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Patient Review Highlights
As a kid grows older, the calcium content in the bones increases. It reaches a peak in early adult age, around 25-28 years and then there is a gradual reduction of calcium from the bones at a slow pace during the rest of the life. The loss of calcium from bones accelerates after menopause in ladies. That means their bones loose calcium at a much faster rate and become weaker and weaker, leading to porous bones. That is called Osteoporosis. Weak bones fracture easily and affect the lifestyle in old age.
So, it is clear that the lower the peak bone mass one attains, the higher are the chances of developing osteoporosis and fractures in old age. That is why it is important to try and reach a higher peak bone mass during growing years of your life.
That can be achieved by calcium and vitamin D rich diet, adequate exposure to sunlight and regular exercises. Ladies after their menopause should check their bone density by DEXA scan atleast once in two years. Discuss with your doctor the risks of developing osteoporosis and fractures, and prevention tips.
Osteoporosis is a condition wherein the bones become brittle and weak; so much so that even mildly stressful activities such as coughing, bending over or even a slight fall (such as the one from a high rise chair) can result in fractures. Osteoporosis-related fractures commonly occur in the spine, hip or the wrist. The human body has a continuous mechanism of bone absorption and removal. In case of osteoporosis, the creation of new bones doesn’t happen in accordance with the removal of old bones.
The bones of the spine get extremely vulnerable to breakage and even cracking open. The fractures in the spine, also known as vertebral compression fractures can cause a sharp stinging pain in the back that may make sitting, standing, or even walking a very tardy task.
Abnormally less or high body weight
Menopause or low levels of sex hormones
Gender: This disorder is more likely to affect women as compared to men. Also women, who are above 50 are more likely to suffer from this debilitating disorder.
Race is a significant risk factor of osteoporosis. If you are of Asian descent, you are more likely to be affected by it.
Having a family history of osteoporosis will put you at a greater risk of this disorder.
Fractured or collapsed vertebra causing back pain
A stooped posture
A shrunken appearance (as if one has had loss of height)
Very fragile bones, thus increasing risks of fractures
Severe and sudden pain in the back
Difficulty in twisting or bending the body
Lower spine fractures are way more troublesome as compared to fractures in the upper spine. Fracturing more than a bone in the spine also remains a huge possibility.
Diagnosis and Treatment:
Firstly, an X-ray or a computerized tomography (CT scan) will be done to have a closer look at the bones. A bone density test is another commonly used method of diagnosing osteoporosis.
Steroids and medications: Some medications may be used to prevent or combat osteoporosis. These include alendronate, ibandronate, risedronate and zoledronic acid.
Physical therapy: Just like muscles, bones get stronger too when you exercise. Weight-bearing and muscle- strengthening exercises are the most helpful in this regard and are considered best for the treatment of osteoporosis. Cardiovascular exercises such as walking, jogging or even swimming can prove to be immensely beneficial.
Diet: Make a diet chart that includes high-calcium food items, dairy products such as yogurt, cheese, and low-fat milk, tofu, green vegetables such as collard greens and broccoli, sea fish such as salmon and sardines.
Salt: Limit salt intake
Therapy: Hormone replacement therapy (treatment method consisting of estrogens to alleviate and treat symptoms of osteoporosis) is another method of treatment that can be recommended by the doctor. If you wish to discuss about any specific problem, you can consult an Orthopedist.
The spine lends structural stability and balance to our body helping us stand upright, while allowing flexibility in various movements. Moreover, it forms a protective canal in which the spinal cord, the most important part of the neural network, flows down from the brain to the rest of our body. The spinal column is an interconnected structure of bony (vertebrae) and cartilage tissues (intervertebral discs) and it is prone to age related wear and tear. Read through to learn more about a herniated disc, its manifestations and treatment options, with special reference to a minimally invasive surgical technique called endoscopic discectomy.
What is a herniated disc?
