THERE IS NO NEED TO OPERATE MORE. WE NEED TO OPERATE BETTER.In spine surgery, doing more does not mean doing better.

When spine surgery is necessary, doing more does not necessarily lead to a better outcome. Today, endoscopy, minimally invasive techniques, navigation and new surgical strategies allow us to operate with increasing precision. But the real evolution in spinal neurosurgery lies above all in understanding how much needs to be done to solve the problem, while avoiding unnecessary involvement of structures that do not need to be treated.

When a patient comes to see me with an indication for surgery, their main concern is often the technique that will be used.

“Doctor, will it be minimally invasive surgery?”

“Can it be done endoscopically?”

“Will you need to use screws?”

“How many levels need to be operated on?”

These are understandable questions. But behind all of them lies an even more important one:

how much surgery is actually necessary to solve the problem?

In recent years, spine surgery has made enormous progress. We now have tools that allow us to see more clearly, reach certain structures through smaller approaches, plan procedures with greater precision and treat conditions that, in the past, required more invasive surgery.

However, this does not mean that the objective should simply be to perform smaller operations.

The objective is different:

to perform the surgery that is necessary, as precisely as possible.

IN BRIEF: Operating better does not necessarily mean operating less. It means choosing the surgery needed to solve the problem, while avoiding extending the procedure to structures that do not need to be treated.

Doing More Does Not Necessarily Mean Treating Better

When we talk about spine surgery, it may seem intuitive to assume that a more extensive operation will provide a more complete solution.

That is not necessarily the case.

Every structure involved in an operation has a function. Muscles, joints, ligaments, vertebrae and discs all contribute to the balance and movement of the spine.

This is why, once surgery is indicated, one of the most important decisions concerns the extent of the procedure.

Which structure needs to be decompressed?

Which level needs to be treated?

Is stabilisation necessary?

How many levels need to be involved?

Can the objective be achieved through a more limited approach?

These decisions are not driven by a desire to perform “less surgery” at all costs.

They depend on the problem we need to solve.

An operation that is too limited may not be sufficient. An unnecessarily extensive operation may involve structures that did not need to be treated.

The quality of surgery also lies in finding the right balance.

IS LESS ALWAYS BETTER? No. An operation must be extensive enough to solve the problem for which it is being performed. The aim is not to perform less surgery, but to avoid unnecessary surgery.

Minimally Invasive Surgery Does Not Simply Mean Making a Smaller Incision

One of the most common misunderstandings concerns the concept of minimally invasive surgery.

A smaller incision is certainly something the patient can see. But that alone does not make an operation less invasive.

As I have previously explained when discussing minimally invasive surgery and its real benefits, what matters most is what happens beneath the skin.

How much tissue do we need to pass through?

How much do we need to alter the anatomy to reach the area requiring treatment?

Which structures can we preserve?

Can we achieve the same surgical result through a less traumatic approach?

Endoscopic and minimally invasive techniques can offer important advantages precisely because, in appropriately selected cases, they allow us to reach the surgical target while limiting disruption to the surrounding tissues.

But the technique must serve the operation.

Not the other way around.

DOES MINIMALLY INVASIVE MEAN BETTER SURGERY? Not automatically. A minimally invasive technique is advantageous when it allows us to achieve the necessary result while reducing disruption to the tissues. The choice always depends on the condition being treated and the objective of the operation.

In Spinal Neurosurgery, a Few Millimetres Can Matter

This principle becomes particularly important when we are working with neurological structures.

The spine is not simply made up of bones and discs.

It also contains the spinal cord and nerve roots.

Spinal stenosis, a disc herniation or other conditions can compress these structures and cause pain, tingling, loss of sensation or reduced strength.

In these cases, our objective is not simply to “fix the spine”.

We need to identify where the compression is located, which neurological structure is involved, and which procedure can relieve that compression effectively and safely.

This is where diagnostic precision and surgical precision become inseparable.

I may have endoscopy, a microscope, navigation or other advanced technologies available to me.

But first I need to know exactly where I need to go and what I need to achieve.

WHY IS PRECISION SO IMPORTANT? Because the spine contains delicate neurological structures such as the spinal cord and nerve roots. The surgical strategy must precisely identify the structure responsible for the symptoms and the objective of the procedure.

Cervical Spine: It Is Not Simply About How Many Levels Appear Degenerated

The issue becomes even more delicate in cervical spine surgery.

An MRI scan may show abnormalities at several levels: disc protrusions, herniations, stenosis or disc degeneration.

But this does not automatically mean that all of those levels need to be treated surgically.

The decision depends on the relationship between what we see on the scans, the patient's symptoms, the neurological examination and any involvement of the spinal cord or nerve roots.

In some cases, surgery at several levels may be necessary. In others, a different strategy may be more appropriate.

This is one of the reasons why complex cervical spine neurosurgery requires particularly careful planning.

Especially when spinal cord compression is present, the question is not simply “how many levels are damaged?”, but:

which levels are actually putting neurological function at risk, and which strategy allows us to treat them in the most appropriate way?

Even apparently minor symptoms can be important. Loss of strength in the hands, or increasing difficulty with fine hand movements, for example, deserves neurological assessment when it may be related to a cervical spine condition.

