Vice Chairman & Head - Ortho Spine, MIS & Robotic Spine Surgery, BLK-Max Super Speciality Hospital, New Delhi
Part 4 of 10 in Indications for Spine Surgery & Advances for Safer Outcomes
A Case Worked Through by Phone: Decompression or Fusion for a Kenyan Patient
August 27, 2026
During the masterclass Q&A, Dr. Innocent Nzili, a doctor in Kenya connected through the Jivo Healthcare network, presented a real patient case for a live opinion, a format Dr. Puneet Girdhar handles as routinely as an in-person referral.
The case as presented
A 32-year-old male had a diffuse L4-L5 disc bulge compressing both traversing nerve roots, plus a left paracentral L5-S1 disc protrusion narrowing the left lateral recess and producing spinal canal stenosis measured at 9.5 millimeters. He had already been through medication and physiotherapy without relief, and was afraid of surgery.
Splitting the decision on instability
Girdhar's answer branched on a single variable: whether there was instability. Without significant back pain or instability, he recommended decompression alone, either bipartal endoscopy through two ports of 4 to 5 millimeters to 1 centimeter, or an MIS tubular approach through a single 2.5 centimeter incision, adding a discectomy at the same sitting if the disc was large. With significant back pain and a dynamic X-ray showing instability, lysis, or discal collapse alongside the foraminal narrowing, the same patient would instead need a TLIF, a cage and screws to restore disc height and decompress both foramina.
Fear of surgery is a separate problem from the indication
Girdhar's closing view on the case was direct: a patient already exhausted by medication and physiotherapy, still suffering, is in his reading past the point where surgery can reasonably be avoided. The fear is real, but it is a counseling problem to be managed alongside the referral, not a reason to keep cycling through conservative treatment that has already failed.
This guide is based on a live Jivo Masterclass — Dr. Puneet Girdhar taught doctors across Africa on March 15, 2026.
FROM THE LIVE Q&A
Dr. Chiku Abeje (Nigeria)
What were you and your colleagues hoping to take away from this session?
Dr. Puneet Girdhar
Spinal surgery takes most of the surgical case volume in neurosurgery at my center in Nigeria. We were expecting to see the procedures Dr. Girdhar uses and how they aid recovery, not only the traditional open decompression we already practice, but also how he performs minimally invasive spine surgery, since it is still an emerging area for us.
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Frequently Asked Questions
How is minimally invasive surgery actually done, since we currently only perform open surgery at our center?▼
I would request that we spend time together if you are planning to come to India, please come to Delhi to our center. I tried my best, but that is all you can cover in an hour when it represents twenty years of work with a lot of technology behind it. You need to observe more, and that would let you move on to minimally invasive work. It is not difficult, but everything new you start in your practice is a steep curve at first, though very achievable, looking at how many MIS centers exist in the world today.
How should we set up communication so patients from Zambia can reach you with their reports?▼
My availability is never really an issue. I usually reply the same day, before going to bed, to most of the queries I get, and I hear from 30 to 40 people a day from all over the place. We look forward to working together and helping your patients from Zambia, at the very least by providing an opinion.
Closing thought on the session▼
Thank you for a very impressive, interesting presentation.
Closing thought on the session▼
Today it seems we were not leaving any stone unturned, so detailed.
How will the Jivo Connect Clinic work on an ongoing basis?▼
We are regularizing the Connect Clinic for monthly consultations, and this month's slot is March 23. Doctors should identify relevant patients and share their reports by March 21 so Dr. Girdhar's team has time to review them in advance and we can communicate a consultation slot. The referring doctor should be present so the patient gets a joint consultation from both of them.
What two minimally invasive options exist for decompression alone, without fusion?▼
Bipartal endoscopy through two ports of 4 to 5 millimeters to 1 centimeter, or an MIS tubular approach through a single 2.5 centimeter incision, with a discectomy added at the same sitting if the disc is large.
What single variable determines whether a patient needs decompression alone versus a TLIF?▼
Whether there is instability. Without significant back pain or instability, decompression alone is recommended; with significant back pain and a dynamic X-ray showing instability, lysis, or discal collapse alongside foraminal narrowing, the patient needs a TLIF instead.
What does a TLIF add that decompression alone does not?▼
A cage and screws to restore disc height and decompress both foramina.
How does Girdhar view a patient's fear of surgery once it has already been recommended?▼
As a separate counseling problem to be managed alongside the referral, not a reason to keep cycling through conservative treatment that has already failed.
In This Series: Indications for Spine Surgery & Advances for Safer Outcomes
- 1.Indications for Spine Surgery
- 2.The Three-Tier Referral System: When Back and Neck Pain Needs a Spine Surgeon
- 3.Cauda Equina Syndrome and the Spine Emergencies That Cannot Wait
- 4.A Case Worked Through by Phone: Decompression or Fusion for a Kenyan Patient
- 5.Minimally Invasive Reduction for Spondylolisthesis: Two Cases From the Same Month
- 6.A Fusion Mass at Twenty-Four: Revising a Childhood Scoliosis Correction That Stopped Short
- 7.Loose Screws and a Cord That Was Swelling Somewhere Else Entirely
- 8.When Cement Alone Is Not Enough for a Fractured Vertebra
- 9.Training the Next Generation: Inside a Two-Year Spine Fellowship and Its Observership Track
- 10.Cross-Border Spine Care: Inside the Jivo Connect Clinic Model