Can a Disk Herniate Again After Surgery
Cureus. 2016 May; viii(5): e622.
Treatment of Recurrent Disc Herniation: A Systematic Review
Monitoring Editor: Alexander Muacevic and John R Adler
Doniel Drazin
one Section of Neurosurgery, Cedars-Sinai Medical Center
Beatrice Ugiliweneza
two Department of Neurosurgery, University of Louisville
Lutfi Al-Khouja
1 Section of Neurosurgery, Cedars-Sinai Medical Centre
Dongyan Yang
3 Department of Epidemiology and Population Health, University of Louisville
Patrick Johnson
1 Department of Neurosurgery, Cedars-Sinai Medical Center
Terrence Kim
iv Deparment of Orthopedics, Cedars-Sinai Medical Center
Maxwell Boakye
ii Department of Neurosurgery, University of Louisville
Received 2015 Sep 24; Accustomed 2016 May 21.
Abstract
Intervertebral disc herniation is one of the most mutual causes of back and extremity pain. The near commonly used surgical treatment is lumbar discectomy. Nigh 0.5-25% go on to develop recurrent disc herniation (rDH) after a successful first discectomy. Currently, there aren't any guidelines to assist surgeons in determining which arroyo is most appropriate to treat rDH. A contempo survey showed pregnant heterogeneity among surgeons regarding treatment options for rDH. It remains unclear which methods lead to better outcomes, equally there are no comparative studies with a sufficient level of evidence. In this written report, we aimed to perform a systematic review to compare treatment options for rDH and determine if ane intervention provides better outcomes than the other; more than specifically, whether outcome differences exist between discectomy alone and discectomy with fusion.
We applied the PICOS (participants, intervention, comparison, outcome, study design) format to develop this systematic review through PubMed. Twenty-seven papers from 1978-2014 met our inclusion criteria and were included in the assay. Nine papers reported outcomes after discectomy and seven of them showed good or excellent outcomes (70.lx%-89%). 10 papers reported on minimally invasive discectomy. The percent change in visual analog scale (VAS) ranged from -50.77% to -86.57%, indicating an overall pain reduction. 4 studies out of the ten reported expert or excellent outcomes (81% to 90.2%). Three studies looked at posterolateral fusion. Three studies analyzed posterior lumbar interbody fusion. For one study, we found the VAS percentage change to be -46.02%. All reported good to excellent outcomes. 6 studies evaluated the transforaminal lumbar interbody fusion. All reported improvement in pain. Four used VAS, and we found the percentage change to exist -54% to -86.5%. The other two used the Japanese Orthopedic Association (JOA) score, and nosotros found the pct change to exist 68.3% to 93.iii%.
We did not discover enough show to support whatever significant difference in outcomes between discectomy alone and discectomy with fusion. The limitation of our study includes the lack of standardized outcomes reporting in the literature. However, reviewing the selected articles shows that fusion may take a greater improvement in hurting compared to reoperation without fusion. Nonetheless, our study shows that further and more in-depth investigation is needed on the of treatment of rDH.
Keywords: recurrent disc herniation, recurrent lumbar disc herniation, spine, spinal fusion, revision fusion, minimally invasive lumbar fusion, interbody fusion, back pain
Introduction
Intervertebral disc herniation is one of the nearly common causes of dorsum and extremity pain that tin can eventually crave surgical intervention. Many surgical approaches take been utilized to treat disc herniation where the type of surgery is dependent upon the level of herniation, blazon of herniation, symptomatology, and surgeon preference. The most commonly used surgical method is a lumbar discectomy [i].
Disc reherniation is the most common crusade of reoperation after primary disc surgery and is defined as disc herniation occurring at the same level in a patient after a definite pain-gratis menstruum of at least half dozen months from initial surgery [2]. Rates of recurrent disc herniation (rDH) have been reported to be between 0.5% and 25% [3]. Although there are many theories as to what increases a patient'southward hazard for reherniation, no one factor has been identified consistently in the literature. Some of these proposed hazard factors include obesity, smoking, male gender, diabetes, weightlifting, the size of the annular tear, and type of chief operation [4-17]. Other causes of reoperation include new disc herniation at a different level, epidural fibrosis, adhesive arachnoiditis, spinal stenosis, and segmental instability [18].
