Posterior unilateral approach · core spine procedure for symptomatic disc herniation
- Indication: radiculopathy that matches the imaging, after at least 6 weeks of failed conservative care (physiotherapy, NSAIDs, activity modification, ± an epidural steroid injection).
- Emergency: cauda equina syndrome needs surgery within 48 hours; a progressive motor deficit is urgent and needs surgery within days.
- Level verification: three-point fluoroscopic confirmation prevents wrong-level surgery, which occurs in 1 to 4 percent of spine cases.
- Limited discectomy: remove the herniated and loose fragments only — the same recurrence rate as aggressive clearance, with fewer complications and better early back-pain outcomes.
- Sequestered fragments: probe the foramen superiorly and inferiorly — up to 30 percent of herniations have fragments that have migrated away from the main fragment.
- “A free abdomen reduces epidural venous pressure by 30 to 40 percent — the single most important positioning factor.
- “SPORT trial: surgery gives faster relief; intention-to-treat differences were small because of heavy crossover, but as-treated analyses favour surgery.
- “Angle the Kerrison UPWARD, away from the dura — a downward plunge causes a dural tear.
- “Nerve-hook probe test: the root should lift freely and be pulsatile, pink and round (a flat, white, immobile root is still compressed).
When & Why
Indication. Microscopic lumbar discectomy relieves radicular leg pain caused by a lumbar disc herniation compressing a nerve root. It is an elective operation for a patient whose dermatomal/myotomal symptoms match the MRI, after a fair trial — at least 6 weeks — of non-operative care (physiotherapy, NSAIDs, activity modification, and usually one epidural steroid injection) has failed. It is not an operation for axial back pain alone. Three situations move the operation from elective to urgent or emergent:
Saddle anaesthesia, bilateral leg symptoms, urinary retention (post-void residual greater than 400 to 500 ml) or progressive bilateral deficit. Surgery within 48 hours.
A worsening motor deficit (e.g. a dropping EHL) on a background of radiculopathy. Surgery within days to limit permanent nerve injury.
Dermatomal leg pain matching the imaging after 6 or more weeks of failed conservative care, with or without a stable motor deficit.
Contraindications. Axial back pain without radiculopathy, symptoms that do not correlate with the MRI, active infection (discitis, epidural abscess), or significant segmental instability (where a fusion is more appropriate). A non-anatomical pain pattern or abnormal illness behaviour is a relative contraindication and a reason to reassess, not operate. Pre-operative work-up.
- MRI is the definitive investigation — confirm the herniation type (posterolateral, foraminal, far-lateral, sequestered), the direction and distance of migration, and any associated lateral-recess or central stenosis.
- CT if the bone anatomy is unclear — transitional (sacralised/lumbarised) vertebrae or revision surgery, where counting levels is harder.
- Flexion–extension radiographs to exclude instability (greater than 3 to 4 mm translation or greater than 10 degrees angulation). The consent conversation. Quote an 85 to 90 percent good–excellent result for leg pain, and the specific risks: dural tear/CSF leak 1 to 7 percent (higher — 15 to 20 percent — in revision surgery), nerve-root injury 0.5 to 2 percent (usually transient), recurrent herniation 5 to 10 percent at 5 years, wrong-level surgery 1 to 4 percent, epidural haematoma 1 to 2 percent, infection (superficial 1 to 3 percent, discitis 0.5 to 2 percent). Most patients go home the same day or after a 23-hour stay, return to sedentary work at 2 to 4 weeks, manual work at 6 to 12 weeks, and full activity by 12 weeks.
The Operation
The goal: through a small unilateral posterior window, expose the interlaminar space at the correct level, create a limited laminotomy, remove the ligamentum flavum, identify and gently retract the traversing nerve root, extract the herniated and loose disc fragments, confirm the root is free, and close watertight. The exposure — positioning, incision, subperiosteal dissection and level confirmation — is laid out as the first steps below, and in depth on the posterior approach to the lumbar spine page. Setup & equipment. Prone on a Wilson frame or Jackson table; an operating microscope (6–16×) or loupes (3.5–4.5×); C-arm fluoroscopy; a self-retaining retractor (Taylor, McCullough or Caspar); a 3–4 mm high-speed burr; Kerrison rongeurs (2 mm, 3 mm, 45° upward-angled); pituitary rongeurs (2 mm, 3 mm); nerve-root retractors (Love, Scoville); angled blunt nerve hooks; Penfield dissectors (#1, #4); a Cobb elevator; bipolar cautery at 8–10 W; and haemostatic agents (Gelfoam, Surgicel, FloSeal). Antibiotic prophylaxis is cefazolin 2 g IV within 60 minutes of incision (vancomycin 1 g if MRSA risk or penicillin allergy).
