05/Sep/2019

What is Hydrocephalus

Hydrocephalus Hydro means water and cephalous means the brain. When there is an obstruction to the flow of cerebrum spinal fluid (CSF) in the brain, it leads to these diseases

What are the kinds of Hydrocephalus? | Hydrocephalus Treatment in India

Hydrocephalus Treatment in India

  • Congenital Hydrocephalus- when there is an obstruction to the flow of CSF from the birth, due to blockage of ventricles it leads to congenital
  • Acquired hydrocephalus- when the flow of CSF is obstructed wither internally due to infection, tumor or bleed or externally when a tumor or mass presses on the ventricle to obstruct its flow.

What are the Types of Hydrocephalus? | Hydrocephalus Treatment in India

  • Obstructive or non-communicating Hydrocephalus– when there is an obstruction to the flow of CSF within the ventricles causing swelling or increase in the size of the ventricles.
  • Communicating Hydrocephalus– here there is no obstruction to the flow of the CSF within the ventricles but there is a defect in the absorption of CSF within the veins over the surface of the brain.

What are the symptoms of Hydrocephalus  Treatment in India?

  • Severe headache
  • Vomiting
  • Sunset sign- inability to look up. So, eyes have a downward gaze, looking like a sunset
  • Enlarging size of the head in congenital
  • Enlargement of veins over the skull.

What are the Hydrocephalus Treatment

  • Shunt surgery– A tube is introduced into the ventricles and tunneled down below the skin into the abdomen- peritoneum called VP shunt or ventriculoperitoneal shunt. VA shunt or Ventriculo Arterial shunt when the lower end of the shunt is introduced into the heart.
  • Third ventriculostomy– here the obstruction to the flow from the third and fourth ventricle is corrected by endoscopy.

Hydrocephalus Treatment in India

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30/Aug/2019

The goal of minimally invasive spine surgery (MISS) is to achieve outcomes equivalent to those of open surgery while minimizing muscle dissection, disruption of ligament attachment sites and collateral damage to soft tissues. In general, minimally invasive spine surgery (MIS) surgery is performed to stabilize the vertebral bones and spinal joints and/or relieve pressure being applied to the spinal nerves — often a result of conditions such as a spinal instability, bone spurs, herniated discs, scoliosis or spinal tumors.

As opposed to open spine surgery, minimally invasive surgical approaches can be faster, safer and require less recovery time. Because of the reduced trauma to the muscles and soft tissues (compared to open procedures), the potential benefits are:

  • Better cosmetic results from smaller skin incisions (sometimes as small as 2 centimeters)
  • Less blood loss from surgery
  • Reduced risk of muscle damage since less or no cutting of the muscle is required
  • Reduced risk of infection and postoperative pain
  • Faster recovery from surgery and less rehabilitation required
  • Diminished reliance on pain medications after surgery

Conditions treated using MIS procedures are:

  • Degenerative disc disease
  • Herniated disc
  • Lumbar spinal stenosis
  • Spinal deformities such as scoliosis
  • Spinal infections
  • Spinal instability
  • Vertebral compression fractures
  • Spinal Tumors

Minimally Invasive Spine Surgery Procedure:

Because the spinal nerves, vertebrae and discs are located deep inside the body, any approach to gain access to the spinal area requires moving the muscle tissue out of the way. In general, this is facilitated by utilizing a small incision and guiding instruments and/or microscopic video cameras through these incisions. Contrary to popular belief, lasers are very rarely used in MIS surgeries.

Common MIS surgery treatment options include:

1). Discectomy:

Spinal discs are essentially elastic rings with soft material inside that serve as cushions between the vertebral bones. If the elastic ring becomes weakened, the soft tissue inside can extrude — or herniate — outside of the elastic ring. The herniated disc material can compress the nerves passing by, thus causing pain. If surgical treatment is recommended to trim or remove the herniated disc, it may be possible to perform this procedure with MIS surgery using tubular dilators and a microscope or endoscope.

2). Spinal decompression:

Spinal stenosis, which is a narrowing of the vertebral canal, is a common condition that can result in compression of the nerves. This can produce a variety of symptoms, including pain, numbness and muscle weakness. If surgery is recommended, it may be possible to remove the bone and soft tissues causing the nerve compression through an MIS approach using tubular dilators and a microscope or endoscope. The more common decompressive procedures include laminectomy and foraminotomy.