Currently, at that place are no guidelines or significant comparative studies to assist surgeons in determining which approach would be most advisable to treat rDH. The American Association of Neurologic Surgeons (AANS) 2014 guidelines report low-level evidence to support fusion for rDH and call for farther investigations with improved study designs to better accost this event [19]. In the absence of guidelines to arroyo patients with rDH, there are significant differences in treatment plans among spine surgeons in the United States, which was evaluated in a survey of spine surgeons by Mroz, et al. [20]. Their survey found that a patient's treatment plan varied based on surgeon feel and operative volume. With the prognosis of repeated back surgery being relatively poor in regards to pain relief and return to piece of work [21], identifying the appropriate treatment for recurrent disc herniation is important to improve prognosis. A recent recommendation by Wang, et al. is to perform a discectomy in patients with rDH and radiculopathy [19]. Fu, et al. reported similar recommendations. Additionally, fusion has been recommended if the patient has associated lumbar instability, radiographic degenerative changes, and/or chronic axial lower back pain [22]. All the same, a repeat discectomy is by and large more difficult due to scar tissue from the primary surgery, and at that place is an increased the risk of dural tears or nerve injury [23]. Furthermore, using a minimally invasive percutaneous endoscopic method was adamant to exist effective in decreasing the chance of fusion and bleeding with reoperation in comparison to conventional revision discectomy [23]. A retrospective study by Ambrossi, et al. establish a substantial amount of healthcare costs associated with recurrent disc herniation averaging $26,593 per patient to diagnose and manage [24]. All in all, information technology is even so unclear which method has shown to be more effective for reoperation.
There are currently no studies directly comparison the various treatments of rDHs. The goal of this systematic review is to compare the various treatment options for rDH and determine if 1 intervention provides better outcomes than the others. More specifically, if there is a difference in outcomes from surgery with and without fusion.
The PICOS format is a technique used to assistance formulate a clinical question and guide the subsequent literature search to provide an evidence-based technique to learn clinical information from the literature [25-26]. Applying the PICOS format in developing this systematic review, we established the following criteria:
- Participants: Adults ≥ 18 with recurrent disc herniation
- Interventions: discectomy, minimally invasive surgical (MIS) discectomy, posterolateral fusion (PLF), posterior lumbar interbody fusion (PLIF), transforaminal interbody fusion (TLIF), anterior lumbar interbody fusion (ALIF)
- Comparisons: discectomy, MIS discectomy, PLF, PLIF, TLIF, ALIF
- Outcomes: whatsoever
- Study Designs: any
The hope is that this written report, with the above criteria, volition help to determine the advantages and disadvantages of various interventions to care for rDH.
Materials and methods
Literature search
A literature search was performed using PubMed with the search term "recurrent disc herniation" with MeSH terms "intervertebral disc displacement", "reoperation", and "recurrence". The search was performed on June 5, 2015. Studies were excluded if they did non address the treatment of recurrent disc herniation, did not state the specific intervention beingness studied, did non report validated outcomes of that specific intervention, or did not accept an adequate sample size (which was arbitrarily determined to be ≥ 10 patients per report grouping). No preference was taken to the type of study (prospective, retrospective, etc.), the length of follow-up, or status of publication. Ultimately, we included papers that had covered a specific surgical treatment selection for recurrent lumbar disc herniation that reported the outcomes of the intervention from unlike studies with an adequate sample size. We first reviewed the abstracts of all the articles that populated following the search for inclusion and exclusion criteria. So, an in-depth review of each individual article was conducted for further inclusion into our analysis.
Information variables
While reading through each newspaper, we looked at the type of surgery used, study type, length of follow-upwards, time spent in the operating room, estimated blood loss, costs associated with re-functioning, visual analogue scale ratings (VAS, pre- and postoperatively), Oswestry Inability Alphabetize (ODI, pre- and postoperatively), length of stay (LOS), re-operation outcomes, complications with re-operation, and pct with good or excellent outcomes. Percent differences of preoperative and postoperative VAS and ODI were calculated by dividing the difference over the preoperative score:
In computing the percent difference in VAS and ODI, we were able to constitute an internal control for each report and more accurately present the boilerplate changes in subjective and objective outcomes after surgery rather than comparison the raw numbers from each study.
Results
Using the queries listed higher up, a search through PubMed resulted in 106 abstracts that met initial screening criteria. Careful assay of these 106 articles brought us to 27 that fit the inclusion criteria to be function of the assay. Of note, some of these 27 articles discussed more than one type of surgery. At that place were eight articles studying repeat surgery with fusion, 17 without fusion, and two studying both. A summary of these papers is listed is listed in Tables 1- 2.
