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Reoperations after first lumbar disc herniation surgery; a special interest on residives during a 5-year follow-up

Reoperations after first lumbar disc herniation surgery; a special interest on residives during a... Background: The overall rate of operations after recurrent lumbar disc herniation has been shown to be 3–11%. However, little is known about the rate of residives. Thus the aim of this study was to explore the cumulative rates of re-operations and especially residive disc herniations at the same side and level as the primary disc herniation after first lumbar disc herniation surgery and the factors that influence the risk of re- operations over a five year follow-up study. Methods: 166 virgin lumbar disc herniation patients (mean age 42 years, 57% males) were studied. Data on patients' initial disc operations and type and timing of re- operations during the follow-up were collected from patient files. Back and leg pain on visual analog scale and employment status were collected by questionnaires. Results: The cumulative rate of re-operations for lumbar disc herniation was 10.2% (95% Cl 6.0 to 15.1). The rate of residives at initial site was 7.4% (95% Cl 3.7 to 11.3) and rate of lumbar disc herniations at other sites was 3.1% (95% Cl 0.6 to 6.2). The occurrence of residive lumbar disc herniations was evenly distributed across the 5 years. Neither age, gender, preoperative symptoms, physical activity nor employment had effect on the probability of re-operation. Conclusion: Seven percent of the lumbar disc patients had a residive lumbar disc operation within five years of their first operation. No specific factors influencing the risk for re-operation were found. Page 1 of 6 (page number not for citation purposes) BMC Musculoskeletal Disorders 2007, 8:2 http://www.biomedcentral.com/1471-2474/8/2 Background muscle weakness. In some cases also, loss of the patellar Surgery for lumbar disc herniation is effective in the or Achilles reflex, regional sensory loss, and a positive majority of cases. Success rates from 76% to 93 % have straight leg raising test (SLR <60) were present. The diag- been reported [1-8]. Patients who have had one operation nosis of lumbar disc herniation was based on preoperative for lumbar disc herniation have shown to be at 5–12.5% clinical status, and spinal nerve root compression detected risk for further operations (including discectomy, other in magnetic resonance imaging (MRI) or computed tom- type of decompression or fusion) over the follow-ups last- ography (CT) and was finally confirmed during surgery. ing from 1 to 20 years [4,7,9,10]. The overall rate of oper- The patients were operated on using the open mini ations after recurrent lumbar disc herniation has been approach described by Wood & Hanley in 1991 [17]. In shown to be 3–11% [11-14]. However, little is known the surgery, herniated fragment was extracted and thereaf- about the rate of residives at the side and level with the ter, loose material from intervertebral disc space was primary operation. removed. In the current five-year follow-up study we analysed the Before surgery, the subjects completed a questionnaire cumulative rate of re-operations for lumbar disc surgery including items about the duration of preoperative back and especially rate of residive disc herniations after a first and leg pain, intensity of pain (visual analog scale, VAS, lumbar disc operation. The risk factors for repeated sur- scale 0–100 mm), leisure time physical activity, employ- gery were also studied. ment status, and physical loading at work (light, medium, heavy or very heavy work). The patients filled a question- Methods naire also 5 years after the surgery confirming that there Two-hundred and ten patients had surgery for lumbar disc were no re-operations done in other hospitals. Data on herniation in Jyväskylä Central Hospital in the year 1999 the patients' initial disc operations and re-operations dur- (~1/1000 inhabitant of the area). Of this number 173 ing the follow-up were collected from patient files of patients (82%) volunteered for a follow-up study, filled a Jyväskylä Central Hospital. In the analysis re-operations at preoperative questionnaire and were referred for 2 and 12 the same side and level as the primary operation and lum- month post-operative check-up visits in the hospital's out- bar disc operations at other sites were analyzed separately. patient clinic. Twelve-month recovery has been reported The ethical committee of Jyväskylä Central Hospital earlier [15,16]. After that they were mailed a 5-year ques- approved the study design and all patients gave written tionnaire retrospectively to obtain their current health