Orthopedics

Feature Article 

Characterization and Risk Factor Analysis for Reoperation After Microendoscopic Diskectomy

Xin Hong, MD; Lei Liu, MD; Junping Bao, MD; Rui Shi, MD; Yudong Fan, MA; Xiaotao Wu, MD

Abstract

A population-based database of 1263 consecutive patients who underwent microendoscopic diskectomy for single-level lumbar disk herniation between 2005 and 2010 was retrospectively analyzed to identify causes and characteristics of reoperation and associated risk factors. A total of 952 patients were eligible. Of these, 58 had revision spinal surgery. Causes and clinical parameters were retrospectively assessed, and possible risk factors were evaluated by multivariate logistic regression analysis. In total, 76 disk herniations were excised with revision diskectomy, with or without interbody fusion. The overall mean interval between primary surgery and revision surgery was 39.05 months (range, 2–95 months). Cumulative overall reoperation rates gradually increased from 1.56% at 1 year to 8.17% after nearly 10 years. Reoperated patients were older and had a higher level of lumbar degeneration, with severe Modic changes (type 1, 17.2%; type 2, 34.5%), vs patients without reoperation (type 1, 1.5%; type 2, 30.6%). In addition, patients with reoperation had a higher rate of obvious adjacent disk degeneration (81.1%). Logistic regression analysis showed that adjacent segment degeneration and Pfirrmann grading for disk degeneration were significant risk factors for reoperation after primary microendoscopic diskectomy (odds ratios, 2.448 and 1.510, respectively). The current study reported a relatively low incidence of reoperation after primary microendoscopic diskectomy. Adjacent segment degeneration and Pfirrmann grading for disk degeneration were identified as risk factors for reoperation after microendoscopic diskectomy to treat lumbar disk herniation. Treatment options for patients with these factors at the first visit should be carefully evaluated. [Orthopedics. 2015; 38(6):e490–e496.]

The authors are from the Department of Orthopedics (XH, JB, RS, YF, XW), Affiliated ZhongDa Hospital of Southeast University, Nanjing, JiangSu Province, China; and the Department of Surgery (LL), Klinikum Rechts der Isar, Technische Universität München, Munich, Germany.

Drs Hong and Liu contributed equally to this work and should be considered as equal first authors.

The authors have no relevant financial relationships to disclose.

This study was supported by the National Natural Science Foundation of China (grants 81272035 and 81071493).

The authors thank Drs Zubin Mao, Xiangfei Kong, and Hui Chen for their assistance with retrospective follow-up of patients.

Correspondence should be addressed to: Xiaotao Wu, MD, Department of Orthopedics, Affiliated ZhongDa Hospital of Southeast University, Nanjing, JiangSu Province, China 210029 ( wuxiaotao@medmail.com.cn).

Received: April 10, 2014
Accepted: August 27, 2014

Abstract

A population-based database of 1263 consecutive patients who underwent microendoscopic diskectomy for single-level lumbar disk herniation between 2005 and 2010 was retrospectively analyzed to identify causes and characteristics of reoperation and associated risk factors. A total of 952 patients were eligible. Of these, 58 had revision spinal surgery. Causes and clinical parameters were retrospectively assessed, and possible risk factors were evaluated by multivariate logistic regression analysis. In total, 76 disk herniations were excised with revision diskectomy, with or without interbody fusion. The overall mean interval between primary surgery and revision surgery was 39.05 months (range, 2–95 months). Cumulative overall reoperation rates gradually increased from 1.56% at 1 year to 8.17% after nearly 10 years. Reoperated patients were older and had a higher level of lumbar degeneration, with severe Modic changes (type 1, 17.2%; type 2, 34.5%), vs patients without reoperation (type 1, 1.5%; type 2, 30.6%). In addition, patients with reoperation had a higher rate of obvious adjacent disk degeneration (81.1%). Logistic regression analysis showed that adjacent segment degeneration and Pfirrmann grading for disk degeneration were significant risk factors for reoperation after primary microendoscopic diskectomy (odds ratios, 2.448 and 1.510, respectively). The current study reported a relatively low incidence of reoperation after primary microendoscopic diskectomy. Adjacent segment degeneration and Pfirrmann grading for disk degeneration were identified as risk factors for reoperation after microendoscopic diskectomy to treat lumbar disk herniation. Treatment options for patients with these factors at the first visit should be carefully evaluated. [Orthopedics. 2015; 38(6):e490–e496.]

