Recurrent Lumbar Disc Herniation: A Narrative Review

Volume 1 | Issue 1 | October 2020-March 2021 | page: 37-45 | Ghanshyam Kakadiya, Viraj Gandbhir, Kshitij Chaudhary

Authors: Ghanshyam Kakadiya [1] , Viraj Gandbhir [1] , Kshitij Chaudhary [1][2]

[1] Department of Orthopaedics, Topiwala National Medical College & BYL Nair Hospital, Mumbai, Maharashtra, India
[2] Department of Orthopaedics and Spine Surgery, Sir HN Reliance Foundation Hospital and Research Center, Mumbai, Maharashtra, India

Address of Correspondence
Dr. Kshitij Chaudhary,
Department of Orthopaedics and Spine Surgery, Sir HN Reliance Foundation Hospital and Research Center, Mumbai, Maharashtra, India


This narrative review aimed to identify various risk factors of recurrent lumbar disc herniation (rLDH) post-discectomy and its management. The rLDH has remained a challenging problem for spine surgeons. The incidence of rLDH is reported widely from 1% to 21%. Many possible patient-related, disc-related, and surgery-related risk factors may predispose the patient to rLDH. Moreover, the clinical and radiological diagnosis of rLDH can be challenging. Once the diagnosis is confirmed, and alternative diagnoses for leg pain have been ruled out, a course of initial non-operative treatment can be attempted. Compared to primary LDH, non-operative treatment is less likely to succeed in rLDH, possibly due to the associated epidural fibrosis and scarring. Various surgical options can be considered, including revision discectomy and fusion. Revision discectomy is usually the primary choice of surgery for the first recurrence. A fusion procedure can be chosen for those who have repeated reherniations or significant associated back pain. Precise patient selection is a must to achieve excellent surgical outcomes.
Keywords: Lumbar disc herniation, recurrent herniation, discectomy, risk factor, Epidural fibrosis, narrative review.



