Indications for Spine Surgery

The indications for spine surgery fall into three groups: compression of the spinal cord or nerves that is causing or threatening a neurological deficit, structural instability such as spondylolisthesis, unstable fractures and deformity, and space-occupying lesions such as an epidural abscess or a tumour. In these groups, surgery is usually the only way to prevent permanent weakness or paralysis. Everything else starts with conservative care.

That is the framework Dr. Puneet Girdhar, then Vice Chairman & Head, Spine Surgery at BLK-Max Super Speciality Hospital, New Delhi, India, set out for doctors across Africa in March 2026. His starting point was a paradox every clinician recognises. Backache is, in his words, second only to headache among the complaints patients carry through life, and nobody is immune to it. Yet very few of those patients need an operation. The skill lies in recognising the few who do, and in sending them to a spine surgeon at the right moment.

Who sees spine patients, and why the indications matter

Dr. Girdhar has performed more than 18,000 spinal operations over two decades. At the time of the masterclass he led a team of eight spine surgeons at BLK-Max, part of Max Healthcare, which he described as the second-largest hospital chain in the country. The department performs more than 1,100 spinal operations a year and sees close to 10,000 spinal outpatients. It runs a dedicated spine operating suite and a rehabilitation unit for spinal cord injury, and trains spine surgeons through a two-year National Board super-speciality programme.

The case mix of a private spine practice is overwhelmingly degenerative. Spinal tumours and congenital defects occur, but most of the work concerns discs and wear-related disease of the spine, which Dr. Girdhar compared with the degeneration that eventually brings patients to knee replacement. From an orthopaedic background, his own practice also covers spinal deformity in children and adults, bone tumours of the spine such as chondrosarcoma, giant cell tumour, myeloma and metastasis, infective spondylodiscitis (infection of a disc and the adjacent vertebrae) and spinal tuberculosis, and degenerative slips. Tumours of the spinal cord itself he leaves to neurosurgical colleagues.

The referring doctor's question is therefore rarely "can this be operated on?" It is "does this patient belong in one of the groups where waiting causes harm?" The three groups below answer it.

The three indications for spine surgery

Dr. Girdhar classified the patients who need spine surgery into three categories. For each, he was explicit that there is no real alternative if the aim is to stop the hands and legs from becoming paralysed.

1. Neurological compression

The first group is any condition in which the spinal cord or the nerve roots are being compressed and the patient is losing function:

• Disc herniation with a neurological deficit, in the lumbar or the cervical spine.
• Progressive spinal stenosis, in which a patient who could walk a given distance a few months ago now develops severe claudication (pain, heaviness or numbness in the legs on walking, relieved by rest) and the walking distance keeps falling.
• Any upper motor neuron sign, such as brisk reflexes or spasticity. These point to myelopathy, meaning compression of the spinal cord rather than a single nerve root, and they need to be dealt with.

2. Structural instability

The second group is instability: the spine can no longer hold its alignment under load.

• Spondylolisthesis, the forward slip of one vertebra on the one below, whether degenerative, lytic (from a defect in the bony arch), isthmic or dysplastic (from a congenital malformation of the facet joints).
• Unstable fractures, such as a burst fracture or a fracture involving the posterior ligamentous complex, the band of ligaments that holds the back of the spine together. Left alone, these progress to deformity and to compression of the cord, and they require stabilisation. Where there is no significant compression and no deficit, Dr. Girdhar prefers minimally invasive stabilisation.
• Spinal deformity, including scoliosis (a sideways curve of the spine) and kyphosis (an excessive forward curve). Correcting a rigid deformity requires releases and osteotomies (controlled cuts through bone, such as Ponte osteotomies, pedicle subtraction osteotomies or vertebral column resection), followed by correction, instrumentation and fusion.

3. Space-occupying pathology

The third group is anything that occupies space inside the spinal canal: an epidural abscess (pus collecting around the membrane that covers the spinal cord) or collection from infection, osteomyelitis (infection of the bone) with bony compression, and any tumour that is causing a neurological deficit or a progressive change in neurology.

These three groups are the destination. How fast a patient should be sent there is a separate question, and Dr. Girdhar answered it with a three-tier referral framework of emergency, early and routine referral, set out in detail in when back and neck pain needs a spine surgeon. The short version: cauda equina syndrome, progressive neurological deficit and suspected infection, malignancy or fracture are same-day emergencies.

Why patients fear spine surgery, and what has made it safer

Patients arrive frightened. They fear paralysis, and many have heard of a neighbour or a friend who had a bad outcome. Dr. Girdhar acknowledged that the fear has a basis in the surgery of the past. A common pattern he has seen is the patient treated with a wide laminectomy alone, in which the bony roof of the canal was removed and the facet joints were damaged. Such patients may improve for a time, but many eventually develop instability and worsening back pain.

Over the last two decades, in his account, that picture has changed completely, and the change has built trust in spine surgery. Three things drove it.

