Clinical Orthopaedics and Related Research®

, Volume 473, Issue 6, pp 1957–1962 | Cite as

Is Sequestrectomy a Viable Alternative to Microdiscectomy? A Systematic Review of the Literature

  • Bahram FakouriEmail author
  • Nitin R. Shetty
  • Thomas C. H. White
Symposium: Current Approaches to the Management of Lumbar Disc Herniation



Traditionally, lumbar discectomy involves removal of the free disc fragment followed by aggressive or conservative excision of the intervertebral disc. In selected patients, however, it is possible to remove only the free fragment or sequester without clearing the intervertebral disc space. However, there is some controversy about whether that approach is sufficient to prevent recurrent symptoms and to provide adequate pain relief.


This systematic review was designed to pose two questions: (1) Does performing a sequestrectomy only without conventional microdiscectomy lead to an increased reherniation rate; and (2) is there a difference in the patient-reported levels of radicular pain?


Systematic MEDLINE and EMBASE searches were carried out to identify all articles published in peer-reviewed journals reporting the outcomes of interest for conventional microdiscectomy versus sequestrectomy for lumbar disc herniation from L2 to the sacrum (Level III evidence and above); hand-searching of bibliographies was also performed. A minimum of Level II evidence was required with a followup rate of greater than 75%. Followup in all studies was from 18 to 86 months. Seven studies met the inclusion criteria for this review. The studies were analyzed for operating time, hospital stay, pre- and postoperative visual analog scale, and reherniation rate.


Patients in both the microdiscectomy and sequestrectomy groups showed comparable improvement of visual analog scale (VAS) score for leg pain. VAS score improvement ranged from 5.6 to 6.5 points in the microdiscectomy groups and 5.5 to 6.6 in the sequestrectomy group. The reherniation rate in the microdiscectomy group ranged from 2.3% to 11.8% and in the sequestrectomy groups from 2% to 12.5%.


This review of the available literature suggests that, compared with conventional microdiscectomy, microsurgical lumbar sequestrectomy can achieve comparable reherniation rates and reduction in radicular pain when a small breach in the posterior fibrous ring is found intraoperatively.


