Expert Spine Surgery for Lasting Relief

Understanding Spine Surgery in the Indian Context

Back and leg pain from disc herniation, spinal stenosis, and deformities affect millions of Indians, particularly desk workers, two-wheeler riders, and manual laborers. At Ajuda Hospitals, our spine surgery program employs minimally invasive techniques—microscopic discectomy, endoscopic decompression, and computer-navigated fusion—to relieve pain and restore function with shorter hospital stays and faster recovery.

Spine surgery is recommended when:

• Conservative treatment fails after 6-12 weeks (physiotherapy, medications, epidural injections)
• Progressive neurological deficits develop (weakness, foot drop, bowel/bladder dysfunction)
• Structural instability causes mechanical pain unresponsive to non-surgical care

Modern advances allow 90% of disc herniations to be treated through 2-3 cm incisions under microscope or endoscope, with overnight discharge. Complex fusions use neuromonitoring (real-time nerve function tracking) and computer navigation (1mm screw placement accuracy) to maximize safety.

Hyderabad's IT workforce faces rising cervical disc disease from prolonged laptop use. Our multidisciplinary team—spine surgeons, neurologists, pain specialists, physiotherapists—delivers evidence-based care for everything from simple disc herniations to complex adult scoliosis.

When to Consult Our Spine Surgery Specialists

Schedule a consultation if back/leg pain persists beyond 6-12 weeks despite physiotherapy, medications (NSAIDs, neuropathic agents), and epidural steroid injections. Early surgical intervention prevents permanent nerve damage.

Our Diagnostic Approach

Comprehensive Neurological Assessment

History:

• Pain location, radiation pattern (dermatomal distribution L4/L5/S1)
• Aggravating factors (bending, lifting, prolonged sitting/standing)
• Neurological symptoms (numbness, tingling, weakness, gait disturbance)
• Red flags: Bowel/bladder dysfunction, saddle anesthesia, progressive motor deficit, night pain/fever (infection/tumor)

Physical Examination:

• Motor Strength (0-5 grading): Hip flexion (L2), knee extension (L3-L4), ankle dorsiflexion (L4-L5), great toe extension (L5), ankle plantarflexion (S1)
• Reflexes: Patellar (L4), Achilles (S1)—diminished/absent indicates nerve root compression
• Sensation: Dermatome mapping (L4 medial calf, L5 dorsal foot, S1 lateral foot)
• Provocative Tests: Straight leg raise (sciatic nerve tension), femoral stretch test (upper lumbar radiculopathy), Spurling's test (cervical radiculopathy)
• Gait Analysis: Trendelenburg gait (hip abductor weakness), steppage gait (foot drop), wide-based gait (spinal stenosis)

Advanced Imaging

MRI (Gold Standard):

• Lumbar Spine: T2-weighted sagittal/axial images show disc herniation (extrusion, sequestration), spinal stenosis (ligamentum flavum hypertrophy, facet arthropathy), nerve root compression
• Cervical Spine: Cord compression (myelopathy), cord signal changes (T2 hyperintensity indicates chronic compression), foraminal stenosis
• Grading Stenosis: Mild (<1/3 canal compromise), moderate (1/3-2/3), severe (>2/3)—correlates with surgical urgency

CT Scan:

• Superior bony detail for facet joint arthritis, pars defects (spondylolysis), fracture classification
• CT Myelogram: If MRI contraindicated (pacemaker, claustrophobia)—contrast injection outlines spinal cord and nerves
• 3D Reconstruction: Pre-operative planning for deformity correction (pedicle screw trajectories, osteotomy angles)

Dynamic X-rays:

• Flexion-Extension Lateral Views: Detect instability (>4mm translation or >10° angulation indicates spondylolisthesis requiring fusion)
• Standing Full-Spine X-rays: Measure scoliosis Cobb angle, sagittal vertical axis (SVA), pelvic incidence-lumbar lordosis (PI-LL) mismatch

Electromyography (EMG/NCS):

• Differentiates radiculopathy (nerve root) from peripheral neuropathy (diabetes), confirms level of compression, assesses chronicity (acute vs chronic denervation)

