Revision surgery for lumbar disc herniation. An analysis of 45 patients

Minimally Invasive Transforaminal Interbody Fusion Versus Microdiscectomy Without Fusion for Recurrent Lumbar Disk Herniation: A Prospective Comparative Study

OBJECTIVE

The objective of this study was to compare the clinical outcome of minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) versus standard revision diskectomy for recurrent lumbar disk herniation (RLDH).

BACKGROUND

RLDH is the most common cause of redo surgery after a microdiscectomy. Commonly, in patients without evidence of spinal instability, many surgeons would simply redo microdiscectomy, while others proceed to a redo microdiscectomy with arthrodesis. According to the literature, there is no evidence of what the best management of an RLDH would be.

METHODS

This study involved 90 patients who underwent lumbar microdiscectomy in the past and were now experiencing a new lumbar disk herniation for the first time. The patients were divided into two groups, each with 45 patients: group A received standard revision microdiscectomy, whereas group B received revision microdiscectomy with MIS TLIF.The Japanese Orthopaedic Association score, operating time, blood loss, duration of hospital stay, costs, and complications were all prospectively recorded in a database and examined. Back and leg discomfort were measured using the visual analog scale.

RESULTS

The mean total postoperative Japanese Orthopaedic Association score across the groups exhibited no statistically significant difference, nor did the preoperative clinical and epidemiological data. Although postoperative leg pain was comparable in both groups, postoperative lower back pain in group A was much worse than that in group B. Additional revision surgery was necessary for six individuals in group A. Group A had higher rates of dural rupture and postoperative neurological impairment. Group A experienced much less intraoperative blood loss, longer operation times, and postoperative hospital stays.

CONCLUSION

In patients with RLDH, revision microdiscectomy is effective. In comparison with conventional microdiscectomy, MIS TLIF reduces intraoperative risk of dural rupture or neural injury, postoperative incidence of mechanical instability or recurrence, and postoperative lower back pain.

STUDY DESIGN

Prospective, randomized, multicenter, comparative study.

Fusion versus nonfusion treatment for recurrent lumbar disc herniation

Background:

Recurrent lumbar disc herniation (RLDH) is one of the major causes for failure of primary surgery. The optimal surgical treatment of RLDH remains controversial.

Aim:

Retrospectively, we evaluate 135 patients and compare the clinical outcomes between fusion and nonfusion treatment of RLDH.

Methods:

Records of 75 men and 35 women aged 28–60 years for conventional revision discectomy alone (nonfusion) and 15 men and 10 women aged 30–65 years for revision discectomy with transforaminal lumbar interbody fusion (TLIF) and transpedicular screw fixation (fusion) were reviewed. Demographics, surgical data, and complications were collected and pre- and postoperative assessment were done by the Visual Analogue Scale (VAS) scale and Japanese Orthopaedic Association (JOA) score. The results after surgery were assessed according to the recovery rate as excellent, good, fair, and poor.

Results:

The mean follow-up period was 28.8 and 24.6 months in Group A (nonfusion) and Group B (fusion group), respectively. The preoperative data between both the groups showed no statistically significant difference. The postoperative mean VAS and JAO scores, recovery rate, and satisfaction rate showed no statistically significant difference except postoperative low back pain and occasional radicular pain and neurological deficit in nonfusion group which was significantly higher than that of fusion group. In comparison to fusion group, nonfusion group required significantly less operative time, less intraoperative blood loss, less postoperative hospital stay, no blood transfusion, and less total cost of the procedure. Satisfaction rate was 80% and 88% in nonfusion and fusion groups, respectively.

Conclusions:

Both convention revision discectomy (nonfusion) and discectomy with instrumented fusion (TLIF) surgery are effective in patients with RLDH.

Factors associated with patient satisfaction for PLIF: Patient satisfaction analysis

Introduction: Posterior lumbar interbody fusion (PLIF) has produced satisfactory clinical outcomes; however, all previous reports have only included evaluations by surgeon-based methods. The purpose of this study was to investigate patient-based surgical outcomes and the factors associated with patient satisfaction for PLIF. Methods: Patients who underwent PLIF for lumbar spondylolisthesis were reviewed (n=443). The average follow-up period was 8 years. Surgical outcomes were assessed using an original questionnaire, a numerical rating scale (NRS), the 36-Item Short Form Health Survey (SF-36), the Japanese Orthopedic Association (JOA) score, and the recovery rate. The original questionnaire consisted of five categories, with patient-evaluated score out of 100 points for surgery, satisfaction, improvement, recommendation to others, and willingness to undergo repeat surgery on a 5-point scale. According to the questionnaire responses, patient-based outcomes were divided into three groups: positive, intermediate, and negative and were compared with the NRS, SF-36, and JOA scores. Furthermore, factors associated with patient satisfaction were examined. Results: A total of 273 patients responded. Response rate was 62%. The average patient-evaluated score for surgery was 82 points. In terms of satisfaction section, positive, intermediate, and negative response rates were 82%, 7%, and 11%, respectively. With respect to other sections, positive, intermediate, and negative response rates were 87%, 7%, and 6% in improvement section; 66%, 23%, and 11% in recommending section; and 72%, 18%, and 10% in repeat section, respectively. The average pre- and postoperative JOA scores were 12 and 24, respectively. Significant correlations were detected between patient-based surgical outcomes and the NRS scores, physical component scores of the SF-36, and the JOA score. Postoperative permanent motor loss and multiple revision surgery were the major factors related to a negative response. Conclusions: High satisfaction rate to PLIF and significant correlation between patient- and surgeon-based surgical outcomes were detected. Postoperative permanent motor loss and multiple revision surgery were the major factors related to a negative response.