informed consent. information. Of the 173 patients, 7 were excluded due to previous back surgery. The final study group followed up Statistics for five years consisted of 166 virgin lumbar disc hernia- The results were expressed as means with standard devia- tions (SD), and medians with interquartile ranges (IQR) tion patients. The age of the patients varied from 16 to 74 years (Table 1). or range. Statistical comparison between the groups was made by using the t-test, Mann-Whitney test (Monte Carlo The indication for the initial surgery was extensive or p-value) and chi-Square or Fisher-Freeman-Halton test unbearable pain radiating down to the lower extremity or where appropriate. Kaplan-Meier estimate was used to Table 1: Sociodemographic and clinical characteristics of the patients at the time of their first operation for lumbar disc herniation. Single operated N = 149 Re-operated N = 17 P-value Number of males 86 (58) 8 (47) 0.40 Age, years, mean (SD) 42 (12) 41 (14) 0.70 Height, cm, mean (SD) 173 (9) 172 (8) 0.61 Body mass index, mean (SD) 26 (4) 26 (3) 0.76 Duration of back pain, months, median (IQR) 10 (3, 24) 12 (6, 117) 0.11 Duration of leg pain, months, median (IQR) 6 (3, 14) 10 (3, 15) 0.19 Intensity of pain before operation, VAS, median (IQR) Back pain 59 (34, 82) 76 (50, 86) 0.070 Leg pain 74 (58, 90) 76 (61, 94) 0.45 Leisure time physical activity, h/week, median (IQR) 3.5 (1.0, 6.8) 5.5 (2.9, 7.5) 0.29 Employment status, no (%): 0.48 Employed 109 (73.2) 12 (70.6) Unemployed 10 (6.7) 3 (17.6) Student 8 (5.4) 1 (5.9) Retired 18 (12.1) 1 (5.9) Other 4 (2.7) - Page 2 of 6 (page number not for citation purposes) BMC Musculoskeletal Disorders 2007, 8:2 http://www.biomedcentral.com/1471-2474/8/2 generate the cumulative proportion of re-operation rates. physical activity or employment status. Of those who 95 per cent confidence intervals of cumulative proportion were employed before the first operation, 47 % in the sin- was obtained by bias corrected bootstrapping (5000 rep- gle-operated group and 67% in the re-operated group lications)[18]. Cox's proportional Hazard Model with worked in physically heavy occupations; there was no sta- bootstrap estimate of variance was used to estimate risk tistical difference between the groups. Also there were no for re-operation. differences between the single-operated and re-operated groups in the site of the disc herniation or in the propor- tion of patients with positive straight leg raising test before Results Of the original 166 patients the cumulative rate of re- the operation (Table 2). operations for lumbar disc herniation over the 5-year period was 10.2% (17 patients, 95% Cl 6.0 to 15.1) (Fig- In the Cox proportional Hazard Model, which included ure 1). Of those, twelve patients [7.4%; 95% Cl 3.7 to age, gender, preoperative symptoms, physical activity and 11.3] had residive at the same side and level as the pri- employment, none of the variables explained the re-oper- mary herniation and five [3.1 %; 95% Cl 0.6 to 6.2] had ations over the five year follow-up (Table 3). herniation at a site other than that of their primary pro- lapse (Figure 2). In addition to re-operated lumbar disc Discussion herniation 6 patients also underwent other back surgery In the present study, the cumulative rate of re-operations during the follow-up (2 had decompressive surgery and 4 for lumbar disc herniation was 10% at 5-year follow-up. had spinal fusion). Three out of twelve residives occurred Atlas et al. 2005 reported outcomes of patients with lum- within one year, and the overall occurrence of residive bar disc herniation treated surgically or nonsurgically lumbar disc herniations was evenly distributed over the 5 [19]. At 10-year follow-up out of 217 surgically treated years. All primary and re-operations were done in the patients 25% had undergone at least one additional lum- same hospital. bar spine operation. Österman et al. 2003 reported an increasing cumulative risk for lumbar re-operations over In terms of age, sex, duration of symptoms, or intensity of time as at the one-year follow-up the risk was 7% and at back and leg pain there was no statistical difference the 10-year follow-up 25% [20]. A Swedish 10-year fol- between the single-operated or re-operated patients at the low-up showed that 10% out of 27 576 patients under- time of the primary disc operation (Table 1). Similarly, no went multiple operations for disc herniation [9]. A large differences between the groups were found in leisure time Finnish study with 25 366 patients and with an average follow-up time of 4 years reported that 12% of the patients had at least one re-operation in the lumbar area [10]. In that study 76% of the first re-operations were repeated