Lumbar Intervertebral Disc Herniation

Lumbar disc herniation is a relatively common cause of back pain and/or leg pain. Although most patients with a symptomatic disc herniation respond to conservative treatment, others do not, and account for a large portion of patients undergoing spinal surgery annually. Approximately 300,000 lumbar discectomy procedures are performed each year in the United States. Risk factors for primary disc herniation include sedentary lifestyle, obesity, smoking, pregnancy, chronic cough, and occupational exposure to repetitive lifting, bending, and twisting. Isolated trauma or injury has not been found to be a consistent risk factor, occurring in only 0.2% to 10.7% of adults with a herniation. ^, The purpose of this chapter is to provide an overview of the evidence regarding management of primary and recurrent disc herniation.

The indications for surgery include intractable radicular leg pain (sciatica) that is unresponsive to conservative measures, a focal motor deficit that impairs function, or the presence of bladder dysfunction. Several different surgical techniques have been used to manage lumbar disc herniation, including open discectomy (with or without the use of a surgical microscope), automated percutaneous discectomy, minimally invasive tubular endoscopic discectomy, and chemonucleolysis. The clinical outcome for these procedures is generally favorable, with 65% to 90% of patients who have undergone surgery reporting good or excellent results. ^, Several studies have demonstrated improved clinical outcomes with surgery compared with conservative treatment.

Despite these favorable outcomes, a number of patients who initially respond well to surgery have a return of symptoms similar to their preoperative state because of a recurrence of herniated disc material at the prior surgical site. The reported incidence of recurrent lumbar disc herniation ranges from 2% to 25%. When it occurs, recurrent herniation is a major contributor to debilitating pain, disability, and the need for reoperation following the primary procedure. It also places a significant burden on the health care system. Ambrossi et al. have demonstrated the mean cost of caring for patients requiring reoperation for recurrent disc herniation to be $39,386 per patient compared with a mean cost of $2315 for patients responding to conservative management.