3). Transforaminal Lumbar Interbody Fusion (TLIF):

This is a technique that is performed for patients with refractory mechanical low back and radicular pain associated with spondylolisthesis, degenerative disc disease and recurrent disc herniation. The procedure is performed from the back (posterior) with the patient on his or her stomach. Utilizing two small incisions, screws and rods are placed between two or more vertebral levels. The intervertebral disc is removed and a cage filled with bone is placed in that void with the goal of stabilizing the levels affected.

As with any surgical procedure, no matter how minimal, there are certain risks associated that include but are not limited to:

  • Possible adverse reaction to the anesthetic
  • Unexpected blood loss during the procedure
  • Localized infections, no matter how small the incision area

And, though uncommon, there is always a small chance that the initial MIS surgery cannot be completed, requiring either a second procedure or full open surgery.


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30/Aug/2019

Spinal cord tumors are much less common compared to brain tumors. It could be benign, meaning it is a non-cancerous mass that started on the spine and isn’t going to spread to other parts of the body as cancerous (malignant) cells might. The majority of tumors results from uncontrolled growth among cells that reside in the spinal column while some tumors are related to a specific disease or to radiation exposure. However the cause behind most spine tumors is unknown and they are neither contagious nor preventable.

Spinal tumor surgery involves the partial or total removal of the spine tumor. Spinal fusion may be used to reconstruct and stabilize the spine. This procedure involves joining the bones together with screws or bone grafts to provide stability. Precision tools and unique surgeries has allowed surgeons to access tumors in a less invasive way than ever before. And while there is a slight risk of damage to the spine due to surgery, there is definite risk of catastrophic nerve or spine injury if the patient opts out of surgery and the tumor continues to grow.

If a person ends up paralyzed because of tumor growth, there is also risks of blood clot and other serious health complications. It is crucial to manage the tumors at the right time.

Symptoms of Spinal Tumor

Non-mechanical back pain, especially in the middle or lower back, is the most frequent symptom of both benign and malignant spinal tumors. This back pain is not specifically attributed to injury, stress or physical activity. However, the pain may increase with activity and is often worse at night. Pain may spread beyond the back to the hips, legs, feet or arms and may worsen over time — even when treated by conservative, nonsurgical methods that can often help alleviate back pain attributed to mechanical causes. Depending on the location and type of tumor, other signs and symptoms can develop, especially as a malignant tumor grows and compresses on the spinal cord, the nerve roots, blood vessels or bones of the spine. Impingement of the tumor on the spinal cord can be life-threatening in itself.

Additional symptoms can include the following:

  • Loss of sensation or muscle weakness in the legs, arms or chest
  • Difficulty walking, which may cause falls
  • Decreased sensitivity to pain, heat and cold
  • Loss of bowel or bladder function
  • Paralysis that may occur in varying degrees and in different parts of the body, depending on which nerves are compressed
  • Scoliosis or other spinal deformity resulting from a large, but benign tumor

Diagnosis

  • An examination to diagnose a spinal cord tumor will look for the following signs:
  • Soreness in the area of the spine
  • Inability to feel pain, heat, or cold
  • An abnormal reflex response

These tests can help confirm the diagnosis and pinpoint the tumor’s location:

  • Imaging tests of the spine, such as a CT scan, MRI, or myelogram, which uses an X-ray in combination with an injection of contrast dye into the spine to better see the tumor
  • Hormone tests
  • Biopsy (removal of a small pieces of the tumor to determine what type it is)
  • Exam of the cerebrospinal fluid and the cells in the fluid

Treatment Options for Spinal Tumor

Pain and swelling can be managed through the use of analgesics and steroids. Patient may be advised to wear a brace to increase spinal stability and minimize pain.

Depending on the type of spine tumor, the tumor’s location, and your medical condition, treatments may include chemotherapy, radiation therapy, and/or surgical removal of the tumor. If surgical removal is not possible due to the tumor’s location, embolization may be performed which limits blood flow to the tumor.

