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Lumbar discectomy

107 citationsUpdated Oct 2026

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Overview

Lumbar discectomy is a surgical intervention for lumbar disc herniation, with nonsurgical management remaining the standard of care for degenerative disk disease [17]. The procedure is indicated for patients with lumbar symptoms, including those who are elderly or obese, provided appropriate indications are met [19]. Age is not a contraindication for decompressive lumbar spine surgery [38]. While preoperative imaging cannot predict the clinical outcome of percutaneous lumbar discectomy [3], the procedure is considered safe and efficacious for relieving symptoms of herniated discs [39]. Clinical outcomes based on statistical performance measures are excellent after discectomy in professional athletes, with postoperative performance scores equivalent to preoperative levels [9]. Surgical management of selected lumbar spine conditions can produce excellent outcomes in athletes of all sports, and microdiscectomy leads to favorable return-to-play rates [11].

Recurrent lumbar disk herniation is the most common complication following primary open diskectomy, defined as recurrent back and/or leg pain after a definite pain-free period of at least 6 months [5]. Revision discectomy can yield results as good as primary surgery [7], although the probability for improvement is not as high as for primary lumbar disc herniation surgery, and patients undergoing repeated surgery are less satisfied [18]. Additional operations after primary disc surgery are needed more frequently than previously reported, and outcomes profoundly deteriorate after the second additional operation [8]. There is a dose-response relationship between the increasing number of previous operations and inferior outcomes among patients operated for degenerative conditions in the lumbar spine [31]. In a military population, 9.6% of patients would require two or more revision surgeries after single-level lumbar microdiscectomy, and 42.1% of revision microdiscectomy patients would ultimately undergo a lumbar arthrodesis at the same level as the initial disk herniation [14].

Discectomy does not always provide the final solution to lumbar disc disease in children, but careful selection of patients and follow-up can produce satisfactory long-term results in most children undergoing discectomy [6]. Biportal endoscopic discectomy is as effective as microscopic discectomy in treating single-level lumbar disc herniation and has distinct advantages in terms of postoperative wound complications [16]. Microendoscopic discectomy and open microdiscectomy yield the same clinical outcome [84]. However, microendoscopic discectomy has a higher reoperation risk compared with microdiscectomy or open discectomy at a median of 4 years of follow-up [56]. Surgeons should select microdiscectomy or open discectomy despite the current popularity of microendoscopic discectomy due to this reoperation risk [56]. Large cohort studies and alternative statistical techniques may yield more accurate estimates of the effectiveness of lumbar diskectomy [10].

Anatomy & Pathophysiology

Disc Structure and Composition

The human spine contains 23 intervertebral disks that separate vertebrae and provide flexibility, accounting for 20% to 30% of spinal length and increasing in size from cervical to lumbar regions [98]. Each disk comprises a central gelatinous nucleus pulposus (NP) surrounded by a fibrous annulus fibrosus (AF) [98]. The NP consists mainly of high concentrations of proteoglycans and water within a loose type II collagen network, where collagen fibrils assume a random orientation [98]. In contrast, the AF has low proteoglycan and water content but high concentrations of type I collagens and small amounts of type II collagens [98]. The AF is organized into 20 to 25 concentric lamellae rich in parallel collagen fibrils, with adjacent lamellae arranged in opposite directions to create an alternating pattern [98]. Water and proteoglycan concentrations increase from the AF to the NP, while collagen content decreases from the outer annulus to the nucleus [98]. With increasing age, NP proteoglycan and water content decrease [98]. Collagen content is highest in cervical disks and lowest in lumbar disks, whereas proteoglycan content follows the opposite trend, being lower in cervical and higher in lumbar disks [98].

Vertebral Endplates

Each vertebral body possesses cartilage end plates, a thin layer of hyaline cartilage separating adjacent vertebrae [98]. These endplates are 1-mm thick concave structures comprising two distinct layers: the cartilage endplate (CEP) of hyaline cartilage and the bony endplate (BEP) of semi-porous cancellous bone [80]. The endplates function as key regulators of nutrient transport into and out of the disc [80]. Until skeletal maturity, microscopic blood vessels penetrate the endplates from adjacent vertebrae to provide vascular supply during spinal growth [80]. Additionally, the endplate acts as a physical barrier protecting vertebrae from cranial and caudal disc herniation [80]. Degenerative bony endplate changes are associated with reduced nutrient supply, declines in proteoglycan and water content within the AF and NP, structural disc changes, and subsequent disc degeneration [80].

Lumbar Vertebral Anatomy

Lumbar vertebral bodies are large, with a transverse diameter exceeding the anterior-posterior diameter [95]. Lumbar pedicles arise from the superior aspect of the vertebral bodies and project more horizontally than thoracic pedicles [95]. L1 pedicles are minimally medially angled, but orientation becomes more medial down the lumbar spine, particularly at L5 [95]. Lumbar transverse processes project more perpendicular to the vertebral body and are large and flat in the upper lumbar spine, while L4 and L5 transverse processes are often smaller [95]. Lumbar spinous processes are thick and project straight dorsally [95]. The superior articular facet arises at the pedicle-lamina junction with an articular surface facing dorsomedially, while the inferior facet extends down from the lamina and nestles snugly on the medial side of the superior facet [95]. The sagittal orientation of lumbar facet joints allows flexion and extension while providing resistance to axial rotation and translation [95].

Neural Elements and Innervation

In the thoracic and lumbar spine, named nerve roots exit below the named pedicle, and disks are named for the vertebral bodies between which they lie [92]. Lateral recess pathology, such as posterolateral disc herniation, typically involves the next nerve root exiting caudal to that disc; for example, an L4-5 posterolateral herniation causes L5 nerve root symptoms [92]. The dorsal root ganglion (DRG) lies within the outer confines of the intervertebral foramen [92]. Distal to the DRG, three branches arise: the ventral ramus, the sinuvertebral nerve, and the dorsal ramus [92]. The sinuvertebral nerve is a small filamentous nerve originating from the ventral ramus that progresses medially over the posterior aspect of the disc and vertebral bodies, innervating the posterior disc, vertebral bodies, and posterior longitudinal ligament [92]. The dorsal ramus courses dorsally, piercing the intertransverse ligament near the pars interarticularis [92]. Its medial branch innervates the facet joint at that level and adjacent levels above and below [92]. Disc innervation occurs through afferent axons with cell bodies within the DRG [92]. Animal studies reveal two paths between the annulus and the DRG: one from the sinuvertebral nerve and another along the paravertebral sympathetic trunk [92]. The lateral annulus is innervated by fibers from the index level and two additional superior levels via sinuvertebral nerves, and also by the DRG from three levels more superior via the sympathetic trunk [92]. Contralateral DRG involvement occurs through both pathways in animal models [92]. Nonsegmental, multilevel innervation patterns have been reported for the ventral disc surface [92]. Innervation of the disc from the vertebral endplate occurs through the sinuvertebral nerve and the basivertebral nerve, with the latter entering the foramen and nerve fibers entering the vertebral margin with vessels [92]. The density of innervation at the vertebral endplate is similar to that seen in the outer annulus [92]. Within the dural sac and at the conus medullaris, the most cephalad nerve roots lie lateral and the most caudad lie centrally, with motor roots ventral to sensory roots at all levels [96]. The arachnoid mater holds the nerve roots in these specific positions [96].

