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Chong Zhao,* Hao Zhang,* Yan Wang, Derong Xu, Shuo Han, Shengwei Meng, Jialuo Han, Houchen Liu, Chuanli Zhou, Xuexiao Ma Department of Spine Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, People’s Republic of China*These authors contributed equally to this workCorrespondence: Xuexiao Ma; Chuanli ZhouDepartment of Spine Surgery, The Affiliated Hospital of Qingdao University, No.59 Haier Road, Qingdao, Shandong, 266000, People’s Republic of ChinaTel +86 18661807895; +86 18661809796Email ma_xuexiao@126.com; justin_5257@hotmail.comPurpose: To investigate the preoperative radiological risk factors for recurrent lumbar disc herniation (rLDH) within 1 year after percutaneous endoscopic transforaminal discectomy (PETD).Patients and Methods: A retrospective case–control study was conducted. Between January 2013 and November 2019, a total of 1210 patients with single-level L4/5 LDH who underwent PETD were enrolled in the present study. In total, 62 rLDH patients were diagnosed and collected based on the clinical and radiological manifestations, and 224 non-rLDH controls were selected from the remaining 1148 patients. Preoperative radiological parameters were collected and measured. An age threshold to distinguish patients into subgroups was established using the Youden index. The relationships between the risk factors and rLDH were evaluated by univariate and multivariate analyses in two subgroups. Predictive models were established based on logistic analysis. The area under the curve (AUC) of receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA) were used to assess the predictive models.Results: In the present study, logistic analysis identified six significant predictors associated with rLDH in the young group: superior endplate concave angle (ECA), sacral slope, Modic changes, sagittal range of motion (sROM), extension intervertebral angle (IVA), and lumbar lordosis. Four significant predictors were identified in the elderly group: disc height index (DHI), retrolisthesis (posterior spondylolisthesis), sROM, and extension IVA. Validation of both models demonstrated excellent model discrimination (AUC= 0.940 and 0.946, respectively). DCA also showed excellent clinical utility and benefits.Conclusion: The nomograms that we constructed could accurately predict individual patient recurrence risk. Individualized measures should be taken for patients of different ages with the above risk factors, and tailored postoperative surveillance of patients who underwent PETD can be planned.Keywords: lumbar disc herniation, percutaneous endoscopic transforaminal discectomy, recurrent LDH, risk factor

Meng Kong,1,2,* Derong Xu,1,* Changtong Gao,3 Kai Zhu,1 Shuo Han,1,2 Hao Zhang,1,2 Chuanli Zhou,1 Xuexiao Ma1 1Department of Spinal Surgery, The Affiliated Hospital of Qingdao University, Qing’dao, Shandong Province 266000, People’s Republic of China; 2Department of Medicine, Qingdao University, Qing’dao, Shandong Province 266000, People’s Republic of China; 3Minimally Invasive Interventional Therapy Center, Qingdao Municipal Hospital, Qing’dao, Shandong Province 266000, People’s Republic of China*These authors contributed equally to this workCorrespondence: Xuexiao Ma Tel +8618661807895Email ma_xuexiao@126.comChuanli ZhouDepartment of Spinal Surgery, The Affiliated Hospital of Qingdao University, No. 59, Hai Er Road, Qing’dao, Shandong Province 266000, People’s Republic of ChinaTel +86 18661809796Email justin_5257@hotmail.comBackground: Percutaneous endoscopic lumbar discectomy (PELD) is an increasingly applied minimally invasive procedure that has several advantages in the treatment of lumbar disc herniation (LDH). However, recurrent LDH (rLDH) has become a concerning postoperative complication. It remains difficult to establish a consensus and draw reliable conclusions regarding the risk factors for rLDH.Purpose: This retrospective study aimed to investigate the risk factors associated with rLDH at the L4-5 level after percutaneous endoscopic transforaminal discectomy (PETD).Methods: A total of 654 patients who underwent the PETD procedure at the L4-5 level from October 2013 to January 2020 were divided into a recurrence (R) group (n=46) and a nonrecurrence (N) group (n=608). Demographic and clinical data and imaging parameters were collected and analyzed using univariate and multiple regression analyses.Results: The current study found a 7% rate of rLDH at the L4/5 level after successful PETD. Univariate analysis showed that older age, high BMI, diabetes mellitus history, smoking, large physical load intensity, moderate disc degeneration, small muscle–disc ratio (M/D), more fat infiltration, large sagittal range of motion (sROM), scoliosis, small disc height index (DHI), small intervertebral space angle (ISA), and small lumbar lordosis (LL) were potential risk factors (P < 0.10) for LDH recurrence after PETD at the L4-5 level. Multivariate analysis suggested that high BMI, large physical load intensity, moderate disc degeneration, small M/D, more fat infiltration, large sROM, small ISA, and small LL were independent significant risk factors for recurrence of LDH after PETD.Conclusion: Consideration of disc degeneration, M/D, fat infiltration of the paravertebral muscles, sROM, ISA, LL, BMI, and physical load intensity prior to surgical intervention may contribute to the prevention of rLDH following PETD and lead to a more satisfactory operative outcome and the development of a reasonable rehabilitation program after discharge.Keywords: percutaneous endoscopic transforaminal discectomy, recurrent LDH, risk factor