Microsurgical Treatment of Lumbar Disc Herniation
Microsurgery for lumbar disc herniation (microdiscectomy) is a surgical procedure in which the herniated disc fragment compressing the nerve is removed under an operating microscope through a small incision (usually 2–3 cm). Thanks to the magnification and illumination provided by the microscope, the nerve root and surrounding tissues are seen more clearly, and damage to muscle and bone structures is minimized. The operation usually takes 45–90 minutes, patients are mostly discharged the following day, and when patients are appropriately selected, significant relief of leg pain is achieved. Microsurgery is one of the widely accepted standard methods in lumbar disc herniation surgery.
What is microsurgery and why is it preferred?
Microsurgery is a technique first described in the 1970s and refined over time. Using the operating microscope, the surgeon obtains a three-dimensional, magnified view. As a result:
- The incision is small, and muscle tissue is detached from the bone only to a limited extent.
- The nerve root, dura (the membrane covering the nerves), and herniated fragment are clearly visualized.
- Only the portion compressing the nerve is removed; most of the healthy disc tissue is preserved.
- Blood loss is minimal, and postoperative pain is generally limited.
- The length of hospital stay is shortened, and mobilization begins early.
For these reasons, microsurgery has for many years been one of the reliable and widely used methods in lumbar disc herniation surgery.
When is surgery necessary for lumbar disc herniation?
Most lumbar disc herniations improve significantly within 6–12 weeks with non-surgical treatment (activity modification following a period of rest, medication, physical therapy, exercise, and, if necessary, epidural steroid injection). The decision to operate is made not solely on the basis of MRI findings, but according to the severity of symptoms, examination findings, and response to treatment.
Conditions Requiring Emergency Surgery
- Cauda equina syndrome: Progressive weakness in the legs, numbness in the groin/genital area (saddle anesthesia), urinary or fecal incontinence, or urinary retention are medical emergencies and must not be delayed.
- Rapidly progressive motor deficit: Marked loss of strength, such as the development of foot drop at the ankle
When is microsurgery
| Period | What to Expect? |
|---|---|
| 0–2 weeks | Short walks; avoiding prolonged sitting, bending, and heavy lifting; wound care |
| 2–4 weeks | Return to desk work (depending on the patient); gradually increasing walking time |
| 4–6 weeks | Starting light exercise and a physical therapy program |
| 6–12 weeks | Gradual strengthening; return to heavy physical work is planned with the surgeon’s approval. |
| 3–6 months | Return to most activities; improvement in muscle endurance |
These periods vary from person to person. Type of work, age, size of the herniation, preoperative nerve damage, and general health status all affect recovery.
The Importance of Rehabilitation
Surgery relieves nerve compression; however, strengthening the core muscles that support the spine and correcting posture and movement habits are important for long-term success. The physical therapy and rehabilitation program consists of strengthening the deep abdominal and back muscles, flexibility exercises, gait training, and, if necessary, specific exercises for nerve-related loss of strength.
Success Rate of Microsurgery
Studies show that, when patients are appropriately selected, rates of significant improvement in leg pain after microsurgery are high. In general, the vast majority of patients (in the range of 85–95%) report meaningful relief of leg pain. Improvement in low back pain, however, is more variable than improvement in leg pain. The duration of preoperative symptoms, the degree of nerve damage, smoking, and the patient’s expectations all affect the outcome.
The most important condition for surgical success is that the symptoms are consistent with the MRI findings and that the decision to operate is made based on the correct indication.
Risks and Complications of Microsurgery
Like any surgical procedure, microsurgery carries risks. Complications are rare, but patients should be informed about them:
- Recurrence (recurrent herniation): Reported in approximately 5–15% of cases; smoking, obesity, and a large annular defect may increase the risk.
- Dural tear (cerebrospinal fluid leak): Seen in a small number of patients; usually repaired during surgery.
- Infection: Wound infection or disc infection (discitis) is rare; the risk is reduced through antibiotic prophylaxis and sterile technique.
