SPINE TREATMENT

In open spine surgery surgeon has to cut the overlaying normal structures like muscles, ligaments and bones to reach the disease into spinal column. After removing the disease surgeon repairs all the structures but they don't regain the strength as they had before surgery. This damage to normal structures is called collateral damage. In MIS spine surgery surgeon puts a tube through the muscle by just creating a small space between muscle fibres by dilation without damaging muscle fibres. Through this tube surgeon reaches to the site of disease directly without any collateral damage. Surgeon removes the disease and as soon as he remove the tube, muscle fibres fall back to normal place thus we are able to treat the spine disease without any collateral damage. This is called minimally invasive spine surgery. According to modality it's been classified into two types. 1. Endoscopic spine surgery 2. Microscopic spine surgery According to site of access it's been classified into four types. 1.Interlaminar 2.Transforaminal 3.Oblique lateral 4.Anterior

Slip disc is one of the most common conditions of the spine which requires surgical treatment. Ninety percent of the patients of slip discs become alright with medications and exercises. Two percent of them have severe compression and symptoms of cauda equina syndrome, which requires emergency surgery. The rest eight percent of the patients have moderate compression and often require surgery. At present the most minimally invasive method to do slip disc surgery is endoscopic surgery. This surgery involves introduction of a small (6 to 8mm) diameter tube through the muscle to the spine. This tube contains a small camera system and a working channel through which instruments are introduced under the vision of the camera and surgery is accomplished. This surgery causes no collateral damage to the normal structures of the spine and thus the patient is able to walk pain-free immediately after the surgery. Due to minimal collateral damage the early and long term results are excellent. This surgery has basically two approaches depending on the route of introduction of the Endoscopic tube. 1. Interlaminar Endoscopy 2. Transforaminal Endoscopy 1. Interlaminar Endoscopy - In this approach the tube is inserted from posteriorly slightly off the midline, through the muscles and between the two laminae of the spine. 2. Transforaminal Endoscopy - In this approach the tube is inserted from the side of the flank, through the muscles and natural foramina into the spine. Both the approaches have similar results and the surgeon decides which approach is required depending on the disease pattern. For more details you can watch the video on our youtube channel.

Microdiscectomy, also called Microlumbar Discectomy (MLD), is performed for patients with a painful lumbar herniated disc. Microdiscectomy is a very common, if not the most common, surgery performed by spine surgeons. The operation consists of removing a portion of the intervertebral disc, the herniated or protruding portion that is compressing the traversing spinal nerve root. Years ago, most spine surgeons would remove a herniated disc using a rather large surgical incision and surgical exposure without the use of a microscope or telescopic glasses, which would often involve a long hospital stay and prolonged recovery period. Today, many surgeons use a microscopic surgical approach with a small, minimally-invasive, poke-hole incision to remove the disc herniation, allowing for a more rapid recovery.

Decompression of neural structures is required in patients of lumber spinal canal stenosis when they have- 1. Neurogenic claudication affecting their daily activities. 2. Progressive weakness in lower limbs. 3. Cauda Equina Syndrome (Weakness of lower limbs + numbness + difficulty in urination and defecation). Decompression can be done by conventional laminectomy method or by Microscopic Decompression (ULBD) method. Laminectomy: Removal of complete lamina and part of facets compressing the nerves. It is associated with a large incision, more tissue dissection, more blood loss, longer hospital stay, need of supplementary fixation in selected cases. MIS Decompression or ULBD (Unilateral laminotomy and bilateral decompression) or Over the top decompression: It is done with the help of microscope or endoscope through a very small incision (2.5-3 cm.) Its advantages are- Minimally invasive, (Small incision). Less blood loss. Easy Recovery. Short hospital stay. Preservation of paraspinal muscles and facets. Avoidance of supplementary fixation.

What is Spondylolisthesis/ slipped spine/ gap in spine? This term is used for a condition of spine in which one of the bone slips over another bone of spine as shown in the picture. When patient is at rest the spine remains in position so there is no pain. Whenever patient stands or walks in this disease, due to the weight of the body the spine slips and patient feels severe back pain due to movement of the bones. This movement also causes traction and pinch on the nerves within spine leading to severe radiating pain (sciatica) down the leg. Therefore patient gradually losses mobility. In the end stage patient develops weakness in leg. What is treatment? This is mechanical problem of spine. This condition can be initially managed with medication and exercises till the pain is not severe. Modern technology has become so advance that we are able to mobilise these patients pain-free on the same day after a minimally invasive surgery. In this surgery we reduce the bones in the normal position and fix them up with screws(TLIF) so they no longer move whenever patient stands or walks. When bones of spine dont move patient gets relief in both back pain and sciatica pain. When patient becomes independent after the surgery? We make the patient sit, stand and walk on the day of the surgery or the very next day. Patient becomes independent from next day or second day varying patient to patient basis.

Traditionally spine fractures are being fixed by open surgery which involves exposure of the spine bones via completely detaching the muscles from the bones. Thereafter pedicle screws are placed into bones and rods applied and muscles approximated with each other and skin closed. After this open surgery and dissection of the muscles they become dysfunctional permanently. This causes loss of natural muscle strength into the lower back resulting in chronic low back pain and failed back syndromes. In the modern era, we fix the spine fractures without any muscle dissection. We insert the pedicle screws percutaneously via small stab incisions via tubes through the muscles without damaging any of the muscle fibres. This causes lesser blood loss , lesser post operative surgical site pain, lesser hospital stay leading to better early and long term outcome in terms of preservation of natural muscle strength and full functional capabilities. Thus, after MIS fracture fixation patients can be made to sit, stand and walk on the same day and can be discharged on the next day. For more details you can watch our video on our YouTube channel "MIS spine clinic".

