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A disk begins to herniate when its jelly-like nucleus pushes against its outer ring due to wear and tear or a sudden injury. This pressure against the outer ring may cause lower back pain. 

If the pressure continues, the jelly-like nucleus may push all the way through disk's outer ring or cause the ring to bulge. This puts pressure on the spinal cord and nearby nerve roots. Not only is this a mechanical compression (squeezing) of the nerves, but the disk material also releases chemical irritants that contribute to nerve inflammation. When a nerve root is irritated, there may be pain, numbness, and weakness in one or both of your legs, a condition called sciatica.

In a herniated disk, the soft, jelly-like center of the disk can push all the way through the outer ring.  (Side and cross-section views shown.)

Lumbar diskectomy, a surgical procedure to treat herniated disks in the lower back, is not required for most patients. Surgeons usually recommend spine surgery only when nonsurgical treatments have failed to relieve painful symptoms or for patients experiencing specific issues, such as:

• Persistent (constant) muscle weakness that affects daily functioning
• Difficulty walking due to pain, weakness, or impaired mobility
• Loss of bladder or bowel control, which can be a sign of severe nerve compression (the nerve is being squeezed or compacted) and requires immediate attention

The decision to proceed with lumbar diskectomy is carefully considered based on the severity of the symptoms and the individual patient's overall health and lifestyle.

Surgery to remove the herniated disk was historically done through a large open incision. Microdiskectomy is a newer surgical procedure commonly used to treat a herniated disk in the spine. It is a minimally invasive technique, performed using a microscope, that aims to relieve pressure on the spinal nerve and ease symptoms.

Another newer surgical option for treating a single herniated disk is endoscopic diskectomy. This minimally invasive procedure involves the use of an endoscope, a thin tube with a camera, which allows the surgeon to visualize and access the affected area. This approach is similar to the arthroscopic approach commonly used in knee, hip, and shoulder surgery.

Endoscopic minimally invasive spine surgery.

Potential benefits of endoscopic diskectomy include:

• Smaller incisions
• Reduced scarring
• A shorter recovery time

In cases where there are disk herniations at multiple levels of the spine, an open procedure with a larger incision may be necessary.

During an endoscopic diskectomy:

• The patient is typically placed under general anesthesia (which causes you to be asleep during the procedure) or given a local anesthetic and sedation (you are awake but relaxed, and the area being treated is numbed with medication).
• The surgeon makes a single 1 cm incision or two 7 mm incisions to access the spine near the herniated disk.
• The surgeon inserts a guide wire through the incision and carefully guides the wire toward the affected disk with the help of fluoroscopic (X-ray) guidance. The endoscope, which is attached to a camera, is then threaded over the guide wire and into the area of the herniated disk.
• Once the endoscope is in position, the surgeon can see the herniated disk and surrounding structures on a video monitor. Water is used to provide better visualization of the spine, enabling the surgeon to directly see and address the problem under greater magnification.

During endoscopic minimally invasive spine surgery, water is used to provide better visualization of the spine, enabling surgeon to directly see and address the problem under greater magnification.

• The surgeon passes specialized instruments through the endoscope to remove the herniated portion of the disk or any fragments that may be compressing (putting pressure on) the spinal nerves.
• Once the procedure is completed, the surgeon removes the endoscope and closes the small incision(s) with sutures (stitches) or adhesive strips.

These are some potential advantages of endoscopic diskectomy compared to open surgery:

• Because it uses smaller incisions, there is less damage to tissue and less pain after surgery.
• There is minimal scarring for improved appearance after surgery.
• It allows for a shorter hospital stay, and you may be able to have an outpatient procedure (you go home the same day as the surgery).
• You can recover and return to daily activities faster.
• There is a lower risk of complications, including infections and excessive bleeding.

These are some potential disadvantages of having endoscopic diskectomy instead of open surgery:

• It requires specialized training and expertise, limiting the availability of experienced surgeons.
• It is not suitable (right) for all types of herniated disks or complex/multiple levels of herniation.
• If a surgeon is new to the technique, there may be higher risks of complications and/or incomplete removal of the herniated disk.
• Possible complications include infection, bleeding, nerve damage, and/or dural tears (tears in the dura, the thin layer of tissue that covers and protects the spinal cord). In addition, symptoms may not go away, or may come back after surgery.
• It is more expensive than traditional open surgery due to the specialized equipment and expertise required.
• Long-term outcomes and effectiveness compared to open surgery are still being studied.

The recovery following endoscopic diskectomy is generally faster compared to open surgery.

• Patients can usually go home the same day as the procedure (outpatient surgery) or after a short hospital stay.
• Post-operative pain can be managed with medication.
• Activities may be restricted for a few weeks, and physical therapy may be recommended. Patients are encouraged to gradually resume their normal activities.
• Follow-up appointments are scheduled to monitor progress and make sure there are no complications.

While the early results of endoscopic diskectomy are promising, spine surgeons will continue to advance the technique.

• Instruments and surgical techniques will continue to be refined (improved) to make the procedure more precise and effective.  
• There will be more comprehensive training programs for surgeons to master the skills needed to successfully perform endoscopic diskectomy. As more surgeons gain expertise performing the procedure, the potential risks will decrease.
• Surgeons will conduct long-term studies looking at the durability and effectiveness of endoscopic diskectomy compared to open surgery. This will help determine the role of endoscopic techniques in the future.