Degenerative Pathophysiology

Lumbar spondylosis results from a degenerative cascade associated with intervertebral disk degeneration [93]. Mechanical progression and disk space narrowing lead to adjacent level pedicle approximation and narrowing of the superior-inferior dimensions of the intervertebral foraminal canal [93]. Ligamentous laxity and vertebral column translation alter loading mechanics and pressure relationships on vertebral bone and joint surfaces, influencing osteophyte formation and facet joint hypertrophy [93]. Intervertebral disk degeneration is a multifactorial process characterized by altered biomechanics of loading, an imbalance of extracellular matrix synthesis and degradation, increased secretion of proinflammatory cytokines, and increased apoptosis and senescence in nucleus pulposus cells [93]. Altered biomechanics lead to further degenerative changes and osteophyte formation [93]. These changes can cause lumbar central and foraminal stenosis, leading to symptomatic nerve compression and radiculopathy [93]. The degenerative process is divided into three stages: dysfunction, instability, and stabilization [64]. The dysfunction stage, seen in individuals 15 to 45 years old, is characterized by circumferential and radial tears in the disc anulus and localized synovitis of the facet joints [64]. The instability stage, found in 35- to 70-year-old patients, involves internal disruption of the disc, progressive disc resorption, degeneration of the facet joints with capsular laxity, subluxation, and joint erosion [64]. The stabilization stage, present in patients older than 60 years, is characterized by progressive development of hypertrophic bone around the disc and facet joints leading to segmental stiffening or frank ankylosis [64]. Disc herniation is considered a complication of disc degeneration in the dysfunction and instability stages [64]. Spinal stenosis from degenerative arthritis is a complication of bony overgrowth compromising neural tissue in the late instability and early stabilization stages [64]. Genetic factors are more important than mechanical stresses in the development of disc herniations [55]. Specific gene loci associated with disc degeneration include variations in the aggrecan gene, metalloproteinase-3 gene, collagen type IX, and alpha 2 and 3 gene forms [128]. TNF-α, interleukin-1β (IL-1β), and interleukin-6 (IL-6) can be found in facet joint tissues in degenerative lumbar disorders [125]. IL-6 from the synovium and cartilage of the facet joints is elevated mainly in lumbar spinal canal stenosis and related degenerative conditions [125]. IL-1β is present in higher concentrations with lumbar spinal stenosis and degenerative changes compared with lumbar herniated disks [125]. IL-1β stimulates the production of matrix metalloproteinases (MMPs) through activation signaling pathways [125]. IL-1β and MMPs are markedly increased in degenerative facets, leading to further proteoglycan degeneration and destruction of the cartilage and joint [125]. Adiponectin has been identified in the process of facet joint osteoarthritis and shown to have greater expression for facet joint osteoarthritis when compared with IL-1β and TNF-α [125]. High-molecular-weight adiponectin has a proinflammatory response whereas the low-molecular-weight isoform has an anti-inflammatory function [125]. Adiponectin has the potential to be a catabolic mediator of osteoarthritis by increasing several MMPs and inducible nitric oxide synthase (iNOS) [125]. Modic changes, particularly Type 2, are common radiological findings in lumbar spine imaging, most frequently occurring at L4/L5 and L5/S1 levels [79]. Modic 1 changes with less advanced degenerative disc disease (≤50%-IVSN) are found in younger men at the L5/S1 level and are associated with less frequent osteophytes [175]. Modic 1 changes with advanced degenerative disc disease (>50%-IVSN) are found in older women at the L4/L5 level [175].

Stenosis Pathophysiology

Lumbar spinal stenosis (LSS) is the final stage of a cascade of events initiated by disk degeneration [52]. As disk height decreases, the loading characteristics of the facets are altered [52]. Facet joint capsules become incompetent, leading to capsular, ligamentum flavum, and facet hypertrophy [52]. The ligamentum flavum becomes less pliable with age [52]. The final stage of the degenerative continuum is a decrease in the diameter of the spinal canal [52]. When the spine is in extension, the spinal canal diameter diminishes, resulting in buckling of the shortened, hypertrophied ligamentum flavum [52]. In flexion, there is a relative increase in the spinal canal diameter [52]. Most authors support a multifactorial etiology of low back pain and leg pain associated with LSS, including mechanical compression, nutritive insufficiency, heredity, structural decompression, individual pain perception, and chemical insult [52]. Degeneration of the disc occurs with disc narrowing and subsequent ligamentous redundancy, which compromises the spinal canal area [91]. Instability may ensue from disc degeneration and ligamentous redundancy [91]. Relative hypermobility precipitates the formation of facet overgrowth and ligamentous hypertrophy [91]. The ligamentum flavum may be markedly thickened into the lateral recess where it attaches to the facet capsule, causing nerve root compression [91]. Facet orientation and facet tropism in the lower lumbar spine are significantly associated with degenerative lumbar spinal stenosis [134]. Canal size is independent of body stature [152]. Abnormal orientations of lamina angle and facet joint angulation may be developmental variations leading to increased likelihood of developmental spinal stenosis [152].

Imaging and Diagnostic Limitations

Findings on magnetic resonance scans were not predictive of the development or duration of low-back pain in asymptomatic subjects [78]. Abnormal magnetic resonance scans of the lumbar spine are found in 76% of asymptomatic matched controls [128]. A systematic review of diagnostic accuracy studies evaluates clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine [24].

Classification

Lee: The Lee classification categorizes the prolapsed type of lumbar disc herniation based on imaging data that is consistent with clinical symptoms and signs [35].

Modified Migrated Disc Herniation: A modified classification for migrated lumbar disc herniation demonstrates good reliability, and the experience level of spine surgeons does not affect this reliability [70].

Song: The Song's classification system has demonstrated value in guiding personalized surgical decision-making for various morphologies of calcified lumbar disc herniation [188].

Pfirrmann: Pfirrmann’s classification grades intervertebral disc degeneration from Grade I to V, with Grades IV and V defined as advanced stages of degeneration [146].