Operative sequence
- Prone on a Wilson frame or Jackson table with hips and knees flexed 90 degrees to open the interspinous space.
- The abdomen must be completely free — pass a hand beneath it. A free abdomen reduces epidural venous pressure by 30 to 40 percent, the single most important positioning factor for a dry field.
- Arms abducted less than 90 degrees on arm boards; all pressure points padded (elbows, knees, ASIS); head neutral on a gel headrest.
- Palpate the spinous processes; the iliac crest (Tuffier's line) crosses the L4–5 disc or the L4 spinous process.
- Place a radiopaque skin marker. Obtain AP and lateral fluoroscopy and count from L5/S1 (most reliable) AND from T12 — two independent counts guard against a wrong-level start.
- A small 2–3 cm vertical midline incision centred over the target level.
- Divide skin and subcutaneous tissue with monopolar cautery down to the white, glistening lumbodorsal fascia.
- Make a vertical fascial incision 0.5–1 cm paramedian on the side of the herniation, avoiding the interspinous ligament.
- With a Cobb elevator, strip the paraspinal muscles subperiosteally and UNILATERALLY off the spinous process and lamina.
- Sweep laterally to expose the inferior edge of the superior lamina, the superior edge of the inferior lamina, the interlaminar window and the medial third of the facet.
- Place the self-retaining retractor; use the smallest effective retractor — over-retraction causes muscle ischaemia. Unilateral dissection means less muscle trauma, less postoperative pain and faster recovery.
- Place a metallic marker (Penfield, K-wire) on the spinous process or lamina and obtain a lateral fluoroscopy.
- Count vertebral levels from L5/S1 AND from T12, and document the image in the operative record.
- Bring the operating microscope in over the interlaminar window at 6–16× magnification with coaxial illumination.
- Surgical loupes (3.5–4.5×) are an acceptable alternative with similar outcomes.
- With a 3–4 mm high-speed burr, thin the inferior edge of the superior lamina from midline out to the lateral edge of the interlaminar space.
- Thin to an eggshell translucency so the blue-grey dura shows through — thinning before Kerrison removal prevents a sudden dural penetration and is the key safety step.
- With 2–3 mm 45° upward-angled Kerrison rongeurs, remove the thinned inferior edge of the superior lamina, working from medial to lateral.
- Create a window about 10–15 mm wide that exposes the ligamentum flavum and the lateral dural edge.
- Angle the Kerrison UPWARD, away from the dura — grasp the bone and pull it toward you and up. A downward plunge is a dural tear.
- The ligamentum flavum is normally 2–3 mm thick but can hypertrophy to 6 mm in stenosis. It is often densely adherent to the dura in elderly and revision cases.
- With a Penfield #4 or a right-angled curette, dissect the ligamentum off the underlying dura working from cephalad to caudad on its deep surface, then grasp with pituitary forceps and peel it away. Never avulse the ligamentum — peel it carefully to avoid a dural tear; sharp micro-scissor dissection may be needed in dense adhesions.
- After the ligamentum is removed, identify the structures in order: the pulsatile blue-white dural sac; the traversing nerve root in the lateral recess (L5 at L4–5); the exiting nerve root in the foramen (L4 at L4–5); the disc space ventral to the neural structures; and the medial facet dorso-laterally.
- Never retract anything until you know what you are retracting.
- With a small blunt retractor (Love, Scoville), gently retract the traversing root medially off the disc space, using minimal force.
- Retract intermittently — release every 5–10 minutes — and retract at the root shoulder, NOT at the dorsal root ganglion. Prolonged or aggressive retraction is the commonest cause of a new postoperative deficit (retraction neurapraxia), which usually recovers over weeks to months if recognised early.
- Make a small 5–8 mm vertical incision (box-cut or cruciate) in the posterior annulus with a micro #15 blade.
- With 2 mm pituitary rongeurs, grasp and remove the extruded fragment and any loose fragments. Remove the herniated and loose fragments only — do not aggressively curette the nucleus and endplates.
