Surgical Treatments

In the Operating Room

Every surgery is performed with a specialized team and intraoperative neuromonitoring, which tracks nerve function throughout the procedure.

Surgery as a Definitive Solution When Conservative Treatment Is Not Enough

Dr. Ernesto Martínez de la Maza
Neurosurgery • Spine Surgery

Surgery: A Carefully Considered Decision

Spine surgery should never be a first option, but when it is truly indicated, it can change a patient's life in a profound and positive way. As a fellowship-trained neurosurgeon, my commitment is twofold: first, to make sure we have explored every appropriate conservative option; second, when surgery is necessary, to perform it with the utmost technical precision and human care.

This page will help you understand when surgery is appropriate, what to expect from the entire process, and how to prepare for the best possible outcome.

1. When Is Spine Surgery Necessary?

Absolute and relative indications for surgical treatment

The decision to operate on the spine is based on specific medical criteria, not on the surgeon's preference or the patient's convenience. There are absolute indications where surgery is urgent and necessary, and relative indications where surgery is a reasonable option after prior conservative treatment has failed.

Absolute Indications: Urgent or Emergency Surgery

These conditions require immediate or urgent surgical intervention, regardless of other factors:

  • Cauda Equina Syndrome: Acute loss of bladder and bowel control, saddle anesthesia, bilateral leg weakness. A SURGICAL EMERGENCY (24-48 hour window)
  • Severe progressive neurological deficit: Muscle weakness that worsens rapidly (for example, foot drop that progresses over days)
  • Progressive cervical myelopathy: Cervical spinal cord compression causing progressive neurological decline, hand clumsiness, and gait disturbances
  • Unstable vertebral fracture: Fractures with a high risk of spinal cord injury or progressive deformity
  • Severe spinal infection: Epidural abscess or discitis with neurological involvement that does not respond to IV antibiotics
  • Tumor with acute neurological compression: A mass causing rapidly progressive neurological symptoms

In these situations, time is critical. Waiting can result in permanent, irreversible neurological damage. If you have any of these symptoms, you should seek emergency neurosurgical evaluation.

Relative Indications: Elective Surgery After Conservative Failure

In these situations, surgery is considered appropriate after a reasonable period of well-executed conservative treatment without significant improvement:

Degenerative Conditions:

  • Herniated disc with severe radiculopathy: Intense radiating pain persisting >6-12 weeks
  • Symptomatic spinal stenosis: Limiting neurogenic claudication despite 3-6 months of treatment
  • Symptomatic spondylolisthesis: Disabling pain or neurological deficit
  • Severe degenerative disc disease: Disabling axial pain confirmed by specific studies

These conditions are often grouped as herniated disc and spinal stenosis.

Deformities and Others:

  • Progressive scoliosis: A deformity that advances, causing pain or cardiopulmonary compromise
  • Severe kyphosis: A structural deformity that affects function or balance
  • Symptomatic pseudarthrosis: Nonunion after prior surgery causing pain
  • Documented spinal instability: Abnormal movement between vertebrae causing symptoms

Criteria for considering elective surgery:

  • Documented failure of appropriate conservative treatment over a sufficient period
  • Significant impact on quality of life or ability to work
  • Clear correlation between imaging findings and clinical symptoms
  • An informed patient with realistic expectations
  • Overall medical condition adequate to tolerate surgery
  • Potential benefit outweighs the case-specific risks

When Surgery Is NOT Recommended

There are situations where surgery has a high likelihood of a poor outcome or is inappropriate:

  • Pain without anatomical correlation: Symptoms that do not match imaging findings
  • Unrealistic expectations: The patient expects a "complete cure" or "never any pain again"
  • Unresolved psychosocial factors: Untreated severe depression, active litigation, obvious secondary gain
  • Severe comorbidities: Medical conditions that make surgery very risky
  • Active smoking: Increases the risk of nonunion; should stop at least 6-8 weeks beforehand
  • Active infection: Must be resolved before elective surgery
  • Uncontrolled morbid obesity: Significantly increases surgical and anesthetic risks

My philosophy: I would rather say "no" to an inappropriate surgery than proceed with a procedure that has a high likelihood of an unsatisfactory result. Unnecessary surgery not only exposes the patient to risks but can also make their condition worse.

