Disc herniations are a pain in the butt. Namely, because the herniated disc fragment frequently pinches the nerves in the lower spine (lumbar spine) that innervate the buttocks. Hence, pain in the buttocks. And back. And legs.
Unfortunately, this type of pain is frequently disabling. Meaning loss of sleep, daily activities, ability to work, athletic pursuits, even worsening of social interactions, as pain frequently limits our ability to connect with others.
Our goal is to help improve your pain and quality of life, while minimizing pain associated with surgery. An endoscopic discectomy drastically reduces the invasiveness of surgery to remove a fractured or herniated disc. By causing less harm to the spine, patients often have better outcomes with regard to postoperative pain, quicker recovery, quicker return to activities, less postoperative pain medication use, as well as reduced risks.
Surgical treatment of a herniated disc
The discs between your spinal bones (vertebrae) provide cushioning and flexibility to your spine. However, like most items which are flexible and cushioning, they can breakdown. Sometimes, that breakdown leads to a tear in the outer lining of the disc, and the pressure of the spine causes the cushioning material to squirt out, or herniate.
Unfortunately, many herniated disk fragments hit or compress a spinal nerve (sometimes called a nerve root). Fortunately, many disc herniations will resorb and disappear by the body’s natural repair and healing. Frequently we use injections to help minimize pain while the disc is healing.
However, there are times when the disc herniation is so substantial that it causes more neurologic problems than just pain, such as weakness, numbness and, and the worst case, bowel and bladder symptoms. Or, the disc does not heal over time and the pain is limiting an individual’s quality of life and activities. In these cases, we recommend surgery to remove the disc fragment
This surgery is called a discectomy, but may also be referred to as a microdisc, microdiscectomy, in similar terms. The goal of the surgery is to remove the portion of the disc that has shifted or herniated, leading to compression of the nerve and pain. So while the surgery is called discectomy, the only goal is to remove fragments of the disc, not the entire disc between your spinal bones.
What is Endoscopic Discectomy?
Endoscopic discectomy is a cutting-edge surgical technique aimed at treating herniated or damaged discs in the spine. The procedure involves the use of an endoscope, a thin tube equipped with a light and camera, which is inserted through a small incision to access the affected disc. We remove the herniated portion of the disc, relieving pressure on the spinal nerves and alleviating pain, weakness, or numbness.
Benefits of Endoscopic Discectomy
Ultra-minimally invasive: The small incision and minimal access reduces trauma to the spinal muscles, which is the most common and obvious source for surgery-related pain. Recent literature also demonstrates reduced muscle breakdown, as measured by muscle proteins in the urine, when an endoscopic technique is utilized. The reduction in muscle breakdown is better than other minimally invasive approaches, like open or tubular microdiscectomy.
Reduced Risks: The minimized opening of the body and use of constant irrigation has been shown to reduce several risks, including infection, bleeding, dural tear (spinal fluid leak), as well as risk of postoperative pain medications and their side effects. Stronger pain medications, i.e., opioids / narcotics, have more side effects, such as constipation and urinary retention, addiction, and, according to the US CDC, opioids increase all-cause mortality. Approximately 98% of our patients not on narcotics will not start a narcotic for this surgery.
Less Pain: most patients experience less postoperative pain compared to open procedures, when compared in head-to-head-
Faster Recovery: Many patients can return to their normal activities within weeks, as opposed to months with more invasive surgeries.
Shorter Hospital Stay: Most patients undergo endoscopic discectomy on an outpatient basis, meaning they can go home the same day or after a short observation period.
Surgical Approach
The endoscopic discectomy is typically performed under local anesthesia and sedation, frequently general anesthesia. Here’s a breakdown of the surgical process:
Preparation: You are positioned comfortably, often lying face down. Imaging, which refers to X-rays or fluoroscopy, is used to identify the spinal bones (vertebrae) where the herniated disc is located.
Incision: A small incision (about 6-7 mm, for approximately width of your pinky fingernail) is made in the skin at the level of the affected disc. A tube is inserted through this incision, and the endoscope is carefully navigated to the herniated disc.
Visualization: The endoscope provides beautiful images of the spinal elements, including the nerves, joints, and disc fragments. The compressed nerve is gently moved away from the disc fragment, and the disc fragment can be removed from underneath the nerve.
