Find Spine Specialists & Information on Spine Surgery

Spinal surgery is a highly specialized medical discipline. It focuses on the surgical treatment of patients with conditions and diseases affecting the spine and spinal cord.

The spine is the supporting structure of the skeletal system. It enables an upright posture and connects the other parts of the skeleton to one another. The spinal canal within the spine houses the delicate spinal cord. For this reason, spinal surgery requires the utmost precision and a skilled spinal surgeon.

As a general rule, spinal surgery requires an interdisciplinary approach. This means that specialists from a wide range of fields use their expertise to address all questions that arise regarding the diagnosis and treatment of spinal disorders. These include, in particular, specialists in orthopedics and trauma surgery, as well as specialists in neurosurgery.

Spinal surgery is often also a subspecialty of neurosurgery—since the spinal cord is the starting point of the peripheral nervous system. The therapeutic and scientific focus of this field is on degenerative and tumor-related disorders of the spine and spinal cord; in other words, it classically addresses spinal cord injuries and spinal disorders. The most common reasons for surgery are tumors or compression.

The range of surgical procedures extends from the treatment of inflammation and paralysis to herniated discs—including those in the cervical spine—and disc degeneration (discopathies), as well as instability of the cervical, thoracic, and lumbar spine. Osteoporosis with neurological symptoms also falls into this category. Incidentally, surgeries on the spine and spinal cord are increasingly being performed using minimally invasive techniques.

The spine is subjected to stress—sometimes extreme—on a daily basis. This can lead to signs of wear and tear—degenerative diseases of the spine. These can be very painful at rest or under stress, such as a herniated disc or narrowing of the spinal canal—spinal stenosis. The following spinal conditions are frequently treated through spinal surgery:

• Degenerative changes (e.g., herniated disc, spinal stenosis, osteochondrosis, spondylosis, spondylarthrosis, and degenerative lumbar scoliosis or neural foramen stenosis),
• Spinal instability (spondylolisthesis or spondylolysis),
• Inflammatory rheumatic diseases, such as ankylosing spondylitis, with associated spinal deformities, or rheumatoid arthritis (chronic polyarthritis),
• Infections and inflammation in the spinal region, such as infectious spondylodiscitis, 
• Spinal injuries, e.g., a vertebral fracture or damage to the spinal cord within the spinal canal resulting from an accident, which can lead to paraplegia,
• Tumors of the spine, such as transspinal tumors or tumors in the spinal cord,
• Scoliosis

The most widely used diagnostic method in spinal surgery is magnetic resonance imaging (MRI), which provides highly detailed images of the vertebral bodies, nerves, and intervertebral discs.

In addition, X-rays of the relevant region of the spine in two planes while standing, as well as a lateral X-ray of the spine while standing—including the femoral heads—are necessary to assess sagittal balance.

Spinal surgery techniques can vary widely and depend heavily on the specific condition. Today, in many cases, an endoscopically assisted,minimally invasive surgical technique is the standard. This spinal surgery method is very gentle on the patient.

Below, you’ll learn more about the various spinal surgery procedures used to treat the most common spinal conditions.

In a herniated disc, a tear or fissure in the annulus fibrosus (the fibrous cartilage ring surrounding the disc) causes disc tissue to protrude into the spinal canal. This compresses the spinal cord or the nerve roots.

This results in severe pain, which often radiates into one limb, and characteristic deficits in sensation, motor function, and reflexes in the area innervated by the pinched nerve root; in some cases, it can also lead to paralysis.

A definitive diagnosis of a herniated disc is made using magnetic resonance imaging (MRI) or, alternatively, computed tomography (CT).

Surgery for a herniated disc is not always necessary. If there are no neurological deficits, conservative treatment measures are often used. These include, for example,

• anti-inflammatory and pain-relieving medications,
• infusions,
• plexus analgesia, and
• CT- or X-ray-guided periradicular injections.

In the latter procedure, cortisone is injected into the affected nerve root under CT or X-ray guidance. This results in pain relief for the majority of patients.

Since the complication rate for disc surgery is relatively high, surgical treatment of a herniated disc should only be considered after conservative measures have failed or when there is a clear indication. Common complications include:

• scarring,
• recurrence of the herniated disc,
• infections,
• leakage of cerebrospinal fluid.

Symptoms that indicate the need for immediate or prompt disc surgery include

• cauda equina syndrome (compression of the nerve fibers in the cauda equina region) with signs of paralysis,
• bladder and rectal paralysis, as well as
• progressive or acutely onset severe muscle weakness.

The standard surgical procedure for a herniated disc today is microsurgical discectomy using a surgical microscope, which has almost completely replaced open discectomy. Alternatively, a herniated disc can also be treated using minimally invasive procedures.

