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World Neurosurgery:X 22(2024)100275Available online 9 February 20242590-1397/2024 The Authors.Published by Elsevier Inc.This is an open access article under the CC BY-NC-ND license(http:/creativecommons.org/licenses/by-nc-nd/4.0/).Lumbar disc herniation:Prevention and treatment of recurrence:WFNS spine committee recommendations Mehmet Zilelia,*,Joachim Oertelb,Salman Sharifc,Corinna Zygourakisd aDepartment of Neurosurgery,Sanko University Faculty of Medicine,Gaziantep,Turkey bDepartment of Neurosurgery,Saarland University Medical Centre,Homburg,Germany cDepartment of Neurosurgery,Liaqat Medical School,Karachi,Pakistan dDepartment of Neurosurgery,Stanford University School of Medicine,Stanford,CA,USA A R T I C L E I N F O Keywords:Lumbar disc herniation Recurrent herniation Prevention of recurrent herniation Risk Factors for recurrent herniation Minimally invasive discectomy A B S T R A C T Objective:This review aims to formulate the most current evidence-based recommendations on the epidemiology,prevention,and treatment of recurrent lumbar disc herniation(LDH).Methods:We performed a systematic literature search in PubMed,Medline,and Google Scholar databases from 2012 to 2022 using the keywords“lumbar disc recurrence.”Screening criteria resulted in 57 papers,which were summarized and presented at two international consensus meetings of the World Federation of Neurosurgical Societies(WFNS)Spine Committee.The 57 papers covered the following topics:(1)Definition and incidence of recurrence after lumbar disc surgery;(2)Prediction of recurrence before primary surgery;(3)Prevention of recurrence by surgical measures;(4)Prevention of recurrence by postoperative measures;(5)Treatment options for recurrent disc herniation;(6)The outcomes of recurrent disc herniation surgery.We utilized the Delphi method and voted on eight final consensus statements.Results and conclusion:Recurrence after disc herniation surgery may be considered a surgical complication,its incidence is approximately 5%and is different from overall re-operation incidence.There are multiple risk factors predicting LDH recurrence,including smoking,younger age,male gender,obesity,diabetes,disc degeneration,and presence of lumbosacral transitional vertebrae.The level of lumbar discectomy surgery and the amount of disc material removed do not correlate with recurrence rate.Minimally invasive discectomies may have higher recurrence rates,especially during the surgeons learning period.However,the experience of the surgeon is not related to recurrence.High-quality studies are needed to determine if activity restriction,weight loss,smoking cessation,and muscle-strengthening exercises after primary surgery can help prevent recurrence of LDH.The best treatment option for recurrent disc herniation is still being discussed.While complications of minimally invasive techniques may be lower than open discectomy,outcomes are similar.Fusion should only be considered when spinal instability and/or spinal deformity are present.Clinical outcomes and patient satisfaction after recurrent disc herniation surgery are inferior to those after initial discectomy.1.Introduction Recurrence after initial discectomy for lumbar disc herniation(LDH)occurs frequently and sometimes may even be considered inevitable.A better understanding of the risk factors for disc recurrence may allow us to develop preventative measures to reduce the incidence of recurrent LDH.The goal of this review is to produce up-to-date,evidence-based recommendations from two international consensus meetings of the World Federation of Neurosurgical Societies(WFNS)Spine Committee on the risk factors for LDH recurrence,surgical and postoperative techniques to avoid recurrence after primary surgery,and the best management of LDH recurrence.Our recommendations are developed for practicing spine surgeons worldwide,with a particular emphasis on those in low and middle-income countries.2.Methods We performed a systematic literature search in PubMed,Medline,*Corresponding author.E-mail address:(M.Zileli).Contents lists available at ScienceDirect World Neurosurgery:X journal homepage: https:/doi.org/10.1016/j.wnsx.2024.100275 Received 28 July 2023;Accepted 1 February 2024 World Neurosurgery:X 22(2024)1002752and Google Scholar databases from 2012 to 2022 using the keywords“lumbar disc recurrence.Pubmed had 1667 initial results,while Med-line had 688 and Google scholar had 16,800 initial results.We applied standardized inclusion/exclusion criteria to narrow our search to 57 final papers.Inclusion criteria included papers in the English language with full text available,prospective,or retrospective clinical trials,meta-analyses,randomized controlled trials,and systematic reviews.Non-human studies and case reports with 50 patients were excluded.Fig.1 shows our search methodology.Papers covered the following topics:(1)Definition and incidence of recurrence after lumbar disc surgery;(2)Prediction of recurrence