Tabular array 1
Handling of Recurrent Disc Herniation without Spinal Fusion Studies
EBL: Estimated Blood Loss; VAS: Visual Analog Calibration; ODI: Oswestry Disability Alphabetize; LOS: Length of Stay; TLIF: Transforaminal Interbody Fusion; DVT: Deep Vein Thrombosis; PLF: Posterior Lumbar Fusion; JOA: Japanese Orthopedic Association; NR: Not Reported; CSF: Cerebrospinal Fluid; PDTS: Posterior Dynamic Transpedicular Stabilisation; PELD: Percutaneous Endoscopic Lumbar Discectomy; OLM: Open up Lumbar Discectomy
| Article | Surgery Type | North (% Female person) | Study Type | Average Follow-Up, Months (Range) | OR Fourth dimension, Minutes (Range) | EBL, mL (Range) | Costs | Percent Change in VAS | Percentage Alter in ODI | Postop LOS, Days (Range) | Outcomes | Percent Showing Good or Excellent Outcomes | Complications in Repeat Surgery | |
| ane | El Shazly, 2013 [27] | Discectomy | 15 (46.7%) | Prospective, Randomized, Comparative | 38.6 ± 7.73 | 125.3 ± 25.32 | 256.7 ± 67.thirteen | $1,520 ± 36.84 | +52.17% in JOA score | NR | iii.four | Overall, all three methods showed meaning improvements postoperatively. Discectomy with fusion was associated with better improvement in pain and less complications. PLF was more than cost-effective compared to TLIF | 86.70% | Recurrent herniation x1, postop instability x1, postop neurological deficit x2, dural tear ten 4 |
| Discectomy with TLIF | 15 (xl%) | 36.iii ± 8.06 | 194 ± 25.58 | 653.iii ± 183.68 | $two,776.7 ± 56.27 | +70.0% in JOA score | NR | 3.5 | 93.xxx% | Postop neurological deficit x1, dural tear x2, DVT x1 | ||||
| Discectomy with PLF | 15 (46.7%) | 36.i ± 8.05 | 186 ± xvi.82 | 660 ± 164.97 | $2,186.7 ± 52.33 | +60.71% in JOA score | NR | 3.three | 86.70% | Dural tear x1, superficial wound infection x1 | ||||
| 2 | Kim, 2012 [37] | Microdiscectomy with CO2 Laser Dissection | 21 (42.9%) | Retrospective | xxx (nine - 36) | NR | NR | NR | -lx.53% | -61.32% (Korean version of ODI) | v.fourteen (two - 15) | Pregnant improvement of pain postoperatively in relation to VAS and ODI | NR | None |
| 3 | Ahsan, 2012 [30] | Discectomy | 18 (22.%2) | Retrospective | NR (12-48) | 141 ± 9 | NR | NR | -83.53% | -77.92% | 5 (iii - 8) | Results of echo discectomy comparable to main surgery | 85% | Foot drop x1, dural tear x3, superficial wound infection x1 |
| four | Shin, 2011 [23] | Endoscopic Discectomy | 41 (31.vii%) | Retrospective | 16 (13-42) | 37 (25 - 96) | Minimal | NR | Back Pain: -34.48%; Leg Hurting: -67.05% | NR | NR | Much comeback in pain without serious neurological deficits or compliations | 90.20% | Thecal sac injury with CSF leak x2, transient postoperative dysesthesia x2, recurrence x2, |
| 5 | Kaner, 2010 [36] | Microdiscectomy with PDTS | twoscore (42.5%) | Prospective | 41 (24 - 63) | NR | NR | NR | -86.57% | -88.56% | NR | Satisfactory comeback in VAS/ODI scores at ii-year follow-up | NR | Foreign body reaction x1, repeat operation for dynamic organisation removal and fusion x1 |
| half-dozen | Lee, 2009 [39] | PELD | 25 (36.0%) | Retrospective | 34.0 ± iv.4 | 45.8 ± 11 | NR | NR | Dorsum: -58.57% Leg: -65.48% | -66.forty% | 0.nine ± 0.v | PELD and OLM both showed favorable outcomes, simply PELD with shorter OR time, shorter LOS, and better disc height preservation compared to OLM | NR | ane patient with persistent leg hurting underwent echo performance with OLM; Recurrence in 1 patient |
| Open Lumbar Microdiscectomy | 29 (24.ane%) | 34.6 ± 4.6 | 73.8 ± 25.7 | Dorsum: -42.59% Leg: -59.30% | -71.16% | iii.8 ± 1.iv | Dural tear x2, voiding difficulty and perineal dysesthesia x1; Recurrence in 3 patients | |||||||
| 7 | Kim, 2009 [38] | Microdiscectomy | 14 (21.4%) | Retrospective | 56 (36-72) | NR | NR | NR | NR | NR | NR | The surgical outcome of first functioning was 79.7% ± ix.3% and of the second functioning was 77.8% ± ten.4% | NR | NR |
| 8 | Ambrossi, 2009 [24] | Bourgeois | 6 | Retrospective | 12 | NR | NR | $2,315 | NR | NR | NR | 5 patients underwent a single epidural steroid injection and 4 patients underwent 4 weeks of outpatient physical therapy | NR | NR |
| Discectomy | 11 | $39,836 | 1 patient without symptom relief subsequently surgery who subsequently underwent fusion | |||||||||||
| ix | Guo, 2009 [29] | Discectomy by Fenestration | 51 (25.five%) | Retrospective | 146.8 | NR | NR | NR | +64.eight% in JOA score | NR | NR | 8 patients (15.seven%) failed revision open up lumbar discectomy past fenestration | lxx.60% | five dural tears, 2 nerve root injuries, and 1 deep infection |