If surgery is required, all or only part of the spine tumor may be removed. Surgery is typically recommended when:

  • Other treatments have failed to relieve pain
  • Spine stabilization is necessary
  • Some spinal vertebrae have destructed
  • A biopsy is needed
  • Nerves are compressed

Recovery after Spinal Tumor Surgery

The typical hospital stay after surgery to remove a spinal tumor ranges from approximately 4-5 days. Any surgery, radiation treatment, or chemotherapy can drain the patient nutritionally. Therefore, a proper diet is important to regain strength. A professional nutritionist can provide guidance. A period of physical rehabilitation is required after surgery to remove a spinal tumor for the patient to build strength, endurance, and flexibility. A patient can work with physical and occupation therapist as well as doctors that specialize in physical recovery following major operations.

The total recovery time after surgery may be as short as three months or as long as a year, depending on the complexity of the surgery. Most patients will feel close to normal by three to four months. The healing process, however, continues for several months after surgery and may last up to a year or more.

It will be required to follow-up with the doctor for a period of time to detect any evidence of recurrence of the tumor. This is usually done with periodic MRI scans. The likelihood of the tumor recurring depends on the type of tumor and whether or not it has spread from elsewhere in the body.

 


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30/Aug/2019

The thoracic spine is the middle region of the back and is made up of twelve vertebrae, T1 through T12.  Injuries to the thoracic spine are less common that other regions, like cervical and lumbar, because the thoracic region has the added protection of the rib cage.  However, the thoracic spine is the main support system involved in activities like twisting and bending so condition like a herniated disc or spinal stenosis can still occur.

Thoracic spine surgery can be an effective treatment for mid-back pain, but should only be considered if conservative and non-operative treatments have failed to provide relief.

Experiencing or suffering from an injury or condition to the thoracic spine and conventional pain relief options like pain medication, NSAIDS, steroid injections and rest have not alleviated the pain, thoracic spine surgery may be the most appropriate thoracic spine treatment option.

Conditions potentially requiring thoracic spine surgery can include:

  • degenerative disc disease
  • herniated disc
  • scoliosis
  • compression fractures
  • kyphosis
  • spondylolisthesis

A herniated disc occurs when the intervertebral disc’s outer fibers (the annulus) are damaged and the soft inner material of the nucleus pulposus ruptures out of its normal space. If the annulus tears near the spinal canal, the nucleus pulposus material can push into the spinal canal. In the thoracic area, there is very little extra space around the spinal cord. When a herniated disc occurs in the thoracic spine it can be extremely serious. In some cases, the first sign of the herniated disc is paralysis below the waist. Luckily, herniated discs in the thoracic area are not nearly as common as in the lumbar spine.

Thoracic Spine Surgery:

1). Laminotomy and Discectomy

The traditional way of treating the herniated disc with surgery is to perform a laminotomy and discectomy. Laminotomy involves making and opening in the lamina and discectomy involves removing the protruding disc.

Surgery for thoracic disc herniation is much more complicated than surgery for a cervical or lumbar herniation. The bones that make the thoracic region more stable and less prone to disc herniation—the ribs and sternum—also make it more difficult to access the region. The thoracic cavity also contains vital organs such as the heart and the lungs.

Because of these obstacles, thoracic discectomy carries an increased risk for complications such as pulmonary issues and irreversible spinal cord injury.

This procedure is performed through an incision down the center of the back over the area of the herniated disc. Once the incision is made through the skin, the muscles are moved to the side to see the back of the vertebrae. X-rays during surgery may be required to make sure that the correct vertebra is chosen. A small opening is made between the two vertebrae where the disc is ruptured. This allows to see into the spinal canal. The term laminotomy (make an opening in the lamina) comes from the fact that usually a small amount of the bone of the lamina must be removed. This is to make room to see into the spinal canal and to allow room to work.

Once this is done, the nerve roots are moved out of the way to see the intervertebral disc. The disc material that has ruptured into the spinal canal is then located and removed. This removes any pressure and irritation on the nerves of the spine. Using small instruments that fit inside the disc itself, nucleus pulposus material inside the disc is removed as much as possible. This is done to prevent any remaining disc material to herniate again after the operation.

After the procedure is complete, the muscles of the back are returned to their normal position around the spine. The skin incision is repaired with sutures or metal staples.

