Lumbar discectomy surgery outcomes

Ross Hauser, MD and Danielle Matias, PA-C

Many people have very successful lumbar discectomy procedures. These are typically not the people we see at our center. We see the people who had lumbar discectomy with less than hoped-for results and a worsening of their condition. In this article, we will explore failed lumbar discectomy and post-surgical treatment outcomes and possible treatments.

This article is part of a series: Companion information to this article:

Article outline:

  • Types of discectomy surgery.
  • Which surgery is better?
  • Why did the lumbar microdiscectomy fail?
  • Overall low back pain improves in approximately 62% of patients who undergo lumbar decompressive surgery.
  • Transforaminal endoscopic lumbar discectomy failure.
  • Loss of disc space.
  • Returning to work.
  • The problem of women and office workers.
  • Lumbar sacralization.
  • Treatment for failed back surgery patients.

If you had a lumbar discectomy or have been told to consider one, you know that this surgical procedure seeks to remove the whole or part of a damaged or herniated disc in the lower back. Your doctors would have told you that the procedure is necessary to remove the disc because it is pressing on your nerves. For some people, this surgery is necessary, especially in instances where there is a loss of sensation, loss of bladder or bowel function, or function in the legs. For others, the surgery was recommended because traditional pain treatments such as painkillers, anti-inflammatories, physical therapy, yoga, and exercise did not alleviate the symptoms. Please see our article Why physical therapy and yoga did not help your low back pain as we expand on the subject of failed treatments.

Types of discectomy surgery

A lumbar discectomy is considered a more traditional “open” surgery meaning a large incision is made. A lumbar microdiscectomy is a surgery that while still an open surgery, is considered minimally invasive as it is performed with a smaller incision. An Endoscopic lumbar discectomy is considered even more minimal with less damage to the surrounding tissue. What is the difference between all these procedures? That depends on the extent of your problem. In some instances, doctors will decide that you will need a spinal fusion because once the lamina, the bone of the vertebrae is cut away to allow for the surgical instruments to get to the herniated disc, the spine may become too unstable and screws, plates, and rods will be needed. Screws, plates, and rods will need a bigger incision.

All three of these surgical options have shown very successful outcomes. As stated above, the very successful outcomes people are not the people we see. But how did they become unsuccessful outcomes people? For most, the answer is continued spinal instability.

In the image below we see a general concept of how open discectomy, endoscopic discectomy, laminectomy, and laminotomy are performed.

Lumbar discectomy surgeries described

Which surgery is better?

Logically, the next question would be: Which surgery is better?

A November 2022 study in the Journal of Clinical Medicine (1) compared outcomes in 6467 patients who underwent either percutaneous transforaminal discectomy, microendoscopic discectomy, or traditional open surgery. What the researchers found were comparable results for all three procedures.

The study notes:

  • Percutaneous (needle puncture, not open incision) transforaminal discectomy being minimally invasive, offered rapid recovery after surgery, but, recurrence rates and revision rates were higher than microendoscopic discectomy and open surgery. This finding is closely related to the incomplete removal of the intervertebral disc during Percutaneous transforaminal discectomy.
  • In terms of its postoperative outcome effectiveness, there were no significant differences between percutaneous transforaminal discectomy and the other two treatment options. In addition, the postoperative recurrence rate and “revision” rate were slightly higher for Percutaneous transforaminal discectomy than that for traditional open surgery and microendoscopic discectomy. This finding is closely related to the incomplete removal of the intervertebral disc during Percutaneous transforaminal discectomy.

Profiles of failed lumbar discectomy cases

Below is a sample of what people tell us in the many emails we get:

Re-herniation

I have a re-herniation at my L5/S1. I already had a partial discectomy, and now my doctor says it is pressing on a nerve, I am looking for other options besides spinal fusion.

Burning nerve pain after L4/L5 microdiscectomy

I had an L4/L5 microdiscectomy 2 and a half years ago. Since that time I have experienced burning nerve pain. I can’t sit for long, lie on my back, or stand for long. As soon as I get out of bed in the morning it starts.

Some mild reoccurrence of symptoms

I had a microdiscectomy at L5/S1 a few months back. The surgery removed a herniated disc that was causing immense pain, mostly with sitting.  Surgery did alleviate the symptoms. I’m mostly better now. However, lately, I have been experiencing some mild reoccurrence of symptoms mostly when I drive or sit for too long. My hip feels very tight.

Unable to bend at the waist

Have had microdiscectomy. It failed. Now facing spinal fusion. I am still unable to bend at the waist, I’m scared to lift more than 10 pounds. Sitting is a major problem.

My pain has returned and surgery is only successful for so long

I had a discectomy in 2019. I’ve had lower back problems, due to degenerative disc, for years. My pain has now returned. The surgery was only successful for so long. I need other alternatives. I want to be able to function normally without pain.

Prolapsed L5/S1 disc

I had a discectomy in 2019 for pain in my left leg and lower back. Now I have a prolapsed L5/S1 disc and the pain has returned.  I am being told I need to remove the remainder of the disc and have fusion. I am afraid of more damage.

