Lumbar disc surgery-Microdiscectomy

Lumbar disc surgery is the surgery to remove herniated disc fragments in the lumbar spine, causing pressure on nerve roots. Microdiscectomy is lumbar disc surgery using microscopic techniques. Microdiscectomy has become a gold standard of surgeries for herniated lumbar discs.

Surgery for herniated disc has undergone considerable advancements over the years. From the era of open disc surgery to the current microdiscectomy/endoscopic discectomy, there has been significant improvement in operative techniques. These improvements have improved patient comfort, reduced post-operative pain, shortened hospital stay and improved long term outcomes.

The number of surgeries for lumbar disc herniations have become quite common. It is important to understand the needs of surgery, techniques of surgery and expectations from surgery.

Who needs a Lumbar disc surgery?

Patients with Sciatica, leg pain caused from compression of nerve in lumbar spine by herniated disc fragments are initially managed conservatively. Most patients do well with rest, analgesic medications and physiotherapy. Surgery is considered in patients who fail to respond to conservative therapy.

  • Persistent disabling pain– If pain in leg caused from herniated disc fragment, Sciatica, does not respond to treatment over time and causes difficulty in carrying out even activities of daily living for prolonged periods, surgery should be considered.
  • Weakness in foot or leg– In case of motor weakness in foot or leg, early surgery should be considered to improve chances of recovery. The most common type of foot weakness from herniated disc fragment is “Foot drop”.
  • Increasing numbness in leg
  • Urinary problems– Sometimes herniated disc fragments cause pressure on large amounts of nerve roots and can cause difficulties in passing urine. This is usually associated with numbness in the peri-anal area. Urinary problems caused by herniated disc fragments warrant urgent surgical decompression as chances of recovery become slim with increasing duration of symptom.

What investigations are required before Lumbar disc surgery?

Magnetic Resonance Imaging or MRI is essential for establishing the diagnosis of herniated disc and to confirm the level of disc herniation.

Dynamic Xrays are required to assess stability of spine as fixation of spine will be required in cases with significant mobility on theses Xrays.

Other investigations include routine blood tests and are done as per the age and medical history of the patient.

How long is the hospital stay for Lumbar microdiscectomy?

Lumbar microdiscectomy is a minimally invasive surgical technique and uses a keyhole type of incision. A significantly shorter and painless post-op recovery period is the foremost advantage of this kind of surgical technique.

In most hospitals, Microdiscectomy for lumbar disc herniations is carried out as a daycare procedure. The patient can go home after a few hours of surgery. In patients with medical problems or elderly, overnight hospital stay is required.

How is Lumbar microdiscectomy performed?

There are many techniques using different retractor systems described for Lumbar microdiscectomy. The underlying principles of all these techniques are same. The incision is small, underlying muscles are split, limited amounts of bone are removed and the herniated disc fragments are removed.

Lumbar microdiscectomy is performed under General anaesthesia. In certain cases, it may be performed under Local anaesthesia as well. Inside the operation room, the patient is positioned prone.

A C-arm, mobile machine for X-rays, is used to locate the level of the herniated disc fragments using bony reference points. A 1.5cm incision is then made over the level of the disc to be removed. After the incision is made, the underlying muscles are split to reach the underlying bone(lamina of the vertebral bone). Tubular shaped retractors are then placed to keep the muscles split and expose the underlying bone. A small hole is made in the laminar part of the bone using a drill to make a corridor to the disc. A ligament, called ligamentum flavum, lies under the bony lamina. This ligament is removed to identify the underlying nerve root affected by the herniated disc fragments. The nerve root is then carefully retracted and herniated disc fragments are removed using grasping forceps. The nerve root should be free and loose once all fragments of herniated discs are removed.

Lumbar Microdiscectomy Surgery Video

Lumbar disc surgery using tubular retractors at L45 level

How is the recovery after Lumbar microdiscectomy?

In modern times, recovery after a lumbar disc surgery is quite smooth. The pain in leg improves rapidly and most patients can start walking within a couple of hours after surgery. Patients do not experience much pain in the back after microdiscectomy.

In 2 weeks, light activities like driving, office work for limited hours, school, routine household work can be resumed. These activities can be increased as per the comfort of the patient over the next few weeks. Strenuous work, lifting weights, contact sports should be avoided for 12 to 14 weeks.

Can a herniated disc recur after surgery?

Yes, it can. In Lumbar Microdiscectomy surgery, complete disc is not removed as was done in the past. Only the fragments which are causing pressure on the nerve root are removed. Loose disc fragments lying within the disc space are also removed to reduce recurrence rates. The disc annulus is the covering of the disc material, and does not have a good blood supply. The disc material herniates through the defect in this disc annulus. Due to its poor blood supply, this defect in the annulus does not heal well for prolonged periods. This leaves the door open for recurrent disc herniation at the same level. The recurrence rate has been widely mentioned to be around 3-5% of all surgeries.

Read more about the causes of Failed back surgery- Why Spine Surgeries fail?

Disclaimer- This is for the general awareness of the patients and cannot replace expert medical advice. Patient treatments need to be individualised and that can be decided based on clinical examination and evaluation by a trained physician.

Need an answer? Ask your question in the comment section below.

Published by DR. HARNARAYAN SINGH

I am a Neurosurgeon and spine surgeon practising in Gurugram, India. Besides Neurosurgery, I love to read, travel and play tennis.

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