Dr Kantha’s focus on spine surgery was shaped by the rise in spinal cases during his time at Hospital Kuala Lumpur (1998–2019), which prompted him to adopt minimally-invasive techniques. — AZMAN GHANI/The Star
When we think of neurosurgeons, brain or skull-based surgery often comes to mind.
However, these specialists also play a central role in treating spinal conditions.
Consultant neurosurgeon Datuk Dr Kantha Rasalingam explains that neurosurgeons are trained to operate on the spine, brain, spinal cord and peripheral nerves.
Orthopaedic surgeons, on the other hand, primarily focus on bones and the structural aspects of the spine.
“Orthopaedic surgeons who wish to specialise in spine surgery must undergo subspeciality training,” says the Neurosurgical Assocation of Malaysia immediate past president.
“For neurosurgeons, however, spine surgery is already part of their core training.”
One key distinction between the specialities lies in surgical technique.
According to Dr Kantha, neurosurgeons receive extensive training in microsurgery, which involves highly-precise procedures using specialised instruments and operating microscopes.
“This expertise is particularly important when working close to the spinal cord and nerves,” he explains.
While orthopaedic surgeons have traditionally focused on bone surgery and biomechanics, many now also use microscopes and advanced surgical techniques.
Today, spine surgery is often a collaborative effort between the two specialities.
“Each speciality brings different strengths,” notes Dr Kantha.
In complex cases, such as long or multi-segment procedures, or surgeries involving the spinal cord or spinal cord compression, both specialists may operate together as a team.
Beyond the bones
When spinal problems involve the nerves or spinal cord, a neurosurgeon is often the specialist best equipped to treat them.
Dr Kantha notes that neurosurgeons are particularly well-suited to treating conditions like myelopathy, which is a neurological condition caused by compression of the spinal cord.
“It can lead to symptoms such as numbness, weakness, tingling, poor balance and loss of fine motor control, most commonly affecting the hands and legs,” he explains.
Neurosurgeons also frequently manage spinal cord tumours, whether benign or malignant, depending on the tumour’s location.
“Because we are trained to operate on the brain and spinal cord – two of the body’s most delicate structures – precision is one of our key strengths,” he says.
While there is overlap between the two specialities, certain spinal conditions are more clearly divided.
Orthopaedic surgeons bring particular expertise in spinal alignment, biomechanics and structural stability.
“For example, scoliosis is typically managed by orthopaedic surgeons, as it involves long spinal segments and biomechanical correction, rather than nerve issues,” he says.
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“Neurosurgeons, on the other hand, commonly manage conditions such as spinal cord tumours and spinal bleeding, which orthopaedic surgeons usually do not perform.”
One of the most common spinal conditions neurosurgeons see, where nerve involvement is a key factor, is the slipped disc.
Dr Kantha explains that a slipped disc occurs when the disc between two spinal bones, which acts as a gel-like shock absorber, gradually dries out with age.
As the disc flattens, often due to prolonged sitting, heavy lifting or poor posture, it can bulge backwards and compress a nearby nerve, causing pain.
“This condition is very common in people over 40,” he says.
“However, we are increasingly seeing it in younger adults due to lifestyle factors such as excessive phone use and improper lifting, particularly in the neck.”
Lifestyle modification plays a key role in prevention, he stresses.
When it comes to treatment, Dr Kantha explains that the focus is always on managing the patient’s symptoms.
Most slipped disc cases do not require surgery, he says.
“Treatment usually begins with medication, pain management and physiotherapy, often over three to six months to allow for recovery.
“If symptoms persist, minimally-invasive procedures may be considered.
“Advances in technology now allow treatments such as radiofrequency therapy, which use precise injections to block pain signals and reduce discomfort.
“There is a wide range of treatment options, from medication at the mildest end to surgery only when necessary,” he notes.
Slipped discs – seen here at L5–S1 level (delineated by the dotted green lines) – are one of the most common spinal conditions neurosurgeons treat. — Prince Court Medical Centre
Surgery only when necessary
Not every spinal condition requires surgery, and careful patient selection is essential.
With nearly two decades of experience and thousands of cases under his belt, Dr Kantha emphasises that surgery is only recommended when it is truly necessary.
“Neurosurgeons today perform fewer spinal operations than in the past because the indications for surgery are stricter,” he explains.
“Surgery is reserved for cases where conservative treatment has failed or where there is a clear medical necessity.”
Conservative treatment includes medication, physiotherapy and other pain-management approaches.
He notes that around 80% of people over 40 experience back or neck pain at some point, but only a small proportion ever require surgery.
“This is why a thorough assessment is so important,” he says.
“Each patient’s condition, such as the size and location of a disc problem or fracture, must be carefully evaluated to determine the most appropriate treatment.”
He adds that decisions are made jointly.
The doctor explains the diagnosis, available options, risks and expected outcomes, while the final decision is reached together with the patient.
Advances in technology
Spine surgery today is also not how it used to be many years ago.
Advances in technology have transformed spinal care, making surgery more precise, less invasive and safer for patients.
According to Dr Kantha, spine surgery has evolved rapidly with the introduction of tools such as endoscopes, surgical navigation systems and robotic assistance.
“These technologies allow surgeons to operate with far greater accuracy and safety,” he explains.
“In the past, a severe slipped disc compressing the nerves required a large open operation that could take two to three hours.
“Today, the same condition can often be treated using minimally-invasive endoscopic spine surgery.”
Keyhole surgery, also known as minimally-invasive surgery, uses small incisions instead of one large cut, allowing surgeons to operate inside the body with the help of a tiny camera.
This technique involves inserting an endoscope through a one-centimetre incision.
A small tube is then used to remove the damaged disc, with the procedure typically taking around 45 minutes.
Dr Kantha clarifies that the tube is not permanent – it is used only to access the spine and is removed after the disc is excised.
Unlike older methods, which required four- to five-centimetre incisions and cutting through muscle, the modern tubular system separates muscle fibres rather than cutting them.
This approach results in less pain, reduced bleeding and faster recovery.
“Instead of an operation lasting two to three hours, the endoscopic approach usually takes under an hour,” he says.
Patients can often walk the next day and are discharged within two to three days, compared with five days to a week following traditional open surgery.
These innovations mean that many patients no longer require large incisions and lengthy hospital stays, instead benefiting from safer procedures and quicker recovery times.
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“We now also have navigation systems, which use specialised devices to show exactly where we are during surgery, and robotics, which assist us in performing procedures,” adds Dr Kantha.
“This shows that a large, invasive surgery is often unnecessary when these alternatives are available.”
He adds that the number of neurosurgeons performing spinal surgery in Malaysia has steadily increased.
“In the early days, there were very few neurosurgeons, and the high volume of brain cases meant that most focused mainly on brain surgery,” he says.
“As the speciality grew, more neurosurgeons began taking on spinal procedures as well.”
Today, an estimated 50 to 60 neurosurgeons in Malaysia regularly perform spinal surgery, reflecting the field’s continued growth and expanding expertise.