Why did the lumbar microdiscectomy fail?

When I was in medical school and residency back in the 1980s, the most common spine operation was disc and bone removal, discectomy, and laminectomy, respectively. Both operations make the spine more unstable, especially a laminectomy. As you can imagine, many people who received laminectomy surgeries had initial pain relief ultimately followed by severe, worsening pain. Many later required large spinal fusions, which can be fraught with a separate set of long-term consequences.

In many cases we have seen, short-term success and long-term failure of the lumbar microdiscectomy occur because of degenerative spinal instability. As the spine became more unstable pressure was exerted on the discs and the discs slipped and herniated. This also caused a flattening of the discs. This problem was discussed by researchers at the University of Texas at San Antonio and the University of Connecticut in a February 2022 paper in the journal Computers in Biology and Medicine. (2) As the name of the journal implies the researchers used computer models to predict “consequences from this surgery on the biomechanics of the spine. . . ”

Using a computer model the researchers focused on the L4-L5 spinal segment to:

  • determine changes in facet joint distance during physiological motions of a lumbar spine in a:
    • healthy-normal condition,
    • after conservative and aggressive percutaneous transforaminal endoscopic discectomy (PTED) to correct lumbar disc herniation,
    • and during mild and severe (disk degeneration);
  • determine spine instability and endplate stresses under various physiological motions.

What they found was that aggressive-percutaneous transforaminal endoscopic discectomy in a healthy disc decreased facet distances in axial rotation, lateral bending, and flexion  (caused the disc to flatten). Mild and severe disc degeneration increases the stiffness of the spine, resulting in a decrease in the range of motion for all conditions. Severe disc degeneration decreased ROM as high as 57% for lateral bending, while a 13% decrease was observed for mild degeneration. High and abnormal endplate stress distributions were observed due to percutaneous transforaminal endoscopic discectomy.

What we have above is a detailed description of the consequences of this surgery on the biomechanics of the spine. The consequences are spinal instability causing disc degeneration.

Overall low back pain improves in approximately 62% of patients who undergo lumbar decompressive surgery

A July 2023 study in the Journal of Neurosurgery (3) looked at lumbar spine decompression surgery, in the form of laminectomy or discectomy, and its ability to help patients with back pain.

  • 25,349 patients included in the study, 92.2% reported significant back pain at baseline.
  • Sixty-two percent of patients attained the minimal clinically important difference in back pain reduction, with 51% reporting a substantial pain improvement. This improvement was observed by 6 weeks post-operation and was mostly maintained at 2 years.
  • Patients with back pain as the primary concern were more likely to attain the minimal clinically important difference compared with those with leg pain as the primary concern
  • Overall low back pain improves in approximately 62% of patients who undergo lumbar decompressive surgery, with 51% experiencing substantial improvement. 

Transforaminal endoscopic lumbar discectomy failure

An August 2023 study in the European Spine Journal (4) analyzed the risk factors that might predict incomplete clinical improvement after transforaminal endoscopic lumbar discectomy (TELD). In this study, 194 consecutive patients who underwent TELD due to lumbar disc herniation were analyzed. Patients with incomplete clinical improvement were defined from patient-reported outcomes of poor improvement in pain or disability after surgery and patient dissatisfaction.

  • Of 194 patients who underwent TELD procedures, 32 patients (16.5%) had incomplete clinical improvement and 12 patients (6.1%) required revision surgery.
  • The average age was 46.4 years old and most of the patients suffered from predominant leg pain (48.9%). The most common surgical level was L4-5 (63.9%).

Risk factors for surgical failure were listed as:

Possible risk factors were:

  • disc degeneration,
  • advanced age,
  • vacuum phenomenon (air in the joint), and
  • spondylolisthesis.

A March 2022 study (5) in the journal Neurospine assessed risk factors in 222 patients for the possibility of poor outcomes following minimally invasive discectomy in function, and back and leg pain scores.

  • Risk factors for  poor short-term functional improvement included:
    • Being an older patient.
    • Lateral recess stenosis (the narrowing of space in the side canals of the vertebrae).
    • and greater disability or lower functionality prior to surgery. 
    • Lumbar facet joint osteoarthritis was identified as a risk factor for poor functional improvement and relief of back pain

The risk factors for  poor short-term pain improvement:

  • Higher levels of back pain pre-surgery were associated with poor short-term relief of back pain, while absence of decreased sensation, and far-lateral disc herniation, were associated with poorer short-term relief of leg pain. Lumbar facet joint osteoarthritis was identified as a risk factor for poor functional improvement and relief of back pain.

Loss of disc space

A March 2024 Korean study (6) wanted to explore the reasons why patients were unsatisfied with the surgical results with a focus on finding clues in the disc height and pain 12 months after surgery in patients who underwent microdiscectomy for herniated lumbar disc.

