At some point in life most people experience acute pain in their lower back which is extremely painful. Pain in the spine causes a lot of discomfort and disruption in the life of an individual and hence, it is always better to get it checked on time. There are patients who even wonder when they should consult a neurosurgeon or a spine surgeon for their back pain. It is advisable that a physical examination is done by a primary care physician for low back pain before consulting a spine surgeon.

Why consult a Physical care Physician First?
The main reason to consult a primary care physician at first is that he would prescribe medications for severe lower back pain. The medications could include non-narcotic pain medications such as Ultram or non-steroidal anti-inflammatory drugs such as Motrin. The physician can even refer you to a chiropractor or for physical therapy to get relief from the back pain. Mechanical means are made use of by a chiropractor mainly to alleviate the back pain of the patient.

If the patient feels better with the physical therapy or the medications prescribed by the family doctor and is able to resume normal activities, then there is no need to see a spine surgeon. It is often recommended to take good care of the back and to exercise. A combination of ergonomics, regular stretching and improved everyday posture is beneficial as it reduces the chance of causing pain in the lower back. Exercise plays a very important role and it provides the possibility of reducing the pain.

Conservative Care for Treating Lower back Pain
It is best for patients to consult a conservative care specialist if after consulting a chiropractor they do not find any reduction in their pain and they do not want to undergo spine surgery. The conservative care specialists are well-trained in rehabilitation of musculoskeletal disorders and specialize in spine care. The role of the conservative care specialist is similar to a cardiologist who specializes in treating neurological disorders.

The specialist for spine care works along with the surgeon in a spine center to treat the lower back pain. The specialist is trained in diagnostic techniques and is capable of making use of a combination of diagnostic tests as well as injection techniques such as epidural steroid injections to diagnose the source of the lower back pain in a patient. They can even advise patients whether it is appropriate to consult a spine surgeon for surgery. Surgery is done to correct the anatomical conditions and it is performed only when non-surgical treatments are not successful in alleviating the pain of the patient.

When Is The Right Time To See A Spine Surgeon?

As life expectancy is increasing so is the incidence of vertebral body (VB) fractures now being the commonest fracture of the body. PVP is an established interventional technique in which bone cement is injected under local anaesthesia via a needle into a fractured VB with imaging guidance providing instant pain relief, increased bone strength, stability, decreasing analgesic medicines, increased mobility with improved quality of life and early return to work in days.

In this era of minimally access surgery replacing open surgeries, PVP is a novel procedure & should be in the first line of management in place of conservatism or major spine surgery for painful uncomplicated compression fracture spine.

Morbidity & consequences of spinal fracture:

Traumatic VB is a painful condition requiring bed rest restricting daily activities markedly
Left untreated it can cause DVT, increase osteoporosis, loss of VB height, respiratory & GI disturbances, emotional & social problems secondary to unremitting pain, loss of independence with high cost of rehabilitation.
High risk of primary or consequential damage to neural, bony or disc element
Increased wedging, deformity & increase incidence of adjacent VB
Chronic pain of altered spine mechanics
Uncomfortable braces & sleep disturbance because of pain & discomfort with its sequels.
Cost of surgery and hospital treatment
Cost of implants
Phobia of surgery
Prolonged recovery period & Extensive rehabilitation
Changed spinal mechanics & transition syndrome
Major surgery & anesthesia with its own complications
Results / Outcome

PVP is a novel procedure with high benefit to risk ratio, which is highly underutilized in relation to the high prevalence of the vertebral.
Different studies show an immediate pain relief in (85   90)% of patients with low complication rate ranging from (1-5)% depending upon the type of lesion.
PVP does augment height of VB but ideal would be kyphoplasty
Patient is either off medicine or on reduced doses.
Patient feels so well that he almost forgets if he had VB

Percutaneous Vertebroplasty (PVP) is an emerging interventional technique in which surgical polymethyl methacrylate bone cement is injected under local anaesthesia via a large bore needle into a vertebral body (VB) under imaging guidance providing increased bone strength, stability, pain relief, decreased analgesics, increased mobility with improved QOL and early return to work. Started in 1984 by Galibert PVP is done in host of indications.

Senile osteoporotic compression remains the commonest Indication. Other indications are Metastatic VB, Multiple myeloma VB, VB haemangioma, Vertebral osteonecrosis & for strengthening VB before major spinal surgery. The benefit has been extended to the traumatic stable uncomplicated VB compression (VCF) which is commoner in younger age group with active life profile and prime of their career where strict bed rest and acute or chronic pain are unacceptable and they are more demanding for proactive treatment approach so as to be back to work ASAP.

Discovering the fact that VB is the commonest of body, its incidence >the hip, it becomes imperative to take it more seriously. With increasing life-span there is more of aged osteoporotic population, more so due to sedentary indoor lifestyle and post menopausal osteoporosis. Diabetics, smokers & alcoholics are at higher risk of developing osteoporosis. I have seen such alcoholic patient developing six spine fractures in just three months time from a single fracture being on complete bed rest.

