Surgery for Recurrent Disk Herniations
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).”
Last modified: February 12, 2019