Metastatic Lung Cancer Presenting During the Treatment Interval of an Acute Lumbar Disc Herniation: A Case Report.

Abstract

Nonoperative management is the mainstay of treatment for acute lumbar disc herniation1,2. Studies have shown that, over the course of six to twelve weeks, the majority of radicular symptoms caused by an acute lumbar disc herniation will resolve spontaneously. Long-term data suggest that nonoperative treatment yields results that are equivalent or nearly equivalent to those of operative treatment without the risks of an operation3-7. In a minority of patients, the symptoms fail to resolve with these nonoperative measures, prompting operative management. Patients with lumbar disc herniation and concomitant secondary-gain issues, such as Workers’ Compensation, tend to have poorer surgical outcomes8 than patients without concomitant secondary-gain issues. The regression of herniated lumbar disc material over time is well documented9-11. Numerous hypotheses have been proposed for the mechanism by which this regression occurs: retraction by posterior longitudinal ligament tension, dehydration, disc degeneration, resorption by macrophage phagocytosis, and immunologic reaction12-16. Evidence of this regression on follow-up magnetic resonance imaging (MRI) is evident as early as six months from the time of the initial imaging study, with continued regression occurring for up to seven years17. Regression on imaging studies correlates with, but lags behind, clinical improvement18. As a result, most practitioners do not routinely perform repeat imaging of patients with MRI-documented disc herniation who have had an unsuccessful course of nonoperative management prior to disc surgery, unless the symptoms have lasted for more than six months. There are no current recommendations for a repeat MRI when a patient has persistent symptoms9-11. On the basis of the available literature, a repeat MRI within six months from the time of initial evaluation would be unnecessary and resisted in most scenarios. In …