before primary surgery;(3)Pre-vention of recurrence by surgical measures;(4)Prevention of recurrence by postoperative measures;(5)Treatment options for recurrent disc herniation;(6)The outcomes of recurrent disc herniation surgery.We collected and organized these papers to answer the following questions.1.What is the definition and incidence of LDH recurrence after lumbar disc surgery?2.Can we predict recurrence before the initial surgery?3.Can recurrence be prevented by surgical measures such as minimally invasive discectomy or open discectomy,aggressive discectomy,and/or ligament repair techniques?4.Can recurrence be prevented by postoperative measures such as ac-tivity restriction,smoking cessation,weight loss,special exercises,and/or muscle strengthening?5.What is the best treatment for recurrent disc herniation:open dis-cectomy,microdiscectomy,endoscopic discectomy,or fusion?6.Are recurrent disc herniation outcomes the same as primary disc surgery?Table 1 contains a summary of the reviewed papers,divided into“Incidence of recurrence”(3 papers),“Prediction of recurrence”(15 papers),“Value of annular closure devices”(3 papers),“Comparison of surgical techniques”(23 papers),“Value of fusion surgery“(8 papers),and“Outcomes of recurrent disc surgery(8 papers).Search results were presented and discussed at two international consensus meetings,the first in Karachi,Pakistan,in May 2022,and the second in Istanbul,Turkey,in September 2022.Ten members of the World Federation of Neurosurgical Societies(WFNS)Spine Committee who are world experts in spine care discussed and voted anonymously on the statements.We used the Delphi method to generate a consensus:participants graded each statement using a Likert-type scale from 1 to 5(1=strongly agree,2=agree,3=somewhat agree,4=disagree,5=strongly disagree).Results are presented as a percentage of respondents who scored each item as 1,2,or 3(agreement)or as 4 or 5(disagreement).Positive or negative consensus was achieved when the sum for agree-ment or disagreement,respectively,was 66%(see Table 2).3.Results and discussion 3.1.Definition and incidence of recurrence after lumbar disc surgery The definition of a recurrent lumbar disc herniation is a new disc herniation at the index level and on the same side as the initial surgery.Although some papers accept contralateral disc herniation at the same level as recurrence,such a definition causes confusion.A retrospective study1 of 5626 Japanese patients undergoing initial disc excision be-tween 1988 and 2007 reported 205 LDH recurrences.Of these,only 101 cases(1.8%)were real LDH recurrences,in that they were at the same level and on the same side as the primary herniation.Studies in literature report varying recurrence rates for LDH,from 0.5%up to 21%.17 Same-side and same-level disk recurrences may vary from 3.8 to 7.4%.1 A systematic review published in 2016 and including 30 studies reports a same-level,same-side LDH recurrene rate Abbreviations WFNS World Federation of Neurosurgical Societies MRI Magnetic resonance imaging CT Computed tomography PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analyses LDH Lumbar disc herniation DHI Disc height index ROM Range of motion Fig.1.Prisma Chart of the review process.M.Zileli et al.World Neurosurgery:X 22(2024)1002753Table 1 List of analysed papers.No Study Type of Study Evidence Level Objective Number of patients Conclusions Incidence of recurrence papersrowhead 1 Aizawa et al1 2012 Retrospective 3 Epidemiology in Japan 5626/192 reoperation Reoperation rate of real recurrent herniations gradually increased from 0.5%at 1 year after primary surgery to 2.8%at 15.7 years.2 Yoshihara et al8 2016 Systematic review 2 Epidemiology trends and outcomes of revision surgery for real rLDH 30 studies The incidence of revision surgery,specifically for real-rLDH,lies between 1.4%and 11.4%.The complication rate is reported between 0%and 34.6%,with dural tear being the most common complication.3 Fritzel et al62 2015 Retrospective 3 Swedish Spine Registry Swespine 13,562 patients/257 reoperation First year recurrence 2%.Patients undergoing repeated surgery were less satisfied Prediction of recurrence papersrowhead 4 Azimi et al4 2015 Retrospective 3 Prediction of recurrence 402/35 reoperation Artificial Neural Network can be used to predict the diagnostic statues of recurrent disc herniation 5 Jia et al16 2021 Retrospective 3 To develop and validate a nomogram useful in predicting rLDH.352 patients/32 recurrence The course of disease,Pfirrmann grade,Modic change,migration grade are risk factors for recurrence.6 Hao et al15 2020 Retrospective 3 Relationship between Modic changes and rLDH 102 patients Recurrent lumbar disc herniation occurs when Modic changes or herniated cartilage are present.7 Huang et al12 2016 Metaanalysis 2 Risk factors for rLDH 17 studies smoking,disc protrusion,and diabetes are predictors for rLDH.8 Kim et al17 2015 Retrospective 3 Risk factors for recurrence of L5S1 level.39 recurrences at L5-S1 