- With an angled nerve hook or Penfield, probe the foramen CEPHALAD (superiorly) and CAUDAD (inferiorly) along the course of the nerve root to find sequestered or migrated fragments — up to 30 percent of herniations have them.
- Remove any identified fragments with the pituitary rongeur. Retained sequestered fragments are a leading cause of failed back surgery, so this step is mandatory, not optional.
- If imaging shows lateral-recess stenosis or the root is still compressed after the discectomy, undercut the medial facet with the burr or Kerrison and remove the medial third only; for foraminal stenosis, remove the lateral aspect of the superior facet to unroof the foramen.
- Preserve greater than 50 percent of each facet to avoid iatrogenic instability.
- With a 2 mm nerve hook, probe around the root: it should lift freely away from the disc and pedicle, the hook should pass circumferentially, and there should be no residual compression from disc or bone.
- The root should be pulsatile, pink and round. A flat, white, immobile root is still compressed — keep looking.
- Remove the retractor and irrigate with warm saline (500–1000 ml). Control epidural bleeding with brief pulses of bipolar cautery at 8–10 W and haemostatic agents (Gelfoam, Surgicel, FloSeal).
- Perform a Valsalva manoeuvre (20–30 cmH2O for 10 seconds) to reveal occult venous bleeding.
- Close the fascia with a watertight 0-Vicryl, the subcutaneous tissue with 2-0 Vicryl, and the skin with staples or a subcuticular 3-0/4-0 Monocryl. A drain is rarely needed for a single-level microdiscectomy.
Wrong-level surgery occurs in 1 to 4 percent of spine cases. Three-point fluoroscopic verification is the standard of care: (1) pre-operative imaging marking, (2) fluoroscopy before incision with a skin marker, and (3) fluoroscopy with an instrument on bone before any bone removal. Document each step, and take extra care with transitional vertebrae — never remove bone without fluoroscopic confirmation on the lamina.
The Kerrison is the commonest cause of an incidental durotomy. Always thin the bone to translucency first, then angle the rongeur upward away from the dura, grasp the bone and draw it toward you. A downward plunge tears the dura.
Remove the herniated and loose fragments only. Carragee (Spine 2006) and the Thome RCT (J Neurosurg Spine 2005) show that aggressive nucleus and endplate curettage only modestly lowers reherniation while producing more back pain and worse early function and satisfaction. The trade-off is that larger anular defects (greater than 6 mm) carry the highest reherniation risk regardless of technique — so limited discectomy, not aggressive clearance, is the standard of care.
Aftercare & Complications
Rehabilitation | Phase | Timing | Milestones | |-------|--------|------------| | Day 0 | Immediately post-op | Neurological examination compared with pre-op; mobilise within 2–6 hours; oral analgesia (NSAIDs ± short-term opioids, neuropathic agents if radicular pain persists). Same-day discharge in 60–70 percent, or 23-hour observation. | | Restrictions | 0–6 weeks | No bending, lifting or twisting (BLT); lift nothing greater than 5 kg; avoid sitting longer than 30 minutes for 2 weeks; walking encouraged. | | Follow-up | Week 2 / Week 6 | Week 2: wound check and suture removal. Week 6: clinical review, start physiotherapy (core strengthening, McKenzie extensions). | | Return to work | 2–12 weeks | Sedentary 2–4 weeks; manual labour 6–12 weeks; heavy lifting 12 weeks. | Around 85 to 90 percent of patients report a good–excellent result, with immediate leg-pain relief in 80 to 90 percent, back-pain improvement in 50 to 60 percent, and a return to baseline activity by 3 to 6 months. Complications
- Recognition
- Intra-op: clear fluid in the field. Post-op: clear wound drainage, fluctuant swelling (pseudomeningocele), positional headache
- Prevention
- Thin bone before Kerrison; angle Kerrison upward; careful ligamentum-flavum dissection; microscope magnification; avoid aggressive curettage
- Management
- Primary repair with 4-0/5-0 Prolene (small tears simple interrupted; large tears a fascial patch and fibrin glue); test with Valsalva; watertight fascial closure; 24–48 h flat bed rest. Unrecognised leak: beta-2 transferrin confirms CSF; revision repair ± lumbar drain
- Recognition
- New post-op motor or sensory deficit in the root distribution; document immediately and compare with pre-op
