Frequently Asked Questions About Endoscopic Lumbar Surgery

This text has been prepared for general patient information within the scope of Prof. Dr. Semih Keskil’s academic areas of interest in spine surgery. There is no single, universally “best” method for every lumbar disc herniation patient. Diagnosis and treatment options are determined by evaluating the patient’s symptoms, physical examination findings, and MRI results together.

What does “endoscopic lumbar surgery” mean?

Answer: Methods referred to in daily practice as “totally boodless” or “fully closed” usually describe endoscopic or percutaneous (performed through a very small skin entry point) lumbar disc procedures. The goal is to remove the portion of the disc compressing the nerve (endoscopic discectomy) and, in suitable cases, to provide limited decompression of bone or ligament tissue causing nerve pressure.
The phrase “endoscopic surgical solution in lumbar disc disease” describes a family of surgical options; it is not suitable for every patient.

Can these operations be performed without general anesthesia?

Answer: Some endoscopic lumbar disc procedures can be performed with local anesthesia plus sedation; in other patients, general anesthesia may be preferred. The choice depends on the location of the herniation, the patient’s pain tolerance, coexisting diseases, and the extent of surgery.

Are endoscopic lumbar disc surgeries risky?

Answer: No surgical method has zero risk. However, low complication rates have been reported in the literature for endoscopic discectomy series. For example, in one meta-analysis, approximate rates were reported as:
• Dural tear: 1%
• Infection: 0.1%
• Temporary dysesthesia (sensory change): 1%
• Recurrence (re-herniation): 5.7%

“Open or closed?” Why are the terms confusing in lumbar disc surgery?

Answer:
• Microdiscectomy: A commonly used method performed under a microscope through a small skin incision.
• Endoscopic discectomy (often called fully closed or bloodless): Performed with an endoscope through a much smaller, needle-like entry point.
Which technique is chosen depends more on the type of herniation and the patient’s neurological findings than on the “open/closed” label.

What are the outcomes and reoperation rates after microdiscectomy?

Answer: In a systematic review, recurrence and reoperation rates after microdiscectomy varied among series; approximately 3–4% for recurrence and about 4–10% for reoperation have been reported. These rates may be influenced by factors such as age, disc characteristics, smoking, workload, and rehabilitation.

How is candidacy for endoscopic lumbar disc surgery evaluated?

Answer:

1. Symptom–exam correlation: leg pain (sciatica) and signs of nerve compression
2. MRI target confirmation: location of the disc fragment compressing the nerve
3. Exclusion/management of urgent findings: progressive weakness, bladder–bowel control problems
4. Comparison of options: endoscopic technique, microdiscectomy, and conservative follow-up

How is endoscopic lumbar disc surgery performed?

Answer:

1. The patient is positioned appropriately on the operating table.
2. In selected cases, local anesthesia and/or sedation may be used; in some patients, general anesthesia is preferred.
3. Without a formal incision, an endoscope is inserted through a few-millimeter skin entry point.
4. The herniated disc fragment compressing the nerve is removed.
5. If necessary, limited bone or ligament tissue causing compression is trimmed.
6. When the procedure is completed, the entry point closes on its own; sutures are usually not required.

In this respect, the method is one of the options described as an “endoscopic surgical solution” for lumbar disc disease. It is not a non-surgical treatment; it is still disc surgery. Even though it is performed through a needle-sized entry, the same essential steps as in open surgery may be required: bone trimming, removal of the disc fragment, opening and partial evacuation of the disc, and cauterization/repair of the treated area.

How long does recovery take after endoscopic lumbar disc surgery?

What is the hospital stay?
Answer: After endoscopic (fully closed) lumbar disc surgery, most patients can be discharged the same day or within a few hours. With other surgical methods such as microdiscectomy, hospital stay is often around one day.

What does “recovery” mean?

Answer: Recovery means:
• Closure of the surgical entry site
• Reduction of nerve-compression–related pain and symptoms
• Safe return to daily activities
Heavy lifting and strenuous work are not recommended before full recovery.

How long does it take to return to daily life?

Answer:
• Light daily activities: within a few days for most patients
• Desk work or light work: usually 1–2 weeks
• Heavy physical work: requires a controlled recovery period lasting weeks to months
Literature reports that approximately 70–80% of patients return to daily living activities within the first few weeks after endoscopic lumbar disc surgery.

Can dementia be cured?

Dementia is not a single disease. Cognitive impairment due to some causes can be reversible. For example:
• Vitamin B12 deficiency
• Thyroid hormone disorders
• Normal Pressure Hydrocephalus (Adams–Hakim disease) — when properly treated — may show improvement in cognitive functions.

What proportion of dementias is due to Normal Pressure Hydrocephalus?

Studies indicate that Normal Pressure Hydrocephalus accounts for approximately 5% of all dementia cases. Its key feature is that it is a potentially treatable cause of dementia.

What are the typical symptoms of Adams–Hakim disease?

(Classic triad):

1. Gait disturbance (small steps, shuffling gait)
2. Recent memory and attention problems
3. Urinary incontinence or unawareness of the need to urinate
   Gait disturbance is usually the earliest symptom.

