Frequently asked questions about spine surgery

Not necessarily. From the approach on one side it is possible to work underneath the midline structures and decompress the opposite side as well. The nerve is freed on both sides through a single point of entry, without detaching the muscles on the other side.

This is not fixation surgery. The aim is to remove whatever is compressing the nerve while preserving the structures that keep the segment stable, which is precisely why no screws are needed. If your case also involved underlying instability, that changes the indication and we would discuss it before deciding anything.

No, they are two different routes. In a micro-approach the work is done under the microscope through a small opening; in endoscopy a few-millimetre optic is passed through the natural exit hole of the nerve root. Each has its ground: the micro-approach also treats central and lateral recess stenosis and frees both sides from a single entry.

Properly indicated, this surgery allows patients to be up the same day or the following one, because the back muscles have not been stripped away. What happens afterwards depends on what is found inside and on the state of your spine beforehand, so I do not give fixed timescales: we agree them with your progress in front of us.

The scar is the least of it. Minimal invasion is not a smaller incision: it is solving the problem with the same guarantees while harming as little healthy muscle, ligament and bone as possible. Here we enter through the foramen, the opening the nerve root already uses, so the canal does not have to be opened artificially. If a smaller incision worsened the outcome, it would not be less invasive, only more cosmetic.

In most cases that is not needed: it is done under local anaesthesia or sedation, as a day case. The final decision is taken with the anaesthetist and with you, depending on the level to be treated, the type of herniation and your general situation.

No, and it is worth knowing that before asking for it by name. Its clearest ground is foraminal and extraforaminal lumbar herniations — those at the exit of the root or just outside it — and foraminal stenosis. Herniations inside the canal can also be treated, but only in selected cases. If yours does not fit, there are other routes equally respectful of stability.

Scope-assisted systems allow small approaches to the thoracic spine that avoid a thoracotomy, that is, opening the chest. It is a specific field and is assessed case by case; it is not the answer for every thoracic lesion.

Replacing the worn disc with an interbody implant and fixing the two vertebrae with screws so that, over time, they knit into a single unit. It is considered when the problem is not only that something is compressing the nerve, but that the segment is moving abnormally.

Fusion rates match those of the open technique, but with far less muscle damage and a shorter recovery: the implant goes in through a lateral corridor and the screws are placed percutaneously, without stripping the muscles off the whole spine.

The fused level stops moving, and that is exactly the aim when abnormal movement is what hurts. That is why fusion only makes sense when it is genuinely indicated: if the case allows movement to be preserved, there are other options — disc replacement, dynamic stabilisation — and they are considered first.

In spondylolisthesis, segmental instability and foraminal stenosis that requires fusion. A herniation or a stenosis without instability is dealt with by decompressing and preserving the stabilising structures, without fixing anything.

Yes: the disc is reached from the front without opening the peritoneum, the sac that wraps the bowel, working in the plane that lies in front of it. The back is not touched at any point, so no scar is left on it.

Because from the front the whole disc can be removed and a large-footprint implant placed, restoring disc height and the lordosis of the segment, which is especially valuable at the lowest levels, L4-L5 and L5-S1. And as the posterior elements are not touched, the structures that provide stability stay intact.

Lordosis is the natural inward curve of the lower back, and it is what allows the head to line up over the pelvis so that standing upright costs no effort. When a disc collapses, that segment loses curve; giving it back is not a cosmetic detail, it is what keeps the whole column balanced.

The prosthesis is implanted through this same anterior approach, but instead of fusing the segment it keeps it moving. Its conditions are far stricter — healthy facet joints, good bone quality, no deformity or instability — so the two are not interchangeable: the choice follows what the spine allows.

Through the flank, along a corridor between the great vessels and the psoas, the muscle that flexes the hip and through which the lumbar plexus runs. By passing in front of the psoas rather than through it, handling of that nerve plexus is reduced.

Not necessarily: from a single incision in the flank, several levels can be reached, often including L5-S1. How many are treated, and in how many sittings, depends on your case and is decided during planning, not on the day.

