Waddell G, Kummel E G, Lotto W N, Graham J D, Hall H, McCulloch J A
J Bone Joint Surg Am. 1979 Mar;61(2):201-7.
One hundred and seventy-nine of the compensation patients in this study who had one low-back operation had to have repeat back surgery. One hundred and three Workmen's Compensation Board patients who were reoperated on by a number of surgeons in the Toronto area were independently reviewed with one to two years of follow-up. Many had residual back pain, limited lumbar movement, presisting nerve-root deficits, and psychological disturbances. Forty per cent of the second operations were successful. Subsequent operations yielded progressively poorer results and made more patients worse than better. Operations were frequently undertaken without clear indications or evidence of correctable organic lesions. The results of repeat operations were better when the preceding operation had given more than six months' relief, when sciatica overshadowed back pain, and when a definite recurrent disc herniation was found. Scarring and neurolysis, previous infection, repair of a pseudarthrosis, and adverse psychological factors precluded a good result. Careful patient selection based on total evaluation of the disability including psychological assessment, accurate localization of the lesion by detailed investigation, and, most important, a logical sequence of decisions based on clear, objective criteria are prerequisites for this complex and demanding surgery. Caution and restraint are required when contemplating repeat back surgery.
本研究中179例接受过一次腰椎手术的工伤赔偿患者不得不再次接受背部手术。103例由多伦多地区多位外科医生再次手术的工人赔偿委员会患者在术后一到两年接受了独立评估。许多患者仍有残留背痛、腰椎活动受限、持续神经根功能缺损以及心理障碍。二次手术成功率为40%。后续手术效果逐渐变差，使更多患者病情恶化而非好转。手术常常在没有明确指征或无可纠正器质性病变证据的情况下进行。如果前一次手术缓解期超过6个月、坐骨神经痛比背痛更严重以及发现明确的复发性椎间盘突出时，再次手术的效果更好。瘢痕形成与神经松解、既往感染、假关节修复以及不良心理因素均不利于取得良好效果。基于对残疾的全面评估（包括心理评估）进行仔细的患者选择，通过详细检查准确确定病变部位，最重要的是基于明确、客观标准做出合理的决策顺序，这些都是这种复杂且要求高的手术的前提条件。考虑再次进行背部手术时需要谨慎和克制。
