Prof. Dr. Mehmet Şenoğlu — Brain, Nerve and Spine Surgery
For years I have observed the change in expression on the faces of my patients when they hear the words “spine surgery.” These two words awaken the same fear in most people: “What if I end up paralyzed? What if I can never walk the way I used to again?” I understand this concern; the spine is a truly delicate structure, with the spinal cord and the nerves running through it. However, I would like to tell you this clearly: thanks to technologies such as the microscope, neuronavigation, and neuromonitoring, spine surgery today has become a field so much safer that it cannot be compared with thirty years ago.
Let me also state one thing from the very beginning: the great majority of my spine patients do not undergo surgery. Spine surgery is not the first option in treatment; it is a solution that comes into play for the right patient, at the right time. In this article, I want to explain in clear language what spine surgery is, in which conditions it is used, with which methods it is performed, and what its risks are.
What Is the Spine? A Brief Anatomy Reminder
The spine is a column made up of vertebrae stacked one on top of the other, extending from the base of the skull to the tailbone. If we separate it into regions: the neck (cervical) has 7 vertebrae, the mid-back (thoracic) 12 vertebrae, the lower back (lumbar) 5 vertebrae, followed by the sacrum and the coccyx.
This structure has three fundamental duties:
- To carry: It carries the body’s load and enables us to stand upright.
- To move: It allows us to bend, turn, and straighten up.
- To protect: This is its most critical duty. The spinal cord passes through the canal in the middle of the vertebrae; nerve roots exit at every level and spread out to the arms and the legs.
Between the vertebrae are the discs, which act as shock absorbers, and at the back are the facet joints, which guide movement. Ligaments and muscles hold this whole structure together. Spine surgery, then, deals with the situations in which this delicate balance is disrupted.
What Is Spine Surgery?
Spine surgery is the field concerned with the surgical treatment of conditions affecting the spine and the nerve structures within it. Broadly speaking, it has two fundamental aims:
- Decompression (making room for the nerve): Relieving a spinal cord or nerve root that is under pressure. In situations such as a herniated disc or canal stenosis, this is the main goal.
- Stabilization (making it solid): Restoring the structure when the spine’s load-bearing capacity or alignment is disrupted. This is needed in fractures, in advanced slippage, and in deformities.
In some operations, only the first is done; in others, both together.
For Which Conditions Is Spine Surgery Used?
Lumbar and Cervical Disc Herniation
This is the situation we encounter most often. When a disc protrudes out of its place and presses on a nerve root, pain radiating into the leg or the arm, numbness, and loss of strength appear. However, roughly 80–90% of herniations resolve without surgery; surgery comes onto the agenda in situations such as severe pain that does not go away or progressive loss of strength.
Spinal Stenosis (Narrowing of the Spinal Canal)
With age, thickening ligaments, enlarging facet joints, and protruding discs narrow the canal. The typical complaint is this: pain and numbness radiating into the legs the more one walks, with relief on sitting down or bending forward. My patients usually describe this as “I feel better when I lean on the shopping cart.” In advanced cases, decompression surgery provides marked benefit.
Spondylolisthesis (Slippage of a Vertebra)
This is the forward slipping of one vertebra over the one beneath it. While low-grade slippages (Grade 1–2) are mostly followed without surgery, fusion surgery may be needed in high-grade, progressive slippages or those causing nerve compression.
Spinal Fractures
Two different pictures need to be distinguished. Traumatic fractures occur after a fall from a height or a traffic accident; if there is a risk of spinal cord damage, they may require emergency surgery. Osteoporotic (bone-loss-related) compression fractures, on the other hand, appear at an advanced age, sometimes even with a simple movement; in some of these, closed methods such as vertebroplasty or kyphoplasty are applied.
Spinal Tumors
Tumors that begin primarily in the spine are relatively rare; what we see more often is the spread of a cancer from another organ to the spine (metastasis). The aim is to relieve the spinal cord from pressure, to preserve the spine’s solidity, and to reduce pain. These cases are managed together with oncology and radiation oncology.
Spinal Infections
Inflammation of the disc and vertebra (spondylodiscitis) is generally treated with antibiotics. However, surgery is required if an abscess has formed, if there is pressure on the spinal cord, or if the spine has collapsed.
Spinal Curvatures (Scoliosis and Kyphosis)
Mild curvatures are managed with follow-up and exercise, and moderate ones in children and adolescents with a brace. Surgery is considered when the curvature exceeds a certain degree, progresses rapidly, or affects organs such as the lungs.
Degenerative Disc Disease
This is the age-related wearing of the discs. Seeing it on an MRI alone is not a reason for surgery; everyone has some degree of wear. Surgery only comes onto the agenda when nerve compression or spinal instability is added.
Does Every Spinal Condition Require Surgery?
