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Dedicated to Neck & Back Pain Management.
 

SURGICAL TREATMENT

Laminectomy Minimally Invasive Laminotomy/Discectomy Endoscopically assisted Lumbar Discectomy Spinal Fusion Surgery Anterior Lumbar Interbody Fusion (ALIF) Posterior Lumbar Interbody Fusion (PLIF) Transforaminal Lumbar Interbody Fusion (TLIF) Dynamic Stabilization of Spine Spinal Arthoplasty

Myths: …
the only solution a spine surgeon can offer is surgery. If you believe the myth you will be interested to learn that out of 100 patients with a back or neck disorder, fewer than 5% require surgery. This means that 95% are treated without surgery. Certain spinal disorders may require surgical consideration. These include bladder or bowel dysfunction, structural instability, tumor, infection, deformity, progressive neurological deficit, and unrelenting pain that cannot be controlled non-surgically. In the 5% group, certain spinal disorders arouse more concern. Notably, incapacitating back pain, inability to move an extremity, leg pain, or loss of bladder or bowel control may be signs of progressive and serious neurological dysfunction. In some cases, surgery may be the immediate treatment.

Another myth about spine surgery is that a long recuperative period in bed is necessary. This simply is not true. Often the patient is up, out of bed and walking the day after surgery. Even following a complex surgical procedure the patient is up, seated in a chair and walking the next day. Rehabilitation or physical therapy may be started the day after surgery to help the patient become mobile. Many patients are quite independent a short time after spine surgery.

The Goal of Spine Surgery
The goal of any surgery is to restore the patient's health. Spine surgery is no exception. Spine specialists want to return each patient to his pre- disease or injury functional level quickly. In general, the success rates are very good.

Surgical Options:

Laminectomy
What is it?
Lumbar Laminectomy is an operation performed on the lower spine to relieve pressure on one or more nerve roots. The term is derived from lumbar (lower spine), lamina (part of the spinal canal's bony roof), and -ectomy (removal).

Why is it done?
Pressure on a nerve root in the lower spine, often called nerve root compression, causes back and leg pain. In this operation the surgeon reaches the lumbar spine through a small incision in the lower back. After the muscles of the spine are spread, a portion of the lamina is removed to expose the compressed nerve root(s).

Pressure is relieved by removal of the source of compression part of the herniated disc, a disc fragment, a tumor, or a rough protrusion of bone, called a bone spur.

What Happens Afterwards?
Successful recovery from lumbar Laminectomy requires that you approach the operation and recovery period with confidence based on a thorough understanding of the process. Your body is able to heal the involved muscle, nerve, and bone tissues. Full recovery, however, takes time as there is bigger incision, extensive muscle stripping, considerable blood loss thus leading to longer hospitalization, prolonged bed rest, more of tissue scarringTOP

Minimally Invasive Discectomy
What is it?
Lumbar microdiscectomy is an operation on the lumbar spine performed using a surgical microscope and microsurgical techniques. A microdiscectomy requires only a very small incision and will remove only that portion of your ruptured disc which is "pinching" one or more spinal nerve roots. The recovery time for this particular surgery is usually much less than is required for traditional lumbar surgery.

Why is it done?
Lumbar microdiscectomy is usually recommended only when specific conditions are met. In general, surgery is recommended when a ruptured disc is pinching a spinal nerve root(s) and you have:
1. Leg pain which limits your normal daily activities
2. Weakness in your leg(s) or feet
3. Numbness in your extremities
4. Impaired bowel and/or bladder function TOP

What is ENDOSCOPIC DISCECTOMY?
Conventional spine surgery requires a long incision and a lengthy recovery period. Minimally invasive surgery, also known as "keyhole" surgery, uses a thin, telescope-like instrument known as an endoscope, which is inserted through small incisions. The endoscope is connected to a tiny video camera - which projects an "inside" view of the patient's body onto television screens in the operating room. Small surgical instruments may then be passed through one or more additional half-inch incisions. Following the procedure, the small incisions are closed with sutures and covered with surgical tape. After a few months, they are barely visible.


