Recurrent Disc Herniation Research Articles

Clinical Outcome of Simple Discectomy for Recurrent Lumbar Disc Herniation

ment (p<0.001). The mean preoperative ODI score was 29.9, and the mean score checked at the last follow up was 3.5. It thus showed 88.3% improvement (p<0.001). Excellent or good satisfaction was reported by fourteen patients (87.5%), and clinical lumbar instability was identified in one patient (6.3%). Conclusions: Simple discectomy without fusion is one of treatment option for recurrent disc herniation without instability.

Recurrent Lumbar Disc Herniation in Pregnant Patient: A Case Report

Introduction: Lower back and leg pain are frequently seen pathologies in pregnancy. However, a small proportion of these complaints develop in association with lumbar disc hernias. Due to maternal and fetal factors, diagnosis and treatment during pregnancy has to be different than for non-pregnant patients. Methods: A 36 year old, 28-week pregnant patient presented with ever-increasing pain in the right leg, lower back, and reduced power in the extensor hallucis longus. The patient had undergone surgery at another clinic about 2.5 years ago because of right L4-5 disc herniation. Therefore the patient was evaluated by lumbar magnetic resonance images [MRI]. The MRI determined the right L4-5 recurrent disc herniation. Results: The patient underwent successful surgery in the lateral decubitus position under general anesthesia. No complications developed in mother or fetus. Conclusion: Recurrent lumbar disc herniation during pregnancy has not been reported. A lumbar micro-discectomy procedure for a pregnant patient resulted in a successful clinical outcome.

Application of the polystyrene model made by 3-D printing rapid prototyping technology for operation planning in revision lumbar discectomy.

The objective was to evaluate the effectiveness of 3-D rapid prototyping technology in revision lumbar discectomy. 3-D rapid prototyping technology has not been reported in the treatment of revision lumbar discectomy. Patients with recurrent lumbar disc herniation who were preparing to undergo revision lumbar discectomy from a single center between January 2011 and 2013 were included in this analysis. Patients were divided into two groups. In group A, 3-D printing technology was used to create subject-specific lumbar vertebral models in the preoperative planning process. Group B underwent lumbar revision as usual. Preoperative and postoperative clinical outcomes were compared between groups included operation time, perioperative blood loss, postoperative complications, Oswestry Disability Index (ODI), Japan Orthopaedics Association (JOA) scores, and visual analogue scale (VAS) scores for back pain and leg pain. A total of 37 patients were included in this study (Group A=15, Group B=22). Group A had a significantly shorter operation time (106.53±11.91 vs. 131.92±10.81min, P<0.001) and significantly less blood loss (341.67±49.45 vs. 466.77±71.46ml, P<0.001). There was no difference between groups for complication rate. There were also no differences between groups for any clinical metric. Using the 3-D printing technology before revision lumbar discectomy may reduce the operation time and the perioperative blood loss. There does not appear to be a benefit to using the technology with respect to clinical outcomes. Future prospective studies are needed to further elucidate the efficacy of this emerging technology.

A combined biomaterial and cellular approach for annulus fibrosus rupture repair

Recurrent intervertebral disc (IVD) herniation and degenerative disc disease have been identified as the most important factors contributing to persistent pain and disability after surgical discectomy. An annulus fibrosus (AF) closure device that provides immediate closure of the AF rupture, restores disc height, reduces further disc degeneration and enhances self-repair capacities is an unmet clinical need. In this study, a poly(trimethylene carbonate) (PTMC) scaffold seeded with human bone marrow derived mesenchymal stromal cells (MSCs) and covered with a poly(ester-urethane) (PU) membrane was assessed for AF rupture repair in a bovine organ culture annulotomy model under dynamic load for 14 days. PTMC scaffolds combined with the sutured PU membrane restored disc height of annulotomized discs and prevented herniation of nucleus pulposus (NP) tissue. Implanted MSCs showed an up-regulated gene expression of type V collagen, a potential AF marker, indicating in situ differentiation capability. Furthermore, MSCs delivered within PTMC scaffolds induced an up-regulation of anabolic gene expression and down-regulation of catabolic gene expression in adjacent native disc tissue. In conclusion, the combined biomaterial and cellular approach has the potential to hinder herniation of NP tissue, stabilize disc height, and positively modulate cell phenotype of native disc tissue.

Minimally invasive transforaminal lumbar interbody fusion: Results of 23 consecutive cases.

