Wera Glenn D, Marcus Randall E, Ghanayem Alexander J, Bohlman Henry H
Department of Orthopaedic Surgery, Case Western Reserve University, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
J Bone Joint Surg Am. 2008 Jan;90(1):10-5. doi: 10.2106/JBJS.F.01569.
Reherniation within the first year following subtotal lumbar discectomy is a rare but noteworthy event. We performed a retrospective, case-controlled study to evaluate the clinical outcomes after early recurrent lumbar disc reherniation.
The records of 1320 patients who had undergone primary subtotal lumbar discectomy were analyzed retrospectively by an independent reviewer. Patients with documented reherniation within twelve months were evaluated with regard to the location of the reherniation, the neurologic status, the rate of reoperation, and the subjective outcome. Patients were evaluated on the basis of a physical examination and a review of medical records. Disc morphology, anular competence, and the presence of free fragments were categorized with use of a modified five-part Carragee classification system. The mean duration of follow-up for this group was 52.6 months. Clinical outcomes were assessed with use of the Oswestry score and the modified criteria of McNab. Twenty-nine historical control patients who had undergone uncomplicated subtotal lumbar discectomy were selected.
We identified fourteen recurrent lumbar disc herniations within one year after the index procedure. All fourteen patients had radicular pain and weakness prior to, and complete relief of radiculopathy after, the index procedure. All reherniations occurred at the same level as the index procedure, but eight occurred in a different direction than the original herniation. All patients underwent reexploration and discectomy, and two underwent single-level posterolateral arthrodesis. Two patients underwent a third procedure. The average Oswestry score at the time of the latest follow-up was 6.4 for the recurrent herniation group, compared with 6.9 for the controls. The outcomes according to the modified McNab criteria were not significantly different between the groups, with the numbers available. The mean duration of follow-up after the second discectomy was 52.6 months.
The rate of early reherniation after subtotal lumbar discectomy is low (1%). It is important to consider the possibility of iatrogenic instability during surgery on the lumbar spine for the treatment of reherniation. Patients who undergo reoperation because of early recurrent lumbar disc herniation can have clinical outcomes comparable with those of patients undergoing an uncomplicated subtotal lumbar discectomy.
腰椎间盘次全切除术后一年内复发是一种罕见但值得关注的情况。我们进行了一项回顾性病例对照研究，以评估早期复发性腰椎间盘突出症再次手术后的临床结果。
由一名独立审阅者对1320例行初次腰椎间盘次全切除术患者的记录进行回顾性分析。对在十二个月内有复发性椎间盘突出记录的患者，就复发位置、神经状态、再次手术率及主观结果进行评估。通过体格检查和病历回顾对患者进行评估。使用改良的五部分卡拉吉（Carragee）分类系统对椎间盘形态、纤维环完整性及游离碎片的存在情况进行分类。该组患者的平均随访时间为52.6个月。使用奥斯威斯（Oswestry）评分和麦克纳布（McNab）改良标准评估临床结果。选取29例接受单纯腰椎间盘次全切除术的历史对照患者。
我们在初次手术后一年内发现14例复发性腰椎间盘突出症。所有14例患者在初次手术前均有神经根性疼痛和无力症状，初次手术后神经根病完全缓解。所有复发均发生在初次手术的同一节段，但8例复发方向与原突出方向不同。所有患者均接受了再次探查和椎间盘切除术，2例接受了单节段后外侧融合术。2例患者接受了第三次手术。复发组在最近一次随访时的平均奥斯威斯评分为6.4，而对照组为6.9。根据麦克纳布改良标准，两组间的结果在可用数据方面无显著差异。第二次椎间盘切除术后的平均随访时间为52.6个月。
腰椎间盘次全切除术后早期复发率较低（1%）。在腰椎手术治疗复发时，考虑医源性不稳定的可能性很重要。因早期复发性腰椎间盘突出症接受再次手术的患者，其临床结果与接受单纯腰椎间盘次全切除术的患者相当。
