To date, the goals of spinal surgery have been easy to define: to ‘decompress’, to ‘realign’ and to ‘fuse’. More recent refinements have been directed towards two new goals: to ‘preserve’ and to ‘protect’.

Preservation of the enveloping soft tissues minimises bleeding and scarring, and reduces pain. This can be facilitated by minimal and alternate access surgery, using techniques such as percutaneous pedicle screw insertion, transpsoas and transsacral vertebral access and endoscopic scoliosis correction. Protection of the neural elements improves the safety of spinal surgery and allows the surgeon to perform more complex procedures. Methods have been developed to accurately guide the surgeon to the target structure or pathology while avoiding neural structures, and to monitor spinal cord and nerve function. Both approaches allow safer instrumentation and deformity correction.

In the past, protection of important structures has been achieved by wide exposures, sacrificing preservation of soft tissues. As this shortcoming has been recognised, techniques have been developed that have radically reduced wound size but often compromised vision and put neurovascular elements at risk. Refinements have attempted to balance these goals. At present, we have a variety of techniques available to us but were hare hampered by cost and complexity. The future will hopefully bring further improvements but perhaps new ideas and approaches that challenge our current concepts of invasive spinal surgery.