|Year : 2016 | Volume
| Issue : 3 | Page : 642-645
The role of instrumented fusion in the management of recurrent lumbar disc herniation
Mohamed S Elsanafiry1, Adel Hanafy1, Ahmed Azab1, Ahmed Sh. Ammar1, Alaa A Elsesy2
1 Department of Neurosurgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||17-Jan-2015|
|Date of Acceptance||15-Mar-2015|
|Date of Web Publication||23-Jan-2017|
Mohamed S Elsanafiry
21 Maktab Elsaha Street, Birket Elsabaa, Menoufia, 32651
Source of Support: None, Conflict of Interest: None
The aim of the present study was to compare the clinical outcome of discectomy alone with discectomy and fusion in the treatment of recurrent lumbar disc herniation.
Lumbar disc herniation is one of the most common spinal conditions and causes widespread medical problems. The management of recurrent disc herniation remains somewhat controversial. Surgical treatment for recurrent disc herniation can be broadly categorized as revision discectomy alone or revision discectomy and fusion.
Patients and methods
Fifty patients (35 M, 15 F) with an average age of 45.9 years (range: 31-60 years) were retrospectively and prospectively evaluated. All patients underwent discectomy (n = 22) or discectomy and fusion (transpedicular screws with or without interbody fusion) at Menoufia University Hospitals, from January 2011 to April 2014 (minimum 12-month follow-up). The clinical and radiographic results were compared between the two groups. Clinical outcome was assessed using the visual analogue scale (VAS) and the Oswestry disability index.
In comparison with the discectomy group, the discectomy and fusion had significantly lesser VAS (leg pain), VAS (back pain), and lesser Oswestry disability index during the follow-up period postoperatively. Complications included cases of seven small dural tear in the discectomy group. There were four cases of dural tear and two cases of superficial wound infection in the discectomy and fusion group. One case of hardware failure was observed in the discectomy and fusion group.
In cases of recurrent lumbar disc herniation, the clinical outcome is better when the patients were operated by using discectomy and fusion rather than using discectomy alone.
Keywords: fusion, lumbar disc, recurrent
|How to cite this article:|
Elsanafiry MS, Hanafy A, Azab A, Ammar AS, Elsesy AA. The role of instrumented fusion in the management of recurrent lumbar disc herniation. Menoufia Med J 2016;29:642-5
|How to cite this URL:|
Elsanafiry MS, Hanafy A, Azab A, Ammar AS, Elsesy AA. The role of instrumented fusion in the management of recurrent lumbar disc herniation. Menoufia Med J [serial online] 2016 [cited 2020 Apr 3];29:642-5. Available from: http://www.mmj.eg.net/text.asp?2016/29/3/642/198747
| Introduction|| |
Lumbar disc herniation is one of the most common spinal conditions and causes widespread medical problems  . The strict definition of recurrent disc herniation is the presence of herniated disc material at the same level, ipsilateral or contralateral, in a patient who has experienced a pain-free interval of at least 6 months since surgery  . Indications for surgery of recurrent lumbar disc herniation (RLDH) are intractable pain that had not responded to conservative management for 6-8 weeks, positive tension sign, and recurrent disc herniation with compression of the nerve root confirmed by MRI  . The management of recurrent disc herniation remains somewhat controversial  . Surgical treatment for recurrent disk herniation can be broadly categorized as revision discectomy alone or revision discectomy and fusion  .
| Patients and methods|| |
The study was performed between January 2011 and April 2014; 50 patients were surgically treated for RLDH at the Department of Neurosurgery, Menoufia University Hospitals. The patients' clinical data were retrospectively and prospectively analyzed as regards the duration before the recurrence of symptoms, the site of new symptoms, the type of the previous operation, the type of new operation, and the outcome after these procedure. The inclusion criteria included cases with RLDH operated by using open or minimal invasive procedures, with at least 6 months of pain relief after primary disc surgery, not responding to medical treatment for 6 weeks preoperatively, and positive radiological findings of recurrence. The accepted cases needed to have RLDH at the same level as the previous discectomy, either the ipsilateral or the contralateral side. The exclusion criteria included cases of RLDH with other spinal pathology, traumatic vertebral fracture, scoliosis, infection, osteoporosis, serious systemic disease, patients with disc herniation at a new level, and patients with recurrent sciatica or low back pain due to perineural fibrosis and scar tissue formation after primary disc surgery. Preoperative assessment was carried out clinically using the visual analogue scale (VAS) and the Oswestry disability index (ODI), and radiologically, using MRI lumbosacral spine with gadolinium and dynamic lumbosacral radiograph with both oblique views. The patients were divided into two groups: group A, in which patients underwent discectomy, and group B, in which patients underwent discectomy and fusion (transpedicular screws fixation with or without interbody fusion). Clinical postoperative assessment was done using VAS and ODI.