The authors are from the Department of Orthopedics (XH, JB, RS, YF, XW), Affiliated ZhongDa Hospital of Southeast University, Nanjing, JiangSu Province, China; and the Department of Surgery (LL), Klinikum Rechts der Isar, Technische Universität München, Munich, Germany.

Drs Hong and Liu contributed equally to this work and should be considered as equal first authors.

The authors have no relevant financial relationships to disclose.

This study was supported by the National Natural Science Foundation of China (grants 81272035 and 81071493).

The authors thank Drs Zubin Mao, Xiangfei Kong, and Hui Chen for their assistance with retrospective follow-up of patients.

Correspondence should be addressed to: Xiaotao Wu, MD, Department of Orthopedics, Affiliated ZhongDa Hospital of Southeast University, Nanjing, JiangSu Province, China 210029 ( wuxiaotao@medmail.com.cn).

Received: April 10, 2014
Accepted: August 27, 2014

Microdiskectomy and minimal diskectomy for lumbar disk herniation have success rates of approximately 90% and decrease surgical exposure and trauma compared with operative diskectomy. In a series of these options (including chemonucleolysis; manual, automated, and laser percutaneous diskectomy; and microendoscopic diskectomy), microendoscopic diskectomy had lasting benefits in numerous cases.1,2 Although the learning curve is arguably steeper, microendoscopic diskectomy allows for high-definition visualization through a small skin incision. However, studies reported a reoperation rate of 2.5% to 12.7%.3–5 The most common reason for revision surgery was recurrent disk herniation. In 74% of cases, reoperation occurs within 6 months after the primary operation. Several diskectomy-related conditions can also lead to revision surgery, including scar, adhesive arachnoiditis, infection, epidural hematoma, pseudomeningocele, and other complications. Good outcomes depend on proper patient selection.6,7

Although risk factors have been established for reoperation after surgery to treat lumbar disk herniation, unfortunately, the underlying risk factors are controversial.8–11 The current study retrospectively reviewed the authors’ experience to investigate the rate of reoperation after microendoscopic diskectomy. The authors also sought to identify specific risk factors associated with revision surgery and characterize their role in determining eligible types of revision surgery.

Materials and Methods

Participants

This retrospective study initially included a consecutive cohort of 1263 patients who underwent single-level microendoscopic diskectomy for lumbar disk herniation between January 2005 and December 2010 at the Department of Orthopedics of the Affiliated ZhongDa Hospital of Southeast University. Patients were treated by 3 senior surgeons according to standard clinical procedures for lumbar disk herniation. The authors retrospectively reviewed the medical records of all patients in the cohort and attempted to contact the patients to assess their satisfaction with treatment and determine whether they underwent revision surgery for recurrent or persistent lumbar symptoms. Patients were excluded for the following reasons: (1) if they died before the follow-up time point of causes unrelated to their surgery; (2) if follow-up was incomplete; or (3) if sociodemographic information and/or radiologic images were missing.

Outcome Measures

Clinical characteristics (age, sex, occupation, weight, smoking history, duration of symptoms, duration of surgery, and blood loss) were obtained from patients’ records and evaluated for a variety of demographic features. Patients who underwent revision surgery for recurrent herniation, epidural scar or adhesive arachnoiditis, lumbar instability, or other causes were also assessed, especially for the following clinical parameters: reason for reoperation, interval between primary surgery and revision surgery, and surgical method. Preoperative imaging studies (radiograph, computed tomography scan, or magnetic resonance imaging scan), obtained both before the initial surgery and before reoperation, were reviewed and analyzed to evaluate the level, laterality, and type of lumbar disk herniation as well as degenerative changes at or adjacent to the operative level.12 Based on T1- and T2-weighted magnetic resonance images, an 8-level modified Pfirrmann grading system and a 3-level Modic change grading system were used to evaluate lumbar intervertebral disk degeneration and a 4-point scale was used to grade the severity of osteoarthritis of the lumbar facet joints.13–15 Additionally, adjacent segment degeneration was estimated with 3 scales to indicate severity: grade 0, no or slight signal change of the nucleus, distinct between the inner and outer fibers of the annulus, with no height loss of the disk; grade 1, mildly hyperintense nucleus, indistinct between the inner and outer fibers of the annulus, with no height loss of the disk; and grade 2, hyperintense nucleus, indistinct between the inner and outer fibers of the annulus, with height loss of the disk. A higher grade was recorded if degeneration of both the upper and the lower adjacent segment was detected.

