Aggressive Versus Limited Discectomy for Lumbar Disc Herniation: Implications for Recurrence and the Role of Fusion at Reoperation

Franz Jooji Onishi^1*, Alberto Fernando Oliveira¹, Telmo Augusto Barba Belsuzarri², Fabio Veiga de Castro Sparapani¹, Sergio Cavalheiro¹, Eduardo Augusto Iunes¹

¹Department of Neurosurgery, Federal University of São Paulo (Unifesp), Medical School, São Paulo, São Paulo, Brazil
²Department of Neurosurgery, Pontifical Catholic University of Campinas (PUC-Campinas), Campinas, São Paulo, Brazil

*Correspondence author: Franz Jooji Onishi, Department of Neurosurgery, Federal University of São Paulo (Unifesp), Medical School, São Paulo, São Paulo, Brazil; Email [email protected]

Citation: Onishi FJ, et al. Aggressive Versus Limited Discectomy for Lumbar Disc Herniation: Implications for Recurrence and the Role of Fusion at Reoperation. J Neuro Onco Res. 2025;5(3):1-8.

Copyright^© 2025 by Onishi FJ, et al. All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Table 1: Demographic and surgical data of patients treated with lumbar fusion for recurrent disc herniation.

The mean age of patients who required revision surgery for recurrent lumbar disc herniation was 34 years (SD ± 5.98). Normality testing using the Shapiro-Wilk test confirmed a normal distribution of age in this group (p = 0.548). A one-sample t-test comparing the recurrence group to the overall surgical cohort mean age of 41.2 years demonstrated a statistically significant difference (t = -3.81, df = 9, p = 0.004), indicating that patients who developed recurrence requiring fusion were significantly younger than the general population of surgically treated patients (Fig. 1).

Figure 1: Boxplot of age distribution in patients undergoing fusion for recurrent lumbar disc herniation, compared with the mean age of the overall cohort (dashed line).

Recurrence was confirmed by MRI imaging studies in all patients. At the time of recurrence, all patients reported radicular symptoms and all also complained of axial low back pain. In six patients, low back pain was the predominant symptom, whereas in four patients, leg pain was the dominant complaint. ALIF was preferentially performed at the L5-S1 level, whereas TLIF was predominantly used for L4-L5 fusions.

Complications

No postoperative neurological deterioration or cerebrospinal fluid leakage was observed in this reoperation cohort. One patient in the ALIF group developed a postoperative abdominal infection associated with a retroperitoneal fluid collection, which required surgical drainage and reintervention. The patient subsequently achieved full recovery and was discharged without further complaints.

Systematic Review and Meta-Analysis                    

A systematic literature search was performed in MEDLINE (PubMed) and EMBASE (Elsevier). A total of 319 records were identified from PubMed and 228 from EMBASE, yielding 547 studies. After application of the inclusion criteria, which required cohorts of at least 50 patients and comparative designs evaluating limited versus aggressive discectomy and fusion versus non-fusion at reoperation, 10 studies were included for qualitative synthesis. Of these, six were randomized or prospective studies evaluating recurrence rates after limited versus aggressive discectomy and four compared revision surgery using fusion versus non-fusion techniques (Fig. 2) [5-14].

Figure 2: PRISMA 2020 flow diagram of study selection, showing identification, screening, eligibility and inclusion of 10 studies.

Recurrence Patterns Across Different Discectomy Strategies

Six prospective and randomized controlled studies evaluated recurrence risk by comparing limited discectomy (fragmentectomy/sequestrectomy) with more aggressive discectomy [5-10]. According to the available literature, no significant difference in recurrence rates was demonstrated between these techniques (Fig. 3).

Figure 3: Forest plot comparing recurrence following limited and aggressive discectomy, with no significant difference observed between techniques.

Clinical Outcomes According to Revision Strategy: Fusion Versus Non-Fusion

Postoperative outcomes were assessed using the JOA score, ODI, axial VAS and the incidence of cerebrospinal fluid leakage and neurological injury. No statistically significant differences were observed between the fusion and decompression-only groups across any of these outcomes (Fig. 4-6).

Figure 4: Forest plot comparing the pre-postoperative difference in axial VAS scores between fusion and non-fusion revision strategies, showing no statistically significant difference between groups.

Figure 5: Forest plot comparing the incidence of postoperative neurological injury between fusion and non-fusion revision strategies, with no significant difference observed between groups.

Figure 6: Forest plot comparing the incidence of cerebrospinal fluid leakage between fusion and non-fusion revision strategies, demonstrating no significant difference between groups.

