Recurrent lumbar disc herniation

Abstract

Recurrent lumbar disc herniations are one cause of the failed back surgery syndrome. The differential diagnoses include retained fragments, spinal stenosis, spinal instability, scar tissue (arachnoiditis and epidural fibrosis), and medical and psychosocial factors. Recurrent herniations occur with a frequency of approximately 15%. They usually recur at the same level and on the same side as in previous discetomy. These patients usually have a pain-free interval of greater than 6 months. Physical findings are most informative when compared with previous findings. Neurotension signs may be caused by epidural fibrosis rather than disc herniation. Magnetic resonance imaging enhanced with gadolinium diethylenetriaminepentaacetic acid/dimeglutemine is the best study to distinguish between epidural scar and herniated disc material. The recurrence rate may or may not be influenced by the type of original discectomy but there is a lower incidence of recurrent herniation when the original procedure includes a fusion. Revision lumbar surgeries have a lower change of good results and a higher incidence of complications compared with primary back procedures. However, in the properly screened patient with an identified recurrent or mechanical lesion, the surgical results of revision laminectomy can yield roughly an 80% chance of good outcome. Techniques of revision laminectomy and the repair of dural lacerations are described.