CASE REPORT Korean J Spine 8(2):129-132, 2011
Rapid Repeated Recurrent Lumbar Disc Herniation after Microscopic Discectomies Dosung Lee, Ki Seong Eom Department of Neurosurgery, Wonkwang University School of Medicine, Iksan, Korea The recurrence of lumbar disc herniation after single-level discectomy is a well-known complication. Pain and neurological symptoms during the first week after surgery can be caused by missed pathology or early recurrent disc herniation. However, recurrent disc herniation that causes segmental instability after repeat operation is rare. Here, we report a case of a 42-year-old woman having a rare complication of rapid recurrent lumbar disc herniation after 2 microscopic discectomies within a short period. We suggest that rapid disc fragmentation and rapid growth of annular defect caused rapid repeated recurrence of lumbar disc herniation and segmental instability. Further investigation will be needed to identify the cause of this rapid disc degeneration. Key Words: Recurrent lumbar disc herniationㆍInstabilityㆍAnnular laxity
INTRODUCTION Single-level lumbar discectomy is a very common surgical procedure and has been proven to be beneficial for patients with back and leg pain. Despite technical advancements, complications following primary discectomy occur in 10 to 30% of cases3,4). Among the complications, recurrent disc herniation after lumbar discectomy has been reported in 5 to 15% of patients13,14). Although the case reported here does not fulfill the strict definition of recurrent disc herniation, which includes a pain-free interval of at least 6 months following surgery14), we present a rare case of rapid repeated recurrent lumbar disc herniation after microscopic discectomies followed by fusion surgery. Furthermore, we review the available literature on the possible mechanisms underlying this rare condition.
tome in the left lower limb. She started experiencing pain immediately after lifting a heavy piece of furniture at her home. According to her medical history, she had received medication for rheumatoid arthritis 5 years before the time of presentation and for a major depressive disorder 2 years before the time of presentation. She experienced severe pain radiating from the buttocks to the calf in her left lower limb, and her straight-leg raising test was positive at 30° on the left side. Magnetic resonance imaging (MRI) revealed a leftsided extrusion of an L4-L5 disc fragment, which was compre- ssing the dural sac and nerve root at this level (Fig. 1). Plain film radiography revealed a mildly decreased disc height of L4-L5, and sagittal range of motion was 8.7° (Fig. 2). Left L5 partial laminectomy and discectomy was performed under the micros-
CASE REPORT A 42-year-old woman presented with a 3-month history of severe pain in the lower back and along the L5-S1 derma● Received: Apr 19, 2011 ● Accepted: May 25, 2011 ● Published: Jun 20, 2011 Corresponding Author: Ki Seong Eom, MD, PhD Department of Neurosurgery, Wonkwang University School of Medicine, 344-2 Shinyong-dong, Iksan 570-749, Korea Tel: +82-63-859-1467, Fax: +82-63-852-2606 E-mail:
[email protected]
Fig. 1. Sagittal (A) and axial (B) T2-weighted magnetic resonance imaging reveal a left-sided extrusion of the L4-L5 disc fragment, compressing the dural sac and nerve root.
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Fig. 2. Preoperative lateral (A) and flexion-extension (B, C) radiographs reveal mildly decreased disc height of the L4-L5 and 8.7° sagittal range of motion.
Fig. 3. Sagittal (A) and axial (B) T2-weighted magnetic resonance imaging after the first recurrence reveal more extruded disc fragments at the same lesion site.
