Disc Replacement:

Tremendous advancements have been made in the field of spinal Biomechanics and reconstructive surgeries during the past 30 years leading to the concept of disc replacement by artificial devices from the concept of spinal fusion. These devices not only maintain the near normal natural motion of the replaced disc but also protect the normal discs from abnormal stresses which is a common problem after fusion surgery. At the same time since these devices do not require any graft harvesting from the patient ,problems related to graft surgery like donor site pain ,infection ,local herniation of organs are avoided. At present we can safely replace one or two level discs of both lower back as well as that of neck region in selected cases of disc degeneration who have failed all other non-operative treatment modalities for at least six months without involvement of posterior joints clinically and radiologically.

Vertebroplasty:

Approximately 85% fractures in old age are caused by osteoporosis (a condition in which total mass of the bones decrease) and remaining 15% are caused by bone weakness caused by other conditions or spread of cancer to the bones. Out of these one third patients may present with significant pain in spite of non-operative measures like bed rest, hospitalization, pain killer medications or bracing. Vertebroplasty is a procedure in which a special type of synthetic cement material is injected inside the broken spine bone, giving excellent results in pain relief with very low incidence of side effects, can be performed in the out patient setting under local anesthesia and light sedation, there by obviating the need of expensive and extensive surgical procedures which usually have high incidence of morbidities and mortalities in such group of patients. The patients can be discharged the same evening or the next day and are able to walk .Procedure can be safely done in osteoporotic fractures, painful spine bones after spread of cancer, non cancerous painful tumors of spine bones or to augment strength of weak spine bone prior to insertion of screws to increase the holding power of the weak bones for other surgical procedures.

Tuberculosis of Spine:

Spinal tuberculosis is the commonest form of bony tuberculosis constituting about 50% of all the cases of tuberculosis of bones and joints. Though previously confined mainly to developing world, rapid spread of AIDS throughout the world has led to rapid surge of tuberculous infection even in developed world also. Patient usually present with stiff and painful movements of spine with localized prominence of spine bones which is painful on deep pressure .In addition during active phase of the disease patient may have low grade temperature in the evening, rapid loss of weight, night sweats and loss of appetite. In advanced stage patient may present with paralysis, the dreaded complication of spinal tuberculosis .Tuberculosis of spine bones, in some children, in spite of adequate treatment with anti-tuberculosis drugs may lead to grotesque, progressive, ugly looking deformity of back because of damage to growth centers of spine during active phase of the disease. Such patients may present with late onset paralysis in the adult or adolescence due to stretching of spinal cord over the bent bones .Progressive paralysis in spite of adequate medical treatment or high risk signs on x-rays in children may require surgical cleaning of infected bone, removal of pressure from spinal cord, straightening of bend in spine bones by fixation with rods and screws so that patient can be mobilized as soon as possible after surgery.

Scheuermann,S Kyphosis:

Scheuermann,s disease is a condition involving either upper back(thoracic spine) or junction between upper and lower back (thoraco-lumbar region).This condition commonly involves spine during growing age ,usually between 11years to 17 years of age. Adjacent vertebral bones become wedge shaped, leading to rigid forward bend of spine with varying severity of back discomfort. Patients may present with disabling back pain either during adolescence or adult age. Progressive curves of less than 65 degrees can be treated by brace. Painful curves of more than 70 degrees are usually treated by surgical correction of deformity which may involve surgery from back or both from back and front depending upon the severity of the deformity with gratifying results.

Ankylosing Spondylitis:

Ankylosing spondylitis is an inflammatory disease characterized by pain along with stiffness of spine and involvement of joints between pelvic bones and spine called sacroiliac joints. Disease usually involves men in second or third decade of life. It is less severe in females .Disease may lead to total loss of spine movements by formation of new bone around spine joints and discs leading to so called “Bamboo Spine” appearance. Chest expansion is decreased .Hip, knee shoulder and elbow may be involved in about 30% of cases. In advanced cases there may be progressive bending of back or neck bones. In advanced cases of neck and back deformities, patient’s gaze is fixed on to the floor, patient is unable to look forward, there is compression of abdominal components, chronic neck and back pain .these deformities are tackled by cutting and removing a part of the bone from spine, straightening the spine and fixing it with rods and screws provided there is no problem around hip joints region. If hip joints are involved, deformities around hip joint is corrected first followed by correction of residual spinal spinal problem.

Scoliosis:

Scoliosis in layman term is simply known as, “hunch –back” or side bending of spine. In fact, it is a three dimensional deformity of spine caused by abnormal rotation of spine bones. It can be caused by birth defects (congenital) of the spine bones, where some of the spine bones may fail to form properly or they may fail to separate from one another partially or completely or it can be a combination of both the defects. Some of these defects require prompt surgery to prevent rapid progression of deformities. There is no role of corrective braces or exercises in prevention or treatment of these birth defects. Another common form of scoliosis is “idiopathic scoliosis” which can be early onset, presenting before five years of age or late onset presenting after five years of age. Patient may present with prominent rib hump, forward protrusion of one breast, prominence and elevation of one side of hip .Head may not be in line with the center of pelvis and may appear to be shifted to one side. For minor degrees of problem, majority of cases can be treated by either keeping them under observation or by bracing them. However some young patient in growing age may present with progressive deformity which may require surgical correction of the deformity.