Background:The use of minimally invasive surgical (MIS) techniques represents the most recent modification of methods used to achieve lumbar interbody fusion. The advantages of minimally invasive spinal instrumentation techniques are less soft tissue injury, reduced blood loss, less postoperative pain and shorter hospital stay while achieving clinical outcomes comparable with equivalent open procedure. The aim was to study the clinicoradiological outcome of minimally invasive transforaminal lumbar interbody fusion.Materials and Methods:This prospective study was conducted on 23 patients, 17 females and 6 males, who underwent MIS-transforaminal lumbar interbody fusion (TLIF) followed up for a mean 15 months. The subjects were evaluated for clinical and radiological outcome who were manifested by back pain alone (n = 4) or back pain with leg pain (n = 19) associated with a primary diagnosis of degenerative spondylolisthesis, massive disc herniation, lumbar stenosis, recurrent disc herniation or degenerative disc disease. Paraspinal approach was used in all patients. The clinical outcome was assessed using the revised Oswestry disability index and Macnab criteria.Results:The mean age of subjects was 55.45 years. L4-L5 level was operated in 14 subjects, L5-S1 in 7 subjects; L3-L4 and double level was fixed in 1 patient each. L4-L5 degenerative listhesis was the most common indication (n = 12). Average operative time was 3 h. Fourteen patients had excellent results, a good result in 5 subjects, 2 subjects had fair results and 2 had poor results. Three patients had persistent back pain, 4 patients had residual numbness or radiculopathy. All patients had a radiological union except for 1 patient.Conclusion:The study demonstrates a good clinicoradiological outcome of minimally invasive TLIF. It is also superior in terms of postoperative back pain, blood loss, hospital stay, recovery time as well as medication use.

Four-year follow-up results of transforaminal lumbar interbody fusion as revision surgery for recurrent lumbar disc herniation after conventional discectomy

This study investigated the safety, effectiveness, and clinical and radiological outcomes of transforaminal lumbar interbody fusion (TLIF) for recurrent lumbar disc herniation (rLDH) following previous lumbar spine surgery. Seventy-three consecutive patients treated for rLDH between June 2005 and May 2012 were included in the study. The previous surgical procedures included percutaneous discectomy, discectomy with laminotomy, discectomy with unilateral laminectomy, and discectomy with bilateral laminectomy. The level of rLDH was L4–L5 in 51 patients, L5–S1 in 19 patients, and L3–L4 in three patients. All patients underwent reoperation using the TLIF technique. Outcomes were evaluated using the Oswestry disability index (ODI), visual analogue scale (VAS) scores for low back pain and leg pain, and the Japanese Orthopaedic Association (JOA) score, based on the results of physical examinations and questionnaires. The range of motion and disc height index of the operative segment were compared between preoperative and postoperative radiographs. The mean follow-up period was 4.1years. The VAS scores for low back pain and leg pain, ODI, and JOA score improved significantly between the preoperative and final follow-up evaluations. The mean recovery rate of the JOA score was 89.0%. The disc space height and stability at the fused level were significantly improved after surgery. The fusion rate at the final follow-up was 93.2%. There were no major complications. These results indicate that TLIF can be considered an effective, reliable, and safe alternative procedure for the treatment of rLDH.

Minimally invasive discectomy versus microdiscectomy/open discectomy for symptomatic lumbar disc herniation.

