The Spine Journal 10 (2010) 575580

Clinical Study

Obesity increases the risk of recurrent herniated nucleus pulposus

after lumbar microdiscectomy
Dennis S. Meredith, MDa,*, Russel C. Huang, MDa, Joseph Nguyen, MPHb,
Stephen Lyman, PhDb
a
Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
b
Department of Epidemiology and Biostatistics, Hospital for Special Surgery, 535 East 70th St., New York, NY 10021, USA
Received 10 August 2009; revised 11 December 2009; accepted 18 February 2010

Abstract 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.
PURPOSE: 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
L2S1 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.
METHODS: 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.
RESULTS: Seventy-five patients were included in the study. The average body mass index (BMI)
was 27.664.6. 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 (33.665.1 vs. 26.963.9,
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]:
2.2569.90). Obese patients were 30 times more likely to require reoperation (OR: 32.81, 95%
CI: 1.67642.70). 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: 2.85102.30, p5.002).
CONCLUSIONS: 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. 2010 Elsevier Inc. All rights reserved.
Keywords: Obesity; Lumbar microdiscectomy; Recurrent herniated nucleus pulposus

FDA device/drug status: not applicable.
Author disclosures: RCH (other relationships, Nuvasive, Inc.).
This study was approved by the Hospital for Special Surgerys Institu-
tional Review Board.
* Corresponding author. Hospital for Special Surgery, 535 East 70th
St, New York, NY 10021, USA. Tel.: (212) 606-1466; fax: (212) 774-1477.
E-mail address: meredithd@hss.edu (D.S. Meredith)
1529-9430/$ see front matter 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.spinee.2010.02.021
Introduction
Recurrent herniation is a common cause of poor out-
comes after lumbar discectomy surgery. Reported rates of
recurrence range from 5% to 11% [16]. The overall rate
of unsatisfactory outcomes after primary lumbar discec-
tomy is 5% to 20%, making recurrent herniation a major
cause of pain, disability, and reoperation [710].
576 D.S. Meredith et al. / The Spine Journal 10 (2010) 575580
Context
Several factors have been found to be associated with
higher recurrence risk after lumbar discectomy. In this
paper, the authors assessed the role of obesity with early
(6-month) postoperative recurrent herniations.
Contribution
The authors found that obesity was a strong and inde-
pendent predictor of recurrent disc herniations in their
patients.
Implication
If true, and able to be generalized, then intraoperative
techniques and postoperative regimens might need to
be adjusted to maximize outcomes in obese patients.
However, more data in support of the authors ndings
is needed. The inuence of other potential confounders
(eg, annular defect type, surgical technique details)
was not assessed. In addition, the patient numbers in
the study were small.
The Editors
Risk factors for recurrent disc herniation previously
reported in the literature include constitutional weakness of
the annular tissue, exposure to repetitive lifting or vibration,
heavy lifting, smoking, the preoperative size of the disc her-
niation as measured on magnetic resonance imaging (MRI),
and the appearance of the herniation at the time of surgery
[1115]. Although obesity has been shown to result in worse
outcomes for both elective and emergent procedures in spine,
orthopedic, thoracic, and general surgery [1628], no previ-
ous studies have investigated the relationship between obe-
sity and recurrent lumbar disc herniation.
In this study, we retrospectively analyzed a consecutive
series of lumbar microdiscectomies performed by a single
surgeon with a minimum 6-month follow-up. Our focus
was the effect of patients body mass index (BMI) on
same-level same-side recurrent disc herniation as defined
by the presence of radiculopathy with a confirmatory
MRI scan and the need for reoperation.
