Spine techniques catalogue

Microsurgery and unilateral micro-approaches

Access to the canal from one side only, under the microscope, to free the nerves while respecting stability.

Through a small approach on a single side, the herniation or stenosis is treated under the microscope. From that same access the opposite side can also be decompressed, without detaching the muscles or removing the structures that keep the segment stable.

It is the basis of most modern decompressive surgery and, when properly indicated, allows patients to be up on the same or the following day.

Endoscopic spine surgery

Removal of herniations through the natural opening where the nerve root exits, using an optic a few millimetres wide.

The intervertebral foramina are the natural exit route of the nerve roots and, at the same time, the best way into the canal without opening it artificially. An endoscope is passed through them to remove the herniation under direct vision.

In most cases it is done under local anaesthesia or sedation, as a day case. Scope-assisted systems also allow small approaches to the thoracic spine that avoid a thoracotomy.

Minimally invasive lumbar fusion (MI-TLIF)

Posterior fusion of a lumbar segment through small incisions with percutaneous screws.

The disc is replaced by an interbody implant through a lateral corridor and the segment is fixed with screws placed percutaneously. Fusion rates match the open technique, with far less muscle damage and a shorter recovery.

I have performed this technique since its beginnings in Spain, and it remains a first-line tool when fusion is genuinely indicated.

ALIF — anterior lumbar interbody fusion

Access to the disc from the front, through the abdomen without opening the peritoneum, leaving the back muscles untouched.

It allows the whole disc to be removed and a large-footprint implant to be placed, restoring disc height and segmental lordosis, which is especially valuable at the lowest lumbar levels.

As the posterior elements are not touched, the structures that provide stability remain intact and there is no scar on the back.

OLIF — oblique lumbar interbody fusion

Anterolateral access through the corridor between the great vessels and the psoas muscle.

It combines advantages of the anterior and lateral routes: a wide implant, restored height and lordosis, and access to several levels, often including L5-S1, from a single incision in the flank.

Because it passes in front of the psoas, it reduces handling of the lumbar plexus that runs through this muscle.

XLIF — lateral lumbar interbody fusion

Access to the disc from the side, through the psoas, with neurophysiological monitoring.

Through a lateral incision an implant is placed that rests on the strongest edges of the vertebra. By restoring disc height it re-tensions the ligaments and widens the canal and foramina without removing bone: this is indirect decompression.

In older patients with degenerative scoliosis it allows powerful corrections with little aggression, even spread over several operations. In its high-correction variant (anterior column realignment) it gives lordosis back to flattened spines.

Cervical disc replacement

Replacing the cervical disc with a mobile implant instead of fusing the segment.

After freeing the spinal cord or nerve root from the front, a prosthesis is placed that keeps the treated level moving. As it does not lock the segment, it reduces the extra load on the neighbouring discs.

It 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.

Lumbar disc replacement

Replacing the degenerated lumbar disc from the front while keeping the segment mobile.

It is implanted through the same anterior approach as ALIF fusion and restores disc height while maintaining movement.

Selection is strict: disc-related pain at one or two levels, healthy facet joints, good bone quality and no associated deformity or instability. Outside that profile it offers no advantage.

Disc-related pain is recognised by how it behaves: it increases with postures that raise the pressure inside the disc, the most characteristic being sitting, because it involves lumbar flexion. 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.

Interspinous devices

Implants between the spinous processes with two specific indications, and among the most misused devices in spine surgery.

They have been used widely outside their indications, as if an implant between the spinous processes were enough to solve any stenosis or instability. Wrongly indicated they fail, and that indiscriminate use is what has given the whole family a bad name.

They have only two correct indications. The first is facet fusion: rigid clamp-type devices that can do the work of pedicle screws, but only in moderate instability and never in severe instability or with advanced osteoporosis, where the anchorage a screw provides is what is needed. And they require bone graft, because without it there is no fusion.

The second is non-pedicle dynamic stabilisation: elastic devices secured with tension bands, such as DIAM or IntraSPINE. They are useful only in minor instability and can never replace screws.

Properly indicated, they work; wrongly indicated, they fail.

Pedicle-based dynamic stabilisation

Pedicle screws joined by a flexible system that controls abnormal movement without fusing the segment, in a completely reversible technique.

It restrains the excessive mobility that causes pain but, unlike a fusion, keeps some movement of the segment. The technique remains current with the Transition system from Globus Medical.