cope. The extruding disc was intraoperatively removed, and a small annular defect was detected. The fragmented disc material from the annular defect was removed. Six days after the primary surgery, she suddenly presented with severe pain, similar to that experienced before the operation. MRI revealed a left-sided extrusion of the L4-L5 disc fragment severer than that detected on preoperative MRI (Fig. 3). During the second microscopic discectomy, we found that the same extruded disc material compressed the dural sac and nerve root. The disc material was removed while the non-fragmented disc was preserved. We confirmed that there was no fragmented disc material in the L4-L5 intervertebral disc space. She did not complain of any pain except that at incision site after the second surgery. Ten days after the primary surgery, the patient presented with sudden severe pain that was similar to her preoperative symptoms. MRI revealed herniation of the same disc fragment (L4-L5) (Fig. 4). Plain film radiography showed segmental instability and a decreased disc space height at the L4-L5 level (Fig. 5). Conventional transpedicular screw fixation and transforaminal lumbar interbody fusion procedures were carried out at the L4-L5 level. Intraoperative findings were
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Fig. 4. Sagittal (A) and axial (B) T2-weighted magnetic resonance imaging reveal severe extrusion of the L4-L5 disc fragment and collapse of the anterior portion of the L4-L5 disc space.
Fig. 5. Flexion (A) and extension (B) radiographs reveal a collapse of the anterior portion of the L4-L5 disc space and segmental instability.
similar to the previous intraoperative findings, but there was no disc material in the L4-L5 intervertebral disc space. She did not complain of back pain and leg pain after the third surgery.
DISCUSSION The clinical definition of recurrent disc herniation is disc herniation at the previously operated site. Although a painfree interval of at least 6 months after the surgery is included in this definition, the pain-free interval should not be restricted to 6 months. Many studies have suggested numerous risk factors for recurrent disc herniation, such as age, smoking, gender, diabetes, disc degeneration, trauma and obesity8,13). However, Swartz et al14) suggested that age, gender, smoking, degree of disc degeneration, and duration of symptoms are not associated with high rates of recurrence. Furthermore, there are many arguments that the shape of the disc may be a risk factor.
Rapid Recurrent Lumbar Disc Herniations 2)
Caragee et al prospectively evaluated the effects of fragment type and annular competence on clinical outcomes after lumbar discectomy. They asserted that a large fragmented disc with massive, posterior, annular tears and no fragment- containing disc had a higher rate of recurrence than a fragment-containing disc with incomplete annular tears and a disc fragment with a small, annular defect. Morgan-Hough et al12) reported a similar result and suggested that a protrusion could indicate the beginning of serial disc material fragmentation, whereas extrusion and sequestration could indicate the end-stage of this process. In contrast, Suk et al13) asserted that disc shape was not related to recurrence. Whether the degree of discectomy is related to recurrence is controversial. Cinotti et al6) did not report a difference in the rate of recurrence associated with partial or complete discectomy. However, McGirt et al11) reported that the incidence of recurrent disc herniation after partial discectomy was greater than that reported after complete discectomy. Kim et al9) suggested that biomechanical factors such as disc height and sagittal range of motion were related to the incidence of recurrent lumbar disc herniation. According to them, a disc with preserved disc height is more unstable and results in a high incidence of recurrence, and the increased sagittal range of motion, which is calculated from the flexionextension radiographs, is the most important risk factor for recurrence. In experimental studies, annular defect was accepted as an important factor in disc degeneration and recurrent disc herniation1). Some studies suggested that the mechanical properties of the disc changed in proportion to the size of the annular defect5). Several researchers reported that the change in disc pressure would disturb matrix synthesis and stimulate production of matrix-degrading enzymes7). The pressure redistribution after discectomy would result in a degenerative reaction in the nucleus and annulus. Kraemer et al10) reported that the rate of recurrence was 0.2% in the first week after lumbar discectomy. They suggested that the causes of early recurrent disc herniation were a missed pathology or a new disc prolapse if there was a pain-free interval after discectomy. In this case, we believe that the cause of first disc herniation might have been a missed pathology. However, plain film radiography and MRI after the recurrence revealed severely decreased disc height, increased sagittal range of motion at the site of lesion, and more extruded disc material. Enlarged annular defect and more extruded disc material were found in the last surgery, and the intervertebral space was empty. Taking these findings into account, we hypothesized that the patient had a low probability of postoperative recurrence. She presented with an extrusion that was regarded as the end-stage in the disc herniation process and with fragmented disc with a small annular defect, which typically has a low rate of recur-
rence. However, the patient had an annular laxity that increased rapidly because of the annular defect. Disc degeneration due to a pressure change after the first surgery may have been faster than that in most cases, and resulted in rapid disc fragmentation and annular defect. The patient then became vulnerable to repeat herniation. Biomechanical test revealed that the disc height had decreased and that the sagittal range of motion had increased gradually. These changes influenced each other, resulting in repeated recurrence and segmental instability. We suggest that rapid disc fragmentation and rapid growth of annular defect caused rapid repeated recurrence of lumbar disc and segmental instability. Further investigation will be needed to identify the cause of this rapid disc degeneration.
