Space age spine surgery for Filipinos

| Written by Padayon UP


Sitting in the UP College of Medicine’s Department of Anatomy, Dr. Rafael Bundoc began by explaining how a big part of his mission was to change the attitudes of Filipinos when it comes to spine surgery. Spread out in front of the orthopedic surgeon as he spoke were his tools — silver streamlined instruments of various lengths. These instruments, and how to use them, held the key to the future of his discipline in the country, Bundoc said.

While he is up to the challenge, Bundoc does indeed have several minds to change. The idea of having your spine operated on is a dreadful thought for patients and doctors alike. This fear was born in the 1960s and 1970s, when spine surgeries were long, bloody affairs.

“In the past it was very dangerous,” he said, “because you go down to the spine, which is a very deep part of the body. To open it up is very bloody and of course, there’s the idea that you might get paralyzed because you have your nerves there. That’s really scary.”

However, Bundoc insisted that technological advances have mostly made these scary scenarios a thing of the past. In their place, we now have a set of tools and techniques that make up Minimally Invasive Spine Surgery (MISS). MISS allows doctors to get a three-dimensional view of your spinal area and the ability to operate on it directly, while leaving only a tiny incision. This not only makes surgeries more precise; it also allows patients to recuperate faster. It also dramatically reduces hospital stays for patients, and the resulting expenses.

As one of the pioneers of MISS in the country, Bundoc is committed to showing both colleagues and patients that this new world is one worth discovering. And as the chair of the 5th ASEAN Minimally Invasive Spine Surgical Techniques (MISST) 2019 Congress last month, he also now wants to show the world that the Philippines can be a leader in using these techniques to improve countless lives.

Five Ailments

When talking of innovative surgical techniques, an obvious question might be: what conditions do they treat? Bundoc says there are five fundamental conditions that afflict humans throughout their lifetime: trauma, congenital deformities, infections, neoplasms (cancers), and degenerative conditions.


Dr. Rafael Bundoc of the University of the Philippines General Hospital (UP PGH) Department of Orthopedic. Photo by Bong Arboleda, UP MPRO.


Bundoc said that of these five, the most common he had encountered affecting the spine are: trauma, infections and degenerative conditions.

“We see a lot of trauma now, especially now that we have so many motorcycles. We treat these minimally invasively because we don’t want to add insult to injury. You already have a massive wound and we don’t want to give you another one.”

Of the infections, the most common he sees is tuberculosis of the spine. Today, with minimally invasive techniques, he and his colleagues need not split open a person’s back to drain the pus from the spine. “Now we just have to make a very small hole, and we’re able to drain the infection.”

But hands down, the most common and what most people associate with spinal problems are degenerative conditions, specifically slipped discs and stenoses. “Our population is graying,” Bundoc says. “Filipinos are living longer and, as we age, we develop lots of spine problems.” For him, the thought of opening the back of an already aged person is a traumatic experience that no patient should go through. Hence, minimally invasive techniques can be both an effective and a dignified solution.

Bundoc explains how the problem evolves in the case of stenosis. “You have a canal in your spine,” he says. And like most other canals in nature, the size of the channel eventually decreases as deposits build up on the bone, in this case, calcium. “Your bones and your ligaments get thicker, and when your spinal cord gets compressed, your back hurts. You can’t walk, and your lower extremities hurt.”


So how does a spine surgeon like Bundoc solve a problem like that? He walks us through a typical surgical process from beginning to end.


Some models of the spine and tools used in minimally invasive spine surgery at the University of Philippines Manila’s College of Medicine. Photo by Bong Arboleda, UP MPRO.


First, after the room has been sterilized and the patient’s back has been scrubbed, a radiology technologist takes a fluoroscopy, a special X-ray of the area to be operated on. After this, and once the patient has been duly anaesthetized, surgeons like Bundoc make what is called a ‘‘stab incision,’’ or a very tiny cut on the back just big enough to fit a specialized endoscope only a few millimeters in diameter.

This scope is connected to a camera system that ends in a set of monitors which allow Bundoc and his colleagues to have a three-dimensional view of the pathology and its surrounding structures. By inserting other very fine instruments, like the pituitary rongeur, a surgeon can then deal with the problem, such as the removal of vertebral discs or bone spurs.

“If you’re going to operate on just a small area, why not direct your attention to just that small area? So other structures can be spared.”

After the surgery, there is virtually no bleeding from the tiny incision made on the patient. Typically, only a single suture is needed to close it; and for patients with good skin, Bundoc says a Band-Aid may suffice. “Then the patient lies down for around an hour to rest. Afterwards, they get up and go home.”

Taking only about an hour, the surgery is a far cry from past procedures where patients needed to recuperate in the hospital for one to two weeks. “We even needed blood transfusions, maybe 1-2 bags. These days we don’t even prepare blood anymore.”

Changing Minds

While the marriage of engineering and medicine has allowed spine surgeons like Bundoc to perform what previous generations might call miraculous operations, it has not been easy for developing countries like the Philippines to train enough specialists to meet demand.

The cost of the sugery remains the most significant barrier. Getting a complete set of tools like the ones Bundoc uses (for which he had to borrow money to acquire) can cost upward of P9 million. Moreover, getting fellowships to master the techniques requires many months of staying in developed countries like Korea, which can be too much for a young physician.


Orthopedic surgeon and 5th ASEAN MISST chair Dr. Rafael Bundoc asks those who really need it to give spine surgery a chance. Photo by Bong Arboleda, UP MPRO.


This is the reason Bundoc was excited about the 5th ASEAN MISST in Manila. With help from local government agencies and the North American Spine Society, the convention brought speakers from 21 countries and four continents to Manila last June 26.

The primary focus of the event was mentorship. Notably, the first two days were a cadaveric workshop, where younger colleagues practiced their techniques on cadavers, ensuring that they can gain mastery there before moving on to the real thing.

Watch the highlights of the 5th ASEAN MISST Congress in Manila

For Bundoc, the next generation could not come any sooner. “Take Korea for example,” he said. “They have a population of 58 million, and, would you believe, around 4,000 spine surgeons. We have a population of 110 million and we only have around 140 spine surgeons. That’s not enough, we have to train more.”

Bundoc noted that 70 percent of all consultations in an orthopedic or neurology clinic are for complaints of some sort of back pain. “And of that 70 percent, maybe 30 percent are candidates for surgery. That may not sound like a lot, but in a country of 110 million, that is a lot of patients.”

“And that’s just for the back,” he continued. “If it gets worse, you get weakness of the legs. And how can you work, much less go around if you have weakness of the legs because of a spine problem?” Sometimes the only solution is to have an operation. “And for those who need it, MISS is heaven-sent.”

To learn more about the 5th ASEAN MISST, please visit:

Text and media by UP MPRO