Its most important feature is that it is a completely reversible technique: it does not damage healthy structures such as muscle or the facet joint capsules. If it fails, it can be removed or replaced by any other available technique.

Its results are very interesting, although the published evidence is not yet solid. That is why I reserve it for selected cases, and I explain this before proposing it.

Adult degenerative scoliosis

Correcting the deformity caused by wear of the lumbar discs and vertebrae.

Wear first flattens the natural lumbar curve and then tilts and shifts the vertebrae. It is often associated with spinal stenosis, but the underlying problem is usually loss of sagittal balance: correcting the sideways tilt alone is not enough.

As these are usually older patients, I favour low-aggression strategies (lateral and oblique routes, percutaneous fixation) and, when appropriate, staged corrections over more than one operation.

Kyphosis and sagittal imbalance: osteotomies

Restoring the curve of the back when it has flattened or reversed, through degeneration or after previous surgery.

Once the pelvis and thoracic spine can no longer compensate, the trunk leans forward and standing upright demands constant effort. In post-surgical flat back and rigid kyphosis, the solution involves osteotomies: removing one or more wedges of bone and fixing the spine again in the correct position.

This is major surgery. Prior study, planning both the degrees of correction and of compensation, is what makes it safe and precise.

Adolescent idiopathic scoliosis

Three-dimensional correction of the curve with pedicle screws and neurological monitoring.

Most adolescent scoliosis is treated without surgery, with exercise and bracing. When the curve is severe or progressing, posterior instrumentation with pedicle screws allows the three planes of the deformity to be corrected vertebra by vertebra.

The whole operation is carried out with continuous neurophysiological monitoring of the spinal cord.

ApiFix MID-C — non-fusion correction in adolescents

A progressive-correction implant that adjusts with the patient's own movement and does not fuse the spine. Its indications are very limited.

The ApiFix MID-C system, now from OrthoPediatrics, is anchored at a few points on the concave side of the curve through small incisions. A ratchet mechanism lengthens with the patient's bending movements and holds the correction gained, preserving spinal mobility.

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.

Spondylolisthesis: single-segment reduction

Realigning the slipped vertebra while fixing only the affected segment.

In isthmic spondylolisthesis, a break in the pars lets the vertebra slide forward. Not all cases need surgery; when there is poorly controlled pain or nerve root compression, I favour reduction with a cantilever manoeuvre on a single fulcrum plus an interbody implant, without fixing a second healthy segment, and it can be done minimally invasively.

In degenerative spondylolisthesis fusion is not mandatory: it depends on the stenosis, foraminal narrowing and the intensity of the back pain.

Software planning, navigation and augmented reality

The correction is simulated before surgery and carried out with intraoperative guidance.

Planning software measures the spinopelvic parameters and simulates how much correction each segment needs. In theatre, navigation and augmented reality guide implant placement with precision.

These are tools serving surgical judgement, not a substitute for it: technology helps carry out the plan, but the plan comes from experience.

Lumbopelvic retraining

The first step: exercise aimed at stability, before considering any surgery.

Strengthening the glutes, abdominals and lumbar muscles stabilises abnormal movement and indirectly tightens the ligaments of the canal, which in mild or moderate stenosis may be enough to control symptoms.

It is worth being clear about the goal, because it is the opposite of what most people assume: what we are after here is stability, not mobility. When the problem stems from instability, gaining range of motion is precisely what is not needed. Stretching routines and flexibility work mobilise still further a segment that already moves too much, which is why a badly aimed programme can make things worse rather than better. The work is about holding, not loosening.

That is also why not any programme will do. It has to be supervised, progressive and sustained: 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 course of exercises with a discharge at the end, it is a change that is kept up.

Indirect decompression

Widening the canal without removing the structures that narrow it.

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

It is especially useful when stenosis comes with disc collapse, deformity or instability.

Canal recalibration and micro-foraminotomies

Selective direct decompression that frees the nerves while respecting laminae, joints and ligaments.

The canal and lateral recesses are recalibrated by removing only the compressing tissue — thickened ligamentum flavum, part of the enlarged joint — and the necessary foramina are widened, keeping the elements that provide stability.

In many cases it avoids a wide laminectomy and, with it, the need for fusion.

Laminectomy with or without fusion

Removal of the posterior arch when compression is extensive and a more conservative technique is not possible.

It is the classic, highly effective technique, but it removes structures that provide stability, so I now reserve it for cases where it is unavoidable.

When it compromises the stability of the segment, it is combined with fusion using implants and bone graft.