Materials and methods
We retrospectively analyzed all patients who underwent
primary one- or two-level lumbar (L2S1) microdiscec-
tomy performed by a single surgeon at our institution
between March 2005 and March 2008. Inclusion in the
study required the presence of radicular pain unresponsive
to nonsurgical treatment and a preoperative MRI scan or
computed tomography myelogram demonstrating a central
or posterolateral herniation of the nucleus pulposus (HNP)
at the level corresponding to the patients symptoms. Addi-
tionally, it is the principal investigators (PI) standard of
care to treat only patients with an intraoperatively identifi-
able anular or subanular defect with discectomy. Patients
with a disc protrusion but no anular or subanular defect
and no extruded disc fragments were treated by decompres-
sion of the nerve root without discectomy. These patients
were not included in the study cohort. Patients with a history
of previous lumbar spinal surgery at the index level(s), with
far lateral (foraminal) disc herniations treated with lateral
decompression, or with prior lumbar fusion at any level
were excluded.
The author used a surgical technique adapted from the
sequestrectomy technique of Williams [29]. An operating
microscope was used to perform a laminotomy. In cases
of extruded HNP, the extrusion was removed entirely. If
an annular defect could be found with a blunt Penfield 4
elevator, an 18-gauge angiocath was inserted into the disc
space and used to irrigate any free loose fragments. With
the exception of the angiocath, the disc space itself was
not entered with any surgical instruments. In cases of sub-
ligamentous herniations, the posterior longitudinal ligament
was bluntly split in a longitudinal direction using a Penfield
4 elevator. Free disc fragments were expressed with irriga-
tion or a small pituitary rongeur, but only free fragments
were removed. Any stable fragments within the disc space
still attached to the disc or end plate were left in situ. The
annulus was never incised sharply.
The decision to obtain a postoperative MRI was based
on the PIs standard of care. An MRI was recommended
for all postoperative patients experiencing persistent or re-
current leg pain. Consequently, not all patients in the cohort
received a postoperative MRI. For the purposes of this
study, a clinically significant recurrent herniation was de-
fined as a disc herniation causing leg pain (as documented
by the PI) with radiographic (MRI) evidence of disc mate-
rial at the same side and level of the index surgery causing
impingement, compression, or deviation of nerve tissue (as
reported by an attending radiologist). Body mass index was
based on the patients height and weight recorded in the
patients chart at the time of the index surgery. Smoking
status and employment as a manual laborer were based
on data recorded in the patients chart at the time of
index surgery. The definitions used for normal weight
(BMI 18.524.9), overweight (BMI 2529.9), and obese
(BMI $30) are widely accepted in the literature.
The PI used a standard postoperative rehabilitation protocol
for all study patients. Patients were mobilized on the first post-
operative day without an orthosis. Patients were instructed to
avoid lumbar forward bending, twisting, or lifting greater than
10 pounds. At 6 weeks after index surgery, these restrictions
were progressively lifted and patients were permitted full un-
restricted activity including manual labor and exercise at 3
months after surgery. Management of recurrent herniation
was also per the PIs standard of care. Revision surgery was re-
served for patients with new neurological deficits occurring
 D.S. Meredith et al. / The Spine Journal 10 (2010) 575580 577

after recurrent HNP or persistent radicular symptoms despite Table 1

nonsurgical management such as oral analgesia, physical ther- Descriptive summary of the patient cohort
apy, and epidural steroid injections. Total patients 75
Descriptive analysis consisted of means and standard Age (y)
Median 46
deviations for continuous variables and frequencies and per- Range 1679
centages for discrete variables. Inferential analysis involved Gender (%)
univariate comparisons to identify risk factors for recurrent Male 61
herniation and revision surgery. Potential risk factors were Female 39
evaluated using chi-square or Fisher exact tests for discrete BMI (%)
Mean (SD) 27.6 (4.6)
variables and presented as unadjusted odds ratios (ORs) Normal (18.524.9) 27
and their respective 95% confidence intervals (95% CIs). Overweight (2529.9) 48