Quick fix of fracture spine makes patient walk back same day instead of bed rest of months together avoiding morbidity & mortality of prolonged bed rest, making bedridden patient walk, in a way bringing patient back to normal life.

In this era of MAS replacing open surgeries, PVP is a novel procedure & should be in the first line of management in place of conservatism or major spine surgery for painful uncomplicated compression.

Morbidity & consequenses of spinal 

Traumatic VB is a painful condition requiring bed rest restricting daily activities markedly.
Left untreated it can cause DVT, increase osteoporosis, loss of VB height, respiratory &
GI disturbances, emotional & social problems secondary to unremitting pain, loss of independence with high cost of rehabilitation.
High risk of primary or consequential damage to neural, bony or disc elements.
Increased wedging, deformity & increase incidence of adjacent VB
Chronic pain of altered spine mechanics.
Uncomfortable braces & sleep disturbance because of pain & discomfort with its sequels.
Morbidity and complication of spinal surgery 

Cost of surgery and hospital treatment
Cost of implants
Phobia of surgery
Prolonged recovery period & Extensive rehabilitation
Changed spinal mechanics & transition syndrome
Major surgery & anesthesia with its own complications
Preparation & Procedure:
X-ray spine in a/p & lat view. CT is more informative of bone & morphology. MRI is good for soft tissue injuries. Ask for pedicle size in all dimensions and construct a 3D image aiming needle placement and cement filling in scan room itself as rehearsal of PVP. This reduces operative time & gives better results. Conventionally PVP is done by hammering the vertebroplasty needle through the bone. Here we use light weight drill to bore through the vertebra. It is important to set the needle at exact entry site & side with right trajectory aiming the defects.

In lateral view needle should go through middle of the pedicle going up to anterior 1/3 of VB. In P/A view the needle can be in midline or paramedian depending upon & if uni/bipedicular approach is planned. Approach varies as per location of vertebra, anterolateral in cervical, costotransverse/parapedicular in thoracic & transpedicular in lumbar vertebra.

Do bone biopsy if there is any doubt about lession. Do dye test (vertebral venography). Make cement more radiopaque by adding barium /or tungsten. Inject cement with 1or2 ml luerlock syringes strictly under fluoroscope in lateral view & cross checking in P/A view. Stop injecting either there is adequate filling or at the first sight of ectopic cement leak. Keep sample cement to see for hardening. Remove needle with rotational movement before cement hardens.

Pain relief is by virtue of different mechanisms postulated :

Cementing of fragments.
Thermal neurolysis of VB nerve ending due to heat of polymerization.
Washing away of nociceptor chemicals.
Neurolytic action of liquid monomer.
By allowing early ambulation decreasing pains of immobility & bed rest.
Complications 

PVP is generally safe with low risk.
Ectopic cement leak is frequent but generally inconsequential.
Outcome 

PVP is a novel procedure with high benefit to risk ratio, which is highly underutilized in relation to the high prevalence of the vertebral
Different studies show an immediate pain relief in (85   90)% of patients with low complication rate ranging from (1-5)% depending upon the type of lesion.
PVP does augment height of VB but ideal would be kyphoplasty.
Patient is either off medicine or on reduced doses.
Patient feels so well that he almost forgets if he had VB

Vertebroplasty (PVP) / Kyphoplasty - Approach To Management Of Vertebral Body Fractures!

If you have been facing back problems in the form of pain and discomfort for a long time despite undergoing treatment and medications, then you must be wondering whether you should go for a spine surgery. With the advancement in technology in the field of medical surgery, spine surgery has gained popularity owing to its effectiveness and high success rate. However, there are plenty of misconceptions regarding spine surgery, which need to be busted so that people do not make decisions based on these false beliefs.

Here are five myths about spine surgery debunked-

  Myth: Surgery is a must if you have damaged discs.
Fact: Many people live with a herniated disc. It is a fairly common spinal condition. The common belief is that you need to undergo a surgery to fix the problem. However, it is not true. In fact, many people have found relief from back pain following non-surgical methods such as physiotherapy and low-key exercises. These are the initial course of the treatment and usually, the patient sees positive results after the completion of the course.

  Myth: Surgery can relieve you from back pain completely.
Fact: Spine surgery is meant to correct spinal problems by restoring the functioning of your spine and reducing back pain. However, a surgery cannot relieve you from the pain completely. In other words, it cannot fix the problem entirely. There are certain parameters, which you need to correct on your own. These include maintaining a healthy body weight, living a healthy and active life, eating a balanced diet etc. Nevertheless, if the spine problem/injury is diagnosed early, the chances of a successful spine surgery increase.

  Myth: Spine surgery has serious repercussions, and it is not worth a try.
Fact: Like all other types of surgery, spine surgery too has a few risks or side effects associated with it. The most common types include blood clots, infection, weakness, and bleeding. However, these are not as serious as it sounds like. Since most of the surgeries are minimally invasive today, the minor side effects do not last more than a week and recovery takes place sooner. The side effects can also be managed with pain management medications well so the patient need not worry.