Conservative Treatment Trial (Unless Red Flags Present)

6-12 Week Protocol:

• Medications: NSAIDs, muscle relaxants, neuropathic agents (gabapentin/pregabalin)
• Physiotherapy: Core strengthening, McKenzie exercises (extension-based), postural training
• Epidural Steroid Injections: Transforaminal (targeted to compressed nerve root) or interlaminar—70% respond; effect lasts 3-6 months

Surgery Indicated If:

• Failed conservative care with persistent debilitating pain
• Progressive neurological deficit (worsening weakness, foot drop)
• Cauda equina syndrome (surgical emergency within 24-48 hours)

Surgical Planning & Consent

Decision Factors:

• Single-level vs multi-level disease
• Disc herniation only vs stenosis + instability (determines fusion need)
• Patient age, bone quality (osteoporosis), comorbidities (diabetes, cardiac disease)
• Occupation, functional goals (manual labor vs desk work)

Treatment Pathways

Our spine surgery protocols follow North American Spine Society (NASS) and AOSpine guidelines:

Lumbar Disc Herniation – Microdiscectomy

Indications: L4-L5 or L5-S1 disc extrusion causing radicular leg pain, failed 6-12 weeks conservative care, MRI-confirmed nerve root compression.

Procedure:

1. Prone position; 2-3 cm midline incision over affected level (identified by fluoroscopy)
2. Operating microscope (6-10x magnification) inserted through tubular retractors (preserves paraspinal muscles)
3. Laminotomy (remove small portion of lamina) exposes ligamentum flavum
4. Retract nerve root medially; identify and remove extruded disc fragment
5. Inspect disc space through annular defect; remove loose fragments (avoid aggressive curettage to prevent instability)
6. Hemostasis; close fascia and skin; no drain needed

Rehabilitation:

• Day 0: Ambulate 4-6 hours post-op; avoid prolonged sitting first 2 weeks
• Week 1-2: Walking program; avoid bending, lifting, twisting (BLT restrictions)
• Week 2-6: Physiotherapy core strengthening, ergonomic training
• Week 6+: Return to desk work; manual labor after 12 weeks

Outcomes: 92% leg pain relief (most within 24 hours). 5-10% recurrence rate at same level over 10 years.

Endoscopic Spine Surgery (UBE/FESS)

Unilateral Biportal Endoscopy (UBE): Two 1 cm portals—one for HD camera, one for instruments. Continuous saline irrigation expands working space. Decompress stenosis or remove disc with minimal muscle damage.

Full Endoscopic Spine Surgery (FESS): Single 8mm portal. Working channel within endoscope. Steeper learning curve but smallest incision.

Advantages Over Microdiscectomy:

• Less post-op pain (VAS 2-3 vs 4-5 at Day 1)
• Faster mobilization (same-day discharge possible)
• Smaller scar, better cosmesis

Outcomes: Equivalent pain relief and recurrence rates to microdiscectomy at 2-year follow-up (per recent RCTs).

Lumbar Fusion – TLIF (Transforaminal Lumbar Interbody Fusion)

Indications: Spondylolisthesis (>Grade 2 slip), recurrent disc herniation, stenosis with instability, failed prior discectomy with segmental instability.

Procedure:

1. Prone position; midline or paramedian incision
2. Subperiosteal muscle dissection; expose facet joints and transverse processes
3. Pedicle screw insertion bilaterally guided by fluoroscopy or navigation (4 screws for single-level fusion)
4. Unilateral facetectomy; retract nerve root to access disc space
5. Complete discectomy; prepare endplates (bleeding bone)
6. Insert PEEK or titanium cage packed with autograft (local bone) or allograft/BMP (Bone Morphogenetic Protein)
7. Connect screws with rods; compress/distract to restore disc height and lordosis
8. Decorticate transverse processes; apply posterolateral bone graft for additional fusion
9. Close in layers over drain

Rehabilitation:

• Day 1-2: Mobilize with lumbar brace; drain removal at 48 hours
• Week 6: X-rays confirm alignment; wean off brace; advance physiotherapy
• Month 3-6: CT scan confirms bridging bone (fusion); return to full activities
• Month 12: Fusion maturation complete

Outcomes: 80-85% fusion rate at 1 year. 70-80% satisfied with pain relief. Adjacent segment disease develops in 2-3% per year (risk of fusion extending to neighboring levels).