2). Microdiscectomy

With improvements have been made in the tools available, minimally invasive approach requiring much smaller incision is used for performing a laminotomy and discectomy. The advantage of this procedure over the traditional approach is that there is less damage to the normal parts of the spine during the operation. It generally results in a shorter hospital stay, less blood loss and post-operative pain, and fewer complications.

To be able to see through the smaller incision, an operating microscope is used. A small incision (as small as two inches) is made in the back just above the area where the disc is herniated. Once the muscles are moved aside and the vertebra can be seen, a microscope is used to finish the operation. The rest of the operation is performed exactly like the more traditional approach.


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16/Aug/2019

Low Back Pain :

Over 80% of the population will suffer from lower back pain during their lives. Although low back pain can be quite debilitating and painful, in about 90 percent of all cases, pain improves without surgery. However, 50 percent of all patients who suffer from an episode of low back pain will have a recurrent episode within one year.

Lumbar Spine :

The lumbar spine (lower back) consists of five vertebrae in the lower part of the spine between the ribs and the pelvis. The bones (vertebrae) that form the spine in the back are cushioned by small discs. These discs are round and flat, with a tough, outer layer (annulus) that surrounds a jellylike material called the nucleus. Located between each of the vertebra in the spinal column, discs act as shock absorbents for the spinal bones. Thick ligaments attached to the vertebrae hold the pulpy disc material in place. Of the 31 pairs of spinal nerves and roots, five lumbar (L1-L5) and five sacral (S1-S5) nerve pairs connect beginning in the area of the lower back.

Common Causes of Low Back Pain :

1). Herniated disc:

The bones (vertebrae) that form the spine in the back are cushioned by small discs. Located between each of the vertebra in the spinal column, these discs act as shock absorbents for the spinal bones preventing the bony vertebrae from grinding against one another. With age, these cushioning discs gradually wear away and shrink, a condition known as degenerative disc disease. The rubbery discs that lie between the vertebrae in the spine consist of a soft center (nucleus) surrounded by a tougher exterior (annulus). A herniated disc occurs when a portion of the nucleus pushes through a crack in the annulus. A herniated disc (also called a bulged, slipped or ruptured) disc.

A herniated disc in the lower back can put pressure on the nerve that extends down the spinal column. This commonly causes pain to radiate to the buttocks and all the way down the leg. This condition is called sciatica.

2). Osteoarthritis:

It is the most common type of arthritis and affects middle-aged or older people most frequently. It can cause a breakdown of cartilage in joints and occur in almost any joint in the body. It most commonly affects the hips, knees, hands, lower back and neck. Cartilage is a firm, rubbery material that covers the ends of bones in normal joints. It serves as a kind of “shock absorber,” helping to reduce friction in the joints. When osteoarthritis affects the spine, it is known as spondylosis.

3). Spondylosis :

 It is a degenerative disorder that can cause loss of normal spinal structure and function. Although aging is the primary cause, the location and rate of degeneration varies per person. Spondylosis can affect the cervical, thoracic and/or lumbar regions of the spine, with involvement of the inter-vertebral discs and facet joints. This can lead to disc degeneration, bone spurs, pinched nerves and an enlargement or overgrowth of bone that narrows the central and nerve root canals, causing impaired function and pain.

When spondylosis affects the lumbar spine, several vertebrae usually are involved. Because the lumbar spine carries most of the body’s weight, activity or periods of inactivity can both trigger symptoms. Specific movements, sitting for prolonged periods of time and lifting and bending all may increase pain. When spondylosis worsens, a patient may develop spinal stenosis.

4). Lumbar Spinal Stenosis:

It is narrowing of the spinal canal, compressing the nerves traveling through the lower back into the legs. If the narrowing is substantial, it causes compression of the spinal cord or spinal nerves, which causes the painful symptoms of lumbar spinal stenosis, including low back pain, buttock pain, and leg pain and numbness that is made worse with walking and relieved by resting. While it may affect younger patients, due to developmental causes, it is more often a degenerative condition that affects people who are typically age 60 and older.

5). Degenerative spondylolisthesis:

Slippage of one vertebra over another is caused by osteoarthritis of the facet joints. Most commonly, it involves the L4 slipping over the L5 vertebra.