Microdiscectomy or open discectomy (MD/OD) are the standard procedures for symptomatic lumbar disc herniation and they involve removal of the portion of the intervertebral disc compressing the nerve root or spinal cord (or both) with or without the aid of a headlight loupe or microscope magnification. Potential advantages of newer minimally invasive discectomy (MID) procedures over standard MD/OD include less blood loss, less postoperative pain, shorter hospitalisation and earlier return to work. To compare the benefits and harms of MID versus MD/OD for management of lumbar intervertebral discopathy. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (November 2013), MEDLINE (1946 to November 2013) and EMBASE (1974 to November 2013) and applied no language restrictions. We also contacted experts in the field for additional studies and reviewed reference lists of relevant studies. We selected randomised controlled trials (RCTs) and quasi-randomised controlled trials (QRCTs) that compared MD/OD with a MID (percutaneous endoscopic interlaminar or transforaminal lumbar discectomy, transmuscular tubular microdiscectomy and automated percutaneous lumbar discectomy) for treatment of adults with lumbar radiculopathy secondary to discopathy. We evaluated the following primary outcomes: pain related to sciatica or low back pain (LBP) as measured by a visual analogue scale, sciatic specific outcomes such as neurological deficit of lower extremity or bowel/urinary incontinence and functional outcomes (including daily activity or return to work). We also evaluated the following secondary outcomes: complications of surgery, duration of hospital stay, postoperative opioid use, quality of life and overall participant satisfaction. Two authors checked data abstractions and articles for inclusion. We resolved discrepancies by consensus. We used standard methodological procedures expected by The Cochrane Collaboration. We used pre-developed forms to extract data and two authors independently assessed risk of bias. For statistical analysis, we used risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with 95% confidence intervals (CI) for each outcome. We identified 11 studies (1172 participants). We assessed seven out of 11 studies as having high overall risk of bias. There was low-quality evidence that MID was associated with worse leg pain than MD/OD at follow-up ranging from six months to two years (e.g. at one year: MD 0.13, 95% CI 0.09 to 0.16), but differences were small (less than 0.5 points on a 0 to 10 scale) and did not meet standard thresholds for clinically meaningful differences. There was low-quality evidence that MID was associated with worse LBP than MD/OD at six-month follow-up (MD 0.35, 95% CI 0.19 to 0.51) and at two years (MD 0.54, 95% CI 0.29 to 0.79). There was no significant difference at one year (0 to 10 scale: MD 0.19, 95% CI -0.22 to 0.59). Statistical heterogeneity was small to high (I(2) statistic = 35% at six months, 90% at one year and 65% at two years). There were no clear differences between MID techniques and MD/OD on other primary outcomes related to functional disability (Oswestry Disability Index greater than six months postoperatively) and persistence of motor and sensory neurological deficits, though evidence on neurological deficits was limited by the small numbers of participants in the trials with neurological deficits at baseline. There was just one study for each of the sciatica-specific outcomes including the Sciatica Bothersomeness Index and the Sciatica Frequency Index, which did not need further analysis. For secondary outcomes, MID was associated with lower risk of surgical site and other infections, but higher risk of re-hospitalisation due to recurrent disc herniation. In addition, MID was associated with slightly lower quality of life (less than 5 points on a 100-point scale) on some measures of quality of life, such as some physical subclasses of the 36-item Short Form. Some trials found MID to be associated with shorter duration of hospitalisation than MD/OD, but results were inconsistent. MID may be inferior in terms of relief of leg pain, LBP and re-hospitalisation; however, differences in pain relief appeared to be small and may not be clinically important. Potential advantages of MID are lower risk of surgical site and other infections. MID may be associated with shorter hospital stay but the evidence was inconsistent. Given these potential advantages, more research is needed to define appropriate indications for MID as an alternative to standard MD/OD.

Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 8: lumbar fusion for disc herniation and radiculopathy.

Patients suffering from a lumbar herniated disc will typically present with signs and symptoms consistent with radiculopathy. They may also have low-back pain, however, and the source of this pain is less certain, as it may be from the degenerative process that led to the herniation. The surgical alternative of choice remains a lumbar discectomy, but fusions have been performed for both primary and recurrent disc herniations. In the original guidelines, the inclusion of a fusion for routine discectomies was not recommended. This recommendation continues to be supported by more recent evidence. Based on low-level evidence, the incorporation of a lumbar fusion may be considered an option when a herniation is associated with evidence of spinal instability, chronic low-back pain, and/or severe degenerative changes, or if the patient participates in heavy manual labor. For recurrent disc herniations, there is low-level evidence to support the inclusion of lumbar fusion for patients with evidence of instability or chronic low-back pain.

Percutaneous pedicle screw and rod fixation with TLIF in a series of 14 patients with recurrent lumbar disc herniation

