The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 90, Issue 1

Scientific Articles | January 01, 2008

Failure within One Year Following Subtotal Lumbar Discectomy

Glenn D. Wera, MD¹; Randall E. Marcus, MD¹; Alexander J. Ghanayem, MD²; Henry H. Bohlman, MD¹

¹ Department of Orthopaedic Surgery, Case Western Reserve University, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106. E-mail address for G.D. Wera: gwera@yahoo.com. E-mail address for R.E. Marcus: randall.marcus@uhhs.com
² Department of Orthopaedic Surgery, Stritch School of Medicine, Loyola University Chicago, 2160 S. 1st Avenue, Maguire Building Suite 1700, Maywood, IL 60153. E-mail address: aghanay@lumc.edu

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Investigation performed at the Department of Orthopaedic Surgery, Case Western Reserve University, University Hospitals Case Medical Center, Cleveland, Ohio

The Journal of Bone and Joint Surgery, Inc.

J Bone Joint Surg Am, 2008 Jan 01;90(1):10-15. doi: 10.2106/JBJS.F.01569

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Abstract

Background: Reherniation within the first year following subtotal lumbar discectomy is a rare but noteworthy event. We performed a retrospective, case-controlled study to evaluate the clinical outcomes after early recurrent lumbar disc reherniation.

Methods: The records of 1320 patients who had undergone primary subtotal lumbar discectomy were analyzed retrospectively by an independent reviewer. Patients with documented reherniation within twelve months were evaluated with regard to the location of the reherniation, the neurologic status, the rate of reoperation, and the subjective outcome. Patients were evaluated on the basis of a physical examination and a review of medical records. Disc morphology, anular competence, and the presence of free fragments were categorized with use of a modified five-part Carragee classification system. The mean duration of follow-up for this group was 52.6 months. Clinical outcomes were assessed with use of the Oswestry score and the modified criteria of McNab. Twenty-nine historical control patients who had undergone uncomplicated subtotal lumbar discectomy were selected.

Results: We identified fourteen recurrent lumbar disc herniations within one year after the index procedure. All fourteen patients had radicular pain and weakness prior to, and complete relief of radiculopathy after, the index procedure. All reherniations occurred at the same level as the index procedure, but eight occurred in a different direction than the original herniation. All patients underwent reexploration and discectomy, and two underwent single-level posterolateral arthrodesis. Two patients underwent a third procedure. The average Oswestry score at the time of the latest follow-up was 6.4 for the recurrent herniation group, compared with 6.9 for the controls. The outcomes according to the modified McNab criteria were not significantly different between the groups, with the numbers available. The mean duration of follow-up after the second discectomy was 52.6 months.

Conclusions: The rate of early reherniation after subtotal lumbar discectomy is low (1%). It is important to consider the possibility of iatrogenic instability during surgery on the lumbar spine for the treatment of reherniation. Patients who undergo reoperation because of early recurrent lumbar disc herniation can have clinical outcomes comparable with those of patients undergoing an uncomplicated subtotal lumbar discectomy.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Introduction

Lumbar disc herniation is one of the most common spinal diseases. The prevalence of this condition has been reported to range from 1% to 2% in North America¹. Depending on severity, the rates of surgery for the treatment of sciatica have been reported to range from 2% to 10%². Accordingly, approximately 200,000 lumbar discectomies are performed annually³. Large, long-term studies have demonstrated rates of repeat surgical intervention after lumbar discectomy on the order of 12%⁴. Epidemiologic studies of lumbar surgery in general have also demonstrated considerable rates of reoperation on the order of 9.5%⁵. However, little has been written about recurrent lumbar disc herniation within the first year after subtotal lumbar discectomy.

The technique of subtotal discectomy differs from microdiscectomy in several respects. Microdiscectomy is performed through the interlaminar space or a small laminotomy, often with use of an operating microscope rather than loupe magnification. A medial facetectomy is rarely performed, and the midline interspinous ligaments are preserved. Free fragments are removed piecemeal, and the disc is débrided back to the vertebral wall only^6,7. In contrast, during subtotal discectomy, the whole soft nucleus is removed through a laminectomy or laminotomy.

We reviewed our experience with recurrent lumbar disc herniation within the first year after subtotal discectomy in order to determine the clinical results in comparison with case controls who had not had reherniation.

