CONSERVATIVE MANAGEMENT OF ACUTE LUMBAR DISC HERNIATION WITH ASSOCIATED RADICULOPATHY: A STUDY

Objective: Acute disc herniation (DH) is a common cause of low back pain (LBP). It ranks fifth in the category of diseases in terms of cost of hospital care. It has higher indirect costs due to absenteeism from work and disability than any other disease. The present study was performed to assess the clinical outcomes of non-surgically treated LBP patients after 6 months of follow-up.
Methods: The present study was prospective study which was performed on 450 lumbar radicular patients visiting the neurosurgery outpatient department having clinical signs and symptoms of acute lumbar DH of less than 3 month duration. Their diagnosis was confirmed by magnetic resonance imaging. The patients were treated conservatively during 6 months. Pain and disability were assessed by visual analog scale (VAS) and Oswestry disability questionnaire, respectively.
Results: About 135 (30%) female and 315 (70%) male participated in the study. During the follow-up period, 27 (06%) patients (21 male and 6 female) showed poor response to conservative treatment and motor weakness and underwent surgical intervention. A significant improvement in the VAS Score was seen after 6 months of conservative treatment than initial evaluation of patients (3.12±1.84, 7.1±1.43, p=0.00). Furthermore, significant improvement in disability score of patients was seen in follow-up period (25.82±16.92, 53.66±17.66; p=0.00).
Conclusion: Results of our study showed that conservative treatment in patients of acute lumbar DH have significant improvement in pain relief and disability without any notable side effect.


INTRODUCTION
Low back pain (LBP) is a common-condition in younger than 50 years of age. The economic burden of lumbar-spine disorders is heavy [1]. It ranks fifth in the category of diseases in terms of cost of hospital care. It has higher indirect costs due to absenteeism from work and disability than any other disease [2]. LBP due to acute lumbar disc herniation (DH) is common disorder at the ages of 40-50 year. Main symptom being radiating pain in the area of the leg typically served by one nerve root in the lumbar or sacral spine [1,2]. Several treatment modalities including surgical and conservative are being applied for these patients. Cauda equina syndrome is the single absolute indication for surgery in a LBP patient [3][4][5]. Maximum patients of acute DH improved with conservative treatment such as bed rest, life style modification, medication, back support, exercise, manipulation, and physical therapy [6,7].
Different studies have reported that conservative treatment with nonsteroidal anti-inflammatory drug (NSAID) cause pain relief in patients with DH. The same studies showed that oral steroid did not have useful impacts on acute lumbar DH [8,9]. Some study used muscle relaxant in acute LBP [9]. Patients who were non responsive to conservative treatment or had contraindications for surgery epidural injection was tried [9][10][11][12]. The present study was performed to assess the clinical outcomes of nonsurgically treated LBP patients after 6 months of follow-up.

METHODS
The present study was prospective study which was performed on 450 lumbar radicular patients visiting the Neurosurgery outpatient department having clinical signs and symptoms of acute lumbar DH of <3 months duration who were confirmed by magnetic resonance imaging (MRI). All these patients were offered surgery and conservative management. Only those patients who were unwilling for surgery and opted for conservative management were included in this study. These patients were on regular follow-up at Neurosurgery clinic of Command Hospital Lucknow.

Study samples
Consecutive sampling of patients was done. Consent both verbal and written was obtained from all patients. All patients were assessed by neurologic and lumbar movement examination, detection of muscle force and straight leg raising test (SLR). MRI was done for all patients and if they had DH, they were included in this study. Patients with degenerative or spinal canal stenosis, tumor, trauma, infection, spondylolysthesis or signs and symptoms of neurologic deficit were excluded from the present study.

Study design
All patients were visited by neurosurgeon; and MRI imaging studies were used for diagnosis confirmation. An independent research physician verified symptoms and signs of selected patients at the time of enrollment. Patients with acute lumbar DH were included. Clinical evaluations was performed by SLR test, muscle strength, reflexes (Patellar and Achilles), sensory changes, the Oswestry Disability Questionnaire (ODQ), 100-mm visual-analogue scale initially and after following for 6 months.

Study period
A prospective study was conducted for 24 months from April 2019 to March 2021.

Conservative treatment
After initial evaluation of each patient conservative treatments such as life style modification, bed rest, drug therapy with NSAIDs, muscle relaxant, triyclic antidepressants, and physiotherapy were prescribed.

