Hirurgia pozvonocnika (Spine Surgery)

© A.E. Simonovich, A.A. Baikalov, 2013

SURGICAL TREATMENT OF PAIN SYNDROME RECURRENCE AFTER REMOVAL OF LUMBAR INTERVERTEBRAL DISC HERNIA* A.E. Simonovich, A.A. Baikalov Novosibirsk Institute of Traumatology and Orthopaedics, Novosibirsk, Russia Objective. To determine the optimal pathogenetically reasonable surgical techniques for pain syndrome recurrence after lumbar discectomy. Materials and Methods. The study included 176 patients operated on for pain syndrome recurrence. Decompressive and decompressive-stabilizing (posterior or anterior interbody fusion, dynamic fixation with DYNESYS instrumentation) reoperations were performed. The results were followed for 3 to 24 months. The dynamics of neurologic status and pain syndrome intensity were assessed with visual-analog scale and the Oswestry index. Results. The main causes of pain syndrome recurrence included herniation of the operated disc (52.8 %) and its combination with degenerative stenosis (9.7 %). Degenerative stenosis alone caused pain recurrence in 21.6 % of cases. Hernia recurrence of the operated disc caused the pain syndrome more frequently within 2 years after the surgery. Degenerative stenosis, both alone and in combination with operated disc hernia, occurred more often during the later follow-up period. Hypertrophic articular processes and vertebral arches, osteophytes, thickened yellow ligament, and peridural fibrosis were the pathomorphologic substrate of stenosis. Fibrous changes were detected intrasurgically in all cases. Peridural fibrosis never was a single cause of neurovascular compression but always was combined with other stenosing factors. Treatment results were better in patients who underwent decompressive-stabilizing surgery. Repeated recurrences of pain syndrome occurred in 9.8 % of cases after surgical decompression and in 1.4 % after decompressive-stabilizing surgery. Conclusion. Decompressive-stabilizing surgery with posterior interbody fusion is a pathogenetically reasonable and technically adequate surgical treatment of pain syndrome recurrence after the removal lumbar disc hernia. Key Words: recurrence, intervertebral disc hernia, degenerative stenosis, surgical treatment.

* Simonovich AE, Baikalov AA. [Surgical Treatment of Pain Syndrome Recurrence after Removal of Lumbar Intervertebral Disc Hernia]. Hirurgia pozvonocnika. 2005;(3):87–92. In Russian. 1 DEGENERATIVE DISEASES OF THE SPINE

Hirurgia pozvonocnika (Spine Surgery)

A.E. Simonovich, A.A. Baikalov. Surgical Treatment of Pain Syndrome Recurrence after Removal of Lumbar Intervertebral Disc Hernia

Invertebral disc herniation is the most frequent reason for compression of spinal cord roots; hernia removal surgeries are the most common type of surgical interventions in patients with degenerative spine lesions [2]. However, despite fairly good discectomy results, the problem of recurrences of pain and neurological syndromes after these surgeries remains rather urgent. Pain syndrome recurrences can be caused by herniation of an operated or a neighboring disc, by various forms of degenerative stenosis of the spinal canal, by peridural fibrosis, or by segmental instability [4, 6, 7]. The frequency rate of pain syndrome recurrence after various types of surgical interventions performed in patients with osteochondrosis is 15 to 50 % [1], while that of reoperations after discectomy, depending on a certain surgical procedure used, may reach 15 % [3, 5, 8, 9]. The objective of this study was to determine the optimal pathogenetically reasonable surgical techniques for pain syndrome recurrence after the removal of hernia of lumbar intervertebral discs.

(7.9 %). The development of recurrences within the period up to one year after the surgical treatment took place in 47.7 %; within 1–5 years, in 44.3 %; and over 5 years, in 8 % of cases. Reoperated patients included 102 males and 74 females aged 25–72 years (Table 1). The indications for reoperations after the removal of herniated lumbar intervertebral discs were as follows: – root and neurogenic pains caused by recurrent hernia of an intervertebral disc or degenerative stenosis of the spinal canal in the absence of effects of conservative therapy; – stable pain syndrome that is caused by segmental instability and is resistant to conservative therapy. The diagnostic complex included the general clinical, anamnestic, and neurological examination; survey and functional radiography of the lumbar spine; MG with Omnipaque in some cases; CT, MRI, and HCT, which were performed with an intravenous or subarachnoidal contrast agent when required. The planning of the level of surgical intervention and its type was based on the principle of clinico-morpho-