• Minimally invasive technique. Minimally invasive surgery is not about the size of the skin incision. It is about preserving the paraspinal muscles, especially the multifidus, which contributes to the dynamic stability of the back. Less soft tissue disruption means less pain, faster recovery, earlier return to work, very little blood loss and, more often than not, no transfusion. Hospital stays shorten and infection rates fall.
• Technology. Dr. Girdhar credits much of the improvement in safety to the operating microscope (he rarely operates without one), endoscopes, intraoperative 3D imaging, navigation and robotics, multimodal neuromonitoring and ultrasonic bone cutting.
• Anaesthesia and pain control. Modern anaesthetic drugs make operations of eight, ten or twelve hours possible, and patient-controlled analgesia has transformed post-operative pain management.

His own career followed this path. He started with open surgery, operated with loupes for a year or two while waiting for a microscope, and has done all his work under the microscope since. Most of it now runs through 18 to 20 mm tubes, and the department has moved further into endoscopy, including biportal endoscopy, in which the endoscope and the instruments enter through two separate small ports. The detail of these techniques, and how they apply to slips, stenosis and fractures, is covered in surgery for spondylolisthesis, stenosis and spinal fractures.

The goals of every spinal operation

Across all three indication groups, the operation has the same three goals: decompress the spinal cord and nerves, stabilise what is unstable, and correct the deformity, restoring the balance of the spine. Dr. Girdhar stressed sagittal balance in particular. When a slipped segment is fused, the surgeon must restore lumbar lordosis, the normal inward curve of the lower back, to reduce stress on the levels above and regain the overall balance of the spine. Expandable interbody cages, now available with 12 degrees of built-in lordosis, have, in his view, been a boon for this.

He also drew a clear line on technique. Posterolateral fusion alone, without support in the front of the spine, risks implant failure. His practice is circumferential (360-degree) stabilisation and fusion, with a cage restoring disc height in front and screws behind. Treatment-cost guidance for these operations is on the spinal decompression and fixation page.

When the indication was missed: deformity and revision

The cost of a missed or late indication is most visible in deformity. Dr. Girdhar's centre treats many patients who present late, including children with neglected congenital curves, post-tubercular kyphosis and adults whose earlier spinal operations did not achieve their goal. A hemivertebra (a malformed, wedge-shaped vertebra) that could be removed in a three to four hour operation at four or five years of age requires a vertebral column resection, the removal of an entire vertebra, once the child presents late with a full-blown deformity. His cases, and the clinical signs that should prompt early referral, are set out in revision spine surgery and neglected spinal deformity.

Decompression or fusion: a decision worked through live

One case shared during the session shows the indications applied to a real decision. A Kenyan referring doctor described a man in his thirties with a diffuse disc bulge at L4-L5 compressing both traversing nerve roots, a disc protrusion at L5-S1 narrowing the left lateral recess, and a spinal canal narrowed to 9.5 mm. The man was afraid of surgery.

Dr. Girdhar's answer turned on two questions: does he have significant back pain, and is the segment unstable? Without those, a decompression alone is enough. With them, he needs a fusion. The full reasoning, and how to counsel a frightened patient, is in when back and neck pain needs a spine surgeon. The questions put to Dr. Girdhar during the session are recorded in the Live Discussion.

Cross-border spine patients: follow-up and continuity of care

Dr. Girdhar treats patients from across Africa and beyond, and he spoke plainly about what that requires. A patient who travels from Africa to India for spine surgery places a great deal of trust in the surgeon, and has little recourse once home. Honesty and ethics come first, but close follow-up matters just as much: understanding the patient's complaints and concerns after discharge, and keeping in touch through video consultations. He conducts five to six video consultations a day with patients around the world, speaking to those who need surgery both before and after the operation, and answers the 30 to 40 queries he receives daily, usually the same day.

In his view, the operation is one part of a whole programme. A patient who arrived in crisis has to be rehabilitated back into the society they came from.

Spine surgery observerships for referring doctors and surgeons

For referring doctors and surgeons who want to see the indications and techniques in practice, Dr. Girdhar offers observerships. There are no selection criteria for observers. They scrub in and watch but do not operate. Placements run from one week to eight or ten weeks. Senior surgeons already in practice tend to come for three to five days or a week to refine specific techniques, while trainees can stay longer. Technicians also come to learn how the equipment can be used more efficiently.

A week is enough to see a great deal. A recent observer from Nepal, a practising surgeon, saw 25 operations in a single week, spanning robotic surgery, deformity correction, endoscopic cases and minimally invasive reduction of slips. Observerships carry a certificate from the hospital, not national accreditation. The accredited routes (the two-year National Board programme and the Spine Society fellowships of one to three months or one year) are not open to overseas trainees.

For doctors with a clinic practice who refer spine patients, Dr. Girdhar sees a particular benefit in observing: until a doctor has seen a procedure performed, it is hard to explain it with conviction to a patient.

How this masterclass fits with Dr. Girdhar's other sessions

This session focused on indications: who needs surgery, and when. Dr. Girdhar's earlier masterclasses concentrate on the techniques and technology themselves. His August 2025 session is summarised in advances in spinal surgery, and his 2024 session in advances in spinal surgery technology. More on the specialty is on the orthopaedics hub.