Neurosurgery and Pain Unit · Service Portfolio

Minimally invasive spine surgery — reserved for when it's truly necessary, not before.

A portfolio of microsurgical, endoscopic, and motion-preserving techniques designed to address the underlying problem while respecting healthy tissues and enabling an early return to an active life.

Colegiación

Col. 54603

Training

Cleveland Clinic · Barrow

Location

Paseo de Gracia 130 · Barcelona

Dra. Mireia Illueca Moreno

Co-Medical Director · Head of Neurosurgery and Pain Management

I — Surgical philosophy

Surgery is not the first step. It is the last resort, when the time comes.

At Monarka, every surgical decision is made within a progressive therapeutic framework: rehabilitation, ultrasound-guided injections, selective nerve blocks, and—only after all the preceding options have been evaluated and exhausted—surgery. This conservative approach is supported by evidence: the majority of lumbar disc herniations resolve with non-surgical treatment, and the decision to proceed with surgery must be based on rigorous clinical criteria[1],[2].

When surgery is truly indicated, the goal is not merely to resolve the compression: it is to do so using the least invasive procedure possible, preserving the structures that provide support and mobility and enable an active life afterward.

Being conservative

Avoid unnecessary damage to healthy tissues, paraspinal musculature, ligaments, and joint structures.

Early function, safe return

Enable a proper, rapid return to daily or sports activities without added risks.

It takes three months to learn how to perform a surgery, three years to know when to perform it, and thirty years to know when not to perform it.

— Henry Marsh, neurosurgeon

II — Surgical objectives

Five non-negotiable principles in every intervention

i

Minimize soft tissue damage during surgical access and throughout the procedure.

ii

Respect the support and mobility structures of the vertebral column.

iii

Use the smallest possible access points, consistent with the safety of the procedure.

iv

Ensure surgical positioning that avoids secondary sequelae and allows for early mobilization.

v

Select the precise technique for each specific case. The right choice is what guarantees the result.

III — Service portfolio

Surgical techniques by anatomical region

1.1 · Microsurgical resection of a herniated disc

With or without microdiscectomy · Gold standard technique for lumbar disc herniation

The standard microsurgical approach allows for the resolution of nerve root compression while preserving paraspinal musculature and supporting structures. Microdiscectomy has been shown to improve radicular pain and function, with sustained long-term results[3],[4].

Incision

2–3 cm

Anesthesia

Epidural with neuroprotective sedation

Duration

30–40 minutes

Position

Lateral decubitus

Four factors converge in one of the most conservative spinal surgeries by international standards: an incision of just 2–3 cm, neuroprotective sedation that avoids general anesthesia, a duration of less than 40 minutes, and a lateral decubitus position that improves venous return compared to the conventional prone position.

Endoscopic resection of a herniated disc

Uniportal and biportal spinal endoscopy · Image-guided minimally invasive surgery

Spinal endoscopy offers a minimally invasive alternative with clinical outcomes comparable or superior to open microdiscectomy for selected indications[6],[7].

Incision

~ 1 cm

Anesthesia

General

Duration

1–2 hours

Position

Prone position

Uniportal endoscopy: optimal for foraminal or extraforaminal hernias. Biportal endoscopy: optimal for lateral recess hernias, avoiding direct damage to the facet joint.

1.2 · Lumbar surgery with implant

Microdiscectomy with annulus fibrosus closure (Disc-Care)

Function-sparing resection · Patient asleep or awake, depending on the case

Reinforcement of the annulus fibrosus following discectomy has demonstrated, in randomized clinical trials with 5-year follow-up, a significant reduction in hernia recurrence and the need for reoperation compared to isolated microdiscectomy[8],[9].

Technique

Microsurgical + implant

Anesthesia

General

Position

Prone position

Added risk

None

Recurrence rate in our series with this system: currently 0.

Percutaneous lumbar arthrodesis with transpedicular screws

With or without an interbody cage · Indication reserved for segmental instability

Reserved for cases where the dominant problem is segmental instability—symptomatic spondylolisthesis or spondylolysis—without disc pathology or direct nerve root compression. The percutaneous approach reduces bleeding, infection, and muscle damage compared to the conventional open technique[10],[11].

Anesthesia

General

Intraoperative image

O-Arm + navigation

Robotics

Mazor X (if applicable)

Neuromonitoring

Systematics

Advantages over open surgery

Limitations to consider

2.1 · Anterior cervical microforaminotomy — Jho technique

Technique of choice for foraminal hernias in patients with high mobility demands.

Originally described by Jho[13],[14], it allows for direct decompression of the cervical nerve root without the need for prosthesis implantation or destabilizing load transmission across the segment. Published clinical series confirm minimal recurrence rates[15],[16].

Posterior alternative: Scoville posterior microforaminotomy — a classic technique, though currently less effective than the anterior approach when there is nerve root compromise due to a soft disc herniation.

2.2 · Cervical surgery with implant

Anterior cervical microdiscectomy with disc prosthesis

Mobile prostheses that preserve segment motion

Indicated for more centrally located hernias or for compression caused by osteophytes and a chronically degenerated disc. In pivotal 7– to 10-year trials, mobile disc prostheses have demonstrated a significant reduction in adjacent-segment disease compared with conventional cervical arthrodesis[17],[18].

