Journal of Spinal Surgery

EDITORIAL DEBATE
Year
: 2022  |  Volume : 9  |  Issue : 3  |  Page : 138--140

Recurrent disc prolapse after lumbar discectomy: Re-do discectomy is sufficient


Sushil Patkar 
 Department of Neurosurgery, Poona Hospital and Research Center, Pune, Maharashtra, India

Correspondence Address:
Sushil Patkar
No. 4 Uma Apartments, Lele Chowk, Ketkar Road, Pune-411004, Maharashtra
India




How to cite this article:
Patkar S. Recurrent disc prolapse after lumbar discectomy: Re-do discectomy is sufficient.J Spinal Surg 2022;9:138-140


How to cite this URL:
Patkar S. Recurrent disc prolapse after lumbar discectomy: Re-do discectomy is sufficient. J Spinal Surg [serial online] 2022 [cited 2023 Feb 1 ];9:138-140
Available from: http://www.jossworld.org/text.asp?2022/9/3/138/356025


Full Text

[AUTHOR:1]

 Introduction



Recurrent lumbar disc herniation (rLDH) was defined as disc herniation at the same level, nearly half of all recurrent herniation occur within the 1st year of the index operation, however, reherniation may occur as long as 8 years after the initial discectomy.[1],[2]

Love and Walsh presented the results of a series of 300 patients undergoing surgical discectomy and were the first to mention about recurrent prolapse.[3] The rate of reherniation reported in the literature varies from 0.5% to 25%.[4] Various reasons such as smoking, obesity, diabetes, and lifting weights have been implicated.[5],[6] A recent analysis of data from the Spine Patient Outcomes Research Trial identified younger age, lack of a sensory or motor deficit, and a higher baseline Oswestry Disability Index score as risk factors for recurrent disc herniation.[2] Advanced disc degeneration instability and decreased disc height were significant risk factors for rLDH.[7],[8] The operative technique of aggressive discectomy versus sequestrectomy has been blamed and debated without conclusion.[9],[10] A major reason for recurrent disc herniation after a discectomy is that the annular rent does not seal completely thus allowing a weakened defect to continue to be exposed to mechanical intradiscal pressure changes.

Diagnosis of a recurrent disc is essentially clinical, based on the recurrence of radicular pain with the same or increased intensity in the same radicular region after a pain-free interval following surgery. New backache or a different region of distribution would suggest instability or a new level of prolapse. Similar to the primary disc prolapse, there is a wide discrepancy between clinical symptoms, radiology, and the natural history of rLDH.

Magnetic resonance imaging (MRI) with contrast is the best imaging study to confirm the diagnosis. An MRI performed with gadolinium will achieve increased uptake due to scar tissue without altering the possible fragment of the herniated disc.[11]

Plain anteroposterior X-ray and lateral dynamic views are necessary to rule out instability and identify the amount of bone present at the previous surgical site which can be removed without damaging the pars interarticularis or facet joint at the symptomatic level. Lamina has been found to regrow after laminectomy.[12] A computed tomography scan can reveal fusion across the anterior vertebral edges, facet joints, and sometimes the remaining disc space making fusion fixation surgery redundant.[13]

 Discussion



The surgical treatment of recurrent lumbar disc remains controversial without any conclusive evidence in literature in favor of any one particular procedure. The surgical goal is to relieve the decompression of the neural structure by the recurrent prolapse without adding any complications. Repeat discectomy remains the most common option with reasonable success.[6],[14]

In patients of the recurrent disc without instability, discectomy alone irrespective of the type of surgery has excellent results.[15] Preoperative dynamic lateral X-rays to rule out instability and anterior-posterior X-ray of the affected level are imperative to check if there is adequate bone over the lateral recess at the affected level which can be removed to reach the disc and explore the root without damaging the pars interarticularis or damaging the facet joint.

Discectomy alone for rLDH has been an option since the problem was identified and continues to be an acceptable option in most recent literature.[15],[16]

The results of discectomy alone for rLDH have been satisfactory in majority of the published literature.