That is the basis of indirect decompression: restoring disc height reduces the disc bulge and re-tensions the ligaments, so the canal and foramina gain calibre without removing bone. Not every stenosis responds this way; when the narrowing is caused by bone or by thickened ligament, it has to be released directly.

In the route to the disc. XLIF passes through the psoas, which is why it is done with neurophysiological monitoring; OLIF passes in front of that muscle. The goals are similar — a wide implant, height and lordosis — and what decides is each patient's anatomy and the levels to be treated.

That is why this technique is always performed with neurophysiological monitoring: the response of the nerve roots is watched continuously while the working corridor is opened, which is how they are located and respected. It does not remove the risk, it controls it, and that is part of the conversation beforehand.

By placing an implant that rests on the strongest edges of the vertebra and restores disc height. As height is regained the ligaments are re-tensioned and the canal and foramina widen by themselves: this is what is called indirect decompression.

That is precisely the profile in which I lean on this route: in older patients with degenerative scoliosis it allows powerful corrections with little aggression, and it can be spread over several operations when doing everything at once would be too much. Whether it is possible depends on your general condition and on the pre-operative study, not only on the X-ray.

It is the high-correction variant of this technique: it can give lordosis back to spines that have flattened, working from the front on the disc itself instead of removing wedges of bone from behind. It is reserved for cases in which loss of curve is the main problem.

That the treated level keeps moving. By not locking it, the extra load that a fusion passes on to the neighbouring discs is reduced. That is the point of a prosthesis, but it only holds up if the condition of the spine is right.

Disc replacement is an established option in patients whose discs are not too degenerated and whose facet joints are healthy. When those conditions are not met, fusion remains the best answer, and I say so plainly: putting a prosthesis into a spine that cannot take one is not preserving movement, it is adding a problem.

Radiculopathy is a problem of a nerve root, the nerve that leaves the spine towards the arm. Myelopathy is a problem of the spinal cord itself. They are two different conditions, and which of the two you have changes both the assessment and the urgency of the decision.

The indications for this technique are cervical disc herniation with radiculopathy and myelopathy from a soft disc at one or two levels. When more levels are involved and the cause is stenosis, the approach is different: options such as cervical laminoplasty come in there.

By how it behaves. Disc-related pain increases with postures that raise the pressure inside the disc, and the most characteristic is sitting, because it involves lumbar flexion: this is the patient who is worse in the car or in a chair than walking. And there is a negative finding that helps just as much: it does not usually respond to treatments aimed at the posterior joint complex, such as facet rhizolysis. If the pain settles with a rhizolysis, it was not discogenic.

Because outside its profile it offers no advantage. It requires disc-related pain at one or two levels, healthy facet joints, good bone quality and no deformity or instability. When those are not met, I would rather say so before operating than implant something that will not help.

No, from the front: it is implanted through the same anterior approach used for ALIF fusion. The back muscles are not touched.

Both restore disc height, but fusion locks the segment and the prosthesis keeps it moving. The choice is not a matter of preference: it depends on whether the facet joints, the bone and the stability allow that movement to be preserved.

It depends what for. These are among the most misused devices in spine surgery: they have been fitted widely outside their indications, as if an implant between the spinous processes were enough to solve any stenosis or instability. Properly indicated they work; wrongly indicated they fail. Before agreeing, ask which of their two correct indications is yours.

The first is facet fusion: rigid clamp-type devices that, in moderate instability, can do the work of pedicle screws. The second is non-pedicle dynamic stabilisation: elastic devices secured with tension bands, such as DIAM or IntraSPINE, useful only in minor instability. Beyond that, no.

It depends on the device and, above all, on how severe the case is. The rigid clamp-type device can replace them in facet fusion, but only in moderate instability and always with bone graft: without graft there is no fusion, however many implants are fitted. In severe instability, or where there is advanced osteoporosis, it does not replace them: there you need the anchorage a screw gives, and fitting a clamp instead is a mistake. The elastic devices never replace screws.

The bad name comes from indiscriminate use, not from the device. An implant that fails where it should never have been placed does not prove that the whole family is useless; it proves the indication was wrong. Properly indicated they have their place, and it is exactly those two.

