Clinical Neurology and Neurosurgery 120 (2014) 136–141

Contents lists available at ScienceDirect

Clinical Neurology and Neurosurgery

journal homepage: www.elsevier.com/locate/clineuro

Review

Spontaneous regression of sequestrated lumbar disc herniations:

Literature review
Mohamed Macki a,b , Marta Hernandez-Hermann a,b , Mohamad Bydon a,b ,
Aaron Gokaslan b , Kelly McGovern b , Ali Bydon a,b,∗
a
Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, USA
b
Johns Hopkins Biomechanics and Surgical Outcomes Laboratory, Baltimore, USA

a r t i c l e i n f o a b s t r a c t

Article history: Lumbar disc herniations (LDH) may regress with conservative management; however, this phenomenon
Received 21 November 2013 is poorly understood for the sequestrated subtype of LDH. We present one of the first comprehensive liter-
Received in revised form 2 January 2014 ature reviews specifically addressing the spontaneous regression of sequestrated intervertebral discs. We
Accepted 17 February 2014
reviewed all publications with lumbar disc herniations, sequestrated subtype. Our results were then nar-
Available online 25 February 2014
rowed to patients who experienced spontaneous regression of the sequestration. Based on our literature
review of 53 cases, patients with sequestrated lumbar disc herniations experienced symptomatic resolu-
Keywords:
tion in a mean of 1.33 ± 1.34 months and radiographic resolution in 9.27 ± 13.32 months. Symptomatic
Disc
Herniation
patients with sequestrated discs present similarly to those with other types of lumbar disc herniations.
Lumbar Sequestrations may have the highest likelihood to radiographically regress in the shortest time frame in
Regression comparison to the remaining subtypes of LDH. The most likely mechanism for regression is an inflam-
Sequestrated matory response elicited against the free fragment. Patients with disc sequestrations may be managed
conservatively, in the absence of intractable pain, inability to walk, weakness or symptoms suggestive of
cauda equina syndrome.
© 2014 Elsevier B.V. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
2. Case presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
3. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
4. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
5. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
6. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Conflicts of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140

1. Introduction most common type of degenerative discogenic disease [2]. Cur-

rently, five ordinal subtypes of LDH are described in the literature:
Lumbar disc herniations (LDH) are the most common cause bulging discs (mildest form), focal protrusions, broad-based pro-
of radicular pain, with an estimated annual incidence of 5 per trusions, extrusions, and sequestrations (severest form) (Fig. 1) [3].
1000 adults [1]. After annular tears and degeneration, LDH are the The severest form of LDH is the sequestrated disc. Also known
as free fragments, sequestrations are no longer attached to their
respective intervertebral disc [3]. Clinically, these patient present
∗ Corresponding author at: Spine Center, Department of Neurosurgery, The Johns
similarly to any type of LDH; therefore, differentiating between
Hopkins Hospital, 600 North Wolfe Street, Meyer 7-109, Baltimore, 21287, USA.
the five subtypes requires magnetic resonance imaging (MRI) for
Tel.: +1 443 722 2133. diagnostic identification [4]. According to the Spine Patient Out-
E-mail addresses: abydon1@jhmi.edu, mbydon1@jhmi.edu (A. Bydon). comes Research Trial (SPORT), out of 2720 patients with LDH, only

