Nomogram Development and Validation for Predicting Postoperative Recurrent Lumbar Disc Herniation Based on Paraspinal Muscle Parameters.

Purpose: Previous studies highlight paraspinal muscles' significance in spinal stability. This study aims to assess paraspinal muscle predictiveness for postoperative recurrent lumbar disc herniation (PRLDH) after lumbar disc herniation patients undergo percutaneous endoscopic transforaminal discectomy (PETD). Patients and Methods: Retrospectively collected data from 232 patients undergoing PETD treatment at our institution between January 2020 and January 2023, randomly allocated into training (60%) and validation (40%) groups. Utilizing Lasso regression and multivariable logistic regression, independent risk factors were identified in the training set to construct a Nomogram model. Internal validation employed Enhanced Bootstrap, with Area Under the ROC Curve (AUC) assessing accuracy. Calibration was evaluated through calibration curves and the Hosmer-Lemeshow goodness-of-fit test. Decision curve analysis (DCA) and clinical impact curve (CIC) were employed for clinical utility analysis. Results: Diabetes, Modic changes, and ipsilesional multifidus muscle skeletal muscle index (SMI) were independent predictive factors for PRLDH following PETD (P<0.05). Developed Nomogram model based on selected predictors, uploaded to a web page. AUC for training: 0.921 (95% CI 0.872-0.970), validation: 0.900 (95% CI 0.828-0.972), respectively. The Hosmer-Lemeshow test yielded χ 2=5.638/6.259, P=0.688/0.618, and calibration curves exhibited good fit between observed and predicted values. DCA and CIC demonstrate clinical net benefit for both models at risk thresholds of 0.02-1.00 and 0.02-0.80. Conclusion: The Nomogram predictive model developed based on paraspinal muscle parameters in this study demonstrates excellent predictive capability and aids in personalized risk assessment for PRLDH following PETD.

Repeat Discectomy or Instrumented Surgery for Recurrent Lumbar Disk Herniation: An Overview of French Spine Surgeons' Practice.

STUDY DESIGN: Retrospective multicenter cohort study. OBJECTIVE: Recurrent lumbar disc herniation (ReLDH) is a common condition requiring surgical intervention in a large proportion of cases. Evidence regarding the appropriate choice between repeat microdiscectomy (RD) and instrumented surgery (IS) is lacking. To understand the indications for either of the procedures and compare the results, we aimed to provide an overview of spine surgeon practice in France. METHODS: This retrospective, multicenter analysis included adults who underwent surgery for ReLDHs between December 2020 and May 2021. Surgeons were asked which of the following factors determined their therapeutic choice: radio-clinical considerations, non-discal anatomical factors, patient preference, or surgeon background. Data on preoperative clinical status and radiologic findings were collected. Patient-reported outcome measures (PROMs) were assessed and compared using propensity scores preoperatively and at 3 and 12 months postoperatively. RESULTS: The study included 150 patients (72 IS and 78 RD). Radioclinical elements, anatomical data, patient preferences, and surgeon background influenced the choice of RD in 57.7%, 1.3%, 25.6%, and 15.4% of the cases, respectively, and IS in 34.7%, 6.9%, 13.9%, and 44.5% of the cases, respectively. At 12 months, patient satisfaction, return to work, and changes in PROMs were not significantly different between the groups. CONCLUSIONS: The decision-making process included both objective and subjective factors, resulting in patient satisfaction in 80.3% to 81.5% of cases, with significant clinical improvement in radicular symptoms in 75.8% to 91.8% of cases, and quality of life in 75.8% to 84.9% of cases, depending on the procedure performed.

Development and Validation of a Nomogram Predicting Postoperative Recurrent Lumbar Disc Herniation Based on Activity Factors.