Modified Lumbar Disc Degeneration: A modified system for lumbar disc degeneration comprises 8 grades, where Grade 1 corresponds to no disc degeneration and Grade 8 corresponds to end-stage degeneration [144].

Fat Infiltration: A 4-grade fat infiltration system is more effective than a 3-grade system in determining the level of fat infiltration in paraspinal muscles and predicting lumbar disc herniation [185, 187].

Other Considerations: The type and extent of cervical disc herniation measured on MRI prior to surgery correlated neither to the severity of symptoms at presentation nor to clinical outcomes at two years postoperatively [46].

Clinical Presentation

Lumbar disc herniation is among the most common causes of lower-back pain and sciatica [37]. The natural history is generally favorable, with most herniations, particularly contained ones, resorbing and diminishing in size over time [140]. Within 3 months of symptom onset, approximately 90% of patients experience symptomatic improvement without surgery [140]. More than half of patients seeking treatment for low back pain recover in 1 week, and 90% recover within 1 to 3 months [41]. In young, active patients, low back pain is most often a self-limiting episode without underlying etiology [133]. The natural history of degenerative disc disease is characterized by recurrent episodes of pain followed by periods of symptomatic or complete relief [64].

Patients typically present with varying degrees of back and leg pain [140]. Leg pain usually follows the dermatomal path of the affected nerve root(s) [140]. Radicular pain may be accompanied by motor, sensory, and/or reflex disturbances [140]. The presence of sciatica is the most sensitive and specific finding for lumbar disc herniation [140]. Lumbar disc herniation may or may not be associated with an inciting event, such as load bearing [140]. Diskogenic pain related to disc degeneration or disc herniation may be worse in flexion, while sitting, or with prolonged axial loading [141]. This pain is often described in a diffuse, bandlike distribution [141]. Residual low back pain after discectomy may reflect increased load and pressure on the disc and endplate in the sitting position [15].

The clinical presentation of recurrent disc herniation may be identical to that of primary herniation but usually has a larger component of axial pain [33]. Most recurrences happen in the relatively early postoperative period, primarily the first 6 months after surgery [33]. Cauda equina syndrome secondary to large central lumbar disc herniations is rare [140].

Physical Examination Findings

The ipsilateral hip and knee may be flexed and externally rotated to relieve root tension [140]. Pain with straight leg raise testing results from increased nerve root tension and a lack of normal excursion of the root at the herniation site [140]. The straight leg raise test must produce radicular symptoms in the distribution of the provoked root; for the sciatic nerve, this means pain distal to the knee [140]. For detecting lumbar disc herniation, the straight leg raise is more sensitive but less specific than the contralateral straight leg raise in patients with single leg radicular pain [141]. A positive crossed straight leg raise test has a higher specificity than a positive ipsilateral test, but the sensitivity varies [140]. The contralateral straight leg raise test puts tension on the involved root from the opposite direction [140].

Lasegue sign: Straight leg raise radiculopathy aggravated by ankle dorsiflexion [140]. Bowstring sign: Straight leg raise radiculopathy aggravated by applying pressure over the popliteus fossa [140]. Kernig test: Involves flexing the neck chin to chest, flexing the hip to 90°, and then extending the leg similar to a straight leg raise to reproduce radiculopathy [140]. Femoral stretch test: Performed with the patient prone, where the examiner stretches the femoral nerve roots to test L2 to L4 irritation [140]. Naffziger test: Involves compression of neck veins for 10 seconds with the patient lying supine, followed by coughing to reproduce radiculopathy [140]. Milgram test: Involves the patient raising both legs 3 inches off the examining table and holding this position for 30 seconds, which may reproduce radiculopathy [140].

In discogenic back pain, a paucity of physical findings is characteristic [41]. Back pain is greater than leg pain, and there is an absence of tension signs [41]. The nerve root(s) affected depends on the level of the herniation and the region within a particular segment where the disc is herniated [140].

Diagnostic Correlation and Imaging

Abnormal magnetic resonance scans of the lumbar spine are found in asymptomatic subjects [62]. Matching diagnosis and treatment to the results of diagnostic studies is risky because numerous studies have documented abnormal imaging in asymptomatic populations [64]. In patients with lumbar disc herniation, the type of herniation on MRI does not correlate to clinical outcomes [46]. Similarly, in patients with cervical radiculopathy, the type and extent of disc herniation measured on MRI prior to surgery correlated neither to the severity of the symptoms at presentation nor to clinical outcomes at two years postoperatively [46].

Radiographs are negative for instability in discogenic back pain but may show disc space narrowing or other stigmata of spondylosis [41]. MRI typically reveals decreased signal intensity in the disc space on T2-weighted imaging in discogenic back pain, with or without annular tear or high intensity zone [41]. MRI with intravascular contrast material has been helpful in identifying recurrent herniations [33]. However, it is difficult to distinguish a peridural scar from a small recurrent herniation on MRI [33].

Prognostic Factors and Patient Characteristics

More severe preoperative paraspinal fatty infiltration is associated with recurrence or reoperation, residual/chronic low back pain, and poorer functional recovery in adults with lumbar disc herniation undergoing lumbar discectomy [66]. Patients with Modic changes have a higher incidence risk of recurrent lumbar disc herniation [76]. Old age, severe grade of surgical-level disc degeneration, and more disc degeneration levels significantly increased the incidence of complications in percutaneous endoscopic transforaminal discectomy [44]. Clinical and nonclinical factors are associated with prescribing opioids and prescribed morphine milligram equivalents following lumbar diskectomy [12]. Physical examination findings have been evaluated for their ability to identify the most common patho-anatomical disorders in the lumbar spine [24].

Investigations

MRI: Magnetic resonance imaging is the standard for advanced spinal imaging, superior to CT in most circumstances for identifying infections, tumors, and degenerative changes within discs [101]. It directly images neural structures, including the nerve root in the foramen [101]. MRI evidence of lumbar disc degeneration was found in 35% of patients aged 20 to 39 years and in 100% of patients older than 50 years [101]. Findings must be carefully correlated with the clinical impression, as the study should be guided by specific questions regarding neural compression, instability, or deformity [101]. A positive T2-weighted image with a high-intensity zone (HIZ) indicates disc degeneration and may be a specific indicator for the physical diagnosis of discogenic low back pain [176]. However, MRI findings were not predictive of the development or duration of low-back pain in asymptomatic subjects [78]. In patients who do not respond to a nonsurgical approach or deteriorate neurologically, MRI is indicated to delineate the pattern and degree of stenosis [52].