extirpations of disc herniations, 21 % decom- pression operations and 3% spinal fusion operations. Four percent of our patients had decompressive surgery or spinal fusion after the first lumbar disc herniation. How- ever, the accurate comparison of the risk for re-operations between studies is not possible due to differences in sam- ples, follow-up times and statistical methods. In the present study the proportion of residive herniations at the same site as the primary disc herniation was 71% from all re-operated patients. This result was in line with the proportion (75%) reported by Suk et al. 2001 [14], while Silvers et al. 1994 reported the rate of residives to be 46% [21]. The relative rate of residives has varied from 1.2% to 7.4% from all lumbar reoperations [4,11,12,22,23]. However, the actual rate of residives out of all reoperations is very difficult to compare between the studies. In many of the previous studies the data collec- tion has been made so long time ago (starting from year Cumul h lin Figure 1 ee rniotion after first lumbar shows 95% ative proporti confidence in on of re-o di terval) sc pera herniation su tions for lumba rgery (dotted r disc 1958) that the diagnostic methods, operation techniques Cumulative proportion of re-operations for lumbar disc as well as criterion for the surgery have changed during the herniotion after first lumbar disc herniation surgery (dotted line shows 95% confidence interval). time span. Further, the follow-up times have varied from 7 months up to 14 years and number of subjects from 28 Page 3 of 6 (page number not for citation purposes) BMC Musculoskeletal Disorders 2007, 8:2 http://www.biomedcentral.com/1471-2474/8/2 after first lumbar disc hernia Cumul Figure 2 ative proportion of retion surgery sidive prolap(dotted line sh se occurring atows 95 the same site as the pr % confidence interval) imary operation (a) and other (b) prolapses Cumulative proportion of residive prolapse occurring at the same site as the primary operation (a) and other (b) prolapses after first lumbar disc herniation surgery (dotted line shows 95% confidence interval). Table 2: The level and site of the first lumbar disc herniation operation and proportion of patients with a positive straight leg raising (SLR) test. Single operated N = 149 Re-operated N = 17 P-value between the groups Level of surgery 0.74 L 4 (2.7) 0 (0) 1–2 L 4 (2.7) 0 (0) 2–3 L 9 (6.0) 0 (0) 3–4 L 72 (48.3) 8 (47.1) 4–5 L -S 57 (38.3) 8 (53.7) 5 1 L -L and L -S 3 (2.0) 1 (5.9) 4 5 5 1 Site of first operation 0.075 right 58 (38.9) 6 (29.4) left 85 (57.1) 9 (53.0) central 7 (4.0) 2 (17.6) SLR before operation 0.91 right 29 (19.5) 4 (23.6) left 36 (24.1) 3 (17.6) both sides 8 (5.1) 1 (5.9) Page 4 of 6 (page number not for citation purposes) BMC Musculoskeletal Disorders 2007, 8:2 http://www.biomedcentral.com/1471-2474/8/2 Table 3: Cox proportional Hazard Model for re-operation after first lumbar disc herniation surgery. Hazard Ratio 95% Confidence Interval * p-value Female sex 1.47 0.19 to 11.19 0.71 Age, years 0.98 0.92 to 1.04 0.53 Body mass index >27.0 1.62 0.42 to 6.29 0.36 Duration of pain, mo 1.01 0.98 to 1.02 0.66 Back pain per 10 mm on VAS 1.17 0.88 to 1.54 0.27 Leg pain per 10 mm on VAS 1.01 0.73 to 1.40 0.94 Leisure time physical activity 1.09 0.93 to 1.28 0.28 Employment 1.16 0.00 to >50 0.96 to 1850 [4,11,12,22,23]. The present study is the only one In the Cox proportional Hazard Model, in which age, gen- where the subjects are followed for equal time period. der, preoperative symptoms, physical activity and employment were included, none of these variables According Suk et al. 2001 the high risk of residives may be explained the re-operations. This result is in accordance explained by the initial annular defect and the trauma to with Kara et al. (2005) with the exception that they the annulus sustained during the lumbar disc surgery reported lack of physical exercise to be a significant pre- [14]. However, the reasons reported for residive disc her- dictor of re-operation (OR 4.60; p = 0.013) [29]. How- niation are conflictive. Cinotti et al. (1998) observed ever, Jansson et al. (2004) reported that patients aged 40 residive disc herniations in patients with severe disc to 59 had an increased risk for re-operations compared degeneration, while recently Dora et al. (2005) reported with patients below age 40 or above age 60 over a median that patients with only minor disc degeneration have a follow-up period of six years [9]. Videman and Battie 6.8-fold increase in the risk for residive disc herniation (1999) concluded in their review that none of the classic compared to those with advanced grade IV degeneration occupational risk factors (heavy lifting, sitting and