Imaging and Navigation: From 'Cut First, See Later' to 'See First, Cut Precisely'

This is a very large grey zone. In general, a patient with acute pain of short duration, no neurological weakness, and quality of life not severely compromised should get a trial of conservative management first. At the other end, a patient who has tried conservative measures without relief, has developed neurological weakness or significantly impaired quality of life, and has imaging confirming nerve compression, needs an honest conversation about surgery as a genuine option. Individual lifestyle demands matter too — the same imaging findings in a sedentary 70-year-old versus someone who needs to travel and stay professionally active can lead to very different recommendations. Treatment has to be individualised.

First, preventing infection: making surgery as minimally invasive as possible, prophylactic antibiotics, and early removal of the urinary catheter, since UTIs are a common source of secondary infection. Second, wound care: dressing changes every second day until suture removal at day ten, sponge bathing rather than full immersion until healed. Third, movement precautions: for three months after discectomy or fusion, no lifting weights, no sitting on the floor, no squatting or forward bending; in the first month, no sitting or travelling continuously for more than 30 minutes without a break. We take follow-up X-rays every month for three months, then every three months up to a year.

For a sportsperson or someone with high physical demands, my approach leans towards spinal fixation rather than decompression alone, for greater long-term stability — consistent with how athletes like Tiger Woods have returned to high-level sport after spine surgery. The realistic return-to-full-sport timeline is about one year, with roughly nine months devoted to rehabilitation under sports-specialist physiotherapists focused on core training and back strengthening. The protocol is tailored to the individual, but the principle is the same: build a strong muscular support system before returning to load.

For office workers: correct sitting posture throughout, back support maintained, screen at eye level, the angle between thigh and lower leg kept greater than 90 degrees, with regular breaks. I recommend pelvic tilts, leg raises, the Cobra pose and the Superman pose for everyone in this group. For heavy weightlifters with back pain but a largely normal MRI, return to lifting within six to eight weeks is reasonable; but with a prolapsed disc, the annulus tear needs six to nine months, sometimes up to a year, to heal, and early heavy loading risks the prolapse escalating into a full extrusion requiring surgery. For patients beyond 60, protein supplementation and resistance training to maintain paraspinal muscle mass become particularly important, since postural slouching and spinal deterioration are largely consequences of muscular atrophy.

Multi-level thoracic stenosis and multi-level lumbar disc disease can both be managed with MISS, including fixation at two or three levels, and technology now makes MISS technically feasible at four or even five levels — though each patient has to be assessed individually. As a broad guide: one- or two-level lumbar disease, MISS without question; three to four levels, roughly half our patients proceed with MISS and half need open surgery, mainly for anatomical reasons, not because MISS is inferior. For sequencing combined cervical and lumbar disease: if there's cervical cord compression causing weakness, we operate on the cervical spine first; if the cervical issue is just radiating arm pain without cord compression, we address the lumbar spine first.

The spine moves during surgery, which invalidates any imaging captured before the operation begins, unlike more fixed anatomical targets in brain or facial surgery.

A 3D C-arm is the cheapest option with lower image quality; a full intraoperative CT scan is the most accurate but carries the highest radiation dose and cost; the O-arm sits in between and is the most widely adopted option.

It projects real-time 3D imaging data onto a screen, letting the surgeon visualise internal anatomy and plan skin entry points and screw trajectories before making any incision.

Greater than 99% safety and accuracy.

No. Beyond routine degenerative surgery, it is also used in deformity correction, cervical instrumentation, atlanto-axial dislocation, and complex revision cases.