REFERENCES 1. Ahlgren BD, Lui W, Herkowitz HN, Panjabi MM, Guiboux JP: Effect of annular repair on the healing strength of the intervertebral disc: a sheep model. Spine 25:2165-2170, 2000 2. Carragee EJ, Han MY, Suen PW, Kim D: Clinical outcomes after lumbar discectomy for sciatica: the effects of fragment type and annular competence. J Bone Joint Surg Am 85:102108, 2003 3. Carragee EJ, Han MY, Yang B, Kim DH, Kraemer H, Billys J: Activity restrictions after posterior lumbar discectomy. A prospective study of outcomes in 152 cases with no postoperative restrictions. Spine 24:2346-2351, 1999 4. Carragee EJ, Spinnickie AO, Alamin TF, Paragioudakis S: A prospective controlled study of limited versus subtotal posterior discectomy: Short-term outcomes in patients with herniated lumbar intervertebral discs and large posterior annular defect. Spine 31:653-657, 2006 5. Chiang CJ, Cheng CK, Sun JS, Liao CJ, Wang YH, Tsuang YH: The Effect of a New Anular Repair After Discectomy in Intervertebral Disc Degeneration: An Experimental Study Using a Porcine Spine Model. Spine 2010 [Epub ahead of print] 6. Cinotti G, Roysam GS, Eisenstein SM, Postacchini F: Ipsilateral recurrent lumbar disc herniation: a prospective, controlled study. J Bone Joint Surg Br 80:825-832, 1998 7. Handa T, Ishihara H, Ohshima H, Osada R, Tsuji H, Obata K: Effects of hydrostatic pressure on matrix synthesis and matrix metalloproteinase production in the human lumbar intervertebral disc. Spine 22:1085-1091, 1997 8. Kim JM, Lee SH, Ahn Y, Yoon DH, Lee CD, Lim ST: Recurrence after successful percutaneous endoscopic lumbar discectomy. Minim Invasive Neurosurg 50:82-85, 2007 9. Kim KT, Park SW, Kim YB: Disc height and segmental motion as risk factors for recurrent lumbar disc herniation. Spine 34: 2674-2678, 2009 10. Kraemer R, Wild A, Haak H, Herdmann J, Krauspe R, Kraemer J: Classification and management of early complications in open lumbar microdiscectomy. Eur Spine J 12:239-246,
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DS Lee, et al. 2003 11. McGirt MJ, Ambrossi GL, Datoo G, Sciubba DM, Witham TF, Wolinsky JP, Gokaslan ZL, Bydon A: Recurrent disc herniation and long-term back pain after primary lumbar discectomy: review of outcomes reported for limited versus aggressive disc removal. Neurosurgery 64:338-344, 2009 12. Morgan-Hough CV, Jones PW, Eisenstein SM: Primary and
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revision lumbar discectomy. A 16-year review from one centre. J Bone Joint Surg Br 85:871-874, 2003 13. Suk KS, Lee HM, Moon SH, Kim NH: Recurrent lumbar disc herniation: results of operative management. Spine 26:672676, 2001 14. Swartz KR, Trost GR. Recurrent lumbar disc herniation. Neurosurg Focus 15:1-4, 2003
