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Spine Surgery

“Setting your posture right”

Overview

Back pain is the second most common affliction of mankind. Almost everybody experiences at least one episode of lower back pain once in a lifetime. The main cause of back pain is wrong body postures and faulty body mechanics. Other causes of back pain are spine infection, spinal trauma and spinal deformity. While many of the spinal problems can be effectively treated by non operative measures, ther are some which need surgical intervention.

Since medical science has progressed in fields of anaesthesia and operation theatre setup, surgical instruments and imaging study, spine surgery has become quite safe and successful. With further evolution of technology spine surgery is moving towards minimal invasive surgical techniques and motion retaining spine surgery. As painful arthritic knee and hip joints can be replaced with artificial but, stable and pain free joints, intervertebral discs can also be replaced and made pain free. Nidhi hospitals have ultra modern Operation Theatre set ups, instruments and intensive care units. This ensures optimum post operative patient care.

Specialized physical therapy infrastructure helps the patient to balance and condition their spine. The spine surgeons of the hospital are Orthopaedic surgeons, well trained in various aspects of spine surgeries and are doing exclusive spine work in their clinical practice.

Slipped Disc (Herniated Disc)

Hearniated Disc Pressing
the nerve root
MRI of lower back showing "Slipped Disc" Endoscopic view of disc removal Surgery done through 25 MM incision

What is it?

Intervertebral Discs are composed of the relatively soft, gelatinous cushions (nucleus pulposus) which are surrounded by a thick fibrous cover (annulus fibrosus). The disc functions as a shock absorber between the hard, bony vertebrae. A herniated disc is a protrusion of the nucleus through the annulus which in turn presses against a nerve traveling through the spinal canal.

Discs herniate most commonly in the lower back, also occur frequently in the lower neck and more uncommonly may occur anywhere.

Why does it happen?

A disc may herniate because of sudden bending forward or lifting heavy weight, sudden trauma, lifting the bag in the wrong way. It can happen because of the cumulative long term effects of poor body mechanics - a lifetime of too much bending and twisting, too many awkward positions. Herniation in the lumbar and cervical spine usually occurs with increased frequency in middle aged patients (30-50 years old). This is because the relatively flexibility & reparative ability of youth is slowly replaced with the stiffness & disc degeneration of progressive age.

How does it manifest?

Depending on the site of herniation, and the amount of pressure on the spine roots or spine itself, a wide range of symptoms are possible. In addition to pain around the site of the herniation i.e. low back pain, many disc patients also experience significant pain somewhere in buttock, thigh, calf or even entire leg. This is because when discsooze and bulge, they ooze and bulge into spaces occupied by nerves. Because these nerves are carrying impulses from brain to different parts of his body, the pain is experienced in those parts of body where the compressed nerve is taking the impulses.

Diagnosis

Several kinds of imaging tests, including x-rays, CT scans and MRI scan are available to confirm the clinical impression of a physical examination. In general, x-rays and CT scans are more informative of bony structures while MRI scan is more helpful for disc pathology and nerve root compression. Herniated disc are rarely a diagnostic mystery.

Treatment

There are different types of treatment options available. At times, doctors often disagree about the treatment of disc disease. The fact is, different patients sometimes respond to the same treatment in very different ways.

At least initially the conservative treatment is best, unless there is clear evidence of severe nerve involvement, significant loss of sensation, partial paralysis, or bowel or bladder dysfunction. By conservative therapy, it means bedrest, mild stretching exercises, heat or ice, massage, braces, and drugs to reduce pain, relax muscles and reduce inflammation. Cervical (neck) or pelvic (lower back) traction, ultrasound therapy and electronic nerve stimulation are also options. When patient doesn’t respond to this, doctor may prescribe epidural injection, that is injecting local steroid directly in to spinal space to reduce nerve inflammation and there y pain of herniated disc.

When conservative therapy fails

For discs that do not respond to conservative treatment, the last option is of course, surgery. It means surgical removal of offending portion of a herniated disc. While surgeries may not help in repairing the the disc itself, it can remove the prolapsed portion of the disc (nucleus pulposus), thereby reducing pressure on the nerves and therefore pain.

Open Discectomy v/s Micro Discectomy

The older, more radical version of this surgery is called an open Discectomy. Where the entire lamina, or back of the spinal canal is removed and the offending disc is approached.

In the newer version of this procedure, called a microdiscectomy, only the small part of the lamina directly surrounding the affected disc is removed or at times it doesn’t require removal of lamina.

Although, some doctors still prefer the older more radical surgery, there is growing evidence that the newer, less invasive procedure, the microdiscectomy is superior. The simple reason being that the more bone is removed, the less strong and stabile the remaining structure is. While removing more lamina will often relieve symptoms initially, there is far greater rate of subsequent complications, o because of the resulting spinal instability.