Kyphoplasty is a minimally invasive surgery for spinal vertebral fractures which should be performed ideally in the first three months of fracture. In this small key hole incision is made percutaneously into the skin. Through the incision a deflated balloon is entered into the fractures bone and inflated in place slowly so as to fill the cement with in collapsed segment in order to regain the normal shape and stability. What are Vertebral Compression Fractures? As age progresses our bones become weak and fragile thus leading to fractures even by minimal trauma like picking up a bucket or slipping in the room or diseases like cancer. One of the major causes of the vertebral fractures is Osteoporosis i.e. bone weakening due to decrease the calcium levels. It is more common in females above 40 years of age after menopause i.e. stop of normal menarche cycle as after which the calcium levels in body are significantly reduced. But balloon kyphoplasty cannot be used in every kind of vertebral fractures. It can only be helpful in vertebral compression fractures with an intact posterior wall of the vertebra. In case the posterior vertebral wall is fractured we cannot do kyphoplasty as the cement may leak out on the spinal cord which may lead to weakness in the leg or paralysis. In such cases we should go for fixation rather than kyphoplasty to stabilize the fracture. What are the causes of vertebral fractures? • Osteoporosis • Injury- fall/accident • Pathologicaldue to tumours

Anterior cervical discectomy and fusion (ACDF) is a type of neck surgery that involves removing a damaged disc to relieve spinal cord or nerve root pressure and alleviate corresponding pain, weakness, numbness, and tingling. A discectomy is a form of surgical decompression, so the procedure may also be called an anterior cervical decompression. ACDF surgery is designed to relieve spinal cord or nerve root pressure in the neck by removing all or part of a damaged disc. The surgery has 2 parts: 1. Anterior cervical discectomy - The surgery is approached through the anterior, or front, of the cervical spine (neck). The disc is then removed from between two vertebral bones. 2. Fusion- A fusion surgery is done at the same time as the discectomy operation in order to stabilize the cervical segment. A fusion involves placing bone graft and/or implants where the disc originally was in order to provide stability and strength to the area.

The disc is the soft cushioning structure located between the vertebras. The disc is flexible enough to allow the spine to bend. An artificial disc (also called a disc replacement, disc prosthesis or spine arthroplasty device) is a device that is implanted into the spine to imitate the functions of a normal disc (carry load and allow motion). REASONS FOR THIS PROCEDURE Not everyone with back pain is a good candidate for a disk replacement surgery. We perform a number of tests to determine if it’s the right procedure for you. Lumbar disk replacement surgery might be recommended if: Severe discogenic back pain which has failed to relieve with >6 months of conservative treatment. No significant facet joint disease or compression on the nerves. No excessively overweight. No previous spinal surgery. No scoliosis or another spinal deformity. INDICATIONS FOR CERVICAL DISC REPLACEMENT Single level discogenic radiculopathy or myelopathy Young patient with discogenic neck pain with normal facet joints.

In this procedure posterior elements of the spine (laminae & spinous processes) are removed to decompress the cervical cord nerves and the vertebrae are fixed with lateral mass screws and rods. This procedure is indicated in patients – Multiple level compression of cervical cord causing cervical myelopathy. Ossified posterior longitudinal ligament, ossified ligamentum flavum Traumatic fractures or tumours Cervical deformities.

What is selective epidural injection/ block? There is an space in the spinal canal which is occupied by the spinal cord, remaining space surrounding the spinal cord or nerves is the epidural space. Therefore the medicine injected into this space spreads directly around the nerves and provide direct effect. In selective injection we directly put the medicine over the nerve which is compressed or inflammed(swollen). Therefore swelling in the nerve is subsided and patient gets direct relief in pain caused by this nerve. Compression over the nerve is not affected by this procedure and that remains as it is. When this block should be given? This procedure is not indicated in every patient of slip disc/ sciatica/ spinal stenosis. Usually this procedure is indicated in a patient who has small disc prolapse/ herniation/ slip disc and his pain is not controlled with atleast 6 weeks or lesser period of medicines. When it should not be given? 1.Cauda equina syndome( involvement of bowel and bladder) 2.In a large disc prolapse with a potential to cause cauda equina syndrome 3.Severe spinal stenosis. What are side effects of this procedure? Usually there are no side effects in trained hands. If the medicine goes into a blood vessel of the nerve it may cause weakness. If the injection has been given in a above-mentioned contraindicated patient it may cause cauda equina syndrome.

Scoliosis This is case of congenital scoliosis which has been surgically corrected by Dr Mukesh Haritwal. The child was suffering for last 13 years. Associated problems were teatehred cord and split cord malformation further complicating the surgery. However, surgery had been performed successfully without any complication. What is scoliosis? Scoliosis is lateral/sideways deviation of spine. What are causes? 1.congenital (by birth) 2. Idiopathic (No cause) 3. Neuromuscular 4. Syndromic Idiopathic scoliosis is the most common cause of scoliosis. It predominantly affects girls. Which scoliosis has best prognosis? Idiopathic scoliosis has best prognosis. What are treatment options? Plaster cast/ bracing- if the curve is less than 40 degree usually responds to bracing and plaster cast. Greater degree of scoliosis usually don't respond. Surgical correction- Greater degree of scoliosis more than 40 degree usually need surgical correction at final stage. When these child need surgery? Surgical correction usually should be performed after the age of 10 years and before peak height velocity. How successful is this operation? 99 percent of the times this operation is successful. Due to recent advances in surgical technology there are usually no complications. How do we prevent neurological problems during surgery? We have most advanced neuromonitoring system which guides the surgeon and gives real time feedback during surgery and prevents complications.