PurposeTo determine if minimally invasive transforaminal lumbar interbody fusion (TLIF) using the Medtronic® Sextant system is a reliable surgical treatment option in patients with recurrent lumbar disc herniation, compared with the traditional open procedure. Patients and methodsClinical and radiographic data were retrospectively collected from a total of 33 patients who underwent single level lumbar fusion between 2007 and 2010. 14 underwent minimally invasive TLIF using the Sextant system, and the other 19 patients underwent the open procedure. All patients suffered from at least first recurrent lumbar disc herniation, and additionally from disc degeneration associated with erosive chondrosis Modic grade I–II due to previous surgical, non-instrumental interventions. ResultsMedian operation time in the minimally invasive group was 140min (95–190); average X-ray exposure time: 2.35min (1.5–3.5); median postoperative resting time in hospital: 5 days (3–7). Postoperative pain relief and mobility improvement were documented with the visual analogue scale (6.9–3.0) and the Oswestry Disability Index (6.8–2.4). All patients benefited from surgery at follow up. These data were on many terms significantly superior compared with data of patients in the open surgery group. ConclusionPercutaneous minimally invasive TLIF technique with the Medtronic® Sextant system is a gentle, tissue protecting and safe alternative procedure for lumbar fusion in patients with recurrent lumbar disc herniation and erosive chondrosis.

The Postoperative Spine

Potential complications following spinal surgery include neural compression due to hematoma, recurrent disk herniation, epidural fibrosis, dural tear with pseudomeningocele formation, and infection. Specific complications relate to the use of spinal instrumentation that include incorrectly positioned instrumentation and failure of spinal fusion leading to instrumentation loosening or breakage. To interpret the postoperative imaging correctly, it is necessary to understand the nature of the surgical procedure that has been performed and the normal postoperative appearances. Magnetic resonance imaging is the mainstay in the evaluation of the postoperative spine. Radiographs and computed tomography continue to have a major role in assessing fusion and in the assessment of complications related to instrumentation.

CORR Insights®: Recurrent Versus Primary Lumbar Disc Herniation Surgery: Patient-reported Outcomes in the Swedish Spine Register Swespine

CORR Insights®: Recurrent Versus Primary Lumbar Disc Herniation Surgery: Patient-reported Outcomes in the Swedish Spine Register Swespine

Annulus Fibrosus Repair

Intervertebral disc (IVD) herniation is a common origin of disabled spine and low back pain (LBP) which cause enormous health care toll. The annulus fibrosus (AF), which constitutes the outer part ...

Combination of Percutaneous Unilateral Translaminar Facet Screw Fixation and Interbody Fusion for Treatment of Lower Lumbar Vertebra Diseases: a Follow‐Up Study

To investigate the feasibility and efficacy of sight-guided percutaneous unilateral translaminar facet screw fixation (TLFSF) with interbody fusion for treatment of lower lumbar vertebra diseases. Twenty-nine adult patients with lower lumbar disease underwent sight-guided percutaneous unilateral TLFSF combined with microsurgical spinal decompression, discectomy, and interbody fusion from June 2007 to June 2008. All 29 patients had low back pain caused by lumbar disc degeneration (20 cases), in situ recurrent lumbar disc herniation (2), primary diskitis (1), lumbar disc herniation with spinal stenosis (3), and first-degree lumbar degenerative spondylolisthesis (3). Twenty-three cases had lesions at L4,5 ; three at L5 S1 , one at L3,4 , L4,5 , and two at L4,5 , L5 S1 . No patient experienced significant postoperative complications. The mean incision length was 4.48 ± 0.55 cm; operative time 1.34 ± 0.22 h; intraoperative blood loss 280 ± 175 mL; and postoperative drainage volume 165 ± 85 mL. Screw position results: type I, 21 cases (23 segments); type II, 7 cases (8 segments); and type III, 1 case (1 segment). Twenty-eight patients were followed up for 24-60 months (average, 47.5 months). Interbody fusion rate was 93.5%). Postoperative intervertebral height recovered significantly; however, loss of intervertebral height occurred during follow-up. Sight-guided percutaneous unilateral TLFSF with interbody fusion for treatment of lower lumbar disease is simple and minimally invasive, with good screw accuracy and security, high fusion rate, and good efficacy. However, specific surgical indications must be strictly followed.

A prospective study of the incidence and outcomes of incidental dural tears in microendoscopic lumbar decompressive surgery.

Little information is available about the incidence and outcome of incidental dural tears associated with microendoscopic lumbar decompressive surgery. We prospectively examined the incidence of dural tears and their influence on the outcome six months post-operatively in 555 consecutive patients (mean age 47.4 years (13 to 89)) who underwent this form of surgery. The incidence of dural tears was 5.05% (28/555). The risk factors were the age of the patient and the procedure of bilateral decompression via a unilateral approach. The rate of recovery of the Japanese Orthopaedic Association score in patients with dural tears was significantly lower than that in those without a tear (77.7% vs. 87.6%; p < 0.02), although there were no significant differences in the improvement of the Oswestry Disability Index between the two groups. Most dural tears were small, managed by taking adequate care of symptoms of low cerebrospinal fluid pressure, and did not require direct dural repair. Routine MRI scans were undertaken six months post-operatively; four patients with a dural tear had recurrent or residual disc herniation and two had further stenosis, possibly because the dural tear prevented adequate decompression and removal of the fragments of disc during surgery; as yet, none of these patients have undergone further surgery.