| ten | Palma, 2008 [32] | Discectomy | 95 (30.5%) | Retrospective | NR | 110 | NR | NR | NR | NR | NR | Overall longer OR time for reoperation compared to chief surgery (110 vs. 75) and an unsuccessful surgery rate of two% | 89% (compared to 95% after primary operation) | 4 dural tears |
| 11 | Hoogland, 2008 [35] | Endoscopic Transforaminal Discectomy | 262 (29%) | Prospective | 24 | NR | NR | NR | -66.71% in back pain; -69.14% in leg pain | NR | NR | Average comeback of back pain of 5.71 points and 5.85 points of leg pain on the VAS scale | 85.71% | 10 patients with complications (three.82%): 3 nervus root irritations and 7 early recurrent herniations |
| 12 | TS Fu, 2005 [22] | Discectomy | 23 | Retrospective | 88.7 (sixty –134) | 100.9 ± 22.8 | 162.7 ± 106.8 | NR | +62.45% in JOA score | NR | 4.seven ± 1.4 | Intraoperative blood loss, length of surgery, and length of hospitalization were significantly less in patients undergoing discectomy alone than in patients with fusion. | 78.3% based on JOA score | 3 dural tears |
| Discectomy with PLF | 18 | 166.3 ± 26.7 | 546.7 ± 206.1 | NR | +66.02% in JOA score | NR | 6.2 ± one.1 | 83.3% based on JOA score | one superficial infection, 2 dural tears, iii residual donor site pain | |||||
| xiii | LY Dai, 2005 [28] | Discectomy | 39 (41%) | Retrospective | 92 | NR | NR | NR | +58.62% in JOA score | NR | NR | The outcomes of repeat discectomy for recurrent disc herniation were satisfactory; 29/39 returned to previous work status or normal daily activities | 74.36% with splendid outcomes | 7 dural tears |
| 14 | Ahn, 2004 [33] | PELD | 43 (25.six%) | Retrospective | 31 (24-39) | 51 (25-100) | NR | NR | -70.41% | NR | NR | The pct of successful outcomes was 81.iv%, whereas the charge per unit of comeback was 95.3% | 81.40% | 1 with incomplete decompression and was converted to open up discectomy; ii with transient dysesthesia |
| 15 | Suk, 2001 [45] | Discectomy | 28 (xl.0%) | Retrospective | NR | 88.ix | NR | NR | NR | NR | 12.ix | Conventional open discectomy every bit a revision surgery for recurrent lumbar disc herniation showed satisfactory results that were comparable with those of primary discectomy | NR | NR |
| 16 | Cinotti, 1998 [34] | Microdiscectomy | 26 (31.0%) | Prospective | 24 months | NR | NR | NR | UTD | NR | i.five (1-3) | 17 patients were able to return to full employment and 4 were able to return to regular daily activities at same level as prior to primary discectomy | 81% | 2 dural tears, ane with postop discitis, one with second recurrent herniation |
| 17 | Silvers, 1994 [twoscore] | Microdiscectomy | 82 (35.0%) | Retrospective | 46.8 (< 12-168) | NR | NR | NR | NR | NR | iv.7 | Patients who presented inside one year of primary surgery with same level and aforementioned side recurrence had poor outcomes post-obit microdiscectomy | NR | 10 dural tears (four with CSF leakage), half dozen wound infections, 2 pseudomeningoceles, 1 wound hematoma |
| 18 | Herron, 1994 [31] | Laminectomy and Discectomy | 46 | Retrospective | 54 (12-128) | NR | NR | NR | NR | NR | NR | Satisfactory outcomes in treatment of rLDH without associated spinal instability. Nigh patients experienced "adept" surgical outcomes with >75% relief in dorsum and leg pain | >75% with expert surgical outcomes | NR |
| xix | Hou, 2015 [46] | Repeat Microendoscopic Discectomy | 25 (52%) | Prospective | 36 (12-72) | 85 (threescore-100) | 68 (twenty-100) | NR | Leg Pain: -71.6% | -54.lxxx% | NR | No nerve root or cauda equina injury | 96% | Small dural tear x3, Recurrence x1 resulting in fusion |
Table ii
Handling of Recurrent Disc Herniation with Spinal Fusion Studies
EBL: Estimated Blood Loss; VAS: Visual Analog Calibration; ODI: Oswestry Disability Alphabetize; LOS: Length of Stay; PLF: Posterior Lumbar Fusion; PLIF: Posterior Lumbar Interbody Fusion; NR: Non Reported; UTI: Urinary Tract Infection; TLIF: Transforaminal Lumbar Interbody Fusion; MIS: Minimally Invasive Surgery; DVT: Deep Vein Thrombosis; JOA: Japanese Orthopedic Clan; PSI: Pedicle Spiral Instrumentation; UTD: Unable to Determine; PSF: Posterior Spinal Fusion
| Article | Surgery Type | N (% Female person) | Written report Blazon | Boilerplate Follow-Up, Months (Range) | OR Fourth dimension, Minutes (Range) | EBL, mL (Range) | Costs | Percent Modify in VAS | Percent Alter in ODI | Postop LOS, Days (Range) | Outcomes | Percent Showing Good or Excellent Outcomes | Complications in Repeat Surgery | |
| 1 | Niu, 2005 [41] | PLF/PLIF by Dual Cages | 14 (43%) | Prospective | 25 (14-36) | 230 (150 - 350) | 623 (200 - 1,300) | NR | NR | NR | NR | No neurological deficits. | 93% | Superficial wound infection x2, UTI x1, wedged disc x1 |