D-Trax System — Posterior cervical interfacet arthrodesis

Percutaneous system for foraminal compression due to facet hypertrophy

It has demonstrated favorable results in terms of improvements in radicular pain and cervical disability in selected patients in prospective IDE studies and 5-year follow-up series[19],[20].

IV — Surgical Technology

Technical precision relies on the best available technology.

Every technical decision is supported by tools that reduce the margin of error: high-definition microscopic visualization, 3D planning, intraoperative imaging, and—when complexity warrants it—robotic assistance[21],[22].

Surgical microscope

State-of-the-art technology for all cranial and spinal microsurgical approaches.

Spinal endoscopy

High-definition uniportal and biportal systems for minimally invasive approaches.

Neuromonitoring (IONM)

International gold standard in instrumented spinal surgery[23],[24].

O-Arm image

Real-time 3D reconstruction for verification of transpedicular screw placement.

3D Navigation

Planning and execution guided by spinal navigation software.

Mazor X Robot

Robotic assistance for complex instrumentation surgeries.

V — Monarka Model

No surgical decision is made in isolation.

Each potential surgical case undergoes independent evaluation by the relevant specialists—neurosurgery, neurophysiology, sports medicine, physiotherapy, and psychology—who then come together in a single clinical session to agree on a unified, personalized plan.

This multidisciplinary consensus model ensures that surgery, when indicated, is performed at the right time and using the precise technique, and is integrated into a comprehensive plan for recovery, rehabilitation, and recurrence prevention.

The same principle guides the technical execution: no spinal surgery involving instrumentation or revision is performed without intraoperative neuromonitoring. It is our minimum safety standard, not an option.

VI — Background of the Unit Head

A neurosurgeon trained at the two international benchmarks in spinal surgery.

Colegiación

Col. 54603

International training

Cleveland Clinic (EE. UU.) · Barrow Neurological Institute (Phoenix, Arizona)

Specialization

Minimally invasive spine surgery · Spinal microsurgery · Spinal endoscopy

Areas of interest

Cervical and lumbar degenerative pathology · Disc herniation in athletes · Motion preservation

Trained at two internationally renowned neurosurgery institutions, Dr. Illueca approaches every case with a philosophy of precision and conservatism: recommending surgery only when necessary, selecting the least invasive technique to resolve the underlying issue, and tailoring the procedure to the patient—not the surgeon.

VII — Frequently Asked Questions

What you should know before considering surgery

When is spinal surgery actually indicated?

Surgery is the final therapeutic step, indicated when conservative treatment fails to resolve the condition, when there is a progressive neurological deficit, or when incapacitating pain does not respond to non-surgical measures.

How does microsurgery differ from spinal endoscopy?

Microsurgery employs a surgical microscope and a 2–3 cm incision; endoscopy is performed through an incision of approximately 1 cm. Each technique has specific indications depending on the case.

What is the Disc-Care device, and why does it reduce recurrences?

An annulus fibrosus closure system implanted after discectomy. Randomized clinical trials have shown a significant reduction in recurrence at 5 years.

When is lumbar arthrodesis performed?

Only when the dominant problem is segmental instability that cannot be resolved using motion-preserving techniques.

What risks does a professional athlete face when undergoing arthrodesis?

It limits the segment's range of motion and transfers loads to adjacent discs and joints such as the hip, with motion-preserving techniques always prioritized for this profile.

What technology is used to improve surgical precision?

Surgical microscope, uniportal and biportal endoscopy, intraoperative neuromonitoring, O-Arm 3D imaging, spinal navigation, and the Mazor X robot when complexity warrants it.

How long does it take to return to activity after a microdiscectomy?

The regimen is individualized; the resumption of daily activities typically occurs early, and the return to sports is planned in a structured manner based on the specific case.

How is it decided if I am a candidate for surgery at Monarka?

Following a comprehensive evaluation and multidisciplinary assessment, the recommended course of action is agreed upon by consensus and explained to the patient, with all alternatives laid out.