MRI-Based Classification of the Morphology and Pathology of the Annulus Fibrosus of the Intervertebral Disc

Introduction The high rate of recurrent disc herniation after discectomy is a prevalent problem. An effective biological annular repair could improve the surgical outcome in patients with contained disc herniation but otherwise minor degenerative changes. To estimate the integrity of the annulus fibrosus (AF) and judge different repair options a better understanding of disc morphology and pathology is crucial.1 Axial- and sagittal T2*-mapping are effective to detect early stages of degenerative disc disease and are especially suited to evaluate the interface between the proton-rich nucleus pulposus and the fibers of the annulus fibrosus.2,3 So far there is no classification of AF morphology or pathology as current classifications only describe localization and extend of the hernia itself. Materials and Methods Prospective consecutive case study of 100 patients requiring MRI diagnostic for suspected lumbar disc herniation. Beside the clinical standard MRI protocol with sagittal T1- and T2-weighted images, axial and sagittal T2*-mapping sequences of the affected and adjacent discs were performed using 3T MRI. Three observers used established classification schemes to assess the grade of degeneration (Pfirrmann, Benneker, Watanabe) and herniation (Carragee, Rajaserakan) and also developed a new classification protocol specific for the annulus fibrosus. Results In the preliminary data four types of annulus morphology/pathology could be found: type 1: healthy, uniform thickness of AF, clear demarcation between nucleus pulposus (NP) and AF. Type 2: concentric thinning with bulge, concentric tears, demarcation between NP and AF unclear. Type 3: nonconcentric thinning, ±radial fissures, ±protrusion, and type 4: herniations with further subgroups. Conclusion Based on preliminary axial and sagittal T2* images a new classification system for AF morphology and pathology could be established. Inter- and intraobserver liability is high. Disclosure of Interest None declared References Guterl CC, See EY, Blanquer SB, et al. Challenges and strategies in the repair of ruptured annulus fibrosus. Eur Cell Mater 2013;25:1–21 Stelzeneder D, Welsch GH, Kovács BK, et al. Quantitative T2 evaluation at 3.0T compared to morphological grading of the lumbar intervertebral disc: a standardized evaluation approach in patients with low back pain. Eur J Radiol 2012;81(2):324–330 Hoppe S, Quirbach S, Mamisch TC, Krause FG, Werlen S, Benneker LM. Axial T2 mapping in intervertebral discs: a new technique for assessment of intervertebral disc degeneration. Eur Radiol 2012;22(9):2013–2019

THE OUTCOMES OF SURGICAL TREATMENT OF RECURRENT LUMBAR DISK HERNIATION WITH DISCECTOMY ALONE AND DISCECTOMY WITH POSTEROLATERAL INTERBODY FUSION

Background: Recurrent lumbar disk herniation (RLDH) is one of the major causes of failure of standard discectomy. The optimal treatment method for RLDH is controversial. In the current study, we aimed to compare the clinical and functional outcomes of treating RLDH with discectomy alone and discectomy associated with posterolateral interbody fusion (PLIF).Material and Methods: There were 41 patients with RLHD after primary discectomy in the current retrospective study. Patients were assigned to 2 groups based on the surgical method: discectomy alone (17 patients) and discectomy with PLIF (21 patients). At the final visit the following variables were measured and compared between groups: the back and radicular pain intensity using visual analogue scale (VAS), functional outcome using oswestry low back pain disability scale (ODI), return to previous work and complication. Patients were followed for 13.9±2.8 and 15±3 months in discectomy alone and discectomy with PLIF groups, retrospectively.Results: Complete fusion was achieved in 24 patients of PLIF group. The back pain intensity was the same; however the radicular pain intensity was significantly lower in PLIF group (1.5±0.9 V.s 2.3±1; p=0.017). Also, the mean of ODI scale was the same. 82.3% of patients in discectomy group and 87.5% of patients in PLIF group returned to previous work and the difference was not significant. One patient in discectomy group and 2 patients in PLIF group developed temporary neurological deficit which disappeared after 3 months.Conclusions: Although both discectomy alone and discectomy with PLIF were associated with favorable mid-term results in treating patients with RLDH, however, the authors recommend using discectomy with PLIF for lower radicular pain.