Surgical Technique

All microendoscopic diskectomy procedures were performed with the same surgical technique under epidural anesthesia with the METRx system (Medtronic Sofamor Danek, Memphis, Tennessee). Flavectomy was completed with a standard longitudinal splitting approach, and laminotomy was performed with a curette with an upward angle and a Kerrison punch to expose the dura and traversing nerve roots clearly. Subsequently, nerve root retraction and diskectomy were performed to remove loose pieces in the disk space with a pituitary rongeur.

Statistical Analysis

All continuous data were presented as mean±SD, and all categorical data were expressed as a percentage or number. Statistical analysis for comparison of clinical features between patients undergoing reoperation and those not undergoing reoperation was performed with unpaired Student’s t test, chi-square test, or nonparametric Kruskal-Wallis test. Stepwise multivariate log-binomial analysis was used to examine the association between risk factors and reoperation, adjusting for confounding risk factors. The model included risk factors that the study investigators considered important in contributing to reoperation, those that were known confounders, and those that had univariate association of P<.15. A Kaplan-Meier estimate was performed to generate the cumulative proportion of reoperation rates. Statistical analysis was performed with SPSS, version 13.0 software (SPSS Inc, Chicago, Illinois), with hypothesis testing using a 2-tailed test of significance and an alpha level of P<.05.

Results

Patient Population

Between 2005 and 2010, a total of 1263 patients underwent microendoscopic diskectomy for lumbar disk herniation at a single spine center. Of these patients, 311 were excluded because they did not return for follow-up (11.24%), they had incomplete radiologic images and/or sociodemographic characteristics (13.06%), or they died of unrelated causes before the follow-up time point (0.31%). As a result, 952 patients were included in the current study (75.38%). Of these, 58 patients underwent revision surgery for severe recurrent or persistent symptoms.

Single Factor Comparison

The demographic features of patients undergoing a single operation or reoperation at the time of initial microendoscopic diskectomy are summarized and compared in Table 1. Analysis showed a significant difference between groups in age, Pfirrmann grading for disk degeneration, Modic changes, and adjacent segment degeneration (P<.05). Not surprisingly, patients who underwent reoperation had higher levels of lumbar disk degeneration. These patients had severe Modic changes (type 1, 17.2%; type 2, 34.5%) compared with patients who underwent a single operation (type 1, 1.5%; type 2, 30.6%). Patients who underwent reoperation also had more obvious adjacent disk degeneration (81.1%) than patients who underwent a single operation (48.1%). A nearly significant difference was found in facet joint degeneration (P=.064), and the rate was higher in patients undergoing reoperation (50%). Furthermore, no significant differences were found in sex; duration of symptoms; level, laterality, and type of lumbar disk herniation; duration of surgery; or blood loss.

Sociodemographic and Clinical Characteristics of Patients at the Time of Primary Operation for Lumbar Disk HerniationSociodemographic and Clinical Characteristics of Patients at the Time of Primary Operation for Lumbar Disk Herniation

Table 1:

Sociodemographic and Clinical Characteristics of Patients at the Time of Primary Operation for Lumbar Disk Herniation

Age, duration of symptoms, level of lumbar disk herniation, Pfirrmann grade, Modic changes, adjacent segment degeneration, and facet joint degeneration were evaluated with multivariate regression analysis (P<.15).

Logistic Regression Analysis

Results of the multivariate logistic regression model to identify statistically significant risk factors with relative risk values and confidence intervals for reoperation are listed in Table 2. Of all assumed risk factors, adjacent segment degeneration on initial magnetic resonance imaging scan had a stronger association with reoperation (odds ratio, 2.448; 95% confidence interval, 1.537–3.898) and was validated as statistically significant. Pfirrmann grading for disk degeneration significantly increased the risk of reoperation (odds ratio, 1.510). Other factors, including age, duration of symptoms, level of lumbar disk herniation, Modic changes, and facet joint degeneration, were excluded by stepwise multivariate logistic regression.