How does it differ from Alzheimer’s disease?

In Normal Pressure Hydrocephalus:
• Memory loss is usually milder and more slowly progressive,
• Severe cortical signs such as marked language disturbance or agnosia are often absent,
• There is a chance of clinical improvement with proper treatment

This condition may occur together with other intracranial problems such as hemorrhage, tumor, infection, or head trauma, or it may arise spontaneously (idiopathic).

How is Normal Pressure Hydrocephalus evaluated?

1. Detailed history and neurological examination
2. Cognitive tests (such as the Mini-Mental State Test)
3. Brain MRI
4. Lumbar puncture or temporary CSF drainage to observe clinical response
   Demonstrated improvement with this tests increases the likelihood of benefit from surgical treatment.

Can dementia be stopped?

If the cause of dementia is Normal Pressure Hydrocephalus, disease progression can be halted, and some patients may experience reversal of symptoms.

What is the success rate of shunt surgery?

According to various series:
• About 60% of patients show marked early clinical improvement after shunt placement,
• Sustained and meaningful improvement in the long-term occurs in about 25–35%,
• The recovery process may extend up to four months.
One of the most important factors affecting success is shorter symptom duration (often less than 6 months).

How does shunt treatment work?

Answer: Shunt systems are valve-and-tube devices that divert excess CSF from the brain to the abdominal cavity in a controlled manner. The goal is to balance pressure and improve gait, urinary control, and cognitive functions. Shunts can remain in the body long term; if malfunction occurs, replacement may be required.

What does spinal canal stenosis mean?

It is the compression of the spinal cord or nerve roots due to narrowing of the spinal canal. When spinal cord injury develops, it is called myelopathy; when the damage becomes visible on MRI, it is termed myelomalacia.

Who is more commonly affected?

More common at older ages, especially in:
• Cervical (neck)
• Lumbar (lower back) regions
With aging, disc dehydration, facet joint enlargement, and ligament thickening increase the degree of narrowing.

What are the symptoms?

1. Neck / back / low back pain
2. Loss of fine motor skills in the hands (e.g., difficulty buttoning)
3. Leg pain and stiffness increasing with walking (neurogenic claudication)
4. Relief when bending forward
5. Bladder–bowel control problems or sexual dysfunction (in advanced cases)

How is canal stenosis evaluated?

• Neurological examination
• MRI imaging (level of narrowing and spinal cord involvement)
• Timely treatment planning if findings are progressive

“When permanent spinal cord damage develops, there is no proven treatment that can reverse it. Therefore, early diagnosis is critical.”

Can canal stenosis improve?

The main problem is mechanical pressure on the spinal cord or nerve roots. In suitable patients, surgical removal of the pressure may lead to reduction or stabilization of symptoms.
In the literature, with correct surgical indication, approximately 60–80% of patients show significant improvement in pain and walking capacity. Outcomes vary depending on disease duration, presence of permanent cord damage (myelomalacia), and accompanying illnesses.

What happens if surgery is delayed?

If the spinal cord remains compressed for a long time, irreversible nerve damage may occur. In such cases, surgery may stop progression, but lost functions may not fully return.

How is canal stenosis treated?

Answer (stepwise approach):

1. Clinical and MRI evaluation
2. If there are no advanced neurological deficits: close follow-up and symptom control
3. If there is progressive weakness, gait disturbance, or bladder–bowel dysfunction: evaluation for surgical decompression

Can canal stenosis be treated without surgery?

Current scientific evidence shows there is no non-surgical method that permanently enlarges the spinal canal. Non-surgical approaches may temporarily reduce symptoms in some patients but do not eliminate the underlying compression.

What does pseudotumor cerebri mean?

It is the presence of increased intracranial pressure findings without a brain tumor. CSF content is usually normal, and no underlying cause is identified.

How common is pseudotumor cerebri?

According to epidemiological studies:
• General population: about 1–2 cases per 100,000 people per year
• Obese women: about 10–20 cases per 100,000
Approximately 90% of patients are obese women of reproductive age, and about 10% are men.

Why pseudotumor cerebri is important?

If untreated, permanent vision loss may develop due to pressure on the optic nerve.

How does pseudotumor cerebri improve?

First-line management includes lifestyle modification (especially weight loss) and medications that reduce CSF production, such as acetazolamide.
• Some studies show that 5–15% weight loss may be associated with regression of papilledema.
• A 1998 study reported at least one-grade improvement in optic disc swelling with about 2.5 kg weight loss; however, visual field loss may not improve in every patient.

How are symptoms controlled?

Answer (stepwise):

1. Medication + weight management
2. Intermittent lumbar puncture (for symptom control)
3. Surgical CSF diversion (if vision is at risk)

“Lumbar puncture may provide temporary relief; it is used selectively due to rare but serious risks such as meningitis/arachnoiditis and the possibility of requiring repeated painful procedures.”

What if there is a risk of vision loss?