2. Types of Spine Surgery Available

Understanding the different surgical techniques

There are multiple surgical approaches to the spine, each with specific indications. The choice of procedure depends on the pathology, its location, the patient's condition, and the surgeon's experience.

Decompression Procedures

Neural Release

Goal: Relieve compression on nerves or the spinal cord

Includes:

  • Microdiscectomy
  • Laminectomy
  • Foraminotomy
  • Corpectomy

Best for: Herniated discs, spinal stenosis, nerve root compression without instability

Fusion Procedures

Stabilization

Goal: Eliminate movement between vertebrae to relieve pain or prevent instability

Includes:

  • Lumbar fusion (PLIF, TLIF, ALIF)
  • Cervical fusion (ACDF)
  • Thoracolumbar fusion
  • Instrumentation with screws and rods

Best for: Spondylolisthesis, severe degenerative disc disease, deformities, instability

Fusion uses spinal implants and stabilization.

Correction Procedures

Realignment

Goal: Correct structural deformities of the spine

Includes:

  • Scoliosis correction
  • Spinal osteotomies
  • Kyphosis correction
  • Multilevel instrumentation

Best for: Progressive scoliosis, kyphotic deformities, sagittal imbalance

These procedures treat scoliosis and kyphosis.

Minimally Invasive Spine Surgery(MIS)

Features:

  • Small incisions (typically 1-3 cm)
  • Less soft-tissue damage
  • Faster recovery
  • Less postoperative pain
  • Earlier hospital discharge

Limitations: Not appropriate for every condition; a significant learning curve for the surgeon; may require longer operative time

Ideal for: Simple herniated discs, some stenosis cases, 1-2 level lumbar fusions

Traditional Open Surgery

Features:

  • Complete direct visualization
  • Maximum control of the surgical field
  • Allows complex corrections
  • Gold standard for complex pathology
  • An established technique with decades of evidence

Considerations: Greater initial impact on soft tissues; typically a longer recovery; more initial postoperative pain

Ideal for: Deformities, tumors, revision surgery, multilevel fusions, complex corrections

Learn more about open spine surgery.

My Approach to Technique Selection

The surgical technique should be selected based on what is best for the patient, not on the surgeon's preferences or current trends. During your consultation, we will discuss:

  • The available options for your specific condition
  • The advantages and limitations of each approach in your case
  • My experience with each technique and the expected results
  • The anticipated recovery time with each option
  • The specific risks of each approach for your anatomy

Important: Sometimes the "less invasive" technique is not the one that produces the best long-term result. My commitment is to the best functional outcome, not to the smallest scar.

3. Complete Preoperative Evaluation

Thorough preparation for safe and successful surgery

Before any spine surgery, we perform a systematic evaluation to ensure you are medically optimized and that we fully understand your anatomy and condition.

Required Imaging Studies

Magnetic Resonance Imaging (MRI):

  • Gold standard for visualizing the spinal cord, nerves, and discs
  • Should be recent (ideally <3 months)
  • With and without contrast for tumors or infections

Computed Tomography (CT):

  • Excellent visualization of bony structures
  • Essential for planning implant placement
  • Useful for evaluating fractures or prior fusions

Dynamic X-rays:

  • Flexion and extension views to assess instability
  • Standing X-rays to evaluate global alignment

General Medical Evaluation

Preoperative Labs:

  • Complete blood count
  • Blood chemistry (glucose, kidney function)
  • Coagulation times
  • Electrocardiogram
  • Chest X-ray if >40 years old

Specialty Evaluations:

  • Anesthesiology: Anesthetic risk assessment
  • Cardiology: If you have heart disease
  • Pulmonology: If you have lung disease
  • Endocrinology: If you have diabetes
  • Hematology: If you take anticoagulants

Critical Preoperative Optimization

Factors that MUST be optimized before elective surgery:

1. Smoking:

  • Stop completely 6-8 weeks beforehand
  • Doubles the risk of nonunion
  • Increases wound complications
  • Referral to a cessation program if needed

2. Blood Sugar Control:

  • HbA1c should be <7% (ideally <6.5%)
  • Fasting glucose <126 mg/dL
  • Uncontrolled diabetes increases infection

3. Body Weight:

  • BMI >40 significantly increases risks
  • Consider preoperative weight loss
  • Improves surgical outcomes and rehabilitation

4. Nutrition:

  • Adequate nutritional status (albumin >3.5)
  • Supplementation if there are deficiencies
  • Important for bone and wound healing

5. Medications:

  • Stop anticoagulants per protocol
  • Adjust antiplatelet agents
  • Continue essential medications
  • Discuss ALL supplements

6. Psychological Status:

  • Depression or anxiety should be treated
  • Realistic expectations established
  • A support system identified

Important: If any of these factors is not optimized, it may be necessary to postpone elective surgery until ideal conditions are achieved. This is NOT an obstacle, but rather an investment in the best possible outcome.