bend- [22,24]. In the present study the age distribution, and thus ing) were predictive of disc degeneration or re-operations apparently also the grade of disc degeneration of all [30]. The risk factors for primary disc herniation have patients was wide (16–74 years) and was comparable to been reported to be structural weakness of the annular tis- that of the patients with residive disc herniation (19–74 sue, and exposure to repetitive lifting, vibration, and years). smoking [31-33]. Some studies have also shown that the onset of radicular pain and recurrent herniation was Earlier studies have suggested that the origin of residive related to a trauma or injury [14,2]. The limitation of the disc herniation may vary [25,26]. Early residive lumbar study is the low number of reoperations and thus the disc herniation is made primarily of disc material left in information of the risk factors should be considered with the intervertebral space. Gradually the disc material may caution. also form fibrocartilaginous tissue, which can be extruded into the spinal canal. A pain-free interval of less than 12 In conclusion, 71 percent of the re-operations for lumbar months after the initial lumbar disc operation and slow disc herniation were residive disc herniations and a minor onset of new complaints are assumed to be characteristic proportion of re-operations occurred due to disc hernia- of an epidural fibrosis with nerve compression. In epi- tions at another side or level. The re-operations were not dural fibrosis the nerve root and the dura are immobilized explained by age, gender, preoperative symptoms, physi- by the epidural scar tissue, and the pressure is exerted on cal activity or employment. the nerve root [25]. Luukkonen has also recently reported that a scar as a surgical finding was a significant factor in Competing interests poor outcome in recurrent nerve compression [27]. In the The author(s) declare that they have no competing inter- present study three out of twelve residives representing ests. possible "actual residives" occurred within one year, while the remainders occurred 2.5 years after the first lumbar Authors' contributions disc herniation, possible reflecting the different reason for AH participated in the study design, acquisition, analysis the re-operation. The distribution of levels of herniated and interpretation of data and drafting of the manuscript. discs in both the single-operated and re-operated patients IK and JY participated in the study design and drafting of was similar to that reported in other studies with a signif- the manuscript. MK participated in drafting of the manu- icant prevalence of L -L and L -S -levels [28,29]. script and HK in statistical analysis of the data and draft- 4 5 5 1 ing of the manuscript. All authors read and approved the final manuscript. Page 5 of 6 (page number not for citation purposes) BMC Musculoskeletal Disorders 2007, 8:2 http://www.biomedcentral.com/1471-2474/8/2 25. Ebeling U, Kalbarcyk H, Reulen HJ: Microsurgical re-operation Acknowledgements following lumbar disc surgery. Timing, surgical findings, and This study was supported by the Medical Research Foundation by Jyväskylä outcome in 92 patients. J Neurosurg 1989, 70:397-404. Central Hospital, Finland. 26. Laus M, Bertoni F, Bacchini P, Alfonso C, Giunti A: Recurrent lum- bar disc herniation: what recurs? (A morphological study of recurrent disc herniation). Chir Organi Mov 1993, 78:147-54. References 27. Luukkkonen T: Medial facetectomy in recurrent lumbar nerve 1. Graver V, Haaland AK, Magnaes B, Loeb M: Seven-year clinical fol- root compression. J Spinal Disord Tech 2005, 18:48-51. low-up after lumbar disc surgery: results and predictors of 28. Gaetani P, Aimar E, Panella L, Debernardi A, Tancioni F, Rodriguez y, outcome. Br J Neurosurg 1999, 13:178-84. Baena R: Surgery for herniated lumbar disc disease: factors 2. Hurme M, Alaranta H: Factors predicting the results of surgery influencing outcome measures. An analysis of 403 cases. for lumbar intervertebral disc herniation. Spine 1987, Funct Neurol 2004, 19:43-9. 12:933-8. 29. Kara B, Tulum Z, Acar U: Functional results and the risk factors 3. Findlay GF, Hall BI, Musa BS, Oliveira MD, Fear SC: A 10-year fol- of re-operations after lumbar disc surgery. Eur Spine J 2005, low-up of the outcome of lumbar microdiscectomy. Spine 14:43-8. 1998, 15:1168-71. 30. Videman T, Battie MC: The influence of occupation on lumbar 4. Loupasis GA, Stamos K, Katonis PG, Sapkas G, Korres DS, Hartofilak- degeneration. Review. Spine 1999, 24:1164-8. idis G: Seven- to 20-year outcome of lumbar discectomy. 