Endoscopic lumbar discectomy

In one minute

Endoscopic lumbar discectomy removes the piece of disc pressing on a nerve in the lower back. It is for leg pain (sciatica) that has not settled after weeks of non-surgical care, or for a leg that is losing strength. The surgeon works through a 7 mm incision with a camera and instruments inside a thin tube, usually under local anaesthesia with sedation. In the largest randomised trial the operation took a median of 30 minutes. Most patients walk the same day and go home within 24 hours; desk work is usually possible within the first weeks.

What the operation is

A lumbar disc herniation is a tear in the outer ring of a disc that lets the soft core push out against a nerve root. Endoscopic discectomy removes that fragment, and nothing else, through an endoscope: a rigid tube a few millimetres wide carrying a camera, a light and a working channel, with saline flowing through it to keep the view clear.

The names describe the route. Full-endoscopic discectomy is the general term and PELD (percutaneous endoscopic lumbar discectomy) the older umbrella name. PTED (percutaneous transforaminal endoscopic discectomy) enters from the side through the opening where the nerve leaves the spine (the foramen). PEID (percutaneous endoscopic interlaminar discectomy) enters from the back, between two laminae (the bony plates that roof the canal).

Who it is for

The operation is for a herniated disc that compresses a nerve root and produces leg pain, numbness or weakness matching the MRI (magnetic resonance imaging). Most herniations never need it: a 2024 meta-analysis of 31 studies found that about 70% shrink on their own with non-surgical care, and 88% of the loose, sequestered type. So the usual path is at least six weeks of staying active, physiotherapy and medication; the BMJ trial below enrolled patients only after six weeks of leg pain.

Surgery is considered when leg pain persists despite that care, when weakness is progressing, or when there is cauda equina syndrome (loss of bladder or bowel control with saddle numbness), which is an emergency. The NICE (National Institute for Health and Care Excellence) guideline NG59 says it plainly: consider spinal decompression for sciatica when non-surgical treatment has not improved pain or function and the imaging matches the symptoms.

It is not the right tool for pain mainly in the back, for a slipping segment (spondylolisthesis) that needs stabilising, or for a herniation that has already reabsorbed.

How it is done

You lie face down on a table that X-rays pass through. For the transforaminal route the anaesthetist gives sedation and the surgeon numbs the skin and the track; you stay responsive and can tell the surgeon at once if an instrument touches the nerve. In the studies pooled in the 2023 Global Spine Journal meta-analysis, the transforaminal route was usually done under local anaesthesia and the interlaminar route under general anaesthesia; the anaesthetist and surgeon decide per patient.

Under X-ray guidance a needle is placed at the target, then a guidewire, a dilator and the working tube. The incision is 7 mm. Through the endoscope the surgeon sees the nerve root, the disc and the fragment, magnified and under continuous irrigation, frees the fragment and lifts it out with small graspers; bone or ligament is thinned only where it blocks the path. When the nerve root moves freely and pulses with your breathing, the tube comes out and the incision takes one stitch. In the BMJ trial the median operating time was 30 minutes; a meta-analysis of 18 studies found the transforaminal route about 18 minutes longer at L5-S1.

Endoscopic compared with open surgery

The largest study is the Dutch PTED trial in the BMJ, 2022: 613 patients with sciatica randomised to transforaminal endoscopic discectomy or open microdiscectomy. At 12 months leg pain was slightly lower after the endoscopic operation (median 7 versus 16 on a 0 to 100 scale), which met the non-inferiority test; the authors called the difference small and possibly not clinically relevant. Recovery differed: 94% of endoscopic patients went home on the day of surgery against 6%, and there were no dural tears against 3%. Repeat surgery within a year was the same, 5% and 6%.

Ruetten's randomised trial of 178 patients in 2008 found equal results at two years, recurrence of 6.2% in both groups, and less back pain and tissue trauma with the endoscope. A 2022 meta-analysis of six randomised trials found complication rates of 5.5% endoscopic versus 10.4% open, grading the evidence moderate to low.