Discussion

The incidence of recurrent lumbar disc herniation remains a subject of ongoing debate, as it lies at the intersection between the natural history of disc degeneration and the effects of surgical intervention. While a substantial proportion of patients with primary disc herniation can achieve satisfactory outcomes with conservative treatment, surgery becomes necessary in selected cases with severe, progressive or refractory symptoms. Even after apparently successful surgery, however, recurrence at the same level continues to represent a complex therapeutic challenge. Multiple patient-related and biomechanical factors have been implicated in recurrence, including age, diabetes mellitus, smoking status, body mass index, the degree of pre-existing disc degeneration, occupational biomechanical demands and rehabilitation protocols [15]. From a surgical perspective, one of the most relevant modifiable factors is the extent of disc removal at the index procedure. Limited discectomy-often termed fragmentectomy, sequestrectomy or extrusectomy-is increasingly favored in modern minimally invasive and endoscopic techniques, as it preserves disc height and segmental motion. However, several studies have suggested that partial disc removal may be associated with higher recurrence rates, particularly when long-term follow-up is considered, likely due to persistent residual nucleus pulposus within the disc space [6,8,16]. The study with the longest follow-up comparing limited versus aggressive discectomy was conducted by Kotil8, with a five-year follow-up period. This study demonstrated a clear difference in favor of aggressive discectomy regarding the recurrence rate of lumbar disc herniation, with recurrence observed in 1.5% of patients undergoing aggressive discectomy compared with 4.1% in those treated with sequestrectomy. These findings underscore the critical importance of follow-up duration in the assessment of recurrence outcomes, as shorter follow-up periods may substantially underestimate the true long-term recurrence risk. Conversely, more aggressive discectomy may reduce the reservoir of remaining nucleus material and theoretically lower the risk of recurrence, albeit at the cost of accelerated disc height loss, altered biomechanics and a greater propensity for axial low back pain [4,5,9]. Nevertheless, several previous systematic reviews and meta-analyses have reached similar conclusions, indicating that sequestrectomy or limited discectomy does not appear to be associated with a higher recurrence rate when compared with more aggressive discectomy. This apparent discrepancy across individual long-term series and pooled analyses further highlights the complexity of recurrence as a time-dependent and multifactorial outcome [1,3]. In our individual cohort, despite the adoption of an aggressive discectomy strategy at the index surgery and a relatively low overall recurrence rate of 3.4%, nearly all patients who did recur presented with a significant axial low back pain component in addition to radicular symptoms. This reinforces the notion that recurrent herniation often reflects a more complex degenerative process rather than a simple mechanical re-extrusion of a disc fragment. Accordingly, all patients in our series who required revision surgery were Treated with Lumbar Interbody Fusion (TLIF or ALIF), aiming to achieve both neural decompression and mechanical stabilization. This strategy is consistent with the growing body of evidence suggesting that fusion may provide superior outcomes in patients presenting with combined axial and radicular pain or with imaging features of advanced segmental degeneration, such as reduced disc height [14,17].

Although our meta-analytic comparisons did not demonstrate statistically significant differences between fusion and non-fusion strategies in terms of axial VAS improvement, cerebrospinal fluid leakage or new neurological deficit, graphical trends marginally favored fusion for both axial pain relief and neurological safety. From a theoretical standpoint, this observation is biomechanically and surgically plausible. Fusion procedures-particularly ALIF and, to some extent, TLIF-allow decompression through alternative surgical corridors that avoid the prior midline scar, epidural fibrosis and compromised dura typically encountered in revision posterior decompressions. By preferentially avoiding previously scarred central canal tissues, these approaches may theoretically be associated with a lower risk of incidental durotomy and iatrogenic neurological complications.

Postoperative rehabilitation and return-to-activity protocols further contribute to the multifactorial nature of recurrence. Aggressive rehabilitation, poor core muscle conditioning, early resumption of high-demand physical activities and inadequate patient adherence to activity restrictions may all exacerbate residual segmental stress and promote recurrent degeneration or instability [18]. Taken together, our findings support the concept that recurrent lumbar disc herniation should not be interpreted merely as a technical failure of the index procedure, but rather as a multifactorial syndrome influenced by biological degeneration, biomechanical instability, surgical strategy and postoperative care. The revision strategy-whether repeat decompression or fusion-must therefore be individualized, taking into account the predominant pain pattern, imaging evidence of disc and segmental degeneration and the mechanical integrity of the involved motion segment.

Study Limitations

This study has several limitations. First, the index surgeries were not performed by a single surgeon; however, all surgeons shared the same surgical philosophy, favoring aggressive discectomy rather than limited fragmentectomy. Second, revision procedures were performed using different fusion techniques, which may have introduced heterogeneity in surgical outcomes. Third, although the mean time to recurrence exceeded three years, the postoperative follow-up after revision surgery remains relatively short, limiting the assessment of long-term consequences. Regarding the systematic review, there was significant difficulty in accurately categorizing different surgical strategies for disc removal (limited discectomy/sequestrectomy versus aggressive discectomy), as definitions varied across studies. In addition, the lack of high-quality randomized controlled trials and the wide variability in follow-up duration among the included studies represent important limitations, particularly given that recurrence rates are known to be time-dependent.

Conclusion

This study supports the use of an aggressive discectomy strategy at the index surgery, rather than a limited fragmentectomy or sequestrectomy, as a means of reducing the risk of recurrent lumbar disc herniation. In our overall cohort, the observed recurrence rate was low (3.4%), which may reflect the effectiveness of this more extensive disc removal approach. However, among the small subset of patients who did develop recurrence, a higher prevalence of axial low back pain and radiological signs of advanced disc degeneration was observed, which consistently led to the indication for lumbar fusion at revision. Therefore, while aggressive discectomy may effectively minimize recurrence, fusion appears to be the most appropriate salvage strategy in patients who recur with significant disc degeneration and axial pain.

Conflict of Interest

The authors declare no material or financial conflict of interest related to this study.

Funding

No source of funding for this study.

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