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April2012 Vol.49 Issue:      2 Table of Contents
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Outcome and Prognostic Factors for Recurrent Lumbar Disc Herniation Surgery

Mohamed AbdelBari Mattar1, Ahmed A. Zaher1, Mohamed Gomaa2, Ashraf Ahmed Zaher2

Departments of Neurosurgery1, Neurology2; Mansoura University; Egypt



Background: Many studies on recurrent disc herniation exist, however only mixed patient populations have been analyzed. Recurrent herniation following disc excision has been reported in 5–11% of patients. Objectives: To analyze the factors that influenced the outcomes of repeat discectomy through a retrospective evaluation of 31 patients with recurrent lumbar disc herniation. Methods: Recurrent lumbar disc herniation is considered when an ipsilateral or contralateral disc herniation at the same level happens, with a pain-free interval more than 6 months. MRI with contrast was done and revision surgery was performed in all patients using conventional open discectomy. Results: The mean pain-free interval was 31 months. During the revision surgery the disc pathology was of the contained type in 8 patients and the noncontained type in 23 patients. Epidural fibrosis was seen in 29 patients. All patients had follow-up of at least 1 year. At the final follow-up, their average JOA score was 24, with the average recovery rate of 72%. There were no demonstrated effects from age, sex, traumatic events, level of herniation, procedures of revision surgery, or dural tear on the recovery rate. However a negative impact on the recovery rate was found related to the following factors: times of prior surgery, side of recurrence, pain-free interval, duration of recurrence symptoms,   associated spinal stenosis. Conclusion: A revision surgery for recurrent lumbar disc herniation showed satisfactory results that were comparable with those of primary  discectomy, therefore a repeat  discectomy  can  be recommended  for  the  management  of  recurrent  lumbar  disc  herniation. [Egypt J Neurol Psychiat Neurosurg.  2012; 49(2): 143-148]

Key words: recurrent lumbar disc herniation, repeat discectomy, outcome.

Correspondence to Mohamed Said Gomaa, Department of Neurology, Mansoura University; Egypt.

Tel.: +201280082600       E-mail:




Recurrent lumbar disc herniation may be defined as recurrent familiar back and leg pain after a definite pain free interval1. The overall rate of unsatisfactory results following discectomy is5% to 20%.2 The causes of failure of discectomy in relieving sciatic pain may be: surgery at a wrong  segment,  insufficient  disc  tissue  removal, unknown  second  disc  herniation, nerve  root trauma,  undetected displaced sequestration, spondylolithesis, extravertebral root compression, and polyneuropathy.3 Furthermore, a recurrent  lumbar disc herniation may occur at the (1) same level, same side (ipsilateral recurrence); (2) same level,  opposite side; or (3) a different level. For decision-making purposes, the first is evaluated and treated uniquely but the latter two clinically behaves similar to an unoperated primary lumbar disc herniation.4

Recurrent herniation has been reported in 5–11% of patients after disc excision. Therefore, recurrent herniation is a major cause of surgical failure.5 It has been reported that the reoperation risk after discectomy is more frequent than previously assumed.

Failed back surgery syndrome has been  frequently reported, but recurrent disc herniation after  discectomy  is relatively lacking in specific studies and is usually reviewed along with other causes of failed disc surgery.6

There have been many studies on recurrent disc herniation or recurrent sciatica, but they have analyzed  primarily  mixed  patient  populations,  including  either  patients  with  spinal  stenosis (foraminal stenosis) or those  with herniation at a new level, perineural fibrosis, or failed back surgery.7 In this study, a group of patients with recurrent disc herniation undergoing repeat discectomy were retrospectively analyzed. The purpose of the current study was to address the prognostic factors related to outcome in these patients treated with repeat discectomy.