Purpose: To develop an individualized predictive model for postoperative recurrent lumbar disc herniation (PRLDH) in patients undergoing percutaneous endoscopic transforaminal discectomy (PETD) by considering postoperative activity factors. Patients and Methods: Retrospectively collected data from 612 LDH patients who underwent PETD in our institution from January 2017 to June 2023. They were divided into a training group (429 cases) and a validation group (183 cases). Lasso regression (Model 1) and random forest (Model 2) were applied for variable selection in the training group. The two models were compared in terms of discrimination (the area under curve, AUC), calibration (calibration curve), and clinical utility (decision curve analysis, DCA). Akaike information criterion (AIC) was used for model comparison, and internal validation employed 1000 times Bootstrap + 10-fold cross-validation. Finally, a Nomogram was constructed to display the results and uploaded to the web version. Results: Among 612 treated LDH patients, 66 (10.78%) developed PRLDH. Model 1, superior in AUC, calibration, DCA, and AIC over Model 2, was chosen as the predictive model. Logistic regression in the training group identified BMI, smoking, activity level score, time to first ambulation, diabetes, Modic change, and Pfirrmann grade as independent predictors of PRLDH. Model 1 exhibited a training group AUC of 0.813 (95% CI 0.753-0.872) and a validation group AUC of 0.868 (95% CI 0.773-0.962). At a Youden index of 0.50, sensitivity was 0.73, specificity was 0.77. Internal validation (1000 times Bootstrap + 10-fold cross-validation) for the training group showed accuracy of 0.889, kappa consistency of 0.112, and AUC of 0.757. The Hosmer-Lemeshow goodness-of-fit tests indicated good discriminative ability for Model 1 in both the training (χ2=2.895, P=0.941) and validation groups (χ2=8.197, P=0.414). The DCA and Nomogram are accessible at https://sofarnomogram.shinyapps.io/PRLDHNom/. Conclusion: The Nomogram predictive model, developed based on postoperative activity factors in this study, demonstrates excellent predictive capability, facilitating risk assessment for the occurrence of PRLDH after PETD.

Associations of recurrent lumbar disc herniation after percutaneous endoscopic lumbar discectomy with age, body mass index, modic change, disc degeneration and sacral slope: A quantitative review.

Recurrent lumbar disc herniation (rLDH) seriously affects the quality of life of patients and increases the medical burden. The purpose of the present study was to determine the risk factors for rLDH after percutaneous endoscopic lumbar discectomy (PELD). The PubMed, Cochrane Library and Embase databases were searched for studies on the factors associated with rLDH after PELD. The databases were searched from inception to March 30, 2023. The combined effects of categorical variables and continuous variables were measured using odds ratios (ORs) and weighted mean differences (WMDs), respectively, and their corresponding 95% confidence intervals (CIs) were calculated. RevMan 5.3 software was used for data analysis. A total of 9 case-control studies were included in this meta-analysis, comprising 5,446 patients. This study explored a total of 18 potential risk factors for rLDH after PELD; ultimately, 5 factors were associated with the risk of rLDH. Meta-analysis showed that older age (WMD=6.49, 95% CI: 2.52 to 10.46), greater body mass index (WMD=1.16, 95% CI: 0.69 to 1.62), modic change (OR=2.48, 95% CI: 1.54 to 3.99), Pfirrmann grade ≥4 (OR=2.84, 95% CI: 1.3 to 6.16) and greater sacral slope angle (WMD=3.48, 95% CI: 0.53 to 6.42) were risk factors for rLDH after PELD. The risk factors identified in the present study may enable clinicians to identify high-risk populations early and to select appropriate surgical procedures to reduce the risk of rLDH. Perioperative interventions targeting the modifiable factors identified in this study may be beneficial for reducing the risk of rLDH.

Endoscopic Revision Strategies and Outcomes for Recurrent L4/5 Disc Herniation After Percutaneous Endoscopic Transforaminal Discectomy.

Objective: We explore the endoscopic revision and surgical techniques for L4/5 recurrent disc herniation (rLDH) after percutaneous endoscopic transforaminal discectomy (PETD). Methods: A retrospective study was conducted. From January 2016 to September 2022, 96 patients who underwent percutaneous endoscopic lumbar discectomy for L4/5 rLDH after PETD were enrolled in the study. Based on the revision approach, the patients were divided into PETD group (57 cases) and percutaneous endoscopic interlaminar discectomy (PEID) group (39 cases). Visual Analogue Scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), and modified MacNab standard were recorded to evaluate the clinical outcomes. Results: No significant differences were found in the demographic data and intraoperative blood loss between the two groups (P>0.05), but the time of operation and intraoperative X-ray fluoroscopy exposures in the PEID group were significantly less than that in the PETD group (P<0.05). The patients' postoperative clinical indexes gradually improved, and the VAS score, ODI index, and JOA score of the patients in both groups showed significant improvement compared with the preoperative period at the 1-week, 1-month, and 6-month postoperative follow-ups (P < 0.05). There was no serious complication observed during the follow-up. Conclusion: For recurrent LDH after PETD of L4/5 segments, percutaneous endoscopic revision can achieve satisfactory results. Among them, PEID has a shorter operative and fluoroscopy time and allows avoidance of the scar that forms after the initial surgery, so it can be considered preferred when both procedures can remove the disk well. However, for some specific types of herniation, a detailed surgical strategy is required.

