Vice Chairman & Head - Ortho Spine, MIS & Robotic Spine Surgery, BLK-Max Super Speciality Hospital, New Delhi
Part 10 of 18 in Spinal Surgery: Advances in Techniques & Technology for Excellent Patient Outcomes
Minimally Invasive vs Open Spine Surgery: How Techniques Have Evolved
August 5, 2026
Minimally invasive spine surgery has largely replaced open spine surgery over the past two decades, moving from large incisions that open the entire back to small cuts guided by microscopes and endoscopes. For patients considering spine surgery in India, this shift means less muscle damage, less pain and a much faster return home.
From open surgery to loupes to microscopes
Open spine surgery, which involves opening the entire back, is now rarely needed. Before microscopes became standard, surgeons used magnifying loupes, which gave no static image and forced the surgeon to keep moving their neck throughout the operation to stay focused on the surgical area. Microscopes changed this by providing strong illumination, magnification and a fixed, coaxial view, and are now considered mandatory equipment in spine surgery training.
Microscopic tubular technique
Dr. Puneet Girdhar of BLK-Max Super Speciality Hospital trained in microscopic tubular technique in the United States under Dr. Kevin Foley, the surgeon who pioneered this approach, and has used it in almost all his surgeries since 2012. In this technique, the surgery is performed through a narrow tube, often just 18 to 22 millimetres wide, so the incision is only around 2 to 3 centimetres.
Endoscopic spine surgery: the newest step
Biportal endoscopy is the newest development in minimally invasive spine surgery, capable of handling around 90 percent of spinal procedures. It cannot replace every technique, particularly for large multi-level deformities that need an entire vertebra removed, where open approaches are still sometimes required. But for most degenerative spine problems, minimally invasive and endoscopic spine surgery now allow smaller cuts, preserved back muscles, less pain and a faster recovery than the open surgery of two decades ago.
Series index | Biportal Endoscopic Spine Surgery: What It Is and How It Works →
This article is based on a Jivo Masterclass session conducted by Dr. Puneet Girdhar, Chairman, Max Institute of Robotics and Minimal Invasive Spine Surgery, BLK-Max Super Speciality Hospital, New Delhi. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
This guide is based on a live Jivo Masterclass — Dr. Puneet Girdhar taught doctors across Africa on August 10, 2025.
FROM THE LIVE Q&A
Dr. Frank, referring physician, Ghana
I'm also trying to go into orthopedic surgery myself, and I'm really happy learning more about it and seeing the advances in the surgery you're doing. Out of curiosity — how many of your own fellows go on to specialize in spine surgery after training under you?
Dr. Puneet Girdhar
I always joke about this with my orthopedic fellows. I've had an orthopedic training program for the last 13 or 14 years, and not even one of them has opted for spine surgery as a career — they're very happy doing a knee replacement, arthroscopy, or a fracture nail instead. Spine surgery has evolved so much that the moment they look into the scope, everything is very tiny, and that can be discouraging — it looks very uphill. It takes a little while to enter the system and understand what's going on through keyholes; one has to be patient, because it has a steep learning curve and the margin of error is not there. So for the last four years I've run a dedicated fellowship national training program for spine fellows — once they're selected and come to me, they don't have the option to go to any other theatre, because they're now committed to spine surgery for the rest of their life.
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Frequently Asked Questions
I wanted to share how Paulina has been doing since her surgery with you — honestly speaking, I was really impressed by her recovery time. She's come back to Ghana and she's always praising your team, and now I have even more patients lining up who also want to come and have a consultation, and possibly the surgery, after hearing about her experience.▼
We feel privileged to be treating your patient, and I hope we have done justice to you, your practice and of course the patient. I think at the end of the day we all have one common goal — we want to see our patients happy. Otherwise you, me and Jivo would not be here on a Sunday evening, leaving our families aside, if we did not have this goal.
I'm also trying to go into orthopedic surgery myself, and I'm really happy learning more about it and seeing the advances in the surgery you're doing. Out of curiosity — how many of your own fellows go on to specialize in spine surgery after training under you?▼
I always joke about this with my orthopedic fellows. I've had an orthopedic training program for the last 13 or 14 years, and not even one of them has opted for spine surgery as a career — they're very happy doing a knee replacement, arthroscopy, or a fracture nail instead. Spine surgery has evolved so much that the moment they look into the scope, everything is very tiny, and that can be discouraging — it looks very uphill. It takes a little while to enter the system and understand what's going on through keyholes; one has to be patient, because it has a steep learning curve and the margin of error is not there. So for the last four years I've run a dedicated fellowship national training program for spine fellows — once they're selected and come to me, they don't have the option to go to any other theatre, because they're now committed to spine surgery for the rest of their life.
How has spine surgery evolved over the past two decades?▼
It has moved from fully open procedures, through magnifying loupes and then microscope-guided tubular techniques, to today's biportal endoscopic approaches.
What were the limitations of using loupes in spine surgery?▼
Loupes gave no static image, forcing the surgeon to keep moving their neck throughout the operation to stay focused on the surgical area.
How small is the incision in microscopic tubular spine surgery?▼
The surgery is performed through a narrow tube, often just 18 to 22 millimetres wide, so the incision is only around 2 to 3 centimetres.
Can biportal endoscopy replace all spine surgery techniques?▼
No. It cannot replace every technique, particularly for large multi-level deformities that need an entire vertebra removed, where open approaches are still sometimes required.
Why are microscopes now considered essential in spine surgery?▼
They provide strong illumination, magnification and a fixed, coaxial view, and are now considered mandatory equipment in spine surgery training.
In This Series: Spinal Surgery: Advances in Techniques & Technology for Excellent Patient Outcomes
- 1.Advances in Spinal Surgery
- 2.Biportal Endoscopic Spine Surgery: What It Is and How It Works
- 3.Cervical Disc Replacement: Treating Neck Disc Herniation While Preserving Motion
- 4.Growth Rods for Early-Onset Scoliosis in Young Children
- 5.Hemivertebra: Why Early Surgery Prevents Severe Spinal Deformity
- 6.Herniated Disc Surgery: Biportal Endoscopic Discectomy Explained
- 7.Kyphoplasty for Osteoporotic Spinal Fractures: A Same-Day Procedure
- 8.Lumbar Canal Stenosis: Symptoms and Modern Minimally Invasive Treatment
- 9.Minimally Invasive Spinal Fusion: Treating Spinal Instability Without Open Surgery
- 10.Minimally Invasive vs Open Spine Surgery: How Techniques Have Evolved
- 11.Navigation and Robotics in Spine Surgery: Why They Improve Accuracy and Safety
- 12.Prolonged Sitting and Disc Degeneration: Why Desk Jobs Are a Spine Risk
- 13.Recovery After Minimally Invasive Spine Surgery: What Patients Can Expect
- 14.Robotic Spine Surgery for Complex and Revision Cases
- 15.Scoliosis and Kyphosis in Children: Types and Warning Signs
- 16.Scoliosis Treatment: When Observation, Bracing or Surgery Is Needed
- 17.Vertebral Column Resection: Correcting Severe Spinal Deformity From Neglected Tuberculosis
- 18.When to See a Spine Specialist: Warning Signs You Shouldn't Ignore