Materials and Methods

Institutional review board approval was obtained for this investigation. The medical records of 1320 consecutive patients who had undergone subtotal lumbar discectomy over a ten-year period (from 1983 to 1992) were screened for recurrent lumbar disc herniation within the first year after surgery. All operations were performed at a single institution by five orthopaedic spine surgeons, including two of us (R.E.M., H.H.B.). The inclusion criteria were an age of more than eighteen years, a history and physical examination findings consistent with sciatica, radiographic confirmation of a herniated nucleus pulposus on magnetic resonance imaging or myelography, and performance of the index procedure at our center. Exclusion criteria included primary infection, instability requiring arthrodesis, malignancy, and scoliosis. The patients in the study group were then compared with case-matched controls. The selection criteria for the controls were an age within three years of the patient, a herniated nucleus pulposus at the same or adjacent lumbar level, and a history of having undergone subtotal lumbar discectomy without complication during the first postoperative year (Table I).

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TABLE I Preoperative Clinical Features of Early Reherniation Group and Controls

	Early Recurrent Lumbar Disc Herniation	Controls
Number of patients	14	29
Age*(yr)	48.3 (27 to 83)	44.6 (31 to 84)
Female gender (no. of patients)	4 (29%)	7 (24%)
Duration of follow-up*(mo.)	52.6 (15 to 87)	59.8 (2 to 217)
No. of levels†	17	29
L3-L4	4	5
L4-L5	6	13
L5-S1	7	11
Modified Carragee class (no. of discs)
I. Fragment-fissure	0	2
II. Fragment-defect	4	4
III. Fragment-contained	0	4
IV. No fragment-contained‡	13	16
V. Calcified	0	3

The values are given as the mean, with the range in parentheses.The distribution of levels was not significant.The number of class-IV discs was significantly higher in both groups (p = 0.018).

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TABLE I Preoperative Clinical Features of Early Reherniation Group and Controls

	Early Recurrent Lumbar Disc Herniation	Controls
Number of patients	14	29
Age*(yr)	48.3 (27 to 83)	44.6 (31 to 84)
Female gender (no. of patients)	4 (29%)	7 (24%)
Duration of follow-up*(mo.)	52.6 (15 to 87)	59.8 (2 to 217)
No. of levels†	17	29
L3-L4	4	5
L4-L5	6	13
L5-S1	7	11
Modified Carragee class (no. of discs)
I. Fragment-fissure	0	2
II. Fragment-defect	4	4
III. Fragment-contained	0	4
IV. No fragment-contained‡	13	16
V. Calcified	0	3

The values are given as the mean, with the range in parentheses.The distribution of levels was not significant.The number of class-IV discs was significantly higher in both groups (p = 0.018).

Each patient underwent subtotal discectomy for the treatment of lumbar disc herniation. All surgeons performed a subtotal discectomy with removal of free fragments and the nucleus pulposus within the disc space. We defined free fragments as unattached disc material that migrated into the spinal canal. The subtotal discectomy was performed under loupe magnification. A laminectomy or laminotomy was performed, followed by removal of the herniated fragments. A box-shaped incision was made with a scalpel in the anulus fibrosis, followed by débridement of the disc space with pituitary rongeurs and curettes. All of the free fragments and the central soft nucleus were removed, leaving the anulus fibrosis in place. The nerve roots and foramina were explored bilaterally. In cases of foraminal stenosis, foraminotomies were performed.

All patients were admitted to the hospital on the day of surgery. All patients received twenty-four to forty-eight hours of perioperative intravenous cephalosporin for prophylaxis against infection. All patients took part in inpatient physical therapy until discharge. The patients' activity orders were "activity as tolerated." The average duration of hospitalization was 2.5 days (range, one to five days).

Operative notes, clinical documents, and radiology reports were evaluated in order to describe and classify the disc herniations. In order to examine anular integrity and the presence of free fragments, each disc was classified retrospectively as type I through V on the basis of a modification of the Carragee system (Table II)⁷. The system was modified to include a fifth class, the calcified disc. The final follow-up examination was performed by an independent reviewer (A.J.G.). Case-control patients were all examined by the senior author (H.H.B.). Clinical outcomes were quantified with use of modified McNab criteria and the Oswestry score^8,9. Neurologic assessment consisted of sensory, motor, and root tension evaluation on physical examination.

