Microscopic / Endoscopic Discectomy

Microscopic and endoscopic discectomy are minimally invasive procedures designed to treat lumbar disc herniation, which often leads to radiculopathy (nerve pain) in the lower back and legs. These techniques have evolved over time, offering significant improvements in surgical precision, recovery time, and patient outcomes compared to traditional open discectomy. The surgery is generally considered when conservative treatments such as medications, physical therapy, and injections have failed to relieve symptoms.

How Common It Is and Who Gets It? (Epidemiology)

Lumbar disc herniation is a common cause of radiculopathy, affecting a significant portion of the active population, especially individuals between 30 and 50 years of age. It is most commonly seen in people who engage in physical activity, heavy lifting, or those with pre-existing degenerative changes in the spine. Approximately 10% of patients with lumbar disc herniation require surgical intervention, such as microdiscectomy or endoscopic discectomy, after conservative treatments fail.

MRI showing sagittal section of the lumbar spine.

MRI showing herniated disc in axial section.

Why It Happens – Causes (Etiology and Pathophysiology)

Lumbar disc herniation occurs when the soft inner material of an intervertebral disc (nucleus pulposus) pushes through a tear in the tougher outer layer (annulus fibrosus), placing pressure on nearby spinal nerves. This leads to symptoms such as:

• Radiculopathy: Pain, numbness, tingling, or weakness radiating down the leg, often referred to as sciatica.

• Degenerative Disc Disease: Over time, the discs lose their ability to cushion the vertebrae, making them more susceptible to herniation.

• Trauma or Repetitive Stress: Sudden injury or repetitive movements can increase the risk of disc herniation.

How the Body Part Normally Works? (Relevant Anatomy)

The lumbar spine consists of five vertebrae (L1-L5) with intervertebral discs between them that act as shock absorbers. The spinal cord runs through the spinal canal, and nerves branch out from the cord through small openings called foramina. These nerves transmit signals to various parts of the body, including the legs and feet. When a disc herniates, it can compress these nerves, leading to pain and dysfunction in the lower extremities.

What You Might Feel – Symptoms (Clinical Presentation)

The primary symptoms of lumbar disc herniation that may require surgical intervention include:

• Radicular Pain: Sharp pain radiating down the leg, often following the path of the sciatic nerve.

• Numbness and Tingling: Sensations in the legs or feet, caused by nerve compression.

• Muscle Weakness: Difficulty in walking or performing daily activities due to impaired nerve function.

• Failed Conservative Treatments: Persistent symptoms despite rest, physical therapy, and medications.

How Doctors Find the Problem? (Diagnosis and Imaging)

To diagnose lumbar disc herniation and determine the need for surgery, doctors typically use:

• MRI: The gold standard imaging technique to visualize disc herniation, nerve compression, and other spinal issues.

• CT Scans: Sometimes used when MRI is unavailable or to get more detailed images of the bones.

• X-rays: To rule out other causes of back pain such as fractures or alignment issues.

• Physical Examination: To assess reflexes, strength, and nerve function, often showing signs of radiculopathy.

Classification

Microscopic and endoscopic discectomy can be classified based on the surgical approach:

• Microdiscectomy: Involves using an operating microscope for a small incision to remove the herniated disc material.

• Endoscopic Discectomy: Uses an endoscope (a small camera) for a less invasive approach, often with even smaller incisions.

Technique

After careful selection of the patient for surgery as indicated above, patients are taken to the operating room where they are put under general anesthesia. After anesthesia, the patients are flipped onto their bellies on a special table. All the bony prominences are well padded and the nerves are well padded.

The area of surgery is well-prepped and draped aseptically. X-ray imaging (Fluoroscopy) is used inside the operating room to identify the level before the decision. Once the incision is given, meticulous dissection and hemostasis is achieved and the back of the spine is reached, the level is again checked under x-ray.

For tubular microdiscectomy, a similar approach is performed with the use of sequential dilation and the use of tubes to visualize the area of interest. This requires no muscle stripping and minimal injury to the muscles.

While performing endoscopic discectomy, a camera is used instead of the operating microscope, and the area of surgery is visualized on a monitor. Special instruments are used to the surgery which allows the camera to project as well as perform the surgery.

After confirming the level, some of the bone from the back of the spine is removed to expose the yellow ligament (ligamentum flavum) underneath. The ligament is also excised to expose the nerve roots.

The nerve roots are carefully retracted to the other side to expose the disc herniation. The extruded disc is removed carefully. Once all the loose disc herniation is removed, the nerve roots are checked for any pressure.

After a satisfactory decompression is achieved, hemostasis is achieved and the wound is closed. We also use vancomycin antibiotics in the wound along with hemostatic agents.

The incision for microdiscectomy is usually about 5 cm. Patients usually use a small dressing on their lower back. After the surgery, the patient is flipped onto their back and recovered from anesthesia and moved to the recovery unit.

Once they are awake and up and about, they are discharged to their home. They are sent with pain medications.

Operating room image of the endoscopic/microscopic lumbar discectomy.

Intraoperative image showing the extracted disc material.

Intraoperative image showing the surgical incision size of minimally invasive lumbar discectomy.

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