To fuse or not to fuse: surgical strategies for recurrent lumbar disc herniation from a 16-nation study

OBJECTIVE: Variations exist among surgeons in the treatment of recurrent lumbar disc herniation (LDH), generating major issues in decision-making models. The authors aimed to identify international nuances in surgical treatment patterns, highlight the differences in responses in each country group and different treatment trends across countries, and identify factors that influence surgical decisions. METHODS: An online survey with preformulated answers was submitted to 292 orthopedic surgeons and 223 neurosurgeons from 16 countries regarding 3 clinical vignettes (recurrence without low back pain, recurrence with severe low back pain, and recurrence with 2-level disc disease). The variability for each country was calculated according to the index of qualitative variation (IQV; ranging from 0 [no variability] to 1 [maximum variability]). To integrate the surgeons' perspectives, 2 Likert-type queries were submitted concerning the specific criteria for fusion and overall decision-making for each clinical case. RESULTS: Except for the case of first recurrence with pure radiculopathy without instability or inflammatory disc disease, where the variability was low (mean IQV 0.24, redo discectomy 86.2%), the other cases showed high variability (mean IQV range 0.63-0.71), with frequent proposals for surgery with implants. For countries with low variability, a high rate of posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) procedures (55.3%) and low rates of anterior/combined procedures (5.9%) and posterolateral fusion (4.9%) were observed. For countries with high variability, a lower rate of PLIF/TLIF procedures was observed (33.1%), with alternate proposals for anterior/combined procedures (20.8%) and posterolateral fusion without interbody fusion (12.8%). Orthopedic surgeons performed significantly more procedures with implants compared with neurosurgeons (p < 0.01). Age, practice type, and the annual number of surgery cases did not play a significant role in the choice of procedures. The most important criteria for fusion were lumbar pain symptoms associated with radiculopathy (77.9% strongly agreed) and the existence of inflammatory disc disease (73.0%). Furthermore, 62.1% of the respondents strongly agreed with performing fusion for all second recurrences. For the final decision, surgeons agreed with following the literature (81.9%), selecting low-morbidity procedures (78.6%), and using a familiar technique (78.6%). Patient preference was an important and/or very important decision factor for 64.1% of respondents. CONCLUSIONS: Significant differences existed between spine surgeons in the surgical treatment of recurrent LDH. Intra- and intergroup variations were observed, reflecting the lack of consensus in the literature and the challenge of adapting differences in habits and training to the few existing guidelines.