31. An HS, Silveri CP, Simpson JM, File P, Simmons C, Simeone FA, Bald- Spine 1999, 24:2313-7. erston RA: Comparison of smoking habits between patients 5. Moore AJ, Chilton JD, Uttley D: Long-term results of microlum- with surgically confirmed herniated lumbar and cervical disc bar discectomy. Br J Neurosurg 1994, 8:319-26. disease and controls. J Spinal Disord 1994, 7:369-73. 6. Weber H: Lumbar disc herniation. A controlled, prospective 32. Kelsey JL, Githens PB, O'Connor T: Acute prolapsed lumbar study with ten years of observation. Spine 1983, 8:131-40. intervertebral disc. An epidemiologic study with special ref- 7. Yorimitsu E, Chiba K, Toyama Y, Hirabayashi K: Long-term out- erence to driving automobiles and cigarette smoking. Spine comes of standard discectomy for lumbar disc herniation: a 1984, 9:608-13. follow-up study of more than 10 years. Spine 2001, 26:652-7. 33. Mundt DJ, Kelsey JL, Golden AL, Panjabi MM, Pastides H, Berg AT, 8. Häkkinen A, Kiviranta I, Kautiainen H, Airaksinen O, Herno A, Ylinen Sklar J, Hosea T: An epidemiologic study of sports and weight J: Does the outcome two months after lumbar disc surgery lifting as possible risk factors for herniated lumbar and cervi- predict the longer-term outcome? Disabil Rehabil 2003, cal discs. Am J Sports Med 1993, 21:854-60. 25:968-72. 9. Jansson KA, Nemeth G, Granath F, Blomqvist P: Surgery for herni- ation of a lumbar disc in Sweden between 1987 and 1999. An Pre-publication history analysis of 27,576 operations. J Bone Joint Surg [Br] 2004, The pre-publication history for this paper can be accessed 86:841-7. here: 10. Keskimäki I, Seitsalo S, Osterman H, Rissanen P: Re-operations after lumbar disc surgery: a population-based study of regional and interspecialty variations. Spine 2000, 15:1500-8. http://www.biomedcentral.com/1471-2474/8/2/prepub 11. Connolly ES: Surgery for recurrent lumbar disc herniation. Clin Neurosurg 1992, 39:211-6. 12. O'Sullivan MG, Connolly AE, Buckley TF: Recurrent lumbar disc protrusion. Br J Neurosurg 1990, 4:319-25. 13. Fandino J, Botana C, Viladrich A, Gomes-Bueno J: Re-operation after lumbar disc surgery: results in 130 cases. Acta Neurochir [Wien] 1993, 122:102-4. 14. Suk KS, Lee HM, Moon SH, Kim NH: Recurrent lumbar disc her- niation: results of operative management. Spine 2001, 15:672-6. 15. Häkkinen A, Ylinen J, Kautiainen H, Airaksinen O, Herno A, Tarvainen U, Kiviranta I: Pain, trunk muscle strength, spine mobility and disability following lumbar disc surgery. J Rehabil Med 2003, 35:236-40. 16. Häkkinen A, Kiviranta I, Kautiainen H, Airaksinen O, Herno A, Ylinen J: Does the outcome two months after lumbar disc surgery predict the longer-term outcome? Disability and Rehabilitation 2003, 25:968-72. 17. Wood EG, Hanley EN: Lumbar disc herniation and open lim- ited discectomy: indications, techniques, and results. Opera- tive Techniques in Orthopaedics 1991, 1:23-8. 18. Efron B, Tibshirani R: An introduction to the bootstrap. New York: Chapman and Hall/CRC; 1998. 19. Atlas S, Keller R, Wu Y, Deyo R, Singer D: Long-Term Outcomes Publish with Bio Med Central and every of Surgical and Nonsurgical Management of Lumbar Spinal Stenosis: 8 to 10 Year Results from the Maine Lumbar Spine scientist can read your work free of charge Study. Spine 2005, 30:936-43. "BioMed Central will be the most significant development for 20. Österman H, Sund R, Seitsalo S, Keskimäki I: Risk of multiple reop- erations after lumbar discectomy: a population-based study. disseminating the results of biomedical researc h in our lifetime." Spine 2003, 28:621-7. Sir Paul Nurse, Cancer Research UK 21. Silvers HR, Lewis PJ, Asch HL, Clabeaux DE: Lumbar diskectomy for recurrent disk herniation. J Spinal Disord 1994, 7:408-19. Your research papers will be: 22. Jackson RK: The long-term effect of wide laminectomy for available free of charge to the entire biomedical community lumbar disc excision. J Bone Joint Surgery 1971, 53B:609-16. peer reviewed and published immediately upon acceptance 23. Cinotti G, Roysam GS, Eisenstein SM, et al.: Ispilateral recurrent lumbar disc herniation. J Bone Joint Surg [Br] 1998, 80:825-32. cited in PubMed and archived on PubMed Central 24. Dora C, Schmid M, Elfering A, Zanetti M, Hodler J, Boos N: Lumbar yours — you keep the copyright Disk Herniation: Do MR Imaging Findings Predict Recur- rence after Surgical Diskectomy? Radiology 2005, 235:562-7. BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 6 of 6 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Musculoskeletal Disorders Springer Journals

Reoperations after first lumbar disc herniation surgery; a special interest on residives during a 5-year follow-up

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Springer Journals
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Copyright © 2007 by Häkkinen et al; licensee BioMed Central Ltd.