Between the year 2005 and 2011, 128 patients operated for recurrent lumbar disc herniation at Mansoura University Hospital  were  reviewed, and  only  31  consecutive  patients (22 men and 9 women) were  selected  to  match  the inclusion criteria provided below. The average age of the patients at the surgery was 42 years (range, 27-62 years). Recurrent disc herniation was considered as disc herniation at the same level as the primary herniation, either on the same or the opposite side. The pain-free interval after primary discectomy should be more than 3 months. The patients with a disc herniation at a new level with respect to the primary herniated disc were excluded from this study.

All these lumbar disc surgeries before admittance to hospital were performed from the posterior approach.  The  procedures included microscopic discectomy in 5 patients, discectomy with unilateral laminectomy (hemilaminectomy) in 13, discectomy with bilateral laminectomy (total laminectomy) in 7, and discectomy with fenestration in 6. The time from prior surgery to that of recurrence averaged 2 years and 7 months (range, 8 months to 3 years).

Nineteen patients experienced their recurrent symptoms after a traumatic event. The mechanism of onset was, fall in 4, sporting accident in 3, lifting in 7, and twisting in 5. The remaining 12 patients had no definite history of injury. The duration of recurrent symptoms ranged from 2 months to 1years. Twenty-seven patients had undergone a conservative treatment such as bed rest, physiotherapy, and analgesia. The level of recurrent disc herniation was L4-5 in 23 cases (15 ipsilateral and 8 contralateral), L5-S1 in 5 cases (4 ipsilateral and 1 contralateral), and L3-4 (ipsilateral) in 3.  The symptoms and signs were shown in Table 1.

All patients had sciatic pain after a pain-free interval following discectomy. Walking capacity was defined as one of the following 4 categories 8.  less than 0.5 km in 6 patients, 0.5 to 1 km in 13 patients, 1 to 5 km in 8 patients, and more than 5 km in 4 patients.

The severity of preoperative clinical symptoms was evaluated by means of a scoring system proposed by the Japanese Orthopaedic Association (JOA score) 9 (Table 2). The average preoperative JOA score in these patients with recurrent lumbar disc herniation was 12.0 (range, 3 to 18). All patients underwent a conventional radiographic evaluation including postero-anterior and lateral lumbosacral views to exclude concomitant spinal pathological conditions. Other preoperative imaging studies included gadolinium-enhanced magnetic resonance imaging (31 patients).

In all patients, a repeat discectomy was performed. Indications for surgery were intractable pain that had not responded to conservative care for more than 2 to 3 months or cauda equina syndrome. The revision surgery was carried out on the basis of a laminotomy (3 patients), unilateral hemilaminectomy (13 patients), or bilateral total laminectomy (15 patients).

During surgical exposure, medial facetectomy, unilateral or bilateral, was usually necessary before discectomy performed, with special care to the scar tissue adhering to and covering the laminae. The surgical outcome was assessed by means of the JOA score. The recovery rate was calculated according to the following formula: The  recovery  rate  =  [(postoperative  score  -  preoperative  score  /(  29  -  preoperative score)]×100%

A 4-grade scale was used to evaluate the subjective opinion of the patients on the overall results with regard to both back pain and sciatic pain:  excellent (almost or totally pain-free), fair (improved, but residual pain), unchanged, or worse.


Statistical Analysis

was made to evaluate the factors that may influence the outcome of repeat discectomy. A Student's t-test, 1-way analysis of variance, or linear regression analysis was used to  determine  the  effect  of these  factors on the  recovery rate  and  P<0.05  was  considered statistically significant.


Table 1. Symptoms and signs in patients with recurrent disc herniation (n = 31).


Symptoms and signs


Back pain


Sciatic pain




L4 and L5 root


L5 root


S1 root


Reduced reflex


Intermittent claudication


Bladder dysfunction


Lumbar tenderness


Positive straight-leg raising test


Motor deficit


Weakness in foot dorsiflexion


Weakness in flexion of the great toe


Sensory deficit


L4 root


Table 2. JOA’s assessment of surgical treatment of low-back pain (JOA score).