Recurrent lumbar disc herniation: A prospective comparative study of three surgical management procedures

Context:

The optimal surgical treatment of recurrent lumbar disc herniation is controversial.

Aim:

To compare prospectively the clinical outcomes of surgical treatment of recurrent lumbar disc herniation by three different methods; discectomy alone, discectomy with transforaminal lumbar interbody fusion (TLIF), and diecectomy with posterolateral fusion (PLF), regardless of the postoperative radiological findings.

Study Design:

This is a prospective, randomized, comparative study.

Materials and Methods:

This is a prospective, randomized, comparative study on 45 patients with first time recurrent lumbar disc herniation. Patients were evaluated clinically by using the criteria of the Japanese Orthopedic Association's evaluation system for low back pain syndrome (JOA score). The patients were classified into three groups: Group A; patients who had revision discectomy alone, group B; patients who had revision discectomy with TLIF, and group C; patients who had revision discectomy with PLF. The mean follow-up period was 37 (±7.85 STD) months.

Results:

The mean overall recovery rate was 87.2% (±19.26 STD) and the satisfactory rate was 88.9%. Comparison between the three groups showed no significant difference with regard to the mean total postoperative JOA score, recovery rate, and satisfactory rate. However, the postoperative low back pain was significantly higher in group A than that of group B and C. Two patients in group A required further revision surgery. The incidences of dural tear and postoperative neurological deficit were higher in group A. The intraoperative blood loss and length of operation were significantly less in group A. The total cost of the procedure was significantly different between the three groups, being least in group A and highest in group B. There was no significant difference between the three groups with regard to the length of postoperative hospital stay.

Conclusion:

Revision discectomy is effective in patients with recurrent lumbar disc herniation. Fusion with revision discectomy improves the postoperative low back pain, decreases the intraoperative risk of dural tear or neural damage and decreases the postoperative incidence of mechanical instability or re-recurrence. TLIF and PLF have comparable results when used with revision discectomy, but PLF has significantly less total cost than TLIF.

A comparative study of the outcomes of primary and revision lumbar discectomy surgery

The outcome of surgery for recurrent lumbar disc herniation is debatable. Some studies show results that are comparable with those of primary discectomy, whereas others report worse outcomes. The purpose of this study was to compare the outcome of revision lumbar discectomy with that of primary discectomy in the same cohort of patients who had both the primary and the recurrent herniation at the same level and side.

A retrospective analysis of prospectively gathered data was undertaken in 30 patients who had undergone both primary and revision surgery for late recurrent lumbar disc herniation. The outcome measures used were visual analogue scales for lower limb (VAL) and back (VAB) pain and the Oswestry Disability Index (ODI).

There was a significant improvement in the mean VAL and ODI scores (both p < 0.001) after primary discectomy. Revision surgery also resulted in improvements in the mean VAL (p < 0.001), VAB (p = 0.030) and ODI scores (p < 0.001). The changes were similar in the two groups (all p > 0.05).

Revision discectomy can give results that are as good as those seen after primary surgery.

Cite this article: Bone Joint J 2013;95-B:90–4.

Clinical outcome and influencing factor for repeat lumbar discectomy for ipsilateral recurrent lumbar disc herniation

OBJECTIVE

Recurrent herniation following disc excision has been reported in 5-15% of patients. There have been numerous studies of recurrent disc herniation, but these have analyzed mixed patient populations. We designed this study to analyze the factors that influencing the clinical results, and efficiency of repeat discectomy for recurrent lumbar disc herniation occurring at the same level and on the same side after primary discectomy.

METHODS

Between 1990 and 2011, a total of 52 patients who underwent repeat discectomy for recurrent lumbar disc herniation were retrospectively analyzed. Clinical outcomes were measured with Macnab criteria and visual analog scale (VAS score). Clinical parameters were also analyzed for influencing factors for outcome.

