Pain Relief by Partial Removal: The Micro-Lumbar Discectomy
- incisionary
- 20 hours ago
- 4 min read
Lumbar disc herniations (LDHs) are a common and early appearance of the degeneration of the lumbar spine. The most common site of LDH is at L4-L5 or L5-S1. The location of a disc herniation can determine the surgical approach. For some, LDHs resolve nonoperatively, but in the case that conservative management fails, surgical interventions can be considered, including the micro-lumbar discectomy.
LDHs result from multiple changes in the intervertebral disc, such as reduced water retention in the nucleus pulposus (a gel-like structure composed of 80% water, type 2 collagen, and proteoglycans, found in the center of the intervertebral discs), an increased type 1 collagen ratio in the nucleus pulposus and inner annulsus fibrosus (a ring-shaped structure surrounding the nucleus pulposus, its inner part is made of type 2 collagen and the outer part type 1 collagen), destruction of collagen and extracellular substances, and an amplified activity of degrading systems such as matrix metalloproteinase expression (production of zinc-dependent enzymes that degrade extracellular matrix proteins, including proteoglycans, glycoproteins, etc), apoptosis (cell self-destruction), and inflammatory pathways. This results in an increase in inflammatory chemokines, as well as mechanical compression of the exiting nerve by the protruding nucleus pulposus. The lumbar pain arises when disc material pressures or contacts the thecal sac (carrying cerebrospinal fluid) or the lumbar nerve roots, resulting in nerve root ischemia (bloodflow obstruction) and inflammation.
Micro-lumbar discectomies start as the patient is positioned pronely on a spine frame or a designated table and is put under general anesthesia to ensure hemodynamic and airway management. The head is reassured by foam support with orbital and facial cutouts to minimize pressure on the eyes, nose, and mouth, while granting airway access. The arms are positioned at 90° abduction and the elbows at 90° flexion with the axillae (armpit) free of compression to prevent neuropraxia (peripheral nerve injury – blocked nerve impulse conduction – due to focal demyelination or ischemia) of the brachial plexus (nerve network supplying the skin and muscles of the upper limb). The patient is administered prophylactic intravenous antibiotics before the incision, fluoroscopic imaging is used for honing in on the accuracy of the incision by directing over the appropriate interspace (or a spinal needle is used to mark it), and the skin is then prepped by sterilization.
Intraoperative radiography confirms the site, and a 2-3 cm marking for a longitudinal midline incision is opened over the interspace with a sharp scalpel. Subcutaneous dissection (cutting through the fatty tissue) with electrocautery reveals the lumbar fascia tissue over the midline. The muscular aponeurosis (fibrous connective tissue) is incised off the side of the approach, and the multifidus is released subperiosteally from the spinous process on one side out to the facet joints using a Cobb elevator. Retractors are then placed to establish the working corridor. Visualization is acquired using an operating microscope. The ligamentum flavum is exposed and detached from the anterior surface of the superior lamina of the inferior vertebra with a curette, then sharply incised and expelled. An angled Woodson elevator may be used beneath the ligament to protect the dura. Partial removal using a Kerrison rongeur grants the appearance of the exiting nerve root and surrounding epidural fat. A blunt, ball-tipped probe is passed into the neuroforamen to prepare the nerve root, which is gently retracted medially. The herniated disc material is then excised to successfully complete the decompression.
The micro-lumbar discectomy is a minimally invasive technique in comparison to the open discectomy, and serves as an intriguing technique to become surgically involved without compromising the patient’s wellbeing. It has reported a lower morbidity, quicker recovery, and no large difference in long-term reoperation rates. It has a less traumatic approach, better visualization of the operative field, and is now considered the “gold standard” for removing most lumbar disc herniations. The major advantage compared to the open discectomy is the minimal trauma to the multifidus (the muscle group running along the spine) and decreased risk of post-operative peridural fibrosis (a frequent complication of lumbar surgery, consisting of the formation of extradural fibrous tissue).
Written by Hana Shqairat at Incisionary
APA References
Dowling TJ, Munakomi S, Dowling TJ. Microdiscectomy. [Updated 2023 Aug 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK555984/
Al Qaraghli MI, De Jesus O. Lumbar Disc Herniation. [Updated 2023 Aug 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560878/
Meng li, Tingting Yan, Yanqiu Cai, Yingyuan Wei, Qiqi Xie,
Expression of matrix metalloproteinases and their association with clinical characteristics of solid tumors, Gene,
Volume 850,
2023,
146927,
ISSN 0378-1119,
Nevan G. Baldwin, Matthew B. Kern, David W. Cahill,
CHAPTER 120 - Complex Lumbosacropelvic Fixation Techniques,
Editor(s): EDWARD C. BENZEL,
Spine Surgery (Third Edition),
Churchill Livingstone,
2005,
Pages 1576-1585,
ISBN 9780443066160,
Gorman, N. (2023, November 3). Multifidus muscle. Kenhub. https://www.kenhub.com/en/library/anatomy/multifidus-muscle
Sandoval MA, Hernandez-Vaquero D. Preventing peridural fibrosis with nonsteroidal anti-inflammatory drugs. Eur Spine J. 2008 Mar;17(3):451-455. doi: 10.1007/s00586-007-0580-y. Epub 2008 Jan 3. PMID: 18172695; PMCID: PMC2270388.
Carballo Cuello CM, De Jesus O. Neurapraxia. [Updated 2023 Aug 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560501/
Comments