Material and Methods The retrospective study included 176 patients who underwent surgical treatment for pain syndrome recurrence emerged after the removal of hernia of lumbar intervertebral discs. The original surgeries were performed in medical institutions of Novosibirsk and other cities over the period between 1991 and 2004; reoperations were carried out at the Neuroorthopaedics Department of the Novosibirsk Research Institute of Traumatology and Orthopaedics in 1992–2004. Interlaminectomy with or without partial resection of articular processes and arch edges was performed in 160 cases; hemilaminectomy, in 15 cases; and laminectomy, in one case. The original surgeries were performed at the following levels: L4–L5 (51 %), L5–S1 (36.4 %), L3–L4 (3.4 %), L3–L4, L4–L5 (1.1 %), L4–L5, L5–S1

Table 1 Sex and age distribution of patients with pain syndrome recurrence

Sex

Number

Age distribution of patients, n (%)

of patients 25–30 years 31–40 years 41–50 years 51–60 years 61–70 years >70 years

Male

102

3 (2.94)

22 (21.57)

49 (48.04)

24 (23.53)

4 (3.92)

0

Female

74

3 (4.05)

23 (31.08)

26 (35.14)

19 (25.67)

2 (2.70)

1 (1.36)

2 DEGENERATIVE DISEASES OF THE SPINE

Hirurgia pozvonocnika (Spine Surgery)

A.E. Simonovich, A.A. Baikalov. Surgical Treatment of Pain Syndrome Recurrence after Removal of Lumbar Intervertebral Disc Hernia

logical conformity, according to which the purpose of a surgery was to eliminate pathomorphological substrate of the developed clinical symptoms. Repeated surgical interventions were decompressive (group 1) and decompressive-stabilizing (group 2). In both groups, the reasons for pain syndrome recurrence after the herniated intervertebral disc were hernia recurrences, various forms of degenerative stenosis of the spinal cord, inadequate decompression of the spinal cord roots, and spinal disc herniation at another level (Table 2). Table 3 shows the types of surgical interventions performed in patients with pain syndrome recurrence. Anterior or posterior interbody fusion with grafts made of porous titanium nickelide or INTERFIX cages combined with transpedicular fixation or without it, as well

Table 3 Surgical interventions performed in patients with pain syndrome recurrence

Types of surgical interventions

Number of patients

Group 1 Microdiscectomy combined with meningoradiculosis

46

Microdiscectomy

16

Meningoradiculosis

2

Osteophyte resection

8

Group 2 Anterior interbody fusion

2

Table 2

Decompression combined with posterior interbody fusion

77

Reasons for pain syndrome recurrence after the removal of intervertebral disc hernia

Decompression combined with posterior interbody fusion and transpedicular fixation

11

Decompression combined with DYNESYS fixation

14

Reasons for pain syndrome recurrence

Observations in groups, n (%) 1

2

37 (51.4)

56 (53.8)

2 (2.8)

15 (14.4)

14 (19.4)

24 (23.1)

Inadequate decompression

6 (8.3)

9 (8.7)

Hernia of a disc at an adjacent level

2 (2.8)

0

Hernia of a disc at an adjacent level combined with stenosis

4 (5.6)

0

Wrong-level surgery

6 (8.3)

0

Acute epidural hematoma

1 (1.4)

0

Recurrent herniation of an operated disc Recurrent herniation of an operated disc combined with stenosis Degenerative stenosis

as dynamic fixation using DYNESYS instrumentation were carried out in order to stabilize spinal segments. The results of surgical treatment for pain syndrome recurrence were studied during the follow-up period of 3–24 months after the surgery. The dynamics of the neurological status and pain syndrome intensity were assessed using the five-point visual-analog scale (VAS) and the Oswestry index. Results and Discussion Recurrent herniae of the operated disc (52.8 %) or their combination with degenerative stenosis (9.7 %) is the most frequent cause of pain syndrome recurrence. 3

DEGENERATIVE DISEASES OF THE SPINE

Hirurgia pozvonocnika (Spine Surgery)

A.E. Simonovich, A.A. Baikalov. Surgical Treatment of Pain Syndrome Recurrence after Removal of Lumbar Intervertebral Disc Hernia

The role of degenerative spinal stenosis in the emergence of pain syndrome recurrence after discectomy should not be underestimated. Various isolated forms of degenerate stenosis caused the recurrence in 21.6 % of cases. The reasons for pain syndrome recurrence were disc herniation at other level (3.4 % of cases) and inadequate compression of the spinal cord roots, wrong-level spine surgery, and postoperative epidural hematoma (12.5 % of cases). Recurrent herniation of the operated disc more frequently caused pain syndrome recurrence during the first two years after the surgery: after 6–12 months in 45.2 % of cases, and after 12–24 months, in 22.5 % of cases. Degenerative stenosis of the spinal canal, both in its isolated form and combined with the herniation of the operated disc, occurred more frequently during the later follow-up period: 1–10 years after the original surgery (Table 4).

