Spine Care



We believe that an unhealthy back is detrimental to well-being and that everyone deserves freedom from disability.
The Spine Care team at Amara is dedicated to handling the complete spectrum of spine ailments of all age groups. The services encompass non-operative management, physiotherapy and safe spine surgeries – from simple minimally invasive surgeries to the most complex conditions like Scoliosis.
MEET OUR TEAM
- Dr. Prasad Gourineni
Consultant Pediatric Spine Surgeon Head of the Department
Mon - Sat : 10 AM - 4 PM BOOK AN APPOINTMENT KNOW YOUR DOCTOR
- EDUCATION
- EXPERIENCE
- RESEARCH
- REWARDS
- Dr. Ashok Reddy Pedaballe
Consultant Spine Surgeon
Mon - Sat : 10 AM - 4 PM BOOK AN APPOINTMENT KNOW YOUR DOCTOR
- EDUCATION
- EXPERIENCE
- RESEARCH
- REWARDS
- Dr. Vivek Mohan, MD
Visiting Consultant Spine
Mon - Sat : 10 AM - 4 PM
- EDUCATION
- EXPERIENCE
- RESEARCH
- REWARDS
- Bindu Priya Kandukuri
Physiotherapist (BPT)
Mon - Sat : 10 AM - 4 PM BOOK AN APPOINTMENT KNOW YOUR DOCTOR- EDUCATION
- EXPERIENCE
- RESEARCH
- REWARDS
- Sravani Boppidi
Physiotherapist(BPT)
Mon - Sat : 10 AM - 4 PM BOOK AN APPOINTMENT KNOW YOUR DOCTOR- EDUCATION
- EXPERIENCE
- RESEARCH
- REWARDS
MEET OUR TEAM



Dr. Prasad Gourineni
Consultant Pediatric Spine Surgeon Head of the Department
Mon - Sat : 10 AM - 4 PM
- EDUCATION
- EXPERIENCE
- RESEARCH
- REWARDS



Dr. Ashok Reddy Pedaballe
Consultant Spine Surgeon
Mon - Sat : 10 AM - 4 PM
- EDUCATION
- EXPERIENCE
- RESEARCH
- REWARDS



Dr. Vivek Mohan, MD
Visiting Consultant Spine
- EDUCATION
- EXPERIENCE
- RESEARCH
- REWARDS



Bindu Priya Kandukuri
Physiotherapist (BPT)
- EDUCATION
- EXPERIENCE
- RESEARCH
- REWARDS



Sravani Boppidi
Physiotherapist(BPT)
Mon, Wed - Fri : 9 AM - 12 PM
3 PM - 5 PM
- EDUCATION
- EXPERIENCE
- RESEARCH
- REWARDS
GET YOUR LIFE BACK



Back Rehab/ Physiotherapy
- Tooth socket preservation after removal
- Immediate implant after tooth removal with crown
- Sinus lift procedure
- Full mouth implants with fixed teeth
- Full mouth disinfection with LASER
- Rehabilitation of full mouth
- Invisalign treatment (invisible aligners) for irregular teeth
- Maxillofacial cosmetic procedures
- Smile designing
- Computer made natural tooth colour Zirconium fillings
- Computer made natural tooth colour zirconium crowns
- Treatment of painful tooth without RCT in children
- Iinvisible aligners for spaces in between teeth



Minimally Invasive Spine Surgeries
Overview
There is an increasing trend towards small incision surgeries in all the surgical fields. Similarly, in spine surgery minimally invasive surgeries are well established and popularized. This is a surgical technique where the skin cut is small compared to the traditional open surgery and muscle damage is minimal. For these surgeries, special instruments are required along with magnification of vision by using either surgical loupes or microscope.
Surgeries include: Transforaminal Lumbar Interbody fusion, fixation and fusion in trauma, laminectomy and endoscopic discectomy




Types
- MIS -TLIF
- MIS- fixation and fusion in trauma
- MIS- laminectomy
- Endoscopic discectomy
- MIS -TLIF
- MIS- fixation and fusion in trauma
- MIS- laminectomy
- Endoscopic discectomy
Advantages
- Less blood loss
- Minimal muscle damage
- Early discharge
- Less post-surgery pain
- Small incision and small scar
Disadvantages
- May not be feasible in some conditions.
- More time than conventional surgery
- More radiation
- Expensive



Spine Pedicle Screw Fixation
Overview
Performed in conjunction with spinal fusion surgery to secure vertebrae of the treated area in a fixed position. The pedicle screws on the spinal segment are connected together with metal rods. Pedicle screw fixation will provide stability and support to the spine after surgery and keeps bone grafts in position while the spine heals.When the bone graft grows and fuses to the surrounding bones, it becomes strong. Although the screws and rods are not required at this time, they can, however, remain in place for most patients and there is no need for removal surgery.
Performed in conjunction with spinal fusion surgery to secure the vertebrae of the treated area in a fixed position, pedicle screw fixation provides stability and support to the spine after surgery and keeps bone grafts in position while the spine heals. The pedicle screws on the spinal segment are connected together with metal rods.
When the bone graft grows and fuses to the surrounding bones, there is no medical necessity for the screws and rods. They can, however, remain in place for most patients and there is no need for removal surgery.




