|Year : 2022 | Volume
| Issue : 2 | Page : 110-113
Incidence of recurrent lumbar disc herniation: A narrative review
Gonzalo Mariscal, Elena Torres, Carlos Barrios
Institute for Research on Musculoskeletal Disorders, School of Medicine and Health Sciences, Valencia Catholic University, Valencia, Spain
|Date of Submission||05-Mar-2022|
|Date of Acceptance||08-May-2022|
|Date of Web Publication||13-Jun-2022|
Institute for Research on Musculoskeletal Disorders, Valencia Catholic University, Carrer de Quevedo, 2, 46001 Valencia, Valencia
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Recurrent disc herniation is a common condition that often results in months of disabling symptoms and additional costs.
Objective: The objective of this study was to investigate the incidence of recurrent disc herniation in patients treated surgically.
Materials and Methods: Clinical trials and prospective studies involving patients treated with different techniques, such as open, percutaneous, or microendoscopic discectomy, were included. The incidence of recurrence as well as the level and the time until the recurrent disc herniation was collected.
Results: Thirteen studies were included. Recurrence of disc herniation ranged from 0% to 14% of patients. Most recurrences occurred at the same level of herniation and on the same side. The time to recurrence of disc herniation ranged from 1 to 5 years.
Conclusion: This study answers the question of how much, when, and where in lumbar recurrent disc herniation.
Keywords: Incidence, lumbar disc herniation, recurrent disc herniation, review
|How to cite this article:|
Mariscal G, Torres E, Barrios C. Incidence of recurrent lumbar disc herniation: A narrative review. J Craniovert Jun Spine 2022;13:110-3
|How to cite this URL:|
Mariscal G, Torres E, Barrios C. Incidence of recurrent lumbar disc herniation: A narrative review. J Craniovert Jun Spine [serial online] 2022 [cited 2022 Jun 26];13:110-3. Available from: https://www.jcvjs.com/text.asp?2022/13/2/110/347325
| Introduction|| |
Recurrence of lumbar disc herniation can be defined in different ways according to the different authors. Some authors consider that it occurs when a disc herniation appears at the same level as the primary herniation, regardless of whether it appears ipsilaterally or contralaterally, in a period of at least 6 months without pain after the first intervention., Some authors define it as disc herniation occurring subsequently at a different level from the primary hernia, although this is a less common definition.
Different studies demonstrate a recurrence frequency between 5% and 15%. Several studies have been carried out to demonstrate the reason for the recurrence of disc herniation. The frequency is expected to be related to the different surgical procedures. Discectomy is the most well-known technique and has different approaches such as simple one discectomy, percutaneous endoscopic discectomy that can be interlaminar, transforaminal, or even a minimally invasive transforaminal interbody fusion.,,,, In addition, the learning curve for specialists is closely related to recurrence.
Risk factors that have been described related to the recurrence of disc herniation include age, gender, body mass index (BMI), smoking, the presence of comorbidities such as diabetes, and the presence of particular radiological features., Complications after surgery, among other issues, must also be considered.,
The objective of this study was to review the studies that address the incidence of recurrent lumbar disc herniation and to describe the demographic characteristics associated with this condition.
| Materials and Methods|| |
Search strategy and study selection
The search was limited to PubMed. We used the following Medical Subject Headings (MeSH): “Recurrent disc herniation and incidence.” The search was limited to English language. Inclusion criteria were: prospective cohort studies or randomized clinical trials that treat patients with different surgical techniques; studies that included at least any of the following outcomes: surgical technique and rate of recurrent disc herniation. Exclusion criteria were: studies that did not treat humans, duplicated studies, and studies that did not share variables.
Baseline data were collected from each study: technique, number of patients, gender, mean age, and follow-up. The incidence of recurrent disc herniation was collected, as well as the level of recurrence and time to recurrence. Incidence was measured by the number of patients with the event under study. The level of recurrence was divided into the same level (further divided into the same side and contralateral side) and different levels. Time to recurrent hernia was measured in years.
This review was carried out using an Excel spreadsheet (version 16.52 for IOS). For quantitative variables, the mean, standard deviation, and range of each study were used.
| Results|| |
[Table 1] shows the main characteristics of the included studies.,,,,,,,,,,, Thirteen studies were included. Six studies used conventional open discectomy as the main technique, two studies used microendoscopic discectomy, one study used percutaneous discectomy, one study used laminectomy or hemilaminectomy, one study used tubular discectomy, one study used open minidiscectomy, and one study combined three techniques (percutaneous discectomy, microendoscopic discectomy, and microdiscectomy). The sample size of the different studies ranged from 60 to 1898 patients. The percentage of male patients was 64%, although not all studies analyzed lumbar disc herniation recurrence according to gender. The age of the subjects ranged from 30 to 53 years.