Significant Risk Factors for Reoperation After Multivariate Log-binomial Analysis

Table 2:

Significant Risk Factors for Reoperation After Multivariate Log-binomial Analysis

Characteristics of Reoperation

In total, 76 disk herniations were treated with revision surgery and were most frequently resected from the L4–L5 level and subsequently from the L5-S1 level. Recurrent disk herniation and epidural scar accounted for 55.17% of revision surgeries; 14 were at the same disk level and 18 were new herniations at a different disk level than the primary herniation. Other reasons for reoperation included lumbar instability (29.31%), lumbar stenosis (6.90%), and spondylolisthesis (5.17%). Of the 58 patients who underwent reoperation, 10 had open diskectomy or secondary microendoscopic diskectomy, 2 had open diskectomy plus interspinous dynamic stabilization device implantation, and 46 had posterior lumbar interbody fusion or transforaminal lumbar interbody fusion for segmental instability or displacement. The overall mean interval between primary surgery and revision surgery was 39.05 months (range, 2–95 months), and 24.15% of reoperations were performed within 1 year after primary microendoscopic diskectomy (Table 3). Kaplan-Meier analysis for overall reoperation rates of the follow-up period is shown in the Figure, with the 95% confidence interval. Cumulative overall reoperation rates at 1, 3, and 5 years were 1.56%, 2.74%, and 5.23%, respectively, and gradually increased to 8.17% after nearly 10 years (Figure).

Clinical Parameters of Patients Undergoing Reoperation After Unsuccessful Surgery for Lumbar Disk Herniation

Table 3:

Clinical Parameters of Patients Undergoing Reoperation After Unsuccessful Surgery for Lumbar Disk Herniation

Cumulative proportion of reoperations for lumbar disk herniation after first microendoscopic diskectomy showing the 95% confidence interval (dotted line).

Figure:

Cumulative proportion of reoperations for lumbar disk herniation after first microendoscopic diskectomy showing the 95% confidence interval (dotted line).

Discussion

Microendoscopic diskectomy combines the benefits of microdiskectomy and open diskectomy, enabling surgeons to successfully address free-fragment disk pathologic factors and lateral recess stenosis. Depending on surgeon experience, patient selection criteria for microendoscopic diskectomy were expanded. In some cases, contraindications were ignored. Examples included double-level lumbar disk herniation, lumbar disk herniation with a single stenotic segment, and lumbar disk herniation with calcification of the posterior longitudinal ligament or ossification of fibrocartilage. Previous studies emphasized that strict adherence to well-defined preoperative selection criteria ensures optimal postoperative outcomes and that microendoscopic diskectomy in inappropriate patients may lead to reoperation.16 However, risk factors for reoperation after primary microendoscopic diskectomy are controversial because studies were conducted with variable population databases. The current study retrospectively reviewed the authors’ experience to investigate the rate of reoperation after microendoscopic diskectomy. Additionally, the authors identified specific risk factors associated with revision surgery and characterized their roles in determining eligible types of revision surgery.

Reported reoperation rates after microendoscopic diskectomy are 2.5% to 12.7%.1,2,4 In this preliminary study, only 20 (2.4%) of 821 patients required reoperation at a mean follow-up of 28 months after microendoscopic diskectomy, and the mean duration between primary operation and reoperation was 1.5 years.5 Teli et al17 found that 15 of 240 such patients underwent additional surgery, with an average interval of 15 weeks. In a 5-year, long-term follow-up study by Casal-Moro et al,4 9 patients (7.5%) underwent reoperation after microendoscopic diskectomy for periradicular fibrosis and recurrence of lumbar disk herniation. In the current study, in a series of 952 patients, 58 patients underwent revision surgery by the follow-up time point. The cumulative overall reoperation rate gradually increased to 8.17% after nearly 10 years, which is comparable to that observed in previous studies.4