1. Kim KT, Park SW, Kim YB. Disc height and segmental motion as risk factors for recurrent lumbar disc herniation. Spine (Phila Pa 1976) 2009;34:2674-8.
2. Weinstein JN, Lurie JD, Tosteson TD, Skinner JS, Hanscom B, Tosteson AN, et al. Surgical vs nonoperative treatment for lumbar disk herniation: The Spine patient outcomes research trial (SPORT) observational cohort. JAMA 2006;296:2451-9.
3. McGirt MJ, Eustacchio S, Varga P, Vilendecic M, Trummer M, Gorensek M, et al. A prospective cohort study of close interval computed tomography and magnetic resonance imaging after primary lumbar discectomy: Factors associated with recurrent disc herniation and disc height loss. Spine (Phila Pa 1976) 2009;34:2044-51.
4. Shin BJ. Risk factors for recurrent lumbar disc herniations. Asian Spine J 2014;8:211-5.
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 annular defect. Spine (Phila Pa 1976) 2006;31:653-7.
6. Keskimaki I, Seitsalo S, Osterman H, Rissanen P. Reoperations after lumbar disc surgery: A population-based study of regional and interspecialty variations. Spine 2000;25:1500-8.
7. Erbayraktar S, Acar F, Tekinsoy B, Acar U, Güner EM. Outcome analysis of reoperations after lumbar discectomies: A report of 22 patients. Kobe J Med Sci 2002;48:33-41.
8. Shimia M, Babaei-Ghazani A, Sadat BE, Habibi B, Habibzadeh A. Risk factors of recurrent lumbar disk herniation. Asian J Neurosurg 2013;8:93-6.
9. Jansson KA, Nemeth G, Granath F, Blomqvist P. Surgery for herniation of a lumbar disc in Sweden between 1987 and 1999: An analysis of 27,576 operations. J Bone Joint Surg Br 2004;86:841-7.
10. Kim KT, Lee DH, Cho DC, Sung JK, Kim YB. Preoperative risk factors for recurrent lumbar disk herniation in L5-S1. J Spinal Disord Tech 2015;28:E571-7.
11. Meredith DS, Huang RC, Nguyen J, Lymas S. Obesity increases the risk of recurrent herniated nucleus pulposus after lumbar microdiscectomy. Spine J 2010;10:575-80.
12. Akmal M, Kesani A, Anand B, Singh A, Wiseman M, Goodship A. Effect of nicotine on spinal disc cells: A cellular mechanism for disc degeneration. Spine (Phila Pa 1976) 2004;29:568-75.
13. Andersen SB, Smith EC, Støttrup C, Carreon LY, Andersen MO. Smoking is an independent risk factor of reoperation due to recurrent lumbar disc herniation. Glob Spine J 2018;8:378-81.
14. Miwa S, Yokogawa A, Kobayashi T, Nishimura T, Igarashi K, Inatani H, et al. Risk factors of recurrent lumbar disk herniation: A single center study and review of the literature. J Spinal Disord Tech 2015;28:E265-9.
15. Robinson D, Mirovsky Y, Halperin N, Evron Z, Nevo Z. Changes in proteoglycans of intervertebral disc in diabetic patients. A possible cause of increased back pain. Spine (Phila Pa 1976) 1998;23:849-56.
16. Mobbs RJ, Newcombe RL, Chandran KN. Lumbar discectomy and the diabetic patient: Incidence and outcome. J Clin Neurosci 2001;8:10-3.
17. Seidler A, Bolm-Audorff U. Occupational risk factors for symptomatic lumbar disc herniation; a case-control study. Occup Environ Med 2003;60:821-30.
18. Yaman ME, Kazanci A, Yaman ND, Bas F, Ayberk G. Factors that influence recurrent lumbar disc herniation. Hong Kong Med J 2017;23:258-63.
19. Morgan-Hough CV, Jones PW, Eisenstein SM. Primary and revision lumbar discectomy: A 16-year review from one centre. J Bone Joint Surg Br 2003;85:871-4.
20. Belykh E, Krutko AV, Baykov ES, Griers MB, Preul MC, Byvaltsev VA. Preoperative estimation of disc herniation recurrence after microdiscectomy: Predictive value of a multivariate model based on radiographic parameters. Spine J 2017;17:390-400.
21. Hou T, Zhou Q, Dai F, Luo F, He Q, Zhang J, et al. Repeated microendoscopic discectomy for recurrent lumbar disk herniation. Clinics (Sao Paulo) 2015;70:120-5.
22. Pfirrmann CW, Metzdorf A, Zanetti M, Hodler J, Boos N. Magnetic resonance classification of lumbar intervertebral disc degeneration. Spine 2001;26:1873-8.
23. Ahlgren BD, Vasavada A, Brower RS, Lydon C, Herkowitz HN, Panjabi MM. Annular incision technique on the strength and multidirectional flexibility of the healing intervertebral disc. Spine 1994;19:948-54.
24. Ellenbogen JR, Marlow W, Fischer BE, Tsegaye M, Wilby MJ. Is the rate of reoperation after primary lumbar microdiscectomy affected by surgeon grade or intraoperative lavage of the disc space? Br J Neurosurg 2014;28;247-51.
25. Newsome RJ, May S, Chiverton N, Cole AA. A prospective, randomised trial of immediate exercise following lumbar microdiscectomy: A preliminary study. Physiotherapy 2009;95:273-9.
26. Licina P, Johnston E. Recurrent disc herniation-diagnosis and management. In: Lumbar Spine Online Tax Book, Section 18. Ch. 2. Spine: International Society for the Study of the Lumbar Spine; ???.
