The purpose of this study is to identify some risk factors
and post-operative predictors for recurrent lumbar disc
hernia (rLDH) during a long-term follow-up in patients
treated with microdiscectomy.
Aim of the paper: This study analyzes some risk factors
and postoperative predictors for recurrent lumbar disc
hernia (rLDH) during a long-term follow-up in patients
treated with microdiscectomy.
Material and methods. We analyzed retrospectively a
consecutive series of patients who underwent lumbar
spinal microdiscectomy for lumbar disc herniation
(LDH) from January 2013 to June 2018 at our Institute.
The rate of rLDH during long-term follow-up was
analyzed and correlated with baseline and post-operative
data.
Results. A total of 263 patients were included with a median
follow-up time of 24 months (from 13 to 43 months

dobran m

IRIS UniversitÃ  Politecnica delle Marche

1 Paracino R.1 Mancini F.2 Lattanzi S.1 Dobran M.1 Department of Neurosurgery, Università Politecnica delle Marche - Ospedali Riuniti, Ancona, Italy.2 Department of Neurology, Università Politecnica delle Marche - Ospedali Riuniti, Ancona, ItalyAbstractThe purpose of this study is to identify some risk factors and post-operative predictors for recurrent lumbar disc hernia (rLDH) during a long-term follow-up in patients treated with microdiscectomy.Aim of the paper: This study analyzes some risk factors and postoperative predictors for recurrent lumbar disc hernia (rLDH) during a long-term follow-up in patients treated with microdiscectomy.Material and methods. We analyzed retrospectively a consecutive series of patients who underwent lumbar spinal microdiscectomy for lumbar disc herniation (LDH) from January 2013 to June 2018 at our Institu-te. The rate of rLDH during long-term follow-up was analyzed and correlated with baseline and post-opera-tive data.Results. A total of 263 patients were included with a me-dian follow-up time of 24 months (from 13 to 43 months). Most of the patients had rLDH within the first 36 months after surgery. At multivariate analysis, recurrence of LDH was associated with higher pre-operative body mass in-dex (BMI) and higher post-operative Oswentry disability index (ODI) with statistical significance. Conclusions. Baseline BMI and post-surgery ODI could predict rLDH after surgery during a long-term follow-up.Keywords: recurrent disc herniation, lumbar disc herniation, lumbar microdiscectomy, discectomy.Article received: 15.12.2021.Article accepted: 15.03.2021.https://doi.org/10.24141/1/7/2/2Corresponding author:  Dobran M. A: Department of Neurosurgery, Università Politecnica delle Marche - Ospedali Riuniti, Ancona, Italy Email: dobran@libero.it  Tel: +39 347 3626 394Risk Factors and Post-Operative Predictors for Recurrent Lumbar Disc Herniation: A Long-term Follow-up StudyJ. appl. health sci. 2021; 7(2): 121-126122 Paracino R. et al. Risk Factors and Post-Operative Predictors for Recurrent Lumbar Disc Herniation... J. appl. health sci. 2021; 7(2): 121-126Finally, coagulation of the annulus, hemostasis and reconstruction were made. Radiological examination included MRI imaging of the lumbar spine before and after surgery. Exclusion criteria were multi segmental spinal canal stenosis, spinal infection, spondylolisthe-sis, vertebral trauma and spinal deformities. Open mi-crodiscectomy was performed by the same group of surgeons using a standard technique. Recurrence of disc herniation was defined as disc herniation at the same level and side of previous microdiscectomy after a period free of postoperative pain for 3 months at least. In this study we evaluated the rate of recurrent lumbar disc herniation (rLDH) after standard microdiscectomy during long-term follow-up and its relationship with baseline and post-operative variables.Statistical analysisValues were presented as mean ± standard deviation (SD) or median (interquartile range [IQR]) for continu-ous variables and as the number (percent) of subjects for categorical variables. The Kaplan-Meier survival curves analysis and log-rank test were used to analyze the time to rLDH and assess differences