Review Question - QID 3795

The patient has a recurrent lumbar disc herniation (RLDH) as evidenced by L5-S1 posterolateral disc protrusion WITHOUT contrast enhancement on MRI. Given that the patient has failed conservative management, the next best step would be revision L5-S1 diskectomy.

RLDH is a common complication following lumbar spine diskectomy. Diagnosis of a RLDH should include a physical exam, standing lumbar spine radiographs, and if indicated, an MRI w/ gadolinium. Disc space protrusion that enhances with gadolinium points towards post-surgical scarring whereas a lack of enhancement is evidence of likely RLDH. Treatment of RLDH is similar to a primary herniation and involves a course of non-operative management followed by diskectomy in patients who fail conservative management. While the overall outcomes of revision diskectomy are considered to be just as good as primary diskectomy, the magnitude of improvement is considered to be less following revision surgery compared to primary surgery.

Shen et al. describe the non-operative management of acute and chronic low back pain. They discuss the importance of exercises, activity modification, behavioral modification as well as non-prescription medication for mild to moderate pain. The authors also discuss the conflicting evidence for the efficacy of transcutaneous electrical nerve stimulation, facet injections, and trigger point injections.

Hlubek et al. review the incidence, risk factors, and treatment of RLDH. Patients who require revision surgery for RLDH improved significantly compared to baseline; however, the magnitude of improvement is less than in primary discectomy patients. They note the following risk factors for RLDH: younger age, lack of a sensory or motor deficit, and a higher baseline Oswestry Disability Index (ODI) score. The authors conclude that for those that fail a trial of conservative management or present with neurologic deficit, both repeat lumbar discectomy and instrumented fusion appear to effectively treat patients with similar complication rates and clinical outcomes.

Figures A through C reveal standing upright, flexion and extension views of the lumbar spine that show normal lordotic alignment without any spondylolisthesis. Figure D is a post-contrast. Figure D is a post-contrast axial T1-weighted MRI of the L5-S1 disc showing a right-sided disc space protrusion without contrast enhancement.

Incorrect Answers:
Answer 1: The patient who has failed a course of nonoperative management presenting with recurrent lumbar disc herniation warrants surgical management.
Answer 2: The patient has a RLDH without signs of surgical site infection. There is no indication for infectious labs at this time.
Answer 4: The patient has a RLDH and as such, a revision discectomy is indicated rather than a complete decompression which would be indicated in lumbar spinal stenosis.
Answer 5: There is no evidence of spondylolisthesis on upright imaging so treatment with revision diskectomy would be most appropriate in this setting. Furthermore, repeat lumbar discectomy is just as efficacious for the treatment of RLDH as instrumented fusion and is much less morbid.