Risk Factors For Recurrent Herniation After Percutaneous Endoscopic Lumbar Discectomy

ObjectiveTo explore the risk factors for recurrent lumbar disc herniation after percutaneous endoscopic lumbar discectomy.MethodsBetween January 1,2015 to December 31,2017,827 patients underwent percutaneous endoscopic discectomy for lumbar disc herniation(LDH)in the Department of Orthopedics,Guangdong Provincial Hospital of Traditional Chinese Medicine.All patients were followed up until January 2019 and the follow-up period was 12-48 months.A total of 724 patients were followed up,with a follow-up rate of 87.5%.There were 47 cases with recurrence,two of them were excluded due to the absence of all imaging data(lumbar X-ray,CT,and MRI),and there remaining 45 patients were all included in the recurrence group.By the end of follow-up,611 patients had no recurrent lumbar disc herniation,and their surgical outcome was evaluated as excellent or good with modified Macnab.198 patients had complete imaging data and selected ats a non-recurront group.By review patient' s clinical records,nursing records,surgical records,and imaging data,compare and analyze the clinical data and imaging materials of the two groups:age,gender,smoking,alcohol consumption,BMI,time of i ll ness,operati ve time,surgical segment,surgical procedure;comorbidities:hypertension,hyperlipidemia,diabetes;bed rest time,wearing waist protection time,and postoperative work intensity;DHI,SROM,intervertebral disc with calcification,lumbosacral transi tional vertebrae,vertebral instabi lity,disc herniation pathological classification,regionalization of intervertebral disc herniation,vertebral endplate changes,disc degeneration grade,facet joint fluid volume.Statistical analysis of data was performed using SPSS 23.0 software.ResultsThe recurrence rate was 6.5%.Comparative analysis of clinical data between recurrent and non-recurrent groups,the result showed that there was no significant difference in age,gender,BMI,time of illness,alcohol consumption,diabetes,hypertension,surgical segment,surgical procedure,operation time,bed rest time,wearing waist protection time,and postoperative work intensity.More smokers in the recurrent group than in the non-recurrent group(24.4%vs.12.6%,p=0.044;odds ratio[OR]=1.860,95%confidence interval[Cl]:1.041-3.324).Patients with hyperlipidemia in the recurrent group more than in the non-recurrent group(44.4%vs.27.3%,p=0.024;OR=1.827,95%CI:1.085-3.075).Comparison of imaging between the two groups,the result showed that there was no significant difference in lumbosacral transitional vertebrae,vertebral instability,intervertebral disc calcification,pathological classification of disc herniation,and localization of intervertebral disc(P>0.05).Patients with Modic changes in the recurrent group more than in the non-recurrent group(37.2%vs.11.1%,P<0.001;OR=2.154,95%CI:1.259-3.684).DHI was 4.41±0.82 and 3.27±0.54 in the recurrent and non-recurrent group,respectively(P<0.001).SROM was 8.3°±4.2° and 4.7°±2.80 in the recurrent and non-recurrent group,respectively(P<0.001).According to the modified Pfirrmann score,the disc degeneration level in the recurrent group was statistically significant compared with the disc degeneration in the non-recurrent group.(P<0.001).According to the height of the intervertebral disc,further divided into two groups,the results showed that the risk of recurrence in the disc height normal group(?,?,?)was 5.2 times(OR=5.174,95%CI:3.073-8.713)that of the disc height reduction group(?,?).Multivariate logistic regression analysis showed that DHI(P<0.001),SROM(P<0.001)and Modic changes(P=0.043)were risk factors for postoperative recurrence.ConclusionDHI,SROM and Modic changes are independent risk factors for recurrence after percutaneous lumbar endoscopy.Preoperative high intervertebral disc height,large changes in the intervertebral angle of flexion and extension,and combined endplate inflammation suggest that the lumbar intervertebral disc may be in an unstable state,resulting in an increased risk of postoperative recurrence.Smoking and hyperlipidemia can accelerate the degeneration of the intervertebral disc through multiple mechanisms,affecting the metabolism of the intervertebral disc and postoperative repair ability,thereby increasing the risk of postoperative recurrence.For patients with multiple risk factors before surgery,the risk of recurrence should be informed before lumbar endoscopic surgery,or lumbar fusion is recommended.