Bonati Spine Institute: Bonati Spine Review & Alternatives

If you are researching the Bonati Spine Institute, you are probably weighing it against a fusion, an open laminectomy, a microdiscectomy, or another round of injections. This page tells you what we actually do, who we turn away, and gives an evidence-based look at every alternative, including the ones we do not perform.

Medically reviewed by Alfred O. Bonati, MD — Founder and Chief Orthopaedic Surgeon, The Bonati Spine Institute; orthopaedic surgery residency and chief residency, Bowman Gray School of Medicine, Wake Forest University  ·  Reviewed August 2026  ·  Written by the clinical team at The Bonati Spine Institute, Hudson, Florida  ·  10 min read

What is the Bonati Spine Institute?

What distinguishes the approach is not a single device. It is the decision to treat the pathology and stop there — to remove the specific tissue pressing on the specific nerve root, through an incision measured in millimeters, without destabilizing the spine and without adding hardware that has to be lived with for the rest of a patient’s life. Every design choice follows from that: outpatient rather than inpatient, local anesthesia rather than general, staged single-level procedures rather than one long multi-level operation.

More than 80,000 procedures have been performed here, with a 98.75% patient-reported satisfaction rate.

The conditions we treat

Patients arrive with a long list of different diagnoses, and the list below is genuinely long. But it is worth understanding why: many of these are different names, or different presentations, of the same underlying problem — something is pressing on a nerve in the cervical, thoracic or lumbar spine. A “slipped disc,” a “prolapsed disc,” a “ruptured disc” and a “herniated disc” describe the same pathology. “Spinal narrowing” and “spinal stenosis” are the same condition. Sciatica, radiculopathy and a “pinched nerve” describe the path of the nerve that is creating the symptoms.

That shared mechanism is why one surgical approach addresses so many named conditions — and it is also why the right question at consultation is never “do you treat my diagnosis?” but “does my imaging show something the Bonati Spine Procedures can reach?”

Disc conditions — herniated disc, bulging disc, prolapsed disc, ruptured disc, slipped disc, annular tear, degenerative disc disease

Narrowing and stenosis — spinal stenosis, spinal narrowing, foraminal stenosis, foraminal narrowing, bone spurs

Nerve symptoms and syndromes — sciatica, radiculopathy, radiculitis, pinched nerves, myelopathy

Joint and structural conditions — facet syndrome, spondylosis, spondylolisthesis

After previous spine surgery — failed back surgery syndrome, adjacent segment disease, arachnoiditis

Injury — whiplash

Location. One surgical center: 7315 Hudson Avenue, Hudson, Florida 34667. Patients travel from across the United States and internationally; we are not a national chain and this is currently the only location where the Bonati Spine Procedures are performed.

What patients say

You can also verify Dr. Bonati’s Florida medical license directly with the state, without taking our word for anything, through the Florida Department of Health license verification portal. We recommend you do this for every surgeon you are considering, not only for us. Dr. Bonati has been licensed since 1980 in North Carolina and 1981 in Florida, continuously without any interruption.

The Bonati Spine Procedures: what actually happens

Understanding the mechanics is the only way to judge whether this is right for you.

You are awake

Procedures are performed under local anesthesia with conscious sedation rather than general anesthesia. You can respond to the surgeon during the procedure, which provides real-time feedback as the nerve is being treated. The published evidence on awake spine surgery is reasonably consistent on several points: shorter operating time, shorter hospital stay, less blood loss, and less postoperative nausea and vomiting than general anesthesia.¹

The incision is millimeters, not inches

Access is through a small portal rather than an open exposure. Muscle is separated rather than cut and stripped from bone. The clinical consequence of that difference is measurable: in a randomized non-inferiority trial of 613 patients published in The BMJ, full-endoscopic discectomy produced a mean scar of 11.7 mm versus 38.4 mm for open microdiscectomy, zero dural tears versus 3%, zero wound infections versus 1%, and 94% same-day discharge versus 6%.² (The published literature uses “endoscopic” for portal-based spine surgery; we use the older term “arthroscopic” for the same family of technique.)

