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faq - back / Lumbar Spine pain

What is a herniated disc?
A disc is the fibrous cartilage pads that lie between the spinal vertebrae; each is made up of two parts: a jelly-like center (the nucleus pulposus) that loses moisture with age, and a tough outer ring (the annulus fibrosus) that can split with age or injury. A herniated disc occurs when the disc's jelly-like center (the nucleus pulposus) ruptures the tough, fibrous outer ring (the annulus fibrosus) oozing through small openings and pressing on the nerves.

What is the difference between a herniated disc and a bulging disc?
A bulging disc is a slight protrusion of the center of the disc (nucleus pulposus) into the spinal canal. A disc herniation is a large protrusion of the nucleus pulposus (center of the disc), which has burst through the annulus fibrosus (outer ring of the disc) into the spinal canal, invading the surrounding nerves and causing pain in the back, buttocks, hips, or legs.

Are bulging or herniated discs normal?
No, they are not "normal" in that we are not born with herniated or bulging discs. They are very common and occur with age and natural dehydration and degeneration of the disc. MRI studies of asymptomatic patients showed that approximately 40% of the population has herniated or bulging discs.

Do all patients of Herniated Disc need surgery?
More than 85%t of the patients with slipped disk will cured by simple means like rest, pain medication and physiotherapy. Only a very small percentage will need surgery.

What is degenerative disc disease (DDD)?
Degenerative Disc Disease refers to the changes occurring in the spine due to wear and tear. There occurs loss of water in the disc, weakening of the annulus (outer lining of the disc) and formation of bone spurs. DDD is very common in the human population & occurs with age, trauma and similar conditions can cause it to happen early in life. It is not always symptomatic.

What is lumbar instability?
Lumbar instability occurs when there is abnormal movement between the vertebras. This can be a result of DDD, a spinal deformity such as Spondylolisthesis, or occur after a decompression procedure.

Do I have to live with Back Pain of DDD?
Generally, the pain associated with degenerative changes can be managed with conservative therapies, exercise, and medication. A very few people may need surgery.
The condition is curable. Most of the people have a myth that they have to live with the pain.

What is Pain Management/ Pain Specialist?
Go to Interventional Pain management

When is surgery necessary for patients with spine problems?
Surgery is only indicated if conservative therapy fails, if there is reoccurring low back/buttock pain, persistent weakness of upper/lower limbs or there is progression of neurological problems. Loss of bowel & bladder is an absolute indication

Will I have irreversible damage if I delay surgery?
Your physician will advise you based on your condition. In general, if there is severe spinal cord compression or a nerve is compressed over a period of time there may be irreversible damage. If a patient experiences an increase in weakness, weakness in the legs, loss of balance, or loss of bladder or bowel control, they should be reevaluated by their spine specialist immediately.

My spinal specialist said I need a fusion?
A fusion is recommended if there is spinal deformity or instability occurring due to various reasons and conservative treatment has not given adequate relief. The commonest symptom of instability is Back-pain.

If I have a fusion does that mean I will never be able to bend?
No. Very little bending capacity comes from the spine. It is from the hips. Fusion of one or two levels does not cause much effect. Infact most of the patients who need fusion already have stiff backs.

My spinal specialist said he would be using implants in my spine. Is this really necessary?
The spinal instrumentation helps the surgeon to restore the alignment and balance of the spine. The instrumentation also acts as an internal brace, stabilizing the spine while the bone fusion grows.

What are the risks associated with spinal surgery?
There are risks associated with any kind surgical procedure. The risks for spine surgery include but are not limited to: intra- operative complications, nerve injury, infection, bleeding, and hardware failure. I expert hands by and large the risks are few.

How quickly can I expect to recover from surgery?
Recovery from surgery is individualized, and depends on the surgical procedure. Modern day surgery aims at a shorter hospital stay, quick recovery and early return to work. By large most of the patients are allowed to walk within 24 hours of surgery.