Who requires it?
Pedicle screw fixation is required in case of:
- Fracture of the spine
- Instability of spine
- Spondylolysthesis
- Any spine procedure, which may compromise inherent spine stability
Complications
While your doctor will take specific measures to help avoid potential complications, as with any surgery, there are risks associated with spinal fusion, such as:
- Infection. To lessen the risk, antibiotics are given before, during, and often after surgery.
- Bleeding. A certain amount of bleeding is expected, but this is not typically significant.
- Pain at graft site. A few patients may experience persistent pain at the bone graft site.
- Recurring symptoms. There could be a recurrence of the original symptoms in some patients. Your doctor can determine what is causing those symptoms.
- Pseudarthrosis. This is a condition where there is not enough bone formation. Smokers, diabetics and elderly patients are more likely to develop it. Moving before the bone starts fusing, may also result in it. In such cases, a second surgery may be needed to obtain a solid fusion.
- Nerve damage. Although rare, it is possible that nerves or blood vessels may be injured during the operation.
- Blood clots. Formation of blood clots in the legs is an uncommon complication but poses significant danger if the clots break off and travel to the lungs.
Warning Signs
Carefully follow your doctor’s instructions related to the warning signs of blood clots (Deep Vein Thrombosis) and infection. The complications are most likely to occur during the first few weeks after surgery.
Warning signs of a blood clot include:
- Swelling in the calf, ankle or foot
- Tenderness or redness, which may extend above or below the knee
- Pain in the calf
While your doctor will take specific measures to help avoid potential complications, as with any surgery, there are risks associated with spinal fusion, such as:
Warning signs of infection include:
- Redness, tenderness, and swelling around wound edges
- Oozing from wound
- Pain or tenderness
- Shaking chills
- High temperature, usually above 101°F if taken with an oral thermometer
On occurrence of any of these symptoms, contact your doctor immediately.



Cervical Laminectomy with Instrumented Fusion
- Tooth socket preservation after removal
- Immediate implant after tooth removal with crown
- Sinus lift procedure
- Full mouth implants with fixed teeth
- Full mouth disinfection with LASER
- Rehabilitation of full mouth
- Invisalign treatment (invisible aligners) for irregular teeth
- Maxillofacial cosmetic procedures
- Smile designing
- Computer made natural tooth colour Zirconium fillings
- Computer made natural tooth colour zirconium crowns
- Treatment of painful tooth without RCT in children
- Iinvisible aligners for spaces in between teeth



ACDR (Anterior Cervical Disc Replacement)
- Tooth socket preservation after removal
- Immediate implant after tooth removal with crown
- Sinus lift procedure
- Full mouth implants with fixed teeth
- Full mouth disinfection with LASER
- Rehabilitation of full mouth
- Invisalign treatment (invisible aligners) for irregular teeth
- Maxillofacial cosmetic procedures
- Smile designing
- Computer made natural tooth colour Zirconium fillings
- Computer made natural tooth colour zirconium crowns
- Treatment of painful tooth without RCT in children
- Iinvisible aligners for spaces in between teeth



Spinal Cord Injury Rehabilitation
- Tooth socket preservation after removal
- Immediate implant after tooth removal with crown
- Sinus lift procedure
- Full mouth implants with fixed teeth
- Full mouth disinfection with LASER
- Rehabilitation of full mouth
- Invisalign treatment (invisible aligners) for irregular teeth
- Maxillofacial cosmetic procedures
- Smile designing
- Computer made natural tooth colour Zirconium fillings
- Computer made natural tooth colour zirconium crowns
- Treatment of painful tooth without RCT in children
- Iinvisible aligners for spaces in between teeth



Microdiscectomy
Overview
In this surgery, the patient is anesthetized and placed in a prone position on the operating table. The surgeon identifies the involved level with image guidance and with microscope or surgical magnifying loupes. A small cut is made in the skin and specially designed retractors used to reach the lamina without making a large skin opening or dissecting a large area of muscles. The soft tissue overlying the involved disc level is removed (flavectomy) and, only if required, a small part of bone is cut (laminotomy). The extruded fragment of disc is removed (fragmentectomy), and the nerve root is relieved from pressure.




Who requires it?
Disc herniation patients with failed conservative management (medications).
Complications
- Infection
- Dural tear
- Very rarely, nerve root injury
- Recurrence of disc herniation
Post-operative advantages
- Patient can be discharged in a day or two.
- Patient will be made to walk on the same day, in an uncomplicated surgery.
- Regular bath can be had as the wound dressings are water- proof.
- Avoid prolonged unsupported sitting for at least 3 months.
- Skin suture removal is not usually required as we use absorbable skin sutures.
Patient:
- Will be made to walk on the same day
- Can be discharged in a day or two
- Can take a bath since the wound dressings are water- proof
- Skin suture removal is not usually required as we use absorbable skin sutures
Precautions: Avoid prolonged sitting for at least 3 months
- Patient can walk on the same day, in an uncomplicated surgery.
- Patient can be discharged in a day or two.
- Regular bath can be taken since the wound dressings are water- proof.
- Skin suture removal is not usually required as we use absorbable skin sutures.
Precautions: Avoid prolonged sitting for at least 3 months



Spine Fracture Fixation
Overview
This is an emergency procedure performed in patients with spinal fracture and increasing neurological sings such as weakness of limbs due to spinal cord injury. This surgery involves fixation of the fractured bone (vertebrae) above and below with pedicle screws and rods. The goal of the surgery is spinal cord decompression with early stabilization and mobilization if the patient has any neurological signs (paralysis or weakness of limbs).
Spine fracture fixation is a surgery wherein the involved fractured bone (vertebrae) is fixed to the above and / or below vertebrae with pedicle screws and rods. The goal of the surgery is early stability and early mobilization and spinal cord decompression, if the patient has any neurological signs (paralysis or weakness of limbs).