The mean interval between primary and revision surgeries was 39.05 months. Only 24.24% of reoperations were performed within 1 year after primary surgery, which was inconsistent with previous reports that indicated that more than half occurred within 1 year. A possible explanation is that real recurrent herniation mainly accounts for earlier reoperation because of the bidimensional version of microendoscopic diskectomy. The authors performed aggressive diskectomy to remove the herniated disk, which would significantly reduce the rate of recurrent herniation, especially early recurrent herniation (within 0.5 year). No Level I studies have recommended a favorable option, aggressive diskectomy or limited diskectomy, for the treatment of primary disk herniation. Compared with limited diskectomy, aggressive diskectomy may result in a decreased incidence of recurrent disk herniation but may be associated with accelerated lumbar degeneration and more back and leg pain.18

Factors associated with reoperation after diskectomy were reported in several studies and include limited diskectomy rather than aggressive diskectomy, larger annular defects, nonobesity, greater disk height, and sagittal range of motion. In contrast, Häkkinen et al9 found no specific factors that affected the risk of reoperation in patients followed up for 5 years after diskectomy.9 In the current study, multiple logistic regression analysis suggested that adjacent segment degeneration is an important risk factor for reoperation (P<.001). Tang and Rebholz19 developed a 3-dimensional finite element model and showed that performing lumbar microdiskectomy in a mildly degenerated disk may have biomechanical effects at the adjacent motion segment that aggravate disk degeneration. Primary microendoscopic diskectomy may affect stress and mobility of the adjacent motion segment and accelerate degeneration, contributing to failed back surgery syndrome and requiring reoperation. Although the mechanism is unknown, on average, patients with adjacent disk degeneration were more likely to undergo reoperation after microendoscopic diskectomy.

Additional risk factors include Pfirrmann grade for disk degeneration (odds ratio, 1.510; 95% confidence interval, 1.071–2.125). Dora et al20 showed that low-grade disk degeneration (grades 1–3) is an important risk factor for recurrent disk herniation. These findings were in agreement with Yorimitsu et al,21 who reported that patients with preserved disk height before initial surgery generally had a favorable initial result but a high risk of recurrent disk herniation. The current study contradicted these findings and showed that reoperation occurred more often with severe disk degeneration. There are several possible reasons. First, patients enrolled in the current study had additional abnormalities, such as lateral stenosis, narrowed intervertebral foramina, a degenerated facet joint, or undetected lumbar instability. Second, previous studies focused on recurrent disk herniation but not total reoperation. Third, additional co-founding factors, such as the morphologic features of disk herniation, the clinical characteristics of patients, and the surgical procedure itself, may be risk factors for reoperation that were not included in some studies.

Additional risk factors may include Modic changes. Some studies have focused on whether Modic changes are associated with an unfavorable outcome.22–24 Chin et al22 reported a trend toward greater improvement in patients without Modic changes. Sørlie et al24 found that patients with Modic type 1 changes had less improvement in back pain 12 months after lumbar diskectomy compared with those who had no or other types of Modic changes. Ohtori et al23 compared the improvement in low back pain score in patients with or without Modic type I changes, but found no statistically significant difference.22–24 These studies showed that Modic changes (especially Modic type 1 changes) had a negative effect on improvement in back pain after surgery, which may lead to an increased need for frequent re-treatment. However, these studies did not examine the relationship between Modic changes and reoperation after lumbar diskectomy. In the current study, although logistic regression analysis suggested that Modic changes were not among the risk factors for reoperation, compared with patients without reoperation, patients undergoing reoperation had a higher rate of preoperative Modic changes before primary microendoscopic diskectomy, especially the rate of Modic type 1 changes (17.2% vs 1.5%). When this result is considered in light of the generally accepted belief that Modic type 1 changes are strong markers of biomechanical instability whereas type 2 changes reflect a more biomechanically stable environment,25–27 microendoscopic diskectomy may lead to an accelerated transition from segmental instability to fixed deformity in the operated disk. Rahme et al28 validated that most patients have Modic changes, particularly type 2 changes, at the operated level after lumbar diskectomy but did not prove that either the preoperative presence of Modic changes or their postoperative course affected the final clinical outcome.

Potential problems associated with revision surgery include increased incidence of dural laceration and nerve root injury, unresolved symptoms, accelerated adjacent segment degeneration, and an increased incidence of the need for reoperation. To minimize the potential challenges associated with revision surgery, surgeons often use an aggressive approach to obtain wide exposure and reconstruct lumbar stability. However, this approach may result in a higher rate of failed back surgery syndrome. Some studies reported that less invasive and less morbid options, including secondary microendoscopic diskectomy, interspinous decompression, and minimally invasive lumbar interbody fusion, are at least as effective as aggressive approaches.29 A rational choice of surgical procedure depends on strict selection of patients who may benefit from a second surgery and comprehensive evaluation of clinical and radiologic parameters.

