INTRODUCTION
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.
PATIENTS AND METHODS
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
|
Number
|
|
Back pain
|
19
|
|
Sciatic pain
|
23
|
|
Unilateral
|
20
|
|
L4 and L5 root
|
1
|
|
L5 root
|
12
|
|
S1 root
|
3
|
|
Reduced reflex
|
10
|
|
Intermittent claudication
|
5
|
|
Bladder dysfunction
|
1
|
|
Lumbar tenderness
|
25
|
|
Positive straight-leg raising test
|
26
|
|
Motor deficit
|
19
|
|
Weakness in foot dorsiflexion
|
13
|
|
Weakness in flexion of the great toe
|
6
|
|
Sensory deficit
|
20
|
|
L4 root
|
2
|
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%).
RESULTS
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).
DISCUSSION
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.
Conclusion
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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