| Results|| |
The mean age of the patients was 45.90 years (range: 31-60 years). There were 35 men and 15 women (2.3: 1). Twelve (24%) patients had diabetes mellitus. Twenty-six (52%) cases were smokers. Twenty-five (50%) patients were included in the hard-work group, 15 (30%) patients in the light-work group, and ten (20%) patients in the nonoccupied group. The time interval before recurrence of pain ranged from 7 to 120 months with a mean of 33.70 months. Discectomy with total laminectomy was the most common previous surgery (30 cases, 60%), followed by discectomy and hemilaminectomy (12 cases, 24%), and then discectomy and laminotomy (eight cases, 16%). All patients had only one previous lumbar surgery except four (8%) cases who had two sets of previous lumbar discectomy. MRI revealed recurrent posterolateral disc herniation in 43 (86%) cases and central in seven (14%) cases. Recurrence level was one (2%) case in the L2-3 and L3-4 levels, 24 (48%) cases in the L4-5 level, 18 (36%) cases in the L5-S1 level. Double level recurrence (L4-5 and L5-S1) was found in six (12%) cases. Regarding the postoperative clinical outcome, VAS (leg pain) was significantly higher in group A (at 3 months = 3.04 ± 0.95, at 6 months = 2.50 ± 0.80, and at 12 months = 1.36 ± 0.95) than in group B (at 3 months = 1.46 ± 1.10, at 6 months = 0.75 ± 0.79, and at 12 months = 0.39 ± 0.49; P < 0.001) ([Table 1]). VAS (back pain) was significantly higher in group A (at immediate postoperative = 3.86 ± 0.99, at 3 months = 2.68 ± 0.89, at 6 months = 2.31 ± 1.04, and at 12 months = 2.31 ± 1.04) than in group B (at immediate postoperative = 2.07 ± 0.89, at 3 months = 1.96 ± 1.07, at 6 months = 1.28 ± 0.85, and at 12 months = 0.71 ± 0.65; P < 0.001, 0.017, 0.001, and <0.001, respectively) ([Table 2]). ODI was significantly higher in group A (postoperative at 3 months = 27.50 ± 8.55, at 6 months = 22.04 ± 7.81, and at 12 months = 14.31 ± 4.16) than in group B (at 3 months = 19.10 ± 7.70, at 6 months = 13.07 ± 6.16, and at 12 months = 10.53 ± 4.15; P = 0.003, <0.001, and 0.004, respectively) ([Table 3]). The operative complications are listed in [Table 4] (pre-operative and post-operative radiology are shown in [Figure 1], [Figure 2] and [Figure 3]).
|Figure 1: A case of a male patient, 57 years old, presenting with low back pain and left sciatica for 3 months, with previous L4 laminectomy with L4-5 discectomy 24 months ago for lift sciatica. (a and b) Sagittal and axial T2WI MRI images showing recurrent L4-5 disc herniation. (c and d) Preoperative radiograph A-P and lateral view. (e and f) Postoperative radiograph A-P and lateral view showing the combined transpedicular screw fixation with interbody autologue bone graft.|
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|Figure 2: A case of a female patient, 30 years old, presenting with left sciatica for 3 months, with previous L4-5 discectomy 15 months ago for left sciatica. (a and b) Sagittal and axial T2WI MRI images showing recurrent L4-5 disc herniation. (c and d) Postoperative radiograph A-P and lateral view showing the combined transpedicular screw fixation with interbody cage.|
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|Figure 3: A case of a male patient, 51 years old, presenting with low back pain and bilateral sciatica for 9 months, with L4-5 discectomy 25 years ago for left sciatica. (a and b) Sagittal and axial T2WI MRI images showing recurrent L4-5 disc herniation. (c and d) Preoperative radiograph A-P and lateral view. (e and f) Postoperative radiograph A-P and lateral view showing transpedicular screw fixation.|
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|Table 1 Distribution of the studied operation types regarding visual analogue scale (leg pain) results (preoperative and postoperative) |
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|Table 2 Distribution of the studied operation types regarding visual analogue scale (back pain) results (preoperative and postoperative) |
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|Table 3 Distribution of the studied operation types regarding Oswestry disability index results (preoperative and postoperative) |
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|Table 4 Distribution of the studied operation types regarding complications |
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| Discussion|| |
There is a number of case series describing outcomes after either reoperative discectomy or reoperative discectomy combined with fusion. Suk et al.  reported that patient outcomes following reoperative discectomy were satisfactory and similar to those in patients treated with primary disc excision. Several other authors have reported similar findings ,,,,,, . These series indicate that patients improve following reoperative discectomy for recurrent disc herniation. Other authors have described the results of reoperative decompression and supplemental fusion for patients with RLDH. The optimal surgical approach for recurrent disc herniation remains a subject of controversy. Discectomy with fusion has several theoretical advantages. Specifically, interbody fusion reduces or eliminates segmental motion, immobilizes the spine, reduces mechanical stresses across the degenerated disc space  , and has higher fusion rates and fewer construct failures  . Lehmann and LaRocca  treated 36 patients following previous lumbar surgery by using spinal canal exploration and spinal fusion. Solid fusion correlated closely with satisfactory outcomes, and the patients in the fusion group tended to have better outcomes than those with disc excision alone. Glassman et al.  used the 36-item short form to perform a prospective study of patients with recurrent herniated discs undergoing reoperative discectomy and fusion. They described significant improvement in physical function, social function, and bodily pain 1 year after the surgery. Iida et al.  reported 46 patients who had underdone either partial or wide laminectomy. They were followed up for more than 1 year after surgery. The total number of cases of instability confirmed at the operated level or at both the operated and adjacent levels was 52.2% (24/46). A large retrospective follow-up study of patients undergoing multiple revisions after lumbar discectomy revealed markedly reduced risk for subsequent operations if the first procedure was a spinal fusion (5.0% after spinal fusion vs. 24.9% after discectomy and 27.2% after spinal decompression)  . Therefore, the use of fusion to treat or prevent segmental instability after repeated discectomy appears to be a reasonable choice in the cases of recurrent disc herniation.
