Efficacy of Repeat Discectomy Alone versus with Spinal Fusion in Recurrent Lumbar Disc Herniation: A Systematic Review and Meta-analysis of Randomized Studies

Introduction: Recurrent lumbar disc herniation (RLDH) is a common and debilitating condition. The primary surgical options are repeat discectomy alone or discectomy with spinal fusion, each having potential benefits and drawbacks. However, an ongoing debate persists regarding the most effective surgical treatment. This meta-analysis aims to clarify the comparative efficacy of repeat discectomy alone versus discectomy with fusion in patients with RLDH.

Methods: Following PRISMA guidelines, we conducted a systematic review and meta-analysis of randomized clinical trials (RCTs) comparing discectomy alone and discectomy with spinal fusion for RLDH. Searches were performed in PubMed, Embase, and Cochrane databases, with data extracted independently by two reviewers. The primary outcomes were Visual Analog Scale (VAS), Japanese Orthopaedic Association (JOA) scale, and re-recurrence. Meta-analysis was performed using a random-effects model, and heterogeneity was assessed with I² statistics.

Results: Four RCTs involving 596 patients met the inclusion criteria. Patients undergoing fusion showed a significantly greater reduction in VAS scores for low back pain compared to those undergoing discectomy alone (SMD -1.91; 95% CI [-3.69, -0.13]; p=0.04; I²=98%). VAS scores for lower limb pain (MD -0.33; 95% CI [-0.70, 0.03]; p=0.07; I2=95%) and JOA scores (MD 0.41; 95% CI [-0.38, 1.20]; p=0.31; I²=0%) did not differ significantly between the groups. The fusion group had a significantly lower re-recurrence rate (RR 0.10; 95% CI [0.02, 0.54]; p=0.008; I²=0%) and reduced postoperative instability (RR 0.11; 95% CI [0.02, 0.63]; p=0.01; I²=0%).

Conclusion : The results of this systematic review and meta-analysis suggest that spinal fusion can enhance spinal stability and reduce re-recurrence rates, but may not improve all aspects of pain and functional recovery. Therefore, the decision between repeat discectomy alone or with fusion should be tailored to the clinical scenario, patient preferences, and the surgeon's expertise.