The second surgery is through scar tissue and involves additional muscle dissection with bone removal. Dural rents with postoperative cerebrospinal fluid leak and iatrogenic postoperative instability are the main challenges. Additional recurrences after second surgery have been encountered and inherent instability as a cause of rLDH was claimed to support the use of fixation fusion. Hence, in recent literature, there has been a trend toward fusion and fixation procedures for rLDH, and the most common option is a transforminal discectomy, interbody fusion and pedicle screw – rod fixation (TLIF). The proponents of TLIF claim that route decreases the chances of a dural rent, a more thorough discectomy, restoration of disc height, and rigid stabilization which relieves backache of preexisting or additional postoperative instability.[16],[17]

The additional operative time, blood loss, implant costs, long-term implications of accelerated adjacent level degeneration, and implant failure remain the issues against TLIF.[18],[19],[20]

Inherent instability as a cause of rLDH was claimed to support the use of fixation fusion in rLDH but without much evidence.

TLIF for rLDH has been supported with some studies claiming lesser postoperative backache and decreased chances of a second recurrence.[4],[21],[22]

Complications of TLIF are well-known in the literature. As TLIF involves cutting of the pars interarticularis (adding instability to reach the disc space) and then performing the discectomy for neural decompression, followed by a fusion fixation to treat the iatrogenic instability seems to be a catch 22 situation. In the absence of preoperative instability to offer TLIF is an iatrogenic surgical overkill. Apart from the perioperative complications of the TLIF procedure, adjacent level disc degeneration remains a potential problem irrespective of claims to project its insignificance or to minimalize it with newer dynamic implants. Long-term implant-related issues such as screw breakage, loosening, delayed infections, and implant migration remain a potential reality. The trade-off between the complications and costs versus the true benefits of the TLIF in the absence of preoperative instability needs to be discussed with the patient for making an informed choice.

The argument to use a transforaminal route and add an interbody cage with pedicle screw fixation seems to be based on fears not supported in the literature and probably reflects a bias of new generation surgeons toward implants which have attracted significant repeated criticism in recent literature. Apart from the surgical enthusiasm, financial incentives by implant manufacturers with manipulated surgical literature have been blamed for the decreased threshold for instrumentation in spinal surgery, and rLDH treatment cannot be immune to the same bias.[23],[24],[25]

Newer options like annular reconstruction to prevent rLDH need to be evaluated[26] Lateral percutaneous transforaminal endoscopic discectomy has gained popularity with supportive evidence for the treatment of disc prolapse and may have an increasing role as an option in the treatment of rLDH to avoid the scar tissue or add iatrogenic instability.[27]

Fusion fixation for all cases of rLDH is unnecessary in the absence of instability.[28]

 Conclusion



Re-do discectomy is adequate to treat rLDH in properly selected patients. There is no evidence for the superiority of any particular procedure for the treatment of rLDH. There is no evidence to support TLIF in all cases of rLDH.

