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Between 2001 and 2005, 43 patients (average age 54.2, range 36–68 years) with recurrent lumbar disc herniation underwent reoperation with the transforaminal lumbar interbody fusion (TLIF) technique at our unit. All cases were followed up for 24–72 months (mean 45 months) and graded using the Japanese Orthopaedic Association (JOA) score system pre- and post-operation and during the follow-up period. The leg pain of all patients was relieved significantly within one month postoperatively. The mean JOA score was improved from 9.3 before surgery to 25.0 at the final follow-up visit (P<0.0001). The average recovery rate was 86.0% (range 52–100%). General clinical outcome was excellent in 23 (53.5%) patients, good in 14 (32.6%) and fair in 6 (13.9%). The fusion rate was 100% two years postoperatively. Three patients (7%) had transient neurological deficits, which resolved completely within 3 months. There were no major complications. We, therefore, believe the TLIF technique to be an effective procedure with satisfactory clinical results for the treatment of recurrent lumbar disc herniation.
Entre 2001 et 2005, 43 patients (âge moyen 54,2 ans entre 36 à 68 ans) ont bénéficié d’une réintervention chirurgicale avec arthrodèse inter corporéale par technique transforaminale pour récidive de hernie discale lombaire. Tous ces patients ont été suivis en moyenne pendant 45 mois et évalués selon le score de la JOA en pré et post opératoire. Les douleurs des membres de tous ces patients ont été nettement améliorées dans le premier mois post opératoire. Le score de la JOA a été également améliorée de 9,3 avant l’intervention à 25 lors de la dernière revue de ces malades (P<0,0001). Le taux moyen de récupération a été de 86% (52 à 100%). L’évolution clinique générale a été excellente chez 23 patients (53,5%), bonne chez 14 patients (32,6%) et médiocre chez 6 patients (13,9%). Le taux de fusion a été de 100% en post opératoire. 3 patients (7%) ont eu des troubles neurologiques transitoires qui ont complètement régressé dans les trois mois. Il n’y a pas eu de complications majeures. L’étude technique TLIF est une technique efficace qui nous donne satisfaction dans le traitement des récidives de hernies discales lombaires.
Recurrent lumbar disc herniation (RLDH) is a major cause of surgical failure, the incidence of which is reported from 5 to 11%, with an increased incidence as the follow-up period is extended [2, 5, 13]. The optimal technique for treating RLDH is controversial. Some authors believe that repeat discectomy is the treatment of choice, with similar clinical results compared to the primary procedure [3, 12], but approach-related complications can be considerable. Scar tissue makes a repeated discectomy more difficult, increasing the risk of dural tear or nerve injury [11, 14].
Some spine surgeons believe that fusion is necessary for treating disc reherniation. As repeated discectomy for either ipsilateral or contralateral recurrence requires the removal of more disc material and posterior elements, such as lamina or facet joint, further invasion at the same surgical level can increase the risk of segmental instability [3, 11]. Iida et al.  reported 46 patients who had underdone either partial or wide laminectomy and were followed up for more than 1 year after surgery. The total number of cases of instability confirmed at the operated level or at both the operated and adjacent levels was 52.2% (24/46). A large retrospective follow-up study of patients undergoing multiple revisions after lumbar discectomy revealed markedly reduced risk for subsequent operations if the first procedure was a spinal fusion (5.0% vs. 24.9% after discectomy and 27.2% after spinal decompression) . Therefore, the use of fusion to treat or prevent segmental instability after repeated discectomy appears to be a reasonable choice in cases of recurrent disc herniation.
Several authors reported the results of posterolateral fusion (PLF) for RLDH , but there are few reports on RLDH treated with the transforaminal lumber interbody fusion (TLIF) technique. TLIF affords the opportunity to achieve stable three-column fixation with anterior support, simultaneous anterior and posterior fusion, and inherent stability through a single posterior surgical approach and unilateral placement of interbody cages. The purpose of this study is to evaluate the efficacy of the TLIF technique for patients with RLDH.