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TABLE II Modified Carragee Classification Scheme⁷

	Classification
	I. Fragment-Fissure	II. Fragment-Defect	III. Fragment-Contained	IV. No Fragment-Contained	V. Calcified
Disc fragment	Extruded or sequestrated	Extruded or sequestrated	Subanular detached fragments	No subanular detached fragment	No free fragment; hard protrusion
Anulus	Minimal defect	Large defect	Intact	Intact	Degenerative

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TABLE II Modified Carragee Classification Scheme⁷

	Classification
	I. Fragment-Fissure	II. Fragment-Defect	III. Fragment-Contained	IV. No Fragment-Contained	V. Calcified
Disc fragment	Extruded or sequestrated	Extruded or sequestrated	Subanular detached fragments	No subanular detached fragment	No free fragment; hard protrusion
Anulus	Minimal defect	Large defect	Intact	Intact	Degenerative

Statistical relevance was determined with a chi-square analysis for categorical variables. A two-tailed Mann-Whitney test was used to evaluate Oswestry scores. A Fisher exact test was used to compare neurologic outcomes after surgery between the two groups. The McNemar test was used to evaluate neurologic outcomes after surgery within groups. The level of significance was set at p < 0.05.

Results

Fourteen (1%) of 1320 patients were identified as having a recurrent lumbar disc herniation within one year after the index procedure. The mean duration of follow-up after the second discectomy was 52.6 months (range, fifteen to eighty-seven months). These fourteen patients included ten men and four women who had had an average age of 48.3 years (range, twenty-seven to eighty-three years) at the time of the index procedure. Each patient had complete relief of sciatica after the index procedure. All recurrent lumbar disc herniations were confirmed with gadolinium-enhanced magnetic resonance imaging or computed tomographic myelography. Twenty-nine case-matched controls were identified. The preoperative patient profiles are summarized in Table I.

Details regarding the disc morphology, the modified Carragee class, the presence of free fragments, procedures, and timing are summarized in Table II and in the Appendix. All of the recurrent disc herniations occurred at the same level as the index procedure. Free fragments recurred in four patients. However, eight reherniations occurred in a different direction than the original herniation. The average time until the recurrence of symptoms was 2.8 months (range, two days to 5.5 months). The average time to reoperation was 4.7 months (range, nine days to 9.5 months). Ten of the fourteen patients described an event that precipitated the recurrence of sciatica symptoms. These events included lifting, twisting, jogging, a fall, and driving over a pothole.

All fourteen patients with early recurrent lumbar disc herniation underwent reexploration and removal of the disc fragments with débridement of the disc space. Laminectomies were widened sufficiently to allow exploration of the lateral recesses and neural foramina. Two patients underwent a single-level posterolateral arthrodesis because of disruption of the posterior elements that was noted during the second procedure. Two patients required a third procedure for a perioperative seroma in one patient and late development of stenosis with disc herniation cephalad to the fusion.

When the patients with a recurrent disc herniation were compared with the case-matched controls, the postoperative outcomes with respect to clinical scores, neurologic examination, and nonsteroidal anti-inflammatory drug use were comparable. Preoperatively, there was a significantly higher prevalence of motor deficits among the early reherniation group as compared with the controls (p < 0.001). However, both groups had sensory improvements postoperatively (Table III). At the time of the latest follow-up, the average Oswestry score was 6.4 for the early reherniation group, compared with 6.9 for the controls (p < 0.50). According to the modified McNab criteria, the outcome was classified as excellent for five patients, good for four, fair for four, and poor for one. These results were similar to those for the controls (p < 0.20). Preoperatively, all fourteen patients with recurrent lumbar disc herniation had documented motor or neurologic deficits, including root tension signs (Table III). At the time of follow-up, one patient had a persistent sensory deficit. Two patients had grade-4 of 5 motor strength, which was a significant improvement in comparison with the preoperative status (p < 0.001). Three patients had persistent root tension signs. In the early reherniation group, there were significant improvements in terms of motor deficits (p < 0.001) and root tension signs (p = 0.008). In addition, there was a strong trend toward improvement in terms of sensory deficits within the recurrent lumbar disc herniation group (p = 0.06). In the case control group, there was a significant improvement in terms of sensory deficits and root tension signs (p = 0.004 and p < 0.001, respectively) and a trend toward improvement in terms of motor deficits (p = 0.12). After surgery, neurologic findings were similar. With the numbers available, the distributions of the level of herniated nucleus pulposus and the modified Carragee classes were not different between the two groups (p < 1.0 and p < 0.51, respectively). Table IV summarizes the postoperative clinical outcomes for the fourteen patients with recurrent disc herniation and the twenty-nine case-control patients.

