Lumbar disc herniation: Prevention and treatment of recurrence: WFNS spine committee recommendations

This review aims to formulate the most current evidence-based recommendations on the epidemiology, prevention, and treatment of recurrent lumbar disc herniation (LDH). We performed a systematic literature search in PubMed, Medline, and Google Scholar databases from 2012 to 2022 using the keywords “lumbar disc recurrence.” Screening criteria resulted in 57 papers, which were summarized and presented at two international consensus meetings of the World Federation of Neurosurgical Societies (WFNS) Spine Committee. The 57 papers covered the following topics: (1) Definition and incidence of recurrence after lumbar disc surgery; (2) Prediction of recurrence before primary surgery; (3) Prevention of recurrence by surgical measures; (4) Prevention of recurrence by postoperative measures; (5) Treatment options for recurrent disc herniation; (6) The outcomes of recurrent disc herniation surgery. We utilized the Delphi method and voted on eight final consensus statements. Recurrence after disc herniation surgery may be considered a surgical complication, its incidence is approximately 5% and is different from overall re-operation incidence. There are multiple risk factors predicting LDH recurrence, including smoking, younger age, male gender, obesity, diabetes, disc degeneration, and presence of lumbosacral transitional vertebrae. The level of lumbar discectomy surgery and the amount of disc material removed do not correlate with recurrence rate. Minimally invasive discectomies may have higher recurrence rates, especially during the surgeon's learning period. However, the experience of the surgeon is not related to recurrence. High-quality studies are needed to determine if activity restriction, weight loss, smoking cessation, and muscle-strengthening exercises after primary surgery can help prevent recurrence of LDH. The best treatment option for recurrent disc herniation is still being discussed. While complications of minimally invasive techniques may be lower than open discectomy, outcomes are similar. Fusion should only be considered when spinal instability and/or spinal deformity are present. Clinical outcomes and patient satisfaction after recurrent disc herniation surgery are inferior to those after initial discectomy.