Regarding biomechanics, the spine is highly complex.

Apart from some wear and tear, for most people, few things go wrong with the spine if we take good care of it by simply moving more, and sitting less.

Although many of us feel our spine may be weak, pain in neck or back is usually from the muscles and joints. If the pain generators are not within the spinal column itself, spinal surgery is unlikely to reduce the pain, unless there is a specific fixable problem.

The following conditions routinely require spinal surgery, depending on the severity of the presenting condition, and responses to non-surgical treatments (medications, radiation, external bracing, physiotherapy, pain injections etc).

• Spine injury – fractures
• Spinal or paraspinous infections
• Spinal cancer, spinal cord tumors
• Spinal cord compression (e.g. from degenerative stenosis or spinal deformity)
• Nerve compression from degenerative spondylosis or disc herniations
• Unstable spine e.g. spondylolysis or traumatic spinal fracture-dislocation

Check out our non exhaustive list of spine diagnoses that may require neurosurgery.

During neurosurgery training there was a senior colleague who would frequently quote the proverbial “surgeons know how to operate, good surgeons know when to operate, the best surgeons know when not to operate”.

This is often true for spinal conditions, because abnormal findings are common with advanced age. When there is no meaningful indication for surgery, “minimally invasive” suddenly becomes “maximally invasive”. The least invasive approach for most musculoskeletal conditions is to find the problem, allow things to heal up naturally, and only use precision spinal surgery if it gets you better faster.

For issues that involve nerves or structural abnormalities, a swift and thorough diagnostic workup should be completed expeditiously, to identify potentially serious problems that may require immediate attention (infection, cancer, biomechanical instability, impending nerve damage).

Access route and surgical corridors for spinal surgery depend on the location of the issue.

The majority of spine lesions can be approached from the back, which may require removal of bone overlying the nerves and spinal cord (laminectomy).

Cervical spine problems (disc degeneration, fractures, deformities or infections compressing the spinal cord in the neck) routinely require an approach through the front below the chin.

Thoracic and lumbosacral spinal disease may require access through the abdomen or chest.

Endoscopic (camera based) tools are essential for work in the chest cavity, e.g. for cancer work or for nerve lesioning to resolve excessive sweating of the hands (palmar hyperhidrosis). 

Robotic assistants and 3D guidance have been getting better since I first trained on them some 15 years ago. They add precision, but one cannot rely on them quite yet. Greatest advantage of robotic and 3D guidance tools is speed and smaller incisions.

Instrumentation and fusion (screws and rods) stabilizes the spine in cases involving cancer, spinal deformity, or traumatic fracture-dislocations (unstable spine).  For those conditions, technology is a blessing.

For the great majority of degenerative spine problems we see in our Silicon Valley communities, spinal stabilization/fusion is unnecessary. Meticulous surgical technique avoids the need for screws and rods. Data shows that even when done minimally invasive, instrumented fusion permanently alters a person’s spinal biomechanics and often contributes to chronic debility later in life.

Click on the spine image below to check out a non-exhaustive list of conditions that may require spine surgery.