- Bleeding and hematoma: Rare.
- Nerve damage: Rare, but temporary or permanent weakness/numbness may occur.
- Persistent or recurrent pain: Low back pain in particular may persist.
- Wrong-level surgery: Prevented by level verification methods.
- Anesthesia-related risks and thromboembolic complications: Rare; reduced by early mobilization.
You should go to the hospital immediately after surgery in the following situations:
- Fever, redness, discharge, or swelling at the wound site
- Sudden-onset leg weakness
- Urinary/fecal incontinence or inability to urinate
- Numbness in the groin area
- Headache that worsens when upright (may be a sign of fluid leakage.)
- Swelling and pain in the calf, sudden shortness of breath
- Continuing the exercises recommended by the physiotherapist
How to choose the right surgeon and center?
Once the decision for lumbar disc herniation surgery has been made, one of the questions patients wonder about most is who should perform the operation and at which center. Lumbar disc herniation surgery is a field that involves working very close to nerve tissue and requires precise technique. For this reason, the surgeon’s experience, the center’s technical infrastructure, and planning of the treatment process through the postoperative period directly affect recovery. Considering the following criteria before making a decision can help you make a more informed choice.
- Being a neurosurgeon or an orthopedics and traumatology specialist experienced in spine surgery
- Availability of an operating microscope and intraoperative imaging (fluoroscopy)
- Clear explanation of all alternatives (including non-surgical treatment) before surgery
- Provision of postoperative physical therapy and rehabilitation support
- An approach that offers realistic expectations rather than guaranteeing definitive results
Frequently Asked Questions About Microsurgical Treatment of Lumbar Disc Herniation
How many hours does microsurgery for lumbar disc herniation take?
Single-level microsurgery usually takes 45–90 minutes. The duration may be longer in cases of recurrent herniation, multiple levels, or when additional decompression is required.
What is the difference between microsurgery and open surgery?
In microsurgery, because the procedure is performed under a magnified view provided by the operating microscope, the incision is smaller and there is less damage to surrounding tissues. In both methods, the goal is to remove the herniated fragment compressing the nerve.
When can I return to work after lumbar disc herniation surgery?
Return to desk work is usually possible within 2–4 weeks. For those doing heavy physical work, this period may extend up to 6–12 weeks. The final decision is made based on the surgeon’s assessment.
Can the herniation recur after surgery?
Yes, there is a risk of recurrence, reported at approximately 5–15%. Weight control, quitting smoking, and regular exercise help reduce the risk.
Does lumbar disc herniation always require surgery?
No. The vast majority of patients with lumbar disc herniation recover with non-surgical treatment. Surgery is considered in situations such as cauda equina syndrome, progressive weakness, or severe pain that persists despite appropriate treatment.
Does pain continue after microsurgery?
Leg pain decreases rapidly in most patients. Numbness, tingling, and mild low back pain may persist for a while. Nerve recovery may take weeks or months.
Are spinal screws used in microsurgery?
Screws or rods are generally not used in standard microsurgery. In special conditions such as spondylolisthesis or instability, stabilization may be planned.
Is physical therapy necessary after surgery?
For most patients, physical therapy and rehabilitation are recommended to strengthen the core muscles, increase mobility, and reduce recurrence.
What is cauda equina syndrome, and why is it an emergency?
The cauda equina is the bundle of nerves in the lower part of the spinal canal. Compression of these nerves can lead to loss of bladder and bowel control, numbness in the groin area, and weakness in the legs. Because delayed treatment increases the risk of permanent damage, emergency surgery may be required.
References
- North American Spine Society (NASS). Clinical guideline for lumbar disc herniation with radiculopathy
- Weinstein JN et al. SPORT (Spine Patient Outcomes Research Trial) study, outcomes of surgical and non-operative treatment of lumbar disc herniation
- Cochrane systematic reviews: Surgical treatment for lumbar disc herniation
- National spine surgery societies and current peer-reviewed literature