27. van de Kelft EJ, van Goethem JW, de La Porte C, Verlooy JS. Early postoperative gadolinium-DTPA-enhanced MR imaging after successful lumbar discectomy. Br J Neurosurg 1996;10:41-9.
28. Van Goethem JW, Salgado R. Imaging of the postoperative Spine: Discectomy and herniectomy. In: Van Goethem JW, van den Hauwe L, Parizel PM, editors. Spinal Imaging, Medical Radiology (Diagnostic Imaging). Berlin, Heidelberg: Springer; 2007.
29. Shafaie FF, Bundschuh C, Jinkins JR. The posttherapeutic lumbosacral spine. In: Jinkins JR, editor. Postherapeutic Neurodiagnostic Imaging. Philadelphia, PA: Lippincott-Raven; 1997. p. 245-66.
30. Swartz KR, Trost GR. Recurrent lumbar disc herniation. Neurosurg Focus 2003;15:E10.
31. Cheng J, Wang H, Zheng W, Li C, Wang J, Zhang Z, et al. Reoperation after lumbar disc surgery in two hundred and seven patients. Int Orthop 2013;37:1511-7.
32. Ahsan K, Najmus-Sakeb, Hossain A, Khan SI, Awwal MA. Discectomy for primary and recurrent prolapse of lumbar intervertebral discs. J Orthop Surg (Hong Kong) 2012;20:7-10.
33. Chen HC, Lee CH, Wei L, Lui TN, Lin TJ. Comparison of percutaneous endoscopic lumbar discectomy and open lumbar surgery for adjacent segment degeneration and recurrent disc herniation. Neurol Res Int 2015;2015:791943.
34. Kim CH, Chung CK, Sohn S, Lee S, Park SB. The surgical outcome and the surgical strategy of percutaneous endoscopic discectomy for recurrent disk herniation. J Spinal Disord Tech 2014;27:415-22.
35. Mehren C, Wanke-Jellinek L, Korge A. Revision after failed discectomy. Eur Spine J 2020;29:14-21.
36. Albayrak S, Ozturk S, Durdag E, Ayden O. Surgical management of recurrent disc herniations with microdiscectomy and long-term results on life quality: Detailed analysis of 70 cases. J Neurosci Rural Pract 2016;7:87-90.
37. Li Z, Tang J, Hou S, Ren D, Li L, Lu X, et al. Four-year follow-up results of transforaminal lumbar interbody fusion as revision surgery for recurrent lumbar disc herniation after conventional discectomy. J Clin Neurosci 2015;22:331-7.
38. Mroz TE, Lubelski D, Williams SK, O’Rourke C, Obuchowski NA, Wang JC, et al. Differences in the surgical treatment of recurrent lumbar disc herniation among spine surgeons in the United States. Spine J 2014;14:2334-43.
39. Qi L, Li M, Si H, Wang L, Jiang Y, Zhang S, et al. The clinical application of jetting suture technique in annular repair under microendoscopic discectomy: A prospective single-cohort observational study. Medicine 2016;95:e4503.
40. Suh BG, Uh JH, Park SH, Lee GW. Repair using conventional implant for ruptured annulus fibrosus after lumbar discectomy: Surgical technique and case series. Asian Spine J 2015;9:14-21.
41. Bailey A, Araghi A, Blumenthal S, Huffmon GV, Annular Repair Clinical Study Group. Prospective, multicenter, randomized, controlled study of annular repair in lumbar discectomy: Two year follow-up. Spine 2013;38:1161-9.
42. Parker SL, Grahovac G, Vukas D, Vilendecic M, Ledic D, McGirt MJ, et al. Effect of an annular closure device (Barricaid) on same level recurrent disc herniation and disc height loss after primary lumbar discectomy: Two-year results of a multi-center prospective cohort study. J Spinal Disord Tech 2013;???:???.
43. Sonmez E, Coven I, Sahinturk F, Yilmaz C, Caner H. Unilateral percutaneous pedicle screw instrumentation with minimally invasive TLIF for the treatment of recurrent lumbar disk disease: 2 years follow-up. Turk Neurosurg 2013;23:372-8.
44. El Shazly AA, El Wardany MA, Morsi AM. Recurrent lumbar disc herniation: A prospective comparative study of three surgical management procedures. Asian J Neurosurg 2013;8:139-44.
45. Qiao G, Feng M. Revision for endoscopic discectomy: Is lateral lumbar interbody fusion an option? World Neurosurg 2020;133:e26-30.
46. Kapetanakis S, Gkantsinikoudis N, Charitoudis G. The role of full-endoscopic lumbar discectomy in surgical treatment of recurrent lumbar disc herniation: A health-related quality of life approach. Neurospine 2019;16:96-104.
47. Cao J, Huang W, Wu T, Jia J, Cheng X. Percutaneous endoscopic lumbar discectomy for lumbar disc herniation as day surgery-short-term clinical results of 235 consecutive cases. Medicine (Baltimore) 2019;98:e18064.
48. Jung YS, Choi HJ, Kwon YM. Clinical outcome and influencing factor for repeat lumbar discectomy for ipsilateral recurrent lumbar disc herniation. Korean J Spine 2012;9:1-5.
49. Zhang S, Chen H. Mini-open transforaminal lumbar interbody fusion through a modified wiltse paraspinal approach for recurrent lumbar disc herniation. Int J Clin Exp Med 2019;12:2525-31.
50. Ahmed OE, Morad SH, Abdelbar AS. Management of recurrent unilateral lumbar disc herniation in a single level: Unilateral versus bilateral pedicle screws fixation with interbody fusion. Egypt J Neurol Psychiatry Neurosurg 2020;56:28.