The aim of the surgery is to remove the compression exerted by the disc on the nerve. It consists of removing the fragment of the herniated nucleus. The use of Endoscopic technique has made possible to carry out the same big surgery regularly with a very small incision.

ADVANTAGES OF ENDOSCOPIC DISCETOMY DISADVANTAGES OF CONVENTIONAL SURGERY
Small incision (1.5 - 2 cm) Larger skin incision
No traumatic back muscle dissection-Minor tissue trauma
 
Extensive tissue dissection- major tissue trauma
 
Less intraoperative bleeding More bleeding
Less chances of complications from scarring, blood loss, infection Higher rate of infection
Patient can walk the same day Pt. may take 2-3 days to walk
Very short hospital stay ( 1 - 2 days) Longer hospital stay
Early return to work & normal activity Delayed return to normal activity & work
 

WHO SHOULD CONSIDER THIS PROCEDURE?
Endoscopic Discectomy is specifically designed for patients with disc problems accompanied by the following:
1. Repeated buttock, groin, low back, or leg pain, numbness or weakness
2. Pain that has not responded to conservative treatments, i.e. bed rest, pain medication, physical therapy, or muscle relaxants & traction for the last 3 weeks
3. There has been increase in pain, numbness & weakness with patient on conservative treatment; loss of control of urination & stool.
4. Herniated disc confirmed by CT scan, MRI Scan, Enhanced CT Scan, Myelography, or Discography.

What happens to the PAIN & other problems AFTER SURGERY?
You have pain in the leg -Sciatica, and pain in the Back, due to continuous spasm of muscles surrounding the vertebral column. After surgery, most of your pain goes immediately. For the next 36 hours you may have some pain especially at night, when you lie in a continuous position. You will not experience the pain which was there on moving & standing.
In case you are suffering form any motor or sensory weakness, depending upon the duration of your problem, the recovery time will vary from few days to weeks. Longer the duration of problem, more will be the time taken for recovery.

What is the DURATION OF CONVALESCENCE?
Your stay in the hospital usually varies form 1 – 2 days. The stitches dissolve on there own & need not be removed. Return to work varies depending upon the nature of your work & severity of the problem. After surgery you should walk a lot so as to permit your back musculature to regain certain flexibility which has been lost due to the disc herniations. Physical therapy including back exercises is very important to regain the lost confidence in your back & vertebral column. With continuous physical activity you can keep your back fit & even return back to more violent activities like playing tennis & badminton.

How to avoid the incidence of a new DISC HERNIA?
The reoccurrence of disc hernia is rare and the best means to avoid a new problem is to protect your vertebral column by keeping your back muscles relax & strong. Only regular physical activities will keep your back musculature in a good state.

What are the risks of ENDOSCOPIC DISCECTOMY?
If performed by experts in this field, minimally invasive spine surgery is as safe as "open" spine surgery in carefully selected cases.

Dr Sanjay Pal has been trained under the guidance of Dr Jean Destandau at the Bagatelle Hospital, France- a pioneer in the field of Endoscopic surgery and has been doing Endoscopic Discectomy since 2004 and has been giving good results.

With this procedure most of the problems & complications of open surgery have been overcome. But we still have an infection rate of 1%. All due precautions are taken , pt is advised to take a shower few hours before surgery, the skin is thoroughly prepared with antiseptic solutions, strict asepsis is maintained in the Operation Theatre & during the post. operative period. The complication if occurs will surely need extra care & evaluation, necessary antibiotic coverage & should heal without any squeal. TOP

Spinal Fusion Surgery
What is it?
A spinal fusion is simply the uniting of two bony segments, whether a fracture or a vertebral joint. The reason for instrumentation with rods and screws is to act as and 'internal cast' to stabilize the vertebra until the fusion, or bony re-growth, can occur.

