Recurrent lumbar disc herniation after single-level lumbar discectomy: incidence and health care cost analysis.

OBJECTIVE: Same-level recurrent lumbar disc herniation complicates outcomes after primary discectomy in a subset of patients. The health care costs associated with the management of this complication are currently unknown. We set out to identify the incidence and health care cost of same-level recurrent disc herniation after single-level lumbar discectomy at our institution. METHODS: We retrospectively reviewed 156 consecutive patients undergoing primary single-level lumbar discectomy at one institution. The incidence of symptomatic same-level recurrent disc herniation either responding to conservative therapy or requiring revision discectomy was assessed. Institutional billing and accounting records were reviewed to determine the billing costs of all diagnostic and therapeutic measures used for patients experiencing recurrent disc herniation. RESULTS: Twelve months after surgery, 141 patients were available for follow-up. Of these patients, 124 (88%) were symptom free or had minimal symptoms not affecting their daily activity. Radiographically proven symptomatic same-level recurrent disc herniation developed in 17 patients (12%) a median of 8 months after primary discectomy. Eleven patients (7%) required revision surgery, whereas 6 (3.9%) responded to conservative therapy alone. Diagnosis and management of recurrent disc herniation were associated with a mean cost of $26,593 per patient, and the mean cost was markedly less for patients responding to conservative treatment ($2315) compared with those requiring revision surgery ($39,836) (P < 0.001). Of 141 primary lumbar discectomies performed at our institution with the patients followed for 1 year, the total cost associated with the management of subsequent recurrent disc herniation was $452,083 ($289,797 per 100 primary discectomies). CONCLUSION: In our experience, recurrent lumbar disc herniation occurred in more than 10% of patients and was associated with substantial health care costs. Development of novel techniques to prevent recurrent lumbar disc herniation is warranted to decrease the health care costs and morbidity associated with this complication. Prolonged conservative management should be attempted when possible to reduce the health care costs of this complication.

Recurrent disc herniation and long-term back pain after primary lumbar discectomy: review of outcomes reported for limited versus aggressive disc removal.

OBJECTIVE: It remains unknown whether aggressive disc removal with curettage or limited removal of disc fragment alone with little disc invasion provides a better outcome for the treatment of lumbar disc herniation with radiculopathy. We reviewed the literature to determine whether outcomes reported after limited discectomy (LD) differed from those reported after aggressive discectomy (AD) with regard to long-term back pain or recurrent disc herniation. METHODS: A systematic MEDLINE search was performed to identify all studies published between 1980 and 2007 reporting outcomes after AD or LD for a herniated lumbar disc with radiculopathy. The incidence of short- and long-term recurrent back or leg pain and recurrent disc herniation was assessed from each reported LD or AD cohort and the cumulative incidence compared. RESULTS: Fifty-four studies (60 discectomy cohorts) met the inclusion criteria, reporting the outcomes of 13 359 patients after lumbar discectomy (LD, 6135 patients; AD, 7224 patients). The reported incidence of short-term recurrent back or leg pain was similar after LD (mean, 14.5%; range, 7-16%) and AD (mean, 14.1%; range, 6-43%) (P < 0.01). However, more than 2 years after surgery, the reported incidence of recurrent back or leg pain was 2.5-fold less after LD (mean, 11.6%; range, 7-16%) compared with AD (mean, 27.8%; range, 19-37%) (P < 0.0001). The reported incidence of recurrent disc herniation after LD (mean, 7%; range, 2-18%) was greater than that reported after AD (mean, 3.5%; range, 0-9.5%) (P < 0.0001). CONCLUSION: Review of the literature demonstrates a greater reported incidence of long-term recurrent back and leg pain after AD but a greater reported incidence of recurrent disc herniation after LD. Prospective, randomized trials are needed to firmly assess this possible difference.