- Prevention
- Gentle intermittent retraction (release every 5–10 min); identify the root before retraction; adequate bone removal; bipolar only at low setting; retract at the shoulder, not the DRG
- Management
- Rule out an epidural haematoma with urgent MRI if progressive. Neurapraxia (commonest): physiotherapy, reassurance, 90% recover over weeks–months. Transection (rare): permanent deficit, neurosurgery consult
- Recognition
- New radiculopathy after a pain-free interval (median 2–4 years); MRI distinguishes new disc from scar (scar enhances with gadolinium)
- Prevention
- Remove all herniated and loose fragments; thorough foramen exploration; limited discectomy; 6 weeks of post-op activity restrictions (no BLT)
- Management
- Conservative first (physiotherapy, epidurals, NSAIDs). If persistent at 6–12 weeks: revision discectomy (70–80% success) versus fusion (lower re-reherniation 2–3% but more complications)
- Recognition
- Persistent symptoms post-op; imaging confirms the wrong level was operated
- Prevention
- Three-point verification: pre-op imaging mark, fluoro before incision, fluoro with instrument on bone before laminotomy; document each; extra caution with transitional vertebrae
- Management
- Intra-op recognition before bone removal: adjust exposure. After bone removal: close and re-operate the correct level in the same sitting if stable. Post-op recognition: honest disclosure, re-operation, root-cause analysis
- Recognition
- Acute severe back/leg pain with rapid neurological deterioration 6–24 h post-op; new cauda equina symptoms (saddle anaesthesia, urinary retention)
- Prevention
- Meticulous haemostasis; bipolar cautery; Valsalva test before closure; haemostatic agents; avoid early anticoagulation for 24–48 h; consider a drain if bleeding is extensive
- Management
- EMERGENCY: MRI for diagnosis, then an IMMEDIATE return to theatre for evacuation and haemostasis. Delay risks a permanent deficit; document deficits and timeline meticulously
- Recognition
- Superficial: wound erythema and drainage. Discitis: severe back pain 2–8 weeks post-op, raised ESR/CRP, MRI disc/end-plate inflammation
- Prevention
- Pre-op antibiotics (cefazolin 2 g); minimise operative time; sterile technique; meticulous haemostasis; watertight closure
- Management
- Superficial: oral antibiotics 7–10 days and wound care. Deep: washout and debridement, cultures, IV antibiotics 2–6 weeks, VAC dressing. Discitis: CT-guided biopsy for culture, IV antibiotics 6–12 weeks, bracing, fusion if unstable
- Recognition
- Symptoms never improve or recur within days; post-op MRI shows residual compression
- Prevention
- Thorough disc-space and foramen exploration with a nerve hook; probe test confirms adequate decompression; liberal intra-op imaging if anatomy is unclear
- Management
- If a residual fragment is confirmed on MRI: revision surgery for removal. If no compression: conservative management (physiotherapy, epidurals, neuropathic agents) — may be scar or nerve irritation
- Recognition
- Mechanical back pain worse with extension; flexion–extension films show greater than 3–4 mm translation or greater than 10° angulation; may develop months–years later
- Prevention
- Preserve greater than 50% of each facet; limit facetectomy to the medial third; assess pre-op for instability; consider fusion if an extensive facetectomy is required
- Management
- Instrumented posterolateral fusion (pedicle screws, rods, graft) if symptomatic instability is confirmed on dynamic imaging
Viva & Exam Focus
LEVELLEVEL — safe level verification
DISCDISC — the surgical sequence
Critical danger structures
The central posterior structure. Protect it by thinning the bone before the Kerrison, angling the Kerrison upward, using microscope magnification and dissecting the ligamentum flavum carefully. Tear rate 1–7% primary, 15–20% revision.
Lies in the lateral recess (L5 at L4–5). Identify it before retraction, retract gently and intermittently (release every 5–10 min), and retract at the shoulder, not at the dorsal root ganglion.
Lies in the foramen (L4 at L4–5), superior to the disc level. It is at risk with a far-lateral disc or a foraminotomy; visualise it before decompression.
Batson's valveless epidural plexus. A free abdomen (positioning), low-setting bipolar (8–10 W) and haemostatic agents (Gelfoam, FloSeal) keep the field dry.
