How Likely Are You to Reherniate After a Discectomy?

It seems like every week, I see a new post in the r/Sciatica subreddit that reads something like:

Help! I’m two months post-microdiscectomy. This morning, I bent over to pick up my glasses off the floor. I immediately felt shockwaves rippling through my sciatica nerve. Now I’m terrified that I’ve reherniated! Has anyone been through this before? What should I do?!

I’ve never actually had a discectomy, micro or otherwise, but after reading a certain number of these posts I started to wonder: just how likely are discs to reherniate after a discectomy?

I’m not the only one who’s curious. Surgeons have long known that some patients will suffer recurring symptoms, and some will need follow-up surgeries. There have been many studies conducted to try and suss out the probability that a patient will reherniate.

These studies vary in terms of the surgical approach used, outcomes measured, length of follow-up, etc., and so the rates of reherniation varied as well. Yet, most of the estimates I found were a bit north of 10%.

Here, I’ve summarized some useful studies on the topic.

In Finland, 10.2% of Patients Needed a Second Surgery Within 5 Years

A study from Jyväskylä Central Hospital in Finland followed 166 patients. After these patients underwent their first discectomy, the researchers kept in touch for 5 years.

During the follow-up period, 12 patients (7.4%) had a reherniation at the same site, while 5 (3.1%) herniated a disc in a different place. 17 patients (10.2%) needed another surgery, although they didn’t always choose another discectomy. 6 patients (3.6%) had either fusions or decompressive spine surgery during the 5–year follow-up period.

The researchers were left scratching their heads as to why some patients reherniated, and others didn’t. None of the factors they tracked, which were suspected to alter the risks, were correlated with higher rates of reherniation. Age, sex, job status, exercise habits, level of pain at the beginning, or length of symptoms, all seemed to be unrelated.

A different study, which I’ve written about elsewhere, asked whether the type of disc herniation mattered. In that study, anyway, there did seem to be a connection.

In Baltimore, 12.8% of Patients Had Recurring Symptoms Within 12 Months

Another study out of Johns Hopkins Hospital in Baltimore followed up with 141 patients who had their first discectomy at a single spinal level.

After 12 months, 20 patients (12.8%) reported symptoms severe enough to interfere with daily life. Of those 20 patients, 3 didn’t benefit from the surgery in the first place.

The other 17 patients had a recurrent lumbar disc herniation at the same level. After trying conservative therapy, 11 of them eventually signed up for a second discectomy. All but one reported some degree of improvement after the second procedure.

The remaining 6 of 17 stuck with conservative treatment. The specifics varied from person to person, but included corticosteroid injections and physical therapy.

It seems that even those patients who benefitted from a discectomy were not completely free of back pain afterwards. Twenty patients later underwent spinal fusion procedures. There was no overlap between the patients who got second discectomies, and those who got fusions.

23.1% of Patients Reherniate, But Only 10.2% Feel Pain

Most of the studies I looked at followed up with patients by giving them questionnaires, and occasionally ordering new imaging scans if the patients reported pain after surgery.

Happily, one 2011 study took a more proactive approach. The researchers followed a group of 108 sciatica patients for two years. All patients had an MRI-confirmed disc herniation that matched their symptoms. Each underwent a discectomy at one of five clinics, with one of five surgeons.

Patients also followed a regular regimen of imaging scans. They got CTs before and after surgery, again at 6 weeks post-surgery, and then again at 3, 6, 9, 12, and 24 months. They got MRIs before surgery, and at 1 and 2 years afterwards.

If they reported a new bout of pain, patients underwent an MRI and CT scan, regardless of the timing. If a CT scan showed a new herniation, patients underwent an MRI to confirm.

When the patients weren’t stuck in an imaging machine, they were busy filling out questionnaires to assess their pain and disability levels, and quality of life. They filled out these surveys about as often as they underwent CT scans.

All that follow-up testing did lead to an interesting result – 25 patients (23.1%) showed a reherniation on their imaging scans. In 14 cases (13.0%), the reherniations were asymptomatic, while in 11 (10.2%) cases, reherniations were tied to renewed pain.

The authors also noted that, at least during the 2 years of the study, the painless reherniations remained painless.

Unfortunately, the outlook wasn’t great for the patients who reherniated and felt it. Even though all of the symptomatic reherniation patients had a second operation, and all of them reported the second surgery helped, their pain and disability levels at 2 years were significantly worse than the patients who either didn’t reherniate, or who didn’t feel their reherniation.

