1. Introduction
Recurrent disc herniation is defined as disc herniation seen at the same level after a painless period of at least 6 months following the first surgery. Recurrent herniation may be on the same or opposite side [1] [2].
Risk of unfavourable outcomes like obesity, diabetes, vibration workers, drivers and psychological factors should be taken into consideration before surgery for the first instance which increases the incidence of recurrence [3].
The reoperation rate following the initial lumbar discectomy ranges between 4% and 18% [4].
The optimal treatment of recurrent disc herniation is still controversial. Some surgeons choose simple discectomy again, while some surgeons advocate fusion surgery. Because recurrent disectomy (ipsilateral/contralateral) requires more disc and posterior spinal component removal (lamina and/or facet joint), recurrent discectomy will increase the likelihood of segmental instability and due to scar tissue; dural tear, and nerve injuries may be greater at simple re-discectomies, some surgeons suggest fusion surgery at first recurrent, regardless of whether instability [5].
The aim of this study was to evaluate the efficacy and safety of fusion in reherniated lumbar disc surgery.
2. Patients and Methods
This retrospective study was carried out on 40 patients 30 male and 10 female age ranged from 30 to 60 years with mean age 45 years who underwent revision discectomy with fusion for reherniated lumbar disc from September 2014 to April 2018 in Neurosurgery Department Al-Azhar University Hospital New Damietta Egypt.
Inclusion criteria:
1) At least 6 months of pain relief after previous disc surgery.
2) The presence of recurrent disc herniation and radicular pain not respond to conservative treatment.
Exclusion criteria:
1) Those with cauda equine syndromes.
2) Patients with spondylolithesis.
3) Reoperation in the early postoperative period for infections.
The study was approved by the local ethical committee and informed consent was obtained from participating patients. Data collection was extracted from hospital records (patient admission sheet medical records imaging studies operative and postoperative details and progressive notes).
3. Preoperative Assessment
All patients were subjected to careful history taking general and neurological examination. All patients had pre operative lumbo-sacral X-ray A-P and dynamic views flexion extension and oblique and MRI examination (Figures 1-3).
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Figure 1. MRI lumbo sacral spine sagittal view show recurrent disc L5 S1.
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Figure 2. MRI lumbo sacral spine axial view show recurrent disc L5 S1.
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Figure 3. Preoperative plain X-ray dynamic view.
Full medical history taking all patients asked about allergies, chronic diseases as diabetes, hypertension, heart diseases, and ask about smoking, previous surgery, and results of physical exams and tests may also include full data about medicines taken and personal habits, activities and work history. The results were evaluated carefully and confirmed that recurrence rate increased with heavy activities and chronic diseases as diabetes.
4. Operative Technique
Surgery was performed after induction of general anesthesia with the patient placed in prone position and the spine flexed. All patients were positioned prone on frame or rolls to avoid abdominal compression and hence reduce venous congestion. Skin incision was given over the previous operative site after full preparation. After muscle dissection soft tissue was cleaned from facet in a lateromedial direction. The medial edge of facet defined with curate and the plane between the dura and the medial facet was appreciated and enlarged. Medial facectetomy was completed. The nerve root identified after removing the remaining ligamentum flavum. Nerve root was retracted and the discectomy completed. Posterolateral fusion and trans-pedicular screw fixation were performed.
Closure was then done in a routine fashion after insertion of a subcutaneous suction drain (Figure 4 & Figure 5).
Clinical symptoms were evaluated pre and post-operatively according the criteria of the “Japanese Orthopedic Associations core” (JOA) [6].
Japanese Orthopaedic Association (JOA) score assessment of the surgical treatment of low back pain (Tables 1-4).
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Figure 4. Postoperative plain X-ray A-P and LAT view show transpedicular fixation (screw rod system) double level L3 L4 L5.
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Figure 5. Postoperative plain X-ray lat view shows transpedicular fixation single level L4 L5.
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Table 1. Subjective symptoms (9 points). (a) Low-back pain; (b) Leg pain and/or tingling; (c) Gait.
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Table 2. Clinical signs (6 points). (a) Straight-leg raising test (including tight hamstrings); (b) Sensory disturbance; (c) Motor disturbance.
