Recurrent Lumbar disc Herniation: to Fuse or not to Fuse Grigory - - PowerPoint PPT Presentation

Recurrent Lumbar disc Herniation: to Fuse or not to Fuse

Grigory Goldberg

Definition

 Disc herniation occurring at the same

level in a patient after a definite pain-free period of at least six months from initial surgery (1)

 Reported rate of 0.5% to 25% (2)

Risk Factors

 Obesity  Smoking  Male gender  Diabetes  Weightlifting  Size of annual tear

True Re-herniation: or is it?

 Epidural fibrosis is a major intra-op

finding in revision discectomy

 Hard to distinguish radiologically fibrosis

• vs. true re-herniation

 Fibrosis has been associated with poor

results from revision laminectomy (4)

True Re-herniation: or is it?

 Lebow et al : ¼ of asymptomatic pts after

discectomy showed MRI re-herniation (5)

 Ozgen et al:

114 pts underwent revision surgery 56 had true recurrence (6)

 Vik et al:

39 pts underwent revision surgery 14 pt had actual recurrence (7)

Pain

 Failed 3-6 months of

conservative tx

 Progression of

radiculopathy

 Neurologic deficit  Positive MRI findings

Fear

 Hard to develop plane

between disc fragment, annulus and neural elements

 Chance of dural tear goes

up to 20% in revision laminectomy (8)

 3 % foot drop due to

excessive traction (8)

 Removal of more bone

with potential for destabilization

 Another recurrent lumbar

disc in the future –THIRD surgery

Answers

 Drazin et al systemic Pubmed review 27 papers (9)

Redo laminectomy (17) vs. TLIF (6) vs. PLIF (4) Discectomy : 70-89% good or excellent outcomes (VAS, JOA, ODI) 8% Dural tear 2% re-herniation 1.2 % neurological complications Posterolateral fusion: 66-86% good or excellent outcomes (JOA, VAS) Longer OR time and higher EBL 9 % dural tear 6% wound infection Transforaminal lumbar interbody fusion : 68.3-93.3% good or excellent outcomes (VAS, JOA) 2.3% dural tear 1.3% required revision surgery (infection, hardware reposition)

Answers



El Shazly et at. Discectomy vs. PLF vs TLIF (10)

Prospective, Randomized, 45 pts with recurrent lumbar herniation 88.9% mean good or excellent outcomes across all procedures ( no difference in JOA score) Postoperative back, incidence of dural tear and neurological deficit was higher in Discectomy TLIF larger good or excellent outcomes vs PLF (93.3% vs. 86.7%) Cost of procedure lowest in discectomy, highest in TLIF



Dower A et al Role of Fusion in Surgical management of recurrent disc herniation (11)

Performed search of Medline, Embase, Chochane databases 37 Studies reviewed Rate of good to excellent outcome similar discectomy vs fusion (79.5 % vs. 77.8%) JOA score higher in pt with fusion

More Answers….



Chen et al. (12)

43 pts underwent TLIF for treatment of recurrent lumbar herniation Mean recovery rate 86% 3% dural tear 7% with transient deficit which resolved, 1 wound infection



Parker et a. (13)

417 pts with surgery for recurrent disc, enrolled into N2QOD registry 32% arthrodesis, 68% discectomy Equivalent improvement in pain after 1 year Length of stay, EBL, rehab higher in fusion Re-operation rate in the first 3 month higher in discectomy



Zhonghai et al. (14)

73 pts treated with TLIF for recurrent herniation Mean recovery rate 93.2 % 4.1% dural tear 6.8% transient neurological deficit

Like and Experience

 Mroz et al surveyed

practicing surgeons (15)

 Surgery type

correlated with length in practice and volume

 Surgeons in practice

more then 15 year or doing more then 200 cases were more likely to fuse

Thank You

• 1. Unilateral percutaneouse pedicle screw instrumentation with minimally invasive TLIF for the treatment of recurrent lumbar disk disease

Sonmez, E, Coven I Sahinturk F, Yilmaz C Turk Neurosurg 2013; 23: 372-378

• 2. Microdiscectomy for recurrent L5-S1 disc herniation.

Berjano P, Pejrona M Damilano M Eur Spine j 2013; 22: 2915-2917

• 3. Results and risk factors for recurrence following single level lumbar micro discectomy.

Moliterno JA, Knopman J, Parikh K, Cohan JN J Neurosurg Spine 2010; 12: 680-686

• 4. Microsurgical reoperation following lumbar disc surgery. Timing, surgical findings and outcome in 92 pts

Ebeling U, Kalbarcyk H J Neurosurg 1989; 70: 397-404

• 5. Asymptomatic same site recurrent disc herniation after lumbar discectomy: results of prospective longitudinal study with 2 year serial
• imaging. Lebow R, Adogwa O, Parker S Spine 2011; 36: 2147-2151
• 6. Findings and outcome of revision lumbar disc surgery.

Ozgen S, Nadri S, Ozek M J Spinal Disorders 1999; 12: 287-292

• 8. Primary and revision lumbar discectomy

Morgan-Hough C, Jones P, Eisenstein S JBJS BR. 2003; 85: 871-4

• 9. Treatment of recurrent disc herniation: a systemic review

Drazin d, Ugiliweneza B, Yang D, Boakye M Cureus 2016 8(5)

• 10. El Shazly A, Wardany M

Recurrent lumbar disc herniation: A prospective comparative study of three surgical management procedures. Asian J Neurosurg 2013

• 11. Surgical management of recurrent lumbar disc herniation and the role of fusion

Dower A, Chatterji R Swart A J Clin Neuroscience 2016 23: 44-50 12 Surgical treatment of recurrent lumbar disc herniation by TLIF Chen Z, Yuan J International Orthopeadics 2009 33: 197-201

13

Arthordesis vs. Revision Discectomy for Recurrent Lumabar disc herniation: Patient reproted outcomes from N2QOD registry Parker S et al The Spine Journal 15(2015) 101S

• 14. Four year follow up results of transforaminal lumbar interbody fusion as revision surgery for recurrent lumbar disc herniation after conventional disc.

Li Z, Tan J HousS Journal of Clinical Neuroscience 22 (2015) 331-337

• 15. Difference in the surgical treatment of recurrent lumbar disc herniation among spine surgeons in the United States

Mroz T, Lubelski D, William S, Wang J Spine Journal 2014: 14: 2334-2343