Hypertrophic articular processes, vertebral arches, osteophytes of vertebral bodies and articular processes, thickened yellow ligament, and peridural fibrosis were the pathomorphologic substrate of stenosis. In some cases, degenerative stenosis had lateral localization as a result of hypertrophy of the inferior articular processes or the presence of osteophytes. It should be mentioned that peridural cicatricial-commissural changes in the area of the preceding surgery were detected intrasurgically in almost all observations. The prevalence and intensity of these changes depended on the invasiveness and the prescription of the original surgery. However, peridural fibrosis was the only reason for the compression of neurovascular formations of the spinal canal in none of observations; it was always combined with other stenosing factors or intervertebral disc hernia. The independent role of peridural fibrosis in pathogenesis of vertebrogenic compression syndromes is prob-

Table 4 Causes of pain syndrome recurrence during different follow-up periods after a surgery

Causes of pain syndrome

Number

Distribution of patients over the time when the recurrence emerged, n (%)

of patients

10 years

Hernia recurrence

93

1 (1.1)

9 (9.7)

42 (45.2)

21 (22.5)

11(11.8)

8 (8.6)

1 (1.1)

Hernia recurrence combined with stenosis of the spinal canal

17

0

0

3 (17.6)

10 (58.9)

4 (23.5)

0

0

Degenerative stenosis of the spinal canal

38

0

0

2 (5.3)

12 (31.6)

10 (26.3)

11 (28.9)

3 (7.9)

Hernia of a disc at another level

6

0

0

2 (33.3)

3 (50.0)

1 (16.7)

0

0

Wrong-level surgery

6

6 (100.0)

0

0

0

0

0

0

Inadequate decompression

15

8 (53.3)

7 (46.7)

0

0

0

0

0

Epidural hematoma

1

1 (100.0)

0

0

0

0

0

0

4 DEGENERATIVE DISEASES OF THE SPINE

Hirurgia pozvonocnika (Spine Surgery)

A.E. Simonovich, A.A. Baikalov. Surgical Treatment of Pain Syndrome Recurrence after Removal of Lumbar Intervertebral Disc Hernia

ably not extremely significant. However, the presence of cicatricial tissues limits the reserve peridural space, while spinal cord roots are attached to the spinal canal walls due to the commissural process. Under these conditions, any spine motions (in particular, in case of instability), may cause tension and deformity of the spinal canal roots; while herniae or osteophytes result in severe manifestations of the spinal nerve root compression syndrome. When performing reoperations, decompression of neurovascular formations of the spinal cord is a challenging task. The reason for that is the presence of cicatricial alterations in the epidural space and frequent combination of recurrent hernia with stenosis of the spinal cord. These circumstances typically impose the demand for extensive decompression, which involves meningolysis and mobilization of spinal cord roots, resection of articular processes and vertebral arches, osteophyte removal, and foraminotomy in some cases. When performing stabilization of spinal segments (group 2), the preference was given to the posterior interbody fusion or posterior interbody fusion combined with transpedicular fixation. Interbody fusion performed through the posterior approach most naturally matched the decompressive surgical intervention and was its logical end. It should be mentioned that laminectomy involving the removal of spinous and articular processes (provided that there are no indications for extensive decompression) is not a requisite for the performance of posterior interbody fusion. Based on our previous experience, we believe that bilateral interlaminectomy involving sparing resection of the arch edges and inferior articular processes of the above vertebra is sufficient for conducting this surgery. Combined with transpedicular fixation, posterior interbody fusion can be performed using a single graft incorporated into the interbody space in an oblique direction through an extended interlaminar approach at the side of decompressive intervention.

The intensity dynamics of the pain syndrome was assessed according to the VAS in patients with pain syndrome recurrence after the decompressive and decompressive-stabilizing surgeries had been performed. In patients who underwent decompressive-stabilizing surgeries, the mean indices of pain intensity 6–12 and 12–24 month after the surgery were lower as compared to those who underwent decompression without stabilization (Table 5).