Cervical Discectomy & Fusion (ACDF)

Indications: Cervical disc herniation causing arm pain (radiculopathy) or spinal cord compression (myelopathy), failed conservative care, progressive weakness.

Procedure (C5-C6 Example):

1. Supine position; transverse skin crease incision right of midline
2. Blunt dissection between carotid sheath (lateral) and trachea/esophagus (medial)
3. Fluoroscopy confirms C5-C6 level; Caspar pins in C5/C6 vertebrae for distraction
4. Operating microscope; complete discectomy under magnification
5. Decompress spinal cord and nerve roots; remove posterior osteophytes
6. Insert PEEK cage (packed with bone graft) into disc space
7. Anterior cervical plate with screws locks construct
8. Confirm alignment on lateral fluoroscopy; close platysma and skin

Rehabilitation:

• Week 0-6: Soft cervical collar; avoid heavy lifting
• Week 6: X-rays confirm stability; wean off collar; physiotherapy ROM exercises
• Month 3: Fusion confirmed; return to all activities

Outcomes: 95% fusion rate. 90% arm pain relief. Dysphagia (swallowing difficulty) in 5-10% first 2 weeks, resolves spontaneously.

Scoliosis Correction Surgery

Indications: Adolescent idiopathic scoliosis >40-50° (risk of progression), adult degenerative scoliosis with pain/neurological deficit, sagittal imbalance.

Procedure (Posterior Spinal Fusion):

1. Prone position; midline incision from T3-L3 (example for thoracolumbar curve)
2. Subperiosteal exposure of lamina, facets, transverse processes
3. Neuromonitoring baseline (MEPs, SSEPs)—alerts to spinal cord injury
4. Pedicle screws inserted every level (10-14 screws typical); computer navigation optional
5. Pre-contoured rods attached; gradual derotation and correction maneuvers
6. Osteotomies (Ponte, PSO) if rigid curves or sagittal imbalance
7. Decorticate fusion bed; apply autograft, allograft, BMP
8. Final neuromonitoring confirms intact spinal cord function
9. Close in layers over drain

Rehabilitation:

• Day 1-2: Log-roll mobilization; ICU monitoring first night
• Week 1: Mobilize with TLSO brace; discharge Day 5-7
• Month 3-6: X-rays confirm curve maintenance; wean off brace
• Month 12: Fusion maturation; return to sports

Outcomes: 60-70% Cobb angle correction. Prevents curve progression. Complication rate 5-10% (infection, proximal junctional kyphosis, pseudarthrosis).

Vertebral Compression Fracture – Kyphoplasty

Indications: Osteoporotic compression fracture causing severe back pain, cancer-related pathological fracture (metastasis, myeloma).

Procedure:

1. Prone position; local anesthesia + sedation (can be done awake)
2. Percutaneous bilateral pedicle cannulation under fluoroscopy
3. Insert deflated balloon tamp into vertebral body; inflate to restore height
4. Remove balloon; inject PMMA bone cement under low pressure (avoid cement leak into spinal canal)
5. Cement hardens in 10 minutes; remove instruments; adhesive dressing

Outcomes: 90% immediate pain relief. Cement leakage (asymptomatic) in 10%; symptomatic leak <1%. Increases subsequent fracture risk at adjacent levels by 15-20% over 2 years.

Technology & Innovation

Intraoperative Neuromonitoring (IONM)

How It Works:

• MEPs (Motor Evoked Potentials): Scalp electrodes stimulate motor cortex; record muscle activity in limbs. Drop >50% alerts surgeon to spinal cord ischemia or injury.
• SSEPs (Somatosensory Evoked Potentials): Peripheral nerve stimulation; record at scalp. Monitors dorsal column (sensation) function.
• EMG (Electromyography): Detects pedicle screw misplacement into nerve root (muscle twitching during screw insertion).

Benefits: Reduces neurological injury from 2% to <0.5% in complex cases (scoliosis, tumor, revision surgery).

