Spine Journal - 2026-07-01 - Journal Article
Radiographic predictors of lumbar disc re-herniation requiring repeat discectomy or fusion: a matched retrospective cohort analysis.
Golubovsky JL, Gu BJ, Massaad E, Dagli MM, Crabill GA, Ghenbot Y, Arena J, Shost M, Welch WC, Ali Z, Judy B, Malhotra NR, Shin JH, Ozturk AK
Topics
Key Takeaway
Preoperative Modic changes (HR 1.86) and facet degeneration index (HR 1.43 per grade) independently predict reoperation for recurrent lumbar disc herniation within 3 years of primary discectomy.
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Summary
This study asked which preoperative radiographic and clinical factors predict reoperation for recurrent LDH within 3 years of single-level microdiscectomy. Using a matched cohort of 250 patients (129 reoperation, 121 controls) with multivariable Cox regression, Modic changes (HR 1.86), facet degeneration index (HR 1.43/grade), Charlson comorbidity index (HR 1.21/point), male sex (HR 1.58), and younger age (HR 0.98/year) were independently associated with recurrence. Adding radiographic parameters to clinical variables improved AUC, particularly for recurrences occurring beyond 1 year.
Key Limitation
The 3-year reoperation endpoint captures only surgically managed recurrences, excluding symptomatic recurrences managed nonoperatively, which likely underestimates the true rLDH rate and may introduce outcome ascertainment bias.
Original Abstract
BACKGROUND CONTEXT
Lumbar discectomy is the standard of care for symptomatic lumbar disc herniation (LDH). However, recurrent LDH (rLDH) necessitates reoperation in 3% to 18% of patients, posing a substantial challenge for both patient counseling and healthcare economics. While studies have focused on demographic and clinical risk factors, the contribution of preoperative radiographic parameters to recurrence risk remains poorly defined.
PURPOSE
This study evaluated preoperative MRIs for patients undergoing one-level lumbar discectomy to determine combined clinical and radiographic factors associated with operative rLDH following a single-level discectomy.
STUDY DESIGN
This retrospective cohort study included adult patients who underwent a primary, single-level lumbar microdiscectomy at a tertiary academic center.
PATIENT SAMPLE
Adult patients undergoing index one-level lumbar discectomy were included. Patients were excluded for revision surgery, fusion, nondiscal pathology, or unavailable preoperative MRI.
OUTCOME MEASURES
Patients were considered to have operative rLDH if they underwent repeat discectomy or discectomy and fusion at the index level within 3 years of their primary surgery. Potential variables included demographics, comorbidities, and radiographic parameters from preoperative MRI, including herniation morphology, disc degeneration (modified Pfirrmann grade), endplate changes (Modic), and facet arthropathy.
METHODS
A multivariable Cox proportional hazards model was used on a matched cohort to identify independent variables associated with time to reoperation. Receiver operating characteristics curves and were developed based on mixed clinical and radiographic models.
RESULTS
Two thousand six hundred eight patients underwent single level lumbar discectomy between 2013 and 2024, of whom 129 (4.9%) required reoperation for rLDH. The matched cohort included 250 patients, of whom 129 (51.6%) required reoperation for rLDH within 3 years. After multivariable adjustment, several factors were independently associated with recurrence risk. Significant radiographic factors included the presence of Modic changes (hazard ratio [HR], 1.86; 95% confidence interval [95% CI], 1.23-2.82; p=.003) and a higher facet degeneration index (HR, 1.43 per grade; 95% CI, 1.30-1.57; p<.001). Significant clinical variables included a higher Charlson comorbidity index (HR, 1.21 per point; 95% CI, 1.08-1.36; p=.002), younger age (HR, 0.98 per year; 95% CI, 0.96-1.00, p=.04), and male sex (HR, 1.58; 95% CI, 1.09-2.30; p=.02). Radiographic factors increased the AUC compared to clinical factors alone, particularly beyond 1 year.
CONCLUSIONS
Higher systemic comorbidity burden, degenerative endplate changes, and worsened facet arthropathy are significantly associated with risk of operative rLDH and should be considered for patient counseling and surgical planning.