CT: Computed tomographic analysis suggests a general lumbar muscle dysfunction in the pain group, particularly of the deep stabilizing muscle system, in symptomatic lumbar discectomy patients [82]. CT is indicated alongside plain radiographs and MRI to delineate the pattern and degree of stenosis in patients who do not respond to a nonsurgical approach or deteriorate neurologically [52].

Myelography: Myelography may be unnecessary if clinical and CT or MRI findings are in complete agreement [108]. Primary indications include inability to get an MRI, suspicion of an intraspinal lesion, or spinal instrumentation causing artifact [108]. It is valuable in a previously operated spine and in patients with marked bony degenerative change that may be underestimated on MRI [108]. Myelogram with CT is indicated to delineate the pattern and degree of stenosis in patients who do not respond to a nonsurgical approach or deteriorate neurologically [52].

Electrodiagnostics: EMG may be helpful to distinguish peripheral neuropathy from lumbar spinal stenosis [52]. Needle EMG has a lower false positive rate than MRI in asymptomatic older adults being evaluated for lumbar spinal stenosis [22].

Plain radiography: Plain radiographs are indicated to delineate the pattern and degree of stenosis in patients who do not respond to a nonsurgical approach or deteriorate neurologically [52]. A positive lumbar extension test is highly predictive of lumbar spinal stenosis [52].

Other Considerations: The presence and progression of lumbar spinal endplate lesions are mainly attributed to lumbar disc herniation and higher hip circumference in men [69]. Signs of early disc degeneration related to tumor treatment can be seen in the intervertebral discs of radiotherapy-treated childhood brain tumor survivors [45].

Prognostic Factors and Recurrence: Physical prognostic factors predicting outcome following lumbar discectomy surgery have been subject to systematic review and narrative synthesis [2]. This is the first comprehensive systematic review of diagnostic accuracy studies that evaluate clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine [24]. Findings provide valuable insights into patient experiences of functioning and disability following lumbar discectomy [4]. Recurrent lumbar disk herniation is the most common complication following primary open diskectomy, defined as recurrent back and/or leg pain after a definite pain-free period of at least 6 months [5]. Making the diagnosis of recurrent disc herniation is significantly more difficult than that of primary disc herniation, with most recurrences happening in the first 6 months after surgery [33]. MRI with intravascular contrast material has been helpful in identifying recurrent herniations, though it is difficult to distinguish a peridural scar from a small recurrent herniation [33]. Repeat surgery for a recurrent lumbar disc herniation was performed with a good probability for improvement, although not as good as for primary lumbar disc herniation surgery, and patients undergoing repeated surgery were less satisfied [18].

Surgical History and Patient Selection: A dose-response relationship exists between the increasing number of previous operations and inferior outcomes among patients operated for degenerative conditions in the lumbar spine [31]. Additional operations after primary disc surgery are needed more frequently than previously reported, and the outcome profoundly deteriorates after the second additional operation [8]. Within a military population, 9.6% of patients would require two or more revision surgeries and 42.1% of these revision microdiscectomy patients would ultimately undergo a lumbar arthrodesis at the same level as the initial disk herniation [14]. Patients who are diabetic, smokers, or have contained disk herniation on MRI should be counseled for a higher risk of recurrence after biportal endoscopic diskectomy [190]. Obese patients who underwent biportal endoscopic lumbar discectomy for lumbar disc herniation showed no significant difference in clinical and radiologic outcomes compared with non-obese patients [191].

Special Populations: A discectomy does not always provide the final solution to lumbar disc disease in children, but careful selection of patients and follow-up can produce satisfactory long-term results in most [6]. Clinical outcomes based on statistical performance measures are excellent after discectomy in professional athletes, as postoperative Performance Scores were equivalent to preoperative levels [9]. Surgical management of selected lumbar spine conditions can produce excellent outcomes in athletes of all sports, with microdiscectomy for lumbar disc herniation leading to favorable return to play rates [11]. Most lumbar spine pathologies in recreational athletes can be managed nonsurgically with excellent outcomes, while surgical treatment is a viable option with good outcomes for those who fail nonsurgical treatment or have neurological risk [13]. Nonsurgical management is the standard of care for lumbar degenerative disk disease, while spondylolysis is typically managed nonsurgically with successful outcomes, though surgery may be required for return to sports [17]. Surgical treatment of intervertebral disk herniation, degenerative spondylolisthesis, and lumbar spinal stenosis provides significant value to the patient over the long term, with no catastrophic progressions to neurologic deficit occurring as a result of watchful waiting [71]. The type and extent of disc herniation measured on MRI prior to surgery correlated neither to the severity of symptoms at presentation nor to clinical outcomes at two years postoperatively in patients with cervical radiculopathy [46].

Treatment

Non-Operative

Nonoperative treatment for lumbar disc herniation is usually effective [126]. Management principles include short-term rest, pain relief, antiinflammatory agents, and progressive directed activity restoration [126]. These measures should generally be continued for at least 6 to 12 weeks if feasible [126]. More than half of patients who seek treatment for low back pain recover in 1 week [41], and 90% recover within 1 to 3 months [41]. Spontaneous resorption of lumbar disk herniation is associated with mechanisms such as inflammation, neovascularization, and macrophage infiltration [148].

Operative

Indications: Surgery is recommended if neurologic deficits progress or manifest as myelopathy [126], or if pain remains at an intolerable level [126]. Indications include no improvement in symptoms after 3 months of conservative treatment or the presence of nerve damage symptoms [35]. Patients with symptomatic L4-L5 disc herniation who have failed conservative treatment for 6 weeks are eligible for surgical intervention [60]. Surgical treatment is a viable option for recreational athletes who fail nonsurgical treatment or have neurological risk [13].

