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Year : 2022  |  Volume : 9  |  Issue : 3  |  Page : 141-143

Recurrent lumbar disk herniation – Fusion is the answer

Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India

Date of Submission04-Jun-2022
Date of Acceptance01-Jul-2022
Date of Web Publication13-Sep-2022

Correspondence Address:
Sachin A Borkar
Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/joss.joss_26_22

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Recurrent lumbar disk herniations (rLDHs) are becoming a common occurrence in present times. However, the optimal surgical strategy for their management is a not clear with discectomy alone and discectomy followed by fusion emerging as the main surgical options. In this editorial debate, we discuss why discectomy and fusion is better option for the management of such cases. The complication rates, treatment satisfaction rates, visual analog scale (VAS) leg pain scores, and rates of adjacent segment disease (ASD) requiring surgery are similar in both the groups. However, the back pain score and reoperation rates are better in fusion surgeries. Moreover, the problems needing reoperations (hardware problems and ASD) in fusion group are easier to treat. Fusion surgery is already indicated in rLDH cases with deformity, instability, and significant axial low back pain. We believe it should be considered in all cases due to negligible risk of recurrence, addressing the iatrogenic spinal instability caused due to extensive bony work, ease of surgery due to more working space, and better restoration of disk height and sagittal balance.

Keywords: Adjacent segment disease, discectomy, fusion, recurrent lumbar disk herniation, TLIF

How to cite this article:
Borkar SA, Bansal T. Recurrent lumbar disk herniation – Fusion is the answer. J Spinal Surg 2022;9:141-3

How to cite this URL:
Borkar SA, Bansal T. Recurrent lumbar disk herniation – Fusion is the answer. J Spinal Surg [serial online] 2022 [cited 2023 Feb 1];9:141-3. Available from: http://www.jossworld.org/text.asp?2022/9/3/141/356024

Recurrent lumbar disc herniation (rLDH) is defined as the occurrence of herniated disc material at the same level in a patient who has undergone discectomy. The rate of reherniation reported in the literature varies from 5% to 18%.[1] The risk factors for rLDH include smoking and diabetes mellitus.[2] Other risk factors include a young age, lack of motor or sensory deficit, and high Oswestry Disability Index (ODI) scores at baseline.[3] However, gender, BMI, and occupation of the patient have not been shown to affect the rates of recurrence.[2]

The treatment options for rLDH include repeat discectomy and discectomy with fusion. However, which option is ideal is a matter of debate. Discectomy and fusion came into picture for rLDH because there have been several concerns regarding only doing discectomy. Discectomy alone does not address inherent micro-instability which was not evident on preoperative dynamic X-rays that may have caused the rLDH. Moreover, revision discectomy requires extensive bone removal compared to index surgery which may cause iatrogenic instability. Epidural fibrosis, less space for working, difficulty in identification and retraction of nerve roots, irritation of dorsal root ganglion, and increased chances of dural tears are some of the other concerns.

Kerezoudis et al. in a meta-analysis found no difference between discectomy and discectomy with fusion with respect to complication rates, visual analog scale (VAS) back and leg pain, ODI score, and Japanese Orthopaedic Association (JOA) score at final follow-up. The postoperative treatment satisfaction rates as measured by MacNab satisfaction criteria were also similar in both the groups.[4] The findings were supported by another meta-analysis by Arif et al. who reported no significant differences between VAS pain scores and complication rates. However, they did report that the success rates and VAS back scores were better in the fusion group but statistical significance was not achieved.[5] Dower et al. in their systematic review noted that although the satisfaction rates in the discectomy group and fusion groups were similar, the back pain and JOA scores were significantly better in the fusion group.[6]

A recent meta-analysis noted the rates of reoperation were higher (9%) in the discectomy group than the fusion group (2%). However, this difference did not reach statistical significance.[7] The causes of reoperation in the two groups were also quite different with recurrent disc herniation being the primary cause in the former and removal of hardware and degeneration of adjacent segments being the cause in the latter.[7] The risk of recurrent disc herniation is negligible in the fusion group and problems such as adjacent segment disease (ASD) and hardware issues which may occur in fusion group are easier to treat than going in a third time to remove a recurrent disc.[8] A summary of relevant studies is presented in [Table 1].
Table 1: The results of major systematic reviews and metaanalysis comparing repeat discectomy and discectomy with fusion in recurrent lumbar disk herniation