When to operate?
This surgery should be performed at the earliest possible time, preferably within 24 hours.
In a patient with spinal cord injury, spine should be stabilized at the earliest possible time, preferably within 24 hours.
Complications
While your doctor will take specific measures to help avoid potential complications, as with any surgery, there are risks associated with spinal fusion, such as:
- Infection. To lessen the risk, antibiotics are given before, during, and often after surgery.
- Bleeding. A certain amount of bleeding is expected, but this is not typically significant.
- Pain at graft site. A few patients may experience persistent pain at the bone graft site.
- Recurring symptoms. There could be a recurrence of the original symptoms in some patients. Your doctor can determine what is causing those symptoms.
- Pseudarthrosis. This is a condition where there is not enough bone formation. Smokers, diabetics and elderly patients are more likely to develop it. Moving before the bone starts fusing, may also result in it. In such cases, a second surgery may be needed to obtain a solid fusion.
- Nerve damage. Although rare, it is possible that nerves or blood vessels may be injured during the operation.
- Blood clots. Formation of blood clots in the legs is an uncommon complication but poses significant danger if the clots break off and travel to the lungs.
Post-op concerns
When can the patient be allowed to walk?
Depending on the patient’s condition, If there is good power in both legs and no major complications, they can walk on the day after surgery
Will this surgery help me recover my strength and neurological function?
Further damage to nerves (spinal cord) will be avoided. Improvement in strength and neurological function may be seen after the surgery, depending on how much damage was done prior to the surgery.
Further damage to nerves (spinal cord) will be avoided it improvement in strength and neurological function may be seen after the surgery, depending on how much damage was done prior to the surgery.
Depending on the patient’s neurology, if there is good power in both legs, then he can be allowed to walk on the next day of an uncomplicated surgery.
Does spine fracture fixation surgery cause recovery of neurology (power of limbs)?
Spine fracture surgery helps in avoiding further damage to nerves (spinal cord) and aids in the natural improvement of neurological fixation. It does not have any direct role in improving neurology.
Should the screws be removed?
Screws are usually not removed. But if the patient has excessive pain or infection, they can be removed.



Occipitocervical Fixation
- Tooth socket preservation after removal
- Immediate implant after tooth removal with crown
- Sinus lift procedure
- Full mouth implants with fixed teeth
- Full mouth disinfection with LASER
- Rehabilitation of full mouth
- Invisalign treatment (invisible aligners) for irregular teeth
- Maxillofacial cosmetic procedures
- Smile designing
- Computer made natural tooth colour Zirconium fillings
- Computer made natural tooth colour zirconium crowns
- Treatment of painful tooth without RCT in children
- Iinvisible aligners for spaces in between teeth



Scoliosis - Deformity Correction Surgery
- Tooth socket preservation after removal
- Immediate implant after tooth removal with crown
- Sinus lift procedure
- Full mouth implants with fixed teeth
- Full mouth disinfection with LASER
- Rehabilitation of full mouth
- Invisalign treatment (invisible aligners) for irregular teeth
- Maxillofacial cosmetic procedures
- Smile designing
- Computer made natural tooth colour Zirconium fillings
- Computer made natural tooth colour zirconium crowns
- Treatment of painful tooth without RCT in children
- Iinvisible aligners for spaces in between teeth



Nerve Root Block (TFES)
Overview
TFES (transforaminal epidural steroid infiltration) is a daycare procedure performed in the operation theatre under C-arm image guidance. The surgeon will identify and insert a needle at the level of nerve compression (disc herniation) under local anesthesia under sterile conditions.




Who requires it?
TFES can be done as a diagnostic or therapeutic procedure.
Diagnostic: When multiple levels are involved and the doctor wants to diagnose the level causing symptoms.
Therapeutic: The local steroid can provide long-term pain relief. The duration of symptom relief varies from person to person. If the leg pain recurs, this injection can be repeated a week apart, with a maximum of up to three injections in a year.
If there is no relief with conservative management and injections, then the patient may require surgical management. Eg: Patients with disc herniation, who do not get relief with conservative therapy.



How long is the hospital stay?
This is a daycare procedure and the patient will require admission for about 6 hours. The actual procedure takes up to 30 minutes, monitoring for complications will be required. . Patient Can be discharged on the same day as the procedure.
Complications
- Temporary weakness in the affected nerve root
- Infection (Arachnoiditis)
- Abnormal blood glucose in diabetics
- No relief in pain



Lumbar Decompression(Laminectomy)
Overview
Lumbar decompression, also known as laminectomy, is a surgical procedure to treat symptoms of central spinal stenosis, which is a narrowing of the spinal canal. The surgery entails removing all or part of the lamina (posterior part of the vertebra) to make more room for the compressed spinal cord and/or nerve roots.




Who requires it?
People who continue to have back pain even after 8-12 weeks of non-surgical treatments such as physical therapy, medications, and/or epidural steroid injections, Surgery is also performed in patients w ith spinal cord tumors to remove the tumor, and as an emergency procedure, if there is progressive weakness of lower limb(s) or if bladder is involved as in cauda equina syndrome.
For those who have not shown improvement in symptoms even after 8-12 weeks of non-surgical treatments such as physical therapy, medications, and/or epidural steroid injections, lumbar laminectomy may be considered.
It may be used in spinal cord tumor surgeries to get the access to remove the tumor. And can be considered as an emergency procedure, if there is progressive weakness of lower limb(s) or if bladder is involved as in cauda equina syndrome.
Complications
Some of the potential complications of lumbar laminectomy include:
Damage to neural tissue: During the procedure there is possibility of injury to the spinal cords dura, cauda equina syndrome, nerve roots, and the formation of scar tissue, leading to neural tissue damage. This may cause weakness, loss of sensation, paralysis, and/or bowel/bladder incontinence.
Repeat surgeries: Instability, due to previous surgical procedures performed on the treated levels, usually results in the need for repeat surgeries in patients with lesser bone density.
Adjacent level degeneration: Instability may occur when surgical treatments to an affected vertebral level may cause degeneration in the adjacent vertebra.
Continued neurogenic claudication: Even after a successful surgery, leg pain may persist while walking or bending the spine backwards.
General anesthesia complications. In rare cases, general anesthesia complications may cause heart and/or lung infection, deep vein thrombosis, or even death. As with any surgery, there is the risk of infection, sepsis, and severe bleeding during or after the procedure. It is advisable to discuss all issues with the doctor before surgery.
Post-op Concerns
- Patient can be discharged in a day or two.
- Patient will be made to walk on the same day, in an uncomplicated surgery.
- Regular bath can be had as the wound dressings are water- proof.
- Avoid prolonged unsupported sitting for at least 3 months.
- Skin suture removal is not usually required as we use absorbable skin sutures.