between sub-groups. Uni- and multivariate analyses by Cox regres-sion model were performed to estimate hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) for the following variables: age, sex, smoking status, body mass index (BMI), disc hernia level, and post-operative Oswentry disability index (ODI). Subgroup analysis was planned based on the post-operative ODI (below versus above the average value observed in the study cohort). Results were considered significant for p values <0.05 (two sided). Data analysis was performed using STATA/IC 13.1 statistical package (StataCorp LP, Texas, USA).IntroductionRecurrent herniation of the lumbar disc after microdis-cectomy is a common complication ranging from 2% to 25% of all operated patients [1]. Still today the factors underlying LDH recurrence are under debate and many authors postulate that heavy activities, advanced age, constitutional weakness of the fibrous annulus could have a role [2]. In patients with rLDH and intractable pain or neurological deficit the revision surgery may be mandatory but clinical results are poor. In this light the knowledge of risk factors for recurrence is important to avoid a reoperation with elevated risk of infection [3], failed back syndrome and elevated costs for the health care system. Aim of the paperThis study analyzes some risk factors and post-opera-tive predictors for recurrent lumbar disc hernia (rLDH) during a long-term follow-up in patients treated with microdiscectomy. The knowledge of the predictive fac-tors may help to identify patients at risk of recurrence.Material and MethodsWe retrospectively reviewed data of consecutive pa-tients who underwent standard lumbar spinal micro-discectomy for disc herniation (LDH) at our institution from January 2013 to June 2018. Under general anes-thesia the patient was positioned prone on frame, a horizontal skin incision of approximately 4 cm in length above the lumbar spinal segment was made followed by the incision of the lumbo-dorsal fascia. Using the operating microscope, a partial hemilaminectomy of the superior and inferior lamina and flavectomy were performed. The hernia and the intra-discal fragments were removed by a combination of water and rongeurs. Paracino R. et al. Risk Factors and Post-Operative Predictors for Recurrent Lumbar Disc Herniation... J. appl. health sci. 2021; 7(2): 121-126  123DiscussionLumbar disc hernia is the most common debilitating dis-ease in adult people. The microdiscectomy is the gold standard of the treatment in patients with persistent pain or motor deficit. Recurrent disc hernia, defined as disc hernia at the same level of previous microdiscec-tomy in patients with a pain-free interval of at least 3 months after surgery [1], is a frequent complication and the major cause of postoperative failure with onset of the failed back syndrome. Still today the treatment of choice for rLDH is under debate with some authors ad-vocating fusion as the treatment of choice while others prefer to repeat microdiscectomy. In this light the prevention of the recurrence is manda-tory and the knowledge of some pre-operative factors related with recurrence may help patient selection or advise for a prudential convalescence in the postopera-tive period.Many studies [1-4-5] in literature analyze the factors influencing the outcome after microdiscectomy for the treatment of lumbar disc hernia. In line with literature our data confirm that age, gender, smoking and type of hernia tion, side of recurrence and duration of recurrent symp toms were not correlated with the outcome. In our series the recurrence rate in a long-term follow-up (13-43 months) was 17,6% with BMI and postoperative ODI value associated with the risk of rLDH (table 2).Obesity causes a persistent heavy load on the vertebral column with joint and intervertebral disc damage [6-7-8]. In our study higher BMI was an independent predic-tor of recurrence both at unadjusted logistic regression ResultsA total of 262 patients were included in this study. The mean age of patients was 46.5 (12.5) years and 161 (61.5%) were males. Baseline