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Medicine & Public Health; Orthopedics; Rehabilitation; Rheumatology; Sports Medicine; Internal Medicine; Epidemiology
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1471-2474
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10.1186/1471-2474-8-2
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17212811
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Abstract

Background: The overall rate of operations after recurrent lumbar disc herniation has been shown to be 3–11%. However, little is known about the rate of residives. Thus the aim of this study was to explore the cumulative rates of re-operations and especially residive disc herniations at the same side and level as the primary disc herniation after first lumbar disc herniation surgery and the factors that influence the risk of re- operations over a five year follow-up study. Methods: 166 virgin lumbar disc herniation patients (mean age 42 years, 57% males) were studied. Data on patients' initial disc operations and type and timing of re- operations during the follow-up were collected from patient files. Back and leg pain on visual analog scale and employment status were collected by questionnaires. Results: The cumulative rate of re-operations for lumbar disc herniation was 10.2% (95% Cl 6.0 to 15.1). The rate of residives at initial site was 7.4% (95% Cl 3.7 to 11.3) and rate of lumbar disc herniations at other sites was 3.1% (95% Cl 0.6 to 6.2). The occurrence of residive lumbar disc herniations was evenly distributed across the 5 years. Neither age, gender, preoperative symptoms, physical activity nor employment had effect on the probability of re-operation. Conclusion: Seven percent of the lumbar disc patients had a residive lumbar disc operation within five years of their first operation. No specific factors influencing the risk for re-operation were found. Page 1 of 6 (page number not for citation purposes) BMC Musculoskeletal Disorders 2007, 8:2 http://www.biomedcentral.com/1471-2474/8/2 Background muscle weakness. In some cases also, loss of the patellar Surgery for lumbar disc herniation is effective in the or Achilles reflex, regional sensory loss, and a positive majority of cases. Success rates from 76% to 93 % have straight leg raising test (SLR <60) were present. The diag- been reported [1-8]. Patients who have had one operation nosis of lumbar disc herniation was based on preoperative for lumbar disc herniation have shown to be at 5–12.5% clinical status, and spinal nerve root compression detected risk for further operations (including discectomy, other in magnetic resonance imaging (MRI) or computed tom- type of decompression or fusion) over the follow-ups last- ography (CT) and was finally confirmed during surgery. ing from 1 to 20 years [4,7,9,10]. The overall rate of oper- The patients were operated on using the open mini ations after recurrent lumbar disc herniation has been approach described by Wood & Hanley in 1991 [17]. In shown to be 3–11% [11-14]. However, little is known the surgery, herniated fragment was extracted and thereaf- about the rate of residives at the side and level with the ter, loose material from intervertebral disc space was primary operation. removed. In the current five-year follow-up study we analysed the Before surgery, the subjects completed a questionnaire cumulative rate of re-operations for lumbar disc surgery including items about the duration of preoperative back and especially rate of residive disc herniations after a first and leg pain, intensity of pain (visual analog scale, VAS, lumbar disc operation. The risk factors for repeated sur- scale 0–100 mm), leisure time physical activity, employ- gery were also studied. ment status, and physical loading at work (light, medium, heavy or very heavy work). The patients filled a question- Methods naire also 5 years after the surgery confirming that there Two-hundred and ten patients had surgery for lumbar disc were no re-operations done in other hospitals. Data on herniation in Jyväskylä Central Hospital in the year 1999 the patients' initial disc operations and re-operations dur- (~1/1000 inhabitant of the area). Of this number 173 ing the follow-up were collected from patient files of patients (82%) volunteered for a follow-up study, filled a Jyväskylä Central Hospital. In the analysis re-operations at preoperative questionnaire and were referred for 2 and 12 the same side and level as the primary operation and lum- month post-operative check-up visits in the hospital's out- bar disc operations at other sites were analyzed separately. patient clinic. Twelve-month recovery has been reported The ethical committee of Jyväskylä Central Hospital earlier [15,16]. After that they were mailed a 5-year ques- approved the study design and all patients gave written tionnaire retrospectively to obtain their current health informed consent. information. Of the 173 patients, 7 were excluded due to previous back surgery. The final study group followed up Statistics for five years consisted of 166 virgin lumbar disc hernia- The results were expressed as means with standard devia- tions (SD), and medians with interquartile ranges (IQR) tion patients. The age of the patients varied from 16 to 74 years (Table 1). or range. Statistical comparison between the groups was made by using the t-test, Mann-Whitney test (Monte Carlo The indication for the initial surgery was extensive or p-value) and chi-Square or Fisher-Freeman-Halton test unbearable pain radiating down to the lower extremity or where appropriate. Kaplan-Meier estimate was used to Table 1: Sociodemographic and clinical characteristics of the patients at the time of their first operation for lumbar disc