TLIF/ MIS - TLIF
- Tooth socket preservation after removal
- Immediate implant after tooth removal with crown
- Sinus lift procedure
- Full mouth implants with fixed teeth
- Full mouth disinfection with LASER
- Rehabilitation of full mouth
- Invisalign treatment (invisible aligners) for irregular teeth
- Maxillofacial cosmetic procedures
- Smile designing
- Computer made natural tooth colour Zirconium fillings
- Computer made natural tooth colour zirconium crowns
- Treatment of painful tooth without RCT in children
- Iinvisible aligners for spaces in between teeth



ACDF (Anterior Cervical Disc Replacement)
- Tooth socket preservation after removal
- Immediate implant after tooth removal with crown
- Sinus lift procedure
- Full mouth implants with fixed teeth
- Full mouth disinfection with LASER
- Rehabilitation of full mouth
- Invisalign treatment (invisible aligners) for irregular teeth
- Maxillofacial cosmetic procedures
- Smile designing
- Computer made natural tooth colour Zirconium fillings
- Computer made natural tooth colour zirconium crowns
- Treatment of painful tooth without RCT in children
- Iinvisible aligners for spaces in between teeth
ADDRESSING YOUR CONCERNS
Is lower back pain quite common?
Almost 80% of the population suffer from low back pain at some time in their adult life. It is one of the most common reasons for doctor visit, sick leave and disability. On a happier note, for 90% of patients, the low back pain is short-lived and goes away within a few days or couple of weeks. However, some cases may take a longer time to show improvement and in a few instances the persistent pain could require a thorough evaluation to identify the cause.
According to experts, almost 80% of the population suffers from lower back pain at some time in their adult life. It is one of the most common reasons people visit doctor, and one of the most common causes for sick leave and disability. On a happier note, for 90% of patients, the low back pain is short-lived and goes away within a few days or couple of weeks. However, some cases may take a longer time to show improvement and in a few instances the persistent pain could require a thorough evaluation to identify the cause.
Overview
Symptoms
- Muscle ache
- Shooting or stabbing pain
- Limited flexibility and/or range of motion
- Inability to stand straight.



What is the back made up of?
Bones, muscles, and other tissues make up the structure that forms the back. The spinal column, in the middle, supports the weight of the upper body and also acts as a protective conduit for the spinal cord – the nervous system that controls the body’s movements and transmits sensations. The spinal column (or spine) comprises about 30 vertebrae, which are small bones arranged one on top of another, through which the spinal cord runs.
Sponge-like pads of cartilage between the vertebrae enable the back to be flexible and also cushion the stress on the bones when the body moves. The vertebrae are held in place by ligaments and tendons attach the muscles to the spinal column.
The spine comprises the following:
- 7 cervical or neck vertebrae
- 12 thoracic or upper back vertebrae
- 5 lumbar vertebrae, commonly known as the lower back
- Sacrum and coccyx, at the base of the spine, which are a group of bones fused together
What are the common causes for lower back pain?
Back pain, in an overwhelming number of cases, is a result of muscle strain due to lifting a heavy weight or twisting; sudden impact in an accident; a herniated disc brought about by stress on tissues and bones of the spine; or osteoarthritis, a degenerative disease of the joints. Lower back pain is commonly caused by:
back pain, can be due to muscle strain associated with lifting a heavy object sudden twisting. It can also be the result of: sudden impact in an accident, herniated disc brought about by stress on tissues and bones of the spine, or osteoarthritis, a degenerative disease of the joints.
Other causes of low back pain are:
- Infection or inflammation
- Fracture
- Cancer
- Infection or inflammation
- Inflammation
- Fracture
- Active Infection
- Cancer
- Referred Pain
When to visit a doctor?
Back pain is as common as the common cold and not everyone needs to visit a doctor. One may try home therapy before visiting a doctor. However, one should be aware that back pain should not be neglected under certain conditions such as:
Back pain is as common as the common cold. However, back pain should not be neglected under certain conditions:
- Back pain in children (<10 years) and the elderly (>70 yrs).
- Back pain in patients with risk of osteoporosis like those on cancer medications, on prolonged bed rest, with hypothyroidism or diabetics, on anti-epileptics etc.
- Back pain that radiates to the leg, with weakness of the leg or foot, loss of sensation in peri-anal area and difficutly with urination (either straining while urinating or urinary leakage. Back pain associated with features of infection like fever, loss of weight, loss of appetite.
- Back pain in children (<10 years) and the elderly (>70 yrs).
- Back pain in patients with risk of osteoporosis like those on cancer medications, on prolonged bed rest, with hypothyroidism or diabetics, on anti-epileptics etc.
- Back pain with neurological signs like radiating pain along the leg / weakness of foot / difficulty in urination (either straining at urination or urinary leakage) and /or loss of sensation in the perianal region.
- Back pain associated with features of infection like fever, loss of weight, loss of appetite.
Importance of accurate diagnosis
Your doctor will take a careful medical history and do a physical exam to decide if you need need an X-ray or other test such as an MRI (magnetic resonance imaging) or a CT (computerized tomographic scan) to confirm diagnosis. Most people with back pain may not require further studies.
The doctor will need to take a careful medical history and do a physical exam to look for certain red flags that indicate the need for an X-ray or other imaging test. In some patients, imaging such as X-ray, MRI (magnetic resonance imaging), or CT (computerized tomography) scan may be advised to confirm diagnosis.
- Muscle strain
- Spondylolisthesis (when one vertebral body slips onto the next)
- Herniated disc (when the cushions between the vertebrae swell up into the space containing the spinal cord or a nerve root, causing pain)
- Osteoarthritis (when the cartilage between joints breaks down, leading to formation of bony spurs that cause pain and swelling.)
- Spinal stenosis (when the bony canal narrows down, putting pressure on the spinal nerves or the spinal cord)
Treatment options for lower back pain
In most cases, the lower back pain is the result of muscle strain and spasm and does not entail surgery.
To treat the pain, the following options may be adopted:
Bed rest for severe back pain. This should not last longer than 2 to 3 days. Patients should get back to active life as soon as possible.
- Medications for severe back pain
- Exercise – effective in speeding up recovery and helping strengthen the muscles of the back and abdomen. It also helps reduce the risk of the back pain recurring.
- Lumbar corsets – helpful only in the work setting. Regular use could weaken spinal and abdominal muscles and delay recovery.
In most cases, the lower back pain is caused due to muscle strain and spasm and does not entail surgery.
To treat the pain, the following options may be adopted:
- Medications.
- Bed rest – although not recommended beyond 2 to 3 days. Patients should get back to active life as soon as possible.
- Exercise – effective in speeding up recovery and helping strengthen the muscles of the back and abdomen. It also helps reduce the risk of the back pain recurring.
- Lumbar corsets – helpful only in the work setting. Regular use could weaken spinal and abdominal muscles and delay recovery.
Surgery for lower back pain
Surgery is rarely indicated for isolated back pain. For back pain associated with any structural problem of the spine, surgery may prove beneficial. The type of surgery would depend on the cause for the back
Sciatica/ Disc Herniation
The human spine is composed of multiple bones (vertebrae) which are interconnected by disco-ligamentous structure called intervertebral disc or simply called as “disc”.
There are 23 discs in a human spine, which help in smooth motion of the vertebrae, thereby giving the flexibility to your spine. Like gel cushion, they absorb pressure and impact.
When small tears occur in the outer layers of the disc, the gel-like central core of disc can protrude into fibrous layer (disc protrusion/bulge) or break through the fibrous layer (disc prolapse/extrusion/herniation). This extruded disc material, by chemical or physical properties, can irritate the nerves at that level innervating upper or lower limbs. Depending on the region of disc herniation it is called lumbar (lower back spine) or cervical (neck) disc herniation.