Recurrent Versus Primary Lumbar Disc Herniation Surgery: Patient-reported Outcomes in the Swedish Spine Register Swespine

BackgroundLumbar disc herniation (LDH) is a common indication for lumbar spine surgery. The proportion of patients having a second surgery within 2 years varies in the literature between 0.5% and 24%, with recurrent herniation being the most common cause. Several studies have not found any relevant outcome differences between patients undergoing surgery for primary LDH and patients undergoing reoperation for a recurrent LDH, but these studies have limitations, including small sample size and retrospective design.Questions/purposesWe (1) compared patient-reported outcomes between patients operated on for primary LDH and patients reoperated on for recurrent LDH within 1 year after index surgery and (2) determined risk factors for worse outcomes.MethodsWe obtained data from the Swedish National Spine Register, Swespine, where patient-reported outcomes are collected using mailed protocols at 1, 2, 5, and 10 years after surgery. Of the 13,562 patients identified who underwent LDH between January 2000 and May 2011, 13,305 (98%) underwent primary surgery for LDH and 257 (2%) underwent reoperation for a recurrent LDH within the first year. Patient-reported outcomes at 1 to 2 years were available for 8497 patients (63%), 8350 of 13,305 (63%) in the primary LDH group and 147 of 257 (57%) in the recurrent LDH group (p = 0.068). We compared leg and back pain (VAS: 0–100), function (Oswestry Disability Index [ODI]: 0–100), quality of life (EQ-5D: −0.59 to 1.0), patient satisfaction, and global assessment of leg pain between groups. We also analyzed rsik factors for worse global assessment and satisfaction.ResultsMean (95% CI) differences in improvement between groups favoring patients with primary LDH were VAS leg pain 9 (4–14), ODI 6 (3–9), and EQ-5D 0.09 (0.04–0.15). While statistically significant, these effect sizes may be lower than the minimal clinically important differences often referred to. Percentage of satisfied patients was 79% and 58% in the primary and recurrent LDH groups, respectively (p < 0.001), and percentage of patients with no or better leg pain (global assessment) was 74% and 65%, respectively (p = 0.008). Reoperation for recurrent LDH represented the largest independent risk for dissatisfaction; this factor and smoking represented similar risks for less improvement in leg pain.ConclusionsRepeat surgery for a recurrent LDH was performed with good probability for improvement, although not as good as for primary LDH surgery, and patients undergoing repeated surgery were less satisfied. Studies on risk factors for recurrence are warranted.Level of EvidenceLevel II, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

The significance of lumbar MRI in the diagnosis of recurrented lumbar disc herniation after surgery

To retrospectively evaluate the clinical evaluation of preoperative lumbar T2 sagittal MRI image in predicting the recurrent lumbar disc herniation (RLDH). Between January 2009 and April 2011, 28 patients were diagnosed as recurrent L4-5 disc herniation within 2.5 years after surgery, and 25 of them were included in the study as relapse group. At the same time, selected 25 patients implemented the same surgical methods in the same level as a control group randomly, they were all with good to excellent result and the follow-up time was at least 2.5 years. There was no statistical significance between the two groups in gender, age and body mass index(BMI) (P > 0.05). The lumbar MRI image of two groups of patients before surgery were collected and analyzed, with the disc degeneration grade classified. The χ(2) test was used to analyzed the difference of degeneration between the two groups of patients before surgery. Rank correlation analysis evaluated the correlation between disc degeneration and the period of time from the first operation to the recurrence. In terms of preoperative lumbar disc degeneration, there were 22 cases of low-grade disc degeneration and 3 cases of advanced disc degeneration in the relapse group and 5 cases and 20 cases respectively in the control group. there was significant difference between two groups (χ(2) = 23.27, P < 0.05), low-grade disc degeneration (gradesIand III) was significantly more frequent in the relapse group than in the control group. The patients with low-grade disc degeneration had a higher risk of recurrence, that was the risk of recurrent disc herniation increased by a factor of 4.4 from advanced disc degeneration to low-grade disc degeneration(OR = 4.4, 95%CI:1.983-9.765, P < 0.05). In cases of recurrence, the time interval between primary surgery and the recurrence of the patient with advanced disc degeneration was longer compared with low-grade disc degeneration (r = 0.733, P < 0.05). Preoperative lumbar MRI image may suggest the possibility of the recurrence lumbar disc herniation.Light disc degeneration is an important risk factor for recurrent disc herniation, and the time interval between primary surgery and the recurrence is positively correlated with severity of disc degeneration.