The laser is a tool, not the treatment

Some tissue is removed with a Holmium:YAG laser and some mechanically, depending on what is being removed and where. The laser is useful because it ablates tissue precisely with limited thermal spread — it is not a separate treatment and it is not what makes the procedure work. The Bonati Spine Procedures’ treatment of the pathology is what makes the procedure work. Be sceptical of any spine practice that markets the instrument rather than the operation.

Nothing is left behind

No rods, no screws, no cages, no artificial discs, no bone graft. Nothing to loosen, migrate, fail to fuse, impinge on a nerve, or require removal later. This is the single largest structural difference between what we do and a fusion, and it drives most of the comparison in the next section.

One problem at a time

Where a patient has multiple levels of pathology, we stage the procedures rather than performing one long multi-level operation. Staging is slower and less impressive-sounding. It is also how you avoid operating on a level that was never the pain generator.

The procedures we perform

“The Bonati Spine Procedures” are not one operation. They are multiple techniques, which are used to target and treat the pathology and eliminate the root cause of the problem, chosen according to what your imaging shows and where. Most patients need one or two of them; nobody needs all of them.

By region — cervical spine surgery, thoracic spine surgery, lumbar spine surgery

Decompression techniques — spinal decompression, foraminotomy, discectomy, laminotomy and limited laminectomy, facetectomy, pediculectomy, decompression of a pars defect

Bone and spur removal — resection of osteophytes, bone fragment removal

Facet procedures — facet thermal ablation (rhizolysis)

After previous spine surgery — scar tissue removal, spinal hardware removal, exploration of a spinal fusion

That last group is worth pausing on, because it is unusual. Removing failed hardware, exploring a fusion that did not take, and clearing epidural scar tissue are revision procedures — the operations a patient needs when someone else’s surgery did not work. A practice that performs them is set up for the failed-back population rather than only for straightforward first-time cases.

Alternatives to consider — and their trade-offs

Spinal fusion

Fusion permanently joins two or more vertebrae using hardware and bone graft. It is the correct operation for genuine instability, significant deformity, tumor and trauma. Our concern is its use for uncomplicated nerve compression, where the published randomized evidence has repeatedly failed to show a benefit over decompression alone.

The fair reading of the three trials together: across more than 500 randomized patients, adding fusion to a decompression has not been shown to improve disability scores, while it reliably adds operating time, blood loss, hospital stay and cost. Three further consequences of fusion are worth understanding before you consent to one:

• Adjacent segment disease. Fusing one segment transfers load to its neighbors. In a cohort of 912 patients followed a mean of 63 months, the predicted prevalence of surgery at an adjacent segment was 13.6% at 5 years and 22.2% at 10 years — rising with each additional level fused, from 1.7% per year for single-level to 5.0% per year for three- and four-level fusions.⁶ In the Swedish national spine register (6,532 patients, up to 10 years), fusion roughly halved index-level reoperation but roughly doubled adjacent-level reoperation.⁷
• The fusion may not fuse. Pseudarthrosis — failure of the bone to unite — is reported in the peer-reviewed literature at 5–15% after lumbar fusion, and accounts for 23.6% of revision fusion surgeries. Smoking triples the risk (OR 3.04); each additional level raises it (OR 1.35).⁸
• Opioid exposure. Prolonged opioid use after lumbar fusion is common. In a single-institution series of 260 fusion patients, 44.2% were still filling opioid prescriptions 90 days after surgery.⁹ That figure comes from a retrospective case series and should be read as one institution’s experience, not a national rate — but it is the direction every study we found points in.

Open, multi-level laminectomy

A word on terminology first, because it matters and because we perform a version of this ourselves. “Laminectomy” describes a family of operations that remove part or all of the lamina to create space around the nerve. They are not all the same operation. A laminotomy or limited laminectomy performed through a millimeter portal under local anesthesia — removing only the bone that is actually causing compression — is a very different undertaking from a wide, multi-level open laminectomy under general anesthesia with an inpatient stay.