In that the aim is not to knit the vertebrae together. The pedicle screws are joined by a flexible system that restrains the excessive mobility causing pain, but the segment keeps some movement instead of being locked.

Yes, and that is its most important feature: it is a completely reversible technique. It does not damage healthy structures such as muscle or the facet joint capsules, so if it does not meet its goal it can be removed or replaced by any other available technique. It closes no doors.

The results are very interesting, but the published evidence is not yet solid, and I tell this to everyone who considers the technique before I propose it. That is why I reserve it for selected cases: the decision is taken knowing exactly what ground we are on.

It remains current, today with the Transition system from Globus Medical. What has changed is not the concept but the judgement applied: it is no longer offered widely, but in chosen cases and after explaining its limits.

No. This curve does not come from adolescence, it is produced by wear: first the natural lumbar curve flattens and then the vertebrae tilt and shift. The origin is different and so is the treatment.

Usually not. A curved spine may not hurt if it is balanced; what causes fatigue and pain is the head no longer lining up over the pelvis. The underlying problem is usually that loss of sagittal balance — the one seen from the side — so correcting the sideways tilt alone falls short.

That is a reasonable worry and it shapes the strategy. As these are usually older patients, I favour low-aggression options — lateral and oblique routes, percutaneous fixation — and, when appropriate, I spread the correction over more than one operation rather than proposing a single long procedure.

They often come together, and frequently the correction itself resolves part of the compression: by restoring disc height through a lateral or oblique route, the canal and foramina gain calibre without removing bone. How much can be solved that way depends on where the narrowing is.

Because standing upright has stopped being free. While the pelvis and the thoracic spine can compensate, the body hides the loss of curve; once that capacity is exhausted, the trunk leans forward and staying upright demands continuous muscular effort. That fatigue is a symptom, not a lack of fitness.

Removing one or more wedges of bone from the vertebra and fixing the spine again in the correct position. It is what makes it possible to recover the curve when the spine is already rigid and cannot be corrected simply by mobilising it.

Yes, it is major surgery and there is no point presenting it otherwise. What makes it safe and precise is the work done beforehand: the study that plans the degrees of correction and of compensation each segment needs. Without that study we do not go into theatre.

That is what we call post-surgical flat back, and it is one of the indications for this technique: the spine lost its curve after the fusion and the trunk no longer sits over the pelvis. It is a mechanical problem, and mechanical problems can be corrected.

Most probably not. Most adolescent scoliosis is treated without surgery, with exercise and bracing. Surgery is considered when the curve is severe or when it is progressing, not because it exists.

Posterior instrumentation with pedicle screws that corrects the three planes of the deformity vertebra by vertebra: not only the curve seen from the front, but also the tilt and the rotation of the vertebrae, which is what produces the deformity of the trunk.

It is the question every parent asks, and the honest answer is that this is why the whole operation is carried out with continuous neurophysiological monitoring of the spinal cord: its function is watched in real time throughout the surgery, not checked at the end.

There is, the ApiFix MID-C system, but its indications are very limited: a single, flexible curve of moderate size that corrects well when bending sideways. Most adolescent scoliosis does not fit that profile, and in those cases it is not an alternative to conventional instrumentation.

The implant is anchored at a few points on the concave side of the curve through small incisions, and no segments are fixed to one another. A ratchet mechanism lengthens with the patient's own bending movements and holds the correction as it is gained.

Only if it fits a very narrow profile: a single, flexible curve of moderate size that corrects well when bending sideways. Most adolescent scoliosis does not, and in those cases it is not an alternative to conventional instrumentation. This is a technique with a narrow indication, not a gentler version of the usual surgery.

Yes, that is its whole point compared with a fusion: as no segments are locked, spinal mobility is preserved. But it is a real advantage only when the curve fits the profile; stretching the indication in order to keep movement does not pay off.

The correction advances with the patient's own movement: the mechanism lengthens as the trunk bends and holds what has been gained. It does not depend on repeated adjustments in theatre.