herniation. Single operated N = 149 Re-operated N = 17 P-value Number of males 86 (58) 8 (47) 0.40 Age, years, mean (SD) 42 (12) 41 (14) 0.70 Height, cm, mean (SD) 173 (9) 172 (8) 0.61 Body mass index, mean (SD) 26 (4) 26 (3) 0.76 Duration of back pain, months, median (IQR) 10 (3, 24) 12 (6, 117) 0.11 Duration of leg pain, months, median (IQR) 6 (3, 14) 10 (3, 15) 0.19 Intensity of pain before operation, VAS, median (IQR) Back pain 59 (34, 82) 76 (50, 86) 0.070 Leg pain 74 (58, 90) 76 (61, 94) 0.45 Leisure time physical activity, h/week, median (IQR) 3.5 (1.0, 6.8) 5.5 (2.9, 7.5) 0.29 Employment status, no (%): 0.48 Employed 109 (73.2) 12 (70.6) Unemployed 10 (6.7) 3 (17.6) Student 8 (5.4) 1 (5.9) Retired 18 (12.1) 1 (5.9) Other 4 (2.7) - Page 2 of 6 (page number not for citation purposes) BMC Musculoskeletal Disorders 2007, 8:2 http://www.biomedcentral.com/1471-2474/8/2 generate the cumulative proportion of re-operation rates. physical activity or employment status. Of those who 95 per cent confidence intervals of cumulative proportion were employed before the first operation, 47 % in the sin- was obtained by bias corrected bootstrapping (5000 rep- gle-operated group and 67% in the re-operated group lications)[18]. Cox's proportional Hazard Model with worked in physically heavy occupations; there was no sta- bootstrap estimate of variance was used to estimate risk tistical difference between the groups. Also there were no for re-operation. differences between the single-operated and re-operated groups in the site of the disc herniation or in the propor- tion of patients with positive straight leg raising test before Results Of the original 166 patients the cumulative rate of re- the operation (Table 2). operations for lumbar disc herniation over the 5-year period was 10.2% (17 patients, 95% Cl 6.0 to 15.1) (Fig- In the Cox proportional Hazard Model, which included ure 1). Of those, twelve patients [7.4%; 95% Cl 3.7 to age, gender, preoperative symptoms, physical activity and 11.3] had residive at the same side and level as the pri- employment, none of the variables explained the re-oper- mary herniation and five [3.1 %; 95% Cl 0.6 to 6.2] had ations over the five year follow-up (Table 3). herniation at a site other than that of their primary pro- lapse (Figure 2). In addition to re-operated lumbar disc Discussion herniation 6 patients also underwent other back surgery In the present study, the cumulative rate of re-operations during the follow-up (2 had decompressive surgery and 4 for lumbar disc herniation was 10% at 5-year follow-up. had spinal fusion). Three out of twelve residives occurred Atlas et al. 2005 reported outcomes of patients with lum- within one year, and the overall occurrence of residive bar disc herniation treated surgically or nonsurgically lumbar disc herniations was evenly distributed over the 5 [19]. At 10-year follow-up out of 217 surgically treated years. All primary and re-operations were done in the patients 25% had undergone at least one additional lum- same hospital. bar spine operation. Österman et al. 2003 reported an increasing cumulative risk for lumbar re-operations over In terms of age, sex, duration of symptoms, or intensity of time as at the one-year follow-up the risk was 7% and at back and leg pain there was no statistical difference the 10-year follow-up 25% [20]. A Swedish 10-year fol- between the single-operated or re-operated patients at the low-up showed that 10% out of 27 576 patients under- time of the primary disc operation (Table 1). Similarly, no went multiple operations for disc herniation [9]. A large differences between the groups were found in leisure time Finnish study with 25 366 patients and with an average follow-up time of 4 years reported that 12% of the patients had at least one re-operation in the lumbar area [10]. In that study 76% of the first re-operations were repeated extirpations of disc herniations, 21 % decom- pression operations and 3% spinal fusion operations. Four percent of our patients had decompressive surgery or spinal fusion after the first lumbar disc herniation. How- ever, the accurate comparison of the risk for re-operations between studies is not possible due to differences in sam- ples, follow-up times and statistical methods. In the present study the proportion of residive herniations at the same site as the primary disc herniation was 71% from all re-operated patients. This result was in line with the proportion (75%) reported by Suk et al. 2001 [14], while Silvers et al. 1994 reported the rate of residives to be 46% [21]. The relative rate of residives has varied from 1.2% to 7.4% from all lumbar reoperations [4,11,12,22,23]. However, the actual rate of residives out of all reoperations is very difficult to compare between the studies. In many of the previous studies the data collec- tion has been made so long time ago (starting from year Cumul h lin Figure 1 ee rniotion after first lumbar shows 95% ative proporti confidence in on of re-o di terval) sc pera herniation su tions for lumba rgery (dotted r disc 1958) that the diagnostic methods, operation techniques Cumulative proportion of re-operations for lumbar disc as well as criterion for the surgery have changed during the herniotion after first lumbar disc herniation surgery (dotted line shows 95% confidence interval). time span. Further, the follow-up times have varied from 7 months up to 14 years and number of subjects from 28 Page 3 of 6 (page number not for citation purposes) BMC Musculoskeletal Disorders 2007, 8:2 http://www.biomedcentral.com/1471-2474/8/2 after first lumbar disc hernia Cumul Figure 2 ative proportion of retion surgery sidive prolap(dotted line sh se occurring atows 95 the same site as the pr % confidence