MODERN neurosurgery and spine care are increasingly focused on two goals: intervening quickly when delay could cause irreversible harm, and avoiding unnecessary intervention when a patient can be safely managed without surgery.
This issue was discussed at a recent Neuroscience Excellence Showcase held at Pantai Hospital Kuala Lumpur.
At the event, consultant neurosurgeon Dr Kevin Sek and consultant spine surgeon Dr Ng Bing Wui explained why timing matters, how modern surgery has evolved, and why a scan alone should never determine whether someone needs an operation.
Time makes all the difference
In a neurological emergency, timely diagnosis can be critical.
Stroke is one of the most com-mon emergencies encountered by neurosurgical teams, and broadly falls into two categories: ischaemic stroke, caused by a blocked blood vessel, and haemorrhagic stroke, caused by bleeding in or around the brain.
“A scan can help you imme-diately identify what type of stroke it is,” said Dr Sek.
This distinction is important because the treatments are very different.
Depending on the type and severity of stroke, treatment may involve medication, an interven-tional procedure performed through the blood vessels, or in selected cases, surgery.
In a brain haemorrhage, some injury may already have occur-red by the time the patient reaches the hospital.
“The goal is to prevent secondary damage,” Dr Sek explained.
As bleeding and swelling increase pressure within the skull, previously unaffected brain tissue can become compromised.
“The longer the pressure increases in the brain, the more normal tissue gets affected.
“The idea is to get in and relieve the pressure as soon as possible.”
Not every brain haemorrhage requires an operation.
The decision depends on factors such as the location and size of the bleed, the patient’s neurological condition, and whether pressure on the brain is increasing.
But when emergency surgery is indicated, unnecessary delay can affect the chances of recovery.
Once the decision to operate has been made, Dr Sek said the team moves quickly.
“Usually, the earlier it’s done, the better the outcomes.
“Speed is of the essence, and experience does make a difference.”
Getting the right specialist
Modern neuroscience is rarely the work of one specialist alone.
The nature of the problem determines who needs to be involved.
“There’s a certain understand-ing among the team,” said Dr Sek.
Depending on the problem, he pointed out that some cases would involve an interventional radiologist, while others may require surgery.
This multidisciplinary approach means the treatment is determined by the patient’s condition rather than by the speciality of the first doctor they see.
Neurologists, neurosurgeons, interventional radiologists and other specialists can contribute different expertise to determine the most appropriate approach.
Dr Sek likened the neurological team to a Formula One pit crew, where every member has a clearly defined role and works together with speed, precision and coordination.
In complex neurological cases, this level of teamwork helps the team move efficiently from diagnosis to treatment, particu-larly in emergencies where delays may affect outcomes.
Smaller approaches to spine surgery
Spine surgery has also changed considerably over the past decade.
“The past five to 10 years have been about reducing unnecessa-ry collateral damage,” said Dr Ng.
Smaller incisions, endoscopic procedures and minimally-invasive or “keyhole” approaches can allow surgeons to reach the problem while reducing disruption to surrounding muscles and other healthy tissues.
“The keyword is minimally-invasive,” he said.
“Methods that can reduce recovery times and make the surgery more straightforward are much more preferable.”
For selected patients, minimally-invasive approaches may mean smaller incisions, less tissue disruption and potentially faster recovery.
However, the smallest incision may not necessarily be the best option for every condition.
The priority remains choosing the procedure that can safely and effectively address the underly-ing problem.
A “slipped disc” doesn’t always mean surgery
One of the most common concerns among patients is whether a diagnosis of a “slipped disc” means that surgery is inevitable.
Dr Ng said the term itself can be misleading. “I feel that the term ‘slipped disc’ is overused, and loosely used,” he said.
What is commonly called a slipped disc usually refers to changes involving an interverte-bral disc, such as a bulging or herniated disc.
Importantly, abnormalities seen on a scan do not always correspond with the symptoms a person is experiencing.
This is why examination by a specialist familiar with spinal conditions is important.
“The term ‘slipped disc’ in a report reflects structural changes.
“What the patient experiences should determine what the next step is,” Dr Ng explained.
If someone is functioning normally and has few or no significant symptoms, an abnormality on a scan may not require surgery.
“If the patient is living a normal life without much problem, then it remains a report,” he said.
Even intermittent pain may initially be managed conserva-tively if it is not significantly affecting daily activities.
When surgery is important
There are, however, situations in which spinal symptoms require more urgent attention.
“If the slipped disc is accompanied by bowel and bladder dysfunction, or if you have weakness in your leg or a foot drop, then surgery has to be considered,” said Dr Sek.
New or worsening muscle weakness, loss of bladder or bowel control, or numbness around the groin or saddle area, can indicate significant nerve compression and should prompt urgent medical assessment.
For patients without these neurological warning signs, the decision can be very different.
“If it’s just pain and you function well, it’s fine if you don’t want surgery,” said Dr Sek.
He described much of elective spine surgery as “lifestyle surgery” because the decision is often influenced by how much the symptoms interfere with the person’s life rather than by an immediate threat to life.
This does not mean spinal conditions are trivial.
Persistent pain can profoundly affect mobility, sleep, work and quality of life.
Rather, it means that for many patients without progressive neurological impairment or other red flags, there may be time to consider the options carefully.
Treat the patient, not the scan
Perhaps one of the most important messages from both specialists is that an MRI or other scan should be interpreted along-side the patient’s symptoms and clinical examination.
“Too many doctors operate on the basis of a scan rather than on what the patient is experiencing,” said Dr Sek.
“It’s important to have another opinion to find out what’s going on.”
Two people with similar-looking scans may experience very different levels of pain and disability.
Their occupations, hobbies, expectations and personal priorities may also differ.
“Everybody’s pain threshold is different,” Dr Sek observed.
Some patients may tolerate their symptoms for years before deciding that circumstances have changed.
He recalled patients who eventually opted for surgery because they wanted to travel or spend more active time with family and grandchildren overseas.
The question, therefore, is not simply “What does my scan show?” but “How is this condition affecting me, and what treatment will give me the best balance between symptom relief, function, risk and recovery?”
In an acute neurological emergency, minutes can matter.
With many spinal conditions, however, there may be more opportunity to weigh those questions carefully.
Modern neuroscience and spine care are therefore not simply about doing more surgery or making surgery less invasive.
They are about doing the right thing at the right time – acting quickly when neurological function is at risk, while ensur-ing that treatment for less urgent conditions is tailored to the person, not just the scan.