Detailed Informed Consent

Informed consent is a process, not just a document. During our preoperative consultations, we will discuss in detail:

  • The specific procedure planned for your case, with diagrams and clear explanations
  • Realistic goals of the surgery (what we can and cannot achieve)
  • General risks of any surgery (infection, bleeding, anesthetic reactions)
  • Specific risks of spine surgery (nerve injury, nonunion, persistent pain)
  • Particular risks of your case based on anatomy and comorbidities
  • Alternatives, both surgical and non-surgical
  • What happens if you decide not to have surgery
  • Expected recovery time and postoperative limitations

My philosophy: A well-informed patient is a better patient. You should never feel pressured to make a decision. You can take all the time you need, ask any questions you have, and seek second opinions if you wish.

4. The Surgical Process Step by Step

What happens on the day of surgery

Understanding the surgical process helps reduce anxiety and allows you to prepare mentally and physically. Here is the typical timeline of surgery day:

1

Admission and Preparation (1-2 hours before)

  • Arrival at the hospital while fasting (nothing by mouth for 8 hours prior)
  • Administrative registration and document verification
  • Changing into a hospital gown, removing jewelry and contact lenses
  • Final nursing assessment (vital signs, identity verification)
  • Placement of an intravenous line
  • Visit from the anesthesiologist for a final assessment
  • Visit from the neurosurgeon to confirm the procedure and mark the surgical site
2

Transfer to the Operating Room and Anesthesia (30-60 minutes)

  • Transfer by stretcher to the operating room
  • Placement of monitors (electrocardiogram, oximeter, blood pressure)
  • Induction of general anesthesia (you will be fully asleep, with no pain or awareness)
  • Intubation for mechanical ventilation
  • Placement of a urinary catheter (while you are asleep)
  • Proper positioning (face down for lumbar surgery, face up or on the side for cervical surgery)
  • Preparation and sterilization of the surgical field
3

Surgical Procedure (Variable depending on the procedure)

Typical duration by type of surgery:

  • Simple microdiscectomy: 1-2 hours
  • 1-2 level lumbar fusion: 2-4 hours
  • Multilevel cervical fusion: 3-5 hours
  • Scoliosis correction: 4-8 hours
  • Complex tumor surgery: 6-12 hours

During surgery:

  • Intraoperative neuromonitoring (for complex surgeries)
  • Use of a surgical microscope for magnified visualization
  • Fluoroscopy (real-time X-ray) to guide implant placement
  • Blood transfusion if necessary (uncommon in simple surgeries)
  • A complete team (anesthesiologist, scrub tech, circulating nurse, surgical assistant)
4

Closure and Immediate Recovery (30-60 minutes)

  • Layered closure (muscle, fascia, subcutaneous tissue, skin)
  • Placement of drains if needed
  • Application of sterile dressings
  • Gradual emergence from anesthesia
  • Extubation once breathing is adequate
  • Immediate neurological assessment (limb movement, sensation)
  • Transfer to the post-anesthesia recovery unit
5

Recovery Room (2-4 hours)

  • Intensive monitoring of vital signs
  • Pain control with intravenous medications
  • Periodic neurological assessment
  • Beginning of mobilization when appropriate
  • Meeting with family once you are awake and stable
  • Transfer to a room once stability criteria are met
6

Postoperative Visit

  • Visit from the neurosurgeon for assessment and explanation of the findings
  • Review of intraoperative images with a family member if available
  • Discussion of immediate care and the recovery plan
  • Answering questions from the patient and family

A Note on Operative Times

Time in the operating room includes not only the surgery itself but also anesthesia, positioning, and closure. If we tell you that "the surgery will take 4 hours," that is the total time you will be in the operating room, not the incision-to-closure time.