References

1Hlubek RJ, Mundis GM Jr. Treatment for recurrent lumbar disc herniation. Curr Rev Musculoskelet Med 2017;10:517-20.
2Abdu 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.
3Truumees E. A history of lumbar disc herniation from Hippocrates to the 1990s. Clin Orthop Relat Res 2015;473:1885-95.
4Drazin D, Ugiliweneza B, Al-Khouja L, Yang D, Johnson P, Kim T, et al. Treatment of recurrent disc herniation: A systematic review. Cureus 2016;8:e622.
5Huang 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.
6Shepard N, Cho W. Recurrent lumbar disc herniation: A review. Global Spine J 2019;9:202-9.
7Kim KT, Park SW, Kim YB. Disc height and segmental motion as risk factors for recurrent lumbar disc herniation. Spine (Phila Pa 1976) 2009;34:2674-8.
8Brooks M, Dower A, Abdul Jalil MF, Kohan S. Radiological predictors of recurrent lumbar disc herniation: A systematic review and meta-analysis. J Neurosurg Spine 2020;34:481-91.
9Watters WC 3rd, McGirt MJ. An evidence-based review of the literature on the consequences of conservative versus aggressive discectomy for the treatment of primary disc herniation with radiculopathy. Spine J 2009;9:240-57.
10Thomé C, Barth M, Scharf J, Schmiedek P. Outcome after lumbar sequestrectomy compared with microdiscectomy: A prospective randomized study. J Neurosurg Spine 2005;2:271-8.
11Mullin WJ, Heithoff KB, Gilbert TJ Jr., Renfrew DL. Magnetic resonance evaluation of recurrent disc herniation: Is gadolinium necessary? Spine (Phila Pa 1976) 2000;25:1493-9.
12Dohzono S, Matsumura A, Terai H, Toyoda H, Suzuki A, Nakamura H. Radiographic evaluation of postoperative bone regrowth after microscopic bilateral decompression via a unilateral approach for degenerative lumbar spondylolisthesis. J Neurosurg Spine 2013;18:472-8.
13Li A, Post A, Dai J, Kamdar P, Tanvir F. Robust bone regrowth achieving autofusion across interlaminar space following lumbar microdiscectomy: Case report. Interdiscip Neurosurg 2019;17:143-5.
14Cinotti G, Roysam GS, Eisenstein SM, Postacchini F. Ipsilateral recurrent lumbar disc herniation. A prospective, controlled study. J Bone Joint Surg Br 1998;80:825-32.
15Guan 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.
16Arif 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.
17Abd El-Kader Hel-B. Transforaminal lumbar interbody fusion for management of recurrent lumbar disc herniation. Asian Spine J 2016;10:52-8.
18Tormenti MJ, Maserati MB, Bonfield CM, Gerszten PC, Moossy JJ, Kanter AS, et al. Perioperative surgical complications of transforaminal lumbar interbody fusion: A single-center experience. J Neurosurg Spine 2012;16:44-50.
19Wong AP, Smith ZA, Nixon AT, Lawton CD, Dahdaleh NS, Wong RH, et al. Intraoperative and perioperative complications in minimally invasive transforaminal lumbar interbody fusion: A review of 513 patients. J Neurosurg Spine 2015;22:487-95.
20Ye J, Yang S, Wei Z, Cai C, Zhang Y, Qiu H, et al. Incidence and risk factors for adjacent segment disease after transforaminal lumbar interbody fusion in patients with lumbar degenerative diseases. Int J Gen Med 2021;14:8185-92.
21Ahsan K, Khan SI, Zaman N, Ahmed N, Montemurro N, Chaurasia B. Fusion versus nonfusion treatment for recurrent lumbar disc herniation. J Craniovertebr Junction Spine 2021;12:44-53.
22Chen Z, Zhao J, Liu A, Yuan J, Li Z. Surgical treatment of recurrent lumbar disc herniation by transforaminal lumbar interbody fusion. Int Orthop 2009;33:197-201.
23Stahel PF, VanderHeiden TF, Kim FJ. Why do surgeons continue to perform unnecessary surgery? Patient Saf Surg 2017;11:1.
24Epstein NE, Hood DC. “Unnecessary” spinal surgery: A prospective 1-year study of one surgeon's experience. Surg Neurol Int 2011;2:83.
25Watts C. Response to “Unnecessary spinal surgery”. Surg Neurol Int 2011;2:108.
26Thomé C, Kuršumovic A, Klassen PD, Bouma GJ, Bostelmann R, Martens F, et al. Effectiveness of an annular closure device to prevent recurrent lumbar disc herniation: A secondary analysis with 5 years of follow-up. JAMA Netw Open 2021;4:e2136809.
27Li X, Hu Z, Cui J, Han Y, Pan J, Yang M, et al. Percutaneous endoscopic lumbar discectomy for recurrent lumbar disc herniation. Int J Surg 2016;27:8-16.
28Onyia CU, Menon SK. The debate on most ideal technique for managing recurrent lumbar disc herniation: A short review. Br J Neurosurg 2017;31:701-8.