Dr. Mukesh Kumar Haritwal

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

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.

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.

WHAT IS A SPINAL TUMOUR? A tumour is an abnormal growth of cells. Spinal tumours can be- Vertebral tumours –affecting the bones of spinal column Spinal cord tumours—affecting the nerves and cord. If cells in the spine grow and multiply abnormally to cause a tumour, this is called a primary tumour. If abnormal cells have spread to the spine from a tumour in another part of the body, this is called a secondary tumour or metastasis. WHAT ARE THE DIFFERENT TYPES OF SPINAL TUMOURS AND WHERE DO THEY OCCUR? NON-MALIGNANT SPINAL TUMOURS Low grade or slow growing spinal tumours can grow but they do not spread to other parts of the body. However, these tumours can grow to a considerable size, causing damage by putting pressure on the tissue around them in the spine. MALIGNANT SPINAL TUMOURS High grade or rapidly growing tumours are called malignant. They are cancerous. They do spread and destroy the tissue surrounding them. The most common spinal tumours are malignant metastases that have spread to the spine from malignant primary tumours in other parts of the body such as the prostate, breasts, lungs, kidneys and bowel. Procedures Done for them are- 1. Transpedicular Biopsy 2. Vertebroplasty 3. Decompressive laminectomy ± Tumor excision 4. Piecemeal or enbloc tumour excision and complex spinal reconstruction Dr. Pravin decides the line of treatment as per international guidelines after thorough clinical and imaging reports evaluation.

The spinal column is involved in less than 1% of all cases of tuberculosis (TB). Spinal TB is a very dangerous type of skeletal TB as it can be associated with neurologic deficit due to compression of adjacent neural structures and significant spinal deformity. Therefore, early diagnosis and management of spinal TB has special importance in preventing these serious complications.

Back pain is frequent complaint. It is the commonest cause of work-related absence in the world. Although back pain may be painful and uncomfortable, it is not usually serious. Even though back pain can affect people of any age, it is significantly more common among adults aged between 25 and 55 years. Pain in the lower back may be linked to the bony lumbar spine, discs between the vertebrae, ligaments around the spine and discs, spinal cord and nerves, lower back muscles. Pain in the upper back may be due to disorders of the aorta, tumors in the chest, and spine inflammation. The risk factors for back pain? • A mentally stressful job • A sedentary lifestyle • Age – older adults are more susceptible than young adults or children • Gender – back pain is more common among females than males • Obesity • Smoking • Strenuous physical exercise • Strenuous physical work What are the symptoms of back pain? The main symptom of back pain is, as the name suggests, an ache or pain anywhere on the back, and sometimes all the way down to the buttocks and legs. If any of the following symptoms accompanies a back pain your should see your doctor: • Weight loss • Elevated body temperature (fever) • Swelling on the back • Persistent back pain – lying down or resting does not help • Pain down the legs • Pain reaches below the knees • Arecent injury, blow or trauma to your back • Difficulty urinating – passing urine is hard • Loss of bowel control • Numbness around the buttocks

INJECTIONS FOR YOUR BACK & NECK CERVICAL EPIDURAL CERVICALFACET BLOCKS LUMBAR EPIDURAL FACET BLOCKS ROOT BLOCKS A lumbar caudal epidural steroid injection is an outpatient procedure for treating low back and leg pain. Facet & root blocks are injection into a specific joints of spine and along the nerve roots as required. Introduction In a lumbar epidural injection, an anti-inflammatory medicine is injected into the epidural space to reduce inflammation. A local anesthetic (numbing medicine) may also be injected. When the injection is done through the bony opening in your tailbone then this is called a caudal epidural injection. An injection in a joint of the back is called a facet joint injection. An injection along the nerve root sleeve is called a root block. Getting Ready for Treatment : • Provide a list of all medicines you take, including aspirin and anti-inflammatory drugs. • Don’t eat 6 hours before the injection but you can have a light drink 4 hours before injection. • Arrange for a responsible adult to drive you home after the procedure. • Bring all X-ray & MRI images on the day of the procedure • You need to stop blood thinning drugs like asprin, clopidogriel etc. 5 – 7 days before the injection. But consult your cardiologist before hand. During the Procedure: The injection takes just a few minutes. But extra time is needed to get ready. Alocal anesthetic will be used to numb your skin. The doctor will then insert a thin needle directly into the epidural space. A type of X-ray or C-arm may be used to ensure the safe and proper position of the needle. Contrast “dye” may be injected into your back, this helps get a better image. Once the doctor is sure the needle is correctly placed the medicine will be injected.