Two honest caveats. The endoscope has a learning curve: the newly trained surgeons' first cases in the Dutch trial had an 11% reoperation rate within a year, against 5% once the learning curve was over. And in observational cohorts it carried more residual fragments and more transient burning in the leg (dysaesthesia) than open surgery.

Risks and how we reduce them

• Recurrent herniation: 5% to 6% within one to two years in the randomised trials and pooled cohorts, up to 15% in the wider literature; male sex, obesity, smoking, diabetes and a large tear in the disc wall raise the risk. The operation removes the loose fragments and leaves the healthy disc; protecting it in the first weeks is part of every recovery plan.
• Dural tear (a nick in the membrane holding the spinal fluid): none in the endoscopic arm of the BMJ trial; 1.3% transforaminal and 2.1% interlaminar in pooled studies. A small tear is sealed during the same operation.
• Transient nerve irritation: burning or tingling in the leg for days to weeks, more common than after open surgery in cohort data (relative risk 3.7). Local anaesthesia with sedation, which keeps the patient responsive so that nerve contact is reported at once, is the safeguard the transforaminal series rely on.
• Infection: none in the endoscopic arm of the BMJ trial against 1% in the open arm; the small incision and the absence of implants are the likely reasons.
• Residual fragment and repeat surgery: both more likely with the endoscope in cohort data (relative risks 5.3 and 1.5). Conversion to open surgery: four of the 125 learning-curve cases in the BMJ trial. The endpoint of the operation is a nerve root that moves freely; when a fragment cannot be reached safely, surgeons convert to an open operation rather than persist.

Across the team's own operations, complications have been well below 1%. That is our figure, not a comparison with anyone else.

Recovery, week by week

Day 0. Everyone in the BMJ trial's endoscopic arm walked on the day of surgery, and 94% went home that day.

Days 1 to 3. Short walks several times a day; no bending, lifting or long sitting.

Week 2. In the trial the median leg pain had fallen from 71 to about 25 on the 100-point scale. Desk work and short drives are usually possible.

Week 6. Median leg pain around 18, disability down by more than half, 70% recovered from leg pain. Physiotherapy starts; physical jobs and sport are discussed at this visit.

Month 3 and beyond. Improvement continued through the year, and 79% reported recovery from leg pain at 12 months. Numbness can lag pain by months. A new leg pain after a pain-free interval should be reported promptly; that is how a recurrence announces itself.

What the evidence says

• Gadjradj and colleagues, BMJ 2022: 613 patients; endoscopic discectomy non-inferior to open microdiscectomy for leg pain at one year, same-day discharge, no dural tears, similar reoperation rate.
• Ruetten and colleagues, Spine 2008: 178 randomised patients; equal results at two years, recurrence 6.2% in both groups.
• Yang and colleagues, World Neurosurgery 2022: 6 trials and 13 cohorts; fewer complications overall with the endoscope, more transient dysaesthesia and residual fragments in cohorts.
• Jitpakdee and colleagues, Global Spine Journal 2023: 18 studies, 1,948 patients; transforaminal and interlaminar routes give comparable outcomes.
• NICE NG59 and the North American Spine Society (NASS) guideline on lumbar disc herniation with radiculopathy: surgery is for sciatica that has not improved with non-surgical care and matches the imaging.

How we do it at spine.uz

We are Tashkent's first endoscopic spine team: five surgeons operating as one team, 27,600+ endoscopic and spine operations in total. The incision is 7 mm. Most endoscopic decompressions are done without general anaesthesia, under local anaesthesia with sedation; the anaesthetist and surgeon decide per patient. No screws or implants are used.

Send your MRI on Telegram or WhatsApp and a doctor from the team replies by voice within 48 hours, free of charge, saying whether this is a herniation we would operate on, which route we would use, and whether waiting is the better choice. The in-person consultation ends with a written team conclusion, and follow-up continues in the same chat.

Preparing for the operation

Bring the MRI files rather than the report alone, any X-rays, a list of your medicines and allergies, and someone to take you home. Tell us about blood thinners, diabetes medication and heart or lung conditions; the anaesthetist will say what to stop, and when to stop eating and drinking. Most patients walk the same day.