What are the considerations and recommendations for a patient undergoing microdiscektomy (microdiskectomy)?

Microdiscectomy: Considerations and Recommendations

Lumbar microdiscectomy is an effective surgical procedure for patients with symptomatic lumbar disc herniation causing radiculopathy when conservative management has failed. 1

Indications for Surgery

• Microdiscectomy should be considered for patients with radiculopathy due to lumbar disc herniation who have failed conservative management for 6-12 weeks 2
• Surgery is not recommended as a first-line treatment except in cases of cauda equina syndrome requiring emergent intervention 3
• Conservative management should be attempted first in most cases, including physical therapy, medication management, and time 1
• Lumbar fusion is not recommended as a routine treatment following primary disc excision in patients with isolated herniated lumbar discs causing radiculopathy 1

Surgical Technique

• The procedure involves making a small (approximately 2 cm) vertical incision and developing a corridor to the lamina 4
• Key steps include radiographic confirmation of the correct level, small laminotomy, mobilization of the compressed nerve root, and removal of herniated disc fragments 4
• An operating microscope is preferred due to the collinear light and magnification offered, though loupes and headlight may be used as an alternative 4
• Minimally invasive discectomy techniques exist but may be associated with slightly worse outcomes for leg pain and low back pain compared to standard microdiscectomy 5

Expected Outcomes

• At first postoperative follow-up, approximately 93% of patients report minimal or no pain 3
• Most patients experience favorable outcomes for radicular symptoms, with associated back pain typically decreasing as well 4
• The mean time to return to sports activities is approximately 9.8 weeks 3
• Long-term outcomes are generally good, with 72.9% of pediatric patients not requiring further follow-up after routine postoperative appointments during a mean follow-up of 8.2 years 3

Complications and Risks

• Common complications include recurrent disc herniation (3.5%), adjacent-level disc herniation requiring decompression (4.5%), wound infections (1.5%), and durotomy with spinal headache 3, 4
• The total risk of reoperation is approximately 7.5% 3
• CSF leak occurs in approximately 2% of cases 3
• Minimally invasive techniques may be associated with lower risk of surgical site infections but higher risk of rehospitalization due to recurrent disc herniation 5

Perioperative Considerations

• Standard anesthetic protocols should include maintenance of adequate hemodynamic control, oxygenation, muscle relaxation, and appropriate analgesia 1
• Normal body temperature should be maintained perioperatively to reduce complications 1
• Early mobilization should be encouraged, with patients ideally spending 2 hours out of bed on postoperative day 0 and 6 hours on postoperative day 1 1
• Early oral nutrition should be started postoperatively 1

Special Considerations

• Lumbar fusion may be considered in addition to discectomy in select cases:
  • Patients with significant chronic axial back pain
  • Manual laborers
  • Severe degenerative changes
  • Instability associated with radiculopathy 1
• Reoperative discectomy with fusion is a treatment option for patients with recurrent disc herniations associated with instability or chronic axial low back pain 1
• Spinal level of herniation may be an important factor modifying effectiveness of surgery, with some evidence suggesting better outcomes for L4-L5 herniations 2

Postoperative Care

• Multimodal postoperative analgesia should be utilized 1
• Early mobilization is strongly recommended to improve outcomes 1
• The average time to return to work is approximately 27-49 days, with arthroscopic microdiscectomy potentially allowing for earlier return compared to open techniques 6
• Regular follow-up is important to monitor for complications or recurrence 3

Microdiscectomy remains the standard surgical treatment for symptomatic lumbar disc herniation when conservative management fails, offering good long-term outcomes with relatively low complication rates.