http://dx.doi.org/10.1016/j.clineuro.2014.02.013
0303-8467/© 2014 Elsevier B.V. All rights reserved.
 M. Macki et al. / Clinical Neurology and Neurosurgery 120 (2014) 136–141
Fig. 1. Classification of the five subtypes of disc herniations in the lumbar spine.
86 (3%) patients had sequestrated discs. However, patients with
symptomatic sequestrations comprised 7% of all surgical candi-
dates (n = 1191) in the SPORT [5].
Sequestrations may undergo spontaneous regression and, even-
tually, complete resolution both radiographically and clinically.
Verified with serial MRIs, this recently reported phenomenon has
been illustrated in 52 cases (12 publications) elsewhere in the lit-
erature (Table 1) [1,6–16]. In this manuscript we present one of the
first comprehensive literature reviews, in addition to a case pre-
sentation, on spontaneous regression of disc sequestrations. Our
analysis focuses on the clinical, radiographic, and pathophysiologi-
cal characteristics of patients undergoing spontaneous regression
of disc sequestrations.
2. Case presentation
A 35 year-old gentleman with a seven-year history of low back
pain presented to the outpatient clinic with back stiffness. Seven
years prior, the patient experienced back pain after attempting
to lift a heavy box. At the time, lumbar X-ray had revealed mild
lumbar spondylosis, and the patient was successfully treated with
physical therapy. Upon presentation, the patient complained of
a one-month history of back stiffness in addition to left buttock
and leg pain after a strenuous exercise maneuver at the gym. The
patient expressed difficulty walking along with “severe pain”. One
month after the acute symptom onset, an MRI of the lumbar spine
revealed a large, left-sided L4-L5 sequestrated disc fragment with
rostral migration, lying behind the L4 vertebral body. The frag-
ment compressed the thecal sac and the left L5 nerve root (Fig. 2).
The patient was managed conservatively with oral non-steroidal
anti-inflammatory medications.
Five months after presentation, the patient’s only complaint
was back stiffness; the lower extremity symptoms had subsided.
The patient denied leg pain, weakness, or bladder and bowel dif-
ficulties. Straight-leg test was negative. Muscle strength in the
lower extremity muscle groups was 5/5 bilaterally. Sensation to
fine touch, proprioception, and pain of the lower extremities was
grossly intact bilaterally. Patellar and Achilles reflexes were 2/4
137
bilaterally. MRI at this time revealed complete resolution of the
sequestered disc fragment (Fig. 3). The only indication of a prior
lesion at the L4-L5 disc space was a focal disc extrusion superim-
posed on an annular disc bulge where T2 imaging suggests a small
annular tear. The patient was managed conservatively with non-
steroidal anti-inflammatory drugs (NSAIDS). On follow-up clinic
examination 6 weeks later, the patient remained asymptomatic
with the exception of some back stiffness. Motor strength, sensa-
tion, reflexes, and bowel and bladder function also remained intact.
3. Methods
We reviewed all published case reports and case series of lumbar
disc herniations, sequestrated subtypes. From this body of litera-
ture, we specifically refined our results to patients who experienced
spontaneous regression of their sequestrated disc. Only cases mon-
itored with serial MRIs were included in the literature review. All
cases were attributed to degenerative changes to the spinal column.
Patients with infectious, metabolic, neoplastic, and/or congenital
causes of lumbar disc herniations were excluded. Fifty-two cases
met the inclusion and exclusion criteria for this manuscript.
Summary statistics are reported in order to describe num-
ber of cases in each publication, average age in each publication,
location of sequestrated disc, symptoms, physical exam findings,
average time to symptom resolution in each publication, average
time to MRI resolution in each publication, and residual symptoms
(Table 1). For comparative purposes, relative information from the
present case presentation was also included in Table 1.
4. Results
We carried out a literature review of 53 cases (including the
present case) of spontaneous regression of sequestrated discs
(Table 1) [1,6–16]. On clinical examination, 37.7% of patients with
sequestrated discs in our literature review reported radiculopathy.
Similarly on physical exam, the literature demonstrates positive
straight leg tests in 41% of cases, hyporeflexia in 7.5% of cases, weak-
ness in 41.5% of cases, and sensory disturbances in 35.8% of cases
 138
Table 1
Characteristics of 53 cases reporting spontaneous regression of sequestrated disc herniations in the lumbar spine.

Author (year) Number of Average age Disc (N = number of Symptoms (N = number Physical exam Average time to symptom Average time to MRI Residual symptoms
cases cases) of cases) (N = number of cases) resolution (months) resolution (months) (N = number of cases)

Ahn et al. [4] (2002) 11 46.4 Back pain (7) (+) straight leg raising 1.0 6.4 Sensory disturbance
test (11), sensory (3), weakness (3)