Absolutely not. This is the point I emphasize most to my patients. The great majority of spinal conditions are managed with non-surgical (conservative) methods:
- Short-term rest and sensible adjustment of activity
- Painkillers and anti-inflammatory medications
- Physical therapy and a personalized exercise program — the most important pillar of treatment
- Ergonomic adjustments, weight control, quitting smoking
- Interventional pain treatments (injections) when needed
Surgery comes onto the agenda when these options are exhausted, or when an emergency situation is present from the outset.
How Is the Decision to Operate Made?
There is a fact here that I want to underline with a thick line: the decision to operate is not made by looking at the MRI; it is made by looking at the patient.
On spine MRIs taken after the age of forty, disc protrusions, wear, and mild narrowing are seen even in people who have no complaints at all. These are the normal traces of life. What is decisive is that your complaints, your examination findings, and the imaging confirm one another. If a finding on the image does not explain the picture the patient is experiencing, that finding is not a reason for surgery.
I generally recommend surgery in the following situations:
- Severe pain that does not go away despite an adequate period of properly applied non-surgical treatment and that disrupts quality of life
- Progressive loss of muscle strength (such as foot drop or loss of dexterity in the hand)
- Disruption of bladder and bowel control (cauda equina syndrome — an emergency)
- Findings of pressure on the spinal cord in the neck (myelopathy)
- A fracture, tumor, or infection that disrupts spinal stability
Methods Used in Spine Surgery
Microsurgery
This is the method in which work is carried out through a small incision, under a surgical microscope. Microdiscectomy, applied in lumbar disc herniation, is its best-known example. Because the microscope provides both magnification and excellent illumination, the nerve tissue is protected far more safely.
Endoscopic Spine Surgery
This is the method performed through an incision of a few millimeters, guided by a camera. It is suitable in selected herniation and canal stenosis cases. Its advantage is that tissue damage is minimal and recovery is fast; however, it is not suitable for every patient or every pathology.
Minimally Invasive Surgery (MIS)
This aims to reach the spine by separating the muscles (with tubular systems) rather than cutting them. It provides less bleeding, less pain, and getting back on one’s feet faster. Even so, this does not mean “every operation should be done in a closed manner” — in some situations, open surgery is still the most correct choice.
Decompression (Laminectomy / Laminotomy)
In canal stenosis, this is the clearing away of thickened ligament and bone tissue from the spine in a way that makes room for the nerve.
Fusion and Instrumentation
This is the fusing together of two or more vertebrae using screw-and-rod systems and bone graft. The aim is to stop the abnormal movement at that level and to make the spine solid. It is applied in slippage, fractures, deformity, and some advanced degenerative conditions.
Let me answer here the question my patients ask most often: “If screws are placed, will I never be able to bend again?” No. There are more than 30 mobile levels in the spine; the fusion of one or two levels does not markedly restrict your daily movements.
Motion-Preserving Surgery (Disc Prosthesis)
Especially in cervical disc herniation, an artificial disc that preserves movement can be placed instead of fusion in suitable patients.
Vertebroplasty and Kyphoplasty
In osteoporotic compression fractures, bone cement is delivered into the vertebral body with a needle, aiming to reduce the pain and to stop the collapse.
The Technologies That Make Surgery Safe
- Neuronavigation and intraoperative imaging (O-arm / C-arm): Enables the screws to be placed with millimetric accuracy.
- Intraoperative neuromonitoring: Throughout the operation, the nerve pathways are monitored electrically; when a risky region is approached, the system gives a warning. This is one of the strongest reassurances against the fear of paralysis.
- Robot-assisted systems: In selected cases, they reduce the margin of error in screw placement.
The Period After Surgery
Recovery varies greatly according to the operation performed and the patient’s age and general condition. For this reason, it would not be right to give a single duration. However, the general framework is this:
- Early movement is essential. After a simple microdiscectomy, patients are usually gotten on their feet the same day or the next day. The belief that “one must lie down for months after surgery” is not correct; immobility delays healing.
- In fusion operations, the fusing of the bone takes months; during this period, certain restrictions and regular follow-up are needed.
- Physical therapy is, in most patients, an inseparable continuation of the operation. Surgery makes room for the nerve; strengthening your muscles again falls to you.
- Smoking seriously hinders the fusing of the bone. I particularly recommend quitting to every patient for whom a fusion is planned.
Risks and Complications
I have to be honest: no operation is without risk. The possible risks of spine surgery are:
- Bleeding and infection
- Cerebrospinal fluid leak
- Nerve injury; rarely, loss of strength or paralysis
- In fusion operations, failure to fuse (pseudarthrosis) or problems with the screws
- The development of a new problem at the adjacent level over time
- Recurrence of the herniation
- General risks related to anesthesia
I must also add this: thanks to microsurgery, navigation, and neuromonitoring, rates of serious complications have decreased markedly compared with the past. However, risks vary according to the operation to be performed, the type of the condition, and your general state of health. Only the surgeon who evaluates you can explain the risk profile specific to you. Do not hesitate to have this conversation.