Surgical Approach / Technique: Microdiscectomy and endoscopic techniques are recommended operative approaches for lumbar disc disease [21]. Biportal endoscopic discectomy (BED) is as effective as microscopic discectomy (MD) in treating single-level lumbar disc herniation [16], with distinct advantages over MD in terms of postoperative wound complications [16]. Percutaneous endoscopic lumbar discectomy under local anesthesia yields improvements in pain and disability across all symptom severity groups [57]. Gradient local anesthesia can satisfactorily and safely control intraoperative pain during percutaneous endoscopic lumbar discectomy via the interlaminar approach [186]. A modified tubular discectomy technique with safe scar dissection is effective for recurrent lumbar disc herniation treatment [170]. The transforaminal endoscopic approach can be used for recurrence after a traditional microdiscectomy [33]. If both the primary and recurrence approaches are transforaminal, the total level of invasiveness is typically less than a primary microscopic approach because there is no violation of the facet joint [33]. Aggressive discectomy is associated with longer operation times compared to limited discectomy [43]. Aggressive discectomy is associated with greater postoperative reductions in disc height index compared to limited discectomy [43]. Aggressive discectomy is associated with greater postoperative Modic changes compared to limited discectomy [43]. No operative technique has been shown to reduce the incidence of recurrent disc herniations [33]. More aggressive disc removal does not reduce the incidence of recurrent disc herniations [33]. More aggressive disc removal does not reduce the motion segment [33]. Spinal fusion is not performed during repeat lumbar disc excision unless an unstable spine is created by the dissection or was identified preoperatively as a correctable and symptomatic problem [33]. The OSE technique is an effective minimally invasive surgical option for the treatment of L5-S1 lumbar disc herniation [131]. The UBE technique is an effective minimally invasive surgical option for the treatment of L5-S1 lumbar disc herniation [131]. The ULIF technique is a safer and more effective minimally invasive surgical method for addressing lumbar spinal stenosis and intervertebral disc herniation [122]. Fully endoscopic transforaminal discectomy may be an effective and alternative treatment option for the upward migration of disc herniation in the upper lumbar area [127]. The DIAM implant could be considered a useful intermediate step procedure for lumbar disc herniation surgery [26].

Adjuncts: Intraoperative epidural steroids are effective in reducing pain in the early stage after lumbar discectomy [58]. Intraoperative epidural steroids are effective in reducing consumption of analgesia after lumbar discectomy [58]. Epidural injection of dexamethasone and vitamin B12 effectively reduces early postoperative low back and leg pain after percutaneous endoscopic interlaminar discectomy [192]. Epidural injection of dexamethasone and vitamin B12 lowers postoperative inflammatory factor expression after percutaneous endoscopic interlaminar discectomy [192]. Epidural injection of dexamethasone and vitamin B12 improves early percutaneous endoscopic interlaminar discectomy outcomes [192]. Closed drainage is beneficial for reducing postoperative low-grade fever after single-level lumbar discectomy [30]. Closed drainage is beneficial for relieving pain in the operation area in the very early postoperative stage after single-level lumbar discectomy [30]. The use of a body surface-assisting puncture device in percutaneous transforaminal endoscopic lumbar discectomy can significantly reduce the number of punctures [194]. The use of a body surface-assisting puncture device in percutaneous transforaminal endoscopic lumbar discectomy can significantly reduce X-ray fluoroscopy radiation dose [194]. The use of a body surface-assisting puncture device in percutaneous transforaminal endoscopic lumbar discectomy can shorten the operation time [194]. The use of a body surface-assisting puncture device in percutaneous transforaminal endoscopic lumbar discectomy does not increase surgical complications [194]. The device for targeted and quantificational foraminoplasty is efficient and safe for percutaneous transforaminal endoscopic discectomy in treating lumbar disc herniation at the L5–S1 level [169]. The Lu’s retractor has potential utility as an effective alternative in minimally invasive spinal procedures for unilateral biportal endoscopic discectomy [40]. The novel transparent visual channel translates into enhanced surgical safety and efficiency for prolapsed lumbar disc herniation [35].

Postoperative Care and Outcomes: Clinical outcomes based on statistical performance measures are excellent after discectomy in professional athletes, with postoperative Performance Scores equivalent to preoperative levels [9]. Full endoscopic transforaminal discectomy remains a safe and effective surgical intervention for treating herniated lumbar discs in the context of obesity [124]. A discectomy does not always provide the final solution to lumbar disc disease in children [6]. The incidence of recurrent disc herniation is reported in 3% to 7% of patients [33]. Patients undergoing revision microdiskectomy for recurrent lumbar disk herniation experience worse clinical outcomes compared with patients undergoing a primary microdiskectomy [68]. Patients undergoing revision microdiskectomy for recurrent lumbar disk herniation experience more revision surgeries compared with patients undergoing a primary microdiskectomy [68]. Within the military population, 9.6% of patients would require two or more revision surgeries after single-level lumbar microdiscectomy [14]. Within the military population, 42.1% of revision microdiscectomy patients would ultimately undergo a lumbar arthrodesis at the same level as the initial disk herniation [14]. Following lumbar diskectomy, clinical and nonclinical factors were associated with prescribing opioids and prescribed MME [12]. The mean duration of postoperative disability before returning to work was 49 days for open laminotomy and discectomy patients [164]. The mean duration of postoperative disability before returning to work was 27 days for video-assisted arthroscopic microdiscectomy patients [164]. Patients undergoing open laminotomy and discectomy used narcotics for a longer duration postoperatively than those undergoing video-assisted arthroscopic microdiscectomy [164]. 93% of patients in the open laminotomy and discectomy group were considered to have had a satisfactory outcome [164]. 97% of patients in the video-assisted arthroscopic microdiscectomy group were considered to have had a satisfactory outcome [164]. No neurovascular complications or infections were encountered in either the open laminotomy or video-assisted arthroscopic microdiscectomy groups [164]. A significant improvement was observed in VAS for leg pain from a preoperative mean of 9.2 to a postoperative mean of 1.5 at three months after tubular microdiscectomy for recurrent lumbar disc herniation [170]. No incidental durotomy, neurological deficits, or mortality were reported in the study of tubular microdiscectomy for recurrent lumbar disc herniation [170]. One patient had superficial wound infection in the study of tubular microdiscectomy for recurrent lumbar disc herniation [170]. Surgical time for biportal endoscopic spine surgery decreased from 87 to 52 minutes in the mastery phase [172]. Conversion to open surgery for biportal endoscopic spine surgery decreased from 3 to 0 cases in the mastery phase [172]. Intraoperative complications for biportal endoscopic spine surgery decreased from 3 to 0 cases in the mastery phase [172]. Postoperative complications for biportal endoscopic spine surgery decreased from 7 to 2 cases in the mastery phase [172]. Rates of revision surgery for biportal endoscopic spine surgery decreased from 4 to 1 case in the mastery phase [172]. A learning curve of 31 cases is suggested for adequate performance of biportal endoscopic spine surgery for lumbar laminectomy and diskectomy [172].

Complications

Recurrence and Reoperation

Long-term follow-up data indicates that the rate of reoperation for intervertebral disc herniation is 15% at eight years post-enrollment [107]. Among patients requiring reoperation, 62% presented with a recurrent disc herniation, while 25% had a complication or other factor [107]. Although repeat surgery for recurrent lumbar disc herniation carries a good probability for improvement, outcomes are not as favorable as those following primary surgery [18]. Patients undergoing repeated surgery report lower satisfaction levels compared with those undergoing primary procedures [18]. Furthermore, patients undergoing revision microdiskectomy experience worse clinical outcomes and a higher frequency of subsequent revision surgeries than those undergoing primary microdiskectomy [68]. In a military population cohort, 9.6% of patients required two or more revision surgeries after single-level lumbar microdiscectomy [14]. Within this same cohort, 42.1% of revision microdiscectomy patients ultimately underwent lumbar arthrodesis at the same level as the initial disk herniation [14].

