Discussion
Revision of spinal surgery is more difficult than primary surgery due to the development of an
anatomic plan and perineural scar tissue. In the first period, the clinical results of revision
surgery were considered worse [3,19]. Later, when the cases affecting the outcome such as
adjacent segment disease and foraminal stenosis were distinguished, similar results with
primary surgery were found [3,4,9,20]. Another study showed that there was no significant
difference between 27 patients undergoing revision surgery and 30 patients undergoing
primary surgery [21]. In our study, there was no significant difference between primary
surgery and revision surgery when additional pathological patients such as adjacent segment
disc degeneration, spinal deformity, spondylolisthesis, and multi-segment spinal canal
stenosis were excluded from the study.
The most appropriate surgical method for RLHD surgery is controversial. Only the
discectomy is introduced as an effective surgical method [3,9,20,21] while some surgeons are
accompanying the addition of fusion [10,22]. Fusion reduces mechanical stress within the
degenerative disc distance and prevents the emergence of a new disc within the affected disc
distance [23,24]. Also, better clinical results have been revealed [3,25]. In some studies,
Visual Analog Pain Scale (VAS) and Oswestry Disability Index (ODI) scores were not
significantly different [26] but some studies show that dynamic stabilization showed better
results regarding ODI scores [26-29]. In our study, surgical procedures were divided into
three groups. In the comparison between three groups, DSTFO and DDS groups showed
better outcomes regarding postoperative JOA score and recovery rate compared to the OD
group. However, these differences were not found statistically significant. However,
postoperative back pain was significantly more severe in the group with the only discectomy.
In general, in revision surgery, neural elements, disc fragmentation and adhesion between the
environment soft tissue occur. It can be challenging to create a surgical plan between these
structures, and it can be risky regarding complication. In revision surgery, the incidence rate
of dural tearing was reported as 20% [3,30], and the incidence rate of drop foot was reported
as 2.9% [31]. In our study, three dural injuries developed in the OD group. In DSTFO and
DDS groups, dural injuries have occurred in one case.
Many studies indicate that fusion surgery reduces recurrence [24,32]. In our study recurrence
was observed in one case from the group OD, while the DSTFO and DDS groups did not
develop recurrence. Besides, compared to 3 groups of follow-up, the duration of hospital stay
following the literature is less in the OD group (p<0,005).The amount of intraoperative
bleeding is less in the OD group (p<0,005). Postoperative lower back pain scores were higher
in the DDS group and clinically significant. However, there was no statistically significant
difference.
As a result, patients with RLDH should be advised to undergo surgery. All three surgical
methods are valid. Posterior stabilization-although the outcomes of patients with fusion and
dynamic stabilization are better, the difference is not significant. Intraoperative blood loss and
hospital stay are less than in patients with the only discectomy and statistically significant. In
the meantime, postoperative back pain is less in patients undergoing discectomy and dynamic
stabilization based on both our clinical observations and results. However, it is not statistically
significant. Extensive series and longer follow-ups are needed to obtain more accurate results.