Minimally Invasive Spine Surgery in Singapore | By Dr Teo Kejia

Microdiscectomy is a commonly performed minimally invasive spine procedure. It addresses herniated discs (when the cushioning between vertebrae pushes out and presses on nerves) that compress spinal nerves, causing leg pain (sciatica) or arm pain. Through a small incision and a tubular retractor, the surgeon uses a high-powered operating microscope to provide the magnification and illumination necessary to safely remove the disc fragment while protecting the delicate nerve roots.

The procedure typically takes under two hours. It is often performed as day surgery or with an overnight stay. Microdiscectomy may provide relief from radiating leg or arm pain, though outcomes differ among patients based on individual health factors.

For patients with spinal stenosis (narrowing of the spinal canal) causing nerve compression, minimally invasive decompression procedures remove bone spurs and thickened ligaments that narrow the spinal canal. Techniques include:

• Laminotomy: Laminotomy is a minimally invasive procedure where a neurosurgeon removes a small “window” of bone from the lamina to relieve pressure on a specific pinched spinal nerve. Unlike a laminectomy, which removes the entire bony roof of the spinal canal, this technique preserves most of the natural bone structure to maintain greater spinal stability. It is an ideal option for treating conditions like herniated discs or localised bone spurs while allowing for a faster recovery through a smaller incision.
• Foraminotomy: Foraminotomy is a spinal decompression surgery that enlarges the neural foramen—the bony opening on either side of the vertebrae (the small bones that make up your spine) through which spinal nerves exit the spinal column. The term derives from “foramen” (opening) and “otomy” (to cut or enlarge). During a foraminotomy, the neurosurgeon carefully removes small portions of bone, disc material, ligament tissue, or other structures that encroach upon the neural foramen, creating more space for the nerve root to function without compression.
• Laminectomy: Laminectomy, sometimes referred to as decompression surgery, is a surgical procedure where the surgeon removes part or all of the lamina—the bony arch forming the back of the spinal canal. This creates additional space for the spinal cord and nerve roots. The procedure aims to relieve pressure that causes pain, weakness, or numbness. Laminectomy directly addresses this issue by widening the spinal canal. The surgeon removes any bone spurs (extra bone growth), thickened ligaments, or disc material contributing to the compression. These procedures aim to create more space for the nerves, helping to relieve symptoms of claudication (leg pain that occurs with walking) and radiculopathy (pain caused by nerve irritation or compression).

These procedures differ based on the anatomical structure being addressed: Laminotomy creates a small window in the bone, Laminectomy removes the entire bony roof to open the central canal, and Foraminotomy focuses specifically on the nerve exit points.

When spinal instability or significant degenerative changes require fusion (joining two or more vertebrae together to prevent movement between them), minimally invasive techniques can accomplish vertebral fusion through smaller incisions. Common approaches include:

• MIS-TLIF (Minimally Invasive Transforaminal Lumbar Interbody Fusion): The surgeon accesses the disc space from a posterior-lateral approach (from the back and side), allowing disc removal, bone graft placement, and stabilisation with screws and rods.
• LLIF/XLIF (Lateral Lumbar Interbody Fusion): The surgeon approaches the spine through the side, particularly useful for certain levels and conditions.
• ALIF (Anterior Lumbar Interbody Fusion): The surgeon approaches from the front, sometimes combined with minimally invasive posterior fixation.

Modern minimally invasive spine surgery relies on several technological aids:

• Tubular retractors: Instruments that gradually widen the surgical corridor and gently spread rather than cut muscle tissue.
• Intraoperative imaging: Real-time X-ray imaging during surgery and sometimes navigation systems for instrument placement.
• Microscopes and endoscopes: Instruments that provide magnification and illumination for visualising small anatomical structures.
• Specialised instrumentation: Long, angled instruments designed for working through narrow corridors.

Thorough preparation helps support surgical outcomes. Before your minimally invasive spine surgery, you can expect:

Medical Evaluation

• Complete medical history review and physical examination
• Blood tests to check your overall health
• Cardiac evaluation (a heart health check) if indicated by your medical history
• Review of current medications, with instructions about which to continue or stop

Imaging Studies (tests that create pictures of your spine)

• MRI scans to create detailed images of soft tissues, discs, and compressed nerves
• CT scans are used when the doctor needs to see bone structures in detail
• X-rays, including flexion-extension views (images taken whilst you bend) to assess spinal stability
• Sometimes, diagnostic injections (pain-relief injections used to pinpoint the exact source of your pain)

Pre-operative Instructions

• Fasting requirements (typically nothing to eat or drink after midnight)
• Medication adjustments, particularly blood thinners (medications that prevent clotting)
• Smoking cessation, as smoking impairs healing and fusion outcomes
• Arrangements for post-operative transport and home support

On the day of surgery, you will be admitted to the hospital or surgical centre. After final preparations and safety checks, you will receive anaesthesia (medication that puts you to sleep). Spine procedures typically use general anaesthesia.

The surgical process follows these general steps:

• Positioning: The surgical team will carefully position you on the operating table. This is usually face-down (prone) for posterior approaches or on your side for lateral approaches.
• Incision and access: The surgeon makes a small incision. They then use sequential dilatators (gradually larger tubes that gently separate tissue) to create a working channel to the spine. This approach minimises muscle damage.
• Procedure execution: The surgeon uses magnification and specialised instruments to perform the necessary work. This might include removing pressure from nerves, taking out damaged disc material, or joining vertebrae together.
• Implant placement (if applicable): The surgeon positions screws, rods, cages, or other implants using imaging guidance (real-time X-ray images that help them place devices precisely).
• Closure: The surgeon closes the incision in layers, often with dissolvable sutures.

Procedure duration varies based on complexity. A microdiscectomy (removal of a small portion of a herniated disc) may take a relatively short time. A fusion procedure (joining two or more vertebrae together) may require several hours.

Following surgery, you will be monitored in the recovery area as anaesthesia wears off. The medical team will:

• Monitor vital signs (such as heart rate, blood pressure, and breathing) and neurological function (your ability to move and feel sensation)
• Manage pain with appropriate medications
• Encourage early mobilisation (getting up and moving) when safe
• Provide wound care instructions
• Watch for any immediate complications

Minimally invasive procedures may allow same-day discharge or a single overnight stay. Fusion procedures typically require a brief hospitalisation. Before discharge, you will receive detailed instructions about wound care, activity restrictions, medications, and warning signs requiring immediate attention.