Surgery for Recurrent Disk Herniations
Hi my name is Dr. John Shim, and I want to discuss the lumbar Co flex interlaminar stabilization surgery. By now you have already tried non-surgical treatments, and have decided to move forward with surgery. Lumbar Coflex interlaminar stabilization is offered because your pain patterns match the spinal stenosis findings on your diagnostic studies. Spinal stenosis means narrowing and pinching of the nerve tissues in the spine. Because surgery will remove some of the important stabilizers of the spine. the coflex interlaminar stabilization procedure along with bilateral lumbar laminotomy decompressions are recommended. Let me show you a typical lumbar MRI of spinal stenosis. This is the sagittal view. It's a side view of your back. For most patients, there are some normal disc levels, but with spinal stenosis, you can see the narrowing of the canal by a combination of bone spurring, ligament enlargements, and disc bulging. The axial view, or the cross-sectional view will provide another angle to visualize spinal stenosis. When compared to a more normal level, you can see the triangular shape of the canal, and the narrowing of the space that is occupied by the nerves that are extending from the spinal cord into the lower body. Of course, I'm simplifying the process. For the surgeon, there are many nuances that need to be considered. Experience does help when planning the operation. Still, the exposure is relatively the same. For a single level, a 4 centimeter incision is made in the midline, spanning across the area of bone removal. Muscles are gently retracted to allow visualization of the boney covering or lamina and the ligament that covers over the spinal canal. Some bone in the middle will need to be removed to allow access. The posterior spinal ligament is removed. Tools including burs, kerrison punches and curettes aid in the removal of the covering bone and ligament. The nerve sack is identified, and protected. Associated bone spurs are removed, and the nerves are given more room to exit the space called the formen. The spine is prepared to accept the coflex interlaminar device. Trial devices are used to measure the appropriate size the device. The device is then implanted to within a few millimeters of the thecal sac, and the fins of the device rest on the lamina of the upper and lower spinal levels. The fins are then compressed onto the posterior spinous processes, securing the device to the spinal bones. The incisions are then closed. If there are no issues, most patients can have the surgery performed on an outpatient basis. For the vast majority of patients, they can resume normal activities within a few weeks. This is the basic animation of the lumbar Co flex interlaminar stabilization operation. You should discuss your individual concerns with your surgeon. This is Dr. John Shim, and I hope this video helps you understand the basics of the lumbar Co flex interlaminar stabilization surgery. Thank you!
Unfortunately, even after successful lumbar discectomy surgery, there is between a 5% and 15% chance of a recurrent disk herniation at the same location. The reason is secondary to the nature, and size of the lumbar disk. Most disk herniations are pieces of annulus, endplate, and or nucleus elements of the disk. The fragments, however, are only a very small piece compared to the whole disk. No matter how much disk is removed during the original discectomy surgery, there is always more disk material available to herniate.
In addition to the amount of disk material still present, the hole where the disk material herniated is still present. Even though there is some scar tissue and repair of the hole, it will never be as strong as the original annulus. Just so it is clear, once a disk herniates, it will always have the 5%-15% chance of re-herniation, with or without surgery.
If you have a recurrent disk herniation after the prior discectomy surgery, most physicians will still try to treat the disk herniation non-surgically.
If you can no longer tolerate the pain, there are different surgical options on how to handle your disk herniation.
- Provided this is only the first recurrence, many Surgeons will consider doing just a repeat discectomy. The results for the proper patient is similar to the original surgery. Some studies have suggested that central recurrent disk herniations at L4-5 should also be fused at the same time, as the L4-5 level is most associated with discogenic back pain, and development of instability.
- After multiple recurrent disk herniations at the same level, the standard answer is to consider repeat discectomy with fusion. Successful fusion will prevent further recurrent disk herniations at the disk level, as most of the disk is removed, and there will no longer be motion at that disk level. Fusions, however, have associated complications, including fusion failure, hardware failure, and potential for accelerated degeneration of the disk levels above/below the level ( Adjacent Segment Disease). The surgeon must consider the possibilities before pursuing the fusion, depending on factors such as age, activity level, medical condition, etc.
- A minority of Surgeons will recommend repeat discectomy and Total Disk Replacement. The rationale is to remove the disk, thus improving the leg pain, as well as replacing the disk to prevent the Adjacent Segment Disease. While the principles seem logical, it usually requires both an incision on the back, to remove the disk, as well as an abdominal incision to replace the disk. The anterior abdominal incision has multiple associated risks, and the long term efficacy of Lumbar Total Disk replacement is still being challenged.
- Certain surgeons are now performing the repeat discectomy, but to protect the disk level bay placing posterior interspinous, or posterior intralaminar stabilization devices. This technology has been used in Europe for more than 15 years, and has been FDA approved for use in one or two level lumbar spinal stenosis.*** The devices provide stability without needing a fusion. This technique has its advantage in that it can be easily converted to a fusion if necessary into the future, and can be performed on a minimal access, outpatient basis. For recurrent lumbar discectomy, it has not be officially studied and it considered an off label use of the device.
If you have a recurrent lumbar disc herniation after the prior successful discectomy surgery, the chances are good that you will have a successful repeat surgical procedure. But know that there are different surgical options. Please discuss them with your Surgeon.
*** Disclosure statement from Paradigm Spine, LLC. “The Coflex interlaminar Technology is an interlaminar stabilization device that is indicated for the use in one or two level lumbar stenosis from L1-L5 in skeletally mature patients with at least moderate impairment in function, who expericnce relief in flexion from their symptoms of leg/buttock/groin pain, with or without back pain, and who have undergone at least 6 months of non-operative treatment. The Coflex is intended to be implanted midline between adjacent lamina of 1 or 2 contguous lumbar motion segments. Interlaminar stabilization is performed after decompression of stenosis at the affected level(s).”
- 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 Jan;95(2):e2378. PubMed PMID: 26765413