Ventriculoperitoneal or lumboperitoneal shunt options performed by neurosurgery are considered. In appropriate patients, up to 80% vision stabilization or improvement has been reported in the literature.

What is optic nerve fenestration?

A procedure performed by ophthalmologists in which small openings are made in the optic nerve sheath to reduce swelling. It may provide short-term benefit but carries risks such as retinal artery occlusion, neuropathy, bleeding, and eye movement disorders.

It is a condition in which the lower end of the spinal cord is abnormally low and tightly attached within the spinal canal. It is usually a congenital developmental variation. It may also be referred to as a thickened filum terminale, fatty filum, or tethered cord.

How is tethered cord syndrome recognized?

In childhood:
• Dark birthmark over the lower back
• Excess hair growth
• Skin dimple
• Nighttime bedwetting

In later years:
• Low back and leg pain
• Weakness and sensory loss
• Bladder–bowel control problems
• Scoliosis may occur.

How is the diagnosis made?

MRI is the gold standard. MRI evaluates:
• A conus medullaris located lower than normal
• Thickened filum terminale or presence of a lipoma

What happens if it is not treated?

Untreated cases may develop:
• Syringomyelia
• Nerve conduction problems
• Permanent motor and sensory deficits

How is tethered cord syndrome treated?

The main treatment is detethering (surgical release of the spinal cord).
Non-surgical approaches are generally supportive and aimed only at symptom relief.

Cerebellar tonsillar herniation is a condition in which the lower part of the cerebellum (the tonsils) descends downward through the opening at the base of the skull. This displacement may disrupt the flow of cerebrospinal fluid (CSF) and cause pressure on the brainstem.

Does cerebellar tonsillar herniation always require treatment?

No. According to the literature, approximately 30–40% of Chiari type I cases are detected incidentally and cause no symptoms. In such individuals, regular clinical and radiological follow-up may be sufficient.

What symptoms may accompany cerebellar tonsillar herniation?

Most common symptoms include:

1. Headache starting at the back of the head/upper neck
2. Neck pain
3. Dizziness and balance problems
4. Weakness in the arms or legs
5. Numbness and tingling
   Symptom severity varies from person to person.

When is surgery required?
Surgery may be considered when:
• Symptoms significantly affect daily life
• Neurological findings due to brainstem compression appear
• MRI shows marked impairment of CSF flow

What helps in cerebellar tonsillar herniation?

Treatment is stepwise:

1. Asymptomatic patients: clinical + MRI follow-up
2. Mild symptoms: pain relievers and supportive treatments
3. Advanced findings: a surgical method called posterior fossa decompression
   The aim of surgery is to reduce pressure on the brainstem and improve CSF circulation.

Can cerebellar tonsillar herniation improve?

The primary goal of surgery is to stop symptom progression and eliminate life-threatening compression. Studies report:
• Significant headache reduction in about 60–70% of patients
• No change in symptoms in some patients
• Symptoms generally do not worsen
As with any surgery, there is a low but present risk of neurological complications.

Can associated conditions improve after Chiari surgery?

Yes. In some patients with Chiari malformation and associated:
• Syringomyelia
• Hydrocephalus
• Mild scoliosis, improvement has been reported after decompression without the need for additional procedures.

Question: What is empty sella, and is it common?

Answer: Empty sella is defined by CSF filling the sella region on imaging with a flattened appearance of the pituitary gland. MRI studies report a wide frequency range of approximately 8–35%.

Practical approach when an empty sella report is received:

1. If symptoms are present (headache, visual complaints, hormonal signs): physician evaluation
2. Endocrine tests if needed
3. Decision on follow-up or treatment based on clinical findings plus test results

What does “Empty Sella is present” mean?

Empty sella refers to a condition in which the sella turcica—the bony cavity that contains the pituitary gland—appears partially or completely filled with cerebrospinal fluid (CSF). The pituitary gland itself usually appears flattened or reduced in size.

Is Empty Sella Syndrome dangerous?

In most cases it does not pose an immediate danger; however, it is not considered trivial. When detected, a comprehensive evaluation is recommended, including:
• Hormonal profile
• Fundoscopic (eye fundus) examination
• Advanced MRI assessment
This approach helps with early detection of associated conditions such as pseudotumor cerebri or CSF leak.

What is the treatment for empty sella?

Empty sella alone usually requires supportive follow-up.
• If hormone deficiencies are present, hormone replacement therapy is given.
• If visual risk, CSF rhinorrhea (CSF leakage from the nose), or meningitis risk develops, surgical options may be considered.

Question: Is an “incidental” pituitary mass common?

Answer: Yes. Pituitary incidentalomas (lesions found by chance on imaging done for another reason) are reported in MRI studies at roughly 10%.

Typical evaluation steps when a pituitary lesion is found on MRI:

1. Hormone tests (over- or under-function)
2. Visual assessment (especially visual fields)
3. Follow-up imaging if needed (for size change)
4. Treatment decision: observation / medication / surgery (depending on lesion type and effect)

“In selected cases, endoscopic/transsphenoidal approaches may be evaluated by the physician.”