First, let’s understand an intervertebral disc. It is essentially a disc shaped, rubber like tough and flexible structure made of outer layers of fibrous cartilage with a softer gel like tissue in the centre. A disc lies between two adjoining vertebral bones of the spine and acts as a shock absorber. This disc undergoes wear and tear changes (degeneration) after a certain age. When the degenerated disc is subjected to any external strain or injury, the substance from the central part of the disc comes out through the tears in the outer fibrous layers. This condition is called a herniated disc. It is also referred to as prolapsed or slipped disc. A disc prolapse can occur in any part of the vertebral column; but, mostly observed in the lumbar (lower back) or in cervical (neck) region.
What happens when an intervertebral disc herniates?
When the inner disc material protrudes through the disc surface, it may pinch or irritate the nerve roots it comes in contact with. It also elicits a severe inflammatory chemical response in that area. If this happens in the lumbar spine, it induces symptoms such as:
Pain in the back, pain running down the leg, weakness of the muscles in the leg supplied by the affected nerve root, numbness or tingling sensation in the respective part of the leg. Loss of bladder and bowel control if a large disc prolapse compresses multiple nerve roots.
If you feel recurring radiating pain in any of the body parts, it would be a good call to see a spine specialist.
What causes disc herniation?
Disc herniation happens as a result of degeneration that is mostly related to the genetic composition of the person. Smoking is another well established factor that causes disc degeneration. Other factors also play a role in the process of wear and tear of the discs. Though the exact reason is hard to pick, disc herniation may be precipitated by strain on the spine during physical work, certain kind of frequent body movements or spinal injury due to any accident. Sometimes adopting improper body posture for physically demanding jobs of time may result in this condition.
What are the treatment options for herniated disc condition?
Most cases of disc herniation can be treated medically with rest, pain relievers, anti-inflammatory medication and physiotherapy. But, if the symptoms persist or the pain is severe or if it is affecting the nerve function causing numbness and weakness, it needs surgical intervention.
Minimally invasive (endoscopic) spine surgery
Spine surgery is generally adopted as the last resort to treat painful disc prolapse that do not respond to medication for a longer period (usually 3 months). Rarely, a severe nerve compression causing weakness of muscles or severe sciatica may need surgical treatment straight away. Conventional open surgery involves cutting the muscles and removing some portion of bone in the spine, which has its own complications and disadvantages. But, the advent of high definition image guided systems and surgical tools, now-a-days spine surgery for herniated discs can be done with minimal invasion.
Endoscopic discectomy for herniated disc is a minimally invasive spine surgery carried out through a small on the back. It involves removal of herniated disc material that protrudes and compresses the adjacent nerve roots, through specially designed spine endoscopes that help in clear visualization of the structures. Instead of cutting the muscles in an open surgery, endoscopic surgery involves dilation of the muscles causing much less damage and procedure related pain. It can also be performed under local anesthesia as a day care procedure in suitable patients.
Are you at high risk of developing a fracture in your spine or hip? read on to know more about osteoporosis.
There is another silently progressing, common disease other than diabetes and hypertension that can cause potentially serious risk to your health in old age. Osteoporosis meaning “porous bones” indicates a condition where your bones become more porous, thinner and weaker due to accelerated loss of bone or reduced bone formation or both. It is most evident in the vertebrae of spine, hip bones and in the wrists.
Thin and porous vertebrae fracture easily. They crumble on their own or due to minor stresses during daily activities like coughing, sneezing, bending forwards. These fractures can be painless and go unnoticed in multiple levels till the spine develops a forward bend and a noticeable loss of height. Or it can cause significant pain and disability, limitation in daily activities and increased dependence on others. A simple slip and fall at home can cause a fracture in the hip bones that can make the patient completely bed ridden. These situations commonly cause depression and general deterioration of health and leads to other risky complications in old age.
Though it is most common women after menopause, it also happens in men above age of 65 years and in those with certain risk factors like liver or kidney disease, thyroid or parathyroid disorders, and certain tumours. Smoking has been proven to cause osteoporosis. Long term steroid intake given for various conditions and medications given for seizure disorders also can cause osteoporosis.