Incidence, location, and time until recurrence
[Table 2] shows the main results. The recurrence rate of lumbar disc herniation varied according to the employed technique: 1%–12% conventional open discectomy, 1%–10.8% microendoscopic discectomy, 5.5%–9.6% percutaneous discectomy, 6% laminectomy, 9.5% tubular discectomy, and 9.2% open minidiscectomy. Regarding the level of recurrence, this data was not provided in all studies. Most of the studies reported recurrence at the same level. Six of the studies reported the recurrent hernia on the same side as the primary hernia, whereas Davis et al., Wera et al., and Matsumoto et al. reported recurrence at the same level but on the contralateral side. Davis et al., Dalgic et al., Yorimitsu et al., Wu et al., and Matsumoto et al. reported the recurrence at a different level than the primary hernia. The time after recurrence was provided by seven studies and ranged from 1 to 4.5 years.
| Discussion|| |
Recurrence of lumbar disc herniation can be defined in several ways, and the most commonly accepted meaning indicates that recurrence occurs at the same level as the primary disc herniation, regardless of whether it is ipsilateral or contralateral.
The incidence of recurrence ranged from 5% to 15%. Recent systematic reviews on disc herniation recurrence focus on the evaluation of risk factors and the comparison of different surgical techniques. There are no recent systematic reviews focused on the incidence of recurrent lumbar disc herniation. The current tendency seems to support the use of less invasive techniques since they have shown satisfactory outcomes. McGirt et al. found that aggressive procedures resulted in a higher pain recurrence rate, whereas those who underwent less invasive procedures had a higher disc herniation recurrence rate. The surgeon, by performing less invasive techniques, has a lower visibility of the surgical site, which could leave part of the hernia remnant or iatrogenic damage to the surrounding tissues.
The current reviews on disc herniation recurrence identify potential factors that may be associated with recurrence: male gender, aging, high BMI, addictive behaviors, diabetes, disc structure, and the presence of specific radiological features.,
Andersen et al. suggested that the reintervention and complication rate in patients with higher BMI are much higher than in patients with lower BMI. Limited activities such as heavy lifting or physically demanding work for a period after surgery may reduce the cases of recurrence, although there are discrepancies with early mobilization.
Regarding tobacco, it is believed to be closely related to recurrence, although the mechanisms are still unclear. Huang et al. concluded that nicotine plays an important role in inhibiting oxygenation and nutrition of the annulus fibrosus of the disc, whereas Akmal et al. analyzed the role of nicotine and concluded that nicotine induces collagen inhibition, which could reduce the cartilaginous content of the annulus fibrosus, thus, leading to degenerative changes and traumatic lesions.
Diabetes also resulted to be a negative predictor of poor prognosis. The healing of the annulus fibrosus of diabetic patients requires a longer healing time, as they have altered physiological proteoglycan composition.
Hao et al. observed that patients presenting with lumbar disc herniation after percutaneous endoscopic discectomy and Modic changes showed a higher risk of recurrence since the cartilaginous endplates are affected, the junction with the vertebral body is weak, and the herniation recurs more easily., In addition, Mok et al. correlated Modic changes with low back pain.
Here is controversy on how recurrent disc herniation should be treated. Li et al. recommend percutaneous endoscopic lumbar discectomy due to the satisfactory outcome. Yao et al. recommended that conservative treatment should be considered initially.
Some of the limitations of this review were the lack of studies dealing with techniques different than conventional open discectomy and the lack of data such as time to recurrence. Moreover, heterogeneity in the sample size of the studies made a difficult comparison. In addition, most studies included recurrence of lumbar disc herniation as a secondary outcome.
| Conclusion|| |
The incidence of recurrent lumbar disc herniation ranged from 0% to 15%. There were no differences between the different techniques, although most studies include conventional open discectomy as the main procedure. The location of recurrence was on the same side as the primary herniation, and the time to recurrence ranged from 1 to 5 years.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Yaman ME, Kazancı A, Yaman ND, Baş F, Ayberk G. Factors that influence recurrent lumbar disc herniation. Hong Kong Med J 2017;23:258-63.
Swartz KR, Trost GR. Recurrent lumbar disc herniation. Neurosurg Focus 2003;15:E10.
Yin SF, Du H, Yang W, Duan C, Feng C, Tao H. Prevalence of recurrent herniation following percutaneous endoscopic lumbar discectomy: A meta-analysis. Pain Physician 2018;21:337-50.
Ajiboye RM, Drysch A, Mosich GM, Sharma A, Pourtaheri S. Surgical treatment of recurrent lumbar disk herniation: A systematic review and meta-analysis. Orthopedics 2018;41:e457-69.
Goker BH, Aydin S. Endoscopic surgery for recurrent disc herniation after microscopic or endoscopic lumbar discectomy. Turk Neurosurg 2020;30:112-8.
Huang W, Han Z, Liu J, Yu L, Yu X. Risk factors for recurrent lumbar disc herniation: A systematic review and meta-analysis. Medicine (Baltimore) 2016;95:e2378.
