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 Arthordesis vs. Revision Discectomy for Recurrent Lumabar disc herniation: Patient reproted outcomes from N2QOD registry 13 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
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