Indications for Spine Surgery

Back pain sits second only to headache among the complaints patients bring to any clinic, yet a small fraction of those cases ever need an operation. Dr. Puneet Girdhar, Vice Chairman and Head of Spine Surgery at BLK-Max Super Speciality Hospital in New Delhi, built his March 2026 Jivo Healthcare masterclass around a working answer to a referring doctor's most practical question: which patients need to be sent up the chain, and how fast.

A practice built for volume and complexity

Girdhar leads a team of eight spine surgeons at BLK-Max, where he has practiced for more than sixteen years. The department runs a two-year super-specialty fellowship that trains postgraduates toward a National Board diploma in spine surgery, alongside a dedicated spine operating suite and a rehabilitation program for spinal cord injury patients. Annual volume has crossed 1,100 spinal surgeries and close to 10,000 outpatient consultations. Since acquiring robotic surgery capability roughly three and a half years ago, the team has performed more than 500 robotic procedures. Over two decades, Girdhar has performed more than 18,000 spinal surgeries, with microtubular work through 18 to 20 millimeter tubes as his daily core technique.

Three tiers of referral

Girdhar sorts referrals into three groups by urgency. The first is same-day emergency: cauda equina syndrome (the triad of saddle anesthesia, lower limb weakness, and difficulty controlling urine from pressure on the lumbar nerves), a progressive neurological deficit from cervical or dorsal myelopathy or a worsening osteoporotic fracture, and any suspected infection, malignancy, or vertebral fracture. The second is early referral, within one to two weeks: severe radicular pain such as sciatica or brachialgia with neurological signs, tumors of the spinal meninges like neurofibroma or lipoma pressing on nerves, spondylolisthesis with gait disturbance, and disabling pain that has resisted six to eight weeks of physiotherapy, medication, or nerve blocks. The third is routine referral: back pain that has not improved after twelve weeks of therapy without radicular pain, evaluated for desiccated discs, sacralization, spina bifida occulta, or spondylolysis, plus cases of diagnostic uncertainty or complicating psychosocial factors.

What the technology changed in the operating room

Robotic navigation now plans pedicle screw trajectories on a 3D model built from an intraoperative scan, with the robotic arm aligning to that plan before the drill goes in, producing what Girdhar calls a near 100 percent precise job. Bipartal endoscopy, adopted over the past year, uses two small ports and a saline medium to decompress the spinal canal from one side while freeing the nerve root on the opposite side, the same over-the-top principle he uses in his daily tubular microscopic work. Vertebral cementing under local anesthesia handles 15 to 20 osteoporotic or malignancy-related fractures a month as a same-day procedure, though a burst fracture or posterior ligament involvement still needs fixation alongside the cement. Multimodal neuromonitoring, expandable cages with up to 12 degrees of built-in lordosis correction, and ultrasonic bone-cutting instruments round out a toolkit that has let deformity and revision surgery move from open exposures toward small-incision correction.

Cases that show the range

The talk moved through patients who illustrate how these tiers and tools meet in practice: a man referred from the United States for dysplastic listhesis and bilateral foraminal stenosis, treated with a two-level TLIF and walking the next day; a 35-year-old woman with grade 3 to 4 listhesis corrected through four small incisions in February 2026; a 24-year-old whose childhood scoliosis surgery abroad had left a solid fusion mass and a persistent hump, revised with multiple osteotomies; and a case referred by phone from Kenya, worked through in real time from nothing more than an MRI description and a patient's fear of surgery.

Referral is the start of a relationship, not the end of one

Girdhar closed the session by tying the clinical framework to Jivo Healthcare's Connect Clinic model: a monthly slot in which referring doctors join the consultation directly, so a patient gets a joint reading from their own doctor and a specialist in New Delhi before any decision to travel is made. The articles that follow work through the referral tiers, the individual cases, and the training and follow-up structure in more depth.