Osteoporosis can be detected easily by a screening test called the dexa scan. Any one above the age of 50 years should consult an orthopaedic surgeon to know if they are at risk of osteoporosis and whether he/she needs a dexa scan. If the dexa scan reveals that you have osteoporosis, you must be evaluated by an orthopaedic surgeon and an endocrinologist to look for other treatable conditions that can cause osteoporosis. There are medications that are prescribed to strengthen the bones and reduce the risk of fractures in future. Diet rich in calcium and vitamin d and supplementary calcium and vitamin d medications are also an essential part of treatment.
Although the vertebral osteoporotic fractures commonly heal in a few weeks with bed rest and medications, some of them may not heal in time or cause severe pain and disability. These patients might need surgical intervention. Vertebroplasty is a procedure that involves injection of bone cement into the broken vertebra and can give immediate pain relief. Kyphoplasty is a similar procedure that can restore the height of the fractured vertebral body and reduce the forward stoop in the spine. Open surgery might be required sometimes if the collapsed vertebra causes a compression of the spinal cord or nerves in the spine. Osteoporotic hip fractures and wrist fractures often need surgical treatment for fixation.
Prevention of osteoporosis should begin in childhood. Growing bones accumulate calcium and the calcium in bones reaches a peak at around age of 26 to 30 years. After that age, there is a slow decline in the bone calcium, which accelerates in old age especially in women after menopause. So those who reach a lower peak of calcium in bones by the age of 30 are at a higher risk of developing osteoporosis in old age. This means that adequate intake of dietary calcium, vitamin d and adequate exercise from young age is very important to prevent osteoporosis.
Prevention of falls and resultant fractures in those who are osteoporotic is an important aspect of treatment. This needs modification of their living spaces to remove the risks of a slip and fall. Routine exercises and an active lifestyle load the bones and make them stronger and it is a must for all those with osteoporosis and those at risk of developing osteoporosis.
What is the cause for my back/neck pain?
The most common cause of back/neck pain is strain or injury due to bad posture during the daily routine activities like sitting, bending forwards and lifting weights etc. Lack of regular exercise to the back and abdominal muscles, age related wear and tear changes in the discs and bones in the spine, obesity are other contributory factors. Severe wear and tear changes (degenerative changes) in the spine can lead to instability and pain that is worse on certain activities. Mechanical back pain usually gets better with bed rest.
A small percentage of patients have a serious problem like a fracture, infection or tumour in the spine causing the back pain. Any pain that is not relieved by rest or is worse at rest, pain that wakes you up from sleep should be considered serious and that needs a consultation with your doctor.
What should I do when I have significant back/neck pain?
If the back/neck pain is not very severe and is of a short duration, then complete bed rest for two to three days will help reduce the pain significantly. Applying ice packs and light massage with a pain balm/gel is helpful. Consult your doctor if the pain is severe, running down in to the legs/arms, not getting better with rest, night pain, if there is numbness/tingling sensation or weakness in the limbs, is associated with fever, or if the pain started after a significant injury/fall. Thorough clinical evaluation by the doctor will help identify those with possible serious causes of back pain and further investigations are advised accordingly.
Is my back pain due to a kidney stone/problem?
Possible. But not always.
Kidney problems, especially renal or ureteric stones can lead to pain in the mid and lower back, usually limited to one side, often pain radiating down to the groin or lower abdomen. There are certain indicators to differentiate pain coming from kidney or other organs in the abdomen from the pain originating in the spinal structures. In general, spine related pain is mechanical i. E, it is worse in positions where the spine is loaded like while in upright posture, walking or bending or getting up from reclined position and generally gets relieved by resting in reclined position.
Pain from the kidneys can start suddenly in any position, can be waxing and waning and may not change related to a particular posture. It may not get relieved by rest and can be severe even while reclined. These are only general indicators and it is always better to check with your doctor and get the right treatment advise.
I have back/neck pain even though my mri says my spine is normal! why?
A very common cause of back or neck pain is bad posture related stress to the spinal structures that happens during the daily routine activities. Sitting/standing posture, especially at work, has a major role in producing significant pain and disability even though the x rays/mri of the spine may be normal.
Bad sleeping posture can lead to pain in the neck/back. Sleep is important to allow the spine to recover from the daily stresses it undergoes while we are awake. Reduced sleeping time and lack of proper sleep can lead to accumulated stress in the spine and result in pain. Lack of adequate exercises to keep the spine flexible and muscles strong is another important factor leading to pain.
