Comparing outcomes of fusion versus repeat discectomy for recurrent lumbar disc herniation: A systematic review and meta-analysis

Objectives: Current surgical treatment options for one-time recurrent lumbar disc herniation (RLDH) include repeat discectomy or discectomy supplemented with fusion. Significant contention exists within the surgical spine community with regard to the most effective treatment modality. The objective of this study is to compare reoperation rates and patient reported outcomes following fusion versus repeat discectomy for RLDH.

Patients and methods: The electronic literature search was performed in Ovid Medline/Pubmed, EMBASE and Cochrane, Scopus and China National Knowledge Infrastructure for human studies directly comparing repeat discectomy with fusion for ipsilateral or contralateral RLDH. Random effects meta-analysis was conducted to pool the estimates of effect, using mean differences (MD) and odds ratios (OR) for continuous and categorical outcomes, respectively.

Results: A total of 1405 patients with RLDH (746 fusions and 659 repeat discectomies) from 15 studies (13 observational and 2 randomized controlled trials) were analyzed. Mean time to reherniation was 54.4 ± 30.4 months, while average follow-up time was 40 ± 11.7 months (range: 12-92.6). No difference was found between fusions and repeat discectomies with regards to related reoperations (OR: 0.68; 95% C.I: 0.14-3.2). Changes in PRO scores from baseline to last follow-up were also similar between the two groups, including VAS-back pain (MD, -0.3; 95% CI, -1.4 to 0.7), VAS-leg pain (MD, -0.3; 95% CI, -1.4 to 0.7), ODI (MD, 0.6; 95% CI, -0.2 to 1.4), JOA (MD: 1.0; 95% CI: 0.02 to 2.0) and MacNab satisfaction (OR: 1.5; 95% CI, 0.9 to 2.3).

Conclusion: Available evidence shows that in treating one-time recurrent disc herniations, repeat discectomy and fusion are associated with comparable reoperation rates, incidence of dural tears, functional outcomes as well as satisfaction with surgical treatment at last follow-up. Future longitudinal, randomized controlled trials should be completed to validate any associations found in this study.