That it has lost its alignment with the one below and moved forward. In isthmic spondylolisthesis this happens because the pars has broken — the bridge of bone joining the front of the vertebra to the back — while in the degenerative form the slip comes from wear.

No. Not every case needs surgery. In the isthmic form I consider it when there is poorly controlled pain or compression of the nerve roots. And in the degenerative form fusion is not even mandatory: it depends on the stenosis, the foraminal narrowing and the intensity of the back pain.

Only the affected one, and I am insistent about this. I favour reduction with a cantilever manoeuvre over a single fulcrum, together with an interbody implant, without dragging a healthy second segment into the fixation. It can also be done minimally invasively.

It can be reduced, that is, repositioned, and that is what I favour when surgery is indicated: recovering the position and fixing it there, rather than simply consolidating the slip.

Software measures the spinopelvic parameters — the relationship between the pelvis and the curves of the spine — and simulates how much correction each segment needs. In other words, the operation is first performed on screen and the numbers are checked before going into theatre.

No. They guide implant placement with precision while I operate, but they are tools serving surgical judgement, not a substitute for it. Technology helps carry out the plan; the plan comes from experience.

I do not present it that way, and you should be wary of anyone who does. It serves to carry out precisely a plan that must have been made well beforehand; if the indication or the planning are wrong, precision only executes the mistake more accurately.

It has to be targeted and with a specific goal: building up the glutes, the abdominals and the lumbar muscles. It is not about moving more in general, it is about working the groups that stabilise the pelvis and the lower back.

It does not widen the canal, it acts on what happens inside it. Strengthening those muscles stabilises the abnormal movement of the segment and indirectly tightens the ligaments of the canal, and in mild or moderate stenosis that may be enough to control the symptoms.

Generally no, and if the problem stems from instability it may be the opposite of what you need. That segment already moves more than it should: stretching routines and flexibility work give it still more range. What we are after here is stability, not mobility; the work is about holding, not loosening. It is the most common misunderstanding, and the one that makes a well-meant programme make things worse.

For as long as you want the benefit. The muscles that stabilise the pelvis and the lower back are built over months, not weeks, and they stop holding as soon as the work is dropped. This is not a treatment with a discharge at the end, it is a change that is kept up.

Then we move to the next step, which is graded according to the region affected, the severity and whether there is back pain or instability. Having started here is not wasted time: it is what shows which part of the problem cannot be solved without touching the spine.

By restoring the height of the disc through a lateral or oblique route. As height is regained, the disc bulge is reduced and the ligaments are re-tensioned, so the canal and the foramina gain calibre without touching the back of the spine.

Yes. The height does not hold by itself: it is regained by replacing the disc with an implant introduced from the flank — this is what the XLIF and OLIF techniques do — and that implant is what keeps the segment at its new height.

It is especially useful when the stenosis comes with disc collapse, deformity or instability, because then a single manoeuvre solves several things at once: height, curve and the calibre of the canal.

Then regaining height is not enough and it has to be released directly, removing only the compressing tissue — thickened ligamentum flavum, part of the enlarged joint. That is canal recalibration, and it also preserves the elements that provide stability.

Only the compressing tissue: the thickened ligamentum flavum and the part of the enlarged joint blocking the nerve's path, plus widening whichever foramina need it. The laminae, the joints and the ligaments that provide stability are preserved.

That is precisely why the work is done this way. By preserving the stabilising elements instead of removing the posterior arch, in many cases a wide laminectomy is avoided and, with it, the need to fuse. Whether that is possible depends on where and how much has to be released.

It is the typical picture of lumbar stenosis: after walking for a while, the legs force you to stop. It is not a circulation problem nor a matter of being out of practice, it is the sign that the canal has become too narrow for the nerves running through it.

No. A laminectomy removes the whole posterior arch; recalibration removes only what compresses and leaves the structure standing. Laminectomy is still necessary when compression is so extensive that no more conservative technique will do.

The posterior arch, the piece of bone that closes the canal at the back. It is the classic technique and it is highly effective at freeing the nerve, but it removes structures that give the segment stability.

