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Recurrent herniated disc at the same level in a young patient
Introduction
The intervertebral disc allows axial loading that results from an upright posture of the spine. The disc is composed of two components, the outer fibrous annulus fibrosus and the central nucleus pulposus, and originates from the notochord. The nucleus pulposus is composed of proteoglycans and water gels held together by type II collagen and elastin fibers. These acts as a shock absorber that helps distribute forces across the end plates. Degeneration over time causes loss of the water content of the nucleus pulposus as well as weakened annulus fibrosus. There is an increase in disc herniations from the ages of 30 to 50 years that decreases after the age of 50. Although the exact cause leading to degeneration and herniation is not fully understood, it appears that sedentary occupations, previous full-term pregnancy, physical inactivity, increased body mass, tall stature, and smoking act as risk factors.
Disc reherniation following an initial surgery is defined as recurrent herniation ipsilateral or contralateral at a previously operated level with return of symptoms after a 6-month symptom-free interval following the index surgery and is reported to occur 25% of the time. Although surgical techniques have advanced since the initial description of the technique by Mixter and Barr, recurrent disc herniations continue to remain a problem. The incidence of reoperation for recurrent disc herniation continues to remain as high as 18%. Although recurrent herniation is common, it should be noted that recurrence of radicular symptoms can also occur from ongoing degeneration, causing foraminal stenosis or excessive epidural scarring resulting in nerve compression. The initial approach to the management of recurrent symptoms due to disc reherniation should remain unchanged from the initial management of disc herniation. This involves physical therapy, nonsteroidal pain management, chiropractic manipulation, and consideration of epidural injection for symptomatic relief. In cases where there is failure of improvement after nonoperative management or when there is neurological deficit, surgical intervention should be considered. The surgical approach following reherniation consists of redo discectomy versus fusion.
Example case
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Chief complaint : left leg pain
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History of present illness : A 49-year-old female with a history of previous L5-S1 hemilaminectomy and discectomy 3 months prior to presentation ( Fig. 3.1 ). After 2 hours sitting in a car, the patient started having left-sided radicular pain in S1 distribution. She has tried gabapentin and Tylenol with minimal relief. She states that her pain is very severe at this time and is debilitating. She is unable to sleep at night. She presents due to ongoing pain. She notes numbness but denies weakness. She underwent repeat imaging ( Fig. 3.2 ).
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Medications : gabapentin, losartan
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Allergies : nonsteroidal antiinflammatory drugs
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Past medical and surgical history : Hodgkin lymphoma, depression, anxiety, reflux, hypertension, tubal ligation, thymus biopsy, cesarean section (C-section), C5-6 anterior cervical discectomy and fusion, ileostomy
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Family history : noncontributory
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Social history : teacher, no smoking history, occasional alcohol
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Physical exam : awake, alert, and oriented to person, place, and time; cranial nerves II-XII, intact bilateral deltoids/triceps/biceps 5/5; interossei 5/5; iliopsoas/knee flexion/knee extension/dorsi, and plantar flexion 5/5
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Reflexes : 2+ in bilateral biceps/triceps/brachioradialis with negative Hoffman; 2+ in bilateral patella/ankle with no clonus or Babinski; sensation decreased in left S1 distribution
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| Preoperative | ||||
| Additional tests requested | None | Complete history and physical |
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| Surgical approach selected | Revision left-sided L5-S1 microdiscectomy | Pending above, left L5-S1 TLIF and right L5-S1 percutaneous fusion | L5-S1 TLIF, MIS, and robotically assisted | Revision left-sided L5-S1 laminectomy and microdiscectomy |
| Goal of surgery | Decompress traversing S1 nerve root | Decompress traversing S1 nerve root, fusion if needed | Decompress traversing S1 nerve root, pain relief | Decompress traversing S1 nerve root |
| Perioperative | ||||
| Positioning | Prone | Prone on Jackson table | Prone | Prone on Wilson frame |
| Surgical equipment |
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| Medications | Steroids | None | None | None |
