الفهرس 
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Abstract
Lumbar disc herniation (LDH) is one of the most common spinal
conditions and causes widespread medical problems.[183] The strict definition
of recurrent disc herniation is the presence of herniated disc material at the same
level, ipsi or contralateral, in a patient who has experienced a pain-free interval
of at least 6 months since surgery [1]. Indications for surgery of recurrent
lumbar disc herniation were intractable pain that had not responded to
conservative management for 6 – 8 weeks, positive tension sign, and recurrent
disc herniation with compression of nerve root confirmed by magnetic
resonance imaging [5]. The management of recurrent disc herniation remains
somewhat controversial [9]. Surgical treatment for recurrent disk herniation can
be broadly categorized as revision discectomy alone or revision discectomy and
fusion [3].
The aim of this study is to compare the surgical outcome for treatment of
recurrent lumbar disc herniation by discectomy alone versus discectomy with
pedicular screw fixation with or without interbody fusion.
Fifty patients were included in this study aged from 31to 60 years; there
were 35 males and 15 females (2.3:1). The patients’ clinical data were
retrospectively and prospectively analyzed as regards the duration before the
recurrence of symptoms, the site of new symptoms, the type of the previous
operation, the type of new operation and outcome after these procedures.
The inclusion criteria included cases with RLDH operated by open or
minimal invasive procedures, with at least 6 months of pain relief after primary
disc surgery, not responding to medical treatment for six weeks preoperatively,
and positive radiological findings of recurrence. The accepted cases must have
RLDH at the same level as previous discectomy, either the ipsilateral or the
contralateral side. The exclusion criteria included cases of RLDH with other
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spinal pathology, traumatic vertebral fracture, scoliosis, infection, osteoporosis,
serious systemic disease, patients with disc herniation at a new level, and
patients with recurrent sciatica or low back pain due to perinural fibrosis and
scar tissue formation after primary disc surgery.
Preoperative assessment was done clinically using visual analogus scale
(VAS) and Oswestry disability index (ODI), and radiologically, using MRI
lumbosacral spine with gadolinium and dynamic lumbosacral X-ray with both
oblique views. The patients were divided into two groups, group (A) patients
underwent discectomy, while group (B) patients underwent discectomy and
fusion (transpedicular screws fixation with or without interbody fusion). Clinical
postoperative assessment was done using VAS and ODI.
Twelve patients (24%) had DM. Twenty six cases (52%) were smokers.
Twenty five patients (50%) were included in the hard work group, 15 patients
(30%) in the light work group and 10 patients (20%) in the non-occupied group.
The time interval before recurrence of pain ranged from 7 months to 120 months
with a mean of 33.70 months. Discectomy with total laminectomy was the most
common previous surgery (30 cases, 60%), followed by discectomy and hemilaminectomy
(12 cases, 24%), then discectomy and laminotomy (8 cases,16%).
All patients had only one previous lumbar surgery except 4 cases (8%) that had
2 sets of previous lumbar discectomy. MRI revealed recurrent postero-lateral
disc herniation in 43 cases (86%) and central in 7 cases (14%). Recurrence level
was one case (2%) in L2-3 and L3-4 level. 24 cases (48%) in level L4-5. L5-S1
in 18 cases (36%) and double level recurrence (L4-5 & L5-S1) was in 6 cases
(12%).
Regarding the postoperative clinical outcome, VAS (leg pain) was
significantly higher among group A (at 3151
0.80 and at 12 month=1.36± 0.95) than among group B (at 3 month=1.46± 1.10,
at 6 month=0.75± 0.79 and at 12 month=0.39± 0.49 (P <0.001).
VAS (back pain) was significantly higher among group A (post-operative
at Baseline =3.86± 0.99, at 3 month=2.68± 0.89, at 6 month=2.31± 1.04 and at
12 month=2.31± 1.04) than among group B (at Baseline =2.07± 0.89, at 3
month=1.96± 1.07, at 6 month=1.28± 0.85and at 12 month=0.71± 0.65 (P
<0.001, 0.017, 0.001 and <0.001respectively).
ODI was significantly higher among group A (post-operative at 3
month=27.50± 8.55, at 6 month=22.04± 7.81and at 12 month=14.31± 4.16) than
among group B (at 3 month=19.10± 7.70, at 6 month=13.07± 6.16 and at 12
month=10.53± 4.15 (P= 0.003, <0.001 and 0.004 respectively). month=3.04± 0.95, Intraoperative dural tear occurred in 11 cases (22%). Superficial wound
infection occurred in 2 cases (4%).Intraoperative disturbance of entry point of
transpedicular screw occurred in 3 cases (6%) and one case have hardware
failure (2%) in their routine follow up after 12 months in the form of broken
screw.