Surgical approach influences recurrence risk. Microendoscopic discectomy may result in an increased reoperation rate despite its benefits, while yielding the same clinical outcome as open microdiscectomy [84]. Similarly, the percutaneous endoscopic lumbar discectomy group demonstrated higher reoperation rates compared with the open discectomy group [197]. Conversely, full endoscopic lumbar discectomy combined with annulus fibrosus repair reduces the postoperative recurrence rate [198]. Patient-specific factors also play a role; patients with Modic changes had a higher incidence risk of recurrent lumbar disc herniation following percutaneous endoscopic lumbar discectomy [76].

Intraoperative and Early Postoperative Complications

Incidental dural tear has a more significant effect on in-hospital morbidity, mortality, and healthcare burdens in lumbar spinal decompression than in lumbar discectomy [109]. Regarding wound management, closed drainage is beneficial for reducing postoperative low-grade fever and relieving pain in the operation area in the very early postoperative stage for single-level lumbar discectomy [30]. Infection rates vary by technique; compared with the open discectomy group, the percutaneous endoscopic lumbar discectomy group showed lower infection rates [197].

Specific procedural complications include negative pressure pulmonary edema, which is an infrequent complication of percutaneous endoscopic interlaminar lumbar discectomy [67]. Post-operative dysesthesia due to existing dorsal root ganglion injury is a unique complication of transforaminal percutaneous endoscopic lumbar discectomy [173]. In a series of 37 patients with highly downward migrated lumbar disc herniation treated with full-endoscopic foraminoplasty, 1 case of recurrence and 4 cases of postoperative dysesthesia occurred [112]. In a series of patients treated with a novel vertebral trench technique for very highly up-migrated lumbar disc herniation, three cases had transient paresthesias after surgery which disappeared in 2 to 3 weeks [163]. In a single-center retrospective study of trans-sacral epiduroscopic lumbar decompression, practice with the procedure and careful patient selection can lower the risk of complications [195].

Recovery

Light activity (weeks): Objective activity trackers demonstrate that lumbar surgery results in a decrease in the amount of activity 1 month just after surgery [151]. For single-level lumbar discectomy, closed drainage is beneficial for reducing postoperative low-grade fever and relieving pain in the operation area in the very early postoperative stage [30].

Full activity (months): Gradual postoperative recovery of activity levels occurs within 3 months following lumbar surgery [151].

Complete recovery / outcome plateau (months): Full functional recovery from back surgery can be protracted, with the primary outcome of interest being the between-group difference in score on the ODI at one-year follow-up [25].

Functional milestones: In adults with lumbar disc herniation undergoing lumbar discectomy, more severe preoperative paraspinal fatty infiltration is associated with recurrence or reoperation, residual/chronic low back pain, and poorer functional recovery [66]. A dose-response relationship exists between increasing number of previous operations and inferior outcomes among patients operated for degenerative conditions in the lumbar spine [31].

Other Considerations: Repeat surgery for a recurrent lumbar disc herniation was performed with good probability for improvement, although not as good as for primary lumbar disc herniation surgery, and patients undergoing repeated surgery were less satisfied [18]. In children and adolescents sixteen years of age or younger, a discectomy does not always provide the final solution to lumbar disc disease, but careful selection of patients and follow-up can produce satisfactory long-term results in most [6]. Increased worker earnings resulting from disc herniation surgery may offset the increased direct medical costs associated with surgery [155]. Findings from a secondary analysis of qualitative data provide insights into patient experiences of functioning and disability following lumbar discectomy [4]. A protocol for a randomised controlled trial exists to assess the impact of activity restrictions on clinical outcomes following lumbar discectomy [1]. A randomized controlled trial protocol evaluates the effectiveness of a treatment regimen involving exercise and patient education for people who have undergone a single-level lumbar microdiscectomy [28].

Athlete-Specific Outcomes: Clinical outcomes based on statistical performance measures are excellent after discectomy in National Football League professional athletes, as postoperative Performance Scores were equivalent to preoperative levels [9]. The average rate of return to sport for professional athletes after lumbar diskectomy was 89% [75]. National Football League linemen have high return-to-play rates after lumbar diskectomy, and those requiring revision decompression also successfully return to play at high rates [85].

