Obesity increases the risk of recurrent herniated nucleus pulposus after lumbar microdiscectomy


      Background context

      Recurrent herniation of the nucleus pulposus (HNP) frequently causes poor outcomes after lumbar discectomy. The relationship between obesity and recurrent HNP has not previously been reported.


      The purpose of this study was to investigate the association of obesity with recurrent HNP after lumbar microdiscectomy.

      Study design

      Retrospective Cohort.

      Patient sample

      We reviewed all cases of one- or two-level lumbar microdiscectomy from L2–S1 performed by a single surgeon with a minimum follow-up of 6 months.

      Outcome measures

      The primary clinical outcomes were evidence of recurrent HNP on magnetic resonance imaging (MRI) and need for repeat surgery.


      All patients with recurrent radicular pain or new neurological deficits underwent a postoperative MRI scan. Recurrent HNP was defined as a HNP at the same side and same level as the index procedure.


      Seventy-five patients were included in the study. The average body mass index (BMI) was 27.6±4.6. Thirty-two patients received an MRI scan. The time from operation to repeat MRI scan varied widely (3 days to 15 months). Eight patients (10.7%) had recurrent HNP. Four patients had persistent symptoms requiring reoperation (5.3%). The mean BMI of patients with recurrent HNP was significantly higher than that of those without recurrence (33.6±5.1 vs. 26.9±3.9, p<.001). In univariate analysis, obese patients (BMI ≥30) were 12 times more likely to have recurrent HNP than nonobese patients (odds ratio [OR]: 12.46, 95% confidence interval [CI]: 2.25–69.90). Obese patients were 30 times more likely to require reoperation (OR: 32.81, 95% CI: 1.67–642.70). Age, sex, smoking, and being a manual laborer were not significantly associated with recurrent HNP. A logistic regression analysis supported the findings of the univariate analysis. In a survival analysis using a Cox proportional hazards model, the hazard ratio of recurrent HNP for obese patients was 17 (OR: 17.08, 95% CI: 2.85–102.30, p=.002).