Why is it done?
Historically spinal fusions have been used to correct Degenerative Spondylolisthesis. The main indication is for Spinal Instability and Back Pain. However, there are many indications for a spinal fusion and it is not the only procedure preformed to treat those various conditions. You should talk to your doctor about what procedure is best for you.TOP

Anterior Lumbar Interbody Fusion (ALIF)
What is it?
Anterior Lumbar Interbody Fusion (ALIF) is a back surgery that involves approaching the spine through an incision in the abdomen. A portion of the affected disc space is removed from the spine and replaced with an implant. Titanium or stainless steel screws and rods may be inserted into the back of the spine to supplement the stability of the entire construct.TOP

Why is it done?
Patients who are suffering from back and/or leg pain are potential candidates for the ALIF procedure. This pain is generally caused by natural degeneration of the disc space.

Posterior Lumbar Interbody Fusion (PLIF)
A posterior lumbar interbody fusion (PLIF) is a type of spine surgery that can be performed in a minimally invasive way. Posterior lumbar interbody fusion (PLIF) is a type of spine surgery that involves approaching the spine from the back (posterior) of the body to place bone graft material between two adjacent vertebrae (interbody) to promote bone growth that joins together, or "fuses," the two structures (fusion). The bone graft material acts as a bridge, or scaffold, on which new bone can grow. The ultimate goal of the procedure is to restore spinal stability.

Today, a PLIF may be performed using minimally invasive spine surgery, which allows the surgeon to use small incisions and gently separate the muscles surrounding the spine rather than cutting them. Traditional, open spine surgery involves cutting or stripping the muscles from the spine. A minimally invasive approach preserves the surrounding muscular and vascular function, minimizes scarring, hastens recovery and decreases hospitalization stay.

Why is it done?
A spinal fusion procedure such as a PLIF may be recommended as a surgical treatment option for patients with a condition causing spinal instability in their lower back, such as degenerative disc disease(DDD) or spinal Stenosis & Spondylolisthesis, that has not responded to conservative treatment measures (rest, physical therapy or medication). The symptoms of lumbar spinal instability may include pain, numbness and/or muscle weakness in the low back, hips and legs.

Your surgeon will take a number of factors into consideration before recommending a PLIF, including the condition to be treated, your age, health and lifestyle and your anticipated level of activity following surgery. Please discuss this treatment option thoroughly with your spinal care provider.

How is it done?
Spinal Access and Bone Removal
First, your surgeon will make a small incision in the skin of your back over the vertebra(e) to be treated. Depending on the bone graft to be used, the incision could be as small as approximately 3 centimeters. In a traditional open PLIF, a 3- to 6-inch incision is typically required.

The muscles surrounding the spine will then be dilated to allow access to the section of spine to be stabilized. After the spine is accessed, the lamina (the "roof" of the vertebra) is removed to allow visualization of the nerve roots. The facet joints, which are directly over the nerve roots, may be trimmed to give the nerve roots more room.

Bone Graft Placement
The nerve roots are then moved to one side and disc material is removed from the front (anterior) of the spine. Bone graft is then inserted into the disc space. Screws and rods are inserted to stabilize the spine while the treated area heals and fusion occurs.
 Your surgeon will then close the incision, which typically leaves behind only a small scar or scars.

After Your Surgery
This minimally invasive procedure typically allows many patients to be discharged the day after surgery; however, some patients may require a longer hospital stay. Many patients will notice immediate improvement of some or all of their symptoms; other symptoms may improve more gradually. TOP

Transforaminal Lumbar Interbody Fusion (TLIF)
A transforaminal lumbar interbody fusion (TLIF) is a procedure that can be performed using minimally invasive spine surgery.
Transforaminal Lumbar Interbody Fusion (TLIF) is a form of spine surgery in which the lumbar spine is approached through an incision in the back. The name of the procedure is derived from: transforaminal (through the foramen), lumbar (lower back), interbody (implants or bone graft placed between two vertebral bodies) and fusion (spinal stabilization).