Management of recurrent lumbar disc herniation: a comparative analysis of posterior lumbar interbody fusion and repeat discectomy.

Background: For recurrent lumbar disc herniation, many experts suggest a repeat discectomy without stabilization due to its minimal tissue manipulation, lower blood loss, shorter hospital stay, and lower cost, recent research on the role of instability in disc herniation has made fusion techniques popular among spinal surgeons. The authors compare the postoperative outcomes of posterior lumbar interbody fusion (PLIF) and repeat discectomy for same-level recurrent disc herniation. Methods: The patients included had previously undergone discectomy and presented with a same-level recurrent lumbar disc herniation. The patients were placed into two groups: 1) discectomy only, 2) PLIF based on the absence or presence of segmental instability. Preoperative and postoperative Oswestry disability index scores, duration of surgery, blood loss, duration of hospitalization, and complications were analyzed. Results: The repeat discectomy and fusion groups had 40 and 34 patients, respectively. The patients were followed up for 2.68 (1-4) years. There was no difference in the duration of hospitalization (3.73 vs. 3.29 days P=0.581) and operative time (101.25 vs. 108.82 mins, P=0.48). Repeat discectomy had lower intraoperative blood loss, 88.75 ml (50-150) versus 111.47 ml (30-250) in PLIF (P=0.289). PLIF had better ODI pain score 4.21 (0-10) versus 9.27 (0-20) (P-value of 0.018). Recurrence was 22.5% in repeat discectomy versus 0 in PLIF. Conclusion: PLIF and repeat discectomy for recurrent lumbar disc herniation have comparable intraoperative blood loss, duration of surgery, and hospital stay. PLIF is associated with lower durotomy rates and better long-term pain control than discectomy. This is due to recurrence and progression of degenerative process in discectomy patients, which are eliminated and slowed, respectively, by PLIF.

Association of spinal-pelvic parameters with recurrence of lumbar disc herniation after endoscopic surgery: a retrospective case-control study.

PURPOSE: This study aimed to investigate the relationship between spinal-pelvic parameters and recurrence of lumbar disc herniation (rLDH) after percutaneous endoscopic lumbar discectomy (PELD) through a retrospective case-control study. METHODS: Patients who underwent PELD for single-segment LDH at our hospital were included in this study. The relationship between sagittal balance parameters of the spine and recurrence was analysed through correlation analysis, and ROC curves were plotted. The baseline characteristics, sagittal balance parameters of the spine and radiological parameters of the case and control groups were compared, and the relationship between sagittal balance parameters of the spine and recurrence of rLDH after PELD was determined through univariate and multivariate logistic regression analysis. RESULTS: Correlation analysis showed that PI and ∆PI-LL were negatively correlated with grouping (r = -0.090 and -0.120, respectively, P = 0.001 and 0.038). ROC curve analysis showed that the area under the curve (ROC-AUC) for predicting rLDH based on PI was 0.65 (CI95% = 0.598, 0.720), with a cut-off of 50.26°. The ROC-AUC for predicting rLDH based on ∆PI-LL was 0.56 (CI95% = 0.503, 0.634), with a cut-off of 28.21°. Multivariate logistic regression analysis showed that smoking status (OR = 2.667, P = 0.008), PI ≤ 50.26 (OR = 2.161, P = 0.009), ∆PI-LL ≤ 28.21 (OR = 3.185, P = 0.001) and presence of Modic changes (OR = 4.218, P = 0.001) were independent risk factors, while high DH (OR = 0.788, P = 0.001) was a protective factor. CONCLUSION: PI < 50.26 and ∆PI-LL < 28.21 were risk factors for recurrence of lumbar disc herniation after spinal endoscopic surgery and had some predictive value for post-operative recurrence.