What are risk factors for developing disc herniation?
Often there is no definite cause for one to have disc herniation. However, it is due to an acute event in the presence of long-standing risk factors in a predisposed individual or a result of exaggerated normal wear and tear and degeneration.
Predisposed individuals (risk factors)
- Overweight
- Smokers
- Poor work ergonomics
- Stress
- Lack of physical exercise
Acute events:
- Improper weight bearing
- Excessive strain
Are you suffering from this problem
The symptoms vary depending on the location and severity of the herniated disc.
- Stabbing pain in the back and/or legs
- Pain, pins and needles or numbness in the legs
- Signs of paralysis
- Awkward posture or slight misalignment of the back
- Loss of urinary control
Diagnosis
Clinical examination will give a fair idea of what the problem could be, and to confirm the diagnosis you may asked to get an X-ray or MRI of the involved region. MRI can delineate exactly at what level disc is herniated and how much it compresses the nerve root involved. However, a study revealed that more than 50% of people with disc herniation don’t have any symptoms. Hence, we don’t recommend getting an MRI done unless you have specific symptoms and signs.



Transforaminal Epidural Steroid Injections (TESI)
Microdiscectomy
Post-op concerns
CLAUDICATION / NUMBNESS OF BOTH LEGS (Lumbar Canal Stenosis)
Wear and tear with age can give rise to degenerative disc disease, a condition where there is progressive deterioration of spinal discs and arthritic changes in facet joints. It can also result in the narrowing of the spinal canal due to overgrowth of bone spurs, leading to spinal stenosis, which can cause pain, numbness and weakness in the legs due to compression of the neural elements.



Most of the cases can be asymptomatic.
When symptomatic, one may develop numbness / pain in both legs after walking for a while, which is relieved after sitting or lying down for some time. This is termed as neurological claudication. The time and distance after which this condition develops may vary from person to person, depending on the amount of compression over the nerve.
A few patients have also complained of back pain, along with bladder & bowel symptoms and weakness in the legs.
The evaluation for this condition will usually involve a review of the patient’s medical history and a physical examination, followed by X-rays. Your doctor may advise dynamic radiographs to evaluate if there is any instability.
MRI is usually done to know the level and severity of compression on the nerve and also to assess the surrounding tissue (facets hypertrophy, ligamentum flavum hypertrophy), and condition of the disc.
Conservative management
Surgical management
Spondylolysis
Each vertebrae of the human spine is a complete ring-like structure, with central vertebral canal consisting of spinal cord and nerve fibers. For better understanding, the vertebrae can be divided into three portions, the front portion (anterior) is called “vertebral body” and the middle portion consists of pedicles on either side of the spinal cord and the posterior (rear) portion consists of facet joints(superior and inferior), pars interarticularis, and the spinous process. Any break or discontinuity in pars interarticularis is called Spondylolysis.



Spondylolysis (also referred to as “pars fracture”) is usually a fracture caused by repetitive stress rather than a break due to injury, and commonly occurs during childhood or adolescence. The crack may affect only one side, but there are quite a few cases with fractures on either side of the vertebra. When this happens, a vertebra could slide forward or backward onto another one; a condition that is known as spondylolisthesis.
Illustration of the Spinal Column and Location of a Pars Fracture (Spondylolysis)