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TABLE III Summary of Neurological Findings

	Early Recurrent Lumbar Disc Herniation	Controls	P Value
Motor deficit
Preoperative	14	4	<0.001
Follow-up	2	0	0.10
P value	<0.001	0.12
Sensory deficit
Preoperative	6	10	0.74
Follow-up	1	1	1.00
P value	0.06	0.004
Root tension sign
Preoperative	11	28	0.09
Follow-up	3	3	0.37
P value	0.008	<0.001

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TABLE III Summary of Neurological Findings

	Early Recurrent Lumbar Disc Herniation	Controls	P Value
Motor deficit
Preoperative	14	4	<0.001
Follow-up	2	0	0.10
P value	<0.001	0.12
Sensory deficit
Preoperative	6	10	0.74
Follow-up	1	1	1.00
P value	0.06	0.004
Root tension sign
Preoperative	11	28	0.09
Follow-up	3	3	0.37
P value	0.008	<0.001

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TABLE IV Postoperative Clinical Outcomes

	Early Recurrent Lumbar Disc Reherniation	Controls	P Value
Number of patients	14	29
Duration of follow-up*(mo)	52.6 (18 to 87)	59.8 (2 to 217)
No. of reherniations	14	2
No. of reoperations	2 (third procedure)	1 (second procedure)
Time to reoperation*(mo)	4.7 (1 to 5.5)	64
Complications	3	0	<0.10
Oswestry score*	6.4 (0 to 20)	6.9 (0 to 23)	<0.5
95% confidence interval	2.4 to 10.4	4.5 to 9.3
McNab criteria			<0.2
Excellent	5	18
Good	4	6
Fair	4	5
Poor	1	0
Nonsteroidal anti-inflammatory drug use	3	4	<1.0

The values are given as the mean, with the range in parentheses (where applicable).

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TABLE IV Postoperative Clinical Outcomes

	Early Recurrent Lumbar Disc Reherniation	Controls	P Value
Number of patients	14	29
Duration of follow-up*(mo)	52.6 (18 to 87)	59.8 (2 to 217)
No. of reherniations	14	2
No. of reoperations	2 (third procedure)	1 (second procedure)
Time to reoperation*(mo)	4.7 (1 to 5.5)	64
Complications	3	0	<0.10
Oswestry score*	6.4 (0 to 20)	6.9 (0 to 23)	<0.5
95% confidence interval	2.4 to 10.4	4.5 to 9.3
McNab criteria			<0.2
Excellent	5	18
Good	4	6
Fair	4	5
Poor	1	0
Nonsteroidal anti-inflammatory drug use	3	4	<1.0

The values are given as the mean, with the range in parentheses (where applicable).

Five of the twenty-nine control patients were evaluated for sciatica again with use of magnetic resonance imaging or computed tomography myelography. One control patient had a reoperation for the treatment of same-level reherniation, at fifty-four months. Another control patient had a reherniation at 217 months but declined surgery. Another control patient had development of lumbar stenosis 140 months after the index procedure but also declined further surgery. Interestingly, one control patient had development of lumbar disc calcification at the surgical level but was totally asymptomatic. In addition, an asymptomatic grade-I spondylolisthesis was discovered on routine radiographs of one control patient at 162 months of follow-up.

Discussion

Early recurrent lumbar disc reherniation is a consequential but rare complication of subtotal lumbar discectomy. In one series of 152 patients, the rates of reherniation within the first year were reported to be 0.7% at six months and 5.5% at twelve months after fragment excision alone¹⁰. According to Carragee et al.¹⁰, the most predictive factor of a good clinical outcome after lumbar discectomy is lack of reherniation. In one study of 101 patients, the rate of reoperation was 7.3% over the long term¹¹. One-third of these reoperations stemmed from reherniation. Carragee et al. noted that patients with anular defects and free fragments (fragment-defect herniations) had high rates of reherniation (27.3%) and reoperation (21.2%)⁷. However, their technique involved the use of fragment excision alone rather than subtotal discectomy. The clinical results of reoperation for the treatment of reherniation after fragment excision have been similar to those associated with uncomplicated lumbar discectomy¹². To our knowledge, no other study has specifically addressed reherniation in the early perioperative period within one year after subtotal discectomy.