Clinical Effects of the End-Love Technique in the Treatment of Recurrent Lumbar Disc Herniation 1 Year After Surgery.

Background: The number of patients with lumbar disc herniation in China is increasing year by year. Percutaneous endoscopic lumbar discectomy (PELD) is currently the main surgical method for treating lumbar disc herniation (LDH). However, with the increase in the number of surgical cases, the number of patients with recurrent lumbar disc herniation (RLDH) is also increasing. Currently, the common method in China is lumbar fusion surgery, but this surgery would cause the loss of fusion segment mobility and considerable postoperative complications. In order to solve the problem above the following technique will be studied: the technique of posterior lumbar laminectomy and nucleus pulposus removal under fully visualized spinal endoscopy (ENDO-LOVE) to treat RLDH. Its clinical effects will be observed in this paper, too. Methods: This series includes RLDH patients treated with ENDO-LOVE technology between January 2017 and January 2021. All patients will undergo at least three follow-up visits one year after surgery. The modified MacNab standard, VAS, JOA, and ODI scores will be used to evaluate clinical efficacy, observe for cerebrospinal fluid leak, nerve root injury, and surgical site infection, and evaluate clinical safety. Results: All 29 patients completed the surgery successfully. Three patients had postoperative pain and numbness in the area of nerve root innervation, and all patients had no serious complications. The VAS, JOA scores and ODI indices of back pain and leg pain 1-day, 3-months, and 1-year postoperatively differed statistically significantly from the preoperative scores (p < 0.05). Efficacy evaluated at 1-year postoperatively using the modified MacNab criteria showed an excellent rate of 89.7%. Conclusion: ENDO-LOVE technology has demonstrated good clinical efficacy and safety in the treatment of patients with RLDH. It should be considered for all patients with this condition.

Minimally invasive tubular microdiscectomy for recurrent lumbar disc herniation: step-by-step technical description with safe scar dissection.

INTRODUCTION: Recurrent lumbar disc herniation (RLDH) is one of the most common reasons for re-operation after primary lumbar disc herniation with an incidence ranging from 5 to 23%. Numerous RLDH studies have been conducted; however, no available studies have provided a specific description of the use of the tubular retractor discectomy technique for RLDH emphasizing safe scar dissection. The objective of this study is to describe a detailed step-by-step technique for RLDH. MATERIAL AND METHODS: A surgical technique reporting on our experience from the year 2013-2021 in 9 patients with RLDH at the same level and same side was included in the study. Clinical outcomes were assessed using the visual analog score (VAS) for leg pain before and three months after surgery. RESULTS: A significant improvement was observed between the preoperative and postoperative VASs [mean (SD): 9.2 (1) vs. 1.5 (1)] for all patients. We did not report any incidental durotomy, neurological deficits or mortality in this study. One patient had superficial wound infection. The study is limited by small population, short follow-up and not reporting stability or spondylolisthesis. CONCLUSION: A modified tubular discectomy technique with safe scar dissection is effective for RLDH treatment. Technically, the only scar needed to be dissected is the scar lateral to the exposed normal dura and the scar extended caudally till the level of the superior end plate of the targeted disc space where the scar can be entered ventrally and the disc fragment retrieved. Adherence to the step-by-step procedure described in our study will help surgeons operate with more confidence and minimize complications of recurrent lumbar disc herniation.

Repeat Discectomy for the Management of Same-Level Recurrent Disc Herniation: A Study of 50 Patients.

