14 Revision Disc Surgery To alleviate nerve root generated leg pain and/or weakness secondary to mechanical pressure from a recurrent disc herniation. 1. The diagnosis is made on the basis of the history, physical examination, and diagnostic studies. 2. The most reliable history is the sudden onset of leg pain in a patient with a previously successful discectomy with a time interval separating the index procedure and the new symptoms that is clearly definable. 3. The physical examination may not be helpful because the straight legraising test is not always positive and neurologic deficits may derive from the index herniation. 4. Imaging studies such as a gadolinium magnetic resonance imaging (MRI) scan may reveal a clear-cut recurrent disc herniation, or other studies may be necessary to confirm the presence of a disc herniation and a symptomatic nerve root (Fig. 14–1). 5. Studies could include a lumbar myelogram, contrast-enhanced computed tomography (CT) scan, CT discography, and selective nerve root block. 1. Loss of control of the bowel and bladder 2. Progressive lower extremity weakness 3. Unacceptable leg pain 1. The inability to verify a recurrent disc herniation to the surgeon’s satisfaction. 2. Scar as the sole diagnosis, not recurrent disc herniation or stenosis. 3. Patient is not a candidate for surgery because of medical reasons. 1. Relief of leg pain with very reasonable probability of success 2. Attempted restoration of motor function 1. The potential for further destabilization of a motion segment in the spine, leading to pain and disability and possible further surgery. 2. More diagnostically difficult assessment with potential for selection error for surgery. To identify the spinal nerve under compression from a recurrent disc herniation and to safely remove the herniated disc. Scar tissue formed from the previous surgical intervention obscures the normal anatomy, challenging the surgeon to expose and verify the anatomy. 1. Operate from identifiable anatomy to help recognize the obscured structures. Avoid a direct assault on scar tissue. 2. Utilize the bony structures to take down scar. 3. Clearly identify the nerve root and its course prior to any surgical maneuver. 1. Does the remnant anatomy allow the surgeon access from a superior or inferior hemilamina? 2. If a total laminectomy or unilateral hemilaminectomy has been performed, does the operating surgeon use a technique addressing the scar tissue as it attaches to the lateral border of the remnant facet? 1. Kneeling position on the Andrews frame to facilitate decompression of the abdomen and secondarily the epidural veins. 2. Hypotensive anesthesia to reduce bleeding. 3. Preincision x-ray with spinal needles used as markers if there is any doubt about the position of the prior incision and the site of the intended revision discectomy. 4. Incision encompassing old scar and extended proximally and distally depending on the exposure need and length of prior surgical scar. 5. Vigorous hemostasis in the superficial wound layers. 6. Fascial incision with cautery and then hemostasis in the subfascial tissue. Remove any visible suture from prior surgery. 7. Identification of remnant bone: a. Careful inspection of plain x-rays (postoperative) and imaging studies to assess the extent of prior surgery and the amount and location of bone present for the intended operation.
Technical Challenges
Goals of Surgical Treatment
Diagnosis
Indications for Surgery
Contraindications
Advantages
Disadvantages
Procedure
Technical Goal
Technical Challenge
Technical Principles
Decision Making
Position and Exposure
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