Spinal Surgery Technology

Spinal surgery technology is the set of tools that now surrounds a spinal operation: CT imaging inside the operating theatre, intraoperative neuromonitoring, high-magnification microscopes, endoscopes, and navigation with robotic guidance. Together they allow surgeons to work through small incisions with greater precision, so that patients who once expected months in bed now walk on the day of surgery or the next morning.

Dr. Puneet Girdhar set out this case in May 2024, when he was Principal Director & Head, Ortho Spine, MIS & Robotic Spine Surgery at BLK-Max Super Speciality Hospital, New Delhi, India. He currently serves as Chairman - Max Institute of Robotics and Minimal Invasive Spine Surgery - Ortho Spine, MIS & Robotic Spine Surgery at BLK-Max Super Speciality Hospital, New Delhi, India. His programme performs close to 1,000 spinal operations a year, sees about 10,000 spine patients annually and trains spine fellows alongside the clinical service. He has operated on more than 15,000 patients, around 1,000 of them from Africa.

This guide covers why technology has reshaped spine surgery, what each layer of the technology does, how it changes the treatment of common and complex conditions, and the referral thresholds Dr. Girdhar gave to doctors who see spine patients first.

Why technology changed spinal surgery

Dr. Girdhar starts from the patient's fear rather than the machine. Patients facing spine surgery worry about three things: that the operation will leave them paralysed, that they will be confined to bed for two to three months afterwards, and what it will cost.

His analogy is aviation. Air travel is safer than car travel because of good technology. Spine surgery has followed the same trajectory: over the last 20 years, technology has been added to almost every spinal procedure. Two of the three fears map directly onto the technology: neuromonitoring and robotic guidance address the fear of paralysis, and keyhole surgery addresses the fear of prolonged bed rest, because patients walk within a day.

Most back pain never needs surgery

The technology matters only for the minority who need an operation. Almost everyone has back pain at some point in life, and in Dr. Girdhar's estimate fewer than 1% of people with back pain need surgical intervention. Most are managed with medicines and physiotherapy.

The conditions that do reach the operating theatre fall into a small number of groups:

• Spinal stenosis, a narrowing of the spinal canal that squeezes the nerves. The typical patient cannot walk a long distance and has to stop and sit down.
• Disc herniation, in which disc material bulges out and presses on a nerve. It causes sciatica, a shooting pain down the leg, or pain into the arm when the problem is in the neck.
• Disc collapse, where a degenerated disc loses its normal height.
• Spondylolisthesis, where one vertebra slips forward on the one below, in some patients because of a fracture in the bony arch at the back of the vertebra.
• Fractures, infection and deformity, including spinal tuberculosis, scoliosis and kyphosis.

Dr. Girdhar's treatment ladder has three steps. Medicines and physiotherapy come first. If they fail, the next step is a nerve block injection into the spine. If that also fails, surgery follows, increasingly as small keyhole endoscopic surgery. For a patient with sciatica who has had no relief from medicines after two weeks, he advises an X-ray and an MRI. That pathway, and the keyhole operations at the end of it, are covered in endoscopic spine surgery for slipped disc and stenosis.

Spinal surgery technology in a modern operating theatre

Dr. Girdhar described five layers of technology at BLK-Max, each with a distinct job.

The layers work together. In a robotic fusion, the CT scan is taken in theatre, the screw paths are planned on screen, the robotic arm moves to the planned position, the surgeon drills through a small incision guided by the arm, and live imaging confirms the result. Throughout, neuromonitoring checks the nerves.

Dr. Girdhar's figures for the robot were direct: screw placement is about 93% accurate without a robot and 100% with it, with less blood loss, a shorter hospital stay and patients walking the day after spinal fixation. Published comparisons generally find robot-assisted screw placement more accurate than freehand placement, although no technique is entirely free of error. The detail of each layer, and what it means for the risk of paralysis, is in spine surgery paralysis risk and the technology that reduces it.

Keyhole surgery is now the default

According to Dr. Girdhar, about 90% of spinal surgeries are now performed through minimally invasive, small incisions. The advantages he listed are less pain, very quick recovery, discharge in about a day and walking again almost at once.

Two cases from his practice show the scale of the change. A patient with lumbar canal stenosis who could not walk for more than five minutes, and had numbness in the legs, underwent a 40-minute endoscopic decompression and walked a kilometre the same evening before going home. A patient with a large disc herniation had the disc removed through a small incision and had immediate relief from pain and numbness.

