|Year : 2016 | Volume
| Issue : 4 | Page : 469-473
Identifying predisposing factors for recurrence after successful surgical treatment of lumbar disc herniation
Farzad Omidi-Kashani1, Aslan Baradaran2, Farideh Golhasani-Keshtan2, Mohammad Dawood Rahimi2, Ebrahim Ghayem Hasankhani1, Maryam Abbasi Moghadam2
1 Department of Orthopedic, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
2 Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
|Date of Web Publication||12-Jul-2016|
Department of Orthopedic, Imam Reza Hospital, Mashhad University of Medical Sciences, Imam Reza Square, Mashhad 9137913316, Iran. Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad
Source of Support: None, Conflict of Interest: None
Background: Recurrent lumbar disc herniation (rLDH) comprises one of the most common complications of lumbar discectomy occurring in about 1-21% of the operated patients. Aim: This study aims to elucidate the role of predisposing factors in producing rLDH in the patients with previous successful lumbar discectomy. Materials and Methods: In this retrospective study, we reviewed 213 patients (133 male; 62%) who underwent simple primary lumbar discectomy in our Orthopedic Department from August 2009 to January 2014. Mean age and follow-up period were 38.1 ± 9.8 years and 48.2 ± 7.3 months, respectively. The term of rLDH referred to those cases who have suffered a relapsed sciatalgia after a primary pain improvement period. We repeated magnetic resonance imaging (MRI) scanning only in those cases with recurrent complaints. Chi-square, Fisher, and Student's t-tests were used for statistics. Results: Recurrent sciatalgia occurred in 39 patients (18.3%), while true rLDH on MRI scanning was detected in 32 patients (15%). Younger age, heavier smoking, and less severity of herniation on primary MRI scanning (protrusion vs. sequestration) play as predisposing roles in creating rLDH, while gender, level or side of LDH, the presence of Modic changes, or body mass index (BMI) have no significant effect. The most common sites of rLDH were same level same side, different level, and same level contra-lateral side, respectively. Conclusion: In the patients who had been successfully treated by simple primary lumbar discectomy, younger age, heavier smoking state, and less protrusion of the herniated disc at the time of the index surgery, were all correlated with more probability of the future rLDH, while BMI, Modic change, sex, level, and side of LDH had no significant role.
Keywords: Disc herniation, diskectomy, recurrence, risk factors
|How to cite this article:|
Omidi-Kashani F, Baradaran A, Golhasani-Keshtan F, Rahimi MD, Hasankhani EG, Moghadam MA. Identifying predisposing factors for recurrence after successful surgical treatment of lumbar disc herniation. Med J DY Patil Univ 2016;9:469-73
|How to cite this URL:|
Omidi-Kashani F, Baradaran A, Golhasani-Keshtan F, Rahimi MD, Hasankhani EG, Moghadam MA. Identifying predisposing factors for recurrence after successful surgical treatment of lumbar disc herniation. Med J DY Patil Univ [serial online] 2016 [cited 2019 Dec 14];9:469-73. Available from: http://www.mjdrdypu.org/text.asp?2016/9/4/469/186065
| Introduction|| |
Lumbar disc herniation (LDH) is the most common spinal disorder throughout the young and middle age. The disease is self-limited in about 85-90% of the patients, although surgical intervention in remaining is inevitably indicated., Lumbar discectomy constitutes the most prevalent and probably easiest spine surgery but not without adverse events., A wide variety range of complications from superficial wound infection to aortic laceration and death have been reported in the literature. Among these, recurrent LDH (rLDH) comprises the most common occurring in about 1-21% of the operated patients.,,,,,
Literature is full of the papers dealing with various modern and less invasive surgical technique can be applied in the surgical treatment of primary or rLDH but there are scanty about the predisposing factors promoted the risk of rLDH. Although some factors like preoperative volume of disc herniation, surgical technique (limited versus aggressive discectomy), cigarette smoking, professional lifting, increased preoperative disc degeneration, disc height, or sagittal range of motion have been relatively known as effective risk factors for creating rLDH,,,, role of the other factors such as sport activities and occupational driving have not been proven previously., In this study, we aim to elucidate the role of some important predisposing factors that may be effective in producing rLDH in the patients with previous successful lumbar discectomy.
| Materials and Methods|| |
In this retrospective study, we first obtained local institutional review board approval (ID number 930537). Then, we reviewed the patients who had been surgically treated in our orthopedic department due to primary LDH from August 2009 to January 2014. Fifteen patients failed to be followed up in our study and finally we could study 213 patients (133 male and 80 female; 62% vs. 38%, mean age 38.1 ± 9.8 years old) with a mean follow-up period of 48.2 ± 7.3 (ranged; 20-72) months.