characteristics of patients are summarized in Table 1. The median follow-up time was 24 [13-43] months. Dur-ing the follow-up, 46 (17.6%) patients presented rLDH, with most cases occurring within 24 months from sur-gery (Figure 1). At the multivariate analysis, higher BMI and higher post-operative ODI were associated with the risk of rLDH (Table 2). The risk of recurrence was signifi-cantly increased in patients with high post-operative ODI value (Figure 2).Table 1. Baseline characteristics of patients Full cohort(n=262)Age (years) 46.5 (12.5)Sex 161 (61.5%)Body Mass Index (kg/m2) 26.3 (3.3)Smoking 159 (60.7)Disc hernia levelL3-L4L4-L5L5-S1 47 (17.9)131 (50)84 (32.1)Post-operative ODI 15 [5-20]Data are mean (SD) or median [IQR] for continuous variables,  and n (%) for categorical variables.Abbreviation: ODI=Oswestry Disability Index.Table 2. Long-term recurrence of lumbar disc herniation Independent VariableUnadjusted Adjusted*HR (95% CI) p value HR (95% CI) p valueAge 1.02 (1.00-1.05) 0.059 1.02 (0.999-1.050) 0.056Sex 0.94 (0.52-1.69) 0.831 0.78 (0.42-1.42) 0.425Smoking 1.47 (0.76-2.84) 0.251 0.15 (0.58-2.2) 0.681Body Mass Index 1.17 (1.06-1.29) 0.002 1.14 (1.03-1.26) 0.007Disc hernia level 0.93 (0.62-1.41) 0.739 0.85 (0.55-1.32) 0.474Post-operative ODI 1.05 (1.02-1.09) 0.003 1.05 (1.01-1.09) 0.014*Adjustment by age, sex, smoking, BMI, disc hernia level and ODI.Abbreviations: CI=confidence interval; HR=hazard ratio, ODI=Oswestry Disability Index. 124 Paracino R. et al. Risk Factors and Post-Operative Predictors for Recurrent Lumbar Disc Herniation... J. appl. health sci. 2021; 7(2): 121-126vated postoperative ODI score with intractable pain the MRI study is mandatory especially when symptoms are present within 24 months from surgery because in our study the rate of recurrence is maximum within 2 years from surgery.analysis (p=0.002) and at adjusted analysis (p=0.007). The ODI score documented disabilities related with pain and vertebral diseases such as spondyloarthro-sis, disc hernia and lumbar stenosis [10-11-12]. In our series elevated ODI score in the long-term follow-up is associated with rLDH. We may postulate that elevated postoperative ODI score values are correlated with the presence of disc material in the vertebral canal and progressive radicular compression. In patients with ele-Figure 1. Time to recurrent lumbar disc herniation Kaplan-Meier estimates for the time to recurrent lumbar disc herniation over follow-upFigure 2. Time to recurrent lumbar disc herniation according to post-operative ODI Kaplan-Meier estimates for the time to recurrent lumbar disc herniation according to post-operative ODI (p for log-rank test=0.017) Paracino R. et al. Risk Factors and Post-Operative Predictors for Recurrent Lumbar Disc Herniation... J. appl. health sci. 2021; 7(2): 121-126  125References1. Recurrent lumbar disc herniation after single-level lum-bar discectomy: incidence and health care cost analysis. Neurosurgery. 2009;65:574-578.2. Yaman ME1,  Kazancı A2,  Yaman ND3,  Baş F4,  Ayberk G2. Factors that influence recurrent lumbar disc herniation. Hong Kong Med J. 2017 Jun;23(3):258-63.3. Dobran M1,  Mancini F1,  Nasi D1,  Scerrati M1. A case of deep infection after instrumentation in dorsal spinal surgery. The management with antibiotics and nega-tive wound pressure without removal of fixation. BMJ Case Rep.  2017 Jul 28;2017. pii: bcr-2017-220792. doi: 10.1136/bcr-2017-220792.4. Ebeling U, Kalbarcyk H, Reulen HJ. Microsurgical reo-peration following lumbar disc surgery: timing, surgi-cal findings, and outcome in 92 patients. J Neurosurg. 1989;70:397-404.5. Meredith DS, Huang RC, Nguyen J, Lymas S. Obesity incre-ases the risk of recurrent herniated nucleus pulposus af-ter lumbar microdiscectomy. Spine J. 2010;10:575-580.6. Dobran M,* Nasi D, Paracini R, Gladi M, Della Costanza M, Marini A, et all. Analysis of risk factors and postopera-tive predictors for recurrent lumbar disc herniation. Sug. Neurol Int 2019; 10:36. 7. Madsbu MA1,  Øie LR2,  Salvesen Ø3,  Vangen-Lønne V4, Nygaard ØP5, Solberg TK6, Gulati S7. Lumbar Microdis-cectomy in Obese Patients: A Multicenter Observational Study. World Neurosurg. 