 39-43, 1996.
• 46. Medrick-Goldberg, T., Lifschitz, D., Pud, D., Adler, R., Eisenberg, E. Intravenous lidocaine, amantadine, and placebo in the treatment of sciatica: a double-blind, randomized, controlled study. Reg Anesth Pain Med 24: 534-540, 1999.
• 47. Obukhov, S.K., Hankenson, L., Manka, M., Mawk, J.R. Multilevel lumbar disc herniation in 12-year old twins. Childs Nerv Syst 12: 169-171, 1996.
• 48. Palazzo, E. & Kahn, M. F. Traitements non chirurgique des sciatiques discales. Rev. Prat. 42: 573-578, 1992.
• 49. Postacchini, F. Results of surgery compared with conservative management for lumbar disc herniations. Spine 21: 1383-1387, 1996.
• 50. Revel, M. Current therapeutic options in sciatica caused by disc herniation. Ver Med Interne 15: 135-143, 1994.
• 51. Sambrook, P.N., Mac Gregor, A .J., Spector, T. D. Genetic influences on cervical and lumbar disc degeneration : a magnetic resonance imaging study in twins. Arthritis Rheum 42: 366-372, 1999.
• 52. Scarpinelli, R. Lumbar disc herniation in eight siblings with a possible family history for disc disease. Acta Orthop Belg 59: 371-376, 1993.
• 53. Schiltenwolf, M. Aspects of conservative pain therapy. Orthopade 28: 966-974, 1999.
• 54. Simotas. A . C., Dorey, F. J., Hansraj, K. K., Cammisa, FJr. Nonoperative treatment for lumbar spinal stenosis. Clinical and outcome results and a 3-year survivorship analysis. Spine 25: 197-203, 2000.
• 55. Song, J. H.; Park, H. K.; Shin, K. M. Spontaneous regression of a herniated cervical disc in a patient with myelopathy. Case report. J. Neurosurg, 90 (1): 138-140, 1999.
• 56. Stevens, C.D., Dubois, R.W., Larequi- Lauber, T., Vader, J.P. Efficacy of lumbar discectomy and percutaneous treatments for lumbar disc herniation. Soz Praventivmed 42: 367-379, 1997.
• 57. Ulreich, A ., Kullich, W. No title. Wien Med Wochenschr 149: 564- 566, 1999.
• 58. Urban, J.P., Roberts, S. Development and degeneration of the inter-vertebral discs. Mol Med Today 1: 329-335, 1995.
• 59. Varlotta, G.P., Brown, M.D., Kelsey, J.L., Golden, A .L. Familial predisposition for herniation of a lumbar disc in patients who are less than twenty-one years old. J Bone Joint Surg Am 73: 124-128,1991.
• 60. Videman, T., Leppavuori, J., Kaprio, J., Battie, M.C., Gibbons, L.E., Peltonen, L., Koskenvuo, M. Intragenic polymorphisms of the vitamin D receptor gene associated with inter-vertebral disc degeneration. Spine 23: 2477-2485, 1998.
• 61. Viton, J. M., Rubino, T., Peretti- Viton, P, Bouvenot, G., Delarque, A . Short-term evaluation of periradicular corticosteroid injections in the treatment of lumbar radiculopathy associated with disc disease. Ver Rhum Engl Ed 65: 195-200, 1998.
• 62. Vroomen, P.C., de Krom, M.C., Wilmink, J.T., Kester, A .D., Knottnerus, J.A . Lack of effectiveness of bed rest for sciatica. N. Engl J Med 340: 418-423, 1999.
• 63. Waddell, G. Biopsychosocial analysis of low back pain. Baillieres Clin Rheumatol 6: 523-557, 1992.
• 64. Weber, H. Lumbar disc Herniation. A controlled, prospective study with ten years of observation. Spine 9: 131-140, 1983.
• 65. Weber, H. The natural history of disc herniation and the influence of intervention. Spine 19: 2234-2238, 1994.
• 66. Wietlisbach, V. Vader, J.P., Porchet, F., Costanza, M.C., Burnand, B. Statistical approaches in the development of clinical practice guidelines from expert panels: the case of laminectomy in sciatica patients. Med Care 37: 785-797, 1999.
• 67. Yamamura, Y.; Cricenti, S., Tabosa, A & Puertas, D. Importância da inervação micro e macroscópica da coluna lombar para o tratamento, pela acupuntura, das lombalgias. Acta Ortopédica Brasileira 3: 155-160, 1995.
• 68. Young, J. L., Press, J. M., Herring, S. A . The disc at risk in athletes: perspectives on operative and non-operative care. Med Sci Sports Exerc 29: 222-232, 1997.
• 69. Zentner, J.; Scheneider, B. & Schramm, J. Efficacy of conservative treatment of lumbar disc herniation. Journal of Neurosurgical Sciences 41: 263-268, 1997.

Publication Dates

• Publication in this collection
  13 Oct 2005
• Date of issue
  Dec 2001

History

• Accepted
  20 Nov 2000
• Received
  06 June 2000