So, right posture and regular exercises are the two most important treatments to prevent such pain from troubling you.
Other structures close to the spine can also lead to back pain. So if the mri of spine is normal, further evaluation might be ordered by your doctor depending on the clinical picture.
Is my back pain due to the spinal/epidural injection that was given in my back many years ago for an abdominal or leg surgery?
No. It is a common perception that the spinal / epidural injection that was given in the past for anaesthesia purpose is the cause for back pain. Many patients associate their back pain to that injection as they remember it as painful event and think that the present pain is related to that procedure. Spinal anaesthesia related back pain doesn't usually last more than 3 to 4 days and almost never beyond one week. So the back pain that continues beyond one week or that starts much later after the spinal anaesthesia is not because of that injection and it needs evaluation by your doctor to find the right cause and treat appropriately.
Is my back pain due to my body weight / pot belly?
Overweight is an important factor contributing to back pain, especially in the lower back. Excess weight and a large belly lead to some changes in posture. The pelvis tilts forwards and the lumbar spine is also pulled forward and this posture can lead to back pain due to additional stress on the spinal joints and muscles. Lack of exercises weakens the back and pelvic muscles and contributes to the problem. Back pain due to other problems in the spine can get worse if overweight is associated. Weight reduction and core strengthening exercises in obese people are helpful in reducing the back pain.
I have back pain. Is it due to slipped disc/disc prolapse?
Not necessarily. Although disc is a predominant source of back pain, all back pains are not because of a disc prolapse. The other structures in the spine like the facet joints, ligaments, vertebrae (bones) or the muscles of the back can be the cause of pain in the back. Less commonly, pain related to abdominal organs like kidneys or pelvic organs can be perceived as back pain.
Does the disc bulge/prolapse seen on my mri get reversed again naturally?
No. The changes that happen in the disc that lead to the prolapse or bulge are not reversible. They are due to age related wear and tear changes and we all know that ageing doesn't get reversed. But usually, the symptoms and signs that are related to a disc prolapse get relieved with appropriate treatment, although the mri picture may continue to be the same. So the treatment decisions are mostly dependent on patient’s symptoms and signs rather than in mri picture alone. Only if the prolapsed disc is causing persistent symptoms and significant neurological deficits, a surgical intervention is considered.
Is lumbar disc prolapse a cause of erectile dysfunction/impotency?
Rarely a large lumbar disc prolapse can result in severe compression of lumbar spinal nerves causing numbness and weakness in both lower limbs and loss of urine and bowel control - a condition called “cauda equina syndrome”. It is only in this condition that a disc prolapse can affect the erectile function. An erectile dysfunction in isolation, without other neurological symptoms and signs, cannot be caused by a disc prolapse.
Does the disc problem affect the ability to become pregnant in future?
No. A disc prolapse/bulge doesn’t affect the ability to get pregnant. But, there is a possibility that the back pain due to a preexisting spinal problem may get worse during pregnancy due to the extra weight that is carried and the relaxation of ligaments of pelvis and spine that occurs as a result of pregnancy related changes.
Does it help to sleep on the floor/hard surface without a bed to cure back pain?
No. It is not advisable to sleep on the floor when there is a back problem. Sleeping on the floor when there is significant back pain can actually make it worse as you need to put an extra strain on the spine while getting up from the floor. Sleeping on the regular cot with a firm mattress is alright. It is advisable not to sleep on a very soft mattress that doesn’t support the spine well and can aggravate the back pain. Do not use a thick pillow or multiple pillows while sleeping as it can cause or aggravate neck/upper back pain. A thin pillow or a rolled sheet supporting the neck is an ideal kind of head rest.
I exercise only when I get back/neck pain!
Many patients say this when asked about any exercise they do. It is not advisable to start exercise when there is significant back or neck pain. But it is essential to start exercises after the pain subsides, to prevent the pain from coming back again. Exercises can help strengthen your spinal muscles, increase flexibility and protect you from recurrent episodes of pain. So it is important to keep exercising when there is no pain, to keep the pain from coming back and troubling you. So do not start exercising when there is pain.