Fusion has changed in the same way. Answering a question from the audience, Dr. Girdhar said that with minimally invasive and robotic techniques a fusion patient walks on the day of surgery, is discharged in one to two days and can return to desk work within a week; sport is usually resumed only once the fusion has consolidated, typically three to six months after surgery.

Complex deformity and reconstruction

At the other end of the spectrum, the same technology supports the largest operations in spine surgery: correction of curves of 90 degrees or more, reconstruction of spines destroyed by tuberculosis, and revision of operations that failed elsewhere. Dr. Girdhar showed cases in which an entire vertebra was removed to correct a deformity, a child with syndromic kyphoscoliosis (a combined sideways and forward curve) treated with growth rods over three to four years, and a curve of almost 100 degrees corrected.

His most pointed warning concerned timing. A child with a congenital hemivertebra, a malformed wedge-shaped vertebra, should have surgery at about four years of age, when the operation takes about four hours. One of his patients was referred at 16 because doctors assumed the child was too young for surgery; by then the deformity required a 16-hour reconstruction. The full set of cases and thresholds is in severe spinal deformity surgery: curves beyond 90 degrees.

When to refer: thresholds for doctors

Dr. Girdhar gave referring doctors a set of practical markers:

1. Sciatica with no relief after two weeks of medicines: obtain an X-ray and an MRI.
2. Failure of medicines, physiotherapy and a nerve block: a surgical opinion is warranted, usually for endoscopic surgery.
3. Decisions about surgery: judge them on the patient's symptoms and the treatment already tried, not on a measurement on the scan. In his words, do not measure the millimetres; measure the patient's symptoms.
4. Idiopathic scoliosis: observe curves under 25 degrees, brace curves of 25 to 40 degrees in a growing child, and refer for a surgical opinion when the curve passes 40 degrees; surgery is generally indicated once it exceeds 45 to 50 degrees.
5. Congenital scoliosis from a hemivertebra: surgery at four or five years of age, not later.
6. Neuromuscular scoliosis: surgery when the curve causes breathing or balance problems.
7. Quadriplegia: establish the cause first, because if the cause is known it can be removed.

For individual patients, he asks referring doctors to share the patient's reports so that he can send a complete written reply. He told the audience that he replies to close to 40 emails and at least 30 WhatsApp images and queries every day, and that a referring doctor should expect an answer the same day or the next.

Taking minimally invasive surgery to resource-limited settings

One question from the audience asked what stands in the way of minimally invasive spine surgery in tropical regions. Dr. Girdhar's answer was that there is no obstacle; the obstacle is in the mind.

He cited Nigeria. If doctors in Congo find routine minimally invasive surgery a challenge, he said, Nigeria faced the same challenge. In the two months before the session, his team performed three minimally invasive spinal operations in Abuja, two of them revisions in patients who had already had a laminectomy (an operation that removes part of the bony arch of the vertebra to relieve pressure on the nerves), and all three patients walked the next day. He was then receiving calls from ten hospitals wanting to start minimally invasive programmes. Doctors from Nigeria were being brought to India for training, as part of a programme to equip local doctors to perform the surgery themselves, and he said he would like to do the same in Congo. His summary: if it can be done here, it can be done there.

The same spirit runs through his answer to a doctor who asked how to become his assistant. Training programmes bring fellows from Africa, he said, and the doctor who asked does not need to be his assistant: he can be his colleague. The full set of audience questions is on the Live Discussion page.

Keeping the spine healthy: diet, exercise and lifestyle

Dr. Girdhar closed with prevention. Humans, he said, are paying the price for evolution: in the computer age, back problems are increasingly common, driven by heavy lifting and long hours at a computer.

Asked whether nutrition matters, he answered that each part of the spine, bones, muscles and nerves, has its own needs, and that a good lifestyle, a good diet and regular exercise are the three things that keep the spine healthy. His component-by-component advice appears at the end of the endoscopic spine surgery article.

How this masterclass relates to Dr. Girdhar's other sessions

This 2024 session concentrated on the technology itself. Dr. Girdhar has since given two further masterclasses: a 2025 session on advances in spinal surgery, covering the evolution from open to endoscopic surgery and scoliosis in children, and a 2026 session on indications for spine surgery, which sets out when back and neck pain needs a surgeon. Costs for the main procedures are listed on the spine surgery cost page, and related specialists are grouped under orthopaedics.