Continuous variables were evaluated using independent sam- Obese ($30) 25
ples t tests. All comparisons regarding the rate of recurrent Side of index surgery (%)
HNP and reoperation were made to the total study cohort Left 33
Right 43
and not just the patients receiving postoperative MRIs. Bilateral 24
Multivariable logistic regression was used to identify Level of index surgery
independent risk factors for recurrence of herniation Total levels 88
reporting adjusted OR and 95% CIs. In addition, Cox Two-level procedures 13
proportional hazards regression was conducted for the as- L2L3 4%
L3L4 13%
sessment of hazard ratios and their corresponding 95% L4L5 42%
CIs to evaluate time to recurrence. All potential risk factors L5S1 41%
were considered eligible for inclusion in both models. Time of maximum follow-up (mo)
Using a forward stepwise procedure, variables that failed Median 24
to achieve a p value of less than .15 were excluded from Range 945
MRI scans to look for recurrent HNP
the final model. Additionally, a Hosmer-Lemeshow test Total patients scanned 32
was used to assess the goodness of fit of the model. Range of times between surgery and scan 3 d to 15 mo
Data analyses were conducted using SPSS version 14.0 Total patients with recurrent HNP 8
(SPSS Inc., Chicago, IL, USA). Levels of recurrent HNP
L4L5 6
L5S1 4
Treatments for patients with recurrent HNP
Results Physical therapy 8
Epidural steroid injection 7
During the study period, a total of 98 patients underwent Reoperation
primary one- or two-level lumbar microdiscectomy. Total patients undergoing repeat discectomy 4
Range of times to reoperation after index surgery 4 d to 6 wk
Twenty-three patients were lost to follow-up or had Levels of reoperation
a follow-up of less than 6 months at the time data were L4L5 4
collected, leaving a total of 75 patients included in the study L5S1 2
cohort. Thirteen patients had a two-level microdiscectomy BMI, body mass index; SD, standard deviation; MRI, magnetic
for a total of 88 levels. Demographic and descriptive char- resonance imaging; HNP, herniation of the nucleus pulposus.
acteristics of the study cohort are presented in Table 1.
The distribution of patients BMI is presented in Fig. 1. A
total of 32 patients met clinical criteria to receive an MRI confirmed intraoperatively in all cases. The time to reoper-
scan. The time from operation to repeat MRI scan varied ation varied from 4 days to 6 weeks after the index surgery.
widely (3 days to 15 months); however, all patients in the The mean BMI of patients with recurrent HNP was sig-
study cohort experienced an interval with resolution of their nificantly higher than that of those without recurrence (BMI
radicular pain. Of those scanned, eight patients (10.7%) met 33.665.1 vs. 26.963.9, p!.001). The disparity between
criteria for recurrent HNP. Including two patients with two the mean BMI of patients requiring reoperation and that
levels of recurrence, six of the recurrent HNPs were at of those who did not was even more pronounced
L4L5 and four were at L5S1. The treatments for those (37.364.4 vs. 27.163.9, p!.001). We then divided the
with herniation included analgesia, physical therapy (eight cohort into those patients with a BMI above and those with
patients), and epidural steroid injections (seven patients). a BMI below the clinically accepted cutoff for obesity.
One patient developed a surgical site infection requiring Univariate analysis of the BMI groups showed that obese
an irrigation and a debridement. Four patients had persistent patients were over 12 times more likely to have recurrent
symptoms requiring reoperation (5.3%). In these patients, HNP compared with nonobese patients (OR: 12.46, 95%
four of the recurrent HNPs were at L4L5 and two were CI: 2.2569.90). Analysis of the BMI groups for reopera-
at L5S1. The presence of a herniated fragment was tion showed that obese patients were even more at risk
578 D.S. Meredith et al. / The Spine Journal 10 (2010) 575580

Table 2
Univariate predictors of recurrent HNP after lumbar microdiscectomy
95% CI
Predictor OR Low High p Value
BMI
O30 12.46 2.25 69.90 .003
!30
Age (y)
!40
4059 0.73 0.14 3.98 .999
$60 0.98 0.15 6.58 .999
Gender
Male 1.06 0.23 4.80 .999
Female
One- versus two-level surgery 2.15 0.37 12.33 .333
Smoking 1.39 0.25 7.67 .657
Fig. 1. Distribution of body mass index (BMI) within the study cohort. Manual labor 1.77 0.18 17.40 .504
HNP, herniation of the nucleus pulposus; OR, odds ratio; CI,
confidence interval; BMI, body mass index.