How to Cite this Article: Kakadiya G, Gandbhir V, Chaudhary K| Recurrent Lumbar Disc Herniation: A Narrative Review | Back Bone: The Spine Journal | October 2020-March 2021; 1(1): 37-45.


(Abstract) (Full Text HTML)      (Download PDF)


Which is Better in Laborers? A Comparison Between Open and Micro Endoscopic Discectomy

Volume 1 | Issue 1 | October 2020-March 2021 | page: 8-12  | Hitesh N. Modi, Tushar Kunder, Neel Bhavsar, Pankaj R. Patel

Authors: Hitesh N. Modi [1][2], Tushar Kunder [1], Neel Bhavsar [1], Pankaj R. Patel [1]

[1] Department of Orthopaedics, NHL Municipal Medical College
and Vadilal Sarabhai General Hospital, Ahmedabad, Gujarat, India.
[2] Department of Spine Surgery, Zydus Hospital and Healthcare
Research Pvt. Ltd., Ahmedabad, Gujarat, India .

Address of Correspondence
Dr. Hitesh N. Modi,
Spine Surgeon, Vadilal Sarabhai General Hospital, Ahmedabad, Gujarat, India.
Spine Surgeon, Zydus Hospital and Healthcare Research Pvt. Ltd., Ahmedabad, Gujarat, India .


Introduction: None of the studies compared the results of open lumbar discectomy (OLD) and microendoscopic discectomy (MED) surgeries in laborers. The aim of this study was to compare the clinical and functional impact of OLD versus MED surgery in laborers to find out which is better.

Materials and Methods: This retrospective study was performed in 91 laborers (54 males and 37 females) who underwent OLD (n = 41) versus MED (n = 50) for the single- or double-level lumbar disc herniation (LDH). All patients were operated at a single institute after a failure of conservative trial for 6 weeks. Patients with associated severe disc degeneration, stenosis, instabilities, or other pathologies were excluded from the study. The clinical results were evaluated with Oswestry Disability Index (ODI), visual analog score (VAS), and duration of return back to work.

Results: The average age of the study group was 39.8 ± 12.1 years. Average follow-up was 50.2 ± 13.9 months. The entire study group comprised manual labor work such as farming or loading work with an average income of US $53.6 ± 14.6 (approximately INR 4000) per month. The patients belonged to low socioeconomic status as per modified Kuppuswamy scale. The post-operative VAS scores were significantly reduced in both MED (7.6–2.0) and open discectomies (7.2–2.1). Improvement ODI scores also showed similar trends for MED (57.3–20.6) and for open discectomies (55.1–20.1). Average duration to return to work was significantly less in the MED group in comparison to the OLD group (18.0 vs. 25.5 days). There were total 4 (4.4%) complications perioperatively. There were one superficial wound infection in the OLD and one dural tear in the MED group. Both were managed conservatively. There was one patient from each group having recurrent disc herniation that was managed conservatively. There were one patient from the MED and two patients from the OLD group who could not return to their previous work or had to modify their work due to back pain.

Conclusion: Although clinical improvement after discectomy surgery in laborers is similar, MED is a promising alternative to OLD in laborers with respect to return to work earlier. Such studies may further throw light in differential management of laborer population with MEDs versus OLD.

Keywords: Lumbar disc herniation; Laborers; Discectomy technique; Early return to work.