| 2 | Li, 2015 [48] | TLIF | 73 (42%) | Retrospective, Unrandomized, example command | 49 (12-85) | 105 (70 - 260) | 260 (xc - 800) | NR | Leg: -86.5%; Back: -84.9% | -55.70% | 8.5 | No implant failure. Successful fusion in 92.3%. No permanent neurological deficit | 91.80% | Dural laceration x3, transient neuro deficits x5, revision surgery x3 |
| 3 | Omid-Kashani, 2014 [47] | TLIF | 51 (59%) | Retrospective | 31.4 (25-50) | NR | NR | NR | Leg: -54%; Back: -55.ane% | -61.90% | NR | Fusion rate 100%, no musical instrument failure | 74.sixty% | Iatrogenic fractional L5 root injury x1 |
| iv | Niesche, 2014 [43] | MIS-TLIF | 14 | Retrospective | 52 (48 - 59) | 140 (95 - 190) | 150 (120 - 370) | NR | -56.52% | -64.71% | 5 (3 - 7) | Solid radiographic fusion at 24 months; no development of adjacent disc disease | 85% | None |
| Open-TLIF | 19 | 130 (80 - 190) | 380 (350 - 620) | NR | -56.52% | -64.71% | ten (8-14) | Solid radiographic fusion at 24 months; improvement in VAS and ODI non every bit significant compared to MIS | 68.30% | 4 revisions due to wound healing disorders, two with neurologic deterioration due to radiculopathy | ||||
| v | Lequin, 2014 [21] | PLIF | 26 | Retrospective | xv.3 | NR | NR | NR | -46.02% | NR | NR | 85% with subjective improvement later on reoperation | 46% with good recovery | 2 hematomas, 2 dural tears, 4 with increased/new neurologic deficits, i superficial wound infection |
| half-dozen | El Shazly, 2013 [27] | Discectomy | 15 (46.7%) | Prospective, Randomized, Comparative | 38.six ± 7.73 | 125.iii ± 25.32 | 256.seven ± 67.13 | $i,520 ± 36.84 | +52.17% in JOA score | NR | 3.four | Overall, all three methods showed significant improvements postoperatively. Discectomy with fusion was associated with better improvement in pain and less complications. PLF was more cost-constructive compared to TLIF | 86.70% | Recurrent herniation x1, postop instability x1, postop neurological deficit x2, dural tear x 4 |
| Discectomy with TLIF | xv (40%) | 36.3 ± 8.06 | 194 ± 25.58 | 653.3 ± 183.68 | $two,776.vii ± 56.27 | +70.0% in JOA score | NR | iii.5 | 93.30% | Postop neurological deficit x1, dural tear x2, DVT x1 | ||||
| Discectomy with PLF | 15 (46.7%) | 36.i ± eight.05 | 186 ± sixteen.82 | 660 ± 164.97 | $2,186.7 ± 52.33 | +sixty.71% in JOA score | NR | 3.3 | 86.70% | Dural tear x1, superficial wound infection x1 | ||||
| seven | Sonmez, 2013 [2] | Unilateral MIS-TLIF with Pedical Screw Instrumentation | 10 (sixty%) | Prospective | 24 | 100 | 150 | 2,900 Turkish Lira | -78.82% | -55.07% | 2.2 | Unilateral MIS TLIF with PSI had comparable results to bilateral instrumentation in improving back pain and was much more than price-effective | NR | None |
| Bilateral MIS-TLIF with Pedical Screw Instrumentation | x (l%) | 147 | 165 | iv,700 Turkish Lira | -79.76% | -fifty.68% | two.3 | NR | None | |||||
| 8 | Chen, 2009 [49] | TLIF | 43 | UTD | 45 (24-72) | NR | NR | NR | +62.8% in JOA score | NR | NR | The mean JOA score was improved from 9.3 earlier surgery to 25.0 at the final follow-upwards visit. The fusion charge per unit was 100% 2 years postoperatively. No implant failure | 86.one% based on JOA score | Three patients (7%) had transient neurological deficits |
| 9 | Fu, 2005 [22] | Discectomy | 23 | Retrospective | 88.vii (threescore –134) | 100.ix ± 22.8 | 162.7 ± 106.viii | NR | +62.45% in JOA score | NR | four.7 ± i.four | Intraoperative blood loss, length of surgery, and length of hospitalization were significantly less in patients undergoing discectomy lone than in patients with fusion. | 78.3% based on JOA score | 3 dural tears |
| Discectomy with PLF | 18 | 166.3 ± 26.7 | 546.7 ± 206.1 | NR | +66.02% in JOA score | NR | 6.2 ± 1.1 | 83.3% based on JOA score | 1 superficial infection, 2 dural tears, and 3 residual donor site pain | |||||
| ten | Huang, 2002 [42] | PLIF with unmarried, central cage and bilateral PSF | 28 (64.iii%) | Retrospective | 14.4 (8-39) | NR | NR | NR | NR | NR | NR | Rate of bony fusion was 82.14%. Several patients with improved economic and functional status | 92.86% | 1 dural tear, 1 with transient paresthesias, and 1 with transient bladder atony |
Of the 27 articles reviewed for assay, seven discussed outcomes from discectomy, 10 from a minimally invasive discectomy, 5 from TLIF, ii from PLIF, one from both PLF/PLIF, and ii comparative studies comparison discectomy and discectomy with fusion (Figures 1- two) [22, 27]. Six of the twenty-seven articles either had a follow-up time < 24 months or were not reported; the other 21 articles had at least a 24-month follow-up. There were 7 prospective studies (26%), 19 retrospective studies (70%), and one where we were unable to make up one's mind whether it was a prospective or retrospective study.
