English
العربية
Endoscopic spine surgery is a surgical technique for relieving pressure on a nerve in the spine. The surgeon reaches the problem area through a small opening and a narrow channel, using an endoscope with a camera that displays the image on a screen. The surgeon then removes the part that is pressing on the nerve, such as a bulging portion of a disc between the vertebrae.
The sources we relied on address this technique in the lower back (the lumbar region), so this article focuses on it. Most people with lumbar disc problems do not need surgery. Surgery is usually discussed after nonsurgical treatment has not helped, or when there is persistent leg weakness or difficulty walking. Loss of bladder or bowel control needs urgent medical evaluation.
After an examination and imaging, the surgeon decides whether endoscopic surgery is suitable for your case. It is not suitable for everyone. This article explains the types of endoscopic spine surgery, how they differ from open and microscopic surgery, what the evidence says about them, and what you may want to ask your surgeon if you are considering the procedure in Turkey.
Types of Endoscopic Spine Surgery and How They Differ From Open Surgery
The term “endoscopic” is used in everyday speech to describe different techniques. The results of one technique should not be generalized to another. The Cochrane review, for example, grouped several techniques, including percutaneous endoscopic and tubular surgery, under the heading of minimally invasive discectomy. On its own, it therefore does not represent full endoscopic surgery.
Open and microscopic surgery
This is the usual technique for removing disc material. The part pressing on the nerve is removed through an incision, using magnifying loupes or a microscope. This description appears in the Cochrane review and on the American Academy of Orthopaedic Surgeons (AAOS) page. You can read about the conventional operation on our page on discectomy in Turkey.
Tubular surgery
A tube is inserted after the tissues are gradually widened, rather than cutting directly through the muscles, and the surgeon works through it. The surgeon may also use an endoscope or microscope directed down the tube. This is the description given by the American Association of Neurological Surgeons (AANS).
Full endoscopic surgery
This is built around a narrow working channel and an endoscope with a camera. AAOS compares the idea to the arthroscopic approach familiar from knee, hip, and shoulder surgery. Cochrane described two routes: through the opening between the vertebrae from the side (transforaminal) and through the space between the laminae from the back (interlaminar). According to guidance from the National Institute for Health and Care Excellence (NICE) in the UK, the choice of technique can be influenced by the symptoms and by the location and size of the disc.
Conditions Treated With Endoscopic Surgery According to the Sources
AAOS describes endoscopic diskectomy as a newer option for treating a single herniated disc in the lower back. AANS states that discectomy and decompression for stenosis may be performed with the tubular technique using a microscope or endoscope.
We will not repeat the explanation of these conditions here. You can read the details on our pages on herniated disc treatment in Turkey and spinal stenosis treatment in Turkey. Treatment of stenosis may involve removing part of the vertebra to create more room for the nerves. To learn about this operation, see laminectomy surgery in Turkey.
The comparisons presented later in this article concern lumbar disc surgery. We did not rely on comparative studies specific to stenosis in this article.
Who May Be a Candidate, and Who May Not
No single technique suits everyone. AANS states that the physician determines which minimally invasive procedures, if any, may be an option. It adds that in some situations these procedures may not be as safe or effective as traditional open surgery, and that some conditions are not truly treatable with them. AAOS states that endoscopic surgery is not suitable for all types of herniated disc, and that herniations at multiple levels may require an open procedure with a larger incision.
A review of minimally invasive surgery for adult spinal deformity indicates that certain forms of severe deformity are still more appropriately treated with open techniques. This refers to minimally invasive surgery in general, not to full endoscopic surgery alone. For conditions such as spinal instability, tumors, or infection, whether any surgical technique is appropriate depends on the details of the case. The surgeon makes that decision after examination and imaging.
How the Procedure Is Performed
According to NICE, a needle is inserted through the skin along the side route under X-ray guidance, and is then exchanged for a series of dilators to create a working channel. The compressing parts of the disc are then removed with an endoscope and instruments passed through it. AAOS states that water is used during the procedure to improve visualization, and that anesthesia may be general, or local with sedation. Spine 2021 describes transforaminal endoscopy as usually performed under local anesthesia. The surgical and anesthesia teams determine what is appropriate for your case. According to NICE, patients can usually move early after the procedure.
What Does the Evidence Say Compared With Conventional Surgery?
Before reviewing the results, three points will help you read them:
- The type of surgery cannot be hidden from the patient or the surgeon, so blinding is impossible. Patient expectations may therefore affect reported pain and satisfaction, and length of hospital stay.