Conclusion

The current study reported a relatively low incidence of reoperation after microendoscopic diskectomy. The factors that contributed to reoperation may not be comparable to the findings of other studies because the current authors used an aggressive strategy during primary microendoscopic diskectomy. Compared with patients who did not undergo reoperation, the reoperated patients were older, had a higher grade of lumbar degeneration, had more Modic changes, and had a higher rate of adjacent disk degeneration. Risk factor analysis showed that adjacent disk degeneration, Pfirrmann grading for the operated disk, may be associated with a high risk of reoperation after primary microendoscopic diskectomy. This finding can help surgeons and patients make surgical decisions. Given the limitation of retrospective data collection and incomplete analysis of possible confounding covariates, the study findings must be confirmed with future investigation that includes prospective enrollment of consecutive cases and a larger patient pool.

References

  1. Smith N, Masters J, Jensen C, et al. Systematic review of microendoscopic discectomy for lumbar disc herniation. Eur Spine J. 2013; 22(11):2458–2465. doi:10.1007/s00586-013-2848-8 [CrossRef]
  2. Riesenburger RI, David CA. Lumbar microdiscectomy and microendoscopic discectomy. Minim Invasive Ther Allied Technol. 2006; 15(5):267–270. doi:10.1080/13645700600958432 [CrossRef]
  3. Aizawa T, Ozawa H, Kusakabe T, et al. Reoperation for recurrent lumbar disc herniation: a study over a 20-year period in a Japanese population. J Orthop Sci. 2012; 17(2):107–113. doi:10.1007/s00776-011-0184-6 [CrossRef]
  4. Casal-Moro R, Castro-Menendez M, Hernandez-Blanco M, Bravo-Ricoy JA, Jorge-Barreiro FJ. Long-term outcome after microendoscopic diskectomy for lumbar disk herniation: a prospective clinical study with a 5-year follow-up. Neurosurgery. 2011; 68(6):1568–1575. doi:10.1227/NEU.0b013e31820cd16a [CrossRef]
  5. Wu X, Zhuang S, Mao Z, Chen H. Microendoscopic discectomy for lumbar disc herniation: surgical technique and outcome in 873 consecutive cases. Spine (Phila Pa 1976). 2006; 31(23):2689–2694. doi:10.1097/01.brs.0000244615.43199.07 [CrossRef]
  6. Dasenbrock HH, Juraschek SP, Schultz LR, et al. The efficacy of minimally invasive discectomy compared with open discectomy: a meta-analysis of prospective randomized controlled trials. J Neurosurg Spine. 2012; 16(5):452–462. doi:10.3171/2012.1.SPINE11404 [CrossRef]
  7. Matsumoto M, Watanabe K, Hosogane N, et al. Recurrence of lumbar disc herniation after microendoscopic discectomy. J Neurol Surg A Cent Eur Neurosurg. 2013; 74(4):222–227.
  8. Cheng J, Wang H, Zheng W, et al. Reoperation after lumbar disc surgery in two hundred and seven patients. Int Orthop. 2013; 37(8):1511–1517. doi:10.1007/s00264-013-1925-2 [CrossRef]
  9. Häkkinen A, Kiviranta I, Neva MH, Kautiainen H, Ylinen J. Reoperations after first lumbar disc herniation surgery: a special interest on residives during a 5-year follow-up. BMC Musculoskelet Disord. 2007; 8:2. doi:10.1186/1471-2474-8-2 [CrossRef]
  10. Kim CH, Chung CK, Park CS, et al. Reoperation rate after surgery for lumbar herniated intervertebral disc disease: nationwide cohort study. Spine (Phila Pa 1976). 2013; 38(7):581–590. doi:10.1097/BRS.0b013e318274f9a7 [CrossRef]
  11. Moliterno JA, Knopman J, Parikh K, et al. Results and risk factors for recurrence following single-level tubular lumbar microdiscectomy. J Neurosurg Spine. 2010; 12(6):680–686. doi:10.3171/2009.12.SPINE08843 [CrossRef]
  12. Macnab I. Negative disc exploration: an analysis of the causes of nerve-root involvement in sixty-eight patients. J Bone Joint Surg Am. 1971; 53(5):891–903.