The technique that we utilized has been associated with rates of reoperation and reherniation of 3.2% and 4.5%, respectively, over the long term¹³. As many surgeons prefer fragment excision alone, differences in surgical technique remain under debate. Balderston et al., in a retrospective study of eighty-three patients who had been managed with fragment excision or disc excision, reported no differences between the two techniques with regard to the rates of reherniation and reoperation¹⁴. However, there was a higher rate of subsequent back pain in the group of patients managed with disc excision and curettage. The investigators believed that the technique of disc space curettage was unwarranted and could increase surgical risks such as great vessel injury¹⁴. However, we observed no instances of great vessel injury after 1320 operations with use of the curettage technique. Moreover, we found a very low rate of early reherniation (1%). The concern regarding the development of back pain after subtotal discectomy was echoed in the recent prospective study by Carragee et al., in which thirty patients who were managed with subtotal discectomy were compared with forty-six patients who were managed with fragment excision alone¹⁵. In that investigation, back pain and Oswestry scores were worse in the subtotal discectomy group. Interestingly, we observed low, equivalent back pain scores (p < 0.5) and high functional scores in both the early recurrent lumbar disc herniation group and the control group.

The Carragee classification system has prognostic value with regard to clinical outcomes and reherniation in the setting of fragment excision⁷. This four-class system is based on anular competence and the presence of a free fragment. Importantly, patients with large anular defects with a concomitant free fragment (class II) are at highest risk for reherniation. Furthermore, patients with an intact anulus and no free fragment (class IV) have lower clinical outcomes scores. We have modified the system to account for calcified discs characterized by a degenerative anulus and a hard disc protrusion by adding class V (Table II). In our series, we found an equivalent distribution of modified Carragee classes between the recurrent lumbar disc herniation group and the control group. Carragee class IV was the most frequent class in both groups (p = 0.018). The postoperative Oswestry scores in our series were low and were comparable with those in other reports^7,15. However, with the numbers available, disc class was not predictive of reherniation or lower clinical scores in our series.

Two patients in our series were noted to have development of instability during reoperation. We performed a single-level arthrodesis in both patients during the second procedure. In one patient, disruption of the facets was iatrogenic and was recognized during reoperation. In the other patient, a bilateral pars stress fracture was recognized during the second procedure for the treatment of reherniation. In the control group, there was a single case of grade-I spondylolisthesis that was found at the time of long-term follow-up. Accordingly, we do not regard subtotal discectomy as a risk factor for instability. However, careful evaluation of the posterior elements is necessary in the setting of repeat lumbar discectomy.

Two patients in the recurrent lumbar disc herniation group underwent a third procedure. One patient with a dural tear required evacuation and débridement of a seroma in the perioperative period. If repaired at the time of surgery, dural tears do not typically cause long-term complications¹⁶. However, in the case of this patient, the ensuing seroma necessitated another procedure. The other patient had development of stenosis and a disc herniation cephalad to the fusion mass at the time of long-term follow-up. She subsequently underwent an uncomplicated laminectomy, discectomy, and extension of the arthrodesis. Disc degeneration cephalad to the fusion mass is the most common abnormality in the transition zone after lumbar fusion¹⁷. However, adjacent-segment degradation also has been shown in patients with degenerative disc disease who have not had surgery¹⁸.

The concern regarding missed or retained fragments is important in the setting of repeat lumbar discectomy. In the microsurgical literature, missed fragments have been implicated in 15% of procedures¹⁹. However, no missed fragments were found among the patients with the earliest reherniations in our series (Case 9, 12, and 13; see Appendix). Most importantly, all of these patients had documented relief of sciatica after surgery, and most of them specifically recalled the occurrence of the reherniation. With our technique of subtotal lumbar discectomy, the rate of missed fragments was low.

The fact that ten of the fourteen patients with early recurrent lumbar disc herniation recalled a specific event that precipitated the reherniation is a key feature of the disease process that should direct the surgeon to reconsider recurrent lumbar disc herniation. Similarly, of the twenty-nine control patients, five eventually presented with symptoms similar to sciatica. Two patients in the control group had late reherniation (at fifty-four and 217 months). One of these patients elected to undergo repeat surgery, and the other declined. In addition, one patient had development of clinically important lumbar stenosis at 140 months.