Table 5 Dynamics of pain syndrome intensity in operated patients (М ± SD)

Type

Number

of surgery

of observations

Pain intensity (VAS), score before

after

after

after

surgery

3 months

10–12 months

12–24 months

back surgeries I

72

3.0 ± 1.2

1.6 ± 0.8

1.8 ± 0.7

1.7 ± 0.9

II

90

3.8 ± 1.0

1.5 ± 0.8

1.4 ± 0.9

1.3 ± 0.9

III

14

4.4 ± 0.7

0.8 ± 0.9

0.2 ± 0.5

0.3 ± 0.6

I

72

4.4 ± 0.7

1.6 ± 0.9

1.1 ± 0.9

0.9 ± 0.9

II

90

4.3 ± 0.7

1.2 ± 0.9

0.7 ± 0.8

0.6 ± 0.8

III

14

4.1 ± 0.7

1.1 ± 0.8

0.2 ± 0.4

0.2 ± 0.4

leg surgeries

I – decompressive surgeries; II – decompressive-stabilizing surgeries involving interbody fusion with or without transpedicular fixation; III – decompressive-stabilizing surgeries combined with dynamic fixation using DYNESYS instrumentation.

5 DEGENERATIVE DISEASES OF THE SPINE

Hirurgia pozvonocnika (Spine Surgery)

A.E. Simonovich, A.A. Baikalov. Surgical Treatment of Pain Syndrome Recurrence after Removal of Lumbar Intervertebral Disc Hernia

The limitations of functional activity assessed according to the Oswestry index after the decompressive-stabilizing interventions were also less pronounced (Table 6). It should be mentioned that the best VAS score and Oswestry indices were obtained for patients who underwent dynamic spine fixation using DYNESYS instrumentation. The integrated assessment of the results of decompressive (group 1) and decompressive-stabilizing (group 2) surgical interventions performed in patients with pain syndrome recurrences that emerged after the herniated intervertebral discs had been removed. The criteria for the assessment of treatment results were as follows: – good results: complete or almost complete returning to the previous (prior to the onset or last recurrence of the disease) level of social and physical activ-

ity; intense physical activity can be limited; the Oswestry index is below 20 % (minimal disturbances in functional activity); – satisfactory results: everyday and social activity recovered not completely; moderate amount of physical activity is possible only; the Oswestry index is 20–40 % (moderate disturbance of functional activity); – unsatisfactory results: surgery had no effect or caused deterioration. The best results were observed in patients who underwent decompressivestabilizing surgeries (Table 7). Continued natural spine degeneration frequently results in the spinal canal stenosis; segmental instability significantly contributes to this process as well. In turn, extensive posterior spinal decompression can cause instability or deteriorate the already existing one. Hence, decompressive surgeries eliminate the compressing substrate and can eventually facilitate the further development of degenerative changes to the spine. Pain syndrome recurrence that required the third surgical intervention to be carried out emerged in 10 cases (9.8 %) after decompressive surgeries and in one case (1.4 %) after decompressive-stabilizing surgery (poste-

Table 6 Dynamics of the Oswestry index in operated patients (М ± SD)

Type

Number

of surgery

of observations

Oswestry index, % before

after

after

after

surgery

3 months

10–12 months

12–24 months

Table 7 Results of surgical treatment for postoperative recurrence of discogenic pain syndromes

I

72

73.8 ± 11.1

25.5 ± 19.6

24.2 ± 8.7

25.0 ± 19.2

II

90

72.2 ± 10.9

20.8 ± 17.5

19.8 ± 15.7

20.6 ± 16.2

III

14

71.2 ± 14.1

19.8 ± 9.8

18.1 ± 9.2

16.4 ± 10.9

Surgery type

Number of patients

Treatment results, n (%) good

satisfactory

unsatisfactory

(р = 0.05)

(р = 0.73)

(р < 0.01)

I – decompressive surgeries; II – decompressive-stabilizing surgeries involving interbody fusion with or without transpedicular fixation;

Decompressive

72

48 (66.7)

9 (12.4)

15 (20.9)

III – decompressive-stabilizing surgeries combined with dynamic fixation using DYNESYS instrumentation.

