Recurrent Lumbar Disc Herniation

Karin R. Swartz, MD, Gregory R. Trost, MD

Disclosures

Neurosurg Focus. 2003;15(3) 

In This Article

Abstract and Introduction

Abstract

Recurrent lumbar disc herniation is a common disease process. It has been noted to occur in 5 to 15% of cases surgically treated for primary lumbar disc herniation. Outcomes in one series approached those after the initial operations, although this is not the case in the experience of most surgeons.

The removal of recurrent lumbar disc herniations requires meticulous surgical technique. Great care is taken to identify the osseous margins of the previous surgical site. Identification and dissection of scar from the dura mater is greatly aided with the use of a microscope.

Introduction

Single-level lumbar discectomy has been proven to have lasting benefit in numerous cases. Good outcomes depend on proper patient selection; however, complications may arise. Discectomy-related complications occur in 15 to 30% of cases and include hemorrhage, soft-tissue infection, nerve root injury, dural tear, recurrent or residual disc herniation, epidural scar formation, discitis, arachnoiditis, pseudomeningocele, facet joint fracture (iatrogenic or stress related), spinal stenosis, and epidural hematoma.[2,17,19,21,24] Potential predictors of poor outcome include misdiagnosis (for example, diabetic polyneuropathy mistaken for radiculopathy), preoperative psychological distress, insufficient rehabilitation, mechanical instability, impaired fibrinolytic activity, diabetes, obesity, and hypertension.[1,5,14,16,17]

The rate of recurrent disc herniation after lumbar discectomy is 5 to 15%.[2,7,17,20,24] The strict definition of recurrent disc herniation is the presence of herniated disc material at the same level, ipsi- or contralateral, in a patient who has experienced a pain-free interval of at least 6 months since surgery. The clinically more appropriate definition, however, is disc herniation at the previously operative site and side. The pain-free interval should not be restricted to the minimum of 6 months. It has been suggested that the mean interval for recurrent pain associated with recurrent herniated discs is 18 months, longer than that for de novo herniated discs or symptomatic epidural fibrosis.[10]

Treatment options of first-time disc herniations include observation combined with aggressive medical management (pharmacological and physical therapies), chymopapain, intradiscal electrothermal coagulation therapy, laserassisted decompression, laminectomy, laminectomy and discectomy, minimally invasive microdiscectomy and endoscopic discectomy, and laparoscopic discectomy; surgical choices for disc recurrent herniations are limited by multiple factors, require longer operative time, and are associated with higher rate of complications, treatment seems to be associated with a similar chance of good outcome.[8,10,13,23,24]

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