VIII — Scientific references

Evidence supporting each indication

Deyo RA, Mirza SK. Clinical practice. Herniated lumbar intervertebral disk. N Engl J Med. 2016;374(18):1763–1772. doi.org/10.1056/NEJMcp1512658
Kreiner DS, et al. Evidence-based clinical guideline for diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J. 2014;14(1):180–191. doi.org/10.1016/j.spinee.2013.08.003
Weinstein JN, et al. Surgical vs nonoperative treatment for lumbar disk herniation (SPORT). JAMA. 2006;296(20):2451–2459. doi.org/10.1001/jama.296.20.2451
Lurie JD, et al. Surgical versus nonoperative treatment for lumbar disc herniation: eight-year SPORT results. Spine. 2014;39(1):3–16. doi.org/10.1097/BRS.0000000000000088
Kim CH, et al. Reoperation rate after surgery for lumbar herniated intervertebral disc disease: nationwide cohort study. Spine. 2013;38(7):581–590. doi.org/10.1097/BRS.0b013e318274f9a7
Ruetten S, et al. Full-endoscopic interlaminar and transforaminal lumbar discectomy vs microsurgical technique. Spine. 2008;33(9):931–939. doi.org/10.1097/BRS.0b013e31816c8af7
Gibson JNA, et al. Randomised controlled trial of transforaminal endoscopic discectomy vs microdiscectomy. Eur Spine J. 2017;26(3):847–856. doi.org/10.1007/s00586-016-4885-6
Thomé C, et al. Annular closure in lumbar microdiscectomy for prevention of reherniation. Spine J. 2018;18(12):2278–2287. doi.org/10.1016/j.spinee.2018.05.003
Kursumovic A, et al. Bone-anchored annular closure following lumbar discectomy reduces complications. J Pain Res. 2018;11:2225–2233. doi.org/10.2147/JPR.S173260
Foley KT, Gupta SK. Percutaneous pedicle screw fixation of the lumbar spine. J Neurosurg. 2002;97(1 Suppl):7–12. doi.org/10.3171/spi.2002.97.1.0007
Goldstein CL, et al. Comparative outcomes of minimally invasive surgery for posterior lumbar fusion. Clin Orthop Relat Res. 2014;472(6):1727–1737. doi.org/10.1007/s11999-014-3465-5
Hilibrand AS, Robbins M. Adjacent segment degeneration and adjacent segment disease. Spine J. 2004;4(6 Suppl):190S–194S. doi.org/10.1016/j.spinee.2004.07.007
Jho HD. Microsurgical anterior cervical foraminotomy for radiculopathy. J Neurosurg. 1996;84(2):155–160. doi.org/10.3171/jns.1996.84.2.0155
Jho HD. Spinal cord decompression via microsurgical anterior foraminotomy for spondylotic cervical myelopathy. Minim Invasive Neurosurg. 1997;40(4):124–129. doi.org/10.1055/s-2008-1053437
Jho HD, Kim WK, Kim MH. Anterior microforaminotomy for treatment of cervical radiculopathy. Neurosurgery. 2002;51(5 Suppl):S46–S53. doi.org/10.1097/00006123-200211002-00007
Saringer W, et al. Microsurgical anterior cervical foraminotomy (uncoforaminotomy) for unilateral radiculopathy. Acta Neurochir (Wien). 2002;144(7):685–694. doi.org/10.1007/s00701-002-0959-9
Lavelle WF, et al. Ten-year outcomes of cervical disc replacement with the BRYAN cervical disc. Spine. 2019;44(9):601–608. doi.org/10.1097/BRS.0000000000002907
Janssen ME, et al. ProDisc-C total disc replacement vs anterior cervical discectomy and fusion. J Bone Joint Surg Am. 2015;97(21):1738–1747. doi.org/10.2106/JBJS.N.01186
Smith WD, et al. Prospective multicenter clinical investigation of a posterior cervical fusion system (DTRAX): 24-month outcomes. Int J Spine Surg. 2018;12(4):447–456. doi.org/10.14444/5054
McCormack BM, et al. Percutaneous posterior cervical fusion with the DTRAX Facet System. J Neurosurg Spine. 2013;18(3):245–254. doi.org/10.3171/2012.12.SPINE12477
Tian NF, et al. Pedicle screw insertion accuracy with different assisted methods: meta-analysis. Eur Spine J. 2011;20(6):846–859. doi.org/10.1007/s00586-010-1577-5
Devito DP, et al. Clinical acceptance and accuracy of spinal implants guided with SpineAssist surgical robot. Spine. 2010;35(24):2109–2115. doi.org/10.1097/BRS.0b013e3181d323ab
Nuwer MR, et al. Evidence-based guideline update: intraoperative spinal monitoring. Neurology. 2012;78(8):585–589. doi.org/10.1212/WNL.0b013e318247fa0e
Sutter M, et al. Validity of multimodal intraoperative monitoring (MIOM) in surgery of spine and spinal cord tumors. Eur Spine J. 2007;16(Suppl 2):S197–S208. doi.org/10.1007/s00586-007-0422-y

IX — Investment

Personalized assessment

The indication, technique, and comprehensive treatment plan are determined following the initial clinical evaluation and a multidisciplinary assessment of the case. A personalized cost estimate is provided.

Request an assessment with the neurosurgery unit.

The first step is a clinical assessment with Dr. Illueca. If surgery is indicated, the case will be presented at a multidisciplinary meeting, and you will be provided with a comprehensive plan covering preparation, the procedure, and recovery.

Monarka Clinic · Paseo de Gracia 130 · 08008 Barcelona · monarkaclinic.com

This page is for informational purposes only. The information provided does not replace a personalized medical consultation or constitute a therapeutic recommendation. Any surgical indication requires an individual assessment and informed consent. Procedures requiring an operating room are performed at facilities authorized by the Department of Health of the Government of Catalonia (Generalitat de Catalunya), in accordance with Decree 151/2017. Your data will be processed by Monarka Clinic in compliance with Regulation (EU) 2016/679 (GDPR) and Spanish Law LOPDGDD 3/2018. You may exercise your rights by contacting privacy@monarkaclinic.com.