Spondylolysis is a common condition in physically active children and teenagers. While some of them may experience symptoms, others may not develop symptoms until later in adulthood.
The symptoms include pain and stiffness in the lower back that gets aggravated with activity and gets better with rest. Hyperextension or abnormal stretching of the lower back will usually worsen the condition as it overloads the pars fracture.
At times, nerve symptoms such as “pins and needles” sensation in a leg, with or without numbness or weakness, may be experienced.
The evaluation for this condition will usually involve a review of the patient’s medical history and a physical examination, followed by X-rays to detect pars fractures.
The doctor may advise a bone scan for early detection of a stress fracture of the pars. In this procedure, chemical "tracers" are injected into the blood stream. The tracers converge in areas of increased metabolism or cell activity in bone tissue, indicating a stress fracture of the pars interarticularis, and then show up on special spine X-rays.
To evaluate a pars defect and visualize healing bone, a CT scan may be used, while to assess the surrounding tissue and condition of the disc an MRI may be recommended.
Spondylolysis treatment is initially nonsurgical and includes rest and bracing, which can last up to 3-4 months. The fracture is assessed with a series of X-rays/ bone scan/ CT scan every few months to see if it has healed.
Physical therapy can also be used to help maintain and strengthen the muscles of the abdomen and back with specific directed exercises.
Surgery
If pain persists after non-surgical treatment, surgery may be required. There are two operations that may be performed:
- Pars repair: This is a minor surgery, wherein the pars fracture is fixed with screws and bone graft, with the principle of bony fusion like any other fracture.
- Interbody fusion: If the procedure is delayed, there can be degeneration of the disc and increased pressure on the nerve roots, wherein pars repair is contra-indicated, then Transforaminal Lumbar Interbody Fusion is performed.
Slipped vertebrae/ Spondylolysthesis
Spondylolisthesis is when a spinal vertebra slip forward over another vertebra caudal to it. There are different types of the condition, depending on the anatomical changes.
Spondylolytic lysthesis: It is caused when the crack in a pars fracture affects both sides of connection (between the lamina and pedicles). The condition can be a direct result of spondylolysis.
Degenerative spondylolisthesis: Usually seen in elderly age group, this condition is caused by the deterioration of the facet joints and discs of the spine.
Congenital spondylolisthesis: Usually seen in the younger age group, this condition is caused due to birth defects in the bony structure of vertebrae (predominantly pars).




Symptoms
- Flat back
- Back pain and stiffness
- Pins and needle sensation in legs
- Numbness in legs
- Bladder symptoms – urinary incontinence / straining at urination
The evaluation for this condition will usually involve a review of the patient’s medical history and a physical examination, followed by standing X-rays, which can grade lysthesis. Your doctor may advice dynamic radiographs to evaluate if the lysthesis is stable or unstable.
A CT scan may be used to evaluate a pars defect or any bony problems, while an MRI may be useful to assess the surrounding tissue, nerves and condition of the disc.
Treatment depends on the clinical symptoms.
Conservative treatment: If the person is asymptomatic or has only back pain / stiffness, then surgery is NOT the first choice. Bracing / exercises and physiotherapy may be tried, which can give satisfactory results.
Surgical treatment: Surgery is recommended if conservative treatment doesn't give good results and / or if the patient has neurological symptoms like leg pain / numbness / bladder symptoms.
Surgery involves decompressing the nerve roots and fixing the bone with or without reducing the lysthesis by using screws and bone graft.
Slipped vertebrae/ Spondylolysthesis
A common problem, neck pain affects most adults at some point of time in their life. It can involve just the neck and shoulders, or may stretch down an arm, with the pain being either a dull ache or like an electric shock in your arm. Other symptoms like a feeling of numbness or muscle weakness in an arm, help in pinpointing the cause of the neck pain.



Some causes of neck pain include:
- Cervical dystonia (spasmodic torticollis)
- Fibromyalgia
- Cervical disc herniation
- Muscle strain
- Cervical spondylosis (disease causing the breakdown of joints)
- Poor posture – while sleeping or working
- Rheumatoid arthritis (inflammatory joint disease)
- Spinal stenosis
- Trauma from accidents or falls
- Whiplash
Most of the time, neck pain goes away by itself in a couple of days. If at all, only a little conservative treatment may be required. Neck pain that persists over several weeks usually responds to exercise, stretching, physical therapy, massage and watchful waiting. Only in very few cases are steroid injections or surgery indicated.
Try these self-care tips to help relieve the discomfort:
- Posture care. If you work on a computer all day, make sure your back is well-supported and that the monitor is at comfortable eye level.
- Hot or cold. A hot water bath can help relax your strained muscles. Apply an ice pack to your neck for 15 minutes at least 3 times a day.
- Stretch : Turn your neck gently from side to side and up and down to give your neck muscles a work out.
- Massage : Rub the painful areas in your neck to help relieve muscle spasms.



Cervical disc herniation
Cervical disc herniation is a clinical condition wherein the intervertebral disc between the two vertebral bodies in the neck can herniate back, pressing on the spinal cord or the nerves that connect the arms and hand.
Cervical disc herniation is a clinical condition wherein the intervertebral disc between the two vertebral bodies in the neck can herniate back, pressing on the spinal cord or the nerves that connect the arms and hand.



Most people (almost 90%) may have disc herniation, yet they would not have any complaints. The remaining 10% may present symptoms like:
i. Neck pain
ii. Shooting pain along the arm up to hand, together with decreased sensation or weakness of the hand.
iii. In rare cases, multiple disc herniations or a single large disc herniation can compress the spinal cord, causing symptoms in both upper limbs and lower limbs. [Cervical myelopathy].
Physical examination by a doctor has a key role in the diagnosis and decision-making on management of this condition. As more than 90% are asymptomatic, unnecessary investigations can cause panic and a sense of nervousness in the patients.
After a clinical diagnosis is made, your doctor may advise an X-ray or MRI of cervical spine to confirm the diagnosis and aid in deciding the treatment.
Almost 80% of symptomatic disc herniation patients can get better with conservative management, in the form of medications, posture care, neck exercises and physiotherapy.
Only few patients who don’t get good relief with conservative treatment may need surgery in the form of either Anterior Cervical Discectomy and Fusion (ACDF) or Anterior Cervical Disc Replacement (ACDR). The surgery is performed on the front of the neck where a small cut is made and the affected disc removed, thereby relieving pressure on the nerve root and spinal cord. Stabilizing is done either by fusion with bone graft (ACDF) or artificial disc replacement (ACDR).
Cervical myelopathy
Cervical myelopathy is a clinical condition that involves compression of the spinal cord in the cervical spine (neck). The cervical spine comprises 7 vertebrae, with 6 intervertebral discs and 8 nerve roots. The spinal cord travels inside the vertebral column that is constructed with vertebrae in the front, cushioned by intervertebral discs, and facet joints and lamina at the back. The branched nerve roots primarily control the function of the shoulders, arms and hands. Any excessive pressure on the spinal cord can cause a decrease in its functioning.