M. Macki et al. / Clinical Neurology and Neurosurgery 120 (2014) 136–141

disturbance (8),
weakness (10)
Gelabert-González 1 66 L4-L5 Back pain, (+) straight leg test, 7
et al. [6] (2007) radiculopathy weakness
Gezici et al. [7] (2009) 1 33 L4-L5 Back pain, (+) straight leg test 15
radiculopathy
Jensen et al. [8] (2006) 8 L3-L4 (1) Sciatica (8) Sciatica (1)
L4-L5 (5)
L5-S1 (2)
Keskil et al. [9] (2004) 2 40.5 L3-L4 Back pain (1), (+) straight leg test (1), 45.5 (+) straight leg test (1),
L4-L5 radiculopathy (2) weakness (2), sensory hyporeflexia (1)
disturbance (2),
hyporeflexia (2)
Nozawa et al. [10] 1 32 L4-L5 Back pain, weakness Sensory disturbance, 1 3
(2009) weakness
Orief et al. [11] (2012) 5 37.4 L4-L5 (3) Back pain (2), (+) straight leg test (5), 1.2 6.8 Sensory disturbance (1)
L5-S1 (2) radiculopathy (2) sensory disturbance
(5), weakness (2),
hyporeflexia (1)
Sabuncuoğlu et al. [12] 2 38.5 L1-L2 Back pain (2), (+) straight leg test (1), 11
(2008) L5-S1 radiculopathy (2) sensory disturbance
(1), hyporeflexia (1)
Singh et al. [13] (1999) 1 43 L3-L4 Back pain, (+) straight leg test 4
radiculopathy
Slavin et al. [14] (2001) 1 23 L5-S1 Back pain, (+) straight leg test, 6.5 7
radiculopathy sensory disturbance
Ryu et al. [15] (2010) 1 53 L4-L5 Back pain, Sensory disturbance 6 Sensory disturbance
radiculopathy
Takada et al. [16] 18 Weakness (6) 0.75 6.75
(2001)
Current case 1 35 L4-L5 Back pain, Benign 1.5 5
radiculopathy
 M. Macki et al. / Clinical Neurology and Neurosurgery 120 (2014) 136–141 139

Fig. 2. Sagittal (A) and axial (B and C) T2-weighted magnetic resonance images of a 31-year-old man, revealed a large left-sided sequestrated disc fragment at the L4-5 level
with upward migration, lying behind the L4 vertebral body and compressing the thecal sac and the left L5 nerve root.

Fig. 3. Sagittal (A) and axial (B and C) T2-weighted magnetic resonance images revealing complete resorption of disc fragment, residual small disc protrusion at L4-L5.

(Fig. 4). On radiographic studies, the spinal levels affected with
sequestrations included L1-L2 (4.2%), L2-L3 (0%), L3-L4 (12.5%), L4-
L5 level (58.3%), and L5-S1 (25%) (Fig. 5).
The mean time from the first diagnostic MRI of a sequestrated
disc herniation to radiographic resolution of the sequestrated disc
was 9.27 ± 13.32 months (N = 35 cases reporting MRI intervals).
From the time of symptom onset, all 53 cases reported improve-
ment in clinical symptoms in a mean of 1.33 ± 1.34 months (N = 19
cases specified a time interval). Back pain decreased by 100%
(n = 19), radiculopathy by 95% (19), weakness by 86% (19), sensory
disturbance by 68% (13), and hyporeflexia by 75% (3) (Fig. 4).
5. Discussion
A subtype of lumbar disc herniations, sequestrated discs are a
radiographic finding in which the herniated fragment is no longer
connected to the parent disc [8]. These free fragments were once
thought to represent benign intraspinal tumors, which were moni-
tored radiographically [17]. However modern advances in imaging
modalities have identified these structures as sequestrations [8].
Although they account for only 3% of all LDH, the sequestrated sub-
type have now received increasing recognition in the literature
by radiologists and spine surgeons alike. Nevertheless, our cur-
rent understanding of this diagnosis remains limited [18]. Since the
identification of sequestrated discs, spontaneous regression (per
serial MRI images) has been documented in 12 publications rep-
resenting 53 cases (including the present case), according to our
literature search (Table 1) [1,6–16].
Clinically, sequestrated discs present identically to other
subtypes of LDH. In a prospective study of 403 patients with all
types of LDH, Kortelainian et al. found a positive straight leg test
in 42% of patients [19]. Hyporeflexic responses were elicited in
7% of patients. Weakness was found in 45% of patients, and a
sensory level was appreciated in 38% of patients. On average, 47%
complained of radiculopathy (51% in the right leg and 43% in the
left leg). Of the lumbar intervertebral levels, the symptoms were

