Is There a Clear Solution for Recurrent Disk Herniations?

Microdiskectomy is the most common surgical procedure used to treat lumbar disk herniations when conservative care fails. Although good to excellent results are achieved about 90 percent of the time, recurrent disk herniation reportedly occurs in 7 percent to 18 percent of cases and is one of the most common causes of reoperation. A post-hoc subgroup analysis of data from the Spine Patient Outcomes Research Trial found that younger patients, patients who had a lack of a sensory or motor deficit, and patients with a higher baseline Oswestry Disability Index (ODI) score were at increased risk of recurrent disk herniation. Carragee et al., prospectively evaluated disk herniation types, rates of reherniation, and the rate of reoperations. They divided disk herniations into four shape-based groups:

  1. fragment-fissure herniations (disk fragment and small annular defect)
  2. fragment-defect herniations (large disk fragment with massive posterior annular tear)
  3. fragment-contained disks (incomplete annular tear)
  4. absence of fragment-contained herniations (annular prolapse)

Of the four groups, the fragment-fissure herniations were associated with the best outcomes, the lowest rate of reherniation (1 percent), and the fewest reoperative procedures (1 percent). Those with annular prolapse had the worst outcomes, with 38 percent of patients experiencing recurrent or persistent symptoms.

Spine surgeons continue to debate how to decrease the rate of recurrent herniations. Strategies to reduce recurrence fall into two categories: intraoperative techniques and postoperative recommendations. Although surgeons have utilized a variety of postoperative bracing, exercise programs, and activity limitations, the only randomized trial on this topic found no difference in the risk of recurrence between patients given activity restrictions for a full six weeks and those allowed to resume normal activities two weeks after surgery.

Intraoperative techniques include variations in diskectomy technique (sequestrectomy versus subtotal diskectomy), the use of a laser to “seal” the disk, annular repair strategies, and barrier closure devices. A minimalist approach to remove the protruding fragmented or compressive portion of the disk alone has been shown in multiple trials to provide at least equivalent results to subtotal diskectomy. Three separate meta-analyses showed no difference in recurrence rate for those techniques. However, some literature has suggested that very aggressive diskectomy has a lower recurrence rate. These results should be viewed in the context of the extensive basic animal and clinical work that links aggressive disk removal to increased degenerative changes at the operative segment.

Fig. 1 The Barricaid® design. Barricaid® is formed from a flexible mesh comprising multiple layers of counter-angulated fibers and a strong titanium bone anchor that anchors the mesh to one of the surrounding vertebral bones.
Courtesy of Intrinsic Therapeutics

Although direct annular repair with suture material does have some support in the literature, the Food and Drug Administration (FDA) has not approved any device specifically for use in the spine that is designed to make this challenging repair easier. Surgeons can use suture devices off-label that have been approved for more general use repairing soft tissues at the time of surgery. Additional attempts at improving annular closure vary and range from sealing with a laser to using biologic agents. Although the use of biological sealants and cell-impregnated scaffolds is attractive, no clinical data exist, and no products or devices are FDA approved for this indication. Much basic science research, however, has been conducted on how to restore the biomechanical function and chemical structure of the disk. Adhesive hydrogels (e.g., fibrin combined with genipin) have shown promise in preclinical testing for sealing off the disk and restoring some of the biomechanical integrity of the annulus.

Barricaid® (Intrinsic Therapeutics, Woburn, Mass.) is an annular closure device designed to prevent reherniation by its check-valve mechanism (Fig. 1). It is formed from a flexible mesh and a strong titanium bone anchor that anchors the mesh to the endplate. The device decreased reherniations by about 20 percent; however, the FDA has not cleared the device, citing concerns regarding implant failure, as well as endplate lesions that might indicate resorption or necrosis (Fig. 2).

If a disk reherniates, surgeons usually perform either a repeat diskectomy alone or supplement decompression with arthrodesis. Fusion at the time of repeat diskectomy is comparable to revision diskectomy alone in terms of reoperation rates, incidence of dural tears, functional outcomes, and satisfaction with surgical treatment. Arthrodesis is associated with higher costs and longer hospital stays. Given this, some surgeons try to limit fusion to a third occurrence at the same level.

Fig. 2 Endplate erosions have been identified as a safety concern with the use of Barricaid®.
Courtesy of the Food and Drug Administration

A 2014 study found that, of 445 U.S. spine surgeons, those who had been in practice for at least 15 years were more likely to select revision microdiskectomy; surgeons in practice for fewer years were more likely to recommend revision microdiskectomy supplemented with posterior or transforaminal lumbar fusion. A 2017 meta-analysis of the current literature found that anterior lumbar interbody fusion is also a safe and feasible approach for the treatment of recurrent disk herniations. This was demonstrated through significant improvements in preoperative ODI and visual analog scale back and leg pain scores, with minimal complications. The anterior approach may be appealing in cases where there is extensive scar tissue from the initial procedure requiring extensive bony resection or in cases of lumbar instability.

Up to 90 percent of patients report being satisfied with their outcomes following diskectomy, but certain types of disk herniations can have a much higher failure rate. Recurrent disk herniation is still a problem without a clear solution.

Antonio J. Webb, MD, is a postgraduate year-5 orthopaedic surgery resident at University of Texas Health Science Center at San Antonio and will be completing his spine fellowship in Plano, Texas, next year.

Christopher D. Chaput, MD, is the chief of the Division of Orthopaedic Spine Surgery at University of Texas Health Science Center at San Antonio.

John P. Malloy, DO, is chief of spine surgery at East Coast Orthopaedics and a clinical professor at Nova South Eastern University in Ft. Lauderdale, Fla.

 

References:

  1. Abdu RW, Abdu WA, Pearson AM, et al: Reoperation for recurrent intervertebral disc herniation in the Spine Patient Outcomes Research Trial: analysis of rate, risk factors, and outcome. Spine (Phila Pa 1976). 2017;42:1106-14.
  2. Bono CM, Leonard DA, Cha TD, et al: The effect of short (2-weeks) versus long (6-weeks) post-operative restrictions following lumbar discectomy: a prospective randomized control trial. Eur Spine J. 2017;26:905-12.
  3. Carragee EJ, Han MY, Suen PW, et al: Clinical outcomes after lumbar discectomy for sciatica: the effects of fragment type and anular competence. J Bone Joint Surg Am. 2003;85-A:102-8.
  4. McGirt MJ, Ambrossi GL, Datoo G, 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.
  5. Mroz TE, Lubelski D, Williams SK, et al: Differences in the surgical treatment of recurrent lumbar disc herniation among spine surgeons in the United States. Spine J. 2014;14:2334-43.
  6. Parker SL, Grahovac G, Vukas D, et al: Effect of an annular closure device (Barricaid) on same-level recurrent disk herniation and disk height loss after primary lumbar discectomy: two-year results of a multicenter prospective cohort study. Clin Spine Surg. 2016;29:454-60.
  7. Thomé C, Barth M, Scharf J, Schmiedek P: Outcome after lumbar sequestrectomy compared with microdiscectomy: a prospective randomized study. J Neurosurg Spine. 2005;2:271-8.
  8. Watters WC III, McGirt MJ: An evidence-based review of the literature on the consequences of conservative versus aggressive discectomy for the treatment of primary disc herniation with radiculopathy. Spine J. 2009;9:240-57.
  9. Wera GD, Dean CL, Ahn UM, et al: Reherniation and failure after lumbar discectomy: a comparison of fragment excision alone versus subtotal discectomy. J Spinal Disord Tech. 2008;21:316-9.

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