Many of the destructive and compression lesions in the spine, including disc herniations, pondylolisthesis, spinal tumors, spinal fractures and spinal infections, may require surgical intervention to stabilize the spine or remove the neural compressive lesion. In recent years, there has been a rapid expansion in the number and complexity of available surgical options. The surgical techniques can be divided into three basic categories.

The first includes the minimally invasive techniques in which the vertebral structure being operated on is approached using either needles or catheters to inject proteolytic chemicals into the disc, steroids or analgesics into the facets and paraspinal soft tissue structures, or a thermal needle into the disc to ablate the discal tissues. These methods, however, can only be used in well-localized lesions that can be accessed percutaneously. The second approach is surgical decompression. This is the more common procedure, as many lesions of the lumbar spine require removal of a mass lesion, such as a disc protrusion, tumor or abscess, througha surgical incision. This requires dissection of the skin and musculature to reach the lesion, followed by the surgical removal of the offending lesion. The spinal structures can be approached surgically from the back through the posterior spinal musculature,through the ribcage via a flank incision, or anteriorly through the neck or abdomen. The third category of surgical procedures are those which attempt to reduce mobility in the spine by fusing two or more segments. Such fusion can be achieved by approaching the spine either posteriorly or anteriorly. The surgeon may elect to place cortical or cancellous bone grafts across two or more vertebrae in order to create a bony fusion through Figure 8.1 Posterior fusion of the lumbar spine Longitudinal section through the lumbar spine shows surgical bone graft fusion of the posterior elements of L3 to the sacrum, with narrowing of the L2–L3 disc and canal at this level due to new bone formation above the fusion