Minimally Invasive Spine Surgery: Percutaneous Discectomy, Kyphoplasty and Disc Replacement

We always start with medication at a lower dose, increasing gradually to control symptoms. The ideal time to move to DBS is around 4 to 5 years after diagnosis, when the required dose is becoming too high, side effects are a problem, or the medication effect is fading — DBS at that stage can abolish or significantly reduce the drug requirement and restore quality of life. At our hospital, the total package including surgery, anaesthesia, device, medicines, testing and hospital stay runs approximately USD 30,000 to 35,000, with the variation depending on rechargeable versus non-rechargeable devices.

For spine surgery, major complications run around 2%, life-threatening complications around 0.5%, and neurological deficit around 1 to 1.5% — 98% of patients do well, 90% do very well, at a centre doing 400 to 500 spine surgeries a year. Patients should understand that surgery corrects the structural problem but can't always undo pre-existing nerve damage, so some residual tingling or numbness may persist even in a good outcome. For brain surgery, mortality is around 1 to 2% and total risk of neurological deficit is 5 to 7% at expert centres, with 93% of patients doing very well after tumour removal — the main caveat is that malignant tumours can recur despite surgery, since resection alone isn't curative and radiotherapy and chemotherapy are also required.

Complete spinal cord injuries will not result in complete neurological recovery, and some patients recover only minimally. What we can address is the secondary symptoms: pain and spasticity, managed with baclofen or morphine pumps, and dorsal cord stimulators, which can improve sensation and reduce spasticity, with some incomplete-injury patients regaining a degree of leg power combined with physiotherapy. If hand function is preserved, we train patients to manage daily life with their upper limbs and a wheelchair. But for complete injuries specifically, meaningful motor recovery is not something we can promise.

I conducted a study on this myself — we took stem cells from the iliac bone and implanted them at the injury site in around 20 patients. One patient showed some improvement, but it couldn't be separated from natural recovery under medication, and statistically we found no significant benefit. We discontinued the trial. Stem cell therapy for complete spinal cord injury is still not recommended anywhere in the world; for partial injuries there may be some benefit, but meaningful recovery from stem cells in complete injuries has not been demonstrated.

Awake craniotomy, used for tumours near the motor cortex or speech areas, requires full patient cooperation throughout — some patients become agitated under partial sedation and we've had to convert to general anaesthesia. For international patients, a translator has to be present in the operating room the entire time, which adds another layer of difficulty. Personally I'm not very keen on it given how demanding it is for the patient; we now prefer using preoperative functional MRI to map eloquent areas and then operate under general anaesthesia while avoiding those mapped regions, which reduces the need for awake craniotomy in many cases.

Contained disc herniations, where the disc bulges and compresses the nerve root but has not fully extruded into the spinal canal, respond well to this minimally invasive approach.

More than 90% of patients report significant pain relief by the next day, with mobilisation starting immediately after.

It is contraindicated with active infection at the fracture site, and with a retropulsed bone fragment compressing the spinal canal, where cement leak carries a risk of paraplegia.

ACDF fuses the diseased segment, which eliminates motion there and pushes stress onto the segments above and below, raising the risk of adjacent segment disease. Disc replacement removes the diseased disc and inserts a prosthesis that preserves motion at the treated level, reducing that risk and shortening or eliminating the need for a postoperative collar.

It is confirmed intraoperatively, as the disc space is visibly seen to open and close with flexion and extension.