- The absence of a statistically significant difference between two techniques does not prove that they are equivalent.
- Results vary between studies, and depend on patient selection and surgeon experience.
Pain and function
A systematic review and meta-analysis published in the journal Spine in 2021, with its search ending in April 2020, found moderate-quality evidence of no difference between transforaminal endoscopy and open microscopic surgery in leg pain and function in the medium and long term. Evidence for back pain was low-quality and limited, and the review did not confirm the reduction in back pain that had been expected with endoscopy. The authors noted that all trials were at risk of bias because blinding is impossible.
In a Dutch multicenter randomized trial published in the BMJ in 2022, endoscopy was non-inferior (no less effective) than open surgery in relieving leg pain. Leg pain was relatively lower with endoscopy, with a statistical difference at the end of follow-up. Secondary results (back pain, function, quality of life, and self-reported recovery) leaned in the same direction. But the authors said the differences were small and may not reach clinical relevance. Cases of surgeons still in their learning phase were excluded from the main analysis, and analyses that included them produced similar results. The authors concluded that transforaminal endoscopy can be considered an effective alternative to open surgery.
The Cochrane review, whose search ended in 2013, found low-quality evidence that minimally invasive surgery was associated with slightly worse leg and back pain, with small differences that did not reach the usual thresholds for clinical importance. It found no clear differences in functional disability. Most of its trials were at high risk of bias, and they included techniques different from what is now called full endoscopic surgery. It should not be presented as the latest word.
Early recovery and hospital stay
In the BMJ trial, blood loss was relatively lower, hospital stay was shorter, and mobilization after surgery was earlier with endoscopy. Spine 2021 pointed to a similar direction in most studies, with a caution that satisfaction and length of stay may be affected by patient expectations. Cochrane found that shorter stays appeared in some trials, with inconsistent results. AAOS states that patients usually go home the same day or after a short hospital stay.
Recurrence and repeat surgery
This point is debated.
- NICE guidance (issued in 2016): In the controlled studies, the difference in recurrence and repeat surgery between transforaminal endoscopy and open surgery was not statistically significant, but the median figures were relatively slightly higher with endoscopy. Among the most common causes of repeat surgery listed was leftover disc fragments or lateral bony stenosis that was not addressed.
- Spine 2021: Repeat-surgery rates were low, and the trials that reported them showed no significant difference between groups.
- BMJ trial: Repeat-surgery rates were similar during follow-up. This was a secondary outcome.
- Cochrane: Rehospitalization for recurrent herniation was relatively higher with minimally invasive surgery.
- A meta-analysis in the Journal of Korean Neurosurgical Society in 2020 (search ended October 2018): Recurrence and repeat surgery were relatively higher with transforaminal endoscopy compared with tubular surgery assisted by an endoscope.
- Its authors noted that most studies were observational, that the number of randomized trials was small and follow-up relatively short, that the definition of recurrence was not uniform, and that publication bias is possible.
- In their discussion, they stated that causes of recurrence and repeat surgery after disc surgery in general include leftover disc material, spinal instability before surgery, and a high degree of disc degeneration.
For this reason, careful evaluation with imaging before choosing a technique matters. And the absence of statistical significance does not mean the techniques are equivalent on this point.
Complications
Spine 2021 described the quality of evidence on complications as very low. It reported that complications were comparable, and that they were reported more often with open surgery although they were generally rare. Cochrane reported relatively fewer infections with minimally invasive surgery. We describe the types of risks in a later section.
Limits of the evidence
The comparative evidence is moderate in quality for some outcomes, such as pain and function in the medium and long term, and low or very low for others, such as back pain and complications. Some differences are relatively small and lean toward endoscopy, while some lean relatively toward open or tubular surgery (slightly higher pain in Cochrane, and relatively higher recurrence in the Korean meta-analysis). The trials are unblinded. It is therefore not appropriate to declare one technique superior to another, and the comparison alone should not decide the choice of technique.
Even so, NICE judged in 2016 that the evidence on safety and efficacy was adequate to support the use of transforaminal endoscopy provided there is clinical governance, informed consent, and audit, and noted that the procedure needs particular experience. Note that Cochrane and NICE are older than the other sources.
Surgeon Experience and the Learning Curve
What we read agrees that full endoscopic surgery requires training and experience.