Between March 2001 and April 2005, 43 patients in our unit underwent reoperation following primary lumbar discectomy. There were 32 men and 11 women, with a mean age of 54.2 years (range 36–68 years).
The inclusion criteria for this study were: (1) at least 6 months of pain relief after primary disc surgery, (2) the presence of recurrent radicular pain unresponsive to conservative treatment, leading to a repeat operation and (3) recurrent disc herniation at the same level as previous discectomy, either the ipsilateral or the contralateral side. Thirty-four patients had one lumbar disc operation before admittance to hospital, seven had two and two had three operations. The primary procedures included discectomy with laminotomy in seven patients, discectomy with unilateral hemilaminectomy in 12 and discectomy with bilateral laminectomy (total laminectomy) in 24. The time from the primary surgery to that of recurrence averaged 9.2 years (range 1.5–23 years). Magnetic resonance imaging (MRI) was conducted for diagnosis in all cases, computed tomography (CT) was performed in seven cases and myelography in two cases. The levels of recurrent disc herniation were 28 cases at L4–5 (23 ipsilateral and five contralateral), 13 at L5–S1 (11 ipsilateral and two contralateral) and two at L3–4 (ipsilateral).
Bilateral dissection was extended just lateral to the facet joints through a midline posterior approach. The epidural scar tissue in the area of the previous laminectomy was left intact. Pedicle screw sites were prepared in the surgeon’s usual fashion. On the symptomatic side, the pars interarticularis was removed and a hemifacetectomy performed on the superior and inferior facets at the level of the spinal segment to be fused. These cuts provide access to the intervertebral disc. The traversing nerve root is protected by sliding a retractor along the upper surface of the pedicle of the inferior vertebra. The exiting nerve root hugs the inferomedial surface of the pedicle and can be directly visualised throughout the procedure. A nearly complete discectomy is performed using disc shavers, curettes and rongeurs. End-plate decortication was performed. Intervertebral disc space spreaders were then sequentially inserted and rotated to restore the normal disc space height. Once the disc space is distracted, the anterior two-thirds of the disc space is packed with cancellous bone from the laminectomy bone or iliac crest autograft. A single Telamon cage (Medtronic Sofamor Danek, Memphis, TN) packed with laminectomy bone is inserted posterolaterally and oriented anteromedially. A lateral fluoroscopic image is obtained to confirm proper positioning of the Telamon cage. Then, connecting rods are placed and compression is applied across the instrumentation to restore segmental lordosis and are locked in place.
The patients were examined and data were recorded preoperatively, at surgery and postoperatively at 3, 6, 12, 24 months and at the latest follow-up. Anterior-posterior and lateral X-rays were done at each interval. Flexion and extension X-rays were done at 12, 24 months and at the latest follow-up. An independent radiologist was invited to determine the fusion status based on radiographic study. Criteria for a successful fusion were the lack of motion, anterior bridging bone and the lack of lucencies on flexion/extension X-rays and/or contiguous bone through the cage using a thin-cut sagittal CT scan. The clinical symptoms were assessed at each interval. The JOA score (Japanese Orthopaedic Association’s evaluation system for low-back pain syndrome) was determined via direct questioning to assess subjective symptoms, clinical signs and the restriction of activities of daily living. The normal score was 29 points (Table 1). The recovery rate of the JOA score also was calculated, following the description of Hirabayashi et al. . Surgery outcomes were assessed based on the recovery rate and were classified using a four-grade scale: excellent, improvement of over 90%; good, 75% to 89% improvement; fair, 50% to 74% improvement; and poor, below 49% improvement.
All cases were followed up for a mean of 45 months (range 24–72 months) postoperatively. The average disc space height at the herniated levels was fairly well maintained. The post-treatment mean disc height at the herniated level was 91.5±11% of the level above the fusion, while the pre-operation mean disc height at the herniated level was 58.6±12.3% of the cephalic adjacent level (p<0.001). No patient had evidence of implant failure. Interbody fusion was graded as definitely solid in 100% of cases 2 years postoperatively (Figs. 1, ,22 and and33).
