Elsevier

World Neurosurgery

Volume 109, January 2018, Pages e761-e769
World Neurosurgery

Original Article
Percutaneous Endoscopic Lumbar Reoperation for Recurrent Sciatica Symptoms: A Retrospective Analysis of Outcomes and Prognostic Factors in 94 Patients

https://doi.org/10.1016/j.wneu.2017.10.077Get rights and content

Background

Recurrent symptoms of sciatica after previous surgical intervention is a relatively common and troublesome clinical problem. Percutaneous endoscopic lumbar decompression has been proved to be an effective method for recurrent lumbar disc herniation. However, the prognostic factors and outcomes of percutaneous endoscopic lumbar reoperation (PELR) for recurrent sciatica symptoms were still unknown. The purpose of this study was to evaluate the outcomes and prognostic factors of patients who underwent PELR for recurrent sciatica symptoms.

Methods

From 2009 to 2015, 94 patients who underwent PELR for recurrent sciatica symptoms were enrolled. The primary surgeries include transforaminal lumbar interbody fusion (n = 16), microendoscopic discectomy (n = 31), percutaneous endoscopic lumbar decompression (PELD, n = 17), and open discectomy (n = 30). The mean follow-up period was 36 months, and 86 (91.5%) patients had obtained at least 24 months' follow-up.

Results

Of the 94 patients with adequate follow-up, 51 (54.3%) exhibited excellent improvement, 23 (24.5%) had good improvement, and 7 (7.4%) had fair improvement according to modified Macnab criteria. The average re-recurrence rate was 9.6%, with no difference among the different primary surgery groups (PELD, 3/17; microendoscopic discectomy, 2/31; open discectomy, 3/30; transforaminal lumbar interbody fusion, 1/16). There was a trend toward greater rates of symptom recurrence in the primary group of PELD who underwent percutaneous endoscopic lumbar reoperation compared with other groups, but this did not reach statistical significance (P > 0.05). Multivariate analysis suggested that age, body mass index, and surgeon level was independent prognostic factors. Obesity (hazard ratio 13.98, 95% confidence interval 3.394–57.57; P < 0.001) was the risk factor affecting re-recurrence according to logistic regression analysis.

Conclusions

PELR is a safe and effective treatment for recurrent sciatica symptoms regardless of different primary operation type. Obesity, inferior surgeon level, and patient age older than 40 years were associated with a worse prognosis. Obesity was also a strong and independent predictor of re-recurrence sciatica symptoms after percutaneous endoscopic lumbar decompression.

Introduction

Recurrent disc herniation is the most common cause of lumbar spinal reoperation. Long-term outcomes after primary discectomy are favorable in most cases, whereas the recurrence of sciatica symptoms is still unpreventable.1, 2, 3, 4, 5 Despite improved surgical techniques, reoperation rates range from 2.8% to 24%.6, 7, 8, 9 A repeated discectomy or microendoscopic discectomy (MED) may result in less comparable outcomes compared with the first surgery, and approach-related complications could be another obvious trouble.6, 10 Scar formation, progressive disc degeneration, and reherniation may lead to increased morbidity after traditional posterior reoperation.10, 11, 12, 13, 14 Epidural scarring may lead to an increased risk of injury to the dura or nerves. Although open MED is a standard method for fragmentectomy, further removal of posterior structures, including the facet joint, could increase the risk of segmental instability. The problems related to scar tissue and retraumatization of the posterior structures can be overcome with the percutaneous endoscopic method.6, 10, 13, 14, 15 Therefore, the optimal surgical treatment of recurrent disc herniation should be sufficient decompression with minimization of operation-induced traumatization and complications.

The advantages of percutaneous endoscopic lumbar decompression could be that there is no need to go through the old scar tissue from the posterolateral approach, which also can be performed with the use of local anesthesia.6, 8, 16, 17, 18 Endoscopic techniques have become the standard in many areas because of the advantages they offer intraoperatively and postoperatively. Previous studies have investigated risk factors, such as age, comorbidities, type of discectomy, and disc morphology, that may be predictive of reoperation.2, 6, 9, 19

However, there are few studies regarding the outcomes or prognostic factors of patients with recurrence sciatica symptom who have undergone percutaneous endoscopic lumbar reoperation. We hypothesized that patient, clinical characteristics, surgeon's level of experience, and primary surgical method would be risk factors for reoperation and evaluated the outcome of patients undergoing percutaneous endoscopic reoperation in different primary surgical groups.

Section snippets

Patients

The study was a consecutive retrospective analysis of the data from the XinQiao Hospital Information Registry database and follow-up questionnaire. The procedure was approved by the Ethics Committee of The Third Military Medical University. Written informed consent was obtained from all patients. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of

Patient Characteristics and Clinical Outcomes

Overall, 94 patients (67 male and 27 female) who met the inclusion criteria underwent PELR. At the primary surgery, PELD was performed in 17 patients, MED in 31 patients, open discectomy (OD) in 30 patients, and transforaminal lumbar interbody fusion (TLIF) in 16 patients. The characteristics of different primary surgical groups were compared (Table 1). In TLIF group, the mean age was 59.4 ± 9.8 years, which was older than the other groups. There also was a significant difference among the 4

Discussion

Most reoperations after lumbar disc discectomy presented during the 0–0.5 year and 1–5 year periods after primary surgery.7 Generally, lumbar interbody fusion had been considered as the final intervention for lumbar degenerative diseases, whereas recurrence of sciatica symptoms after the previous surgical intervention is a relatively common and troublesome clinical problem. New radicular pain after surgery for disc herniation-induced sciatica mostly resulted from scar tissue, recurrent

Conclusions

In conclusion, PELR is a safe and effective treatment not only for recurrent disc herniation after limited disc decompression but also as an alternative surgical intervention for recurrent sciatica after TLIF. Body mass index, surgeon level, and patient age were independent risk factors associated with clinical outcome. Consideration of these factors might be helpful in treating patients with definite sciatica symptoms. The relevant use of updated endoscopic approaches may be helpful in

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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