Our inclusion criteria were all the patients with primary single level L4-L5 or L5-S1 LDH who had been surgically treated with simple partial discectomy without any instrumentation or fusion. All the surgical procedures were carried out by the two authors (FOK and EGH) with the same technique throughout these years. Our surgical technique included minimal skin incision, unilateral paravertebral muscle dissection, minimal laminotomy, flavectomy, and partial discectomy. The patients with spinal stenosis (pathology is beyond the limit of the intervertebral disc), two or more levels of LDH, absence of recovery after primary surgery, spinal instabilities, the patients treated with any kind of instruments or spondylodesis, or a follow-up period <1 year were excluded. The term of rLDH referred to those cases who have suffered a relapsed sciatalgia after a primary postoperative recovery period. We meant sciatalgia as a feeling of intense pain (with or without numbness and muscle weakness) in the leg caused by irritation of the sciatic nerve.
At the last follow-up visit, we visited the patients and fulfilled a questionnaire to assess demographic data, body mass index (BMI), job, duration of preoperative sciatica, any significant underlying disease, smoking status, clinical symptoms, and signs. The imaging characteristics (including level and side of the LDH, morphology, and Modic changes) at the preoperative era were extracted from the medical record' archives. In all the cases with rLDH, magnetic resonance imaging (MRI) scan with and without gadolinium was requested and level and side of the rLDH were exactly assessed and differentiated from postoperative adhesive arachnoiditis [Figure 1] and [Figure 2].
|Figure 1: (a and b) Axial and sagittal T2-weighted images show a 36-year-old female patient with a same level, same side recurrent L4-L5 lumbar disc herniation|
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|Figure 2: (a and b) Axial and sagittal T2-weighted images pertaining to a 29-year-old male patient with a history of previous discectomy (left sided L5-S1 disc herniation) 3 years ago. He presented with right-sided L5-S1 disc re-herniation (same level, contralateral side)|
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We used Chi-square and Fisher tests for categorical variables and Student's t-test for continuous variables. Statistical analysis was carried out by Statistical Package for Social Sciences (SPSS) version 11.5 for Windows (SPSS Inc., Chicago, IL, USA) while P< 0.05 was considered significant.
| Results|| |
Recurrent complaints in leg (sciatalgia) during this follow-up period occurred in 39 patients (18.3%). MRI scanning with gadolinium contrast revealed adhesive arachnoiditis in 7 cases, while true rLDH was detected in 32 patients (15%). Reoperation was carried out in nine patients (4.2%). In other word, only 28.1% of the patients with true rLDH ultimately required surgical intervention. The role of various factors in the pathogenesis of rLDH is shown in [Table 1]. According to this table, the age <40 years old, smoking, and less severity of herniation on primary MRI scanning (protrusion vs. sequestration) play as predisposing factors in creating rLDH, while gender, level or side of LDH, the presence of Modic changes, or BMI have no significant effect on rLDH. The numbers of the cases in different subgroups of smoking patients are not sufficient to take a detailed conclusion With respect to the morphology; our data showed that risk of rLDH was significantly higher in protrusion cases relative to the other two groups, but the risk of rLDH among the patients with sequestration or extrusion was not statistically different.
|Table 1: Contributing factors in creating recurrent lumbar disc herniation|
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Among the patients with rLDH, same level, same side re-herniation occurred in 23 cases (71.9%), same level, contra-lateral side re-herniation in 3 (9.4%), and different level re-herniation in 6 (18.8%). As the most common type of our rLDH is the same level, same side re-herniation [Figure 1], iatrogenic creation a defect in annulus fibrosus and posterior longitudinal ligament to evacuate the herniated section of the intervertebral disc, may play an important role in the pathogenesis of rLDH.
| Discussions|| |
First report of symptomatic LDH was carried out by Mixter and Barr in 1934. After that, lumbar disc surgery gradually became popular and nowadays, lumbar discectomy constitutes the most common surgery of the spine throughout the word. Like any other surgery, this invasive procedure is not without side effect. A wide range of trivial to life-threatening adverse effects may occur due to lumbar discectomy among them, rLDH is one of the most prevalent. Our study showed a clinical recurrence rate of 15% during a follow-up period of 48 months while it seems that younger age, heavier smoking state, and less protrusion of the herniated disc play as predisposing factors for creating re-herniation.