Because many cases of stenosis can be solved by removing only what compresses — recalibration and micro-foraminotomies — or by widening the canal indirectly. If the same result can be achieved while preserving structure, there is no reason to take it away. Laminectomy is left for cases where it is unavoidable.

It is not automatic. A fusion with implants and bone graft is added when the removal compromises the stability of the segment. How much has to be taken away, and therefore whether fusion is needed, is part of the planning and is discussed beforehand.

In multilevel cervical stenosis there is an alternative that avoids removing the arch: laminoplasty, in which the arch is repositioned and fixed to give the spinal cord room instead of being taken out.

No. The posterior arch is opened like a door and fixed a few millimetres away from the spinal cord, so room is gained while the bone stays in place.

No: it achieves the same decompression of the spinal cord as laminectomy and is far less destabilising, precisely because the arch is not removed. That is the reason for choosing it when several levels are affected and the cervical curve is preserved.

Its indication is cervical myelopathy — suffering of the spinal cord itself — caused by multilevel stenosis, with one condition: that the cervical curve is preserved. If the neck has lost its curve, the approach changes and has to be assessed differently.

By supporting the vertebral body from the moment it sets: the fractured vertebra stops moving with every gesture and the fracture pain settles quickly. It is injected through a needle, percutaneously and under X-ray control.

Cement leakage is the risk to watch for, and X-ray control throughout the injection is exactly what minimises it. This is not a procedure without risk, it is a procedure done while watching.

It is true that in the long term the outcome may match conservative treatment. The difference is time: performed early, the saving in time spent in pain and with restricted mobility is dramatic. The sooner the better — and case selection still matters, because not every fracture is suitable.

It generally does not correct the collapse: its aim is to give support and take the pain away, not to restore the shape of the vertebra. When recovering height and reducing wedging is what matters, the option considered is kyphoplasty, and only in recent fractures.

The balloon expands the collapsed vertebra before it is filled, aiming to recover part of the lost height and reduce the wedging. It makes sense when the fracture is contributing to the deformity of the back, not only when it hurts.

When the fracture is recent and the wedging is significant. It only manages to expand the vertebra in recent fractures; in older ones it offers no advantage over vertebroplasty, and then there is no reason to complicate the procedure.

This is not a decision to leave sitting. Doing it early dramatically shortens the time spent in pain and with restricted mobility, and the balloon only expands the vertebra while the fracture is recent: waiting can rule out the very part of the technique that justifies it.

Probably not. Small collapses that do not deform the back can be treated with a brace and pain relief, or with cement if the goal is to shorten the time in pain. The balloon is justified by the wedging, and without wedging it adds nothing.

No. Small collapses that do not deform the back can be treated with a brace and pain relief. The decision depends on the fracture and, above all, on the person who has it.

Because of the time spent getting there. In the long term the outcome may be similar, but conservative treatment achieves it at the cost of a period of pain and restricted mobility that older people tolerate poorly. When the fracture allows it, that is why I propose cement early.

Then cement alone is not enough and the solution combines percutaneous techniques with fixation. It is a different situation and it is planned as such.

Treating the fracture does not treat the osteoporosis. In every case the underlying bone has to be dealt with, and there exercise remains the best prevention. It is the part most often neglected and the one that pays off most in the long run.

The name is old and misleading; that is why it is now called persistent spinal pain syndrome. It describes pain that continues after surgery, and the first task is to find out why: after repeated insults — herniations, stenosis, operations, scarring — the nervous system itself may be generating the pain signal even though there is no longer a mechanical cause.

Because it is not the same kind of pain. When the signal is sustained by the nervous system itself rather than by damage that can be corrected, standard painkillers help little. Treatment then relies on neuromodulating drugs, which act on that transmission.

It depends, and that is exactly what has to be established before touching anything. The first step is a complete work-up to rule out a correctable problem: a non-union, a misplaced implant, a degenerated neighbouring segment or a back that has lost its curve. Those can be corrected surgically. If there is none, further surgery is not the answer.

Neuromodulating drugs and, when they are not enough, spinal cord stimulation. It also has an advantage when it comes to deciding: it is implanted in two stages, with a trial period before anything permanent is placed.