Background Same-level recurrent disc herniation remains a challenge in spine surgery. Although most surgeons agree on discectomy as the treatment of choice for primary lumbar disc herniation, the management of recurrent disc herniation remains ambiguous and largely depends on the operating surgeon. Many surgeons recommend repeat discectomy over fusion because it is cheaper and less invasive. In this study, we analyzed 50 patients who underwent a repeat discectomy. Materials and methods The patients in the study had previously been managed for lumbar disc herniation and then presented with either recurrent same-level herniation or symptoms attributed to the same level. The patients were then managed with a repeat discectomy without fusion. We analyzed the preoperative and postoperative Oswestry Disability Index (ODI), duration of surgery, blood loss, duration of hospitalization, and complications. Results Fifty patients were included: 27 females (54%), and 23 males (46%). They were followed up for an average of 2.81 years (range: 1-4). The mean duration of hospitalization was 4.06 ± 1.5 days (range: 2-8). The operative time was 104.60 minutes (range: 50-195), with an intraoperative blood loss of 85.40 mL (range: 50-150 mL). Durotomy occurred as a complication in eight (16%) patients. The recurrence rate was 26%, with 36% progressing to fusion. The change in preoperative ODI and postoperative ODI was 20.94 ± 7.24 (6-37), with a p-value of 0.04. There were no long-term complications recorded. Conclusion Repeat discectomy is a good management option for same-level recurrent disc herniation. The procedure is associated with low intraoperative blood loss and a short operating time, but there is a significant risk of durotomy. The risk of recurrence remains a concern due to the progression of degenerative changes, especially in the presence of Modic-2 changes. These advantages and disadvantages should be discussed with patients.

Machine Learning Prediction Model and Risk Factor Analysis of Reoperation in Recurrent Lumbar Disc Herniation Patients After Percutaneous Endoscopic Lumbar Discectomy.

OBJECTIVE: To investigate the risk factors of reoperation after percutaneous endoscopic lumbar discectomy (PELD) due to recurrent lumbar disc herniation (rLDH) and to establish a set of individualized prediction models. METHODS: Patients who underwent PELD successfully from January 2016 to February 2022 in a single institution were enrolled in this study. Six methods of machine learning (ML) were used to establish an individualized prediction model for reoperation in rLDH patients after PELD, and these models were compared with logistics regression model to select optimal model. RESULTS: A total of 2603 patients were enrolled in this study. 57 patients had repeated operation due to rLDH and 114 patients were selected from the remaining 2546 nonrecurrent patients as matched controls. Multivariate logistic regression analysis showed that disc herniation type (P < .001), Modic changes (type II) (P = .003), sagittal range of motion (sROM) (P = .022), facet orientation (FO) (P = .028) and fat infiltration (FI) (P = .001) were independent risk factors for reoperation in rLDH patients after PELD. The XGBoost AUC was of 90.71%, accuracy was approximately 88.87%, sensitivity was 70.81%, specificity was 97.19%. The traditional logistic regression AUC was 77.4%, accuracy was about 77.73%, sensitivity was 47.15%, specificity was 92.12%. CONCLUSION: This study showed that disc herniation type (extrusion, sequestration), Modic changes (type II), a large sROM, a large FO and high FI were independent risk factors for reoperation in LDH patients after PELD. The prediction efficiency of XGBoost model was higher than traditional Logistic regression analysis model.

Tubular Microdiscectomy for Recurrent Lumbar Disc Herniation: A Valuable Alternative to Endoscopic Techniques.

OBJECTIVE: The efficacy of tubular microdiscectomy (TMD) in the treatment of recurrent lumbar disc herniation (rLDH) is still unclear, especially compared with the endoscopic technique. We performed a retrospective study to analyze this question. METHODS: We retrospectively included all patients with an rLDH confirmed by magnetic resonance imaging who underwent TMD between January 2012 and February 2019. The general data included sex, age, body mass index, level of rLDH, first surgical approach, reoperation interval, occurrence of dural leak, re-recurrence, and re-reoperation. The clinical outcome was evaluated using a visual analog scale for leg pain, and the modified MacNab criteria were used to evaluate patient satisfaction. RESULTS: The visual analog scale score for leg pain was statistically significantly reduced from 7.46 preoperatively to 0.80 postoperatively (P < 0.00001), and the patient satisfaction was good or excellent in 85.7% of cases, according to the modified MacNab criteria. Complications occurred in 3 of the 15 included patients: 2 dural tears (13.3%) and 2 re-recurrence (13.3%), but none of the patients underwent a third surgical procedure. CONCLUSIONS: TMD seems to be an efficient technique for the surgical treatment of leg pain caused by rLDH. In the literature, this technique seems to be at least as good as the endoscopic technique and is easier to master.

Development and Validation of a Prognostic Model for the Risk of Recurrent Lumbar Disc Herniation After Percutaneous Endoscopic Transforaminal Discectomy.

