Comparison of Two Methods of Epidural Steroid Injection in the Treatment of Recurrent Lumbar Disc Herniation

STUDY DESIGN: Prospective study. PURPOSE: We compared the effects of two methods of epidural steroid injection in patients with recurrent disc herniation. OVERVIEW OF LITERATURE: To our knowledge, there is no previous report of such a comparison in these patients. METHODS: The study was performed with 30 patients with relapsed lumbar disc herniation whose pain was not relieved by conservative remedies. The patients were divided into two groups, each of 15 patients, and entered the study for caudal or transforaminal injections. The degree of pain, ability to stand and walk, and the Prolo function score were evaluated in both groups before the injection and 2 months and 6 months after the injection. RESULTS: The degrees of pain reduction in the caudal injection group in the second and sixth months were 0.6 and 1.63, respectively, and in the transforaminal injection group were 1.33 and 1.56, respectively. The difference between the two methods was not statistically significant. Similarly, no other evaluated criterion showed a significant difference between the methods. CONCLUSIONS: In the current study, the caudal and transforaminal steroid injection methods showed similar outcomes in the treatment of relapsed lumbar disc herniation. However, more detailed patient categorizing may help in finding possible subgroups with differences.

Revisional Percutaneous Full Endoscopic Disc Surgery for Recurrent Herniation of Previous Open Lumbar Discectomy

STUDY DESIGN: A retrospective study. PURPOSE: To determine the feasibility and effectiveness of revisional percutaneous full endoscopic discectomy for recurrent herniation after conventional open disc surgery. OVERVIEW OF THE LITERATURE: Repeated open discectomy with or without fusion has been the most common procedure for recurrent lumbar disc herniation. Percutaneous endoscopic lumbar discectomy for recurrent herniation has been thought of as an impossible procedure. Despite good results with open revisional surgery, major problems may be caused by injuries to the posterior stabilized structures. Our team did revisional full endoscopic lumbar disc surgery on the basis of our experience doing primary full endoscopic disc surgery. METHODS: Between February 2004 and August 2009 a total of 41 patients in our hospital underwent revisional percutaneous endoscopic lumbar discectomy using a YESS endoscopic system and a micro-osteotome (designed by the authors). Indications for surgery were recurrent disc herniation following conventional open discectomy; with compression of the nerve root revealed by Gadolinium-enhanced magnetic resonance imaging; corresponding radiating pain which was not alleviated after conservative management over 6 weeks. Patients with severe neurologic deficits and isolated back pain were excluded. RESULTS: The mean follow-up period was 16 months (range, 13 to 42 months). The visual analog scale for pain in the leg and back showed significant post-treatment improvement (p < 0.001). Based on a modified version of MacNab's criteria, 90.2% showed excellent or good outcomes. There was no measurable blood loss. There were two cases of recurrence of and four cases with complications. CONCLUSIONS: Percutaneous full-endoscopic revisional disc surgery without additional structural damage is feasible and effective in terms of there being less chance of fusion and bleeding. This technique can be an alternative to conventional repeated discectomy.

Postlaminectomy Spinal Stenosis after Lumbar Discectomy / 대한척추외과학회지

STUDY DESIGN: Retrospective study OBJECTIVES: To investigate the type of postsurgical spinal stenosis in patients who had undergone a primary laminectomy and discectomy for a herniated lumbar disc, and to evaluate the clinical outcomes of the revision operation. SUMMARY AND LITERATURE REVIEW: Spinal stenosis occurs frequently after a laminectomy and discectomy. Facet joint arthritis, hypertrophy of the ligamentum flavum, iatrogenic instability, postsurgical scarring or any combination of these conditions can cause spinal stenosis. MATERIALS AND METHODS: Twenty-four patients, who had postsurgical spinal stenosis were reviewed. Patients with a simple recurrent disc herniation without a spinal stenosis were excluded. The mean age was 52.5 years (range 31~70). There were 19 males and 5 females. The primary discectomy were performed at L4-5 in 21 patients, L5-1 in 2 patients, and both L4-5 and L5-1 in 1 patient. The mean interval between the first discectomy and revision surgery was 11.6 years (range 2.7~40). The anatomical site of the spinal stenosis, combined herniated disc, height of the disc space, segmental instability, hypertrophy of facet joint and thickening of the ligamentum flavum in radiographs was evaluated. The clinical outcome was measured using the Oswestry disability index. RESULTS: Lateral spinal stenosis was observed in all patients. Eight patients showed both central and lateral stenosis. The lateral stenosis was caused by hypertrophy of the facet joint in 20 patients and a thickening of the ligamentum flavum in 8 patients. Nineteen patients showed herniated lumbar disc, including disc protrusion in 8 patients, disc extrusion in 9 patients, and disc sequestration in 2 patients. A loss of disc height was observed in 12 patients, segmental instability in 5 patients, and spondylolisthesis in 3 patients. All the patients received posterior decompression and posterolateral fusion with pedice screw instrumentation. Eighteen patients received a discectomy simultaneously. The average Oswestry score at the last visit was 24.4. CONCLUSIONS: Postlaminectomy spinal stenosis resulted from a lateral spinal stenosis associated with facet joint hypertrophy. Recurrent disc herniation also contributed to the novel development of symptoms. A wide decompression and fusion provided good clinical outcomes.

The Role of CT/Discography in Assessing Postoperative Disc Herniation

Successful management of patients with persistent or recurring pain after lumbar disc surgery requires comprehensive evaluation to accurately localize the anatomic sources of pain. The results of reoperation for recurrent disc herniation are uniformly good, whereas those of reoperation for scar tissue are poor. There have been few studies comparing the ability of enhanced MRI and CT/discography to distinguish between scar tissue and recurrent disc herniation. We evaluated 23 patients with recurring pain after lumbar disc surgery. Two neurosurgeons independently reviewed CT/discography and MRI of each patient before and after gadolinium enhancement. To determine the accuracy, sensitivity, and specificity of each test, responses were compared with surgical findings and CT/discography was found to be more sensitive and specific in distinguishing between scar and recurrent disc herniation. Characteristics associated with recurrent disc herniation include nonenhanced or rim-enhanced abnormality surrounding a low signal on enhanced MRI. and extension of contrast into the epidural space on CT/discography. For determining the need to repeat open disc surgery, combined MRI and CT/discography is more accurate and sensitive than either test alone.