Introduction: Comparative effectiveness of spinal fusion versus revision discectomy for lumbar recurrent disc herniation(RDH) has yet to be evaluated. By analyzing nationwide longitudinal patient-reported outcomes spine registry, we characterized utilization of arthrodesis for lumbar RDH and analyzed its associated outcomes versus discectomy alone.
Methods: N2QOD registry prospectively enrolls spine surgery patients via representative sampling and prospectively collects measures of surgical safety and patient-reported outcomes for one-year postoperatively. All lumbar surgery cases performed for same-level, same-side RDH without listhesis or instability were queried to compare outcomes between revision discectomy with arthrodesis versus without arthrodesis.
Results: 417 RDH patients were enrolled with one-year follow-up[135(32%) arthrodesis, 282(68%) discectomy]. Patients treated with arthrodesis more frequently presented with back versus leg dominant symptoms, had greater back pain scores(VAS: 7 vs 6), and more frequently had symptoms for >3months. High ASA grade and unemployment were greater in arthrodesis cohort. Baseline ODI, QALY, and all other variables were similar. Length of surgery, blood loss, length of hospitalization, peri-operative complications(3.8% vs 1.4%, p=0.13), and need for in-patient rehabilitation were greater in arthrodesis vs. discectomy cohort. Fusion was associated with delayed return to work. In first 3 months after surgery, re-operation was lower in arthrodesis cohort(1.5% vs 3.7%, p=0.20), incidence of 1-year reoperation was similar (9.7% vs 8.3%, p=0.73). Significant and equivalent improvements in pain, disability, and QALY were reported one-year after surgery in both cohorts. In subset analysis of RDH patients with back dominant symptoms and baseline BP-VAS =8, revision discectomy alone provided equivalent health benefit as compared to arthrodesis.
Conclusions: Arthrodesis is associated with greater healthcare utilization and morbidity, but also with a trend of reduced 3month re-operation with equivalent one-year outcomes. Revision discectomy alone may be most efficient treatment option for patients experiencing recurrent disc herniation without listhesis or instability, particularly in those without back dominant symptoms.
Patient Care: In selected patients with recurrent disc herniation, revision discectomy alone vs. arthrodesis may be the better surgical option.
Learning Objectives: Revision discectomy alone may be most efficient treatment option for patients experiencing recurrent disc herniation without listhesis or instability, particularly in those without back dominant symptoms.