1. Balagué F, Mannion AF, Pellisé F, Cedraschi C. Non-specific low back pain. Lancet 2012;379:482-91.
2. McCall IW. Lumbar herniated disks. Radiol Clin North Am 2000;38:1293-309.
3. Van Boxem K, Cheng J, Patijn J, Van Kleef M, Lataster A, Mekhail N, et al. 11. Lumbosacral radicular pain. Pain Pract 2010;10:339-58.
4. Yoke CO, Ann TK. Study of lumbar disc pathology among a group of dockworkers. Ann Acad Med Singap 1979;8:81-5.
5. Yadav RI, Long L, Yanming C. Comparison of the effectiveness and outcome of microendoscopic and open discectomy in patients suffering from lumbar disc herniation. Medicine (Baltimore) 2019;98:e16627.
6. Kulkarni AG, Bassi A, Dhruv A. Microendoscopic lumbar discectomy: Technique and results of 188 cases. Indian J Orthop 2014;48:81-7.
7. He J, Xiao S, Wu Z, Yuan Z. Microendoscopic discectomy versus open discectomy for lumbar disc herniation: A meta-analysis. Eur Spine J 2016;25:1373-81.
8. Rompe JD, Eysel P, Zöllner J, Heine J. Prognostic criteria for work resumption after standard lumbar discectomy. Eur Spine J 1999;8:132-7.
9. Singh T, Sharma S, Nagesh S. Socio-economic status scales updated for 2017. Int J Res Med Sci 2017;5:3264-7.
10. Hoy DG, Smith E, Cross M, Sanchez-Riera L, Buchbinder R, Blyth FM, et al. The global burden of musculoskeletal conditions for 2010: An overview of methods. Ann Rheum Dis 2014;73:982-9.
11. Rothoerl RD, Woertgen C, Brawanski A. When should conservative treatment for lumbar disc herniation be ceased and surgery considered? Neurosurg Rev 2002;25:162-5.
12. Foley KT. Microendoscopic discectomy. Tech Neurosurg 1997;3:301-7.
13. Tullberg T, Isacson J, Weidenhielm L. Does microscopic removal of lumbar disc herniation lead to better results than the standard procedure? Results of a one-year randomized study. Spine (Phila Pa 1976) 1993;18:24-7.
14. Muramatsu K, Hachiya Y, Morita C. Postoperative magnetic resonance imaging of lumbar disc herniation: Comparison of microendoscopic discectomy and Love’s method. Spine (Phila Pa 1976) 2001;26:1599-605.
15. Schizas C, Tsiridis E, Saksena J. Microendoscopic discectomy compared with standard microsurgical discectomy for treatment of uncontained or large contained disc herniations. Neurosurgery 2005;57:357-60.
16. Shin DA, Kim KN, Shin HC, Yoon DH. The efficacy of microendoscopic discectomy in reducing iatrogenic muscle injury. J Neurosurg Spine 2008;8:39-43.
17. Garg B, Nagraja UB, Jayaswal A. Microendoscopic versus open discectomy for lumbar disc herniation: A prospective randomised study. J Orthop Surg (Hong Kong) 2011;19:30-4.
18. Bhatia PS, Chhabra HS, Mohapatra B, Nanda A, Sangodimath G, Kaul R. Microdiscectomy or tubular discectomy: Is any of them a better option for management of lumbar disc prolapse. J Craniovertebr Junction Spine 2016;7:146-52.
19. Brock M, Kunkel P, Papavero L. Lumbar microdiscectomy: Subperiosteal versus transmuscular approach and influence on the early postoperative analgesic consumption. Eur Spine J 2008;17:518-22.
20. Mayer HM, Brock M. Percutaneous endoscopic discectomy: Surgical technique and preliminary results compared to microsurgical discectomy. J Neurosurg 1993;78:216-25.
21. Bookwalter JW 3rd, Busch MD, Nicely D. Ambulatory surgery is safe and effective in radicular disc disease. Spine (Phila Pa 1976) 1994;19:526-30.
22. Caspar W, Campbell B, Barbier DD, Kretschmmer R, Gotfried Y. The Caspar microsurgical discectomy and comparison with a conventional standard lumbar disc procedure. Neurosurgery 1991;28:78-86.
23. Perez-Cruet MJ, Foley KT, Isaacs RE, Rice-Wyllie L, Wellington R, Smith MM, et al. Microendoscopic lumbar discectomy: Technical note. Neurosurgery 2002;51:S129-36.
24. Fujii Y, Yamashita K, Sugiura K, Ishihama Y, Manabe H, Tezuka F, et al. Early return to activity after minimally invasive full endoscopic decompression surgery in medical doctors. J Spine Surg 2020;6:S294-9.

How to Cite this Article: Modi HN, Kunder T, Bhavsar N, Patel PR | Which  is Better in Laborers? A Comparison Between Open and Micro Endoscopic Discectomy| Back Bone: The Spine Journal | October 2020- March 2021; 1(1): 8-12.


(Abstract) (Full Text HTML)      (Download PDF)