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Is it true that even today, the results of reinterventions after unsuccessful spine surgeries are often unsatisfactory, despite major diagnostic and therapeutic advances in the field of spinal surgery. Based on our observations of cases with failed back surgery syndrome in the Department of Orthopaedic Surgery, the University of Balgrist Zürich, the indications for a reintervention and the choice of the surgical procedure are reported. The use of decompression as re-intervention is successful only in cases where there is an unequivocally demonstrable lack of space for the nervous system due to recurrent hernia or narrow spinal canal. In such cases it may be possible, subject to careful assessment of the criteria, to perform a percutaneous nucleotomy as an alternative to a conventional microsurgical discectomy. Nowadays decompression by means of instrumental spinal fusion is usually indispensable as re-intervention after unsuccessful surgeries.

In the last few years, the operative treatment of severe spondylolisthesis has aimed to reduce the gliding movement between the vertebral bodies proceeding then to a spondylodesis. So far, various questions have remained open. When, with which techniques and with which patients should the reduction of the vertebral gliding be performed? How do these results compare with the spondylolisthesis fused operatively "in situ" without any correction at the same time? In order to answer the various questions raised, we examined patients operatively treated with spondylolisthesis of more than 50%, both clinically and radiologically. 20 patients with a ventral spondylodesis and reposition were compared with 98 patients having had a dorsal fusion without reposition. In most cases of progressive vertebral gliding, it is possible to effect alignment of the lumbar curvature even with complex procedures e.g. Halo-Pelvic Traction or usage of Harrington Instruments. The reposition of the spondyloptosis has a positive influence on the Pelvic Tilt.

In total consolidated dorsal fusion it is possible that the decreased intervertebral distance as well as the displacement can increase. 50 patients treated in the period from 1925 till 1977 with a spondylolisthesis of more than 50% have been reviewed. 36 of them were treated by a dorsal fusion, the 14 other patients without operation. Increased displacement was found in 43 cases. This phenomen will be brought about the deflective deformation of the dorsal fusion. Depending on the elasticity bone rebuilding under substinent biomechanical conditions is possible. In the course of time, total intercorporal consolidation leads to a difinitive stability and relief of pain.

To our knowledge, the method of percutaneous nucleotomy dates back to the first description made by Hijikata in 1975. Compared to the classical hemilaminotomy, the main advantage of this method is that it reduces bone and soft tissue damage in the segment to a minimum. Furthermore, this method avoids disagreeable complications encountered in chemical nucleotomy, for a example, anaphylactic shock, the escape of the nucleolytic agent into the spinal canal, etc. The indication for this method should be avoided in the case of a prolapse within the spinal canal and especially when it is displaced outside the level of the disc. In the period between 1979 and 1981 we carried out percutaneous nucleotomies in 20 patients with a disc herniation mostly combined with a narrow spinal canal or spondylolisthesis. The clinical results from 14 of the 20 patients were described as "very good" or "good". We consider the proportion of patients showing good clinical results to be high, bearing in mind that the indication was not just disc hernia alone but was in most cases associated with other lumbar pathologies.

Opinions on the treatment of disc herniation are very controversial and the results reported vary, very much indeed. Most often, one decided--and still decides--to excise the disc herniation in conjunction with hemilaminotomy or flavectomy; this method having been carried out from 1974 to 1983 on 598 patients, at the department of Orthopaedic Surgery, Balgrist, of the University of Zurich. A follow-up of over 400 patients has proved to be very informative: whereas very good or good clinical results can be reported in 73.6% of such cases with disc herniation, alone, these not having undergone operation before, similar results were only found in 27.2% of those who had also been suffering from additional causes of lumbalgia like a relatively narrow spinal canal, spondylolisthesis, spondylolysis or nearthrosis for instance. This finding is of paramount importance when attempting to improve the overall results. It is very necessary to separate the complex cases from the "simple" disc herniation ones. At the same time, those patients suffering from lumbalgia due not only to a herniated disc but also to other additional causes arising from alterations to the lumbar spinal canal must be judged and treated differentially. The present follow-up permits conclusions and considerations correspondingly.

Percutaneous nucleotomy was first described in 1975 by Hijikata in Japan. We introduced this method since 1979 for the treatment of lumbar disc herniation at the Department of Orthopaedic Surgery, the University of Zürich, Balgrist, improved the original instruments of Hijikata and employ since 1982 various arthroscopes in order to remove nucleus pulposus more accurately and effectively under direct visual control (discoscope). This method was performed between 1979 and 1986 in our clinic in 75 patients with lumbar disc herniation. The clinical result was designated as excellent or good in 48 of 75 patients (65%). The 7 years experiences with this procedure are reported on this paper.

From 1965-1975 in the orthopedical Univ. Clinic Balgrist, Zurich, there were 177 reoperations after total hip prostheses necessary. In 91 replacements the interval between first and second operation was an average of 4.1 years, in 67 prosthesis-removements 2.1 years. The follow-up showed a relationship between bacteriological culture taken before and during operation and clinical results. The decision to change or remove the prostheses should be made on the positive or negative bacteriological results.