INTRODUCTION
Spontaneous regression of prolapsed intervertebral discs (PIVDs) is an established, well-reported phenomenon.[1] The commonality based on location, in the decreasing order of incidence, is lumbar, cervical, and thoracic.[2,3] In 1985, Teplick and Haskin were the first to report such a phenomenon in the lumbar region, documented via computed tomography (CT) imaging.[4] Krieger and Maniker were the first to document a spontaneously regressing cervical herniated disc via a magnetic resonance imaging (MRI) technique.[5] Since then, many isolated case reports and small case series have been published to better understand this occurrence in the cervical region. Among the 76 cases (11 case reports; five case series) of regressed cervical discs reported to date, none deal with traumatic injuries.[1] To the best of our knowledge, this is the first reported case of a traumatic cervical disc showing a spontaneous regression.
CASE REPORT
We report the case of a 60-year-old hypertensive male patient, who had an alleged history of fall from an approximate height of 15 feet in March 2021. He sustained skin bruises to his upper back secondary to the impact on the ground. There were no associated injuries to the head/torso/any of the extremities. There was no loss of consciousness or Ear Nose and Throat (ENT) bleed or seizures. Furthermore, there was no history suggestive of preexisting degenerative cervical disease. The patient became quadriplegic with graded sensory loss from C5 dermatomes and below, with complete sensory loss below D4 dermatomes bilaterally. Bowel–bladder sensation and control were completely lost.
The patient was taken to a local tertiary care hospital and evaluated. CT and MRI spine imaging revealed a D4-D5 fracture-dislocation with spinal cord injury (causing physiological transaction at D4) and a C5-C6/C6-C7 herniated disc causing cord compression and injury [Figure 1]. The patient was managed conservatively with tapering steroid doses and immobilization with a cervical and a dorsal spine brace. Gradually, the power in bilateral upper limbs recovered to grade 3/5 in the initial 4 months. No recovery was noticed in the lower limb power or bowel–bladder sensation and their controls. He continued to have Foley’s urinary catheter in situ and required diapers.
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Figure 1: Magnetic resonance images of cervico-dorsal spine in sagittal (a) and axial (b and c) T2-weighted sections revealing a C5-C6 (b)/C6-C7 (c) PIVD compressing the anterior aspect of the spinal cord (with cord changes), and a D4-D5 fracture-dislocation resulting in a physiological dorsal cord transection. PIVD: Prolapsed intervertebral disc
In view of no further neurological improvements seen, the patient was brought to us in the outpatient clinic, 6 months postfall, for a second opinion. The patient was examined and found to have a posttraumatic quadriparesis (upper limbs 3/5; lower limbs 0/5) with features of complete cord transaction below D4 dermatomes. At the time, the patient also had an infected decubitus ulcer. Radiological imaging performed 6 months prior (at the time of injury) was reviewed. In view of the significant compression at the C5-C6 level with partial improvement in the upper limbs power, a possible ongoing dynamic cord injury secondary to C5-C6 PIVD was suspected. The patient was planned for an anterior cervical discectomy and fusion (ACDF) at the C5-C6 level once the decubitus ulcer was managed. Plastic surgery consultation and admission were sorted to manage the decubitus ulcer, and render it noninfectious. The patient underwent multiple surgical ulcer debridement procedures by the plastic surgery team. After a month, the patient’s pressure sore was healed. Before the patient’s transfer to the neurosurgical trauma unit, he was advised for a repeat MRI cervico-dorsal spine, which to everybody’s surprise, showed a near-complete spontaneous regression of the C5-C6 PIVD with reversal of cord changes at the said level [Figure 2]. Hence, the plan for C5-C6 ACDF was abandoned and the patient was continued on conservative management and an aggressive rehabilitation plan.
Figure 2: Follow-up magnetic resonance imaging done at 6 months interval, in sagittal (a) and axial (b and c) T2-weighted sections, showing the near complete regression of the previously seen C5-C6 (b)/C6-C7 (c) PIVD and the accompanying cord changes. Sequelae of D4-D5 fracture-dislocation and cord transection can be visualized. PIVD: Prolapsed intervertebral disc
DISCUSSION
Spontaneous regression of PIVD is an established phenomenon.[1] The general profile of cases undergoing such regression includes extruded discs with predominant radiculopathy features. Usually, cases with significant myelopathic symptoms end up being operated upon. Similarly, the threshold for operative management is very low in cases of traumatic PIVD with myelopathic features. We report a rare case of traumatic cervical PIVD showing spontaneous regression in 6 months, although an already existing local degenerative phenomenon could not be ruled out. We acknowledge the fact that cases like these must be operated upon early to prevent progressive dynamic injury. As the patient came to our center late (6 months postinjury), we came across such an occurrence in a traumatic cervical PIVD. Our case underscores the importance of repeating an MRI before a delayed surgical procedure in cases of traumatic PIVDs, especially in patients of lower- and middle-income countries (LMICs) with financial constraints. Consequentially, we could avoid unnecessary surgical intervention in our patients, along with it, the associated surgical risks and financial burden.
Tables 1 and 2 summarize the available case reports and case series, respectively, on the spontaneous regression of cervical PIVDs. A recent review article by Sharma etal. summarized three possible mechanisms for cervical herniated disc’s regressions/resorptions– (1) dehydration and shrinkage of prolapsed nucleus pulposus, (2) retraction of the prolapsed disc, and (3) enzymatic and/or phagocytic degradation of the extruded nucleus pulposus due to an inflammatory reaction/neovascularization.[1] Our patient’s spontaneous regression of the C5-C6 PIVD could be secondary to a combination of such mechanisms. The potential use of a contrast-enhanced MRI in predicting the possibility of spontaneous regression in extruded/sequestrated cervical disc was also highlighted.[20] A rim of contrast uptake around the prolapsed disc fragment represented the presence of vascularized granulation tissue and increased the chances of enzymatic/phagocytic degradation.
Table 1: List of published isolated case reports with spontaneous cervical disc regressions
Table 2: List of published case series with spontaneous cervical disc regressions
CONCLUSION
Spontaneous regression of cervical PIVD is an established phenomenon, even in traumatic cases. The factors reported favoring regression are – extruded disc and a contrast-enhancing rim around the extruded disc. Although we do not advocate a conservative line of management in traumatic cervical PIVD with myelopathy, but this report highlights the importance/justification of repeating an MRI before a delayed surgical procedure, especially in poor uninsured patients of LMICs. And to keep an ever-watchful eye to not to miss such a clinical possibility.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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