6). Degenerative scoliosis:

It occurs most frequently in the lower back and more commonly affects people aged 65 and older. Back pain associated with degenerative scoliosis usually begins gradually and is linked with activity. The curvature of the spine in this form of scoliosis is often relatively minor. Surgery may be indicated when nonsurgical measures fail to improve pain associated with the condition.

Vertebral fractures. Usually caused by osteoporosis (brittle bones)

Diagnosing Low Back Pain:

Diagnosis is made based on history, symptoms, a physical examination and the results of diagnostic studies, if required. Some patients may be treated conservatively and then undergo imaging studies if medication and physical therapy are ineffective. Tests used to help confirm the causes of back pain include:

  • X-rays
  • Magnetic Resonance Imaging (MRI)
  • Computerized axial tomography (CAT) scan or CT scan
  • Bone scan
  • Bone density test
  • Nerve Conduction Studies (NCS)

Lower Back Pain Treatment Options

1). Non Surgical (Conservative):-

It include physical therapy, back exercises, weight reduction, steroid injections (epidural steroids), non steroidal anti-inflammatory medications, rehabilitation and limited activity. It aims at relieving the inflammation in the back and irritation of nerve roots. Usually four to six weeks of conservative therapy is advised before considering surgery.

Anti-inflammatory medications to reduce swelling and pain and analgesics to relieve pain. Most pain can be treated with nonprescription medications, but if pain is severe or persistent, a doctor may recommend prescription medications.

Epidural injections may be prescribed to help reduce swelling. This treatment is not recommended repeatedly and usually provides only temporary pain relief.

Physical therapy and/or prescribed exercises may help stabilize the spine, build endurance and increase flexibility. Therapy may help with the resumption of normal lifestyle and activities. Yoga may be effective for some people in helping to manage symptoms.

Maintaining a proper weight is crucial to effective management of osteoarthritis. Being overweight is a risk factor for osteoarthritis. Practice good posture when sitting or standing. When lifting something, lift with the knees, not with the back.

Smoking — the bad habit that increases the risk of dozens of diseases — can also lead to backaches. Get help to kick the habit of smoking.

2). Surgical:-

When conservative treatment for low back pain does not provide relief, surgery may be needed. One may be a candidate for surgery if:

  • Back and leg pain limits normal activity or impairs quality of life
  • Progressive neurological deficits develop, such as leg weakness and/or numbness
  • Loss of normal bowel and bladder functions
  • Difficulty standing or walking
  • Medication and physical therapy are ineffective
  • The patient is in reasonably good health

Following are some of the procedures for treating low back pain:

  • A discectomy relieves pressure from a nerve root pressed on by a bulging disc or bone spur. In this procedure, a small piece of the lamina, a bony part of the spinal canal is removed.
  • A foraminotomy is a surgical procedure that opens up the foreman, the bony hole in the spinal canal where the nerve root exits.
  • Radiofrequency lesioning or ablation is a way to use radio waves to interrupt the way the nerves communicate with each other. A special needle is inserted into the nerves and heats it, which destroys the nerves.
  • Spinal fusion makes the spine stronger and cuts down on painful motion. The procedure removes discs between two or more of the vertebrae and then fuses the vertebrae next to each other with bone grafts or special metal screws.
  • A spinal laminectomy, also known as spinal decompression, removes the lamina to make the size of the spinal canal bigger. This relieves pressure on the spinal cord and nerves.

How To Prevent Low Back Pain:

There are many ways to prevent low back pain. Practicing prevention techniques may also help lessen the severity of the symptoms of a lower back injury. Prevention involves exercising the muscles in the abdomen and back, losing weight in case overweight, lifting items properly (bending at the knees and lifting with the legs), and maintaining proper posture.

Sleep on a firm surface and sit on supportive chairs that are at the correct height. Avoid high-heeled shoes. Quit smoking – nicotine causes degeneration of spinal discs and also reduces blood flow.




About Dr. Arun Saroha


Dr.Arun Saroha is working as Neurosurgeon with a special interest in spine surgery for the last 15 years. He specializes in Neuro-oncology, Paediatric Neurosurgery, Neurotrauma, Stroke & Cerebrovascular surgery including Transnasal surgeries. He has also been performing instrumented/ Non-instrumentation spine surgeries, including minimally invasive spine surgeries. He has performed more than 6,000 Neurosurgeries (Spine and Brain) successfully till date with patients from all over the world.




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