I.                  Subjective symptoms (9 points)

A.     Low-back pain

a.              None                                                                                                                                                                                                                                                                                                                                3

b.             Occasional mild pain                                                                                                                                                                                                                                                               2

c.              Frequent mild or occasional severe pain                                                                                                                                                                                                             1

d.             Frequent or continuous severe pain                                                                                                                                                                                                                     0

B.     Leg pain and/or tingling

a.              None                                                                                                                                                                                                                                                                                                                                3

b.             Occasional slight symptoms                                                                                                                                                                                                                                                   2

c.              Frequent slight or occasional severe symptoms                                                                                                                                                                               1

d.             Frequent or continuous severe symptoms                                                                                                                                                                                                           0

C.     Gait

a.              Normal                                                                                                                                                                                                                                                                                                       3

b.             Able to walk farther than500 m, although it results in pain, tingling, and/or muscle weakness                                                         2 

c.              Unable to walk farther than 500 m because of leg pain, tingling, and/or muscle weakness                                          1

d.             Unable to walk farther than 100 m because of leg pain, tingling, and/or muscle weakness                                          0

II.                Clinical signs (6 points)

A.     Straight-leg raising test (including tight hamstrings)

a.              Normal                                                                                                                                                                                                                                                                                                       2

b.             30°-70°                                                                                                                                                                                                                                                                                                        1

c.              <30°                                                                                                                                                                                                                                                                                                                                 0

B.     Sensory disturbance

a.              None                                                                                                                                                                                                                                                                                                                                2

b.             Slight disturbance (not subjective)                                                                                                                                                                                                                       1

c.              Marked disturbance                                                                                                                                                                                                                                                                0

C.     Motor disturbance (MMT)*

a.              Normal (grade 5)                                                                                                                                                                                                                                                                                        2

b.             Slight weakness (grade 4)                                                                                                                                                                                                                                                        1

c.              Marked weakness (grade 3-0)                                                                                                                                                                                                                                                  0

III.               Restriction of activities of daily living (14 points)

Activities of daily living                                                                                           Severe                              Moderate                                  None

Turning over while lying                                                                      0                                      1                                                          2

Standing                                                                                               0                                      1                                                          2

Washing                                                                                               0                                      1                                                          2

Leaning forward                                                                                   0                                      1                                                          2

Sitting (1 hr)                                                                     0                                      1                                                          2

Lifting or holding                                                                                 0                                      1                                                          2

Walking                                                                                                0                                      1                                                          2

IV.               Urinary bladder function (- 6 points) (incontinence, urinary retention)

a.      Normal                                                                                                                                                                                                                                                                                                                                        0

b.     Mild dysuria                                                                                                                                                                                                                                                                                                                                - 3

c.      Severe dysuria                                                                                                                                                                                                                                                                                                                            - 6

* MMT indicates manual muscle testing: grade 5 (normal, 100%), grade 4 (good, 75%), grade 3 (fair, 50%), grade 2 ( poor, 25%), grade 1 (trace, 10%), and grade 0 (0%).




During the revision surgery the disc pathology was of the contained type in 8 patients and the non-contained type in 23 patients. Epidural fibrosis was seen in 29 patients. There were 9 dural tears during the revision surgery. The dural tears were directly repaired using sutures in 5 of the 9 patients. No cerebrospinal fluid leakage was seen except in 3 cases that were stopped later following strict conservative treatment. All these patients had follow-up of at least 1 year. At the final follow-up, their JOA score was between 12 and 29 (average, 24), with the recovery rate of 29% to 100% (average, 72%).

There were 18 excellent, 8 fair, and 5 unchanged results. Eighteen patients graded as excellent results returned to their previous work status or normal daily activity. Of those patients graded as fair, 2 had significant improvement with regard to both back pain and sciatic pain, and 6 needed analgesic drugs, although they had pain relief to different degrees. In the rest 5 patients, 4 had undergone 2 previous lumbar surgeries. No further revision surgery was needed.