BACKGROUND: Recurrence of lumbar disc herniation (LDH) is an adverse event after percutaneous endoscopic transforaminal discectomy (PETD). Accurate prediction of the risk of recurrent LDH (rLDH) after surgery remains a major challenge for spine surgeons. OBJECTIVES: To develop and validate a prognostic model based on risk factors for rLDH after PETD. STUDY DESIGN: Retrospective study. SETTING: Inpatient surgery center. METHODS: Clinical data were retrospectively collected from 645 patients with LDH who underwent PETD at the Affiliated Hospital of Xuzhou Medical University from January 1, 2017 to January 1, 2021. Predictors significantly associated with rLBH were screened according to least absolute shrinkage and selection operator (LASSO) regression, and a prognostic model was established, followed by internal model validation using the enhanced bootstrap method. The performance of the model was assessed using receiver operating characteristic (ROC) curves and calibration curves. Finally, the clinical usefulness of the model was analyzed using decision curve analysis (DCA) and clinical impact curves (CICs). RESULTS: Among the 645 patients included in this study, 56 experienced recurrence of LDH after PETD (8.7%). Seven factors significantly associated with rLDH were selected by LASSO regression, including age, type of herniation, level of herniation, Modic changes, Pfirrmann classification, smoking, and history of high-intensity physical work. The bias-corrected curve of the model fit well with the apparent curve, and the area under the ROC curve was 0.822 (95% confidence interval, 0.76-0.88). The DCA and CIC confirmed that the prognostic model had good clinical utility. LIMITATIONS: This is a single-center study, and we used internal validation only. CONCLUSIONS: The prognostic model developed in this study had excellent comprehensive performance and could well predict the risk of rLDH after PETD. This model could be used to identify patients at high risk for rLDH at an early stage to individualize the patient's treatment modality and postoperative rehabilitation plan.

Long-term outcome of redo discectomy for recurrent lumbar disc herniations.

PURPOSE: Recurrent lumbar disc herniation (RLDH) is an important cause of morbidity and healthcare costs. The goal of this investigation is to assess surgical outcomes and their predictors in patients who underwent revision discectomy for RLDH, with a minimum follow-up of ten years, to shed light on the best treatment to offer to these patients. METHODS: Patients who underwent revision discectomy to treat RLDH between 2004 and 2011 in our Department were enrolled. Demographic, clinical, and surgical data were collected. The need of third intervention for RLDH was the primary outcome. Patient's satisfaction, Core Outcome Measures Index, Oswestry Disability Index, and EuroQoL-5D scores were also evaluated. RESULTS: This study includes 55 patients, with a mean follow-up time of 144 months [112-199]. In this period, a third intervention was needed in 30.9% (n = 17) of patients. Most recurrences took place in the first 2 years after the second surgery (58.8%, n = 10) and the risk of needing a third surgery decreased over time. After 5 years, the probability of not having surgery for recurrence was 71% [CI 95%: 60-84%], with a tendency to stabilize after that. An interval between the first discectomy and the surgery for recurrence shorter than 7.6 months was identified as a predictor for a second recurrence. CONCLUSION: The risk of needing a third surgery seems to stabilize after five years. Patients with an early recurrence after the first discectomy seem to have a higher risk of a new recurrence, so an arthrodesis might be worth considering.

Spinal Fusion Versus Repeat Discectomy for Recurrent Lumbar Disc Herniation: A Systematic Review and Meta-Analysis.

OBJECTIVE: Recurrent lumbar disc herniation (RLDH) is one of the major causes of failure for primary surgery. Repeat discectomy (RD) and spinal fusion (SF) are 2 surgical options for RLDH. The objective of our study is to compare the effectiveness of SF compared with RD in the treatment of RLDH. METHODS: We systematically searched PubMed, Embase, Cochrane Library, Web of Science, and Ovid Medline for studies (published between Jan 1, 1959 and July 8, 2022; no language restriction) comparing SF and RD for the RLDH. Odds ratio and weighted mean difference were calculated for binary outcomes and continuous outcomes. The quality of each outcome was graded using the Grading of Recommendations, Assessment, Development and Evaluations criteria. RESULTS: We identified 5029 studies, of which 11 studies were included. There were 2 randomized controlled trials and the remaining were observational studies. Comparing SF and RD groups, no differences were found in visual analog scales for leg and back and Oswestry Disability Index. Furthermore, the Japanese Orthopaedic Association scores of SF were significantly higher than the RD group. In terms of complications, the incidence of neurological deficit, segmental instability, and re-recurrence is significantly lower with SF than with the RD group. Lastly, the SF group was associated with longer hospital stays and operation time, and more blood loss. CONCLUSIONS: The pooled evidence suggests that fusion achieves better results than RD for RLDH. The results of this review should be further confirmed by future high-quality randomized controlled trials.