2018 Feb;110:e1004-e10108. Miwa S, Yokogawa A, Kobayashi T, et al. Risk factors of recurrent lumbar disc herniation: a single center study and review of the literature. J Spinal Disord Tech. 2015;28:E265-E269.9. Nicholas Shepard, and Woojin Cho. Recurrent Lumbar Disc Herniation: A Review. Global Spine Journal. 1-8; 2017.10. Shin Byung-Joon Risk Factors for Recurrent Lumbar Disc Herniations Asian Spine J. 2014 Apr; 8(2): 211–215.11. Tonosu J1, Takeshita K, Hara N, Matsudaira K, Kato S, Ma-suda K, Chikuda H. The normative score and the cut-off value of the Oswestry Disability Index (ODI). Eur Spine J. 2012 Aug;21(8):1596-602.12. Weimin Huang, MD, Zhiwei Han, PhD, Jiang Liu, PhD, Lili Yu, MD, and Xiuchun Yu, MD. Risk Factors for Recurrent Lum-bar  Disc  Herniation: A Systematic  Review and Meta-Analysis. Medicine (Baltimore). 2016 Jan;95(2):e2378.ConclusionsIn patients operated for lumbar disc hernia by micro-discectomy baseline BMI and postoperative ODI value predict rLDH in a long-term follow-up. Funding: No funding was received for this research.Compliance with ethical standards.Conflict of interest: The authors have no known conflicts of interest to declare. The manuscript submitted does not contain information about medical device(s)/drug(s). All authors contributed to the design of the study. Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional committee and with the latest amendment of the Helsinki declaration.Informed consent: Informed consent was obtained from all individual participants included in the study.Acknowledgements: None.126 Paracino R. et al. Risk Factors and Post-Operative Predictors for Recurrent Lumbar Disc Herniation... J. appl. health sci. 2021; 7(2): 121-1261 Paracino R.1 Mancini F.2 Lattanzi S.1 Dobran M.1 Department of Neurosurgery, Università Politecnica delle Marche - Ospedali Riuniti, Ancona, Italy.2  Department of Neurology, Università Politecnica delle Marche - Ospedali Riuniti, Ancona, ItalySažetakCilj. Ova studija analizira određene čimbenike rizika i poslijeoperacijske prediktore za ponavljajuću herniju lumbalnog diska (engl. recurrent lumbar disc hernia – rLDH) tijekom dugotrajnog praćenja bolesnika liječenih mikrodiskektomijom.Metode. Retrospektivno smo analizirali niz uzastopnih serija pacijenata koji su podvrgnuti lumbalnoj spinalnoj mikrodiskektomiji zbog hernije lumbalnog diska (engl. lumbar disc hernia – LDH) u razdoblju od siječnja 2013. do lipnja  2018. u našem Institutu. Stopa ponavljajuće hernije lumbalnog diska tijekom dugotrajnog praćenja analizirana je i korelirana s početnim anamnestičkim podacima i poslijeoperacijskim podacima.Rezultati. U studiju je uključeno ukupno 263 pacijenta s prosječnim vremenom praćenja od 24 mjeseca (od 13 do 43 mjeseca). Većina pacijenata imala je ponavljajuću her-niju lumbalnog diska u prvih 36 mjeseci nakon operacije. Pri multivarijantnoj analizi, recidiv hernije lumbalnog diska povezan je s višim indeksom tjelesne mase (engl. body mass index – BMI) prije operacije i višim Oswestry indeksom invaliditeta nakon operacije (engl. Oswestry disability index – ODI) sa statističkom značajnošću.Zaključak. Početni indeks tjelesne mase i poslijeopera-cijski Oswestry indeks invaliditeta mogu poslužiti kao prediktori ponavljajuće hernije lumbalnog diska nakon operacije tijekom dugotrajnog praćenja.Ključne riječi: ponavljajuća hernija diska, hernija lumbalnog diska, lumbalna mikrodiskektomija, diskektomija.ČIMBENICI RIZIKA I POSLIJEOPERACIJSKI PREDIKTORI ZA PONAVLJAJUĆU HERNIJU LUMBALNOG DISKA: DUGOROČNO PRAĆENJE

English

Risk Factors and Post-Operative
Predictors for Recurrent Lumbar Disc
Herniation: A Long-term Follow-up
Study

https://iris.univpm.it/bitstream/11566/294368/1/2021%20Mar%2015%20-%20Journal%20of%20applied%20health%20sciences%20-%20Risk%20Factors%20and%20Post-Operative%20Predictors%20for%20Recurrent%20Lumbar%20Disc%20.pdf

Risk Factors and Post-Operative Predictors for Recurrent Lumbar Disc Herniation: A Long-term Follow-up Study

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