I HAVE CERVICAL SPINE PROBLEMS AT SEVERAL LEVELS: DO THEY ALL NEED SURGERY? Not necessarily. The number of levels that need to be treated depends on neurological compression, symptoms, the clinical examination and imaging findings. Abnormalities at several levels on an MRI scan do not automatically mean that all of those levels need to be operated on.

Stabilise When Necessary, Preserve Whenever Possible

Another example is spinal stabilisation.

When instability is present, or when the surgical procedure itself makes stabilisation necessary, screws, rods or other systems may be essential to achieve the desired result.

But even in this situation, the question should not simply be:

“Do we use screws or not?”

The question is:

is stabilisation necessary in this case, and how extensive does it need to be?

Stabilisation inevitably alters the biomechanics of the part of the spine involved. This does not mean it should be avoided when it is necessary, but it does mean that there should be a clear indication for it.

Many patients are understandably concerned that spinal stabilisation may prevent them from moving normally. I have also addressed this when answering the question “Can you still bend with screws in your back?”.

Once again, the issue is not whether we use more or less technology.

It is about using it where it is needed and to the extent that it is necessary.

DOES SPINAL STABILISATION MEAN LOSING MOVEMENT? It depends on the location and extent of the procedure. Stabilisation limits movement in the segments that are treated, but not necessarily in the entire spine. This is why it is important to determine precisely which levels need to be stabilised.

Endoscopy, Navigation and Robotics: More Tools Mean More Options

Spinal neurosurgery now has access to tools that were far less widely available only a few years ago.

In selected cases, endoscopy allows us to reach certain structures through very small approaches.

Navigation can provide greater control during specific stages of an operation.

Robotics can support the planning and execution of particular procedures.

Minimally invasive techniques can reduce tissue disruption in certain operations.

All of this represents important progress.

But there is another aspect that I find even more significant:

having more tools allows us to tailor surgery more closely to the individual patient.

Not every patient needs to be operated on in the same way.

And conditions with the same name do not necessarily require the same operation.

This is why the real question is not which technique is the newest, but how to choose the most appropriate surgical procedure for that individual patient, their anatomy and their specific condition.

DO ROBOTICS AND ENDOSCOPY ALWAYS MAKE SURGERY BETTER? They are tools that can offer important advantages in selected procedures. Their value, however, depends on the indication: technology is useful when it helps us achieve the surgical objective more effectively, not simply because it is newer.

“Doctor, What Is the Best Operation?”

It is a question patients often ask me.

The answer is that there is no single operation that is best in every situation.

There is the most appropriate operation for that particular patient.

Sometimes it will be an endoscopic procedure.

Sometimes a traditional approach will be necessary.

In some cases, decompression will be sufficient.

In others, stabilisation will also be required.

Sometimes we will need to treat a single level; at other times, several levels.

The quality of surgery is not measured by how sophisticated the technique is or how small the incision may be.

It is measured by our ability to achieve the therapeutic objective without doing less than is necessary, but also without doing more than is needed.

WHAT IS THE BEST TYPE OF SPINE SURGERY? There is no single technique that is best in every situation. The procedure must be chosen according to the condition, the patient's anatomy, the neurological structures involved and the objective we need to achieve.

There Is No Need to Operate More. We Need to Operate Better.

For me, this does not mean performing smaller operations at all costs.

It means something different.

It means knowing different techniques so that we can choose between them.

It means planning the operation around the individual patient, not simply around the name of the condition.

It means preserving what can be preserved and treating what needs to be treated.

It means using technology when it offers a genuine benefit.

And it means recognising that, when we work close to nerves and the spinal cord, precision is not simply a detail of surgery: it is an integral part of surgery itself.

Modern spinal neurosurgery gives us an ever-growing range of possibilities.

But progress does not mean doing more and more.

It means being able to do exactly what is needed.

What Is Happening to Me? Patients' Questions

If I need spine surgery, is a smaller operation always better?

No. The objective is not to perform the smallest possible operation, but the most appropriate procedure to solve the problem. In some cases, a minimally invasive technique may offer important advantages; in others, a more extensive operation may be necessary.

If I have several disc herniations or several degenerated levels, do they all need to be operated on?

Not necessarily. Imaging findings need to be assessed alongside the patient's symptoms and neurological examination. We need to determine which levels are clinically relevant and which actually need to be treated.

If spinal stabilisation is recommended, does that mean I will no longer be able to bend?

Not necessarily. It depends on the area involved and the extent of the stabilisation. The objective is to stabilise the segment that requires it while, whenever possible, preserving the function of the other parts of the spine.

Does endoscopic surgery always mean less surgery?

No. Endoscopy is a very useful tool for selected indications, but it cannot replace other procedures when those procedures are necessary to treat the condition correctly.

How can I understand whether the proposed operation is the most appropriate one?

It is useful to ask what problem the operation is intended to solve, which structures will be treated, why that particular technique has been chosen and what alternatives may be available. In complex cases, or when major surgery has been proposed, it may also be useful to request a Second Opinion in spinal neurosurgery.

Fabio TresoldiSenior Consultant Neurospine Surgeon

For information about specialist consultations or to request a Second Opinion in spinal neurosurgery, please visit the relevant sections of this website.