There were no demonstrated effects (P<0.05) from age (γ = -0.203), sex (t = 0.694), traumatic events (t = 0.813), level of herniation (F = 1.891), procedures of revision surgery (F = 0.757), or dural tear (t = 1.346) on the recovery rate.

However a significant impact on the recovery rate was found related to the following factors: times of prior surgery, where the 1st time revision is always associated with earlier improvement and better results (F=11.93, P=0.007), side of recurrence, where ipsilateral disc herniation in the subsequent presentations is frequently associated with unsatisfactory results (r=-0.394, P≤ 0.01),   pain-free interval, where the duration of relief of less than 6 months was predictive of unsatisfactory results (r=0.74, P=0.01), duration of recurrence symptoms where the duration of sciatica and sick leave has a much great influence, where longer durations may reflect unsatisfactory results (rho=-0.6, P<0.05), associated spinal stenosis, which is inversely proportionate to outcome of revision surgery ( r=-0.453 and p ≤ 0.001).




Recurrent disc herniation is considered when the herniation developed in the same level as the prior discectomy10-12, either on the same or the opposite side, on the other hand it should be considered as a new herniation if it happened at a new level although many other authors included the latter situation in their study series as a recurrent one.13-15

Recurrent  disc  herniation  has  been  reported  in  varied  proportions  among  patients  after discectomy.  Ozgen et al.16 reported findings of revision surgery in 114 patients with prior lumbar discectomy. Disc herniation was noted at the operated level, on the same or the opposite side, in 56 patients (49.1%). Davis14 retrospectively analyzed 984 patients who underwent standard discectomy, 970 (88%) of whom presented the following after an average follow-up of 10.8 years: 6% of the patients were submitted to repeat surgery for a recurrent or new herniation. Of these, 50% had a  recurrent  herniation,  34%  herniated  at  a  new  level,  and  16%  had  a contralateral herniation at the operated level.

After following up prospectively 100 patients who had undergone standard discectomy for 10 years, Lewis et al.17 found a recurrent herniation in 13 of 16 patients during revision surgery. In the current study the incidence of recurrent disc herniation couldn’t be exactly determined in a true figure, since not all patients stick to the regular medical follow up designated for them, others my refuse admittance to hospital for resurgery, or they might seek medical service elsewhere.

The present study showed that the symptoms and signs of patients with recurrent disc herniation were not different from those with a primary discectomy. The predominant complaint of the patients was often typical sciatic pain.  This finding was similar to the results of Jonsson and Stromqvist 8. In addition, 6 patients (all were above the age of 50 years) had both sciatic pain and intermittent claudication owing to the decreased capacity of the spinal canal, caused by degeneration of the lumbar vertebrae.18

The severity of sciatica and the positive straight-leg raising test appeared significantly decreased in these patients. And this might be explained by the decrease of water and proteoglycan in the disc because of aging and, therefore, the decrease of degree of disc herniation.

It has been shown that the long-term outcomes of patients surgically treated for recurrent disc herniation have a wide range of variation19-22. That may be related to the different inclusion criteria applied in these studies. Patients with recurrent herniation were often reviewed together with those presenting herniation at a new level5,14,15,19 or those with failed lumbar surgery due to other causes5,23,24,11,16. Suk et al.12 showed that satisfactory results from conventional open discectomy as a revision surgery for recurrent lumbar disc herniation were comparable with those of primary discectomy. Satisfactory outcomes were also obtained from the current study. None of the patients had a poor result, although 3 patients with pain relief at different degrees still needed analgesic drugs.