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Critics of fusion for rLDH often highlight that the operative time, more blood loss, longer hospital stay, and higher costs associated with fusion with are major concerns.[8] However, we beg to differ in this regard. The higher operative time (approximately a mean of 70–100 min more) and blood loss (approximately 200–250 ml more) are a one-time compromise which are unlikely to have any long-term consequences.[7] The hospital stay of the patient is dictated by hospital policies and surgeons decision, besides the procedure itself. With the advent of Early Recovery After Surgery (ERAS) protocol adoption at various hospital across the world, the length of hospital stay and added costs are expected to come down.[9] More recent techniques of awake lumbar spinal fusion and minimally invasive techniques have further brought down the length of hospital stay.[10] On the cost aspect, while the operative cost for a discectomy is less than a fusion, a cost-utility analysis on patients of rLDH did not find any significant difference between them at 2-year follow-up.[11] Long-term high quality, cost–benefit analysis studies comparing discectomy, and fusion for rLDH can further clarify how cost differences balance out in long term.

One of the other concerns with fusion surgeries compared to discectomies is the risk of ASD. It is typically thought that the rates of ASD are higher with fusion surgeries, but that is only partially correct. Bydon et al. in study including 751 patients of single-level lumbar discectomy noted an incidence of ASD needing reoperation to be 4% over 3.11 years. The reoperation rate was estimated to be 1.35% annually.[12] No studies relating to ASD in discectomy post-rLDH are available in literature but the rates may be even higher. In another study involving 1000 patients who were operated with posterior lumbar interbody fusion (PLIF) had an incidence of ASD of 9% at a mean follow-up of 8.3 years. The estimated probability of ASD needing revision surgery was estimated to be 6.2% and 9.9% at 5 and 10 years postoperatively, respectively. The annualized incidence of ASD needing surgery was calculated to be 1% annually for 10 years postsurgery.[13] Hence, the rates of clinically significant ASD requiring surgery are similar after discectomy alone and discectomy and fusion surgeries.

Fusion surgery options include instrumented posterolateral fusion (PLF), PLIF, transforaminal lumbar interbody fusion (TLIF), lateral lumbar interbody fusion (LLIF), and anterior lumbar interbody fusion (ALIF).[14],[15],[16],[17] There are very few studies comparing these different options in rLDH. In a retrospective study by Li et al., ALIF, LLIF, and TLIF/PLIF were compared in total of 2625 patients operated for rLDH. They found that patients receiving PLIF/TLIF and LLIF had a significantly shorter hospital stay than patients who had ALIF. The risk of digestive system complications was also higher in the ALIF group.[15] In another retrospective study on 51 patients comparing PLIF and TLIF for rLDH noted similar outcomes in both the groups. However, the operative time and the incidence of dural tears were lower in the TLIF group.[14] In another prospective randomized study on 45 participants, discectomy, TLIF, and PLF were compared. They concluded that back pain scores were better and risk of dural tears was lower in fusion groups compared to the revision discectomy group. Results between PLF and TLIF group were comparable. However, the cost was higher in the TLIF group.[18] Based on the above discussion, TLIF and PLF are reasonable options for considering fusion in rLDH.