Our concern is with the second, not the first. Removing structural bone across several levels can itself destabilize the segment, which is precisely why open laminectomy is so often paired with a fusion. The published data tracks that distinction: in a claims analysis of 102,047 lumbar procedures, the highest rate of failed back surgery syndrome occurred after multi-level inpatient decompression, at 10% within a year — against 8.4% overall, and 4.3% for procedures performed in an outpatient setting.¹⁰ A separate patient-reported survey of 1,842 lumbar surgery patients found 20.6% met a definition of failed back surgery syndrome.¹¹ Those two figures measure different things — coded diagnoses versus patient dissatisfaction plus residual symptoms — and the gap between them is itself worth knowing.

The lesson we draw from that data is about scale and setting rather than about the technique’s name: remove the bone that is causing the problem, and no more than that.

Open microdiscectomy

The conventional operation for a herniated disc, and a good one. The relevant question is not whether it works but whether the open exposure is necessary. A BMJ trial found full-endoscopic discectomy non-inferior on leg pain at 12 months, with less scarring, fewer dural tears, and vastly higher same-day discharge.² A meta-analysis of 4,018 patients found endoscopic approaches reduced hospital stay by 2.57 days and halved overall complications (OR 0.53, p=0.009).¹²

Who is not a candidate

We decline patients. Being told what a center will not treat is more informative than a list of what it will.

• True mechanical instability or significant scoliosis. These often genuinely need stabilization, and decompression alone can make an unstable segment worse. Note this is the unstable subset — a stable, low-grade slip causing nerve compression is frequently treatable.
• Tumor, infection, or acute fracture. Different problem, different specialty, urgent referral.

What we will not claim

Spine surgery marketing has a credibility problem, and the loudest numbers are usually the least supported. So, explicitly:

• We do not claim a 100% success rate, or that no patient has ever had a complication. Any surgical practice of meaningful volume and duration has had complications, poor outcomes, and dissatisfied patients. Ours has. A center claiming otherwise is either very new, very small, or not counting carefully.
• We do not claim FDA approval of our surgical technique. The FDA clears and approves medical devices. It does not approve surgical techniques or procedures. Any practice claiming FDA approval of a named procedure is describing something that does not exist as a regulatory category.
• We do not claim to be the least invasive spine surgery in the world, or any similar superlative. There is no measurement standard behind such a claim and no body that adjudicates it.
• We do not claim the Bonati Spine Procedures are right for every patient. See the section above on who is not a candidate.

Questions to ask any spine surgeon — including us

1. How many times have you personally performed the specific procedure you are recommending for me? Over what period?
2. What is your complication rate, and how do you track it?
3. What happens if this does not work? What is the next option, and does this procedure foreclose any of them?
4. Why this operation rather than decompression alone — or rather than fusion? What in my imaging drives that choice?
5. Will anything be implanted? If so, what, and what is the revision rate for it?
6. Who is in the operating room, and what is each person licensed to do?
7. What anesthesia, and what are the risks for someone my age with my medical history?
8. What conservative treatment should I complete first?
9. What is the total cost, including facility, anesthesia, imaging and follow-up?

Frequently asked questions

Is the Bonati Spine Institute legitimate?

It is a licensed Florida outpatient surgical facility, founded in 1984 in Hudson, Florida by Alfred O. Bonati, MD, who has held a valid Florida medical license continuously since 1981. You do not have to take that from us: Dr. Bonati’s Florida medical license can be verified independently through the Florida Department of Health.

Do you use fusion or implants?

No. The procedures performed here treat the pathology causing the problem. No rods, screws, cages, artificial discs or bone graft are implanted. We do remove hardware placed by other surgeons when it has failed, but we do not put any in. If your condition genuinely requires stabilization, we will tell you that and refer you.

Am I awake during the procedure?

Yes. Local anesthesia with conscious sedation. You are comfortable and can respond to the surgeon, the anesthesiologist and the surgical team who are actively monitoring you. General anesthesia is not used.