Different factors that influence the long-term outcome of revision surgery for recurrent disc herniation have been shown to be of a predictive value for prognosis. Regarding the current study we  found  that the outcome of the studied patients was corresponding to duration of symptoms relief  following primary discectomy where shorter  durations  (6  months  or  less) predicted a poorer outcome.  Finnegan et al.25 and Waddell et al.26 have noted that the duration of relief of less than 6 months or 1 year predicted a poor prognosis. Another factor that influences the outcome with a great impact is the duration of sciatica where patients who developed longer durations in this respect got a much worse prognosis than others in the current study. Nygaard et al.27 retrospectively reviewed 93 consecutive primary discectomies to evaluate the prognostic value of symptoms (lumbar pain and sciatica) and sick leave. They found that the duration of the present attack of sciatica and sick leave before surgery was significantly longer in the group with an unsatisfactory outcome compared with the group with a satisfactory outcome, concluding that the duration of sciatica and sick leave before the operation had value as a predictive factor affecting the overall result after surgery for lumbar disc herniation. Vucetic et al.28, also had similar findings. In a prospective 2-year follow-up study of 160 consecutive patients undergoing primary surgery for suspected lumbar disc herniation, they demonstrated that the duration of sciatica of less than 7 months was one of the factors predicting return to work at 2 years. 

A negative impact on the recovery rate was found related to times of prior lumbar surgeries where in this study the 1st time revision was always associated with better improvement. Baba et al.6 and O’Sullivan et al.11 noted that the outcome was inversely related to the times of operation. The patients who had a first-time revision had an earlier improvement and better results. It was noted in the current study that ipsilateral disc herniation in the subsequent presentation is much more associated with unsatisfactory results than those patients who developed recurrence contralateral to previous surgery and this might be explained by unnoticed excessive traction on the corresponding nerve root while surrounded by different degrees of fibrosis and adhesions owing to the previous surgery as well as the high possibility of nerve root and dural injuries.

Finally  patients  who  showed  associated  spinal  canal  stenosis as an integral part of their presentation, they developed a much worse results than those who haven’t that entity and this may related to the ongoing spinal degenerative process and its sequelae.



Standard open discectomy as a revision surgery for recurrent lumbar disc herniation showed satisfactory results that were comparable with those of primary discectomy. According to the results of this study, repeat  discectomy can be recommended for the management of recurrent lumbar  disc  herniation  however  many  prognostic  factors  should  be kept in  consideration  while planning for the revision surgery including times of prior surgery (where the 1st time revision is always associated with earlier  improvement  and  better results), side of recurrence (where ipsilateral  disc  herniation  in  the  subsequent  presentations is frequently associated with unsatisfactory results),  pain-free interval (where the duration of relief of less than 6 months was predictive of unsatisfactory results),  duration of recurrence symptoms (the duration of sciatica and sick leave has a much great influence, where  longer  durations may reflect unsatisfactory results), associated spinal stenosis (inversely proportionate to outcome of revision surgery).


[Disclosure: Authors report no conflict of interest]




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الملخص العربى


العوامل المنذرة بنتائج جراحة الانزلاق الغضروفى القطنى المرتجع


تهدف هذه الدراسة الى تحليل العوامل التى تؤثر فى جراحة الغضروف المرتجع وذلك بتقييم31 مريضا ممن أجروا جراحة الغضروف القطنى المرتجع بأثر رجعى. وقد تم فحص هؤلاء المرضى جميعاً بعمل اشعة بالرنين المغناطيسى باستخدام الصبغة على الفقرات القطنية. وكانت نتيجة الجراحة ممتازة فى 18 مريضاً ومتوسطة فى 8 فى حين ان 5 مرضى لم تستقر حالتهم بعد الجراحة واثبتت الدراسة انه لا يوجد تاثير لكل من عوامل السن والجنس والإصابة ومستوى الغضروف وطريقة إجراء  الجراحة او ترق الأم الجافية على نتيجة الجراحة فى حين أن العوامل التى تؤثر سلبيا على نتيجة الجراحة وجد أنها تشمل موعد إجراء الجراحة السابقة وجهة الارتجاع وفترة اختفاء الآلام. وخلصت هذه الدراسة أن جراحة الانزلاق الغضروفى المرتجع نتائجه مرضية تضاهى نتائج جراحات الغضروف التى تجرى لأول مرة وبناءاً على ذلك فتوصى هذه الدراسة بإعادة الجراحة لاستئصال الغضروف المرتجع.

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