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Keywords
Recurrent Disc Herniation
Recurrent Herniated Disc
Lumbar Microsurgery
Recurrent Lumbar Spinal Stenosis

Definition
Recurrent Lumbar Disc Herniations occur after a surgical procedure has been performed. Most recurrent disc herniations occur after a previous discectomy (partial disc removal) has occurred.

Indications
The indications for surgery for recurrent disc herniation are similar to the un-operated disc herniation: pain in the leg, weakness in the leg, leg numbness from pressure exerted on the lumbar spinal nerve(s) at a single or multiple levels.

Technical Considerations
Recurrent disc surgery occurs most frequently at the side and level of previous surgery. The most important technical consideration is the surgeon’s ability to navigate scar from the previous surgery and to define the pressure on the nerve and remove the herniated disc.

Literature Review
Featured References
Historical Perspective: Failure and recurrence have been historical components of lumbar spine surgery. Although the last two decades have brought better definitions for first time surgical intervention, a percentage of patients will be confronted with the prospect of repeat operation. Out of the chaos of random surgical decision-making, the orderly selection of patients for first time lumbar decompression was proposed by Rothman.[1] This algorithmic (decision-making chart) concept of initial criteria for surgical selection would hopefully lead to a pool of patients with better results, thus minimizing the number of "failed surgeries."
In 1979, the algorithmic concept was extrapolated to data by Finnegan and Rothman in a landmark study on the Multiply-Operated Back.[2] In this study, mechanical compression from herniated disc or spinal stenosis and instability were viewed as diagnoses leading to good results in repeat surgery. Conversely, the diagnosis of epidural scar or fibrosis was associated with failure.
Therefore, the selection and evaluation process for patients with pain after an initial operation (index operation) was oriented towards the inclusion of patients with optimal diagnoses for re-operation and the exclusion or pursuit of alternative strategies for those patients with other diagnoses. This selection process became the algorithm (decision-making chart) for assessing the multiply operated back.[3]
Current Concept: The result of surgery to decompress a lumbar nerve root(s) is tied to the intra-operative diagnosis. At the time of surgery, if the surgeon discovers a “true recurrent disc herniation” or “true bony compression of the nerve (spinal stenosis)” or a combination of the two diagnoses, then the result can be excellent. The surgical result where the primary focus is removing scar tissue around a nerve is poor.The entire pre-operative evaluation with diagnostic studies (MRI, CT, CT-discogram, discogram, myelogram, CT-myelogram, plain xrays, etc.) is designed to determine whether the patient has one of the following: recurrent herniated disc, recurrent spinal stenosis or spinal instability (abnormal movement of the bones). The evaluation is designed to exclude patients who have scar tissue around the nerve but no other explanation for their leg symptoms (recurrent disc herniation, recurrent spinal stenosis, or spinal instability).
The possible combinations are numerous but this grid demonstrates a strategy of thinking for evaluation of the patient with prior surgery.

Jonsson evaluated 93 consecutive prospective patients 2 years after undergoing surgery for repeat nerve decompression. [4]

Patients with excellent or fair results as related to the intra-operative diagnosis (what was discovered at surgery) are listed below:
Recurrent Disc Herniation = 94.7%
Central Spinal Stenosis = 73.6%
Lateral Recess Stenosis = 88.8%
Scar Tissue = 45.17%[4]
Cinotti reviewed patients with recurrent disc herniations on the same side and the same level as prior surgery and those with recurrent disc herniations on the opposite side but the same level as the initial operation.[5, 6] He found that there was no difference in the outcome of the recurrent disc herniation and the outcome of the initial operations.[5, 6] In other words, the same percentage of patients obtain a good result from their initial disc operation as they do if they have an operation for a “true recurrent disc herniation.”In conclusion, the patient with recurrent disc herniation, recurrent stenosis or instability can achieve potentially good results with repeat surgery. The patient with persistent or recurrent symptoms without these diagnoses needs further evaluation to determine treatment options.

Complications
Potential complications of surgery involve the anatomic approach, the actual procedure, and the closure. Other complications are medical complications, anaesthesia complications and longer term complications in the post-operative period.
Injury to the neurological structures include nerve root injury, and dural tear (tearing of the fluid sac surrounding the nerves). Bone injuries include facet joint destruction and instability. Vascular injury from penetration of the front of the disc space is rare. Wound problems include drainage, infection, wound breakdown, and bleeding.

Author’s Comment
The recurrent disc herniation occurs in 5-15% of patients undergoing surgery for herniated disc. These recurrences are currently not predictable by objective studies and probably relate to an immeasurable factor in live human beings: the mechanics of the disc space and tension in the outer wall of the disc. Surgery for recurrent disc herniation can be very successful and may approach the success rate for initial disc operations. The topic of recurrent disc herniation often includes spinal stenosis and comments about instability because these three entities clearly have potential for definable results in repeat surgery. [1-45]

References
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