Stand-Alone Open Disectomy versus Fixation in Management of Recurrent Lumbar Disc Prolapse

Abstract Background 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 had experienced a pain-free interval of at least 6 months following discectomy. Objective The main objective of the systematic review was to compare the outcome of repeated surgery after these two techniques. Methods In the present systematic review, we evaluated 655 patients from 9 studies undergoing surgery for RLDH. Both procedures stand-alone open discectomy and discectomy with fusion were found to cause significant improvement in symptoms and disability following revision of different surgical techniques used in the primary surgery. These were open surgery. All patients showed no improvement or unsatisfactory outcome after a variable periods of proper conservative treatment. Results From the results of this systematic review concerning the recurrent lumbar disc: Recurrent lumbar disc herniation was common in males due to higher physical stress and activity. Both procedures were found to cause significant improvement in symptoms and disability following revision surgery. Fusion was found to be associated with longer operative time (70 min on average), higher intraoperative EBL (220 ml on average) and delayed hospital discharge (an average of 3 days). No significant differences were found with regards to functional outcomes, reoperation rates and dural tears between the two cohorts. Repeat discectomy alone may cause or exacerbate lumbar instability. Sciatica was the first presenting symptoms in all cases while back pain was present significantly more in patient done discectomy alone. There was no significant difference between the two approaches regarding the sensory deficit or muscle weakness. Treatment options for recurrent disc herniation include observation and aggressive medical management or operative intervention, in this systematic review all patients were managed surgically, after failure of conservative management. The optimal surgical approach for recurrent disc herniation remains a subject of controversy. Discectomy with fusion has several theoretical advantages. Dural tear was the main immediate intraoperative complication. The surgical treatment was successful with excellent or good outcome in the majority of cases with no significant difference between the two approaches and it is widely accepted that the results after repeated surgery are comparable to those of the first surgery. There was no significant factor influencing the outcome of surgery including age, sex, diabetes, duration of symptoms or pain-free interval and level or side of recurrence. Conclusion Surgery for recurrent lumbar disc herniation can be very successful and may approach the success rate for initial operations provided proper patient selection, good and thorough examination and investigations and proper surgical technique. Available evidence shows that in treating recurrent lumbar discs herniation, repeat discectomy and fusion are associated with comparable reoperation rates, incidence of dural tears, functional outcomes as well as satisfaction with surgical treatment at last follow-up. The findings should be viewed within the context of variable length of follow-up in the included studies; as such, the true long term implications of fusion as compared to repeat discectomy remain to be elucidated. Longitudinal randomized controlled trials are needed to provide firm evidence in this field.