The immediately failed lumbar disc surgery: incidence, aetiologies, imaging and management

Studies on immediate failed back surgery syndrome (iFBSS) following lumbar microdiscectomy are rare. Our aim is to describe the incidence and the causes of these immediate failures to define the value of radiological imaging for identification of the underlying pathology and to propose a management algorithm. We defined iFBSS as persistence, deterioration or recurrence (during hospital stay) of radicular pain and/or sensorimotor deficits and/or sphincter dysfunction after microdiscectomy, which was uneventful from the surgeon's perspective. The medical records of 1546 patients undergoing discectomy for mediolateral lumbar disc herniations were screened for iFBSS. The pre- and postoperative imaging, surgical records, therapy and outcome of patients with iFBSS were reviewed. Forty-four of 1546 patients (2.8%) with iFBSS were identified. All patients underwent reoperation. Overseen disc material/re-herniation (n = 22), epidural hematoma (n = 6), inadequate decompression of accompanying recessal stenosis (n = 2) and dural tear with fascicle herniation (n = 1) were found to be causative. In 13 patients, who revealed no clear pathology intraoperatively, we diagnosed a battered root syndrome (nerve root swelling due to excessive surgical manipulation). The correct diagnosis could be established by neuroradiological imaging in 25 of 43 radiologically investigated patients (57%). In our study, the radiological workup was of limited value for the correct differentiation of the various aetiologies of iFBSS. Therefore, the authors believe that the treatment strategy should strongly rely on the clinical presentation. To avoid unnecessary surgery in cases of battered root syndrome, we propose to proceed to reoperation only in patients with new or persistent radiculopathy despite adequate antiedematous medical therapy.