Fig. 5. The number of spontaneous regressions of disc sequestrations at each

Fig. 4. Signs, symptoms, and physical exam findings of 53 cases reporting sponta- intervertebral level. N = 24 out of the 53 cases reporting a disc level where the
neous regression of sequestrated disc herniations in the lumbar spine. sequestration occurred.
140 M. Macki et al. / Clinical Neurology and Neurosurgery 120 (2014) 136–141
most commonly attributed to the L4-L5 herniations accounted for
56.8% of all cases. Similarly, we found the most commonly affected
level at L4-L5 (n = 14, 58.3%), which is the most common level for
all types of herniated discs (Fig. 5) [20].
In the present review of 53 cases, all patients were treated
conservatively with a combination of bed rest, oral analgesics,
spinal anesthetic blocks, and/or physical therapy. Spinal anesthetic
blocks were primarily epidural spinal injections. Without regres-
sion of the discs, however, spontaneous symptomatic resolution
may be the natural course of any intervertebral disc hernia-
tion [5,21–23]. Several studies have reported similar outcomes
in surgical versus conservative cohorts after long-term follow-up
[24–27].
Radiographic determinants of sequestrated intervertebral discs
also merit discussion. Takada et al. argued that the time to radio-
graphic resolution depended on the type of lumbar disc herniation.
Consistent with our case, Takada et al. reported that all 18 cases of
sequestrated discs had completely resolved after 9 months whereas
extruded discs resolved after 12 months. But, protruded discs
showed little to no signs of regression after 12 months. Takada et al.
explained that patients in the protruded disc cohort required the
longest time to appreciate even minimal regression because (A)
the patients were younger in age; and (B) the nucleus pulposus
of protruded discs which are rich with collagen fibers and carti-
lage cells in the younger population require a longer absorption
time [22]. On the other hand, the faster rate of radiographic resolu-
tion seen with sequestrated discs was traditionally associated with
dehydration and shrinkage, as the free fragment was no longer sup-
plied with nutrients from the parent disc [14,28,29]. More recently,
authors now postulate that the sequestrated discs, unlike other
LDH subtypes, trigger an inflammatory response characterized by
neovascularization and immune cell-mediated degradation. The
subsequent increase in blood flow to these free fragments explains
why the disc sequestrations enhance with Gadolinium (Gd) con-
trast. In fact, Autio et al. suggested that sequestrated discs with
higher levels of Gd diethylenetriamine pentaacetic acid (Gd-DTPA)-
enhanced MRIs served as a predictors for their higher resorption
rate [16].
Whether LDH should be treated conservatively or surgically
remains a source of controversy. Initial management for patients
with the sequestrated subtype of LDH may be conservative due to
the higher likelihood and faster rate of resolution in comparison
to the other LDH subtypes. Patients with intractable pain, inabil-
ity to walk, weakness, bowel or bladder dysfunction, history of
prior surgery, and others remain candidates for earlier surgical
intervention. Future studies with a similar design in prospective,
randomized trials are required to determine the optimal treat-
ment for patients with the sequestrated subtype of intervertebral
discs.
6. Conclusions
We present one of the first comprehensive literature reviews
specifically addressing spontaneous regression of sequestrated
discs. Sequestrations have the highest likelihood to radiograph-
ically regress in the shortest time frame (mean = 9.27 months
with serial MRIs) in comparison to the remaining four subtypes
of LDH. Clinically, symptomatic resolution, if it were to hap-
pen, occurred in 1.33 months. The most likely mechanism for
regression is an inflammatory response elicited against the free
fragment. Some patients with disc sequestrations may be man-
aged conservatively initially, in the absence of intractable back pain,
inability to walk, prior lumbar surgery, weakness, bowel/bladder
dysfunction, or other symptoms suggestive of cauda equina syn-
drome.
Funding
No funding has been contributed to this conception of this
manuscript. Ali Bydon is the recipient of a research grant from
Depuy Spine. He serves on the clinical advisory board of MedIm-
mune, LLC. The remaining authors do not have disclosures related
to the work in this manuscript.
Conflicts of interest
The authors declare no conflict of interest
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