Number of Papers by Type of Surgery
MIS: Minimally Invasive Surgery, PLF: Posterior Lumbar Fusion, PLIF: Posterior Lumbar Interbody Fusion, ALIF: Anterior Lumbar Interbody Fusion
Number of Papers by Type of Surgery and Yr of Publication
MIS: Minimally Invasive Surgery, PLF: Posterior Lumbar Fusion, PLIF: Posterior Lumbar Interbody Fusion, TLIF: Transforaminal Lumbar Interbody Fusion, ALIF: Anterior Lumbar Interbody Fusion
Discectomy
Of the nine articles reporting on the outcomes of discectomy for rDH, five (55.5%) reported VAS, JOA, or ODI scores for their written report population. Of the 5 that did study these variables, four were on the JOA scale, which is a modified ODI [22, 27-29]. The percent comeback in JOA amid these studies ranged from 52.17% to 64.8%. Only one study reported ODI scores [30]. As a event, no authentic calculations can be made to determine the average VAS and ODI changes after discectomy for rDH. Seven of the 9 studies reported the percentage of patients showing good or first-class outcomes, which ranged from 70.lx% to 89% [29, 31-32]. Of the total 326 patients undergoing discectomy from nine studies, dural tear was the nearly common complexity reported occurring in 26 patients (8%) with three studies not reporting on complications. Ane reherniation occurred in 0.three% [27]. Neurological deficits or nervus root injuries occurred in five patients (1.5%).
Minimally invasive discectomy
Of the ten articles reporting on the outcomes of minimally invasive discectomy for rDH, half-dozen (60%) reported VAS and four (40%) reported ODI. Percent comeback in VAS among these studies ranged from 50.77% to 86.57%, indicating an overall pain reduction after operation for rDH using a minimally invasive discectomy. Percentage improvement in ODI ranged from 61.32% to 88.56% (based on preoperative and postoperative values). Four of the nine studies reported the percentage of patients showing proficient or excellent outcomes, which ranged from 81% to 90.2% [23, 33-40]. Of the total 579 patients undergoing minimally invasive discectomy, dural tear was the nearly common complexity reported and occurred in 23 patients (iv%). Twelve patients had reherniation (ii%). One of the ten manufactures reviewed did not report on complications [38]. Neurological complications occurred in seven patients (1.2%): four with transient dysesthesia and 3 with nerve root irritations.
Posterolateral fusion (PLF)
Iii studies were noted to accept evaluated patients undergoing PLF later rDH. One of these studies performed PLIF in 12 of the fourteen patients evaluated, so it was instead excluded from this category [39]. The two remaining studies analyzed the PLF treatment in rDH and reported back pain based on the JOA scale, showing an improvement by 60.71% and 66.02% [22, 27]. El Shazly, et al. and Fu, et al. reported good or first-class outcomes in 86.seventy% and 83.3%, respectively. El Shazly, et al. also constitute PLF to exist more cost effective than TLIF, but patients undergoing TLIF had a meliorate improvement in JOA score (seventy% vs. 60.7%, respectively) and a larger percentage showing either skillful or first-class outcomes (93.3% vs. 86.seven%). Fu, et al. establish much longer OR times and larger EBL with PLF compared to discectomy alone but, overall, showed better outcomes with PLF. Of the 33 patients from the ii studies who underwent PLF, three patients had dural tears (9%) and two had superficial wound infections (half dozen%).