for revision surgery, with the likelihood of reoperation be-
ing approximately 30 times greater than that of nonobese
reoperation. The odds ratio of recurrent HNP and the need
patients (OR: 32.81, 95% CI: 1.67642.70). We also per-
for reoperation for patients with a BMI $30 (the clinical
formed separate univariate analyses based on patients
cutoff for obesity) were both highly significant across
age, sex, one- versus two-level surgery, smoking status,
multiple analyses.
and whether the patient was a manual laborer. There was
Overall, our recurrence rate of 10.7% is within the range
no statistically significant difference in the rate of recurrent
reported by previous studies [16]. There are several
HNP or reoperation in any of these groups (Tables 2 and 3).
established techniques for lumbar discectomy. The effect
A post hoc power analysis revealed that we were underpow-
of surgical technique on rates of recurrent HNP remains
ered to detect differences resulting from smoking or if the
controversial [3032]. Patients in the current study under-
patient was a manual laborer.
went sequestrectomy with minimal to no removal of
The independent effect of BMI on recurrent HNP was
intradiscal nucleus pulposus and minimal to no manipula-
analyzed using a logistic regression model that adjusted
tion or enlargement of preexisting annular defects. Other
for age, sex, one- versus two-level surgery, and smoking
techniques include the use of a scalpel to enlarge the
and manual labor status. This confirmed the statistically
annular defect and vary in the amount of intradiscal nucleus
significant association between obesity and recurrent
pulposus removed. It is uncertain whether the findings of
HNP. Additionally, none of the other variables demon-
the current study would apply to patients undergoing sur-
strated a significant association with recurrent HNP. A
gery using these different techniques. Another factor that
Hosmer-Lemeshow test was used to assess the goodness
of fit of the model (p5.996). Although the regression
model was able to converge and proved to be a well- Table 3
fitted model to the data, the adjusted odds ratio for the as- Univariate predictors of reoperation after lumbar microdiscectomy
sociation was not greater than 10% for all assessments. 95% CI
Consequently, only the crude odds ratio is reported. Predictor OR Low High p Value
Finally, a survival analysis was performed using a Cox BMI
proportional hazards model, which showed that the OR of re- O30 32.81 1.67 642.7 .003
current HNP for obese patients increased over time by a factor !30
of 17 (OR: 17.08, 95% CI: 2.85102.30, p5.002) (Fig. 2). Age (y)
!40
4059 2.40 0.23 24.57 .627
$60 2.14 0.08 55.75 .999
Discussion
Gender
We retrospectively investigated the effect of patients Male 0.61 0.08 4.62 .638
BMI on rates of recurrent HNP after one- or two-level Female
lumbar microdiscectomies. We found a statistically signifi- One- versus two-level surgery 6.89 0.86 55.19 .100
cant difference in the BMI of patients with recurrent HNP Smoking 1.36 0.13 14.05 .999
compared with those without. This difference was more Manual labor 1.12 0.05 23.19 .999
pronounced in those patients with recurrent HNP requiring OR, odds ratio; CI, confidence interval; BMI, body mass index.
 D.S. Meredith et al. / The Spine Journal 10 (2010) 575580
Fig. 2. Hazard function for recurrence based on body mass index (BMI).
The x-axis depicts time in days after the index operation. The y-axis de-
picts the cumulative odds ratio (OR) of recurrent herniation of the nucleus
pulposus (HNP) based on a Cox proportional hazard model. The hazard
ratio of recurrent HNP for obese patients was 17 (OR: 17.08, 95% confi-
dence interval: 2.85102.30, p5.002).