Moderate disk degeneration,a large sROM,a small L5 vertebral transverse process,and a low iliac crest height index are biomechanical risk factors of rLDH in L5S1.Being male and having a large annular defect are also risk factors.9 Shin et al22 2018 Retrospective 3 To investigate risk factors for rLDH after discectomy including lumbosacral transitional vertebrae 119 patients/21(17.6%)recurrence Lumbosacral transitional vertebrae and a hypermobile disc in flexion-extension radiography are risk factors for rLDH.10 Siccoli et al9 2021 Retrospective 2 To investigate risk factors for rLDH especially the effect of age on recurrence in a prospective registry 3013 patients/166(5.5%)reoperation Younger patients do not have a higher reoperation probability.However,older patients tend to experience recurrent LDH significantly earlier after the index surgery.11 Yao et al26 2016 Retrospective 3 To search the risk factors of recurrence after MED 111 patients Age(50 years old),obesity(body mass index 25),the treatment period,modic change,nonmigrated herniation,and central herniation are potential risk factors for recurrence.12 Yin et al14 2018 Meta-Analysis 2 To search the epidemiological prevalence of recurrent herniation in patients following PELD and to analyze the potentially related risk factors.63 studies PELD is associated with 3.6%recurrence rate.It usually occurred within 6 months postoperatively.Older age(50 years),obesity(BMI 25),upper lumbar disc and central disc herniation are risk factors for recurrence after PELD.Different surgical approaches(PETD or PEID),lateral discs,migrated discs and foraminoplasty did not affect the incidence.13 Li et al21 2020 Retrospective 3 To evaluate the association between facet joint parameters(facet orientation and facet tropism)and rLDH 246 patients With the decrease of facet orientation,the risk of rLDH increases continuously.Facet joint parameters may play a more important role in the pathogenesis of rLDH 14 Yaman et al19 2017 Retrospective 3 To determine the risk factors for rLDH.126 patients Risk factors for recurrence are higher disc height,higher body mass index,Modic changes.15 Li et al13 2018 Retrospective 3 To investigate the clinical features and the risk factors for rLDH in China.321 patients Gender,age,current smoking,BMI,occupational lifting,trauma,surgical procedures,herniation type,disc height index,facet orientation,facet tropism,and sROM are risk factors for rLDH.16 Yu et al18 2020 Retrospective 3 To investigate the risk factors with the recurrence of L5S1 disc herniation after PETD.484 patients The recurrence of L5S1 disc herniation following PETD was associated with increased age and BMI,more severe disc degeneration,increased sagittal range of motion,increased lumbar lordosis,and sacral slope.(continued on next page)M.Zileli et al.World Neurosurgery:X 22(2024)1002754Table 1(continued)17 Chang et al23 2016 Retrospective 3 To investigate the risk of recurrence of LDH in patients with scoliosis who underwent microdiscectomy.58 patients/6(10.3%)reoperations The recurrence rate is significantly higher among the scoliosis group than the nonscoliosis group(33.3%vs 2.3%).18 Ellenbogen et al33 2014 Retrospective 3 Surgeon grade and/or disc space lavage has an impact in reducing the re-operation rate 971 patients/52 recurrence Surgeon grade and intervertebral disc lavage have not been found conclusively to be factors in the rate of recurrence.There is a possible trend towards intervertebral disc lavage reducing the rate of recurrence Value of annular closure devicesrowhead 19 Choy et al38 2018 Metaanalysis 2 Outcomes and complications of annular closure device for disc herniation.4 trials Use of Barricaid and Anulex devices are beneficial for short term outcomes to reduce symptomatic disc reherniation 20 van den Brink et al36 2019 Randomized multicenter trial 1 Is implantation of a bone-anchored annular closure device following lumbar discectomy reducing the risk of recurrent herniation.554 patients Among patients with large annular defects following limited lumbar discectomy,additional implantation with a bone anchored device lowered the risk of symptomatic reherniation and reoperation over 1 year follow-up.Serious adverse events occurred less frequently in the ACD group 21 Ledic et al37 2015 Prospective single-arm studies 2 To assess the benefits of disk reherniation reduction and disk height maintenance in limited discectomy combined with the implantation of the annular closure device.75 patients Limited lumbar diskectomy combined with the use of an annular closure device provided very low rates of disk reherniation and exhibited excellent disk height maintenance Comparison of surgical techniques for recurrent disc herniationrowhead 22 Chang et al24 2014 Metaanalysis 2 Comparison of minimally invasive discectomy with standard discectomy 16 trials/2139 patients 7 studies reported a higher recurrence with minimally invasive discectomy.23 G oker
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