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The immediately failed lumbar disc surgery: incidence, aetiologies, imaging and management

Abstract

Studies on immediate failed back surgery syndrome (iFBSS) following lumbar microdiscectomy are rare. Our aim is to describe the incidence and the causes of these immediate failures to define the value of radiological imaging for identification of the underlying pathology and to propose a management algorithm. We defined iFBSS as persistence, deterioration or recurrence (during hospital stay) of radicular pain and/or sensorimotor deficits and/or sphincter dysfunction after microdiscectomy, which was uneventful from the surgeon’s perspective. The medical records of 1546 patients undergoing discectomy for mediolateral lumbar disc herniations were screened for iFBSS. The pre- and postoperative imaging, surgical records, therapy and outcome of patients with iFBSS were reviewed. Forty-four of 1546 patients (2.8 %) with iFBSS were identified. All patients underwent reoperation. Overseen disc material/re-herniation (n = 22), epidural hematoma (n = 6), inadequate decompression of accompanying recessal stenosis (n = 2) and dural tear with fascicle herniation (n = 1) were found to be causative. In 13 patients, who revealed no clear pathology intraoperatively, we diagnosed a battered root syndrome (nerve root swelling due to excessive surgical manipulation). The correct diagnosis could be established by neuroradiological imaging in 25 of 43 radiologically investigated patients (57 %). In our study, the radiological workup was of limited value for the correct differentiation of the various aetiologies of iFBSS. Therefore, the authors believe that the treatment strategy should strongly rely on the clinical presentation. To avoid unnecessary surgery in cases of battered root syndrome, we propose to proceed to reoperation only in patients with new or persistent radiculopathy despite adequate antiedematous medical therapy.

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Comments

Luciano Mastronardi, Roma, Italy

In this interesting paper, the authors reported their retrospective experience on immediate FBSS after microdiscectomy in a large series of newly diagnosed lumbar disc herniation operated on in a 10-year period.

Microdiscectomy is one of the most common procedures for every neurosurgeon, and the topic is very actual.

In this large series, 2.8 % of patients had an unsatisfactory result (persisting pain or persisting/new appraisal of neurological deficits) for

1. Mechanical root compression caused by residual disc herniation (50 % of cases) or by other less common reasons (hematoma, residual osseous stenosis, fascicle herniation) or

2. Intense swelling by excessive nerve root manipulation

The management algorithm proposed by the authors seems to be very reasonable: in patients with recurrent, persisting or mildly deteriorating symptoms after surgery for microdiscectomy, they recommend to start with antiedematous therapy (usually successful in treating root swelling).

In case of failure or if further deterioration occurs, other causes of iFBSS have to be considered. Even if postoperative neuroradiological examinations could be not conclusive, I agree with the authors that the attempt to establish a diagnosis is mandatory. Nowadays, after some days of failed therapy with steroids or other antiedematous therapy, a lumbar MRI is advisable for planning the second surgery. In some selected cases, CT with intradural c.e. could add some more information. In any case, as the authors conclude, if antiedematous therapy fails and/or rapid neurological deterioration occurs, re-surgery had to be considered even if the imaging workup does not demonstrate an unconfutable cause of iFBSS.

In conclusion, this article reports data confirming that the common sense is the best way for treating iFBSS. Microdiscectomy is a very common procedure, and this scientific confirmation that a prudent behaviour is recommendable in case of iFBSS seems to me very reasonable.

Florian Roser, Cleveland Clinic Abu Dhabi

The authors should be commemorated to tackle a very important ‘everyday’ topic in spine surgery. The results of their study led to a care-path, which should be strictly followed in those patients. It is a promising (and by economic means, the cheapest) finding that still a careful established clinical diagnosis is the best predictor for the correct treatment option in the individual patient. Only if short-term antiedematous treatment to resolve a temporary nerve root swelling is not of benefit, imaging would be the next escalation step in the diagnostic setup.

However, most studies of lumbar disc surgery are flawed by the fact that it is an everyday surgery, and at teaching institutions with a high caseload, many different surgeons in various stages of experience are exposed to these procedures. Although standards might exist, the intraoperative handling is imperative for the direct outcome of the affected nerve root. The experienced surgeon does know without any further diagnostic whether the outcome will be as anticipated or more prolonged and could act upfront, e.g. with application of topical agents.

Nowadays, most of the primary lumbar disc surgeries are performed on an outpatient basis or with a maximum of 3 days hospital stay. In this respect, and especially in a competitive health care system, failed back patients are not necessarily adherent to the initial caregiver, the presented results can be biased due to the fact that many iFBSS patients do not present back at their initial point of care. So, results should be interpreted with caution.

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Rohde, V., Mielke, D., Ryang, Y. et al. The immediately failed lumbar disc surgery: incidence, aetiologies, imaging and management. Neurosurg Rev 38, 191–195 (2015). https://doi.org/10.1007/s10143-014-0573-3

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  • DOI: https://doi.org/10.1007/s10143-014-0573-3

Keywords

  • Lumbar discectomy
  • Failed back surgery syndrome
  • Re-herniation