Microsurgical discectomy: The standard surgical procedure for a herniated disc

During microsurgical discectomy, performed under general anesthesia with the patient in the prone position, the protruding portion of the intervertebral disc (partial discectomy) or the entire disc—as well as disc tissue that has slipped into the spinal canal—is removed through a small skin incision. This reduces the pressure on the spinal cord or the nerve root.

Although this disc surgery is relatively minimally invasive for the patient, complications can occur, as with any surgery. For example, in rare cases, the nerve may be injured during the procedure. As a result, patients may experience sensory abnormalities and impairments in motor function, bladder and bowel function, as well as sexual dysfunction. Some patients also develop what is known as Failed Back Surgery Syndrome. In this condition, despite successful disc surgery, radiating pain in the leg and sensory disturbances persist over the long term.

Other Surgical Methods for Herniated Discs

In open discectomy—which is now rarely performed due to the higher rate of serious complications (e.g., in cases of spinal deformities)—the disc material is removed through a larger skin incision.

Another option for treating a herniated disc is endoscopic discectomy. In this procedure, performed under local anesthesia, high-resolution endoscopes, video systems, and micro-instruments are used.

The surgical instruments and the endoscope are inserted through small skin incisions, and the disc tissue is carefully removed. However, this procedure cannot be used for every type of herniated disc (not for disc material that has detached and is located within the spinal canal) or at every location along the spine (not between the lumbar spine and the sacrum).

For herniated discs where the annulus fibrosus remains intact, minimally invasive procedures are also used. Common procedures include, for example,

• thermal ablation,
• chemonucleolysis, and
• laser ablation.

In these methods, the intervertebral disc tissue is dissolved using heat, a chemical (chymopapain), or a laser.

If the entire intervertebral disc is removed during surgery for a herniated disc, an implant may occasionally need to be inserted as a disc replacement.

Age- and stress-related degenerative changes (signs of wear and tear) in the spine develop in most people as they age. However, they do not always cause clinical symptoms.

Spinal canal stenosis (narrowing of the spinal canal) can result from bony spurs in the spinal canal, degenerative changes and bulging of the intervertebral disc, as well as osteoarthritis of the small facet joints.

As a result, the spinal cord is irritated by the now-narrowed canal, or the nerve roots are no longer adequately supplied with blood, leading to the typical symptoms of spinal canal stenosis: abnormal sensations and pain that radiate into the legs and usually result in a reduced walking distance.

In addition to such signs of wear and tear, there are other acquired (e.g., spinal surgery) and congenital (e.g., spinal malformations) causes that can lead to the development of spinal canal stenosis.

Asymptomatic spinal stenosis does not require treatment. However, if spinal stenosis causes symptoms, the decision regarding whether and which treatment is necessary depends on the clinical presentation, the extent of the narrowing, and the patient’s level of distress.

Treatment for spinal stenosis may consist of conservative measures (e.g., physical therapy), medication (for pain relief), or surgery.

However, surgery is absolutely necessary in only about 2% of patients with spinal canal stenosis.

Surgery for Spinal Canal Stenosis

An absolute indication for surgery for spinal canal stenosis exists in cases of

• a significantly reduced pain-free walking distance,
• in cases of unbearable pain,
• acute, severe neurological deficits (symptoms of paralysis) or bladder and bowel dysfunction, as well as
• cauda equina syndrome.

However, surgery is also strongly recommended in cases of treatment-resistant pain with limited mobility.

During spinal stenosis surgery, the structures that narrow the spinal canal are removed. This reduces pressure on the nerves (decompression). Today, minimally invasive surgical techniques are the standard.

The following procedures are available in spinal surgery:

• In decompression with fusion, the spinal canal is widened, and the vertebrae are then connected to one another using screws and rods, thereby stabilizing the spine. Damaged intervertebral discs are removed, and a so-called cage (titanium cage) is implanted as a spacer.
• In ventral nucleotomy with fusion, the intervertebral disc is removed using microsurgical techniques, the affected vertebrae are fused together, and a spacer is inserted.
• In ventral uncoforaminotomy with fusion, the vertebral body in the area of the spinal canal is milled away to widen it, and the spine in this section is stabilized by fusing the affected vertebrae.
• In intradiscal electrothermal therapy (IDET), the nerve fibers in the intervertebral disc are destroyed by slow heating, thereby strengthening the collagenous tissue in the disc.
• In decompression with implantation of an intervertebral disc prosthesis, the spinal canal is widened and the defective intervertebral disc is replaced with an implant.
• In a corpectomy with spondylodesis, a vertebra is removed, the adjacent vertebrae are fused together, and a titanium cage is inserted into the gap to serve as a spacer.
• In straightening spondylodesis with fusion, several vertebrae are fused together.

In motion-preserving surgical procedures (e.g., flexible spinal stabilization), a dynamic implant is inserted. It stabilizes the vertebrae while preserving their mobility.

Scoliosis is a deformity of the spine in which the spine is displaced laterally, the vertebrae are twisted (rotation), and the vertebral bodies are distorted.