      Obesity was a strong and independent predictor of recurrent HNP after lumbar microdiscectomy. Surgeons should incorporate weight loss counseling into their preoperative discussions with patients.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Spine Journal
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Connolly E.S.
        Surgery for recurrent lumbar disc herniation.
        Clin Neurosurg. 1992; 39: 211-216
        • Fandino J.
        • Botana C.
        • Viladrich A.
        • Gomez-Bueno J.
        Reoperation after lumbar disc surgery: results in 130 cases.
        Acta Neurochir (Wien). 1993; 122: 102-104
        • Jackson R.K.
        The long-term effects of wide laminectomy for lumbar disc excision: a review of 130 patients.
        J Bone Joint Surg Br. 1971; 53: 609-616
        • O'Sullivan M.G.
        • Connolly A.E.
        • Buckley R.F.
        Recurrent lumbar disc protrusion.
        Br J Neurosurg. 1990; 4: 319-325
        • Thomalske G.
        • Galow W.
        • Ploke G.
        Critical comments on a comparison of two series (1000 patients each) of lumbar disc surgery.
        Adv Neurosurg. 1977; 4: 22-27
        • Gaston P.
        • Marshall R.W.
        Survival analysis is a better estimate of recurrent disc herniation.
        J Bone Joint Surg Br. 2003; 85: 535-537
        • Crock H.V.
        Observations on the management of failed spinal operations.
        J Bone Joint Surg Br. 1976; 58: 193-199
        • Greenwood J.
        • McGuire T.H.
        • Kimball F.
        A study of the causes of failure in the herniated intervertebral disc operation: an analysis of sixty-seven reoperated cases.
        J Neurosurg. 1952; 9: 15-20
        • Law J.D.
        • Lehman R.W.
        • Kirsch W.M.
        Reoperation after lumbar intervertebral disc surgery.
        J Neurosurg. 1952; 9: 1520
        • Pheasant H.C.
        Sources of failure in laminectomies.
        Orthop Clin N Am. 1975; 6: 319-329
        • Matsui H.
        • Terahata N.
        • Tsuji H.
        • et al.
        Familial predisposition and clustering for juvenile lumbar disc herniation.
        Spine. 1992; 17: 1323-1328
        • An H.S.
        • Silveri C.P.
        • Simpson J.M.
        • et al.
        Comparison of smoking habits between patients with surgically confirmed herniated lumbar and cervical disc disease and controls.
        J Spinal Disord. 1994; 7: 369-373
        • Kelsey J.L.
        • Githens P.B.
        • O'Connor T.
        • et al.
        Acute prolapsed lumbar intervertebral disc: an epidemiologic study with special reference to driving automobiles and cigarette smoking.
        Spine. 1984; 9: 608-613
        • Mundt D.J.
        • Kelsey J.L.
        • Golden A.L.
        • et al.
        An epidemiologic study of non-occupational lifting as a risk factor for herniated lumbar intervertebral disc.
        Spine. 1993; 18: 595-602
        • Carragee E.J.
        • Han M.Y.
        • Suen P.W.
        • Kim D.
        Clinical outcomes after lumbar discectomy for sciatica: the effects of fragment type and annular competence.
        J Bone Joint Surg Am. 2003; 85: 102-108
        • Olsen M.A.
        • Nepple J.J.
        • Riew K.D.
        • et al.
        Risk factors for surgical site infection following orthopaedic spinal operations.
        J Bone Joint Surg Am. 2008; 90: 62-69
        • Olsen M.A.
        • Mayfield J.
        • Lauryssen C.
        • et al.
        Risk factors for surgical site infection in spinal surgery.
        J Neurosurg. 2003; 98: 149-155
        • Friedman N.D.
        • Sexton D.J.
        • Connelly S.M.
        • Kaye K.S.
        Risk factors for surgical site infection complicating laminectomy.
        Infect Control Hosp Epidemiol. 2007; 28: 1060-1065
        • Olsen M.A.
        • Lock-Buckley P.
        • Hopkins D.
        • et al.
        The risk factors for deep and superficial chest surgical-site infections after coronary artery bypass graft surgery are different.
        J Thorac Cardiovasc Surg. 2002; 124: 136-145
        • Olsen M.A.
        • Sundt T.M.
        • Lawton J.S.
        • et al.
        Risk factors for leg harvest surgical site infections after coronary artery bypass graft surgery.
        J Thorac Cardiovasc Surg. 2003; 126: 992-999
        • Tucker M.C.
        • Schwappach J.R.
        • Leighton R.K.
        • et al.
        Results of femoral intramedullary nailing in patients who are obese versus those who are not obese: a prospective multicenter comparison study.
        J Orthop Trauma. 2007; 21: 523-529
        • Rosen D.S.
        • Ferguson D.S.
        • Ogden A.T.
        • et al.
        Obesity and self-reported outcome after minimally invasive lumbar spinal fusion surgery.
        Neurosurgery. 2008; 63: 956-960
        • Djurasovic M.
        • Bratcher K.R.