Cervical laminoplasty

The posterior arch is repositioned to give the spinal cord room without removing it.

In multilevel cervical stenosis, the posterior arch is opened like a door and fixed a few millimetres away from the spinal cord. It is as effective as laminectomy and far less destabilising.

Vertebroplasty

Injection of cement into the fractured vertebra through a needle.

The cement supports the vertebral body as soon as it sets and the fracture pain settles quickly. It is done percutaneously under X-ray control, which is what minimises the risk of cement leakage.

Timing is what matters. In the long term the outcome may match conservative treatment, but when performed early the saving in time spent in pain and with restricted mobility is dramatic: the sooner, the better. Case selection still matters, and it generally does not correct the collapse.

Kyphoplasty

A balloon expands the collapsed vertebra before it is filled with cement.

As well as supporting the vertebra, it aims to recover part of the lost height and reduce wedging, which makes sense when the fracture contributes to the deformity of the back.

As with vertebroplasty, doing it early dramatically shortens the time spent in pain and with restricted mobility. It also only expands the vertebra in recent fractures; in older ones it offers no advantage over vertebroplasty.

Osteoporotic fractures: tailored treatment

From bracing and pain relief to surgical stabilisation, depending on the fracture and the patient.

Small collapses that do not deform the back can be treated with a brace and pain relief. In the long term the outcome may be similar, but at the cost of a period of pain and restricted mobility that older people tolerate poorly; that is why, when the fracture allows it, I propose cement early.

If there is instability, the solution combines percutaneous techniques with fixation. And in every case the underlying osteoporosis must be treated: exercise remains the best prevention.

Failed back surgery syndrome

Pain that persists after surgery; now termed persistent spinal pain syndrome.

After repeated insults — herniations, stenosis, operations, scarring — the nervous system itself may generate the pain signal even though there is no longer a mechanical cause. That is why standard painkillers help little.

The first step is a complete work-up to rule out a correctable problem. If there is none, treatment combines neuromodulating drugs and, when these are not enough, spinal cord stimulation.

Revision surgery

Restructuring a previous operation that has not solved the problem or has created a new one.

Non-union, misplaced implants, degeneration of the neighbouring segment or a back that has lost its curve after a fusion are mechanical problems that can be corrected surgically.

These are demanding cases, where experience weighs more than any technology. They are planned with the same balance study as a deformity and, whenever possible, through routes that avoid crossing the previous scar again.

Percutaneous sacroiliac fixation (iFuse)

Stabilisation of the sacroiliac joint with implants inserted through a small incision in the buttock.

Before operating, it must be confirmed that the pain really comes from the joint, with a specific examination and diagnostic blocks.

Once the source is confirmed, implants are placed across the joint to stabilise it and promote fusion, in a short operation with a quick recovery.

Spinal cord stimulation

An electrode over the spinal cord blocks the transmission of chronic pain.

It is implanted in two stages. First the electrode is placed, under partial anaesthesia, and connected to an external generator for a trial period of one to two weeks. Only if pain is significantly reduced is the permanent generator implanted under the skin, like a pacemaker, controlled by the patient with a remote.

The trial stage makes it possible to confirm the benefit before committing to the implant.

Facet and intradiscal radiofrequency

A probe inserted through a needle acts on the nerves of the facet joints or on the disc itself, without open surgery.

Radiofrequency is applied at two levels. In the facet joints (rhizolysis) it interrupts the small nerve branches that carry joint pain. Inside the disc (nucleoplasty) it reduces the volume of the nucleus and relieves pressure on the nerve root. It is a day-case procedure.

There are no studies with sufficient statistical evidence, but the results are reasonable and consistent, and in my experience very good, with practically no risk and at low cost. As good practice, a prior diagnostic block helps confirm where the pain comes from.

Spinal tumours

Treatment of lesions that occupy the canal or destroy the vertebra.

Microsurgical approaches to the canal allow removal of lesions compressing the spinal cord or nerve roots, and stabilisation rebuilds the spine when the tumour weakens it.

The goal is set together with oncology: relieve compression, stabilise, and preserve neurological function and quality of life.

Percutaneous fracture fixation

Screws inserted through the skin that stabilise the fracture without opening the back.

In traumatic or pathological vertebral fractures, percutaneous fixation stabilises the segment with minimal blood loss and muscle damage, allowing early mobilisation.

It can be combined with cement injection into the fractured vertebra when the bone is fragile.