Staartjes VE, de Wispelaere MP, Miedema J, Schröder ML. Recurrent lumbar disc herniation after tubular microdiscectomy: Analysis of learning curve progression. World Neurosurg 2017;107:28-34.
McGirt MJ, Ambrossi GL, Datoo G, Sciubba DM, Witham TF, Wolinsky JP, et al.
Recurrent disc herniation and long-term back pain after primary lumbar discectomy: Review of outcomes reported for limited versus aggressive disc removal. Neurosurgery 2009;64:338-44.
Hao L, Li S, Liu J, Shan Z, Fan S, Zhao F. Recurrent disc herniation following percutaneous endoscopic lumbar discectomy preferentially occurs when Modic changes are present. J Orthop Surg Res 2020;15:176.
Davis RA. A long-term outcome analysis of 984 surgically treated herniated lumbar discs. J Neurosurg 1994;80:415-21.
Liu X, Yuan S, Tian Y, Wang L, Gong L, Zheng Y, et al.
Comparison of percutaneous endoscopic transforaminal discectomy, microendoscopic discectomy, and microdiscectomy for symptomatic lumbar disc herniation: Minimum 2-year follow-up results. J Neurosurg Spine 2018;28:317-25.
Moliterno JA, Knopman J, Parikh K, Cohan JN, Huang QD, Aaker GD, et al.
Results and risk factors for recurrence following single-level tubular lumbar microdiscectomy. J Neurosurg Spine 2010;12:680-6.
Carragee EJ, Han MY, Suen PW, Kim D. Clinical outcomes after lumbar discectomy for sciatica: The effects of fragment type and anular competence. J Bone Joint Surg Am 2003;85:102-8.
Benzakour A, Benzakour T. Lumbar disc herniation: Long-term outcomes after mini-open discectomy. Int Orthop 2019;43:869-74.
Wera GD, Marcus RE, Ghanayem AJ, Bohlman HH. Failure within one year following subtotal lumbar discectomy. J Bone Joint Surg Am 2008;90:10-5.
Dalgic A, Yildirim AE, Okay O, Uckun O, Alagoz F, Polat O, et al.
Initial discectomy associated with aging leading to adjacent disc disease and recurrence. Turk Neurosurg 2016;26:595-600.
Eun SS, Lee SH, Sabal LA. Long-term follow-up results of percutaneous endoscopic lumbar discectomy. Pain Physician 2016;19:E1161-6.
Yorimitsu E, Chiba K, Toyama Y, Hirabayashi K. Long-term outcomes of standard discectomy for lumbar disc herniation: A follow-up study of more than 10 years. Spine (Phila Pa 1976) 2001;26:652-7.
Wu X, Zhuang S, Mao Z, Chen H. Microendoscopic discectomy for lumbar disc herniation: Surgical technique and outcome in 873 consecutive cases. Spine (Phila Pa 1976) 2006;31:2689-94.
Matsumoto M, Watanabe K, Hosogane N, Tsuji T, Ishii K, Nakamura M, et al
. Recurrence of lumbar disc herniation after microendoscopic discectomy. J Neurol Surg A Cent Eur Neurosurg 2013;74:222-7.
Li X, Hu Z, Cui J, Han Y, Pan J, Yang M, et al.
Percutaneous endoscopic lumbar discectomy for recurrent lumbar disc herniation. Int J Surg 2016;27:8-16.
Andersen SB, Smith EC, Støttrup C, Carreon LY, Andersen MO. Smoking is an independent risk factor of reoperation due to recurrent lumbar disc herniation. Global Spine J 2018;8:378-81.
Akmal M, Kesani A, Anand B, Singh A, Wiseman M, Goodship A. Effect of nicotine on spinal disc cells: A cellular mechanism for disc degeneration. Spine (Phila Pa 1976) 2004;29:568-75.
Robinson D, Mirovsky Y, Halperin N, Evron Z, Nevo Z. Changes in proteoglycans of intervertebral disc in diabetic patients. A possible cause of increased back pain. Spine (Phila Pa 1976) 1998;23:849-55.
Shi H, Zhu L, Jiang ZL, Wu XT. Radiological risk factors for recurrent lumbar disc herniation after percutaneous transforaminal endoscopic discectomy: A retrospective matched case-control study. Eur Spine J 2021;30:886-92.
Mok FP, Samartzis D, Karppinen J, Fong DY, Luk KD, Cheung KM. Modic changes of the lumbar spine: Prevalence, risk factors, and association with disc degeneration and low back pain in a large-scale population- based cohort. Spine J 2016;16:32-41.
Yao Y, Zhang H, Wu J, Liu H, Zhang Z, Tang Y, et al.
Minimally invasive transforaminal lumbar interbody fusion versus percutaneous endoscopic lumbar discectomy: Revision surgery for recurrent herniation after microendoscopic discectomy. World Neurosurg 2017;99:89-95.
[Table 1], [Table 2]