- Age-related changes, causing compression of the spinal cord from disc/ facets/ ligametum flavum hypertrophy
- Trauma to cervical spine: whiplash injury.
- Cancers
- Cervical spine deformity
The symptoms of cervical myelopathy may appear in the neck or may be felt elsewhere in the body
Neck symptoms include:
- Pain
- Stiffness
- Reduced range of motion
With the progression of the condition, you may experience a shooting pain that originates in the neck and travels down the spine.
Other symptoms include:
- Weakness in the arms and hands
- Numbness or tingling in the arms and hands
- Clumsiness and poor coordination of the hands
- Difficulty handling small objects
- Difficulty in maintaining balance
Early detection of cervical myelopathy helps in effective treatment. To diagnose the condition, your doctor may:
- Conduct a physical exam and measure muscle strength and reflexes.
- Advise further tests, including an MRI scan, an X-ray or a CT myelogram of the neck.
- Perform electrical tests to check communication between the nerves in your arms & hands and your brain through the spinal cord.
To treat cervical myelopathy, while there are non-surgical options such as physical therapy and cervical collar brace, surgery is often necessary to eliminate the compression of the spinal cord and prevent deterioration of the condition.
The surgical procedures include widening of the spinal canal (laminoplasty) and spine decompression surgery with spinal fusion, which helps stabilize the spine after herniated discs, bone spurs or ossified ligaments are fully or partially removed.
Based on your condition, your doctor may recommend the surgery to be performed from the back of the neck (posteriorly) or from the front of the neck (anteriorly).
Scoliosis
Scoliosis is abnormal side-to-side curvature of the spine. Normally a human spine is straight when seen from back, any deviation to the side by more than 10 degrees is considered scoliosis.



There are many reasons for abnormal curvature of the spine. Based on the reason behind the abnormal, there are classified.
i. Idiopathic scoliosis -This is the most common variant, in which there is no reason that could be identified.
ii. Congenital scoliosis – This is due to abnormal development of vertebra during early development.
iii. Muscular/ Paralytic scoliosis – This variant is seen in children with muscle weakness like cerebral palsy, muscular dystrophy.
iv. Degenerative scoliosis – This is seen in elderly due to normal wear and tear (degeneration) of spine joints / ligaments and disc.
- Clothes not fitting properly or hanging unevenly
- Curvature of spine observed while in bathing suit or changing
- Changes in walking style
- Reduced range of motion
- Difficulty in breathing
- Cardiovascular problems
- Back pain
- Lower self-esteem
Since early diagnosis and treatment initiation plays an important role in the disease progression and decision making, consult a doctor on observing any symptoms of scoliosis in your child.
Scoliosis can usually be diagnosed by physical examination. However, your doctor may advise you to get full radiographs of spine to classify what type it is, check curve magnitude, and level of involvement. You may be asked to get further radiographs, to know the correctability or flexibility of the curve by getting side bending/ traction views.
An MRI may be required if you have any neurological symptoms, along with scoliosis. A CT scan may be required to plan for surgery, especially in the presence of bony anomalies like in congenital scoliosis.
Most children with mild scoliosis may not require treatment with a brace or surgery, but need regular check-ups to see if there have been changes in the curvature of their spines as they grow.
Before beginning treatment, a few factors are taken into consideration:
- Girls have a higher risk of progression than boys.
- The larger the curve the more likely it is to worsen over time.
- S-shaped curves tend to worsen more than C-shaped curves.
- Curves in the central section of the spine worsen more often than those in the upper or lower sections of the spine.
- If a child's bones have stopped growing, it lowers the risk of curve progression. That's why use of braces is more effective for children whose bones are still growing.
Braces
If your child has moderate scoliosis, your doctor may recommend wearing a brace to prevent further progression of the curve.
The most common type of brace is made of plastic and is contoured to the body so as to fit perfectly under the arms and around the rib cage, lower back and hips, making it practically invisible under the clothes.
Since a brace’s effectiveness increases with the number of hours it is worn, it is advised to have one on 24 hours a day. Braces do not hinder children’s participation in sports or other physical activities, and can even be taken off if, for instance, they want to go swimming.
Once bones stop growing, the braces are discontinued. This typically occurs:
- About two years after girls begin to menstruate
- When boys need to shave daily
- When there are no further changes in height
Surgery
As severe scoliosis progresses with time, your doctor may suggest surgery to reduce the severity of the spinal curve and to prevent it from worsening.
Spinal fusion is the most common type of scoliosis surgery. In this procedure, two or more of the bones in the spine are connected together so that they can’t move independently. Pieces of bone or a bone-like material are placed between the vertebrae. Metal rods, hooks, screws or wires typically hold that part of the spine straight and still while the old and new bone material fuses together.
In case the scoliosis is progressing rapidly in a young patient, doctors can install a length adjustable rod that keeps pace with the child’s growth. The rod, attached to the top and bottom sections of the spinal curvature, is usually lengthened every six months.
Spine Fracture - Traumatic
Fall from height and road traffic accidents are the two most frequent causes of a spine fracture. The spine is a highly stable structure by the virtue of disco-ligamentous structures, protecting the spinal cord in the spinal canal. In trauma, bone or disco-ligamentous structural failure can put the spinal cord at risk of compression and thereby cause neurological deficit (paralysis).



Back or neck pain depending on the site of injury, immediately after the fall / accident.
Some may develop weakness of hands or legs, and then this is called acute traumatic spinal cord injury.
Principle: DO NO HARM
Patient should be shifted on a flat sheet, preferably a stretcher/ spine board. Trying to lift the patient or shifting to a wheelchair can worsen the situation and also cause permanent injury to spinal cord



You doctor may advise to get X-ray (Radiographs), CT scan/ MRI, depending on the clinical situation.
Most spine fractures, apart from a few, don’t require surgery.
Conservative management
Non-operative management includes medications, physical therapy and occupational therapy.
Surgery
Depending on the severity of the fracture, it can be treated by a brace or surgery (pedicle screw fixation).









