What is the recommended treatment for symptomatic herniated discs that have not responded to conservative management, specifically regarding microdiscectomy?

Microdiscectomy for Symptomatic Herniated Discs

Microdiscectomy is the recommended surgical treatment for patients with symptomatic lumbar disc herniation and radiculopathy who have failed conservative management for at least 6 weeks. 1

Indications for Surgical Intervention

• Persistent radiculopathy (leg pain in a dermatomal distribution)
• Neurological deficits (weakness, sensory changes)
• Failed conservative management for 6-8 weeks, including:
  • NSAIDs/COXIBs at maximum tolerated doses for 2-4 weeks
  • Manual therapy and exercise
  • Epidural steroid injections
  • Activity modification

Earlier surgical intervention may be considered in cases of:

• Severe or progressive neurological deficits
• Cauda equina syndrome (medical emergency)

Microdiscectomy Procedure

Microdiscectomy involves the removal of herniated disc material compressing nerve roots using microscopic visualization. The key steps include:

1. Small 2-cm vertical incision
2. Development of surgical corridor to the lamina
3. Radiographic confirmation of correct level
4. Small laminotomy and removal of any facet osteophytes
5. Mobilization of compressed nerve root
6. Removal of herniated disc fragments
7. Wound closure 2

The procedure can be performed using:

• Operating microscope (preferred for collinear light and magnification)
• Loupes with headlight as an alternative 2

Outcomes and Effectiveness

Microdiscectomy provides excellent outcomes for properly selected patients:

• Superior to continued nonsurgical treatment for patients with symptoms lasting more than 6 weeks 1
• Good relief of radicular symptoms
• Associated back pain typically decreases as well
• Allows expeditious return to daily activities and work 3

Minimally Invasive Variations

Several minimally invasive discectomy (MID) techniques exist:

• Microendoscopic discectomy
• Percutaneous endoscopic discectomy
• Transmuscular tubular microdiscectomy

While these techniques may offer advantages such as shorter hospital stays and less blood loss, evidence suggests they may be slightly inferior in terms of leg pain relief and low back pain relief compared to standard microdiscectomy. MID techniques also have higher rates of rehospitalization due to recurrent disc herniation, though they show lower rates of surgical site infections 4.

Potential Complications

Common complications include:

• Recurrent disc herniation (most common)
• Disc herniation at another level
• Wound infections
• Durotomy with spinal headache 2

Post-Surgical Care

• Regular clinical and functional assessments
• Radiographic evaluation at 12 months post-surgery
• Gradual return to activities as tolerated

Important Considerations

• Imaging findings often correlate poorly with pain symptoms, highlighting the importance of clinical correlation 1
• Relying solely on imaging without clinical correlation can lead to inappropriate treatment 1
• The goal of surgery is to restore functional abilities and allow return to daily activities 3

Microdiscectomy remains the gold standard surgical approach for symptomatic lumbar disc herniation that has not responded to conservative management, with well-established long-term outcomes and effectiveness 5.