        • Glassman S.D.
        • et al.
        The effect of obesity on clinical outcomes after lumbar fusion.
        Spine. 2008; 33: 1789-1792
        • Park P.
        • Upadhyaya C.
        • Garton H.J.
        • Foley K.T.
        The impact of minimally invasive spine surgery on perioperative complications in overweight or obese patients.
        Neurosurgery. 2008; 62: 693-699
        • Cole 4th, J.S.
        • Jackson T.R.
        Minimally invasive lumbar discectomy in obese patients.
        Neurosurgery. 2007; 61: 539-544
        • Patel N.
        • Bagan B.
        • Vadera S.
        • et al.
        Obesity and spine surgery: relation to perioperative complications.
        J Neurosurg Spine. 2007; 6: 291-297
        • Gepstein R.
        • Shabat S.
        • Arinzon Z.H.
        • et al.
        Does obesity affect the results of lumbar decompressive spinal surgery in the elderly?.
        Clin Orthop Relat Res. 2004; 426 (148–144)
        • Dossett L.A.
        • Heffernan D.
        • Lightfoot M.
        • et al.
        Obesity and pulmonary complications in critically injured adults.
        Chest. 2008; 134: 974-980
        • Williams R.W.
        Microlumbar discectomy: a conservative surgical approach to the virgin herniated lumbar disc.
        Spine. 1978; 3: 175-182
        • Carragee E.J.
        • Spinnickie A.O.
        • Alamin T.F.
        • Paragioudakis S.
        A prospective controlled study of limited versus subtotal posterior discectomy: short-term outcomes in patients with herniated lumbar intervertebral discs and large posterior anular defect.
        Spine. 2006; 31: 653-657
        • Barth M.
        • Weiss C.
        • Thome C.
        Two-year outcome after lumbar microdiscectomy versus microscopic sequestrectomy: part 1: evaluation of clinical outcome.
        Spine. 2008; 33: 265-272
        • McGirt M.J.
        • Graces Ambrossi G.L.
        • Datoo G.
        • et al.
        Recurrent disc herniation and long-term back pain after primary lumbar discectomy: review of outcomes reported for limited versus aggressive disc removal.
        Neurosurgery. 2009; 64: 338-345
        • Ebeling U.
        • Kalbaryck H.
        • Reulen H.J.
        Microsurgical reoperation following lumbar disc surgery: timing, surgical findings, and outcome in 92 patients.
        J Neurosurg. 1989; 70: 397-404
        • Reith C.
        • Lausberg G.
        Risk factors of recurrent disc herniation.
        Neurosurg Rev. 1989; 12: 147-150
        • Epstein J.A.
        • Lavine L.S.
        • Epstein B.S.
        Recurrent herniation of the lumbar intervertebral disk.
        Clin Orthop. 1967; 52: 169-178
        • Kim J.M.
        • Lee S.H.
        • Ahn Y.
        • et al.
        Recurrence after successful percutaneous endoscopic lumbar discectomy.
        Minim Invasive Neurosurg. 2007; 50: 82-85
        • van Rijn J.C.
        • Klemetso N.
        • Reitsma J.B.
        • et al.
        Symptomatic and asymptomatic abnormalities in patients with lumbosacral radicular syndrome: clinical examination compared with MRI.
        Clin Neurol Neurosurg. 2006; 108: 553-557
        • Borenstein D.G.
        • O'Mara Jr., J.W.
        • Boden S.D.
        • et al.
        The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects: a seven-year follow-up study.
        J Bone Joint Surg Am. 2001; 83: 1306-1311
        • Callaghan J.P.
        • McGill S.M.
        Intervertebral disc herniation: studies on a porcine model exposed to highly repetitive flexion/extension motion with compressive force.
        Clin Biomech (Bristol, Avon). 2001; 16: 28-37
        • Schmidt H.
        • Kettler A.
        • Heuer F.
        • et al.
        Intradiscal pressure, shear strain, and fiber strain in the intervertebral disc under combined loading.
        Spine. 2007; 32 (478–455)
        • Wilder D.G.
        • Pope M.H.
        • Frymoyer J.W.
        The biomechanics of lumbar disc herniation and the effect of overload and instability.
        J Spinal Disord. 1988; 1: 16-32
        • Rodacki A.L.
        • Fowler N.E.
        • Provensi C.L.
        • et al.
        Body mass as a factor in stature change.
        Clin Biomech (Bristol, Avon). 2005; 20: 799-805
        • Yar T.
        Spinal shrinkage as a measure of spinal loading in male Saudi university students and its relationship with body mass index.
        Saudi Med J. 2008; 29: 1453-1457
        • Fabris de Souza S.A.
        • Faintuch J.
        • Valezi A.C.
        • et al.
        Postural changes in morbidly obese patients.
        Obes Surg. 2005; 15: 1013-1016
        • Gilleard W.
        • Smith T.
        Effect of obesity on posture and hip joint moments during a standing task, and trunk forward flexion motion.
        Int J Obes (Lond). 2007; 31: 267-271

      Linked Article