In South Korea, a Five-Year Reoperation Rate of 13.4%

Maybe you’re bothered by the small scale of these studies, with their double- and triple-digit sample sizes. Maybe you’re looking for a study with a larger cohort. Like, an entire country.

One group of researchers from South Korea actually did go that far. They mined the database of the Korean National Health Insurance system (which all South Korean citizens are included in) for information on spine surgery procedures and follow-up procedures.

They started by identifying the people who had their first spine surgery for a herniated disc in 2003. It turns out there were 18,590 patients who met these criteria. Then, these patients were followed for five years to see whether they underwent any additional spine procedures.

Most patients (12,816, or 68.9%) underwent an open discectomy, while 3,001 (16.1%) got an endoscopic discectomy.

The overall reoperation rate was 13.8% for open discectomies, and 12.4% for endoscopic discectomies. The timeline for a second surgery, among those who had one, skewed early.

Within the first 90 days, 4.9% of the open discectomy group, and 5.1% of the endoscopic discectomy group had had a second operation. From 91 days to the end of the 5-year follow-up period, 9.3% of the open discectomy group and 7.8% of the endoscopic discectomy group had a second operation.

Since this study relied on national data, it can’t explain why some patients chose one type of surgery over another, or what factors might have led patients to have a second surgery.

Patients didn’t fill out any questionnaires, nor were they given regular MRIs. Their imaging scans were read by radiologists all over the country, and their surgeries were performed at many different facilities. Individual differences could easily be hidden in the aggregate data, although on the flipside, this study provides a nice snapshot of the country as a whole.

Conclusion

If you suspect you have reherniated, you’re not alone. A sizeable minority of patients who have discectomies go on to have recurring bouts of pain. Many studies put the rate of reherniation (or at least, recurring pain) above 10%.

What to do about a reherniation is less clear, and that question is not answered in these studies. Whatever treatment option you decide to pursue, you are entitled to curse your rotten luck.

You Might Also Like:

• The Twin Spine Study: Is Disc Degeneration Genetic?
• Microdiscectomy vs. Conservative Care for Sciatica: How Do They Measure Up?
• New Study Asks, “How Well Do Epidural Injections Treat Sciatica?”
• Sitting and Back Pain: What’s the Connection?

References

1. Garcés Ambrossi, Giannina L., Matthew J. McGirt, Daniel M. Sciubba, Timothy F. Witham, Jean-Paul Wolinsky, Ziya L. Gokaslan, and Donlin M. Long. 2009. “Recurrent Lumbar Disc Herniation After Single-Level Lumbar Discectomy: Incidence and Health Care Cost Analysis.” Neurosurgery (Congress of Neurological Surgeons) 65 (3): 574–578. doi:10.1227/01.NEU.0000350224.36213.F9.
2. Häkkinen, Arja, Ilkka Kiviranta, Marko H, Neva, Hannu Kautiainen, and Jari Ylinen. 2007. “Reoperations after first lumbar disc herniation surgery; a special interest on residives during a 5-year follow-up.” BMC Musculoskeletal Disorders (BioMed Central) 8 (2). doi:10.1186/1471-2474-8-2.
3. Kim, Chi Heon, Chun Kee Chung, Choon Seon Park, Boram Choi, Min Jung Kim, and Byung Joo Park. 2013. “Reoperation Rate After Surgery for Lumbar Herniated Intervertebral Disc Disease: Nationwide Cohort Study.” Spine (Lippincott Williams & Wilkins) 38 (7): 581–590. doi:10.1097/BRS.0b013e318274f9a7.
4. Lebow, Richard L., Owoicho Adogwa, Scott L. Parker, Adrija Sharma, Joseph Cheng, and Matthew J. McGirt. 2011. “Asymptomatic Same-Site Recurrent Disc Herniation After Lumbar Discectomy: Results of a Prospective Longitudinal Study With 2-Year Serial Imaging.” Spine (Lippincott Williams & Wilkins) 36 (25): 2147–2151. doi:10.1097/BRS.0b013e3182054595.
5. Lopez, Gregory, and Gunnar B.J. Andersson. 2018. “Annular Repair.” Chap. 48 in Rothman-Simeone and Herkowitz’s The Spine, Seventh Edition, by Steven R Garfin, 869-872. Elsevier.