What if I have already had a failed back surgery?

Patients who have already had a fusion, laminectomy or discectomy elsewhere that did not resolve their symptoms are one of the most important parts of this practice. Failed back surgery syndrome is one of the conditions treated here, and scar tissue removal, hardware removal and exploration of a fusion are among the most important procedures performed. Prior surgery does not automatically exclude you.

How long is recovery?

Patients leave the institute the same day and typically begin walking immediately after surgery. Return to normal activity varies by procedure, by level, and by patient — we will give you a specific expectation at consultation rather than a marketing number here.

Does insurance cover it?

Coverage varies by carrier and plan, and our team will go through your benefits with you before you commit to anything. We also offer several payment options.

References

1. Rajjoub R, Ghaith AK, El-Hajj VG, et al. Comparative outcomes of awake spine surgery under spinal versus general anesthesia: a comprehensive systematic review and meta-analysis. Eur Spine J. 2024;33:985–1000. link.springer.com
2. Gadjradj PS, Broulikova HM, van Dongen JM, et al. Full endoscopic versus open discectomy for sciatica: randomised controlled non-inferiority trial. BMJ. 2022;376:e065846. bmj.com
3. Försth P, Ólafsson G, Carlsson T, et al. A Randomized, Controlled Trial of Fusion Surgery for Lumbar Spinal Stenosis. N Engl J Med. 2016;374(15):1414–1423. nejm.org
4. Karlsson T, Försth P, Öhagen P, Michaëlsson K, Sandén B. Decompression alone or decompression with fusion for lumbar spinal stenosis: five-year clinical results from a randomized clinical trial. Bone Joint J. 2024;106-B(7):705–712. boneandjoint.org.uk
5. Austevoll IM, Hermansen E, Fagerland MW, et al. Decompression alone or with fusion for degenerative lumbar spondylolisthesis (NORDSTEN-DS): five year follow-up of a randomised, multicentre, non-inferiority trial. BMJ. 2024;386:e079771. bmj.com
6. Sears WR, Sergides IG, Kazemi N, Smith M, White GJ, Osburg B. Incidence and prevalence of surgery at segments adjacent to a previous posterior lumbar arthrodesis. Spine J. 2011;11(1):11–20. PMID 21168094
7. Joelson A, Nerelius F, Holy M, Sigmundsson FG. Reoperations after decompression with or without fusion for L4–5 spinal stenosis with or without degenerative spondylolisthesis: a study of 6,532 patients in Swespine, the national Swedish spine register. Acta Orthop. 2021;92(3):264–268. actaorthop.org
8. Luksanapruksa P, Boonsirikamchai W, Wilartratsami S, et al. Pseudarthrosis risk factors in lumbar fusion: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2024;25:433. link.springer.com
9. Canseco JA, Chang M, Karamian BA, et al. Predictors of Prolonged Opioid Use After Lumbar Fusion and the Effects of Opioid Use on Patient-Reported Outcome Measures. Global Spine J. 2023;13(6):1582–1591. journals.sagepub.com
10. The incidence of failed back surgery syndrome varies between clinical setting and procedure type. J Clin Neurosci. 2022;103:56–61. PMID 35810607
11. Inoue S, Kamiya M, Nishihara M, et al. Prevalence, characteristics, and burden of failed back surgery syndrome: the influence of various residual symptoms on patient satisfaction and quality of life as assessed by a nationwide Internet survey in Japan. J Pain Res. 2017;10:811–823. dovepress.com
12. Muthu S, Ramakrishnan E, Chellamuthu G. Is Endoscopic Discectomy the Next Gold Standard in the Management of Lumbar Disc Disease? Systematic Review and Superiority Analysis. Global Spine J. 2021;11(7):1104–1120. journals.sagepub.com

This page is for general education and is not medical advice. Individual results vary. Only an evaluation of your imaging and history by a qualified physician can determine whether any procedure is appropriate for you.