Decompressive-stabilizing

104

84 (80.8)

10 (9.6)

10 (9.6)

6 DEGENERATIVE DISEASES OF THE SPINE

Hirurgia pozvonocnika (Spine Surgery)

A.E. Simonovich, A.A. Baikalov. Surgical Treatment of Pain Syndrome Recurrence after Removal of Lumbar Intervertebral Disc Hernia

rior interbody fusion). The reasons for pain syndrome recurrence after decompressing surgeries included hernia of an operated disc (4 cases), degenerative stenosis (5 cases), and herniation of a disc at an adjacent level (1 case). The time when recurrent disc herniation was observed varied from 12 to 25 months after the reoperations. Migration of a graft having an insufficient diameter towards the spinal canal was the reason for pain syndrome recurrence after performing a decompression and posterior interbody fusion. The graft was replaced with the larger one, corresponding to the height of the interbody foramen. Negative results and pain syndrome recurrence were detected in neither one of 14 cases of dynamic spine fixation using DYNESYS instrumentation.

spinal canal, and herniation of the adjacent intervertebral discs (less frequently). Peridural fibrosis is an aggravating factor. Recurrence of herniation of the operated disc and degenerative stenosis of the spinal canal are the most common reasons for the recurrence of pain syndrome requiring surgical treatment within the follow-up period up to one year and during the later follow-up periods, respectively. The frequent demand for conducting extensive decompression during reoperations (in particular, in patients with stenosis of the spinal canal) makes it necessary to stabilize the damaged spinal segment. Decompressive-stabilizing surgeries in patients with pain syndrome recurrence are pathogenetically reasonable, since they allow one to perform both the full-fledged extensive decompression and to stabilize the damaged spinal segment. Decompressive-stabilizing surgeries involving posterior interbody fusion (with or without transpedicular fixation) are adequate situations, when pain syndrome recurrence after lumbar discectomy is caused by hernia recurrence or degenerative stenosis of the spinal canal. There is a technical feasibility of performing any decompressive intervention for spinal canal, which ends in spine stabilization through the same approach.

Conclusions Pain syndrome recurrence after the removal of hernia of the lumbar intervertebral discs emerges after continued spine degeneration. Among the natural reasons for the recurrence are recurrent herniation of operated discs (including its combination with degenerative stenosis of the spinal canal), degenerative stenosis of the References

3. Hu RW, Jaglal S, Axcell T, et al. A population-based study of reoperations after back

1. Gel’fenbein MS. [International Congress Devoted to Therapy of Chronic Pain Syndrome

surgery. Spine. 1997;22:2265–2270.

after Thoracic Spine Surgeries “Pain Management’98” (Failed Back Surgery Syndrome)].

4. Kayaoglu CR, Calikoglu C, Binler S. [Re-operation after lumbar disc surgery: results

Neurosurgery. 2000;(1–2):65. In Russian. 2. Krylov VV. [Current state of neurosurgical management in patients with spine and spinal

in 85 cases]. J Int Med Res. 2003;31:318–323. 5. Keskimaki I, Seitsalo S, Osterman H, et al. Reoperations after lumbar disc surgery:

cord injuries and disorders in Moscow (based on the data of neurosurgical hospitals, Public

a population-based study of regional and interspecialty variations. Spine. 2000;25:

Health Committee in 1997–1999)]. Neurosurgery. 2001;(1):60–66. In Russian.

1500–1508. 7 DEGENERATIVE DISEASES OF THE SPINE

Hirurgia pozvonocnika (Spine Surgery)

A.E. Simonovich, A.A. Baikalov. Surgical Treatment of Pain Syndrome Recurrence after Removal of Lumbar Intervertebral Disc Hernia

6. Kloc W, Imielinski BL, Wasilewski W, et al. [Repeated operations for recurrent lumbar disc herniations]. Neurol Neurochir Pol. 1999;(33):1367–1372. In Polish. 7. Schlarb H, Wender H. Re-operation perfomed on patients suffering from an intervertebral disc prolapsed in the lumbar region. Adv Neurosurg. 1977;4:32–35.

Corresponding author:

8. Silvers HR, Lewis PJ, Asch HL, et al. Lumbar diskectomy for recurrent disk herniation.

Alexander Simonovich

J Spinal Disord. 1994;(7):408–419.

ul. Frunze 17, Novosibirsk, 630091 Russia,

9. Weir BK, Jacops GA. [Reoperation rate following lumbar discectomy. An analysis

Novosibirsk Research Institute of Traumatology and Orthopaedics,

of 662 lumbar discectomies]. Spine. 1980;5:366–370.

[email protected]

Aleksandr Evgenyevich Simonovich, MD, DMSc, Prof.; Andrey Aleksandrovich Baikalov, MD, PhD, Novosibirsk Institute of Traumatology and Orthopaedics, Novosibirsk, Russia. 8 DEGENERATIVE DISEASES OF THE SPINE