Metastasis to Spine:

Incidence of spread of cancer to spine from primary tumors of other parts of body is increasing in recent years .This is primarily because of better control of local problem by surgery and newer anti-cancer medications, as a result a large number of patients are surviving for longer time and approximately 10% patients are presenting with painful cancerous deposits in spine bones. Patients usually presents with two types of pain, one is the pain caused by deposit of cancer tissue, this pain is more during night. Second type of pain is mechanical pain which is more on standing or sitting caused by loading of spine, this type of pain is relieved by bed rest. Surgery on spine bones is indicated for relief of pain if the original cancer is not responsive to radiotherapy or chemotherapy, if the spine has become unstable because of destruction of spine bones by tumor tissue, if there is fracture with bony fragment in the spinal canal, advanced all around compression of spinal cord by tumor tissue and when in some cases you do not know where the primary tumor is. Surgery usually requires fixation with screws –rods –titanium cylinders construct or plates. There is about 94% to 100% relief of local pain after surgery.

Spondylolisthesis (Slipped Vertebra):

Spondylolisthesis is forward slipping of one vertebral body over the adjacent level. Slipping of the vertebral body can be due to either a birth defect in the joints of the vertebrae which lock the two adjacent vertebrae or due to some developmental defects in posterior aspect of vertebral bones leaving a weak area which can be undergo minor fractures on repeated movements of spine, area can undergo elongation or a defect containing fibrous tissue appears. Majority of cases remain problem free, however in some children there is rapid progressive slipping of the vertebral body especially during the growth spurt phase .In very advanced cases the whole of vertebral body slips in the forward direction and lies in front of the adjacent vertebra. Such advanced degrees of slips may lead to gradual bladder or bowel paralysis. Patients with intractable pain not responding to conservative treatment regardless of degree of slip, patients in growing age with more than 50% slip, any patient of slipped vertebra with neurological symptoms like weakness of leg muscles, bladder, bowel sensation loss require surgical management. Basic aim of surgery is to correct local spinal biomechanics, remove the pressure on the nerves and prevent further progression of the deformity. If done properly the chances of success of the surgery are around 90% to 95%.

Minimally Invasive Video Assisted Discectomy:

Discectomy is one of the commonest surgeries performed on the spine worldwide. Classical indications of disc surgery are severe radiating pain from back to leg going beneath the knee usually to the calf muscle or to the side of the legs despite supervised non-operative management which includes bed rest, analgesics, exercises, local heat or cold therapy, braces, epidural steroids etc. In addition there should be a radiological demonstrable disc herniation compressing the nerve root which should correlate with clinical findings. Non-operative management should be continued at least for four to six weeks. Emergency indication of disc surgery include sudden onset of paralysis of foot or calf muscles, loss of sensation around anal opening, loss of function of bladder or bowel control in addition to the pain in the legs. Minimally invasive Discectomy is a procedure in which through a 2.5 cm small incision an endoscope is inserted and under video monitor disc fragment is removed. There is minimal post-operative discomfort and patient can be discharged the next morning.

Spinal Canal Stenosis:

Spinal canal Stenosis (narrowing of the space for spinal cord and nerves) is a common condition in elderly population usually after fifth decade of life .It is a part of the normal age related wear and tear changes which become symptomatic in 10% to 15% of the patients. Patients usually present with radiating pain, tingling, numbness both the legs on walking or going down stairs which gets relieved on taking rest or bending forwards .this is called neurological claudication. This condition has to be differentiated from the other similar condition which happens in diabetic patients where small blood vessels supplying the legs become narrow leading to diminished blood supply to the limbs. A careful clinical examination and history can usually differentiate between the two conditions. Initial treatment is usually non-operative consisting of measures like spine flexion exercises, local heat therapy, epidural steroid injections, nasal calcitonin. There is no role of traction and ill fitting braces usually can aggravate the problem by straightening the spine leading to further narrowing the space for nerves. There are various surgical options varying from laminectomies, laminoplasy, and instrumentation with fusion depending upon the age of patient, general condition and co-morbidities.

Spinal injuries:

Paralysis is one of the most devastating complication of spine injuries .In developing world road traffic accidents are one of the major cause of spine injuries while in the developing world fall injuries followed by road traffic accidents constitute a major chunk of these patients While primary injury to the spinal cord and nerve tissues happens at the time of accident ,particular care should be taken while managing the patient at the site of accident as well as proper immobilization and proper transportation of the patient to the centers dealing with such trauma, with the basic aim being to prevent further injury to the spinal cord. Ideally patient should be shifted to advanced trauma management center as soon as possible .If the patient reaches trauma center or hospital within eight hours of accident ,high dose steroid therapy should be started and if general condition of the patient permits ,in unstable injuries, operative stabilization should be done as soon as possible. Basic purpose of such of such surgery being earliest possible rehabilitation of the patient and providing better environment around spinal cord for neural recovery to take place by removing pressure of displaced bony fragments and soft tissues on spinal tissue. However it should be clear that neural recovery is never the aim of the surgery as in majority of the cases with complete paralysis, permanent injury to the spinal cord has already taken place at the time of accident.