Percutaneous transforaminal endoscopic lumbar discectomy for sciatica

Endoscopic spinal surgery (ESS) is a type of minimally invasive spinal surgery (also known as keyhole surgery) whereby a small (1-2 cm) incision (cut) is made to allow the placement of a tube with a camera through which various long instruments are used to perform the surgery.

The images are transmitted on a high-resolution screen.

X-ray is used to place the working channel at the appropriate level.

Percutaneous Transforaminal Endoscopic Lumbar Discectomy is a type of ESS where the disc is accessed from the side of the spine, via the foramen (passageway through which the nerve roots run). This is a new interventional procedure for UCLH.

ESS can be used to treat a variety of common spinal problems including:

• Disc prolapse / herniation with sciatica (pain radiating to the leg(s))
• Lumbar canal stenosis with back pain radiating to the legs and neurogenic claudication
• Back pain secondary to arthritis in the facet joints

You are candidate for ESS if you have one of the above conditions and continue to have debilitating symptoms that have failed to respond to conservative management including:

• Medical treatment, pain killers, neuromodulating agents
• Physiotherapy
• Injections
• Alternative therapies (acupuncture etc...)

All possible precautions are taken to avoid complications during your surgery, but all operations have risks and your surgeon will explain all the benefits and risks of this operation to you. Your consultant will explain your risk in detail. Please discuss them with your surgeon when you are in clinic.

This operation is performed under local anesthesia and/or sedation, meaning that you are not completely asleep during the surgery, and your anesthetist will talk to you about the risks of anesthesia before your procedure.

Female patients must tell their anaesthetist and surgeon if they are or could be pregnant. Anaesthetic drugs and x-rays used during the procedure can be harmful to unborn babies.

Problems that may happen straight away

• Nerve root injury is extremely rare and can lead to pain, numbness, or weakness
• A common symptom (not necessarily a complication) is a feeling of numbness or hypersensitivity (dysesthesia) in your leg after surgery. This can occur immediately after surgery or days/weeks later.
• Leakage of spinal fluid can occur during the surgery (< 0.5%); in case of a small tear in the dura (membrane containing the nerves and spinal fluid), this usually resolves spontaneously. A larger tear may require re-exploration and repair.
• The risk of bleeding / blood clot developing around the nerve is very rare but can lead to worsening pain and weakness requiring re-exploration to remove the blood clot.

Problems that may happen later

• The surgeon will only remove those parts of the prolapsed disc which are pressing on the nerve root, not the whole disc. Some of the remaining disc tissue may become displaced in the future causing a recurrence of your symptoms.
• Infection can develop in the skin wound or deeper in the soft tissues or even in the disc space (called discitis). We minimise this risk by giving a dose of an antibiotic at the start of the anaesthetic. We will ask you to keep the wound clean and dry.
• Any other infection you may develop, including chest or urinary tract infection, will be treated according to trust guidelines.
• Scar tissue may develop around the decompressed nerve root resulting in pain or change in the feeling in your leg.

Problems that are rare, but serious

• Very rarely, injury to a major blood vessel may occur when the prolapsed disc is being removed.

Sometimes the ‘slipped’ part of the disc shrinks back, so there is a chance that your leg pain may get better by itself. This becomes less likely after a longer period of symptoms.

Problems with power or sensory loss, passing urine or controlling your bowels are unlikely to improve without surgical intervention.

Your surgeon will discuss all alternative treatments and their risks and benefits with you. Alternative treatments include:

• Physiotherapy. Physiotherapists can give advice about exercises to strengthen the muscles of the spine and improve posture.
• Pain-relieving medicines. Consult your pharmacist or GP about the safety and suitability of these medicines. Your GP may prescribe stronger painkillers, but these may have other side-effects such as constipation.
• Nerve root injection for radiculopathy can be done as a day-case procedure. However, this may offer only temporary relief of symptoms.
• Alternative surgical options are available including conventional open microdiscectomy

If you have existing medical conditions, such as high blood pressure or diabetes, you may like to visit your GP practice to make sure that you are as fit as possible for your surgery.

Make sure you arrange your domestic and social situation so that it will be possible and comfortable for you to go home at the correct time. For instance:

• Arrange for somebody to collect you on discharge
• Make sure you have shopped for adequate food supplies for when you get home  
• Tidy your house so you do not need to do housework when you get home
• Ensure you have a supply of simple pain killers available at home, such as paracetamol

If you think you will need some social support after discharge, please speak to your GP and let us know as soon as possible.