Clinical efficacy of transforaminal endoscopic discectomy in the treatment of recurrent lumbar disc herniation: a single-center retrospective analysis.

PURPOSE: To investigate the clinical efficacy of transforaminal endoscopic discectomy (TED) in treating recurrent lumbar disc herniation. METHODS: Clinical datal of 31 patients who were hospitalized in the Department of Pain Management, First Affiliated Hospital of Nanchang University, between 2015 and 2018 due to recurrent lumbar disc herniation were collected and analyzed retrospectively. Visual analogue scale (VAS) scores and Japanese Orthopedic Association (JOA) scores were used to assess alterations of patients' leg pain intensity and nerve function, respectively. The Modified MacNab criteria were used to evaluate patients' excellent and good rates. RESULTS: Compared to clinical data before surgery, there was a significant reduction in VAS scores (P < 0.01) along with a significant improvement in JOA scores (P < 0.01) at 2 years after revision surgery. The patients' excellent and good rates were 83.9% at the 2 years after surgery. CONCLUSION: The TED is safe and effective in the long term and is applicable to the treatment of recurrent lumbar disc herniation.

Comparison of Primary Versus Revision Lumbar Discectomy Using a Biportal Endoscopic Technique.

STUDY DESIGN: Retrospective study. OBJECTIVE: To compare the clinical outcomes of the biportal endoscopic technique for primary lumbar discectomy (BE-LD) and revision lumbar discectomy (BE-RLD). METHODS: Eighty-one consecutive patients who underwent BE-LD or BE-RLD, and could be followed up for at least 12 months were divided into two groups: Group A (BE-LD; n = 59) and Group B (BE-RLD; n = 22). Clinical outcomes included the visual analog scale (VAS), Oswestry Disability Index (ODI), and modified MacNab's criteria. Perioperative results included operation time (OT), length of hospital stay (LOS), amount of surgical drain, and kinetics of serum creatine phosphokinase (CPK) and C-reactive protein (CRP). Clinical and perioperative outcomes were assessed preoperatively and postoperatively at 2 days and at 3, 6, and 12 months. Postoperative complications were noted. RESULTS: Both groups showed significant improvement in pain (VAS) and disability (ODI) compared to baseline values at postoperative day 2, which lasted until the final follow-up. There were no significant differences in the improvement of the VAS and ODI scores between the groups. According to the modified MacNab's criteria, 88.1 and 90.9% of the patients were excellent or good in groups A and B, respectively. OT, LOS, amount of surgical drain, and kinetics in serum CRP and CPK levels were comparable. Complications in Group A included incidental durotomy (n = 2), epidural hematoma (n = 1), and local recurrence (n = 1) and in Group B incidental durotomy (n = 1) and epidural hematoma (n = 1). CONCLUSION: BE-RLD showed favorable clinical outcomes, less postoperative pain, and early laboratory recovery equivalent to BE-LD.

Recurrence of lumbar disk herniation after microdiscectomy: a two-center retrospective analysis of 1214 cases and identification of risk factors.