Posterior lumbar interbody fusion (PLIF)
One of the three studies analyzed reported preoperative and postoperative VAS with a pct improvement of 46.02% [21]. Lequin, et al. reported 46% with skillful outcomes, Huang, et al. reported 92.86% with adept or excellent outcomes, and Niu, et al. reported 93% with good or excellent outcomes [21, 41-42]. There were 68 patients who underwent PLIF betwixt the three studies reviewed. 3 patients had dural tears (4.4%) and six patients had neurological complications (8.eight%). The neurological complications included worsening or new neurological deficits in iv patients, one patient with transient paresthesias, and one patient with float atony.
Transforaminal lumbar interbody fusion (TLIF)
Four of the six studies used the VAS metric to assess pain while the other 2 utilized the JOA scale. VAS improvement ranged from 54% to 86.5%. JOA scale change improvement was reported from 62.viii% to 70%. Percent showing adept or excellent outcomes ranged from 68.3% to 93.three% in the five studies reporting these findings. Niesche, et al. found no complications utilizing a minimally invasive TLIF approach with 85% showing skillful or excellent outcomes [43]. In that location were 216 patients who underwent TLIF from the six studies reviewed. 5 patients (2.3%) had dural tears, 10 with neurological deficits postoperatively (4.6%), and three requiring revision surgery (ane.3%).
Discussion
In reviewing the 23 articles that reported treatment outcomes for rDH, it is nonetheless difficult to define which intervention is the most advisable to use. All of the papers showed overall positive results in relieving pain when comparing preoperative and postoperative functional outcome measures, such every bit the VAS, JOA, and ODI. VAS and ODI are currently the most valuable resource of objective data in measuring the level of success. Information technology is difficult, however, to place whatsoever objective measures of success through radiographic imaging. A study past Cheng, et al. looked at the charge per unit of get-go-time recurrent herniations in 207 patients based on the type of primary surgery and constitute that there was a lower charge per unit of recurrence using a traditional open arroyo versus a microendoscopic discectomy or percutaneous endoscopic discectomy (37.8% vs. 47.1% and 70.6%, respectively) [44]. There is an insufficient amount of published data to help determine the near advisable method of treating rDH at this time. Being that disc herniation is one of the nearly common back problems requiring surgical intervention, identifying the appropriate methods to accurately diagnose and treat rDH with standard outcomes measures would exist worthwhile to investigate. This would also assistance to plant the most cost-constructive intervention (surgical and not-surgical) with the everyman associated morbidity.
The choice between echo discectomy and discectomy with fusion for rDH has been a highly debated topic [45-49]. In one perspective, fusion is normally costlier, associated with more complications, longer OR times, larger EBL, and longer hospitalizations. In the analysis performed here, it seems that TLIF is the more than superior fusion pick based on the greatest decrease in VAS/ODI compared to the other fusion studies reviewed. However, the lack of published information on other forms of fusion and limited comparative studies makes it more than difficult to accurately make this conclusion. One of the two comparative studies reviewed by Fu, et al. compared discectomy and discectomy with PLF and found better comeback of hurting after fusion. However, fusion was also associated with more complications, more claret loss, and longer operative times compared with discectomy alone [22].
From a surgical decision-making perspective, it was difficult to determine indications or a reliable algorithm for selection of fusion for rDH from the articles reviewed. Mroz, et al. published their findings from a survey identifying the surgical treatment patterns among spine surgeons in the U.s.a. for lumbar rDH and found that the number of surgeries performed and years of practice had a statistically significant affect on the type of surgery performed [20]. They concluded that a surgeon practicing for 15-20 years is less likely to perform a revision microdiscectomy with fusion versus revision microdiscectomy alone. Notwithstanding, they likewise establish that college volume surgeons with > 200 cases per year were more likely to perform a fusion to address rDH. This variance could be indicative of multiple factors, including surgeon preference and patient characteristics, merely nosotros need to consider the lack of proper evidence-based information as a probable reason for the lack of definitive recommendations. One consideration is to use the National Neurosurgery Quality and Outcomes Database (Due north2QOD) registry, which is a prospectively nerveless sampling of patients who experienced same-level, same-side rDH, had either a discectomy or arthrodesis, and had one-year follow-upwardly [50]. This registry collects the same data variables on all patients, which allows for improve statistical analysis than when trying to combine data in a meta-analysis. Additionally, this volition assist in performing more than accurate comparative analyses to make up one's mind indications or generate a reliable algorithm for the treatment of rDH. The abstract by McGirt, et al. found greater healthcare utilization and morbidity with arthrodesis in their comparative analysis of 417 patients in the N2QOD registry and concluded that revision discectomy is the more efficient treatment pick [50].