We will:

• Arrange a pre-assessment check to make sure you are fit for an anaesthetic
• Organize appropriate scans or x-rays for your operation if necessary
• Write to you to let you know when your operation will be
• Answer any questions you may have about your operation

We want to involve you in all the decisions about your care and treatment. If you decide to go ahead with treatment, by law we must ask for your consent and will ask you to sign a consent form. This confirms that you agree to have the procedure and understand what it involves, including the risks. Staff will explain all the benefits, risks and alternatives before they ask you to sign a consent form.

If you are unsure about any aspect of your proposed treatment, please don’t hesitate to speak with a senior member of staff again.

We want to involve you in all the decisions about your care and treatment. If you decide to go ahead with treatment, by law we must ask for your consent and will ask you to sign a consent form. This confirms that you agree to have the procedure and understand what it involves, including the risks. Staff will explain all the benefits, risks and alternatives before they ask you to sign a consent form.

If you are unsure about any aspect of your proposed treatment, please don’t hesitate to speak with a senior member of staff again.

Surgery is performed under local anaesthesia / sedation. This mean that you are awake during the procedure but will not feel any pain. The anesthetist will give you some medication to relax you and may make you sleepy. Some medication will be injected to numb the pain around the surgical site. Your surgeon can communicate with you to make sure you are okay.

You will be lying on your stomach. The level where the surgery needs to be done is identified using X-ray. Local anaesthetic (numbing) is injected, and a small cut (~ 1cm) is made on your side.

The working channel with camera and light source is inserted and the disc removed, nerves decompressed. Once the surgery is finished, the skin is closed with a dissolvable stitch.

In recovery

• After surgery, you will be taken to recovery
• You will be met by the nurses who will ensure that you are comfortable and that your pain is controlled
• You will be reviewed by your surgeon to make sure that your symptoms have improved
• You will then be transferred back to the ward

On the ward

• The nursing team will review you
• Your surgeon and spinal clinical nurse specialist will come to see you, answer any questions you may have and make sure you are safe for discharge
• You will be asked to mobilize around the ward before being discharged home
• You will be given painkillers to take home
• You will also be given the spinal wound care booklet and some spare dressings
• Please ask a friend or family member to come pick you up as driving or taking public transport right after an operation is not recommended

You will be given an appointment to come back to the clinic 6-8 weeks after your surgery.

1. Transforaminal endoscopic surgery for symptomatic lumbar disc herniations: a systematic review of the literature. Nellensteijn et al. Eur Spine J (2010) 19:181-204
2. Full endoscopic vs open discectomy for sciatica randomised controlled non inferiority trial. Gadjradj et al 2022.
3. Endoscopic Spinal Surgery (BESS and UESS) Versus Microscopic Surgery in Lumbar Spinal Stenosis: Systematic Review and Meta-Analysis. Kang et al. 2022
4. Cost-effectiveness of full endoscopic versus open discectomy for sciatica. Gadjradj et al. 2021.
5. Percutaneous Transforaminal Endoscopic Discectomy Versus Open Microdiscectomy for Lumbar Disc Herniation. Gadjradj, Harhangi et al. 2020.
6. Curative effect comparison of transforaminal endoscopic spine system and traditional open discectomy: a meta-analysis. Yuan et al. 2020
7. Therapeutic effect of transforaminal endoscopic spine system in the treatment of prolapse of lumbar intervertebral disc. Tao et al. 2018.
8. Transforaminal endoscopic discectomy versus conventional microdiscectomy for lumbar disc herniation: a systematic review and meta-analysis. Zhang et al. 2018
9. PTED study: design of a non-inferiority, randomised controlled trial to compare the effectiveness and cost-effectiveness of percutaneous transforaminal endoscopic discectomy (PTED) versus open microdiscectomy for patients with a symptomatic lumbar disc herniation. Seiger et al. 2017.
10. Efficacy of Transforaminal Endoscopic Spine System (TESSYS) Technique in Treating Lumbar Disc Herniation. Pam et al. 2016.
11. Full-Endoscopic Procedures Versus Traditional Discectomy Surgery for Discectomy: A Systematic Review and Meta-analysis of Current Global Clinical Trials. Li et al. 2016

You may find the following websites helpful:

• www.brainandspine.org.uk
• www.spine-health.com
• www.spineuniverse.com
• www.back.com
• www.patient.co.uk

UCLH cannot accept responsibility for information provided by other organisations.

Victor Horsley Neurosurgical Department
National Hospital for Neurology and Neurosurgery
Queen Square London
WC1N 3BG

Switchboard: 0845 155 5000 / 020 3456 7890
Direct line: 020 3448 3568 / 3150 / 3395
Fax: 020 3448 3340