Completion: After the successful removal of the disc fragment, epidural steroids are frequently injected -to provide longer duration reduction in inflammation around the spinal nerve. The endoscopic instruments are removed, and the small incision is closed with an absorbable (dissolving) suture and sterile tape is applied on top of the skin.
However, because of the technical complexity of the surgery, many surgeons do not offer this option.
Risks and Potential Complications
Like any surgical procedure, endoscopic discectomy carries risks, though these are generally lower than those associated with open surgery. Some of the potential complications include:
Recurrence of Herniation: The most common complication, in terms of frequency, is that another disc fragment herniates out. In some cases, another surgery to remove a second fragment may be beneficial in improving your quality of life.
Incomplete relief of symptoms: Sometimes, particularly with large disc fragments and severe nerve compression or longstanding disc herniations, the nerve does not recover perfectly. This can lead to a disappointing resolution of pain, weakness, or numbness. We may only be able to improve one cause of back pain. Moreover, surgery cannot erase age. Age-related back pain is universal; unfortunately, spine surgery cannot make you 18 years old again.
Infection: Although rare, infection at the incision site or deeper in the spine can occur. In our series, only 1 patient of approximately 1,200 patients had an infection1 , which occurred after swimming. We therefore recommend avoiding submersion, including pools, hot tubs, and bathtubs, until 1 month after surgery
Bleeding: While the endoscopic approach minimizes bleeding, there is still a small risk of bleeding after the surgery -which may require revision surgery.
Dural Tear: A tear in the membrane (dura mater) surrounding the spinal cord, which can cause a cerebrospinal fluid (CSF) leak. Dural tears are minimized with the fluid irrigation of the endoscope – which pushes away the dura. CSF leaks are exceptionally rare in endoscopic surgery, unlike open surgeries, since there is less muscle injury.
Nerve Injury: Because the nerve has to be moved to remove the disc fragment, there is a slight risk of damaging nearby nerves during the surgery, which could result in weakness, numbness and/or new pain. Fortunately, in most cases, any worsening in function usually recovers with time.
Anesthesia-related complications: Adverse reactions to the anesthesia. The risks of your anesthesia are reviewed with you by our anesthesia team immediately prior to surgery. In some cases, when individuals have multiple medical problems, we may ask you to see our anesthesiologists prior to surgery to make the best plans.
Need for Conversion to Another Surgery: In unforeseen circumstances, our team may need to convert to a traditional open surgical approach during the procedure. This is exceptionally rare.
Medical complications: These are problems that are independent of the surgery, but may occur because in association with surgery. For example, blood clot may form in the legs (deep vein thrombosis – DVT) or lungs (pulmonary embolism – PE) if you are not moving much after surgery. Other examples include: opioid or other pain medication problems, such as drug dependence or addiction, bowel obstruction, etc.
It is important to understand risk factors are often patient-specific, and that we will provide our best estimate of your risks – not generalized estimates.
What to Expect After Surgery
After the procedure, you will spend a short period in a recovery area to allow the sedating medications to wear off, and most can go home the same day.
Postoperative Care: You may experience mild discomfort or soreness at the incision site, which is typically managed with anti-inflammatory pain medications.
Activity Restrictions: Initially, we recommend that you avoid strenuous activities, such as lifting heavy objects or bending excessively, for a few weeks to allow your body to heal.
Physical Therapy: A physical therapy program may be recommended to strengthen the muscles around the spine and improve mobility. Everyone tends to do well with a coach helping them out to achieve their goals.
Follow-up Appointments: a 6 week follow-up appointment is set prior to surgery. Additional follow-up appointments are established to assess the success of the surgery, additional needs or other considerations. Imaging tests, such as MRI or X-rays, may be used to confirm that the herniated disc has been adequately removed and that no further issues are present.
Recovery and Long-Term Outlook
Recovery from endoscopic discectomy is typically quicker compared to traditional open spinal surgery. Many patients report a significant reduction in pain and an improved ability to perform daily activities within a few weeks. However, full recovery may take several months as the body continues to heal.
While most patients achieve lasting relief, it’s important to maintain a healthy lifestyle, engage in regular exercise, and avoid activities that could strain the spine to reduce the risk of future problems.
- Mahan, M. A. et al. Full-endoscopic spine surgery diminishes surgical site infections – a propensity score-matched analysis. Spine J 23, 695–702 (2023).