In regards to reporting the rates of reherniation, ane business in the literature is the lack of distinguishability between radiographic prove of reherniation and symptomatic reherniation. Lebow, et al. plant that almost one-fourth of patients who underwent a lumbar discectomy had radiographic evidence of reherniation with the majority being asymptomatic [51]. Furthermore, these asymptomatic reherniations did not develop any clinical consequences at the two-year follow-up. In regards to the studies reviewed in this analysis, information technology is unclear whether they had radiographic or symptomatic show of reherniation. For example, Vik, et al. reported outcomes on 39 patients who underwent revision surgery due to suspected herniation but then found that recurrence had been found in only 14 of them [52]. Similarly, Ozgen, et al. studied 114 patients with previous lumbar disc surgery who underwent re-exploration and constitute that only 56 had a truthful recurrence of herniation [18]. Epidural fibrosis, a major intraoperative finding in non-rDH revision surgeries, is often difficult to distinguish with advanced imaging and presents with similar clinical symptomology. This has been shown in previously published studies to be associated with poor results from revision surgical intervention [53-57]. It appears from these reported data that many patients who practise not accept a true recurrence are still undergoing surgical handling in place of a more conservative management without the morbidity of a second performance. Formulating a more concrete prepare of diagnostic criteria for rDH would help delineate the apply of symptomatic versus radiographic diagnosis. It would be worthwhile to perform a comparative analysis along with a cost-effectiveness analysis to decide if the costs of imaging to diagnose rDH outweigh the costs of unnecessary operations for patients who were incorrectly diagnosed or having clinical symptomatology lone.
In our review of the literature for the cervical and thoracic spine, the rates of rDH were rarely mentioned. Although the incidence of rDH in these spinal regions occurs less frequently compared to the lumbar spine, the management is somewhat like. It would exist of value to determine the efficacy of these various interventions to better guide our treatment algorithms.
Study limitations
Some of the limitations of this study include the modest number of papers currently published on the treatment of rDH and the reporting of standardized outcome measures. Additionally, of the papers that were included, there was a broad spectrum of definitions of rDH, making information technology hard to compare the patients selected for treatment and their outcomes. The lack of uniformity in postoperative data collection was farther amplified by not all of the studies reporting similar time points later on surgery for postoperative VAS and ODI. The possible variability in when the VAS and ODI were recorded in each paper could be a limitation that we were unable to correct for, given the data reported.
Futurity outlook/recommendations
Futurity studies assessing outcomes of the treatment of recurrent disc herniation are needed in lodge to plant a better perspective on the proper approach to and direction of recurrent disc herniation. Studies using registries tin assist amend elucidate these questions past allowing more comparative analyses to be done and work towards making more than accurate treatment recommendations and algorithms [45]. This includes further investigation of hazard factors for recurrence and comparative studies on the outcomes of these surgical techniques. Identifying truthful risk factors for recurrent herniation can help stratify patients for different handling options and possibly take an touch on on costs if reherniation tin can be avoided. Another consideration is the question of accurate versus precise diagnosis of recurrence. Although it is difficult right now to institute an authentic diagnosis, having a ameliorate definition of rDH would allow for improve precision and standardization of what the literature describes every bit rDH. Several of the studies reviewed noted performing MRIs on each patient to decide if reherniation had occurred, simply this may not be necessary or the nigh cost-effective method of diagnosis and treatment.
Nosotros developed a set of recommendations for futurity studies on surgical outcomes, which are summarized in Table 3. In gild to achieve more accurate results on the outcomes of a surgical intervention for rDH, prospective studies with a minimum ii-twelvemonth follow-upward are needed to properly assess the long-term implications after surgery. We hope that these factors, forth with already published reporting guidelines, will aid produce studies that tin can change the way patients are treated for rDH in the future.
Table 3
Recommendations for Future Studies in Recurrent Disc Herniation Treatment.
| Recommendations: |
| 1. How recurrence of disc herniation was determined (imaging, symptomatology, etc.) |
| ii. Which level and side (ipsilateral or contralateral) the reherniation was located |
| 3. Time frame after primary operation |
| 4. Which intervention(s) are being studied |
| iv. Reporting of preoperative VAS/ODI |
| v. Reporting postoperative VAS/ODI immediately later surgery and at 6-month intervals for at least 2 years |
| 6. Percent with good or first-class outcomes using MacNab'south assessment |
| 7. Complicating factors to reherniation (i.e. fibrosis, etc.) |
| 8. Fourth dimension until render to work or regular daily activities |
Conclusions
The current assay was non able to conclude on any significant deviation in outcomes in comparing one surgical method to some other. This is largely based on the lack of standardized reporting of outcomes in the literature, which makes information technology difficult to combine these data points for analysis with such a pocket-sized power. Still, in reviewing the few selected manufactures that met our stringent criteria, nosotros concluded that fusion may take a greater improvement in hurting and functional outcomes compared to reoperation without fusion at the toll of more complications, increased blood loss, and longer operative times for the treatment of rDH.
Notes
The content published in Cureus is the event of clinical experience and/or research past independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of information or conclusions published herein. All content published inside Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should non be deemed a suitable substitute for the advice of a qualified wellness intendance professional. Exercise not disregard or avoid professional medical advice due to content published within Cureus.
The authors have declared that no competing interests exist.
Human Ethics
Consent was obtained by all participants in this study
Animal Ethics
Animal subjects: This report did not involve animal subjects or tissue.
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