Leg pain decreased rapidly (within one month) in all patients and continued to decrease at the time of the latest follow-up. The mean JOA score of the patients showed improvement, improving from 9.3 before surgery to 25.0 at the final follow-up visit (p<0.0001). The average recovery rate was 86.0% (range 52–100%). General clinical outcome, based on the JOA score, was excellent in 23 (53.5%) patients, good in 14 (32.6%) and fair in six (13.9%).
Dural laceration occurred during the surgical decompression in two patients; both were repaired during the operation and there were no cerebrospinal fluid leaks post-operatively. One patient displayed a superficial wound infection. Following appropriate debridement and antibiotics, the wound healed without sequelae. Three patients (7%) had transient neurological deficits, which were resolved completely in 3 months. There were no major complications, either permanent neurological deficit, pulmonary embolism, perioperative cardiac event or death.
The optimal surgical approach for recurrent disc herniation remains a subject of controversy. Discectomy with fusion has several theoretical advantages. Specifically, interbody fusion reduces or eliminates segmental motion, immobilises the spine, reduces mechanical stresses across the degenerated disc space  and may reduce additional herniation at the affected disc space . Lehmann and LaRocca  treated 36 patients following previous lumbar surgery by spinal canal exploration and spinal fusion. Solid fusion correlated closely with satisfactory outcomes, and the patients in the fusion group tended to have better outcomes than those with disc excision alone.
Revision spinal surgery is more challenging than primary surgery, owing to the indistinct anatomical planes and perineural scarring. Ebeling et al.  reported a complication rate of 13% after repeated discectomy, and dural tears and infections were the most common problems. However, TLIF provides an approach through facetectomy to enter unscarred virgin tissue. Therefore, the surgeon can approach the target site safely without demanding dissection of the fibrotic scar tissues, and excessive retraction of scarred nerve root and dura, the potential risk of dural tear and nerve injury may also be decreased. Only two (4.7%) cases experienced dural tear during surgery in our series, which is lower than the previous reports [8, 9].
Postoperative degenerative changes after the conventional discectomy can arise with time. Gradual disc space subsidence and impingement of the superior facet could result in foraminal stenosis. In our series, we found foraminal stenosis in 11 patients, the average disc space height at the recurrent levels was 58.6±12.3% of the cephalic adjacent level. The distraction spreaders were sequentially inserted until the desired annular tension was achieved. As the intervertebral disc space height increases, so does the neuroforaminal volume. The post-treatment mean disc height at the recurrent level was 91.5±11% of the level above the fusion. Because the foraminal portion can be exposed in the course of the TLIF approach, adequate foraminal decompression can be easily accomplished. Satisfactory outcomes were obtained from our study. None of the patients had a poor result, although three patients had transient neurological deficits, which were completely resolved within 3 months. These are comparable with the rates of satisfactory clinical results reported by others [2, 3, 12, 15].
We used a single cage inserted diagonally from the symptomatic side. A more lateral entry point compared with posterior lumbar interbody fusion (PLIF) is selected, which can reduce dura and nerve root retraction and minimise the risk of neurological injury. Zhao et al.  demonstrated that, as only unilateral facetectomy is required for the insertion of a single cage, the stiffness of the construction is significantly superior to the stand-alone two-cage analogue. Because the Telamon cage has 3 or 8 degrees of lordosis, TLIF enables the reconstruction of the anterior column and restores lumbar lordosis. Bone grafting of the available surface area of the disc space is important for fusion success. Before cage insertion, the prepared laminectomy bone or iliac crest autograft was grafted into the prepared disc space and in the cage. Because we used only one cage, there was more space for the bone graft than when two cages were inserted. We believe that the bone outside the cage has greater fusion potential than the bone inside the cage. The placement of additional bone grafts around the single cage may enhance the fusion rate; there were no pseudarthroses in our series.
Based on these clinical outcomes, as well as the theoretical advantages of TLIF, we found the TLIF technique to be an effective procedure with satisfactory clinical results for the treatment of recurrent lumbar disc herniation. It can restore the stability and lordosis of the lumbar spine, and has low complication rates.