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| hernations. Two levels herniations were found in four patients. Clinical characteristics of the traction and control groups, before and after the treatment period are given in Table 1. The difference between the two groups with treatment was not significant in relation to presence of low back pain, VAS, number of patients with presence of motor deficits, and sensory deficits (p>0.05). However for the presence of sciatica, SLR angle, and degree of motor loss (5) between before and after the treatment, the difference between the traction and control groups were statistically significant (p<0.05). Patella reflex was decreased in four (9%) of all patients included. Three had L3-L4 herniation and the other had L4-L5 herniation. Eleven patients had diminished Achilles reflex. Of these, seven had L5-S1 herniations, one had L4-L5 herniation, three had two-level herniations (one had L4-L5 and L5-S1 herniations; two had L3-L4 and L4-L5 herniations). In the traction group, while seven patients had diminished reflexes before the treatment, we observed full recovery in four and fore the treatment, we observed full recovery in four and partial recovery in one patient after the treatment. In the control group, the number of patients with diminished reflexes was eight, and none of them had improvement. The difference of improvement regarding the reflex findings between the traction and control groups was statistically significant (p<0.01). When the CT findings were evaluated, the relative size of the herniated disc material, that is, the "herniation index" was 276.6 ± 129.6 in the traction group before the treatment, and it decreased to 212.5 ± 84.3 with the treatment. The difference between before and after the treatment in traction group was found significant (p<0.01). In the control group, pretreatment value was 293.4 ± 112.1, and it decreased to 285.4 ± 115.4 after the treatment. This decrease was not significant (p>0.05). The mean improvement in traction group was 63.7 (23%), whereas it was eight (3.7%) in the control group (Table 1). "The degree of improvement in CT" was accepted as the difference between pre and post treatment herniation indices. In the traction group, there was a significant positive correlation between "the degree of improvement in CT" and the relative size of herniated disc (r=0.763; p<0.01). Hence, the improvement was better in patients with |
relatively larger hernations in CT before the treatment. A similar relation was not present in the control group (p>0.05). We divided the patients in the traction group into two, according to the mean size of herniated disc material (mean herniation index: 276.6), 15 patients had small and nine had large disc herniations. The mean herniation index value of patients with small disc herniations were 203.3 ± 16.6, and of patients with large hernias were 298.0 ± 23.9. The decrease in the herniation index of patients with smaller hernias were 17.4 (8.5%) with treatment. However, in patients with larger herniations, this decrease was 140.6 (36.3%), and the difference between these decrements in the two groups was significant (p < 0.01). In the traction group, 19 (79.2%) patients had decrease in the size of the hernia in CT, whereas only two patients did not show any difference. ________________________________________
Discussion Regression of herniation by CT with conservative treatment was first shown in 1984. In 1985, regression or total disappearance of herniation was shown by CT in 11 patients. Maigne and Deligne [7] has shown in five patients that herniations did not change or even increase in size by CT after the treatment, without any worsening in clinical findings. However, many investigators have reported improvements in CT or MRI images of lumbar disc herniations with conservative treatment. In our study, of the two groups, significant decrease in the size of disc herniation by CT with conservative treatment was only seen in the traction group. This indicated that one of the effective components for decreasing the size of herniated disc in the conservative treatment is lumbar traction. In previous studies, with adequate traction forces, decrease in lumbar lordosis, 20-30% decrease in intradiscal pressure, increase in disc height, separation of vertebral bodies, widening in the apophyseal joint spaces and intervertebral foramina and reduction of trapped capsular fold were reported. It was also stated that blood flow to nerve roots increases with the |
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