Why is it done?
A spinal fusion procedure such as a TLIF may be recommended as a surgical treatment option for patients with a condition causing spinal instability in their lower back, such as degenerative disc disease, spondylolisthesis or spinal stenosis, which has not responded to conservative treatment measures (rest, physical therapy or medication). The symptoms of lumbar spinal instability may include pain, numbness and/or muscle weakness in the low back, hips and legs.

Your surgeon will take a number of factors into consideration before recommending a TLIF, including the condition to be treated, your age, health and lifestyle and your anticipated level of activity following surgery. Please discuss this treatment option thoroughly with your spinal care provider. TOP

Dynamic Stabilization of Spine
Spinal fusion has been the gold standard for treatment of back pain for years. But, spinal fusion alters the biomechanics of the back, potentially leading to premature disc degeneration at adjacent levels, a particular concern for younger patients. This produces "Transitional Syndromes", not infrequently is the cause for additional surgery.

Dynamic stabilization, also known as soft stabilization or flexible stabilization, has been proposed as an adjunct or alternative to fusion. Dynamic stabilization uses flexible materials to stabilize the affected lumbar region while preserving the natural anatomy of the spine. It is intended to alter the load bearing pattern of the motion segment and to control any abnormal motion while leaving the spinal segment mobile. The hypothesis behind stabilization is that control of abnormal motions and more physiologic load transmission would relieve pain and prevent adjacent segment degeneration. The expectation is that once normal motion and load transmission are achieved, the damaged disc may repair itself, unless the degeneration is too advanced.

Dr Sanjay has been trained to use the DIAM and Dynesys, both of which are presently available in India.

DIAM is an interspinous device and is made of silicon. Dynesys system, involve pedicle screws joined across lumbar segments with nonelastic bands. With these constructs, surgeons attempt to create a posterior tension band to place the motion segment in extension and to limit movement in other directions. An important element of this technique is the preservation of the posterior ligaments and facet joints during surgical exposure. Clear contraindications are Osteoporotic bone and evidence of severe segmental instability (that is, gross Spondylolisthesis).

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                                  DYNESYS                     DIAM

Spinal Arthoplasty
Since we all know that though fusion helps in relieving pain and discomfort, but over a period of time there occurs adjacent level degeneration and the pain may return in few cases. Spinal Arthoplasty helps to maintain the motion at the affected level and may prevent adjacent level degeneration. Over the years Cervical Disc Replacement has gained more popularity in terms of overall results over the Lumbar Disc replacement.

Who are the patients who will benefit?
People having a Symptomatic Disc Disease between C3-C7. There may be Myelopathy or radiculopathy due to Herniated Disc or Spondylosis in patients with age form 18 to 60 yrs.

Where you should not do Disc Replacement?
->When there is marked instability of spine
-> Severe DDD with OA of Facet Joints
-> Compromised vertebral bodies
-> Prior surgery at the same level
-> Severe Osteoporosis
-> Active Infection
-> Rheumatoid Arthritis
-> Active Malignancy
-> Surgical Procedure

It is similar to the anterior cervical Discectomy and fusion. This surgery involves the use of a new medical device, which is designed to replace the disc which sits between the vertebrae of your neck. Your disc which is damaged or diseased is surgically removed through an incision made in the front of the neck. In its place, your surgeon will prepare a space and insert a Cervical Disc Prosthesis. The device utilizes a ball and socket design which is designed to allow for motion to be preserved.

What should I expect from surgery?
The surgical procedure is expected to relieve the symptoms of nerve or spinal cord compression caused by the damaged disc. The surgery associated with Cervical Disc System is designed to allow for motion at the operated disc level, unlike a fusion surgery.TOP

* "The information contained here is not intended as a substitute for professional medical evaluation and management. It should be used only as a starting point for further research. A physician should always be consulted for any health problem."

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