Swartz and Trost defined rLDH as an experience of another LDH more than 6 months after the primary operation. In our study, we did not limit the “without pain” time to 6 months, and we assumed every relapse of clinical complaints of sciatalgia after a period of recovery as rLDH. Literature reveals that recurrence rate of lumbar discectomy has a wide range from 1% to 21% depending on the definition of recurrence, surgical technique, duration of follow-up period the patients assessed after the index procedure, and etcetera.,,,,,
Our study showed that there is a significant relationship between smoking and rLDH. Most of the other studies are also strong endorsements of this issue.,, Miwa et al. in a retrospective study on 298 patients who underwent lumbar discectomy, compared clinical characteristics of the recurrent with nonrecurrent patients. Their results showed that current smoking and occupational lifting strongly correlated with rLDH. Intervertebral discs are the biggest avascular structures in the body and theirs nutrition supply are driven by diffusion. Smoking contracts capillary vessels, affects cellular multiplication and metabolism and delays the healing process of the tissues., Therefore, smoking not only increases primary degeneration of the intervertebral discs but also upsurges the rate of rLDH.
Dewing et al. in a prospective longitudinal clinical study assessed the clinical outcome of lumbar discectomy in relation to herniation type and level. They studied 197 cases and followed them up for 3 years. They reported six cases with rLDH (3%) while four of them underwent reoperation. Their study showed that the patients with L5-S1 LDH, sequestered, or extruded disc had a better clinical outcome and less recurrence. In comparison, our follow-up period and recurrence were greater, while we could not find any correlation between the level of LDH and rLDH. In contrast to our study, Miwa et al. and Oh et al. in two separate studies have reported that recurrence rate of LDH in sequestrated type was higher than the other types., In another retrospective study conducted by Dora et al., they evaluated the role of disc herniation volume on the probability of rLDH and finally found that herniation volume doesn't have a role in creating rLDH after lumbar discectomy.
Our study could not find a relationship between the severity of Modic change and probability of rLDH, although this might be due to the rarity of the prevalence of more severe forms of Modic change among our relatively young patients. In the study carried out by Abrishamkar et al., they evaluated the relationship between the severity of Modic change and prevalence of rLDH in 34 cases. In their study, rLDH was more prevalent in the patients with lower grades of Modic scale.
Literature is ambiguous about the role of BMI in the pathogenesis of rLDH. Moliterno and co-authors retrospectively reviewed 217 cases with a history of tubular discectomy for single level LDH. They concluded that nonobese cases with a relatively lower BMI were at greater risk for rLDH. Vice versa, Meredith in a retrospective cohort study, strongly proposed that obesity is a strong and independent risk factor for rLDH. In our study, we could not find a relationship between BMI and prevalence of rLDH.
Our study has some important flaws. Although obtaining MRI scanning from all the operated patients seems more exactly, in LDH issue, clinical complaints are much more important. Therefore, we repeated MRI scanning in only those cases with clinically rLDH. Our study had a retrospective design and inevitably had its own limitations. This study was also driven only from one academic center. Perhaps, a more comprehensive multi-centric and prospective study could obtain more reliable results.
| Conclusion|| |
This study showed that in the patients who had been successfully operated by simple primary lumbar discectomy, younger age, heavier smoking state, and less protrusion of the herniated disc at the time of the index surgery, were all correlated with more probability of rLDH, while BMI, Modic change, sex, level, and side of LDH, had no significant role.
The authors would like to thank Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences for financial support. This paper is based on a medical student's thesis pertaining to MA.
Financial support and sponsorship
Mashhad University of Medical Sciences.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]