Important: Complex surgeries may take longer than estimated. This is NOT necessarily a bad sign - it means we are being meticulous and careful. We will keep your family informed during lengthy procedures.

5. Hospitalization and Immediate Postoperative Care

The first days after surgery

The hospital stay varies depending on the type of surgery and your individual recovery. Here is what you can expect:

Type of Surgery Typical Hospital Stay Mobilization Drains
Microdiscectomy Outpatient or 1 night Walking the same day Generally no
1-2 Level Lumbar Fusion 2-4 days Next day with a brace Frequently yes
Cervical Fusion 1-2 days Same day with a collar Frequently yes
Scoliosis Correction 5-7 days Day 2-3 with assistance Yes, multiple
Complex Tumor Surgery 5-10 days (may include ICU) Depending on neurological deficit Yes

Care During Hospitalization

Pain Management:

  • Multimodal analgesia (a combination of medications)
  • PCA (patient-controlled analgesia) for major surgeries
  • Transition to oral medications once tolerating food
  • Pain scales monitored regularly

Complication Prevention:

  • Prophylactic anticoagulation to prevent thrombosis
  • Pneumatic compression stockings
  • Breathing exercises with an incentive spirometer
  • Frequent position changes
  • Surgical wound care

Progressive Mobilization

The Importance of Early Mobilization:

  • Reduces the risk of venous thrombosis
  • Prevents pneumonia
  • Speeds bowel recovery
  • Improves mood
  • Identifies neurological deficits early

Typical Progression:

  • Day 0: Sitting at the edge of the bed with assistance
  • Day 1: Walking short distances with a walker/help
  • Day 2: Walking in the hallway, getting in and out of bed independently
  • Day 3+: Walking progressively longer distances

Postoperative Warning Signs

Notify the medical team IMMEDIATELY if you have:

Neurological:

  • New weakness in the arms or legs
  • Loss of sensation
  • Loss of bladder or bowel control
  • Pain that worsens significantly
  • Changes in mental status or confusion

General:

  • Fever >38.5°C (101.3°F)
  • Excessive or bloody drainage from the wound
  • Redness, warmth, or swelling at the wound
  • Difficulty breathing or chest pain
  • Severe swelling/pain in the calf

Hospital Discharge Criteria

You will be discharged once you meet the following criteria:

  • Pain controlled with oral medications
  • Able to walk safely (with or without assistance, depending on the procedure)
  • Tolerating oral feeding without nausea/vomiting
  • Adequate bladder/bowel function
  • No fever or signs of infection
  • No active neurological or medical complications
  • Surgical wound clean and dry
  • Drains removed if they had been placed
  • Discharge instructions understood by the patient/family
  • Follow-up appointment scheduled

6. Recovery and Rehabilitation

The road back to full function

Recovery after spine surgery is a gradual process that requires patience, discipline, and commitment. Long-term success depends both on the surgical technique and on your active participation in rehabilitation.

Immediate Phase (0-2 Weeks)

Protection

Main goals:

  • Wound healing
  • Pain control
  • Complication prevention
  • Safe basic mobilization

Permitted activities:

  • Frequent short walks
  • Basic self-care activities
  • Resting in comfortable positions

Restrictions:

  • Do NOT lift >2-5 kg
  • NO twisting of the spine
  • NO deep bending
  • NO driving until cleared

Early Phase (2-6 Weeks)

Progressive Activation

Main goals:

  • Increase activity tolerance
  • Begin formal physical therapy
  • Resume basic daily activities
  • Initial bone consolidation (fusions)

Permitted activities:

  • Progressively longer walks
  • Gentle stretching exercises
  • Light household activities
  • Driving short distances (if cleared)

Typical milestones:

  • Week 2: Removal of sutures/staples
  • Week 3-4: Significant reduction in pain
  • Week 6: First follow-up X-ray

Intermediate Phase (6-12 Weeks)

Strengthening

Main goals:

  • Progressive muscle strengthening
  • Improved endurance
  • Return to sedentary work
  • Full functional independence

Intensive physical therapy:

  • Core stabilization exercises
  • Paraspinal strengthening
  • Functional exercises
  • Postural training

Activity progression:

  • Week 8: Return to desk work
  • Week 10: Light recreational activities
  • Week 12: Assessment for more vigorous activities

