One of the significant advancements in human medicine was the use of surgery for treating diseases. Eventually, humans began to consider that instead of opening up the body to reach the organ that needed surgery, it would be ideal to use a camera. Thus, the endoscope was invented.

Before the development of the endoscope, for many years, surgeons in various fields used microscopes during operations. Since the invention of the endoscope, it has been widely adopted. One major advantage of using an endoscope in lumbar disc surgery is that the muscles and bones covering the spinal canal do not need to be damaged or removed.

Procedure of Endoscopic Lumbar Disc Surgery

In endoscopic lumbar disc surgery, a needle is first inserted into the disc space. Then, a series of telescopic tubes—similar to radio antennas—are introduced. A thin tube is first slid over the needle, followed by larger tubes, until finally a tube wide enough to pass the endoscope is inserted into the disc space. Through this, the damaged disc is removed.

This minimally invasive procedure is much smaller than open surgery. As a result, the patient experiences less pain after the operation and can return to normal activities more quickly.

Evolution and Use of Endoscopy in Surgery

Endoscopy was initially used for the gastrointestinal tract. Over time, it was also introduced into abdominal surgeries, known as laparoscopy, where instead of opening the abdomen, several small incisions are made, and surgical tools and a laparoscope are inserted—for example, to remove the gallbladder.

For several years now, endoscopy has been used in neurosurgery and spinal surgeries. These are called minimally invasive techniques, especially for removing lumbar discs.

It’s important to note that not all conditions can be treated with this method. Specific indications are required for lumbar disc removal via endoscopy. The results of endoscopic surgery are comparable to open surgery, but with fewer complications due to less tissue manipulation.

In endoscopic lumbar disc surgery, the skin incision is about 1.5 to 2 cm, whereas in open surgery it is about 5 cm. Therefore, minimal trauma is inflicted on the spinal muscles. Additionally, nerve roots and the dura are less manipulated, resulting in fewer adhesions.

In many cases, the patient can be discharged the same day, and recovery time is shorter than that of open lumbar surgery.

Indications for Endoscopic Lumbar Disc Surgery

This method is suitable when:

  • The herniated disc affects one or a maximum of two levels.
  • The disc is unilaterally herniated.
  • The patient does not have significant spinal canal stenosis.

Thus, patients with bilateral leg pain or centrally herniated discs do not benefit from this method.

Surgical Approaches

There are two main techniques:

  1. Transforaminal approach
  2. Interlaminar approach

For the L5-S1 level (the last lumbar disc), the interlaminar method is preferred, while for higher levels (e.g., L4-L5), the transforaminal approach is used.

The operation can be performed under local anesthesia with sedation or general anesthesia.

Success Rate and Safety

  • Success rate: Around 90% for endoscopy, compared to 86% for open surgery.
  • In open surgery, a part of the vertebra called the lamina is removed to reach the disc, whereas in endoscopic surgery, no bone removal is required.
  • Complication rate: Around 4%, with the most common being tingling or nerve root pain, occurring in about 10% of cases, which usually resolves within a few weeks.

Typical Steps of Endoscopic Lumbar Disc Surgery

1- Patient preparation:

  • Transferred to operating room and given anesthesia (usually general).

2- Sterilization and incision:

  • Lumbar area is cleaned and a small horizontal incision is made.

3- Access to disc space:

  • Special surgical tools are used to access the disc.

4- Removal of damaged disc material:

  • Inflamed or herniated parts are removed using surgical tools or lasers.

5- Nerve decompression:

  • Any compressed nerves are released.

6- Closure:

  • Skin is sutured.

7- Recovery from anesthesia:

  • Patient is awakened and monitored.

8- Post-operative care:

  • Short hospital stay followed by rest, physical therapy, and medications for inflammation and pain relief.

Advantages of Endoscopic Lumbar Disc Surgery

  1. Minimally invasive: Less tissue damage.
  2. Less bleeding and swelling.
  3. Faster return to daily activities.
  4. Reduced post-operative pain.
  5. High precision and visibility with the endoscope.
  6. Faster symptom relief by nerve decompression.
  7. Lower risk of complications.
  8. Shorter recovery time.

Disadvantages of Endoscopic Surgery

  1. Requires advanced equipment and technology, which may not be widely available.
  2. Needs high surgical skill and experience.
  3. Limited access to deeper or central disc herniations.
  4. May need to convert to open surgery if complications arise.
  5. General surgical risks: infection, bleeding, hematoma.
  6. Risks associated with anesthesia.
  7. Longer operation time compared to open surgery.

Potential Complications

  • Nerve root injury, possibly leading to muscle weakness or leg paralysis.
  • Post-operative infections, despite thorough irrigation during surgery.
  • Sometimes, the surgeon may switch to open surgery intra-operatively if endoscopic access is not possible.

Limitations of Endoscopic Surgery

  • Not suitable for L5-S1 level in many cases due to pelvic obstruction.
  • Not ideal for bilateral leg pain, central herniations, or patients with spinal stenosis due to small foramina.

Surgical Outcomes

In appropriate candidates, results are excellent, with around 80% improvement. The torn part of the disc is removed, and the rest of the disc heals with scar tissue, sealing the rupture and relieving pressure from the nerve root.

Suitable Candidates for Endoscopic Disc Surgery

  1. Patients with unilateral leg pain, e.g., left or right sciatica.
  2. Patients whose leg pain is greater than back pain.
  3. MRI shows no disc calcification or central herniation.
  4. Patients without spinal stenosis.

Frequently Asked Questions

1. Is it painful?

No, it involves minimal post-operative pain.

2. Is long-term hospitalization needed?

No, most patients are discharged the same day and return to routine quickly.

3. Is it suitable for everyone?

Only for patients with specific disc herniation types and symptoms.

4. Is physiotherapy required afterward?

Yes, your doctor may recommend a rehabilitation program.

5. Is it a permanent solution?

Yes, in most cases, it eliminates the disc problem permanently.