Lumbar disc herniation (LDH) is one of the most common indications for lumbar spine surgery, and the lifetime incidence for disc surgery is estimated to be between 1% and 2%, although there are regional differences in and between countries. The most common indications for surgery are radiating pain (Sciatica) and neurologic symptoms (Weakness, numbness or bowel- bladder symptoms) resistant to nonoperative treatment, and the majority of patients who undergo surgery benefit from it.
The Spine Patient Outcomes Research Trial (SPORT) evaluated the effects of surgery versus nonoperative treatment for Lumbar Disc Herniation. Patients with diabetes or with workers compensation should be counseled about the possibility of not improving more with surgical treatment compared to nonoperative treatment over time. In patients undergoing L5-S1 discectomy, retrolisthesis may lead to worse postoperative patient-reported outcomes, compared to patients without retrolisthesis. Obese patients do not benefit as much as nonobese patients, but both groups benefit from surgery over nonoperative treatment.
Recurrent low backache following surgery for degenerative disc disease manifests in short-term (6–24 months) and long-term (24 months). The range of backache varies from 3% to 34% for short- term and from 5% to 36% for long-term.
The incidence of recurrent disc herniation is 5%. Some of these proposed risk factors include obesity, smoking, male gender, diabetes, weightlifting, the size of the annular tear, and type of primary operation.
A not uncommon challenge for the spine surgeon has been the reherniation at the same level following Lumbar discectomy. Attempt at more aggressive discectomies to try to reduce the incidence of reherniation did not yield the desired result and have been associated with greater postoperative degeneration and back pain. Carragee (2006) reported an 11% incidence of persistent back or leg pain after limited discectomy which doubled with aggressive discectomy.
The patient factors associated with larger improvements in Oswestry Disability Index at 4 years with either surgical or nonoperative treatment included a higher baseline Oswestry Disability Index, BMI of less than 30, not being depressed, being insured, having no litigation pending, not having workers compensation, and having symptoms for less than 6 weeks, though there were others. Factors leading to improvement with surgical treatment were mostly related to anatomic characteristics of the disc herniation such as posterolateral, sequestered herniations or direct effects of the disc herniation (predominantly leg pain, intact sensation)..
Disc reherniation is defined as disc herniation occurring at the same level in a patient after a definite pain-free period of at least six months from initial surgery. Magnetic Resonance Imaging with intravenous Gadolinium is the investigation of choice.
Currently, there are no guidelines or significant comparative studies to assist surgeons in determining which approach would be most appropriate to treat rDH.
The frequency of same-level disc herniation requiring reoperation is 6%. The American Association of Neurologic Surgeons (AANS) 2014 guidelines report low-level evidence to support fusion for rDH. A recent recommendation by Wang, et al. is to perform a discectomy in patients with rDH and radiculopathy. Fu, et al. reported similar recommendations. Additionally, fusion has been recommended if the patient has associated lumbar instability, radiographic degenerative changes, and/or chronic axial lower back pain. The revision procedure is fusion in 5% and revision discectomy in 95% of the cases. Fusion may have a greater improvement in pain and functional outcomes compared to reoperation without fusion at the cost of more complications, increased blood loss, and longer operative times for the treatment of rDH.