Late Phase (3-6 Months) and Long-Term Maintenance

Optimization and Prevention

Goals:

  • Full return to pre-injury activities (if appropriate)
  • Documented solid bony fusion (for fusions)
  • Optimal strength and endurance
  • Establishing a lifelong exercise routine
  • Month 3: Fusion X-rays, increased activities
  • Month 4-5: Return to moderate physical work (case by case)
  • Month 6: Fusion CT, clearance for full activities
  • Month 12: Final evaluation, consolidated fusion

Long-term maintenance: After full recovery, regular exercise and good postural habits are essential to maintaining results. The levels adjacent to a fusion are under greater stress and can degenerate over time if good supporting musculature is not maintained.

Return-to-Activity Timelines

The following are general timelines that may vary depending on your procedure and individual progress:

Activity Microdiscectomy Simple Fusion Multilevel Fusion
Walking Immediate Day 1 Day 2-3
Driving 1-2 weeks 4-6 weeks 6-8 weeks
Desk work 2-4 weeks 6-8 weeks 8-12 weeks
Light physical work 4-6 weeks 3-4 months 4-6 months
Heavy physical work 6-12 weeks 4-6 months 6-12 months
Low-impact sports 4-6 weeks 3-4 months 4-6 months
High-impact sports 3 months 6-12 months 12+ months or never
Intimacy 2-4 weeks 6-8 weeks 8-12 weeks

Note: These are general ranges. Your specific timeline will be individualized during follow-up visits.

7. Expected Long-Term Outcomes

Realistic expectations and success rates

It is essential to set realistic expectations about the outcomes of spine surgery. The "success rate" depends on how success is defined, the type of surgery, and the condition being treated.

✓ Defining "Success" in Spine Surgery

Surgical success is NOT defined as:

  • Complete elimination of pain (unrealistic)
  • A spine "as good as new" (degeneration cannot be reversed)
  • No limitations of any kind

Success IS defined as:

  • Significant improvement in pain (typically a 50-80% reduction)
  • Resolution or improvement of neurological deficit
  • Return to important functional activities
  • Improvement in overall quality of life
  • Patient satisfaction with the procedure
  • No need for additional surgery in the short term

Success Rates by Procedure

Lumbar microdiscectomy:

  • 85-95% significant improvement in leg pain
  • 5-10% disc herniation recurrence at 5 years
  • Patient satisfaction >90%

Lumbar fusion for stenosis/spondylolisthesis:

  • 70-85% improvement in pain and function
  • Solid fusion rate of 85-95%
  • 10-15% require additional surgery at 10 years

Cervical fusion:

  • 80-90% improvement in arm pain
  • Fusion rate >95%
  • Satisfaction >85%

Scoliosis correction:

  • Average curve correction of 50-70%
  • Improvement in balance and function
  • Satisfaction 70-85% (lower than other surgeries)

Factors That Negatively Affect Outcomes

Studies have identified predictors of poorer surgical outcomes:

Medical Factors:

  • Active smoking (doubles the risk of nonunion)
  • Uncontrolled diabetes
  • Morbid obesity (BMI >40)
  • Severe osteoporosis
  • Multiple comorbidities

Psychosocial Factors:

  • Untreated major depression
  • Active litigation
  • Pending workers' compensation
  • Unrealistic expectations
  • Poor social support
  • Substance abuse

Important: These factors do NOT mean you cannot benefit from surgery, but it is crucial to address them before or alongside surgical treatment to optimize outcomes.

Revision Surgery (Reoperations)

Sometimes additional surgery is required for various reasons:

Reasons for reoperation:

  • Disc herniation recurrence: 5-10% at 5 years
  • Adjacent segment disease: 3-5% per year after fusion
  • Pseudarthrosis (nonunion): 5-15% depending on risk factors
  • Hardware failure: Rare with modern technique (<2%)
  • Postoperative infection: 1-5% depending on the procedure
  • Symptomatic epidural hematoma:<1%

Revision surgeries are more challenging: They have lower success rates than primary surgeries (60-75% vs. 85-95%) due to scar tissue, altered anatomy, and diminished bone quality. For this reason, it is critical to optimize the first surgery.

The Reality of Surgical Outcomes

Most appropriately selected patients have excellent outcomes. Spine surgery, when indicated and performed correctly, is one of the most rewarding procedures for both the surgeon and the patient.