Statistical analysis
Mann-Whitney and Wilcoxon test were used to analyze study data using SPSS software 14.0. Significant difference between study variables was detected using Two-tailed significance level of 0.05.

RESULTS
About 135 (30%) female and 315 (70%) male included in the study. 252 patients (56%) had disc extrusion (DE) and 198 (44%) patients had DH. The most affected level in patients with DE and DH was L4-L5 (Table 1). A significant improvement in the visual analog scale (VAS) Score was seen after 6 months of conservative treatment than initial evaluation of patients (3.12±1.84, 7.1±1.43, p=0.00) ( Mean of SLR degree in study patients after 6 months follow-up significantly improves in comparison with initial evaluation (68.22±15.67, 43±11.93; p=0.00). In initial evaluation DE patients had no significant difference in mean of SLR degree as compared to DH patients (41.25±10.05, 43.40±13.92; p=0.66) and same was also seen after 6 months of follow-up (67.91±14.36, 68.57±17.40; p=0.88). Oswestry Disability Score mean had significant difference between patients of two groups in initially (p=0.032). VAS and SLR degree mean did not show a significant difference in patients with surgical and conservative treatment.

DISCUSSION
In the present study, all the patients were followed up for 6 months. Only 27 patients required surgical intervention as they were unresponsive to conservative treatment and showed progressive muscle weakness. The severity of pain as measured by VAS was one of the patient outcome predictor significantly improved after 6 months conservative treatment than initial evaluation. Peul et al. in their study evaluated surgery versus prolonged conservative treatment for sciatica for a period of 1 year, they reported that pain relief was achieved in 1 st -26 th week of conservative treatment [12]. The present study also demonstrated that the clinical outcome in patients with acute lumbar DH who were treated conservatively was similar to those who were treated surgically after 6 month of follow-up. However, the patient who had early surgery their recovery rate and pain relief was faster. Ahn et al. reported that VAS and Oswestry Disability scoring showed a greater change in the sequestrated group than other group. Patients can be treated successfully by conservative treatment and outcomes in central extruded DH patients were as good as sequestered DH [13]. Owlia et al. in their study on lumbar radicular pain found that pain relief was achieved in 75% of all the patients when treated conservatively with epidural injection after 1 month of follow-up [14]. Pearson et al. in their study found that discectomy had better results in improvement of back pain than conservative treatment and this difference was maintained for 2 years [15].
Oswestry Disability Score in our study improved significantly with conservative treatment in 6 month follow-up period. In initial evaluation significant difference between mean of Oswestry Disability Score in two types of herniation (DE and DH) was seen. However, this significant difference wasn't seen after 6 months follow-up. Ahn et al. and Weinstein et al. in their studies have shown significant improvement in the Oswestry Disability Score in patients with acute lumbar DH on conservative treatment [13,16]. Masui et al. performed their study on 21 lumbar disk herniation patients who were treated non-surgically and were followed for a minimum of 7 years. They investigated patients' clinical outcomes at the initial, 2-year follow-up. MRI study showed that clinical outcome did not depend on the size of herniation or the grade of degeneration of the intervertebral disc in the minimum 7 year follow-up [17].
Mean of SLR degree after 6 months follow-up significantly improved than initial evaluation. Mean of Oswestry Disability Score had significant difference between patients of conservative treatment and surgery treatment. Despite small number of studied cases and rather short period of follow-up, this study is in concordance with the similar studies.
Limitations of the present study are, firstly randomization of samples was not done in our study. Secondly, we assessed the pain and disability by VAS and ODQ s in our patients, other methods may show different results. The favorable outcomes associated with the conservative management in DHs should be further confirmed in controlled trials.

CONCLUSION
According to the results of our study, conservative treatment in patients with acute lumbar DH causes significant pain relief and disability improvement without any notable side effects. Conservative management with proper patient selection can reduce risk of inappropriate surgery in patients with lumbar DH. There is no relationship between clinical outcome at the end of 6 months of conservative treatment and type of DH in the initial evaluation. About 94% of patient with conservative treatment clinical improvement was seen. Oswestry Disability Score can be a good prognostication indicator for future surgery operations.

ACKNOWLEDGMENT
The authors would like to thank the Department of Radiodiagnosis and Imaging, Command Hospital, Lucknow and all the team members who supported while preparing this article.

AUTHORS' CONTRIBUTIONS
All the cases presented in the current study were clinically evaluated by Ashok Kumar and TJ Rappai. Ashok Kumar, Neerav Porwal,