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“A 42-year-old builder has 8 weeks of left L5 radiculopathy (lateral leg pain, EHL weakness) with an L4–5 posterolateral disc herniation on MRI. Physiotherapy has failed and one epidural gave only temporary relief. How do you manage him?”
“During an L4–5 microdiscectomy you notice clear fluid in the field after removing the ligamentum flavum. What is your diagnosis and management?”
“A 55-year-old woman has an uneventful L5–S1 discectomy for right S1 radiculopathy and goes home the same day. The next morning she calls with severe back pain, new bilateral leg weakness and numbness around her bottom. What is your diagnosis and management?”
Indications
- Radiculopathy matching the imaging after 6 or more weeks of failed conservative care
- EMERGENCY: cauda equina — surgery within 48 hours
- URGENT: a progressive motor deficit — surgery within days
- Not for axial back pain alone without radiculopathy
Key evidence
- SPORT (RCT, n=501): faster relief with surgery; ITT differences small/not significant due to high crossover
- Limited vs aggressive discectomy (Carragee, Thome RCT): aggressive resection marginally lowers reherniation but worsens back pain and early outcomes
- Cochrane (Rasouli): MIS vs open/microdiscectomy give similar pain relief; MIS lowers infection but raises rehospitalisation for reherniation
- Wrong-level surgery: 1–4% — three-point verification is the standard
Danger structures
- Dural sac and cauda equina (tear rate 1–7%)
- Traversing nerve root — L5 at L4–5 (lateral recess)
- Exiting nerve root — L4 at L4–5 (foramen)
- Epidural venous plexus (Batson's) — valveless; a free abdomen reduces its pressure
Critical technique points
- Free abdomen — the single most important positioning factor (30–40% lower venous pressure)
- Three-point fluoroscopic level verification
- Thin the bone before the Kerrison; angle the Kerrison UPWARD
- Limited discectomy plus mandatory foramen exploration for sequestered fragments
- Valsalva test (20–30 cmH2O) before closure; watertight fascial closure
Emergencies
- Epidural haematoma: severe pain plus a new deficit 6–24 h post-op → emergency MRI → immediate evacuation
- Cauda equina: bilateral symptoms plus saddle anaesthesia plus urinary retention → surgery within 48 hours
- Progressive motor deficit: urgent surgery within days
Background & Evidence
The disease. A lumbar disc herniation prolapses nucleus pulposus through a torn posterior annulus and compresses an adjacent nerve root, producing dermatomal leg pain (sciatica), a myotomal weakness and reflex change. The L4–5 and L5–S1 levels account for the overwhelming majority, giving L5 and S1 radiculopathies respectively. Most acute herniations improve with time — the operation is for the minority whose pain persists or whose neurology deteriorates. Herniation classification (by location). Where the fragment sits dictates the approach:
- Frequency
- The commonest — about 90%
- Implication for surgery
- Standard interlaminar microdiscectomy; the traversing root is the one compressed
- Frequency
- About 7–10%
- Implication for surgery
- Needs a foraminotomy; the exiting root is compressed and may be harder to see
- Frequency
- 1–3%
- Implication for surgery
- A paramedian approach; the exiting root in the foramen
- Frequency
- Uncommon but dangerous
- Implication for surgery
- Risk of cauda equina; a bilateral or wider approach may be needed
Natural history and the role of surgery. Disc herniations are common; many are asymptomatic and most symptomatic ones settle within 6 to 12 weeks. The SPORT trial (Weinstein, 2006) randomised 501 surgical candidates with imaging-confirmed herniation and at least 6 weeks of radiculopathy to open discectomy versus individualised non-operative care. Both groups improved substantially; the intention-to-treat differences favoured surgery but were small and not statistically significant, because of heavy bidirectional crossover (only about half of those assigned to surgery had it within 3 months, and about 30 percent assigned to non-operative care crossed over). The as-treated analysis, however, favoured surgery. The message: discectomy is elective and offers faster relief, but many patients improve without it — share the decision after an adequate conservative trial, and reserve urgency for a progressive deficit or cauda equina syndrome. Limited versus aggressive discectomy. Two studies anchor modern practice. Carragee (Spine, 2006) compared a subtotal (aggressive) cohort with a historical limited-discectomy cohort: reherniation was 18 percent versus 9 percent (a non-significant trend), but the subtotal group had significantly worse back pain and function. The Thome RCT (J Neurosurg Spine, 2005) randomised 84 patients to sequestrectomy (fragment-only) versus microdiscectomy and found no excess recurrence with fragment-only removal and at least equivalent outcomes. Together they establish limited discectomy as the standard. The Cochrane review (Rasouli, 2014) adds that minimally invasive/tubular approaches give clinically similar pain relief to open microdiscectomy — with lower infection but higher rehospitalisation for reherniation — so the choice rests on surgeon experience.
