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| decrease in the pressure of the nerve roots [4, 8-10]. It has been found in myelography that the size of the filling defect can be decreased with traction [11]. It is estimated that traction exerts its effect by creating a negative intradiscal pressure and tightening the posterior longitudinal ligament [9]. Cyriax has shown that during vertebral traction a negative pressure was generated in the disc, and so protrusion was reversed [8]. These results together with ours indicated that lumbar traction is effective in decreasing the size of the herniated material in lumbar disc herniation through these mechanisms, and lumbar traction should be used in the conservative treatment of lumbar disc herniation beginning in the first days of treatment. In our study there was a statistically significant decrease in the size of herniation in the traction group. Detailed evaluation revealed that symptomatic improvement of the patients was better than the decrease in size of the herniated material seen by CT. The reason for this might be related to the fact that herniations cause clinical symptoms after a certain degree, and clinical improvements are seen when the size of herniation decreases below that degree. So small disc herniations on CT may be associated with vague symptoms or even may be asymptomatic. In our study although traction decreased the size of herniation by about 23%, the improvement in symptoms and signs were much better. Bush et al. [12] reported a higher incidence of resolution in patients with larger herniations, with aggressive conservative management. Clinical progression was also found better in these patients. In most patients who did not respond to therapy, size of the herniated disc materials remained unchanged, whereas in patients with larger disc herniations the ratio of improvement was found to be higher. "Diffuse bulging" always remained the same, and their prognosis was poor [12]. Dullerud and Nakstad [13] reported an association between the initial size of the hernias and improvement after treatment, with larger herniations decreasing more in size. In our study when we evaluated the patients whom traction was found to be ineffective, we saw that the average size of their herniations was relatively smaller ("herniation index": 183.0) than others. This result may also be related to personal differences in the responses to traction. Greater herniations tend to diminish in size quickly due to sequestration or dehydration. Another possibility is the retraction of nuclear material to the annular tear [12]. The reason for lesser improvement in smaller disc herniations may be related to denser fiber arrangement in this area, since it prevents neovascularization of herniation, and causes lesser passive water loss [7]. In a study conducted by Reust et Al. [14], patients were divided into three groups and were given 5, 15, and 50-kg traction, respectively. They reported no significant difference between the groups in respect to fingertip to ground distance, pain and SLR test degrees. In our study, we did not find any significant difference between change in pain before and after the treatment in both traction and control groups. But changes in SLR angle and sciatica before and |
after the treatment were significant only in the traction group. In the lumbar region, nerve roots in dural sheath can move about 2-5 mm [15]. The SLR test detects loss of this movement of nerve roots due to disc herniation. The increase in SLR angle and degree of sciatica in our patients in traction group was probably a result of the decrease in root irritation due to the decrease in size of herniated discs. Disappearance of low back pain or sciatica after surgery varies between 35 and 95% [16]. There was no difference in prognosis of neurologic deficit between surgical and conservative treatments [17]. In a retrospective study on patients with disc herniation without significant stenosis, successful responses were seen in 90% of patients with physical treatment. In over 85% of patients, response is successful immediately after the surgery, and this is more apparent in patients with severe preoperative radicular pain [5]. Presence of minimal to mild neurologic deficits does not affect the indications for choosing either surgical or conservative treatments. Even in patients with significant neural deficits, radiculpathies or anatomical defects, total improvements can be achieved with non-surgical methods [16]. In all of the patients with relative indications for surgery, it should be delayed until a successful response is seen after the conservative treatment [5]. The main importance of surgery is relieving sciatia, but also relieving low bakc pain. About 70% of patients report a decrease in low back pain [2. 4]. In our study, the ratio of patients who were relieved from low back pain and sciatica were 63 and 60%, respectively, in patients who were given traction along with other physical therapy modalities. Surgical treatment of lumbar disc herniation does carry some risks and complications like thromboembolism, infection, perforation of dura mater, and neurological complications [2]. Long-term results of patients' discogenic low back pain without progressive neurologic deficits do not differ between various conservative treatments [11]. Therefore, in patients without absolute indications for emergency surgery, traction and other physical therapy modalities should initially be applied. The data presented here suggest that continuous lumbar traction is an effective method of treatment in patients with lumbar disc herniation. It is one of the effective components for decreasing the size of the herniated disc material. Patients with greater disc herniations might respond better with traction compared to those with smaller herniations. ________________________________________
References
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