Computer Navigation & Robotics

O-Arm + Stealth Navigation (Medtronic): Intra-operative CT scan creates 3D map of spine. Real-time instrument tracking overlaid on CT images guides pedicle screw placement.

Mazor X Robotic System: Pre-operative planning on CT scan. Robotic arm positions drill guide for perfect screw trajectory. Surgeon drills and inserts screw through guide.

Benefits: Reduces screw misplacement from 15% (free-hand) to <2% (navigated). Fewer reoperations for malpositioned screws.

Biologics for Fusion Enhancement

BMP-2 (Bone Morphogenetic Protein): Recombinant protein stimulates bone formation. Higher fusion rates than autograft alone (95% vs 85%) but controversial due to off-label use and side effects (ectopic bone, radiculitis).

Cellular Bone Graft (Stem Cells): Bone marrow aspirate concentrate or mesenchymal stem cells mixed with scaffold. Emerging alternative to BMP with fewer side effects.

What to Expect: Your Care Journey

Pre-Operative Phase (1-2 Weeks Before)

• Spine surgeon consultation: Review MRI, discuss surgery type, realistic expectations
• Pre-anesthesia checkup: ECG, chest X-ray, blood tests; optimize comorbidities
• Physiotherapy "prehab": Core strengthening, spine hygiene education—improves post-op outcomes
• Smoking cessation mandatory (10x higher non-fusion rate if continue smoking)

Day of Surgery

• Admission 2 hours pre-op; IV antibiotics (cefazolin)
• General anesthesia; positioning (prone for posterior approach, supine for anterior ACDF)
• 1-4 hours surgery depending on complexity
• Recovery room 1-2 hours; ICU if complex fusion/scoliosis

Post-Operative Days 1-3

• Day 1: Mobilize with physiotherapist; walk with walker/brace; drain removal at 48 hours
• Pain Control: Epidural catheter (fusion) or oral opioids (discectomy); transition to acetaminophen/tramadol by Day 3
• Wound Care: Transparent dressing; dry sterile environment
• X-rays: Confirm implant position, vertebral alignment

Discharge & Follow-Up

• Discharge: Day 1-2 (microdiscectomy), Day 3-5 (fusion), Day 5-7 (scoliosis)
• Week 2: Suture removal, wound check
• Week 6: X-rays assess healing; physiotherapy advance strengthening
• Month 3-6: CT scan confirms fusion (bridging bone across disc space)
• Annual: Long-term surveillance for adjacent segment disease

Preventing Complications

Spine surgery complications are uncommon (<5%) but include:

Dural Tear (1-5%)

Cerebrospinal fluid leak from torn dura (covering of spinal cord). Managed with surgical repair, bed rest, abdominal binder. Persistent leak may require blood patch.

Nerve Root Injury (<1%)

Retraction injury or screw misplacement causes new weakness or numbness. Neuromonitoring detects most intra-operatively allowing immediate correction.

Infection (1-3%)

Higher with fusion (longer operative time, implants). Deep infection requires washout, IV antibiotics 6 weeks. Implant retention possible if early (<6 weeks).

Non-Union/Pseudarthrosis (5-15% Fusion)

Risk Factors: Smoking (10x risk), multi-level fusion, obesity, inadequate fixation.

Prevention: Smoking cessation, bone graft/BMP, rigid fixation with pedicle screws. CT scan at 1 year confirms bridging bone.

Adjacent Segment Disease (2-3%/Year Post-Fusion)

Accelerated degeneration of level above or below fusion. May require extension of fusion. Non-fusion techniques (disc replacement) may reduce risk but longer-term data needed.

Why Ajuda for Spine Surgery?

Take the First Step

If back or leg pain is limiting your life—preventing work, sleep, or daily activities—expert spine care can provide lasting relief. Our team will thoroughly evaluate your condition and explore all options, reserving surgery for when it truly offers the best outcome.

Schedule Your Evaluation: Call 9010550550 or WhatsApp to book an MRI review and consultation. Bring recent imaging, medication list, and prior treatment records.

Restore your mobility and quality of life with Ajuda's advanced spine surgery program.