The mechanical ones: a non-union — a fusion that never knitted — misplaced implants, degeneration of the neighbouring segment, or a back that has lost its curve after a fusion. All of these can be corrected surgically.

Whenever possible, no. Routes are planned that avoid crossing the previous scar again, because tissue that has already been operated on does not behave the same way. Whether that is possible depends on where the problem to be corrected lies.

The same balance study used for a deformity: it is not enough to look at the operated level, you have to see how the whole spine sits over the pelvis. Many failures only make sense when the whole picture is looked at.

Then it is not a revision case, and operating will not improve it. That is the territory of persistent spinal pain syndrome, where the answer lies in neuromodulating drugs and, if they are not enough, in spinal cord stimulation. Telling one from the other is the most important part of the assessment.

It is not assumed: before operating it has to be confirmed, with a specific examination and with diagnostic blocks, which serve to check whether the pain really comes from that joint. Without that confirmation there is no point in proposing fixation.

Because it hurts low in the back, an area that almost everyone — patients and doctors alike — puts down to the disc straight away. It is a cause of low back pain that often goes unnoticed, which is why it is worth thinking of when the disc does not explain what is happening.

Implants are placed across the joint through a small incision in the buttock, to stabilise it and promote its fusion. It is a short operation with a quick recovery.

That is one of the situations in which this joint comes onto the list: sacroiliac pain after lumbosacral fusions is a recognised indication. But the order does not change: first confirm the source, then decide.

It does not act on the cause, it acts on the message: placed over the spinal cord, it interferes with the transmission of the pain signal to the brain. That is why it is an option once there is no structural cause left to correct.

That is what the trial stage is for, and it is the best feature of this technique. First the electrode is placed, under partial anaesthesia, and connected to an external generator for one to two weeks. Only if the pain is significantly reduced is the permanent generator implanted.

If you get through the trial stage, yes: the permanent generator is implanted under the skin, like a pacemaker, and you control it yourself with a remote.

For failed back surgery syndrome with radicular pain, and for chronic neuropathic pain that does not respond to medication. In other words, it is reached after a correctable mechanical problem has been ruled out, not before.

It is radiofrequency applied to the facet joints, the small joints that link the vertebrae at the back: the probe interrupts the nerve branches that carry pain from that joint. It is done with a needle, as a day case.

It is the same technology applied inside the disc: it reduces the volume of the nucleus and so relieves pressure on the nerve root. Its indication is specific, a small contained disc herniation.

I will give you the facts as they are: there are no studies with sufficient statistical evidence. The results are reasonable and consistent, and in my experience very good, with practically no risk and at low cost. With that in front of you, the decision is yours.

As good practice, a prior diagnostic block, which helps confirm where the pain is coming from before treating it. Treating a joint that is not the one hurting does not fail because of the technique, it fails because of the diagnosis.

Microsurgical approaches to the canal allow removal of lesions compressing the spinal cord or the nerve roots. What can be removed, and what should be, depends on the type of lesion, and it is not a decision taken alone: it is set together with oncology.

To relieve the compression, stabilise the spine and preserve neurological function and quality of life. The aim is not always to cure the tumour, and saying so clearly from the outset is part of the treatment.

Because a tumour that destroys or weakens the vertebra leaves the spine unable to hold itself up. Stabilisation rebuilds that structure; without it, freeing the spinal cord may not be enough.

No, it is one piece within it. The surgical aim is set together with oncology and adjusted to what the tumour treatment needs at each stage.

Through the skin, via small incisions, without stripping the muscles off the spine to reach the bone. In terms of stabilisation the result is that of a fixation, but without the damage of an open approach.

Minimal blood loss and minimal muscle damage, which allows early mobilisation. With a fracture, being able to move soon is not a comfort detail: it is much of the treatment.

It is a fair concern in osteoporotic bone, and that is why the fixation can be combined with cement injection into the fractured vertebra. It is assessed before operating, not during.

Unstable vertebral fractures, pathological ones — those occurring in bone already weakened by disease — and osteoporotic bone when there is instability. A stable fracture without deformity does not need screws.