The outcomes in terms of back pain, functional score, and neurologic improvements in the early recurrent lumbar disc herniation group were similar to those in the control group. All fourteen patients in the early recurrent lumbar disc herniation group had improvement of preoperative neurologic or motor deficits, with the exception that one patient had a persistent sensory deficit and two patients had persistent grade 4 or 5 motor strength. In the control group, one of the twenty-nine patients had a persistent sensory loss. A small number of patients in each group had remaining root tension signs and required nonsteroidal anti-inflammatory drugs for pain relief. Three patients in the recurrent lumbar disc herniation group, including the one patient in our series who had a poor result, were involved in a Workers' Compensation claim. Involvement in a Workers' Compensation claim or litigation has been associated with poorer outcomes in patients with musculoskeletal diseases and those undergoing surgical procedures^20,21.

In summary, recurrent lumbar disc herniation within one year is an infrequent but important occurrence after subtotal lumbar discectomy. When patients present with recurrence of sciatica after lumbar discectomy, we advocate a thorough evaluation. If recurrent lumbar disc herniation is diagnosed, we advocate reexploration of the disc, nerve roots, and foramen. Free fragments and loose material from the nucleus should be débrided. The outcomes for these patients can be expected to be similar to those for patients who undergo an uncomplicated single-level subtotal lumbar discectomy.

Appendix

A table showing the clinical details of the patients with a recurrent disc herniation is available with the electronic versions of this article, on our web site at (go to the article citation and click on "Supplementary Material") and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM). Image Not Available

Acknowledgements

Note: The authors would like to thank Carter Petty, MS, for his assistance with the statistical analysis.

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Topics

diskectomy ; hernias ; repeat surgery ; sciatica ; lumbar spine disc herniation ; lumbar diskectomy ; arthrodesis

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Glenn D. Wera, M.D.,

Posted on March 10, 2008

Dr. Wera et al. respond to Dr. Finnegan

Case Western Reserve University, Case Medical Center, Cleveland, OH

We greatly appreciate Dr. Finnegan's constructive remarks regarding our recent article entitled â€œFailure within one year following subtotal lumbar discectomyâ€. A key benefit of subtotal lumbar discectomy is a very low reherniation rate which we and Carragee et al. have confirmed(1,2). As Dr. Finnegan has underscored, an evaluation, as we described, is critical when lumbar disc reherniation is suspected. We thank him for highlighting these points.

References:

1. Wera GD, Dean CL, Ahn UM, Marcus RE, Cassinelli EH, Bohlman H, Ahn NU. Reherniation and failure following lumbar discectomy: a comparison of fragment excision alone versus subtotal discectomy [abstract]. Spine J. 2006;6:103S.

2. Carragee EJ, Spinnickie AO, Alamin TF, Paragioudakis S. A prospective controlled study of limited versus subtotal posterior discectomy: short-term outcomes in patients with herniated lumbar intervertebral discs and large posterior anular defect. Spine. 2006 Mar 15;31(6):653-7.

Walter J. Finnegan, M.D., J.D.

Posted on February 20, 2008

Failure within one year following subtotal lumbar discectomy.

Orthopedic Associates of Allentown, Allentown, PA

To The Editor:

In the recent excellent article by Wera et al.(1),"Failure within one year following subtotal lumbar discectomy", two items were of great interest to me:

1.) A mere 1% incidence of early re-herniation.

2.) Notation that the average time until recurrence of symptoms was only 2.8 months, a radical departure from the time frame that we had published in 1979(2), wherein the greatest predictor of non-fibrosis pathology was a pain-free interval (PFI) of six months after disc excision.

We accept these new data at face value, and with appropriate humility, noting that "the only constant is change." Although disappointed to see that our experience was not reproducible, it is clearly important for spinal surgeons to be aware of the modest probability for recurrent disc herniation at the operated level in a much shorter time frame than we would have predicted. Also of note is the fact that more than half of the re-herniations were in a different direction from the original. 70% of those with recurrent herniation apparently were able to relate the occurence to a specific event such as lifting/twisting/jogging/fall.

We congratulate the authors for undertaking such a comprehensive and long-term study; of course, we did not have the benefit of Dr. Carregee's classification back in the 1970's.

The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated .

References:

1. Wera GD, Marcus RE, Ghanayem AJ, Bohlman HH. Failure within one year following subtotal lumbar discectomy. J bone Joint surg Am. 2008;90:10-15.

2. Finnegan, WJ et al. J Bone Joint Surg Am. 1979;61:1077-82

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Glenn D. Wera, Randall E. Marcus, Alexander J. Ghanayem, Henry H. Bohlman; Failure within One Year Following Subtotal Lumbar Discectomy. The Journal of Bone & Joint Surgery. 2008 Jan;90(1):10-15.

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