What is Endoscopic Discectomy? How do I know if I am a candidate?
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. The major benefits being—smaller scar, shorter hospital stay and early return to work. Your physician will explain the treatment options and the pros and cons of each.

Is it true that Spinal Fusion can be done by Minimally Invasive Techniques?
Spinal fusion is now done through small incisions with the help of special instrumentations. Dr Sanjay Pal has good training and experience in various Minimal Invasive technologies and the good news is that these implants are freely available in India.

Do You Recommend Lumbar Disc Replacement?
The results with Lumbar Disc Replacement have not been as encouraging as with Cervical Disc Replacement. I would rather recommend Dynamic Stabilization of Spine.

What is Dynamic Stabilization of Spine?
Dynamic 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.

Why should I come to you for surgery?
The most important thing in selecting your pain physician is – training. Dr Sanjay Pal has been trained at best of the centers in India and abroad and under the most senior spine surgeons. He is widely traveled and has received training form the most advanced centers in Mumbai, France, Singapore and Italy. He is well experienced and extremely dedicated to the cause of Neck`n`Back pain management. Surgery is offered to a very limited number of patients; mostly as a last resort. He is the only trained Spine Surgeon in the region offering a comprehensive pain management for back and neck pain. He is trained in Minimally Invasive Surgery, Dynamic Stabilization of Spine and Cervical Arthoplasty.

Why don't other physicians perform these procedures?
Other physicians also perform these procedures, but because these are relatively new techniques, the numbers of trained surgeons are very few. Many physicians say they can perform minimally invasive surgery, but really can only perform lumbar discectomy type procedures. Minimally Invasive Spine Surgery requires special training and a very long learning curve. Dr Sanjay Pal is among the pioneer surgeons to do Minimally Invasive Spine Surgery in North India. Ours is the first Superspeciality Neck ‘n Back Pain clinic in Punjab.

Why don't more physicians learn this new technology?
First of all, this is very sophisticated surgery. Many surgeons would have trouble learning how to perform these procedures. It is almost like fixing a car through the muffler, the surgeon has to rely on scopes and cameras to guide him. It takes a lot of time and dedication to learn these techniques. Secondly, many doctors get fixed in how they treat patients. It is easier for them to treat patients with techniques that they learned in residency training, than to take the effort and risks of learning new techniques. At Orthopedic`n`Spine Center pain clinic every patient and is his problem is individualized and the most appropriate treatment is given.

What are the risks and complications of your Endoscopic surgery?
Endoscopic spine surgery is very safe and complications are low. The most common complication is infection and this is usually discitis and related to disc surgeries. The incidence of discitis is similar to conventional surgery and is around 5%. Other risks include nerve damage, bleeding, etc. but these are very rare and to date we have not had any cases of nerve damage. Bleeding is usually only around 100 cc's and thus is minimal.

What are your results?
Obviously it depends on your problem, if you have had prior surgery, and the amount of nerve damage you have had. But to give a ballpark percentage, about 70 to 90% of our patients get what they term as "good to excellent" relief. This compares to conventional surgery where most get 50 to 70% "good to excellent" results. Also, if you have never had surgery, you could expect to be closer to 90% successful results.

What are my limitations after surgery?
Generally, we don't want you to perform any excessive bending or heavy lifting (greater than 10 lbs.) for about three to six weeks after the surgery. We encourage a gradual return to normal activities over this period of time. Often, many individuals who have desk type jobs can return to work within 2-3 weeks. We do stress to patients to "take it easy" for about a 1-2 months to let the spine heal. Once the wound heals patients are advised spinal exercises. Long walks are the best form of exercises and patients are encouraged to do so.

Will I have to have physical therapy? If so, for how long?
Your physician will determine if you need physical therapy. In general, I prescribe physical therapy for my patients between 4 and 12 weeks post-surgery. Core stabilization, stretching, and muscle conditioning are very important to a patient's long term health.

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