Key Evidence

• [L2] This document describes the protocol for a randomised controlled trial to assess the impact of activity restrictions on clinical outcomes following lumbar discectomy, aiming to provide an evidence base for postoperative care. [1] (10.1186/s12891-017-1681-3)
• [L2] This article is a correction to a previously published systematic review and narrative synthesis regarding physical prognostic factors predicting outcome following lumbar discectomy surgery; it does not contain new clinical conclusions or data. [2] (10.1186/s12891-018-2288-z)
• [L3] Preoperative imaging studies cannot predict the clinical outcome of percutaneous lumbar discectomy. [3] (10.2106/00004623-199504000-00011)
• [L5] Findings provide valuable insights into patient experiences of functioning and disability following lumbar discectomy. [4] (10.1186/s12891-024-07790-7)
• [L5] Recurrent lumbar disk herniation is the most common complication following primary open diskectomy, defined as recurrent back and/or leg pain after a definite pain-free period of at least 6 months. [5] (10.5435/00124635-201006000-00005)
• [L4] A discectomy does not always provide the final solution to lumbar disc disease in children, but careful selection of patients and follow-up can produce satisfactory long-term results in most. [6] (10.2106/00004623-199805000-00009)
• [L3] Revision discectomy can give results that are as good as those seen after primary surgery. [7] (10.1302/0301-620x.95b1.30413)
• [L3] Additional operations after primary disc surgery are needed more frequently than previously reported, and the outcome profoundly deteriorates after the second additional operation. [8] (10.1302/0301-620x.104b5.bjj-2021-1706.r2)
• [L4] Clinical outcomes based on statistical performance measures are excellent after discectomy in this patient cohort as postoperative Performance Scores were equivalent to preoperative levels. [9] (10.1097/brs.0b013e3181bf8bb5)
• [L1] Large cohort studies and alternative statistical techniques may yield more accurate estimates of the effectiveness of lumbar diskectomy. [10] (10.5435/00124635-200810000-00002)
• [L4] Surgical management of selected lumbar spine conditions can produce excellent outcomes in athletes of all sports, with microdiscectomy for lumbar disc herniation leading to favorable return to play rates and direct pars repair leading to high return to play rates. [11] (10.1016/j.csm.2016.05.006)
• [L3] Following lumbar diskectomy, clinical and nonclinical factors were associated with prescribing opioids and prescribed MME. [12] (10.5435/jaaos-d-24-00908)
• [L5] Most lumbar spine pathologies in recreational athletes can be managed nonsurgically with excellent outcomes, while surgical treatment is a viable option with good outcomes for those who fail nonsurgical treatment or have neurological risk. [13] (10.5435/jaaos-d-24-00979)
• [L3] Within this group, 9.6% would require two or more revision surgeries and 42.1% of these revision microdiscectomy patients would ultimately undergo a lumbar arthrodesis at the same level as the initial disk herniation. [14] (10.5435/jaaos-d-24-00879)
• [L3] Furthermore, residual LBP may reflect increased load and pressure on the disc and endplate in the sitting position. [15] (10.1186/s12891-021-04015-z)
• [L1] BED is as effective as MD in treating single-level lumbar disc herniation but has distinct advantages in terms of postoperative wound complications. [16] (10.1302/0301-620x.107b5.bjj-2024-1560.r1)
• [L5] Nonsurgical management is the standard of care for lumbar degenerative disk disease, while spondylolysis is typically managed nonsurgically with successful outcomes, though surgery may be required for return to sports. [17] (10.5435/jaaos-d-16-00135)
• [L2] Repeat surgery for a recurrent lumbar disc herniation was performed with good probability for improvement, although not as good as for primary lumbar disc herniation surgery, and patients undergoing repeated surgery were less satisfied. [18] (10.1007/s11999-014-3596-8)
• [L3] The data suggest that it is reasonable to operate on patients who are elderly and obese and who have lumbar symptoms, with the appropriate indications. [19] (10.1097/01.blo.0000141901.23322.98)
• [L1] This is the first comprehensive systematic review of diagnostic accuracy studies that evaluate clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine. [24] (10.1186/s12891-017-1549-6)
• [L1] [25] (10.1186/1471-2474-11-17)
• [L3] The authors suggest that DIAM implantation could be considered a useful intermediate step procedure for lumbar disc herniation surgery. [26] (10.1186/s12891-021-04929-8)
• [L3] This article presents the rationale and design for a randomized controlled trial evaluating the effectiveness of a treatment regimen for people who have undergone a single-level lumbar microdiscectomy. [28] (10.1186/1471-2474-7-70)
• [L1] For single-level lumbar discectomy, closed drainage is beneficial for reducing postoperative low-grade fever and relieving pain in the operation area in the very early postoperative stage. [30] (10.1186/s12891-020-03504-x)
• [L3] We found a dose-response relationship between increasing number of previous operations and inferior outcomes among patients operated for degenerative conditions in the lumbar spine. [31] (10.1302/0301-620x.105b4.bjj-2022-0704.r1)
• [L3] [35] (10.1186/s13018-026-06902-4)
• [L5] [37] (10.1097/01.blo.0000198724.54891.3a)
• [L4] Age is not a contraindication for decompressive lumbar spine surgery. [38] (10.1186/s13018-020-01968-0)
• [L4] Percutaneous endoscopic lumbar discectomy is a safe and efficacious technique to relieve symptoms of herniated discs and this improvement in back pain and leg symptoms translates to improvement in quality of life. [39] (10.1186/1749-799x-4-20)
• [L3] These findings support its potential utility as an effective alternative in minimally invasive spinal procedures. [40] (10.1186/s13018-025-05932-8)
• [L3] However, aggressive discectomy is associated with longer operation times and greater postoperative reductions in disc height index and Modic changes compared to limited discectomy. [43] (10.1186/s12891-024-07498-8)
• [L3] In addition, old age, severe grade of surgical-level disc degeneration and more disc degeneration levels significantly increased the incidence of complications. [44] (10.1186/s12891-021-04940-z)
• [L3] Signs of early disc degeneration related to tumor treatment can be seen in the intervertebral discs of survivors. [45] (10.1186/s12891-023-06509-4)
• [L2] In patients with cervical radiculopathy, the type and extent of disc herniation measured on MRI prior to surgery correlated neither to the severity of the symptoms at presentation, nor to clinical outcomes at two years postoperatively. [46] (10.1302/0301-620x.104b11.bjj-2022-0657.r2)
• [L3] Given the higher reoperation risk with microendoscopic discectomy compared with microdiscectomy or open discectomy at a median of 4 years of follow-up, surgeons should select microdiscectomy or open discectomy, despite the current popularity of microendoscopic discectomy. [56] (10.1097/corr.0000000000002322)
• [L3] PELD under local anesthesia yielded remarkable improvements in pain and disability across all symptom severity groups, supporting its broader adoption with tailored risk stratification to enhance long-term success. [57] (10.1186/s13018-025-06419-2)
• [L1] There is relatively strong evidence that intraoperative epidural steroids are effective in reducing pain in the early stage and reducing consumption of analgesia. [58] (10.1186/1471-2474-15-146)
• [L1] [60] (10.1186/s12891-020-03396-x)
• [L1] In adults with LDH undergoing lumbar discectomy, more severe preoperative paraspinal FI is associated with recurrence or reoperation, residual/chronic low back pain, and poorer functional recovery. [66] (10.1186/s12891-026-09649-5)