Spinal Stenosis

Stenosis is defined as narrowing. This term is commonly applied to a specific spinal problem where an abnormal reduction in size of the spinal canal, which transmit nerves results in leg pain. Narrowing of the spinal canal will generate Compression of the nerves as they pass through this narrowing, and it will causes arm or leg symptoms such as numbness, weakness, or pain. Symptoms from spinal stenosis, which occur with activity, are defined as neurogenic claudication.

As the narrowing of spinal canal occurs over the time (gradual wear and tear change), typically the symptoms are insidious in onset and rarely occur acutely. The patient usually complain that over weeks or months he or she has noticed difficulty in walking. After certain amount of walking, the legs become tired or numb. At times it compels the patient to stop walking and to sit or to stoop forward. Changes in position of the spine can affect symptoms quickly as many patients admit that when they lean on a shopping cart, the tiredness in their legs improves. Forward bending produces widening of the spinal canal and nerve holes which relieves pressure on the nerves and decreases symptoms.

As with other spinal problems, conservative measures like rest, pain medicines and physical therapy are useful to alleviate the symptoms in the early stages. Physical therapy may improve muscle tone and fitness, but ultimately can not reverse the bony narrowing and nerve compression, which is the primary problem. Another conservative option is to inject cortisone-epidural injections. Here, a needle will be placed in the space around the spine at or near the narrowing and cortisone will be injected on the nerves. Because of the anti-inflammatory effect of cortisone, it may reduce nerve swelling. If the nerve swelling decreases, the relative relationship of the nerve diameter to the bony hole becomes favorable, thereby reducing symptoms. Three epidurals can be injected at an interval of 10-15 days.

When the symptoms do not respond to conservative treatments, then surgery is indicated. The surgery known as decompression-“removal of bony narrowing around nerves” is usually required. The operative strategy will depend not only on the location of the spinal narrowing, but the relative stability and condition of the spine as a whole. If the stenosis is associated with instability, then stabilization and fusion may have to be performed with the nerve decompression. Stenosis with curvature of the spine (scoliosis or kyphosis), may also complicate the treatment. In these conditions, the bony narrowing relieved with surgery may recur quickly in a curved spine because of asymmetric collapse on the concavity of the curve. Stabilization and fusion may have to accompany the decompression in these cases for long term, sustained good results after surgery.

The usual decompression procedures are laminectomy and laminotomy. Every patient's surgical treatment should be individualized according to spinal anatomy and clinical presentation.

Degenerative Spine

 
Degenerative Instability Cervical Spine Fusion Decompression with screw fixation relieves leg & back pain Reconstruction of lumbar lordosis

As age increses, as our hair become white, our spine also degenerates. Many elderly patients suffer from degenerative spine disease where their nerves are compressed certain spinal level becomes unstable. These patients with their instability of spine experience nerve compression and thus disabling back and leg pain, tingling and numbness of both lower limbs, difficulty in walking and standing. These can happen in lower Back and neck also. Our surgeons do operate on this kind of degenerated spine where, they take the pressure off from nerves and also put specialized spinal implants to stabilized and reconstruct the spine.

Spinal Deformity

Right sided spine deformity
before surgical correction
Straight back after correction Right sided spine deformity
before surgical correction
Straight spine after correction

An 18 years old girl from western part of Gujarat, had bend spine. She noticed the bend of her back for last 6 years which was gradually increasing. Obviously being a teen aged girl , she wanted to have her back as straight as possible. She underwent a single stage surgical correction where spine surgeons’ corrected her bent back and restored normal balance of spine. She used to put on a nicely fitted, light weighted brace on her back and allowed to move around within a week of surgery.

Disc Replacement

   
Before Surgery After Surgery    

Mrs. Patel, a 42 years old lady, by profession used to work through the microscope, was suffering from chronic neck pain. It was also spreading to her left arm and disabled her from performing even routine activities of daily living. Her MRI scan was suggestive of disc degeneration with prolapse to irritate the nerve fibers. Spine surgeons operated upon her and replaced her damaged disc with the artificial disc. On first day after surgery, she was allowed to come out of bed and to walk without any collar support. She was also allowed to move her neck without any restriction. It is now around 2 years of her surgery and she has gone back to her original occupation.

Spinal Reconstruction

A 19 year old girl, fallen down from the height and broke her back. She had fractured her Lumbar first vertebra and got paralysis of her both legs. Her magnetic resonance scan showed severe compression over spinal cord which necessitates her to undergo a major spinal reconstruction surgery, where surgeons’ approached her spine from front and also from back in single sitting. They take the pressure off from the spine and also stabilized the broken spine with specialized spinal implants. She recovered from her paralysis of legs and started walking within 3 months of injury.

 
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