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Table 3. Restriction of activities of daily living (14 points).
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Table 4. Urinary bladder function (6 points) (incontinence urinary retention).
Surgical outcome assessed according to the recovery rate as described by Hirabayashi et al. [6]
The results were classified into a four-grade scale: excellent improvement > 90%, good 75% - 89%, fair 50% - 74% and poor < 49%. Differences in preoperative symptoms and post-operative outcomes were statistically analyzed. The statistical significance was set at a P-value.
5. Results
Forty patients with recurrent lumbar disc were surgically treated 30 male 75% and 10 female 25% the mean age at the time of surgery was 45 years range from 30 - 60 years. The recurrent time to the primary surgery ranged from 9 - 24 months with a mean duration of 17 months (Table 5). The most common complaint was low back pain and radicular pain. Overall JOA score of the patients showed improvement, moving from (6.54 points) before surgery to (12.65 points) at the final follow-up. Low back pain, radicular pain ability to walk, straight leg raising, and manual muscle testing valuated by JOA score are shown in Table 6.
Surgical outcome, based on recovery rate, was excellent in 30 (75%) patients, good in 6 (15%) patients, fair in 2 (5%) patients, and poor in 2 (5%) patients (Table 7).
No major complications were observed. There was one case with superficial infection and they had received parental antibiotics with no need for surgical intervention. Five patients had dural tears which were repaired intra-operatively with no subsequent sequelae (Table 8).
6. Discussion
Reherniated lumbar is an important disease which seen commonly. The rate of recurrent disc herniation after lumbar discectomy is 5% to 15% [5]. So that, recurrent lumbar disc herniation (RLDH) is a major cause of surgical failure [7], the recurrent disc herniation is the major cause of the failed back surgery syndrome [8]. The optimal surgical approach (simple discectomy with or without fusion of the affected segment) for recurrent disc herniation remains a subject of controversy [9] [10].
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Table 5. Age, sex, and duration of recurrence.
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Table 6. Severity of clinical symptoms before and after surgery.
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Table 7. Results assessed by JOA score.
For this reason, its accurate management is of great importance. In the modern LDH surgery, various techniques have been identified and applied since the Love’s operation was identified [11].
There is a number of case series describing outcomes after either preoperative discectomy or postoperative discectomy combined with fusion [12].
In the present study, we done revision discectomy with fusion this technique resulted in satisfactory results.
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 [13] in the present study which conducted on 40 patients with first time recurrent lumbar disc herniation after exclusion of those with cauda equine syndromes, and patients with spondylolisthesis. After a mean follow-up of 18 months, the mean postoperative recovery rate was 85% and the satisfactory rate was 90%.
In the present study, the surgical outcome assessed according to JOA score, was excellent in 30 patients (75%) good in 6 patients (15%) fair in 2 patients (5%) and poor in 2 patients (5%). Tsai-Sheng et al. [10] reported in their study that, general clinical outcome, based on the JOA score, was excellent in 20 (48.8%) patients, good in 13 (31.7%), fair in 4 (9.8%), and poor in 4 (9.8%). clinical outcome was satisfactory (excellent or good) in 78.3% of patients whom received discectomy in 83.3% [10].
As regards the complications in the present study was found that 5 patients (12.5%) had dural tear and 1 (2.5%) patients had superficial infection. Tsai-Sheng et al., stated in their series that, there were five patients (3 in the non-fusion group and 2 in the fusion group) had a dural tear and one patient in the fusion group had a superficial infection [10].
Tsai-Sheng et al. [10] stated that, the optimal surgical approach (simple discectomy with or without fusion of the affected segment) for recurrent disc herniation remains a subject of controversy [10], but in the present study it was found that revision discectomy with fusion has several advantages in the surgical outcomes, specifically, lumbar fusion which minimizes segmental motion, immobilizes the spine decrease mechanical stresses across the degenerated disc space, and may reduce reherniated disc at the same level.
7. Conclusion
Fusion in re-herniated lumbar disc remains a controversial decision. But the surgical outcome is more satisfactory when revision discectomy is done with fusion rather than by using discectomy alone and this confirmed in our study revision discectomy with fusion in reherniated lumbar disc is a worthy choice according to our study.