interval) imary operation (a) and other (b) prolapses Cumulative proportion of residive prolapse occurring at the same site as the primary operation (a) and other (b) prolapses after first lumbar disc herniation surgery (dotted line shows 95% confidence interval). Table 2: The level and site of the first lumbar disc herniation operation and proportion of patients with a positive straight leg raising (SLR) test. Single operated N = 149 Re-operated N = 17 P-value between the groups Level of surgery 0.74 L 4 (2.7) 0 (0) 1–2 L 4 (2.7) 0 (0) 2–3 L 9 (6.0) 0 (0) 3–4 L 72 (48.3) 8 (47.1) 4–5 L -S 57 (38.3) 8 (53.7) 5 1 L -L and L -S 3 (2.0) 1 (5.9) 4 5 5 1 Site of first operation 0.075 right 58 (38.9) 6 (29.4) left 85 (57.1) 9 (53.0) central 7 (4.0) 2 (17.6) SLR before operation 0.91 right 29 (19.5) 4 (23.6) left 36 (24.1) 3 (17.6) both sides 8 (5.1) 1 (5.9) Page 4 of 6 (page number not for citation purposes) BMC Musculoskeletal Disorders 2007, 8:2 http://www.biomedcentral.com/1471-2474/8/2 Table 3: Cox proportional Hazard Model for re-operation after first lumbar disc herniation surgery. Hazard Ratio 95% Confidence Interval * p-value Female sex 1.47 0.19 to 11.19 0.71 Age, years 0.98 0.92 to 1.04 0.53 Body mass index >27.0 1.62 0.42 to 6.29 0.36 Duration of pain, mo 1.01 0.98 to 1.02 0.66 Back pain per 10 mm on VAS 1.17 0.88 to 1.54 0.27 Leg pain per 10 mm on VAS 1.01 0.73 to 1.40 0.94 Leisure time physical activity 1.09 0.93 to 1.28 0.28 Employment 1.16 0.00 to >50 0.96 to 1850 [4,11,12,22,23]. The present study is the only one In the Cox proportional Hazard Model, in which age, gen- where the subjects are followed for equal time period. der, preoperative symptoms, physical activity and employment were included, none of these variables According Suk et al. 2001 the high risk of residives may be explained the re-operations. This result is in accordance explained by the initial annular defect and the trauma to with Kara et al. (2005) with the exception that they the annulus sustained during the lumbar disc surgery reported lack of physical exercise to be a significant pre- [14]. However, the reasons reported for residive disc her- dictor of re-operation (OR 4.60; p = 0.013) [29]. How- niation are conflictive. Cinotti et al. (1998) observed ever, Jansson et al. (2004) reported that patients aged 40 residive disc herniations in patients with severe disc to 59 had an increased risk for re-operations compared degeneration, while recently Dora et al. (2005) reported with patients below age 40 or above age 60 over a median that patients with only minor disc degeneration have a follow-up period of six years [9]. Videman and Battie 6.8-fold increase in the risk for residive disc herniation (1999) concluded in their review that none of the classic compared to those with advanced grade IV degeneration occupational risk factors (heavy lifting, sitting and bend- [22,24]. In the present study the age distribution, and thus ing) were predictive of disc degeneration or re-operations apparently also the grade of disc degeneration of all [30]. The risk factors for primary disc herniation have patients was wide (16–74 years) and was comparable to been reported to be structural weakness of the annular tis- that of the patients with residive disc herniation (19–74 sue, and exposure to repetitive lifting, vibration, and years). smoking [31-33]. Some studies have also shown that the onset of radicular pain and recurrent herniation was Earlier studies have suggested that the origin of residive related to a trauma or injury [14,2]. The limitation of the disc herniation may vary [25,26]. Early residive lumbar study is the low number of reoperations and thus the disc herniation is made primarily of disc material left in information of the risk factors should be considered with the intervertebral space. Gradually the disc material may caution. also form fibrocartilaginous tissue, which can be extruded into the spinal canal. A pain-free interval of less than 12 In conclusion, 71 percent of the re-operations for lumbar months after the initial lumbar disc operation and slow disc herniation were residive disc herniations and a minor onset of new complaints are assumed to be characteristic proportion of re-operations occurred due to disc hernia- of an epidural fibrosis with nerve compression. In epi- tions at another side or level. The re-operations were not dural fibrosis the nerve root and the dura are immobilized explained by age, gender, preoperative symptoms, physi- by the epidural scar tissue, and the pressure is exerted on cal activity or employment. the nerve root [25]. Luukkonen has also recently reported that a scar as a surgical finding was a significant factor in Competing interests poor outcome in recurrent nerve compression [27]. In the The author(s) declare that they have no competing inter- present study three out of twelve residives representing ests. possible "actual residives" occurred within one year, while the remainders occurred 2.5 years after the first lumbar Authors' contributions disc herniation, possible reflecting the different reason for AH participated in the study design, acquisition, analysis the re-operation. The distribution of levels of herniated and interpretation of data and drafting of the manuscript. discs in both the single-operated and re-operated patients IK and JY participated in the study design and drafting of was similar to that reported in other studies with a signif- the manuscript. MK participated in drafting of the manu- icant prevalence of L -L and L -S -levels [28,29]. script and HK in statistical analysis of the data and draft- 4 5 5 1 ing of the manuscript. All authors read and approved the final manuscript. 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