References
Key references 1. Weinstein JN, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA. 2006;296(20):2441–2450. 2. Kreiner DS, et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J. 2014;14(1):180–191. 3. Jacobs WC, et al. Surgical techniques for sciatica due to herniated disc: a systematic review. Eur Spine J. 2012;21:2232–2251. 4. Watters WC 3rd, et al. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis. Spine J. 2009;9(7):609–614. 5. Mayer HM, Brock M. Percutaneous endoscopic discectomy: surgical technique and preliminary results compared to microsurgical discectomy. J Neurosurg. 1993;78(2):216–225. 6. Rasouli MR, et al. Minimally invasive discectomy versus microdiscectomy/open discectomy for symptomatic lumbar disc herniation. Cochrane Database Syst Rev. 2014;(9):CD010328. 7. McMorland G, et al. Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study. J Manipulative Physiol Ther. 2010;33(8):576–584. 8. Carragee EJ, et al. A prospective controlled study of limited versus subtotal posterior discectomy. Spine. 2006;31(6):653–657. 9. Thome C, et al. Outcome after lumbar sequestrectomy compared with microdiscectomy: a prospective randomized study. J Neurosurg Spine. 2005;2(3):271–278. 10. Desai A, et al. Lumbar microdiscectomy: a historical perspective and current technical considerations. Cureus. 2019;11(3):e4204.
SPORT randomized trial: surgery vs nonoperative care for lumbar disc herniation
- 501 surgical candidates with imaging-confirmed herniation and at least 6 weeks of radiculopathy randomised to open discectomy versus individualised nonoperative care
- Adherence was poor: only 50% assigned to surgery had surgery within 3 months and 30% assigned to nonoperative care crossed over to surgery
- Both groups improved substantially; intention-to-treat between-group differences favoured surgery but were small and not statistically significant for primary outcomes
- High bidirectional crossover means the trial cannot prove superiority or equivalence on ITT analysis
Limited versus subtotal posterior discectomy for herniated lumbar discs
- Prospective subtotal (aggressive) discectomy cohort (30 patients) compared with a historical limited-discectomy cohort (46 patients)
- Reherniation 18% (limited) vs 9% (subtotal), a non-significant trend (P=0.1)
- Subtotal discectomy had significantly worse back pain (VAS, P=0.02) and worse Oswestry/return-to-work at 12 months
- Patient satisfaction at 2 years was higher in the limited-discectomy group despite the reherniation trend
Sequestrectomy versus microdiscectomy: prospective randomized study
- 84 patients (60 years or younger) with free, subligamentary or transanular herniations randomised to sequestrectomy versus microdiscectomy
- Reherniation within 18 months 5% (sequestrectomy) vs 10% (microdiscectomy) — no excess recurrence with fragment-only removal
- Sequestrectomy had shorter operating time and a trend to better SF-36 and Patient Satisfaction Index (3% vs 18% unsatisfied)
- Prolo good/excellent outcome in 92% (sequestrectomy) vs 76% (microdiscectomy)
Minimally invasive discectomy versus microdiscectomy/open discectomy (Cochrane review)
- 11 RCTs/quasi-RCTs, 1172 participants comparing minimally invasive discectomy with open/microdiscectomy
- Minimally invasive techniques showed marginally worse leg and back pain (differences below clinically meaningful thresholds, low-quality evidence)
- Minimally invasive discectomy had lower surgical-site and other infection risk
- Minimally invasive discectomy carried higher risk of rehospitalisation for recurrent herniation
NASS evidence-based guideline: diagnosis and treatment of lumbar disc herniation with radiculopathy
- Multidisciplinary systematic review answering 29 clinical questions with graded recommendations
- Discectomy provides more effective short-term symptom relief than conservative care for confirmed herniation with correlating radiculopathy
- MRI is the most appropriate non-invasive test to confirm herniation and correlate with the symptomatic level
- Supports surgery for patients failing an adequate course of conservative management with concordant imaging