To conclude, while fusion surgery is already indicated in rLDH cases with deformity, instability, and significant axial low back pain,[19] we believe it should be considered in all cases of recurrent disc herniation. The reasons for the same are as follows. First, the risk factors associated with rLDH such as young age, diabetes, and smoking are not going to change and will continue to be risk factors later also. Second, in recurrent cases, there is risk of creating iatrogenic instability with discectomy alone which is not the case with fusion. Third, fusion surgery (especially TLIF) allows doing a more thorough job and giving extra space for the removal of disc, helps restoring disc height avoiding foraminal stenosis, and restores lumbar lordosis.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Shepard N, Cho W. Recurrent lumbar disc herniation: A review. Global Spine J 2019;9:202-9.  Back to cited text no. 1
Huang W, Han Z, Liu J, Yu L, Yu X. Risk factors for recurrent lumbar disc herniation: A systematic review and meta-analysis. Medicine (Baltimore) 2016;95:e2378.  Back to cited text no. 2
Abdu RW, Abdu WA, Pearson AM, Zhao W, Lurie JD, Weinstein JN. Reoperation for recurrent intervertebral disc herniation in the spine patient outcomes research trial: Analysis of rate, risk factors, and outcome. Spine (Phila Pa 1976) 2017;42:1106-14.  Back to cited text no. 3
Kerezoudis P, Goncalves S, Cesare JD, Alvi MA, Kurian DP, Sebastian AS, et al. Comparing outcomes of fusion versus repeat discectomy for recurrent lumbar disc herniation: A systematic review and meta-analysis. Clin Neurol Neurosurg 2018;171:70-8.  Back to cited text no. 4
Arif S, Brady Z, Enchev Y, Peev N. Is fusion the most suitable treatment option for recurrent lumbar disc herniation? A systematic review. Neurol Res 2020;42:1034-42.  Back to cited text no. 5
Dower A, Chatterji R, Swart A, Winder MJ. Surgical management of recurrent lumbar disc herniation and the role of fusion. J Clin Neurosci 2016;23:44-50.  Back to cited text no. 6
Tanavalee C, Limthongkul W, Yingsakmongkol W, Luksanapruksa P, Singhatanadgige W. A comparison between repeat discectomy versus fusion for the treatment of recurrent lumbar disc herniation: Systematic review and meta-analysis. J Clin Neurosci 2019;66:202-8.  Back to cited text no. 7
Guan J, Ravindra VM, Schmidt MH, Dailey AT, Hood RS, Bisson EF. Comparing clinical outcomes of repeat discectomy versus fusion for recurrent disc herniation utilizing the N2QOD. J Neurosurg Spine 2017;26:39-44.  Back to cited text no. 8
Garg B, Mehta N, Bansal T, Shekhar S, Khanna P, Baidya DK. Design and implementation of an enhanced recovery after surgery protocol in elective lumbar spine fusion by posterior approach: A retrospective, comparative study. Spine (Phila Pa 1976) 2021;46:E679-87.  Back to cited text no. 9
Abode-Iyamah K, Ghaith AK, Bhandarkar AR, De Biase G, Rajjoub R, Chen SG, et al. Single-level awake transforaminal lumbar interbody fusion: A Mayo Clinic institutional experience and national analysis. Neurosurg Focus 2021;51:E4.  Back to cited text no. 10
Selva-Sevilla C, Ferrara P, Gerónimo-Pardo M. Cost-utility analysis for recurrent lumbar disc herniation: Conservative treatment versus discectomy versus discectomy with fusion. Clin Spine Surg 2019;32:E228-34.  Back to cited text no. 11
Bydon M, Macki M, Kerezoudis P, Sciubba DM, Wolinsky JP, Witham TF, et al. The incidence of adjacent segment disease after lumbar discectomy: A study of 751 patients. J Clin Neurosci 2017;35:42-6.  Back to cited text no. 12
Okuda S, Yamashita T, Matsumoto T, Nagamoto Y, Sugiura T, Takahashi Y, et al. Adjacent segment disease after posterior lumbar interbody fusion: A case series of 1000 patients. Global Spine J 2018;8:722-7.  Back to cited text no. 13
Li L, Liu Y, Zhang P, Lei T, Li J, Shen Y. Comparison of posterior lumbar interbody fusion with transforaminal lumbar interbody fusion for treatment of recurrent lumbar disc herniation: A retrospective study. J Int Med Res 2016;44:1424-9.  Back to cited text no. 14
Ye YP, Hu JW, Zhang YG, Xu H. Impact of lumbar interbody fusion surgery on postoperative outcomes in patients with recurrent lumbar disc herniation: Analysis of the US national inpatient sample. J Clin Neurosci 2019;70:20-6.  Back to cited text no. 15
Yang Y, Yan X, Li W, Sun W, Wang K. Long-term clinical outcomes and pain assessment after posterior lumbar interbody fusion for recurrent lumbar disc herniation. Orthop Surg 2020;12:907-16.  Back to cited text no. 16
Fu TS, Lai PL, Tsai TT, Niu CC, Chen LH, Chen WJ. Long-term results of disc excision for recurrent lumbar disc herniation with or without posterolateral fusion. Spine (Phila Pa 1976) 2005;30:2830-4.  Back to cited text no. 17
El Shazly AA, El Wardany MA, Morsi AM. Recurrent lumbar disc herniation: A prospective comparative study of three surgical management procedures. Asian J Neurosurg 2013;8:139-46.  Back to cited text no. 18
Wang JC, Dailey AT, Mummaneni PV, Ghogawala Z, Resnick DK, Watters WC 3rd, et al. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 8: Lumbar fusion for disc herniation and radiculopathy. J Neurosurg Spine 2014;21:48-53.  Back to cited text no. 19


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