RESULTS

Based on Macnab criteria, an excellent surgical outcome was achieved in 28 cases (54%), a good outcome in 22 cases (42%), a fair outcome in 1 case (2%), and a poor outcome in 1 case (2%). Based on VAS score, 47 of 52 patients (90%) showed more than 4 score improvement. Age, sex, diabetes mellitus, smoking, time interval between repeat and primary discectomy, duration of recurrent symptoms, and extent of disc herniation did not significantly affect Macnab criteria and VAS score. However, a traumatic event showed less VAS score improvement whereas not affecting on Macnab criteria.

CONCLUSION

Conventional open lumbar discectomy performed as repeat surgery for recurrent herniation showed satisfactory results. Based on the results of this study, repeat discectomy can be recommended for the management of recurrent lumbar disc herniation. Further study is needed to evaluate factors related to the outcomes of repeat discectomy.

Long-term outcomes of the revision open lumbar discectomy by fenestration: A follow-up study of more than 10 years

A total of 51 patients who underwent the second open discectomy by fenestration from January 1988 through December 1994, were followed for an average of 146.8 months. The long-term follow-up results were evaluated through direct examinations and questionnaires. At the final follow-up, according to the Macnab classification an excellent and good outcome was achieved in 70.6% of the cases, and 78.4% were satisfied with their results. The failure rate was 15.7% (8 patients). Excluding those 8 failed cases who needed another reoperation, the average improvement calculated by Japanese Orthopaedic Association (JOA) scores was 64.6%. Factors that were associated with a fair and bad outcome included smoking, isolated trauma or injury, fibrosis and the duration of the remaining or recurrent primary postoperative symptoms. We noted that psychosociological signs were probably negative predictors of lumbar disc surgery outcome. Because the revision operation is typically associated with a higher complexity, selection of suitable surgical candidates and determination of valid indications for operative treatment are very important.

Recurrent lumbar disc herniation after discectomy: outcome of repeat discectomy

BACKGROUND

Recurrent disc herniation after discectomy is relatively lacking in specific studies and is usually reviewed along with other causes of failed disc surgery. The purpose of the current study was to address the outcome in the patients who had recurrent disc herniation treated with repeat discectomy and to identify the factors that may influence the outcome.

METHODS

Thirty-nine patients who underwent repeat discectomy for recurrent lumbar disc herniation were retrospectively analyzed. Of these patients, 27 had recurrent disc herniation at the L4 to L5 level, 11 at the L5 to S1, and 1 at the L3 to L4. They almost had the typical presentation of sciatica. The time from prior discectomy to that of recurrence ranged 6 months to 17 years (average, 5 years and 4 months). The Japanese Orthopaedic Association (JOA) score averaged 12 (range, -3 to 18). All patients had a follow-up evaluation at 1 and 15 years (average, 7 years and 8 months) after surgery.

RESULTS

Their JOA score increased to 12 to 29 (average, 24), with the recovery rate of 29% to 100% (average, 72%). Twenty-nine patients returned to their previous work status or normal daily activity, 7 had significant improvement, and 3 needed analgesic drugs although they had pain relief to different degrees.

CONCLUSIONS

The outcomes of repeat discectomy for recurrent disc herniation were satisfactory. No factors such as age, sex, traumatic events, times of prior surgery, level of herniation, side of recurrence, pain-free interval, duration of recurrence symptoms, walking capacity, the preoperative JOA score, associated spinal stenosis, procedures of revision surgery, and dural tear were found to be of predictive value for a prognosis of revision surgery for recurrent disc herniation (P>.05).

Medial facetectomy in recurrent lumbar nerve root compression

This study investigated the outcome of medial facetectomy in reoperations after a previous discectomy. In a consecutive series of 98 patients with varying combinations of disc herniation, lateral stenosis, and scar, a good or moderate outcome was reached in 57% of the patients. Scar as an operative finding was a significant factor for poor outcome, especially in patients with preoperative symptoms for >1 year.

Re-operation after lumbar disc surgery: results in 85 cases

In this retrospective study, 85 patients previously operated on for lumbar disc herniation who had undergone re-operation due to persistent pain or recurrence of the symptoms were investigated. The surgical findings were: recurrent herniation (20%), epidural fibrosis alone (36.4%), small recurrent herniation with epidural fibrosis (28.2%), herniation at another level (10.6%), spinal stenosis (2.4%), lumbar pseudomeningocele (1.2%) and adhesive arachnoiditis (1.2%). The overall success rate of re-operation was 60%. The best results were obtained in recurrent disc herniation (47.1%) excellent and 35.3% good results) and in herniation at another level (77.8% excellent and 22.2% good). Re-operation in epidural fibrosis had less-satisfactory results (29.1% excellent and 12.9% good).

Current concepts in intervertebral disc restoration

A current focus of treatment for degenerative disk disease is the restoration of the intervertebral disk. This article summarizes the structure and function of the intervertebral disk, the pathogenesis of its degeneration, and the clinical relevance of degenerative disk disease. Current literature relating to intervertebral disk replacement and regeneration is reviewed.