Recurrent Lumbar Disc Herniation

Diagnosis

Recurrence of lumbar disk herniation after microdiscectomy at the L4-L5 level.

The patient’s complaints:

Limited movement in the lower back has been a concern for the past two years. Despite being in relatively good health, I first experienced pain and discomfort in my lower back. A year ago, I noticed a deterioration in my well-being, with a significant increase in spinal pain, radiating pain in my right lower limb and weakness.

While visiting Spain, my condition worsened and I went to hospital, where a neurosurgeon examined me and I underwent an MRI scan of the lumbosacral spine. Based on the results of the MRI scan, a sequestered L4–L5 disc herniation was diagnosed. I underwent emergency surgery — a right-sided microsurgical decompressive laminectomy and removal of the L4–L5 disc herniation.

The postoperative period was relatively favourable — the pain subsided, but the reduced sensation persisted. However, given the persistent sensory disturbances, a repeat MRI scan of the lumbosacral spine was performed, revealing a recurrence of the L4–L5 disc herniation.

I currently experience discomfort in the lumbar region and reduced sensation along the posterior surface of the right lower limb, right foot and third and fourth toes.

Patient's questions:

• Are there currently any indications for surgery? If so, which technique would be used? Would it involve a rigid fixation device or a polymer-based implant such as the ProDisc?
• What is your opinion on the ProDisc intervertebral disc prosthesis?
• If surgery is not performed, what is the prognosis?
• Is there currently a herniated disc?
• Apart from surgery, what other methods could be used? For example, radiofrequency ablation of the spine or another method.
• If surgery is necessary, what types of spinal surgery do you perform? What is the recovery process like, and what are the postoperative contraindications?
• I currently have numbness in my leg. Could this be resolved with surgery?
• What is your opinion on plasma/stem cell injections?

Response from spinal surgeon Dr Bitter:

I have carefully reviewed the provided CT and MRI scans of your spine, as well as your medical history and current symptoms. Based on this information, I will now answer your questions.

• Currently, there are no absolute indications for surgery. Your current condition is characterised by residual numbness in the right lower limb, with no significant pain present. However, if your symptoms worsen in the future and surgery becomes a consideration, given the signs of microinstability of the spinal motion segment and the significant changes to the intervertebral joints, I would consider the use of dynamic systems (such as the ProDisc prosthesis or other polymer implants) to be inappropriate. In this case, rigid stabilisation would be indicated. Taking into account the anatomical features, two options could be considered:

1. TLIF (transforaminal lumbar interbody fusion): a classic stabilising operation via a posterior approach with placement of a fixation device; or
2. The second option is ALIF (anterior lumbar interbody fusion), which involves a ventral surgical approach via an anterior incision in the abdominal region.

• An intervertebral disc prosthesis is designed to preserve mobility in the affected part of the spine. However, it is not recommended for your condition. CT and MRI scans have revealed severe degenerative changes in the intervertebral joints, as well as signs of instability. In such circumstances, preserving mobility with a disc prosthesis would not solve the problem. Instead, it would lead to further biomechanical complications and joint overload.
   
• In this case, the prognosis is favourable, even with a conservative approach. In my opinion, the current numbness is due to nerve compression that was present before the first operation and may persist for a long time. Provided there is no progressive motor deficit, such as weakness in the foot or unbearable pain, there is no risk in not having the operation.

• Recent MRI scans have revealed a left-sided medial disc herniation at the L4–L5 level. This is causing slight compression of the left L5 nerve root, and a small synovial cyst has formed in the left facet joint. The images also reveal significant narrowing of the left lateral recess. However, based on your symptoms, you are not experiencing any pain or discomfort in your left leg, meaning the condition remains 'asymptomatic' for now. The herniation is not clinically manifest. On the right side, where you experience numbness, no nerve root compression is visible in the images.

• As your current numbness in the back of your right leg is the result of a previous injury to the nerve root on that side, standard nerve blocks or radiofrequency ablation (RFA) are not very helpful here, as these procedures are designed to relieve acute pain rather than restore sensation.

  However, if the numbness is significantly impacting your quality of life or developing into unpleasant neuropathic sensations such as burning or 'pins and needles', I would recommend consulting a chronic pain specialist.

  One modern approach to such cases is neurostimulation, which involves implanting an SCS probe. This involves first carrying out a trial stimulation by inserting a temporary electrode. If you feel an improvement or reduction in discomfort within a few days, a permanent pulse generator can then be implanted. This is placed under the skin.

  If surgery becomes necessary in the future, for example if you experience pain in your left leg due to narrowing of the lateral recess or if your lower back pain worsens, you will have to choose between a posterior (TLIF) and an anterior (ALIF) approach.

  I should mention that the anterior approach (ALIF) is a technically complex procedure. It requires an incision to be made in the abdomen and work to be carried out close to major blood vessels. While it is highly effective, it is associated with a higher risk of vascular complications. For this reason, I recommend that such an operation should only be performed in specialist centres where the surgical team includes a vascular surgeon who can monitor the procedure and ensure safety.

  Postoperative recovery following stabilisation surgery involves early mobilisation, but axial loading must be strictly limited. For instance, you should avoid lifting heavy objects, bending deeply or twisting for the first 2–3 months after the operation, until a solid bony block has formed.

• It is highly unlikely that the numbness in your leg will disappear following surgery. MRI scans show that the right nerve root is now completely free and not under any mechanical pressure. The numbness essentially represents the nerve tissue’s ‘memory’ of the previous herniation. While the operation aims to relieve compression, it cannot repair a nerve that has already been damaged. In this case, surgical intervention will not help, so we use only conservative methods to correct the condition, such as neuromodulation (SCS), which I described above.

• We do not use stem cell or plasma therapy in this case. From an evidence-based medicine perspective, the effectiveness of this method in treating recurrent disc herniation and chronic neuropathy (numbness) has not been proven. This technique is not considered standard or recommended practice in modern neurosurgery.