Acute Spinal Cord Injury
A spinal cord injury (SCI) — is damage to the spinal cord resulting in a change, either temporary or permanent, in its normal motor, sensory, or autonomic function.
Prognosis or scope of improvement in weakness/ function depends on various factors like severity of injury/ time since injury/level of injury etc.
If the SCI is complete, the chances of neurological improvement are very bleak.
We have great hope that ongoing research will make the repair of spinal cord injuries possible in the near future. Presently, effective treatments and rehabilitation programs enable a number of people with spinal cord injuries to lead productive, independent lives.



The ability to control your limbs after a spinal cord injury depends on two factors: the place of the injury along your spinal cord and the severity of injury to the spinal cord.
The severity of the injury is often classified as either of the following:
- Complete. If all feeling (sensory) and all ability to control movement (motor function) are lost below the spinal cord injury, the injury is called complete.
- Incomplete. If there is some motor or sensory function below the affected area, your injury is called incomplete.



Paralysis as a result of a spinal cord injury may be referred to as:
- Tetraplegia Also known as quadriplegia, it means that your arms, hands, trunk, legs and pelvic organs are all affected by the spinal cord injury.
- Paraplegia. It means all or part of the trunk, legs and pelvic organs are affected.
Emergency symptoms
- Extreme back pain or pressure in neck, head or back
- Weakness, incoordination or paralysis in any part of the body
- Numbness, tingling or loss of sensation in hands, fingers, feet or toes
- Loss of bladder or bowel control
- Difficulty in balancing and walking
- Impaired breathing
- An oddly positioned or twisted neck or back
A serious injury to the head and neck calls for immediate medical evaluation for the possibility of a spinal injury. It should be assumed that the victim has a spinal injury unless proved otherwise since:
- The signs of a serious spinal injury may not always be immediately obvious. If not recognized, a more severe injury may occur.
- Numbness or paralysis may occur immediately or gradually as bleeding or swelling occurs in or around the spinal cord.
- The time between injury and treatment is critical to determine the severity of complications and the extent of expected recovery.
A traumatic spinal cord injury may stem from a sudden blow to the spine that fractures, dislocates, crushes or compresses one or more of the vertebrae. It may also be caused by a gunshot or knife wound that penetrates and cuts the spinal cord.
The most common causes of spinal cord injuries include:
- Road accidents
- Falls - usually in the older age group
- Gunshot & knife wounds
- Injuries from sports and physical activity
- Alcohol abuse
- Diseases like cancer, arthritis, osteoporosis and inflammation of the spinal cord
The areas most often affected include:
- Bladder control. While the bladder continues to store urine from the kidneys, the brain may not be able to exercise control because the message carrier (the spinal cord) is injured. This increases risk of urinary tract infections, kidney infections and kidney or bladder stones.
- Bowel control. Even though the stomach and intestines work as they did earlier, control of bowel movements is often altered.
- Skin sensation. Loss of all or part of skin sensation, means it cannot send a message to the brain when it is affected by things such as prolonged pressure, heat or cold.
- Circulatory control. Problems ranging from low blood pressure to swelling of your extremities, may arise. Changes in circulation may also increase risk of developing blood clots, such as deep vein thrombosis or a pulmonary embolus.
- Respiratory system. If the abdominal and chest muscles are affected, it may make breathing and coughing difficult.
- Muscle tone. Patients may experience one of two types of problems: uncontrolled tightening or motion in the muscles (spasticity) or soft and limp muscles lacking muscle tone (flaccidity).
- Fitness and wellness. Patients commonly experience weight loss and muscle atrophy, but restricted mobility may also lead to a more sedentary lifestyle, place you at risk of obesity, cardiovascular disease and diabetes.
- Sexual health. Sexuality, fertility and sexual function may be affected. While men may notice changes in erection and ejaculation; women may experience changes in lubrication.
- Pain. Muscle or joint pain may be experienced due to overuse of particular muscle groups. Nerve pain can occur in those with an incomplete injury.
- Depression. The mental strain of coping with all the changes and living with the pain, may causes some to slip into depression.
Slipped vertebrae/ Spondylolysthesis
Spondylolisthesis is when a spinal vertebra slip forward over another vertebra caudal to it. There are different types of the condition, depending on the anatomical changes.
Spondylolytic lysthesis: It is caused when the crack in a pars fracture affects both sides of connection (between the lamina and pedicles). The condition can be a direct result of spondylolysis.
Degenerative spondylolisthesis: Usually seen in elderly age group, this condition is caused by the deterioration of the facet joints and discs of the spine.
Congenital spondylolisthesis: Usually seen in the younger age group, this condition is caused due to birth defects in the bony structure of vertebrae (predominantly pars).




Symptoms
- Flat back
- Back pain and stiffness
- Pins and needle sensation in legs
- Numbness in legs
- Bladder symptoms – urinary incontinence / straining at urination
The evaluation for this condition will usually involve a review of the patient’s medical history and a physical examination, followed by standing X-rays, which can grade lysthesis. Your doctor may advice dynamic radiographs to evaluate if the lysthesis is stable or unstable.
A CT scan may be used to evaluate a pars defect or any bony problems, while an MRI may be useful to assess the surrounding tissue, nerves and condition of the disc.
Treatment depends on the clinical symptoms.
Conservative treatment: If the person is asymptomatic or has only back pain / stiffness, then surgery is NOT the first choice. Bracing / exercises and physiotherapy may be tried, which can give satisfactory results.
Surgical treatment: Surgery is recommended if conservative treatment doesn't give good results and / or if the patient has neurological symptoms like leg pain / numbness / bladder symptoms.
Surgery involves decompressing the nerve roots and fixing the bone with or without reducing the lysthesis by using screws and bone graft.
Rehabilitation is a multidisciplinary approach working towards the common goal of making the spinal cord injured person functionally independent physically, psychologically and occupationally, as much as possible.