Visual Analog Scale Score Disc Herniation Lumbar Disc Herniation Radicular Pain Lumbar Discectomy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Baek GS, Kim YS, Lee MC, Song JW, Kim SK, Kim IH. Fragmentectomy versus Conventional microdiscectomy in single-level lumbar disc herniations : comparison of clinical results and recurrence rates. J Korean Neurosurg Soc. 2012;52:210–214.CrossRefPubMedCentralPubMedGoogle Scholar
  2. 2.
    Barrios C, Ahmed M, Arrotegui J, Bjornsson A, Gillstrom P. Microsurgery versus standard removal of the herniated lumbar disc. A 3-year comparison in 150 cases. Acta Orthop Scand. 1990;61:399–403.CrossRefPubMedGoogle Scholar
  3. 3.
    Barth M, Diepers M, Weiss C, Thome C. Two-year outcome after lumbar microdiscectomy versus microscopic sequestrectomy: part 2: radiographic evaluation and correlation with clinical outcome. Spine (Phila Pa 1976). 2008;33:273–279.CrossRefGoogle Scholar
  4. 4.
    Barth M, Weiss C, Thome C. Two-year outcome after lumbar microdiscectomy versus microscopic sequestrectomy: part 1: evaluation of clinical outcome. Spine (Phila Pa 1976). 2008;33:265–272.CrossRefGoogle Scholar
  5. 5.
    Carragee EJ, Spinnickie AO, Alamin TF, Paragioudakis S. A prospective controlled study of limited versus subtotal posterior discectomy: short-term outcomes in patients with herniated lumbar intervertebral discs and large posterior anular defect. Spine (Phila Pa 1976). 2006;31:653–657.CrossRefGoogle Scholar
  6. 6.
    Casper W. A new surgical procedure for lumbar disk herniation causing less tissue damage through a microsurgical approach. Adv Neruosurg. 1977;4:74–80.CrossRefGoogle Scholar
  7. 7.
    Cauchoix J, Ficat C, Girard B. Repeat surgery after disc excision. Spine (Phila Pa 1976). 1978;3:256–259.CrossRefGoogle Scholar
  8. 8.
    Connolly ES. Surgery for recurrent lumbar disc herniation. Clin Neurosurg. 1992;39:211–216.PubMedGoogle Scholar
  9. 9.
    Eismont FJ, Currier B. Surgical management of lumbar intervertebral-disc disease. J Bone Joint Surg Am. 1989;71:1266–1271.PubMedGoogle Scholar
  10. 10.
    Fakouri B, Patel V, Bayley E, Srinivas S. Lumbar microdiscectomy versus sequesterectomy/free fragmentectomy: a long-term (> 2 y) retrospective study of the clinical outcome. J Spinal Disord Tech. 2011;24:6–10.CrossRefPubMedGoogle Scholar
  11. 11.
    Faulhauer K, Manicke C. Fragment excision versus conventional disc removal in the microsurgical treatment of herniated lumbar disc. Acta Neurochir (Wien). 1995;133:107–111.CrossRefPubMedGoogle Scholar
  12. 12.
    Frymoyer JW, Pope MH, Clements JH, Wilder DG, MacPherson B, Ashikaga T. Risk factors in low-back pain. An epidemiological survey. J Bone Joint Surg Am. 1983;65:213–218.PubMedGoogle Scholar
  13. 13.
    Jaikumar S, Kim DH, Kam AC. History of minimally invasive spine surgery. Neurosurgery. 2002;51:S1–14.CrossRefPubMedGoogle Scholar
  14. 14.
    Kahanovitz N, Viola K, Muculloch J. Limited surgical discectomy and microdiscectomy. A clinical comparison. Spine (Phila Pa 1976). 1989;14:79–81.CrossRefGoogle Scholar
  15. 15.
    Kast E, Oberle J, Richter HP, Borm W. Success of simple sequestrectomy in lumbar spine surgery depends on the competence of the fibrous ring: a prospective controlled study of 168 patients. Spine (Phila Pa 1976). 2008;33:1567–1571.CrossRefGoogle Scholar
  16. 16.
    Kirkaldy-Willis WH, Wedge JH, Yong-Hing K, Reilly J. Pathology and pathogenesis of lumbar spondylosis and stenosis. Spine (Phila Pa 1976). 1978;3:319–328.CrossRefGoogle Scholar
  17. 17.
    Kotilainen E, Valtonen S. Clinical instability of the lumbar spine after microdiscectomy. Acta Neurochir (Wien). 1993;125:120–126.CrossRefPubMedGoogle Scholar
  18. 18.
    McGirt MJ, Ambrossi GL, Datoo G, Sciubba DM, Witham TF, Wolinsky JP, Gokaslan ZL, Bydon A. Recurrent disc herniation and long-term back pain after primary lumbar discectomy: review of outcomes reported for limited versus aggressive disc removal. Neurosurgery. 2009;64:338–344; discussion 344–345.Google Scholar
  19. 19.
    Mixter WJ, Barr JS. Rupture of the intervertebral disc with involvement of the spinal canal. N Engl J Med. 1934;211:210–215.CrossRefGoogle Scholar
  20. 20.
    Mochida J, Nishimura K, Nomura T, Toh E, Chiba M. The importance of preserving disc structure in surgical approaches to lumbar disc herniation. Spine (Phila Pa 1976). 1996;21:1556–1563; discussion 1563–1564.Google Scholar
  21. 21.
    Oxford Cenre of Evidence Based Medicine. The Oxford Levels of Evidence 2. Oxford, UK: Oxford Centre of Evidence Based Medicine; 2009.Google Scholar
  22. 22.
    Riesenburger RI, David CA. Lumbar microdiscectomy and microendoscopic discectomy. Minim Invasive Ther Allied Technol. 2006;15:267–270.CrossRefPubMedGoogle Scholar
  23. 23.
    Sadhasivam S, Kaynar AM. Iatrogenic arteriovenous fistula during lumbar microdiscectomy. Anesth Analg. 2004;99:1815–1817, table of contents.Google Scholar
  24. 24.
    Soliman J, Harvey A, Howes G, Seibly J, Dossey J, Nardone E. Limited microdiscectomy for lumbar disc herniation: a retrospective long-term outcome analysis. J Spinal Disord Tech. 2014;27:E8–E13.CrossRefPubMedGoogle Scholar
  25. 25.
    Spengler DM, Ouellette EA, Battie M, Zeh J. Elective discectomy for herniation of a lumbar disc. Additional experience with an objective method. J Bone Joint Surg Am. 1990;72:230–237.PubMedGoogle Scholar
  26. 26.
    Thome C, Borm W, Meyer F. Degenerative lumbar spinal stenosis: current strategies in diagnosis and treatment. Dtsch Arztebl Int. 2008;105:373–379.PubMedCentralPubMedGoogle Scholar
  27. 27.
    Vaughan PA, Malcolm BW, Maistrelli GL. Results of L4-L5 disc excision alone versus disc excision and fusion. Spine (Phila Pa 1976). 1988;13:690–695.CrossRefGoogle Scholar
  28. 28.
    Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine (Phila Pa 1976). 1983;8:131–140.CrossRefGoogle Scholar
  29. 29.
    Weinstein JN, Lurie JD, Tosteson TD, Tosteson AN, Blood EA, Abdu WA, Herkowitz H, Hilibrand A, Albert T, Fischgrund J. Surgical versus nonoperative treatment for lumbar disc herniation: four-year results for the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976). 2008;33:2789–2800.CrossRefGoogle Scholar
  30. 30.
    Wenger M, Mariani L, Kalbarczyk A, Groger U. Long-term outcome of 104 patients after lumbar sequestrectomy according to Williams. Neurosurgery. 2001;49:329–334; discussion 334–335.Google Scholar
  31. 31.
    Williams RW. Microlumbar discectomy: a conservative surgical approach to the virgin herniated lumbar disc. Spine (Phila Pa 1976). 1978;3:175–182.CrossRefGoogle Scholar
  32. 32.
    Yasargil MG. Microsurgical operation of herniated lumbar disc. Adv Neruosurg. 1977;4:81.CrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2014

Authors and Affiliations

  • Bahram Fakouri
    • 1
    Email author
  • Nitin R. Shetty
    • 1
  • Thomas C. H. White
    • 1
  1. 1.Guys and St Thomas’ HospitalLondonUK

Personalised recommendations