In this study of 118 patients who underwent microdiscectomy, disc height was seen to decrease up to 12 months after surgery. The decrease in disc height at 1, 6, and 12 months after discectomy showed a significant association with worse pain scores 12 months after discectomy. The researchers recommended the more “Aggressive discectomy” surgery the near or complete removal of the disc with the thinking if the disc is not there, it cannot herniated again from the pressure of the vertebrae squeezing it.

Returning to work

A March 2024 study (7) in the Global Spine Journal led by the Department of Orthopedics Surgery, University of British Columbia examined the ability to return to work after elective degenerative lumbar spine surgery. Specifically, the researchers looked at workload intensity and its impact on return-to-work capabilities.

Study highlights:

  • 1290 patients who underwent a primary one- or two-level elective lumbar spine surgery for degenerative conditions were followed.
  • Of the 1290 patients, the overall rate of return to work was 82% at one year.
  • Workload (heavy work or more sedentary work) impact offered no significant difference in time to return to work after a fusion procedure, with an average time to return to work being 10 weeks. For the non-fusion procedure, the sedentary group had a statistically significantly quicker time to return to work than the light-moderate and heavy-very-heavy groups.

Return to work was seen as:

  • 84% for patients with sedentary work.
  • 77% for patients with a heavy-very heavy workload.

The problem of women and office workers

A November 2023 paper in the journal Cureus (8) suggests its findings offer significant insights into the prevalence of low back pain following discectomy as well as the risk factors associated with it. The researchers found that the prevalence of lower back pain six months after surgery was 49.3%, which was in line with previously published findings indicating a range of 3% to 36% for recurring back pain after lumbar discectomy. The study also found people with office-based jobs had the highest rate of lower back pain among all occupations (60.5%) which demonstrated that an increased risk of low back pain is associated with office employment that requires extended periods of sitting with poor ergonomics. The number of spinal operations that a patient had contributed to a pre-surgery expectation by the patient that they would continue to have lower back pain after the surgery. Women had a much greater rate of disability after surgery than men.

Lumbar sacralization

A March 2024 study in the journal World Neurosurgery (9) evaluated the impact of lumbar sacralization (the abnormal fusion of the L5-S1 vertebrae) on the surgical outcomes of L4-L5 microdiscectomy. Two hundred and forty patients were divided into two groups of 120 patients. One group had no lumbar sacralization, the other group did. The groups were followed to assess outcomes including recurrence of pain and disability following the surgery.

Results:

  • Postoperative radicular and back pain was more severe in lumbar sacralization patients.
  • L4-L5 microdiscectomy in patients with lumbar sacralization was associated with higher recurrence rates, worse disability, and worsening of spinal curves.

For further discussion please see our articles Sacroiliac Joint Dysfunction Symptoms and Treatment Options, and Sciatica and lumbar radiculopathy treatments.

Treatment for failed back surgery patients

This next section is condensed and summarizes information from our more extensive article Causes And Treatments Of Failed Back Surgery Syndrome

In this article, we discuss the following options of:

  • More surgery.
  • Epidural steroid and non-steroid injections.
  • More on exercise therapy and physical therapy.
  • Opioids and pain medications.
    • We discuss the problems of opioid use before surgery leading to post-surgical opioid use and complications.
  • Spinal cord stimulators.
  • Prolotherapy injections.
  • PRP injections.

Platelet Rich Plasma Therapy in combination with Prolotherapy

  • For patients with back pain, PRP treatment takes your blood, similar to a blood test, and re-introduces the concentrated blood platelets from your blood into the areas of the spine where damage may be present.
  • Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma. Platelets play a central role in blood clotting and wound/injury healing.
  • The procedure and preparation of therapeutic doses of growth factors consist of autologous blood collection (blood from the patient), plasma separation (blood is centrifuged), and application of the plasma rich in growth factors (injecting the plasma into the area.) In our office, patients are generally seen every 4-6 weeks. Typically three to six visits are necessary per area. In our practice, PRP is used in conjunction with dextrose Prolotherapy to stimulate the healing of the ligament and tendon attachments of the spine that cause pain, muscle spasms, degenerative discs, and other conditions.

Summary and contact us. Can we help you?

Many people have pain after spinal surgery, however, the pain may not be as severe as it was before the surgery. Why? Because the back surgery involved removing supporting structures, such as a lamina, facet, or disc, thus weakening surrounding segments. Back pain is commonly due to several factors and surgery may have eliminated only one. It is possible, for example, to have back pain from a lumbar herniated disc and a sacroiliac joint problem. Surgery may address the herniated disc problem but not the sacroiliac problem.

We hope you found this article informative and that it helped answer many of the questions you may have surrounding your back problems and spinal instability.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

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References

1 Zhao XM, Chen AF, Lou XX, Zhang YG. Comparison of three common intervertebral disc discectomies in the treatment of lumbar disc herniation: a systematic review and meta-analysis based on multiple data. Journal of Clinical Medicine. 2022 Nov 8;11(22):6604. [Google Scholar]
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