  13. Griffith JF, Wang YX, Antonio GE, et al. Modified Pfirrmann grading system for lumbar intervertebral disc degeneration. Spine (Phila Pa 1976). 2007; 32(24):E708–E712. doi:10.1097/BRS.0b013e31815a59a0 [CrossRef]
  14. Modic MT, Steinberg PM, Ross JS, Masaryk TJ, Carter JR. Degenerative disk disease: assessment of changes in vertebral body marrow with MR imaging. Radiology. 1988; 166(1 pt 1):193–199. doi:10.1148/radiology.166.1.3336678 [CrossRef]
  15. Weishaupt D, Zanetti M, Boos N, Hodler J. MR imaging and CT in osteoarthritis of the lumbar facet joints. Skeletal Radiol. 1999; 28(4):215–219. doi:10.1007/s002560050503 [CrossRef]
  16. Liu WG, Wu XT, Guo JH, Zhuang SY, Teng GJ. Long-term outcomes of patients with lumbar disc herniation treated with percutaneous discectomy: comparative study with microendoscopic discectomy. Cardiovasc Intervent Radiol. 2010; 33(4):780–786. doi:10.1007/s00270-009-9720-6 [CrossRef]
  17. Teli M, Lovi A, Brayda-Bruno M, et al. Higher risk of dural tears and recurrent herniation with lumbar microendoscopic discectomy. Eur Spine J. 2010; 19(3):443–450. doi:10.1007/s00586-010-1290-4 [CrossRef]
  18. 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(2):338–344. doi:10.1227/01.NEU.0000337574.58662.E2 [CrossRef]
  19. Tang S, Rebholz BJ. Does lumbar microdiscectomy affect adjacent segmental disc degeneration? A finite element study. J Surg Res. 2013; 182(1):62–67. doi:10.1016/j.jss.2012.09.012 [CrossRef]
  20. Dora C, Schmid MR, Elfering A, et al. Lumbar disk herniation: do MR imaging findings predict recurrence after surgical diskectomy?Radiology. 2005; 235(2):562–567. doi:10.1148/radiol.2352040624 [CrossRef]
  21. Yorimitsu E, Chiba K, Toyama Y, Hirabayashi K. Long-term outcomes of standard discectomy for lumbar disc herniation: a follow-up study of more than 10 years. Spine (Phila Pa 1976). 2001; 26(6):652–657. doi:10.1097/00007632-200103150-00019 [CrossRef]
  22. Chin KR, Tomlinson DT, Auerbach JD, Shatsky JB, Deirmengian CA. Success of lumbar microdiscectomy in patients with Modic changes and low-back pain: a prospective pilot study. J Spinal Disord Tech. 2008; 21(2):139–144. doi:10.1097/BSD.0b013e318093e5dc [CrossRef]
  23. Ohtori S, Yamashita M, Yamauchi K, et al. Low back pain after lumbar discectomy in patients showing endplate Modic type 1 change. Spine (Phila Pa 1976). 2010; 35(13):E596–E600.
  24. Sørlie A, Moholdt V, Kvistad KA, et al. Modic type I changes and recovery of back pain after lumbar microdiscectomy. Eur Spine J. 2012; 21(11):2252–2258. doi:10.1007/s00586-012-2419-4 [CrossRef]
  25. Modic MT. Modic type 1 and type 2 changes. J Neurosurg Spine. 2007; 6:150–151. doi:10.3171/spi.2007.6.2.150 [CrossRef]
  26. Rahme R, Moussa R. The Modic vertebral endplate and marrow changes: pathologic significance and relation to low back pain and segmental instability of the lumbar spine. AJNR Am J Neuroradiol. 2008; 29:838–842. doi:10.3174/ajnr.A0925 [CrossRef]
  27. Vital JM, Gille O, Pointillart V, et al. Course of Modic 1 six months after lumbar posterior osteosynthesis. Spine. 2003; 28:715–721. doi:10.1097/01.BRS.0000051924.39568.31 [CrossRef]
  28. Rahme R, Moussa R, Bou-Nassif R, et al. What happens to Modic changes following lumbar discectomy? Analysis of a cohort of 41 patients with a 3- to 5-year follow-up period. J Neurosurg Spine. 2010; 13(5):562–567. doi:10.3171/2010.5.SPINE09818 [CrossRef]
  29. Isaacs RE, Podichetty V, Fessler RG. Microendoscopic discectomy for recurrent disc herniations. Neurosurg Focus. 2003; 15(3):E11. doi:10.3171/foc.2003.15.3.11 [CrossRef]