Clinical Outcome of Fusion in Recurrent Herniated Lumbar Disc

Background Data: Discectomy in recurrent lumbar disc herniation may not be an efficient treatment without fusion especially with prominent low back pain after primary surgery; therefore discectomy with fusion may be a good solution inrecurrent lumbar disc herniation. Purpose: The goal of this study was to focus on the efficacy of fusion in recurrentlumbar disc surgery. Study design: This study was carried out at different hospitals and the data was collected prospectively and retrospectively. Patients and methods: 50 patients (30 males and 20 females) underwent revisionsurgery following primary lumbar discectomy between 2009 and 2013. This study includes (50) patients with clinically and radiologically documented recurrentlumbar disc herniation scheduled for surgery. This includes (30) males and (20)females. All patients had a discectomy and postero-lateral fusion in re-operation. Patients’ age ranged from 25 years to 45 years with mean age 30 years. All patients in this study were presented with low back pain and recurrent radicular pain with mean duration of 21 months. Peri-operative assessments were carried using “Japanese Orthopedic Associationscore” (JOAs), and radiographic follow-up. Results: Follow-up ranged from 12-36 months with a mean follow-up 22.9 months; 25 patients had an excellent outcome, 20 patients had a good outcome, 3 patients had a fair outcome, and 2 patients had a poor outcome. Conclusion: Fusion surgery for recurrent lumbar disc herniation is effective and beneficial procedure. (2014ESJ062)

Posterior lumbar interbody fusion with stand-alone Trabecular Metal cages for repeatedly recurrent lumbar disc herniation and back pain

Patients with recurrent sciatica due to repeated reherniation of the intervertebral disc carry a poor prognosis for recovery and create a large burden on society. There is no consensus about the best treatment for this patient group. The goal of this study was to evaluate the 12-month results of the placement of stand-alone Trabecular Metal cages in these patients. The authors performed a retrospective analysis of 26 patients with recurrent disc herniations treated with stand-alone posterior lumbar interbody fusion (PLIF) with Trabecular Metal cages. At 1 year patients were evaluated using the Roland Morris Disability Questionnaire (RMDQ) and a visual analog scale (VAS) for back and leg pain. Furthermore, Likert scores of perceived recovery and satisfaction with the treatment were recorded. Lumbar spine radiographs after 1 year were compared with postoperative radiographs to measure subsidence. Stability of the operated segment was assessed using dynamic radiography. The patient group consisted of 26 patients (62% male) with a mean age of 45.7 ± 11.4 years (± SD). Patients had a history of 1 (31%), 2 (42%), or more (27%) discectomies at the same level. The mean follow-up period was 15.3 ± 7.3 months. At follow-up the mean VAS score for pain in the affected leg was 36.7 ± 27.9. The mean VAS score for back pain was 42.5 ± 30.2. The mean RMDQ score at follow-up was 9.8 ± 6.2. Twelve (46%) of the 26 patients had a global perceived good recovery. With respect to treatment satisfaction, 18 patients (69%) were content or very content with the operation and would recommend it. Disc height was increased immediately postoperatively, and at the 1-year follow-up it was still significantly higher compared with the preoperative height (mean 41% ± 38.7%, range -25.7 to 126.8, paired t-test, both p < 0.001), although a mean of 7.52% ± 11.6% subsidence occurred (median 2.0% [interquartile range 0.0%-10.9%], p < 0.003). No significant correlation between subsidence and postoperative back pain was found (Spearman's rho -0.2, p = 0.459). Flexion-extension radiographs showed instability in 1 patient. Although only 46% of patients reported a good recovery with significant reductions in back and leg pain, 85% of patients reported at least some benefit from the operation, and a marked improvement in working status at follow-up was noted. In view of previously published poor results of instrumented lumbar fusion for patients with failed back surgery syndrome, the present data indicate that Trabecular Metal interbody fusion cages can be used in a stand-alone fashion and should not always need supplemental posterior fixation in patients with recurrent disc herniation without spinal instability, although a long-term follow-up study is warranted.