A blood clot in the leg is termed as Deep Vein Thrombosis or DVT. This blood clot can be fatal, because it usually blocks the passage of blood to the heart by damaging the one way valves of the veins. This can also reach other organs like the lungs, in which situation the case becomes complicated and may also lead to death. There are various ways of preventing the onset of these clots. Follow these points to know more.
- Blood Thinners: Prolonged hospital stay and a major surgery like joint replacement can lead to blood clots in the legs or DVT. Therefore, it is imperative to ask your doctor about a prescription for blood thinners, which can help in better blood flow despite minimal motion in the legs or stiffness.
- Compressions Stockings: If you have been in the hospital for a prolonged period or suffering from leg paralysis, then the risk of blood clots is greater than most others. You can make use of compression stockings, which will help in preventing clots by holding the area tight so that the blood is forced to pump and flow. These should be used every time you are admitted to the hospital.
- Exercise: It is important to keep moving in case you are travelling in a long flight that is over four hours long. Also, you can try certain mild exercises, in case you have a long standing condition of pain or cramping in the leg muscles and joints. From simple toe flexes to muscle strengthening exercises like the heel or towel hook, you can ensure that the tightening action makes your muscle firm so that the blood clots do not have a chance to form. You may also need to lose weight in case you are overweight so that you can alleviate the risk of these clots.
- Water: Staying hydrated is something that we all need to follow in any case, but it is especially important if you are risk of developing blood clots in the legs. Drinking plenty of fluids is a natural way of thinning the blood, especially if you have been in bed or travelling for prolonged periods.
- Loose Fitting Clothing: You may want to wear loose fitting clothing when you are travelling or in the hospital so that you do not end up unnecessarily compressing an area in a way that will be detrimental for the blood flow there. Wearing loose clothing ensures that the blood flow carries on as per its normal routine without any blockages.
It is important to remember the above points so that you keep blood clots in the legs at bay. If you wish to discuss about any specific problem, you can consult an orthopedist.
The spine plays a very crucial role, both from a person’s movement and sensation point of view. It carries the nervous supply for a lot of internal organs and the lower body. By virtue of its structure, it also helps in movement through the disks. Due to various reasons, spinal injury is common, causing pain along the back, lower extremities, neck etc.
Medicines and exercise are the first line of treatment for most spinal injuries. The issue, however, is that these only provide relief from the pain and the medicines, but do not actually ‘rectify’ the underlying problem. Whether it is a herniated disk or a pinched nerve, the medicines and exercise can relieve the symptoms, but the disk continues to be herniated and the nerve continues to be pinched. Definite treatment is in the form of surgery, and with recent advancements in the field of spinal surgery, there are minimally invasive surgical options, which provide complete cure with minimal recovery time. Some of the benefits of this are listed below-
- Smaller incision compared to traditional surgical procedures, where only the injured area is accessed
- The surrounding tissues are untouched, unless they are injured and require repair
- Lesser bleeding compared to earlier techniques
- Lesser painful procedure
- Reduced hospitalization period
- Quicker recovery and return to normal activities
The question, however, is whether this is indicated in everybody. A detailed discussion with your surgeon keeping the below points in mind will help identify the answer for this. The main driver should be the answer to the question – will the surgery be able to effectively relieve you of the pain and symptoms? Additionally, the following factors help in getting better results out of a minimally invasive spinal surgery.
- Presence of symptoms relating to nerve compression, including pain from the spine down the leg.
- Recent onset of symptoms, with pain starting days to months before seeing the doctor. This indicates the condition is relatively new and so damage is minimal, indicating favorable outcome. Chronic pain conditions take slightly longer time compared to recent injuries.
- People with active lifestyle who engage in regular physical exercise are likely to have better benefits from the minimally invasive procedure.
- Smoking reduces blood flow to the spine, leading to disk degeneration and weakening of bones. Healing is highly slowed down and recovery is overall delayed.
- Excessive weight puts strain on the back, and so healing can be delayed or badly affected with more complications. It is not a contraindication, but be prepared for a longer recovery period.