In most cases, the cause of scoliosis is unknown (idiopathic scoliosis). Only in about 10% of patients with scoliosis can the cause be attributed to a congenital disorder (congenital scoliosis) or be a consequence of another condition (secondary scoliosis, e.g., following trauma or in cases of muscular dystrophy).

Mild scoliosis is actually not that uncommon. It either causes no symptoms at all or remains stable with physical therapy. However, if the scoliosis continues to progress, it can manifest, for example, as a rib hump, an asymmetrical head posture, and back problems.

If it continues to progress, it can lead to severe limitations in movement and degenerative changes in the vertebral bodies, and even to significant deformation of the rib cage.

Surgery for Scoliosis

About 90% of all patients with scoliosis do not require surgery. In these cases, scoliosis can be treated conservatively with physical therapy and, if necessary, a brace. However, if the heart and lungs are constricted by the deformation of the rib cage, surgery becomes unavoidable.

The Principles of Scoliosis Surgery

• Straightening the curvature as much as possible
• Correction of rotation
• Stabilizing the correction with implants
• Fusion of the spine.

Scoliosis surgery can be performed from the front (ventral), from the back (dorsal), or from both sides (dorsoventral or ventrodorsal). The following procedures may be used:

• In dorsal scoliosis correction, the lateral curvature of the spine is corrected by inserting screws and hooks into the vertebrae of the affected segment, which are then connected to a rod system. However, this fusion of the spine restricts the overall mobility of the vertebral column.
• In ventral derotation spondylodesis, the spine is exposed through the chest or abdomen, the intervertebral discs in the affected area are removed, and screws are inserted into the vertebral bodies to be corrected. The screws are then connected with a rod. Wearing a brace is often still necessary after the surgery.
• The ventrodorsal procedure is performed for some severe forms of scoliosis (e.g., double curves). The dorsal and ventral approaches can be performed in one or two sessions.

A vertebral fracture can occur in the vertebral body, the spinous process, or the vertebral arch. In most cases, a vertebral fracture results from an accident, a fall, or physical trauma. Due to bone fragments or displacement of the spine, the spinal canal is often affected in a vertebral fracture. This carries the risk of paraplegia.

In older adults, a vertebral fracture can also result from osteoporosis. A stable vertebral fracture may be asymptomatic.

However, the following symptoms may also occur:

• Sudden onset of back pain
• Abnormal reflexes
• Sensory disturbances
• Signs of paralysis
• Limited mobility
• Paraplegia

A stable vertebral fracture can often be treated conservatively. This includes

• pain management,
• mobilization through physical therapy,
• improving posture, and
• back-friendly movement,
• and, if necessary, wearing a brace.

An unstable vertebral fracture that affects the spinal cord and/or internal organs must be treated surgically through spinal stabilization (usually via kyphoplasty or spondylodesis).

All spinal surgery should be performed by a specialist. The primary goal is spinal stabilization through the dynamic or static fusion of the vertebrae in the affected segment of the spine. Spinal stabilization relieves pressure on structures that are already damaged or compressed and prevents further damage to the spinal cord and nerves.

The following surgical methods are commonly used to treat vertebral fractures:

• Spondylodesis (vertebral fusion): Fusion of two or more vertebrae. Spondylodesis is a common procedure for spinal stabilization in which screws are inserted into the vertebrae and connected with rods. The procedure is also used to treat spondylolisthesis.
• Kyphoplasty: a minimally invasive procedure in which either a balloon is inserted into the collapsed vertebra and the resulting cavity is then filled with bone cement, or the fractured vertebra is stabilized using only a special bone cement.

Spine specialists are usually medical specialists in the fields of orthopedics and trauma surgery, as well as neurosurgery. Their medical subspecialty is spinal surgery.

The field of neurosurgery encompasses the diagnosis, as well as the surgical and conservative treatment, follow-up care, and rehabilitation of diseases, injuries, and malformations affecting the central nervous system, the blood vessels, and the peripheral and autonomic nervous systems.

The residency program currently lasts six years, with five years generally devoted to inpatient care and six months to intensive care for neurosurgical patients. Half a year or a full year may currently be recognized, for example, as part of specialty training in related surgical fields such as trauma surgery, orthopedics, general surgery, or in a non-surgical specialty such as neurology. In addition, as mentioned above, many specialists in spinal disorders also hold board certification in orthopedics and trauma surgery.

It is not possible to designate a hospital or spine center as the “best hospital” or “top hospital” for spinal surgery. There are certainly spinal surgeons who specialize in specific procedures and have extensive experience. You can find these experts in spinal surgery in the Leading Medicine Guide.

Leading Medicine Guide features only highly qualified specialists from Germany, Austria, and Switzerland. Every specialist must meet the strict LMG quality guidelines. In addition, all listed spine surgeons possess a high level of professional expertise and have extensive experience in the field of spine surgery.