- NICE guidance states that the procedure requires particular experience, training, and mentoring, and should only be done by surgeons who perform it regularly.
- AAOS notes that a surgeon who is new to the technique may have a higher risk of complications and incomplete removal of the disc.
- Spine 2021 described the learning curve as relatively long and difficult. A systematic review on transforaminal endoscopy published in World Neurosurgery in 2020 described it in much the same way.
As for the number of cases needed for proficiency, there is no agreed figure. As Spine 2021 summarized that review, a certain case number was commonly used as a threshold for proficiency, but the evidence was insufficient to support any number. This is consistent with the BMJ trial’s exclusion of learning-curve cases from its main analysis. So ask your surgeon about their experience with your specific condition, not only about an overall number.
Risks and Complications
No surgery is without risk. AAOS lists possible complications including infection, bleeding, nerve damage, and tears of the dura (the membrane surrounding the spinal cord and nerves), and notes that symptoms may not go away or may return after surgery. AANS adds the possibility of a reaction to anesthesia, unexpected blood loss, and localized infection however small the incision.
NICE guidance describes complications reported in the literature for transforaminal endoscopy, most of them transient sensory disturbance. It also lists less common events such as dural tears, infection of the disc and vertebrae, bleeding behind the abdominal lining (retroperitoneal hematoma), and cysts after discectomy. Outcomes vary between patients.
Conversion to Open Surgery During the Operation
A surgeon may start with the endoscope and then find that the operation cannot be completed this way. AANS states that there is a small chance that minimally invasive surgery cannot be completed, requiring either a second procedure or open surgery. In a small comparative study reviewed by NICE, removal of the disc was not completed endoscopically in some patients and open surgery was required. NICE’s summary does not specify whether this occurred during the same procedure or later.
For a traveling patient, this means that conversion, or the need for an additional procedure, may affect:
- The length of hospital stay and time spent in the country.
- Travel plans and the date of return.
- The final cost.
- The expected recovery period.
Discuss this possibility with the surgical team before you travel:
- What would happen if the operation were converted to open surgery?
- Does the patient sign a consent for that in advance?
- How might the stay and cost change?
- How would the situation be managed?
This article does not promise any particular outcome. It points out that this question should be asked early.
Recovery After Surgery
AAOS describes recovery after endoscopic surgery as relatively shorter than after open surgery, and its page is educational material. As we saw, blinding is impossible and patient expectations may affect what is reported. AAOS states that patients usually go home the same day or after a short hospital stay, that activities may be restricted for a period, that physical therapy may be recommended with a gradual return to normal activities, and that follow-up appointments are scheduled. The time frame varies between patients depending on the condition, the job, and the surgeon’s instructions, and the surgeon determines it.
Travelers have special questions: when can I fly? And how will follow-up be handled after I return home? These are questions to put to the team before surgery.
Questions to Ask Your Surgeon Before Deciding
Write these questions down and bring them to the consultation:
- How many endoscopic operations have you performed for a condition similar to mine?
- Why did you choose endoscopic surgery for my case instead of microscopic or tubular surgery?
- Which route do you recommend (transforaminal or interlaminar), and why?
- What happens if the operation cannot be completed endoscopically and is converted to open surgery? How would that affect my stay, cost, and travel plans?
- How are complications managed if they occur, and who is responsible?
- What is the follow-up plan after I return to my country, and who will follow my care there?
- What is the likelihood of my problem returning, and what increases it? (without any promise of a result)
- What does the package include, and what does it not include?
Estimated Cost at O9 Medical
The estimated cost at O9 Medical for this procedure ranges from USD 3,000 to USD 12,000.
This range is wide because the cost varies with the type of procedure, the number of levels treated, the complexity of the case, the length of hospital stay, tests, and physical therapy. The figure is an initial estimate and not a binding offer, and the final price is determined after your case is evaluated. Always ask what the package includes and what it does not include before making a decision.
Having Surgery in Turkey and the Role of O9 Medical
O9 Medical helps patients understand the available options, arrange communication with medical providers, and obtain the information needed to make their decision. This help is not a substitute for a direct medical evaluation, and we do not guarantee any particular outcome or success rate.
When choosing a doctor or center, focus on the questions listed above rather than on marketing promises. You can browse the spine surgery specialty page to learn about the specialty. Make sure you have a clear channel of communication after surgery, and a stated plan for follow-up after you return home.
Medical note: this information is for general education. It does not replace consultation with a specialist doctor and is not a diagnosis or a prescription.