| Conclusion|| |
In cases of RLDH, the clinical outcome is better when the patients are reoperated by using discectomy and fusion rather than by using discectomy alone.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kaner T, Sasani M, Oktenoglu T. Minimum two-year follow-up of cases with recurrent disc herniation treated with microdiscectomy and posterior dynamic transpedicular stabilisation. Open Orthop J 2010; 4
Karin SR, Gregory TR. Recurrent lumbar disc herniation. Neurosurg Focus 2003; 15
Suk KS, Lee HM, Moon SH, Kim NH. Recurrent lumbar disc herniation: results of operative management. Spine (Phila Pa1976) 2001; 26
Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, et al.
Guidelines 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 2005; 2
Robert MG, Mitchel BH, Christopher MB. The role of fusion for recurrent disk herniations. Semin Spine Surg 2011; 23
Ozgen S, Naderi S, Ozek MM, Pamir MN. Findings and outcome of revision lumbar disc surgery. J Spinal Disord 1999; 12
Cinotti G, Roysam GS, Eisenstein SM, Postacchini F. Ipsilateral recurrent lumbar disc herniation. A prospective, controlled study. J Bone Joint Surg Br 1998; 80
Baba H, Chen Q, Kamitani K, Imura S, Tomita K. Revision surgery for lumbar disc herniation. An analysis of 45 patients. Int Orthop 1995; 19
Ebeling U, Kalbarcyk H, Reulen HJ. Microsurgical reoperation following lumbar disc surgery. Timing, surgical findings, and outcome in 92 patients. J Neurosurg 1989; 70
Haglund MM, Moore AJ, Marsh H, Uttley D. Outcome after repeat lumbar microdiscectomy. Br J Neurosurg 1995; 9
Herron L. Recurrent lumbar disc herniation: results of repeat laminectomy and discectomy. J Spinal Disord 1994; 7
Jonsson B, Stromqvist B. Repeat decompression of lumbar nerve roots. A prospective two-year evaluation. J Bone Joint Surg Br 1993; 75
Barrick WT, Schofferman JA, Reynolds JB, Goldthwaite ND, McKeehen M, Keaney D, et al.
Anterior lumbar fusion improves discogenic pain at levels of prior posterolateral fusion. Spine (Phila Pa 1976) 2000; 25
Hosam HH. Posterolateral fusion versus posterior interbody fusion in adult lumbar isthmic spondylolisthesis. Menoufia Med J 2014; 27
Lehmann TR, LaRocca HS. Repeat lumbar surgery. A review of patients with failure from previous lumbar surgery treated by spinal canal exploration and lumbar spinal fusion. Spine (Phila Pa 1976) 1981; 6
Glassman SD, Minkow RE, Dimar JR, Puno RM, Raque GH, Johnson JR. Effect of prior lumbar discectomy on outcome of lumbar fusion: a prospective analysis using the SF-36 measure. J Spinal Disord 1998; 11
Iida Y, Kataoka O, Sho T, Sumi M, Hirose T, Bessho Y, et al.
Postoperative lumbar spinal instability occurring or progressing secondary to laminectomy. Spine (Phila Pa 1976) 1990; 15
Osterman H, Sund R, Seitsalo S, Keskimaki I. Risk of multiple reoperations after lumbar discectomy: a population-based study. Spine (Phila Pa 1976) 2003; 28
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]