| Anatomical considerations | Thecal sac, medial facet joints | Left S1 nerve roots | Exiting and traversing nerve roots | L5-S1 disc space, lamina, medial facets, thecal sac, left S1 nerve root |
| Complications feared with approach chosen | Instability | Nerve root injury, CSF leak, pseudoarthrosis, screw malposition | Nerve root injury | Nerve root injury, CSF leak |
| Intraoperative | ||||
| Anesthesia | General | General | General | General |
| Exposure | L5-S1 | L5-S1 | L5-S1 | L5-S1 |
| Levels decompressed | L5-S1 | L5-S1 | L5-S1 | L5-S1 |
| Levels fused | None | L5-S1 | L5-S1 | None |
| Surgical narrative | Position prone, incision over previous lumbosacral incision, identify level using lateral fluoroscopic shot, dissect soft tissue off of remaining L5 lamina on left side in subperiosteal fashion, identify normal landmarks, dissect scar tissue off of bone and dura under microscopic visualization, establish normal anatomical plane between traversing S1 nerve root and medial facet joint, extend hemilaminotomy or medial fasectomy if needed, retract common thecal sac and S1 nerve root medially, incise disc space with 11 blade, remove disc herniation with pituitary rongeur, bone wax to bleeding bone edges, wound closed in anatomical layers | Position prone, x-ray to determine level, posterior slightly extend incision over prior incision if in appropriate location, use Cobb to expose bony lamina adjacent to prior defect, place pedicle screws to distract and open foramen, remove left-sided facet to expose nerve root and disc herniation, decompress nerve root, remove disc material, scrap out disc material and cartilaginous end plates, size intervertebral biomechanical strut device, pack with allograft cancellous bone until firm using interbody impact or to where x-ray looks like it is fused, place bone packed cage (PEEK or titanium) and push toward midbody, place rod on left and compress, percutaneous screws on right with fluoroscopy, place right percutaneous rods, layered closure with drain | Position prone, intraoperative O-arm with CT and robot registration, MIS percutaneous screw insertion using robot, placement of rod on contralateral side, placement of tubular retractor, serially dilate on ipsilateral side, perform TLIF with microscopic visualization, placement of bullet cage, placement of ipsilateral rod, layered closure | Position prone, identify level with x-ray and mark L5-S1 disc, midline incision through previous surgical scar, dissect through scar tissue, look for normal brain anatomy, expose inferior edge of L5 lamina and superior edge of S1 lamina and medial edge of L5-S1 facet, identify borders of previous laminectomy, resect inferior edge of left superior lamina with Kerrison rongeur until normal dura is exposed and entrance to lateral recess revealed, undercut ipsilateral medial facet, decompress nerve roots starting at shoulder of root with Kerrison parallel and just superficial to the root, identify left S1 nerve root, release nerve roots from previous surgery scar tissue and adhesions, mobilize it medially using nerve root retractor to expose disc herniation, confirm adequate decompression verified with Frazier dural dissector via lateral recess to the neural foramen, layered closure |
| Complication avoidance | Identify normal landmarks, extend bone work if needed | Identify normal landmarks, place pedicle screws to distract disc space, significant packing of disc space with allograft bone, decompression from left and placement of right percutaneous pedicle screws | MIS, robotically assisted, percutaneous screws | Look for normal anatomy, decompress nerve roots starting at shoulder of root with Kerrison parallel and just superficial to the root, confirm adequate decompression verified with Frazier dural dissector via lateral recess to the neural foramen |
| Postoperative | ||||
| Admission | Floor | Floor | Floor | Floor |
| Postoperative complications feared | Wound dehiscence, radiculitis, CSF leak | Nerve root injury, CSF leak, pseudoarthrosis, screw malposition | Nerve root injury, durotomy | Nerve root injury, CSF leak, wound infection |
| Anticipated length of stay | Overnight | 1–2 days | 1–2 days | 1 day |
| Follow-up testing | None | L-spine x-rays prior to discharge and 3 weeks after surgery | L-spine x-rays prior to discharge | None |
| Bracing | None | None | None | None |
| Follow-up visits | 4–6 weeks after surgery | 3 weeks after surgery | 2 weeks after surgery | 6 weeks after surgery |
CSF , Cerebrospinal fluid; DEXA , dual-energy x-ray absorptiometry; IOM , intraoperative monitoring; MIS , minimally invasive surgery; PEEK , polyether ether ketone; TLIF , transforaminal lumbar interbody fusion.
Differential diagnosis
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Lumbar disc reherniation
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Spinal instability
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Failed back syndrome
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