Sociodemographic and Clinical Characteristics of Patients at the Time of Primary Operation for Lumbar Disk Herniation

CharacteristicSingle Operation (n=894)Reoperation (n=58)P
Age, mean±SD, y40.58±12.0344.71±11.33.011a
Sex, female/male, No.574/32037/21.941
Body weight, mean±SD, kg68.81±10.8368.98±13.04.909
Duration of symptom, mean±SD, mo37.70±57.4326.35±60.49.146
Smoking, No. (%)115 (12.88)7 (12.07).858
Occupation, No. (%)
  Employed560 (62.6)34 (58.6)
  Unemployed204 (22.8)17 (29.3).337
  Student57 (6.4)1 (1.7)
  Retired73 (8.2)6 (10.3)
Level of herniation, No. (%)
  L3–L412 (1.3)1 (1.7)
  L4–L5375 (41.9)32 (55.2).129
  L5-S1507 (56.7)25 (43.1)
Laterality of herniation, No. (%)
  Unilateral603 (67.4)44 (75.9)
  Central288 (32.2)14 (24.1).390
  Far lateral3 (0.3)0 (0)
Type of herniation (Macnab classification), No. (%)
  Protrusion7 (0.8)0 (0)
  Subligamentous extrusion465 (52.0)27 (46.6)
Transligamentous extrusion414 (46.3)30 (51.7).681
  Sequestration8 (0.9)1 (1.7)
Disk degeneration (Pfirrmann grade), No. (%)
  Grade 352 (5.8)0 (0)
  Grade 4235 (26.3)8 (13.8)
  Grade 5376 (42.1)24 (41.4).002a
  Grade 6213 (23.8)22 (37.9)
  Grade 718 (2.0)4 (6.9)
Modic change, No. (%)
  No change597 (66.9)26 (44.8)
  Type 113 (1.5)10 (17.2)
  Type 2273 (30.6)20 (34.5).000a
  Type 310 (1.1)2 (3.4)
Adjacent disk degeneration, No. (%)
  Grade 0464 (51.9)11 (19.0)
  Grade 1393 (44.0)40 (69.0).000a
  Grade 237 (4.1)7 (12.1)
Facet joint degeneration, No. (%)
  Grade 0579 (64.8)29 (50.0)
  Grade 1291 (32.6)26 (44.8)
  Grade 224 (2.7)3 (5.2).064
  Grade 30 (0)0 (0)
Duration of surgery, mean±SD, min47.92±17.6846.81±16.24.642
Blood loss, mean±SD, mL35.65±13.6634.31±11.37.466

Significant Risk Factors for Reoperation After Multivariate Log-binomial Analysis

Risk FactorCoefficientStandard ErrorPOdds Ratio (95% Confidence Interval)
Pfirrmann grade0.4110.175.0191.510 (1.071–2.125)
Adjacent disk degeneration0.8950.237.0002.448 (1.537–3.898)

Clinical Parameters of Patients Undergoing Reoperation After Unsuccessful Surgery for Lumbar Disk Herniation

ParameterNo. (%)
Cause
  Recurrent disk herniation or epidural scar32 (55.17)
  Spondylolisthesis3 (5.17)
  Lumbar stenosis4 (6.90)
  Lumbar instability with/without disk herniation17 (29.31)
  Other2 (3.45)
Interval between primary and revision surgeries, y
  <114 (24.14)
  1–531 (53.45)
  >513 (22.41)
Surgical method for reoperation
  Secondary diskectomy (open diskectomy/microendoscopic diskectomy)10 (17.24)
  Open diskectomy plus interspinous process decompression implantation2 (3.45)
Laminectomy plus intervertebral fusion46 (79.31)

10.3928/01477447-20150603-57

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