influences the comparison of our data with previous studies
is the definition of recurrent HNP. In previous studies,
several distinct conditions have been referred to as recur-
rent disc herniation. These include recurrence at the same
vertebral level and side as the primary herniation
[2,4,9,10,33]; the same vertebral level but contralateral side
[4,33,34]; and herniation at a different vertebral level
[1,4,9,35]. Same-side same-level recurrent herniation is
a distinct condition because the presence of an incision
through the annular ligament from the primary surgery
may increase the risk of recurrence. Additionally, incom-
plete primary discectomy may contribute to the recurrence
of symptoms, and postoperative scar formation may mimic
symptoms of recurrence and/or complicate attempted
reoperation. Although the interval between index surgery
and recurrent HNP was relatively short in a small number
of patients in this cohort, all patients experienced a docu-
mented period with resolution of their radicular pain before
the recurrence of symptoms.
Previously, Kim et al. [36] demonstrated a significantly
higher mean BMI (24.9 vs. 22.9) in recurrent versus nonre-
current groups after percutaneous endoscopic lumbar dis-
cectomy. However, neither of their groups met the
clinical cutoff for obesity, and they do not quantify the odds
ratio for recurrence. Smoking and manual labor, which we
used as proxy for repetitive lifting or vibration, have been
previously shown to be predictors of recurrent HNP;
however, that was not the case in our cohort [1214]. Both
smokers and manual laborers were relatively poorly repre-
sented in our cohort, and our data were underpowered to
579
demonstrate these effects. We attempted to control for the
effect of postoperative activity level through the use of
a standardized rehabilitation protocol for 3 months after
surgery. Our data do confirm that one- versus two-level sur-
gery, age, and sex are not significant predictors of recurrent
HNP. Carragee et al. [15] reported that both the anteropos-
terior disc length assessed on preoperative MRI and the in-
traoperative appearance of the disc herniations were
predictors of the risk for recurrent HNP. However, these
data were not available for our cohort. It is unclear how this
limitation affects our conclusions because our study used
a different surgical protocol. For instance, symptomatic
disc protrusion without a herniated fragment or defect in
the annulus was shown by Carragee et al. [15] to have
the highest risk of recurrent HNP within their classification
system. It is not our standard of care to perform discectomy
on these patients, and consequently, they are not repre-
sented in our cohort.
The use of a retrospective design from the cases of a sin-
gle surgeon at a single institution is a notable limitation of
our study. Although statistically significant, the results of
our analyses have a large 95% CI because of the relatively
low number of recurrent HNPs within our series. The use of
a multisurgeon prospective design by future studies would
strengthen these findings.
Given the high rate of asymptomatic abnormalities noted
on MRI studies of the lumbar spine especially in older pa-
tients, it is unlikely that imaging our entire patient cohort
would have added significantly to our findings [37,38]. In
fact, the rate of postoperative MRI scans within our cohort
is higher than previous studies. This is likely because of our
low threshold for obtaining postoperative imaging even in
cases where we believe that the symptoms may resolve.
This is, however, a strength in the context of this study be-
cause it decreases the likelihood that a recurrent HNP was
missed.
Clinical studies by Kelsey et al. [13] and Mundt et al.
[14] have suggested that increased loading of the operative
disc whether via a single traumatic event or lower intensity
repetitive loading contributes to recurrent HNP. This theory
is supported by several biomechanical studies showing that
the relatively small cyclical increases in intradiscal
pressures can cause high shear and fiber strains along the
posterolateral aspect of the annulus fibrosus leading to disc
herniation [3941]. Additionally, these studies show that
intradiscal pressures are highest in flexion. In the obese in-
dividual, studies have shown an increased loss of disc
height as the individual transitions from supine to sitting
or standing positions relative to normal weight controls,
suggesting increased axial loading of the disc during most
daily activities [42,43]. Increased loading of the disc is
further accentuated by a demonstrated increase in forward
flexed posture in obese individuals during sitting and
standing activities [44,45].
In summary, the risk of recurrent HNP and reoperation
after lumbar microdiscectomy is significantly increased
580 D.S. Meredith et al. / The Spine Journal 10 (2010) 575580
by obesity. Physicians should incorporate weight loss coun-
seling into their preoperative discussions with patients.
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