I have seen countless patients who came to my office desperate and limited by pain, and who, after appropriate surgery, have reclaimed their lives, returned to work, enjoyed their families, and taken part in activities they thought they had lost forever.

However, surgery is not magic. It requires:

  • Appropriate selection of patient and procedure
  • Excellent surgical technique
  • Careful perioperative management
  • Active patient participation in rehabilitation
  • Realistic expectations and patience during recovery
  • Long-term commitment to healthy habits

When all of these elements align, the results are deeply satisfying and life-changing.

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Frequently Asked Questions

  • When does spine surgery truly become necessary?

    Surgery is considered the right option only after non-surgical treatments (such as physical therapy, medications, and injections) have failed to provide enough relief, or in situations where there is a neurological risk. The three main indications for proceeding with surgery are:

    • Intractable pain: severe pain that drastically affects your quality of life and does not respond to other treatments.

    • Neurological deficit: the presence of weakness, loss of sensation, or loss of reflexes in the arms or legs that does not improve or that worsens.

    • Spinal instability: whether from a fracture, an infection, or a severe degenerative process, the spine has lost its structural integrity.

    • In emergencies, such as severe trauma or cauda equina syndrome, surgery is immediate and necessary to prevent permanent neurological damage.

  • What are the fundamental goals of spine surgery? What are we trying to correct?

    Every spine surgery, regardless of the technique, is based on one or more of these three fundamental pillars:

    • Decompression: the act of relieving pressure on the nerve structures. This means removing whatever is “pinching” the spinal cord or the nerve roots—whether a herniated disc, a bone spur (osteophyte), a thickened ligament, or a tumor.

    • Stabilization (fusion): if part of the spine is unstable or becomes unstable after decompression, it must be fixed. This is achieved by creating a bony bridge (fusion) between the vertebrae, held in place with titanium implants (screws and rods) while the bone heals.

    • Deformity correction: in conditions such as scoliosis or kyphosis, the goal is to realign the spine to a more anatomical and balanced position, using instrumentation to guide and maintain the correction.

  • I have heard the term “spinal fusion” or “arthrodesis.” What does it mean, and does it mean I will lose all my mobility?

    A “spinal fusion” or “arthrodesis” is the surgical process by which two or more vertebrae are made to unite into a single solid bone. The goal is to eliminate movement in a segment that is painful, unstable, or dysfunctional.

    It is natural to worry about losing mobility, but it is important to understand two things:

    • Fusion is performed on very few segments of the spine. The rest of your spine (cervical, thoracic, and lumbar) will keep its normal movement.

    • Often, the segment that is fused already had abnormal, painful movement. By eliminating that pathological movement, the pain is eliminated, which in practice can lead patients to feel more mobile and functional overall. Most patients do not notice a significant limitation in their daily activities.

  • How safe is modern spine surgery? How are the nerves protected during the procedure?

    Safety in spine surgery has advanced dramatically. “Safe” is our guiding principle, and we achieve it by integrating three cutting-edge technologies into EVERY one of our surgeries:

    • Surgical microscope: gives us a magnified, brilliantly illuminated view, allowing us to work with exquisite precision around the delicate nerve structures.

    • Neuronavigation (O-arm): a surgical “GPS” that provides a real-time 3D map of your spine, ensuring that every screw and implant is placed with millimeter precision in the safest and most solid part of the bone.

    • Intraoperative neurophysiological monitoring: a team of experts watches the function of your spinal cord and nerves throughout the operation. If anything comes near a nerve structure, they alert us instantly, allowing us to prevent any damage.

    This “trifecta” of technology has transformed the safety of spine surgery.

  • Is surgery the final solution, or what comes next?

    Surgery is not a “magic wand,” but the mechanical step that creates the conditions for your body to heal and recover. It is the beginning of the next phase of your treatment. After surgery, long-term success depends on:

    • A period of healing and fusion: your body needs time to heal and, in the case of a fusion, for the bone to grow and solidify.

    • Rehabilitation and physical therapy: this is a crucial component. A personalized rehabilitation program will help you strengthen the supporting muscles, safely regain mobility, and learn to move in a way that protects your spine.

    Surgery corrects the structural problem; rehabilitation teaches your body to function optimally with that correction. Your active participation in this process is the key to a successful and lasting result.