Managing Expectations: What Does Surgery Promise, and What Does It Not?
I am including this heading in particular, because most disappointments arise from here.
The area in which spine surgery is at its strongest is relieving pain radiating into the arm or the leg due to nerve compression. In this type of pain, the results are generally very satisfying. In contrast, in chronic low back pain due to years of wear, expectations of surgery should be more measured; here, exercise, weight control, and lifestyle changes are often more decisive than surgery.
Furthermore, surgery does not return your spine to the state it was in at the age of twenty. Our aim is to free you from pain and to restore your function — not to turn back time.
For Which Symptoms Should a Doctor Be Consulted Without Delay?
The following findings require urgent evaluation. If one of them is present, please go to the nearest emergency department without delay:
- Losing control of urine or stool, incontinence
- “Saddle-shaped” loss of sensation in the anal region, buttocks, and inner thighs
- Suddenly starting, progressive marked loss of strength in the legs or arms
- Loss of dexterity in the hands (difficulty with buttoning or writing), impaired balance, stumbling while walking
- Low back pain accompanied by fever, night sweats, and weight loss
- Severe low back or neck pain after trauma
- Pain that does not go away with rest and wakes you from sleep at night
Frequently Asked Questions
Below, I have gathered the most frequently asked questions about spine surgery along with brief answers. These answers are for general information; the information that applies to your specific situation is the one given by the doctor who examines you.
What is spine surgery, and for which conditions is it used?
It is the surgical treatment of conditions affecting the spine and the nerve structures within it. Lumbar and cervical disc herniation, canal stenosis, spondylolisthesis, spinal fractures, tumors, infections, and curvatures such as scoliosis are its main areas of application. The aim is either to make room for the nerve (decompression) or to make the spine solid (stabilization).
Which department should one go to for spine surgery?
Spinal conditions are handled by physicians working in the field of spine surgery within Neurosurgery (Brain and Nerve Surgery) and Orthopedics. In the non-surgical treatment process, meanwhile, Physical Medicine and Rehabilitation plays an important role. Going to neurosurgery does not mean you will definitely have surgery.
Does every spinal condition require surgery?
No. The great majority are managed with medication, physical therapy, exercise, and lifestyle adjustments. Surgery comes onto the agenda in situations such as severe pain that does not go away, progressive loss of strength, disruption of sphincter control, or a fracture, tumor, or infection that disrupts spinal stability.
Does spine surgery cause paralysis?
This is the fear I hear most often. Nerve injury and the resulting loss of strength are a risk that exists theoretically but is rarely seen. Today, thanks to microsurgery, neuronavigation, and intraoperative neuromonitoring, this risk has decreased markedly. I recommend discussing your own risk level with your surgeon.
Can closed (endoscopic) spine surgery be done for everyone?
No. Endoscopic and minimally invasive methods give very good results in selected patients; however, not every pathology can be safely resolved with these methods. In situations such as slippage, advanced deformity, or those requiring wide decompression, different techniques may be needed. “Closed” does not always mean “better”; the right method for the right patient is what matters.
If screws and plates are placed in the spine, will movement be restricted?
Not markedly. Because there are many mobile levels in the spine, fusing one or two levels does not seriously affect your daily life. Furthermore, in some situations such as cervical disc herniation, a disc prosthesis that preserves movement is also an option in suitable patients.
How long does recovery take after spine surgery?
It varies greatly according to the operation performed; for this reason, it would not be right to give a single duration. While patients are usually on their feet very quickly after procedures such as microdiscectomy, in fusion operations the fusing of the bone takes months. Only the surgeon following you can tell you the exact duration.
Does a herniation recur after surgery?
Recurrence is a situation that is possible but seen in a minority. The most effective ways to reduce the risk are strengthening the abdominal and back muscles with regular exercise, adopting the correct lifting technique, maintaining weight control, and quitting smoking.
My MRI shows a herniation and wear — should I have surgery?
Seeing a finding on an MRI is not a reason for surgery on its own. After the age of forty, a significant proportion of people who have no complaints at all also have similar findings. What is decisive is that your complaints and examination findings match the imaging. We treat the patient, not the image.
Disclaimer (Legal Notice)
The information contained in this article has been prepared for general informational purposes only and in no way replaces a medical examination, diagnosis, or treatment. The diagnosis of spinal conditions, the decision to operate, the surgical method to be applied, the risks, and the recovery process vary greatly according to the type of the condition, the severity of the complaints, the examination findings, and the person’s general state of health, and can only be determined by a doctor who evaluates you. For any decision regarding diagnosis and treatment, always consult a specialist physician. If the emergency symptoms mentioned above are present, go to the nearest healthcare facility without delay.