• [Case_report] Although NPPE is an infrequent complication, especially in patients undergoing percutaneous endoscopic interlaminar lumbar discectomy, this case report highlights the importance of early diagnosis and prompt treatment of NPPE to prevent the development of potentially fatal complications. [67] (10.1186/s12891-018-2306-1)
• [L3] [68] (10.5435/jaaos-d-18-00366)
• [L3] The presence and progression of these lesions are mainly attributed to lumbar disc herniation and higher hip circumference in men. [69] (10.1186/s12891-023-06379-w)
• [L3] The modified classification has good reliability and its experience level of spine surgeons does not affect the reliability. [70] (10.1186/s13018-023-03688-7)
• [L4] Surgical treatment of intervertebral disk herniation, degenerative spondylolisthesis, and lumbar spinal stenosis provides significant value to the patient over the long term, with no catastrophic progressions to neurologic deficit occurring as a result of watchful waiting. [71] (10.5435/jaaos-20-03-160)
• [L4] The average rate of return to sport for professional athletes after lumbar diskectomy was 89%. [75] (10.1177/0363546512458570)
• [L3] Patients with Modic changes had a higher incidence risk of recurrent lumbar disc herniation. [76] (10.1186/s13018-020-01695-6)
• [L2] The findings on magnetic resonance scans were not predictive of the development or duration of low-back pain. [78] (10.2106/00004623-200109000-00002)
• [L4] Modic changes, particularly Type 2, are common radiological findings in lumbar spine imaging, most frequently occurring at L4/L5 and L5/S1 levels. [79] (10.1186/s12891-025-09182-x)
• [L5] [80] (10.1002/jor.25240)
• [L3] The present results suggest a general lumbar muscle dysfunction in the pain group, in particular of the deep stabilizing muscle system. [82] (10.1186/1471-2474-12-65)
• [L5] Microendoscopic discectomy and open microdiscectomy yield the same clinical outcome, but microendoscopic discectomy might result in an increased reoperation rate despite its benefits. [84] (10.1097/corr.0000000000002405)
• [L4] National Football League linemen have high return-to-play rates after lumbar diskectomy, and those requiring revision decompression also successfully return to play at high rates. [85] (10.1177/0363546510388901)
• [L3] [107] (10.2106/jbjs.n.01287)
• [L3] The effect of dural tear on in-hospital morbidity, mortality, and healthcare burdens was more significant in lumbar spinal decompression than in lumbar discectomy. [109] (10.1007/s00402-013-1843-1)
• [L4] [112] (10.1186/s12891-022-05254-4)
• [L3] The ULIF technique is a safer and more effective minimally invasive surgical method for addressing lumbar spinal stenosis and intervertebral disc herniation. [122] (10.1186/s12891-024-07287-3)
• [L1] Nevertheless, it remains a safe and effective surgical intervention for treating herniated lumbar discs in the context of obesity. [124] (10.1186/s12891-024-07455-5)
• [L4] Fully endoscopic transforaminal discectomy may be an effective and alternative treatment option for the upward migration of disc herniation in the upper lumbar area. [127] (10.3390/brainsci10060363)
• [L3] The OSE technique is an effective minimally invasive surgical option as well as the UBE technique in the treatment of L5-S1 LDH. [131] (10.1186/s13018-023-04159-9)
• [L3] Facet orientation and facet tropism in the lower lumbar spine are significantly associated with degenerative lumbar spinal stenosis. [134] (10.1155/2020/2453503)
• [L3] [144] (10.1186/s12891-017-1522-4)
• [L3] [146] (10.1186/s12891-018-2086-7)
• [L4] Spontaneous resorption of lumbar disk herniation is a promising avenue for non-surgical management, associated with mechanisms such as inflammation, neovascularization, and macrophage infiltration. [148] (10.1186/s13018-025-05959-x)
• [L2] The objective activity tracker demonstrated that lumbar surgery results in the amount of activity decreasing 1 month just after surgery followed by gradual postoperative recovery within 3 months. [151] (10.1186/s12891-020-3102-2)
• [L2] Canal size is independent of body stature, and abnormal orientations of lamina angle and facet joint angulation may be developmental variations leading to increased likelihood of developmental spinal stenosis. [152] (10.1302/0301-620x.103b4.bjj-2020-1792.r1)
• [L2] Increased worker earnings resulting from disc herniation surgery may offset the increased direct medical costs associated with surgery. [155] (10.1007/s11999-013-3440-6)
• [L4] [163] (10.1186/s12891-021-04548-3)
• [L1] [164] (10.2106/00004623-199907000-00008)
• [L3] The device is efficient and safe for PTED in treating lumbar disc herniation at the L5–S1 level. [169] (10.1186/s13018-021-02533-z)
• [L4] [170] (10.1186/s13018-023-04226-1)
• [L4] [172] (10.5435/jaaosglobal-d-23-00161)
• [Paper] [173] (10.1055/s-0031-1287774)
• [L4] Modic 1 changes with less advanced degenerative disc disease (≤50%-IVSN) are found in younger men at the L5/S1 level and are associated with less frequent osteophytes, whereas those with advanced degenerative disc disease (>50%-IVSN) are found in older women at the L4/L5 level. [175] (10.1186/s12891-017-1407-6)
• [L1] A positive MRI T2-weighted image of the lumbar disc with HIZ indicates disc degeneration and may be a specific indicator for the physical diagnosis of discogenic low back pain. [176] (10.1186/s13018-023-04187-5)
• [L3] Using the 4-grade fat infiltration system to determine the level of fat infiltration in the paraspinal muscles is more effective in predicting lumbar disc herniation compared to the 3-grade system. [185] (10.1186/s13018-023-04247-w)
• [L4] Gradient local anesthesia can satisfactorily and safely control intraoperative pain during the PELD via the interlaminar approach. [186] (10.1186/s13018-020-01939-5)
• [L3] The 4-grade fat infiltration system was seen to be more effective than the 3-grade fat infiltration system in the determination of the level of fat infiltration in the paraspinal muscles and the prediction of lumbar disc herniation. [187] (10.1186/s12891-022-05180-5)
• [L4] The Song's classification system has initially demonstrated significant value in guiding personalized surgical decision-making. [188] (10.1186/s13018-025-06342-6)
• [L4] Despite the minimally invasiveness and high visualization capabilities of biportal endoscopy, patients who are diabetic, smoker, or contained disk herniation on MRI should be counseled for higher risk of recurrence. [190] (10.5435/jaaosglobal-d-25-00137)
• [L3] Obese patients who underwent BELD for lumbar disc herniation showed no significant difference in clinical and radiologic outcomes compared with non-obese patients. [191] (10.1186/s12891-022-06082-2)
• [L1] Epidural injection of dexamethasone and VB12 effectively reduces early postoperative low back and leg pain, lowers postoperative inflammatory factor expression, and improves early PEID outcomes. [192] (10.1186/s13018-024-05210-z)
• [L2] The use of a new body surface-assisting puncture device in percutaneous transforaminal endoscopic lumbar discectomy surgery can significantly reduce the number of punctures and X-ray fluoroscopy radiation dose, as well as shortening the operation time, without increasing surgical complications. [194] (10.1186/s12891-022-05985-4)
• [L4] Practice with the procedure and careful patient selection can lower the risk of complications. [195] (10.1186/s13018-017-0691-z)
• [L3] Compared with the OD group, the PELD group showed higher reoperation rates and lower infection rates. [197] (10.1302/0301-620x.103b8.bjj-2020-2541.r2)
• [L3] Full endoscopic lumbar discectomy combined with annulus fibrosus repair reduces the postoperative recurrence rate and achieves satisfactory clinical outcomes. [198] (10.1186/s13018-024-04725-9)

See Also

• Lumbar disc herniation
• Lumbar spinal stenosis
• Low back pain
• Sciatica
• Cauda equina syndrome
• Cervical radiculopathy
• Degenerative spondylolisthesis
• Lumbar decompression

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