Background/aim: To present the incidence of recurrent lumbar disc herniation (RLDH) and to identify radiological and patient-related risk factors that lead to recurrence after lumbar disc herniation (LDH) treatment with microdiscectomy. Materials and methods: Between January 2013 and December 2021, 1214 patients who had undergone microdiscectomy for LDH were included in this retrospective study. Patients were divided into two groups, the recurrent group and the non-recurrent group, and their demographic, clinical and radiologic characteristics were recorded. The association between the variables and RLDH was assessed by univariate and multivariable logistic regression analyses. Results: Mean ages were similar in the recurrent (51.48 ± 13.63) and non-recurrent(50.38 ± 14.53) groups (p=0.232). Males represented 59.6% of the recurrent group and 49.8% of the non-recurrent group (p=0.002). Multivariable logistic regression revealed that being a male (p=0.009), diabetes mellitus (p=0.038), smoking (p<0.001), grade 4&5 disc degeneration (p<0.001), and having protruded (p=0.002), extruded LDH (p<0.001), paracentral (p=0.008) and foraminal LDH (p=0.008) were independently associated with recurrence. Conclusion: To reduce RLDH frequency and need for revision surgery, modifiable risk factors should be minimized before and after the initial surgery. Also, in patients with unmodifiable risk factors, patients should be clearly informed about the risk for recurrence and possible alternative treatment methods should be considered.

Spinal Morphometry As A Novel Predictor For Recurrent Lumbar Disc Herniation Requiring Revision Surgery: Results of A Case Control Study.

Introduction: There is conflicting data on the risk factors for recurrent lumbar disc herniation (rLDH). Most of the predictors for rLDH identified so far are acquired risk factors or radiological factors at the level of the herniation. Whole lumbar spine (WLS) morphometry has not been evaluated as a possible predictor of rLDH. Objectives: We aimed to evaluate if preoperative spinal morphometry can predict the occurrence of rLDH requiring revision surgery. Methods: This retrospective case-control study on 250 patients included 45 patients operated for rLDH, 180 controls without rLDH who had previously undergone microdiscectomy for a single level lumbar disc prolapse, and a holdout validation set of 25 patients. Morphometric variables related to the WLS were recorded in addition to previously identified predictors of rLDH. Logistic regression (LR) analysis was performed to identify independent predictors of rLDH. Results: LR yielded four predictors of which two were WLS morphometric variables. While increasing age and smoking positively predicted rLDH, increasing WLS interfacet distance and WLS dural-sac circumference negatively predicted rLDH. The LR model was statistically significant, χ2 (4) =15.98, P = 0.003, and correctly classified 80.3% of cases. On validation, the model demonstrated a fair accuracy in predicting rLDH (accuracy: 0.80, AUC: 0.70). Conclusions: Larger mean lumbar bony canals and dural sacs protect from the occurrence of symptomatic rLDH. These WLS morphometric variables should be included in future risk stratification algorithms for lumbar disc disease. In addition to the previously recognized risk factors, our study points to an underlying developmental predisposition for rLDH.

A Clinically Applicable Predictive Score in Lumbar Disc Disease for Formulating a Surgical Plan.

STUDY DESIGN: Case control study. OBJECTIVE: Micro-lumbar discectomy or Interbody fusion procedure are work-horse surgical procedures in management of lumbar disc disease. Spine surgeon in their early years of practice gets confused in choosing ideal surgical plan when dealing with a complex scenario. A clinical score is needed to guide spine surgeons in choosing an optimal surgical plan. MATERIALS AND METHODS: Study was done with research grant approval from AO Spine. A predictive score was formulated as per hypothesis following a pilot study. Two fellowship trained spine surgeons-one using the score (Group A) and other not using score (Group B-control) treated 40 patients included in their respective group. All patients were analysed preoperatively, post-surgery at 12 months follow-up with Visual analog scale score for back pain, leg pain, Oswestry disability index score, SF-36 score. Change in parameters at 12 months follow-up were analysed statistically. P ≤ .05 was considered statistically significant. Success rate of individual surgeon who managed respective group of patients and Difficulty index of surgeon who managed without using score was evaluated at 12 months follow-up. RESULTS: Success rate of Group A-surgeon was higher than Group B-surgeon .15% of Group B patients had poor surgical outcome at follow-up. Statistically significant improvement in Group A patients were seen in all 3 evaluated parameters when compared to Group B patients at 12 months of follow-up (P ≤ .05). Difficulty index of surgeon who didn't use the score was 15%. CONCLUSION: The proposed predictive score comprising all risk factors, can be used by spine surgeons when they are confronted with difficult scenario in decision-making. Accuracy, reliability and validity of the score needs to be evaluated in a larger scale. LEVEL OF EVIDENCE: Ⅲ.