  Myth: Visiting a spine surgeon means you will definitely need a surgery.
Fact: Your orthopaedic may advise you to see a spine surgeon if the symptoms of your spine injury/problem become severe. This does not necessarily mean you will have to undergo a surgery. Sometimes, the doctor may schedule an appointment with the surgeon to have a unique perspective of the condition. Surgery is prescribed only as the last resort.

  Myth: Undergoing a surgery once means you will need another one soon.
Fact: If you have gone under the knife once, it does not necessarily mean you will need another surgery soon. Multiple surgical procedures are required only if the patient has sustained complex trauma to the spine. Such cases are rare. Usually, the patient undergoes spine surgery once, following which he/she is provided with a post-operative guideline. The guideline suggests engaging in mild exercises and making vital lifestyle changes to ensure fast recovery.

If you have been suffering from persistent, recurring pain in the back or neck that has altered or affected your quality of life in a negative way, its time you should consult a doctor. Do not hesitate if you need to undergo e a spine surgery urgently. The facts stated above will help clear your mind and eliminate any false belief that you had been holding in.

Spine Surgery - Busting The Myths Around It!

Fractures are simply a break in a bone. They can be caused due to injury, (traumatic fractures) or a pre-existing condition like osteoporosis that causes weakening of bones (pathologic fractures). There are many ways to classify fractures. All fractures fall into the major categories of simple and compound fractures. Simple fractures are fractures where bones remain inside the skin and don t jut out. They are also called closed fractures.

Compound fractures, also called open fractures, are broken bones that penetrate through the skin. These types expose the bone and deep tissues to the environment. Compound fractures are more serious of the two. The healing here may be affected due to deep infections for which antibiotics need to be used. There are many different sub types of fractures and we re only going to skim through them here.

Comminuted fractures: Severe fractures in which a bone breaks into several smaller pieces.
Avulsion fractures: A small piece of bone is completely torn off from the main bone due to fierce pulling off a part of the body.
Other types of fractures are characterised by the many different angles the bone breaks into like transverse, oblique and spiral fractures.

Diagnosis
When a bone is broken there are symptoms like swelling that doesn t subside on its own and pain. In such a case it s imperative that one goes to a doctor for a diagnosis. Doctors can usually recognise most fractures by examining the injury and taking an X-ray. The X-ray also provides a clear idea about the type of fracture and the degree of displacement of the bone. And, it s important that the patient doesn t wait too long before approaching a doctor. This is because bones begin to heal very quickly after a fracture and the bone tissue will heal using any tissue available. This can lead to a misalignment of broken pieces of bone and cause disability and loss of function.

There are cases when X-ray may not show a fracture. This is especially common in fractures in the hip and wrist in older people. For diagnosing these, doctors will get some other tests done such as a computed tomography (CT) scan, magnetic resonance imaging (MRI), or a bone scan.

Treatments
Fractures have to be treated by doctors. The doctors set the fractured bones in their proper place and hold them there so that they can heal. Setting a bone is called "reduction." Reduction without surgery is called "closed reduction." But if the fracture is serious, it s going to require surgery with bone repositioning, called open reduction.

In extreme cases, pins, plates, screws, rods, or glue are used to hold the fractured bones in place, inside the body. Once the bone abutment has been treated, the bone is immobilised to allow the broken pieces to heal. In most cases, the fractured part is set in a rigid cast. The fractured ends of the bone can be fixed into place using metal pins connected to an external frame. This is removed after the bone has healed.

Fractures - How To Diagnose Them?

An orthopaedic fracture is a serious issue that will require lots of care for the bones to heal and re-join. A broken bone is usually plastered so that the tissue may grow back together by fusing eventually, over a period of weeks. When these bones begin to rebuild in an effort to come together, the new bones are called soft callus. This will require lots of energy, which primarily comes from calories. This ensures that essential proteins like amino acids can be taken from the right type of food which would stimulate good blood flow. 

So, let us take a look at the best diet that one can follow in order to recover from a fracture.

Kale: Leafy green vegetables and herbs like kale can help in supplying good amount of protein and iron as well as calcium, which is highly important for good and strong bones. One can also find plenty of calcium in salmon and other kinds of sea food like sardines; consuming these can speed up the process. Sea vegetables like seaweed can also help in the process.
Yogurt: Calcium can be supplied by various other kinds of food including yogurt, which has two kinds of amino acids. These amino acids are lysine and glutamine, which can assist the bones in swift calcium absorption for better recovery of the broken bones.
Spinach: This is a very important ingredient in the bone healing process thanks to its dual elements of calcium and zinc, which come together to cause the appropriate chemical reaction for bone rebuilding. Other zinc heavy food items include pumpkin seeds and wheat germ as well as red meat.
Broccoli: Ingredients like broccoli are rich in Vitamin K1, which is known to very good for the bone recovery process. This vitamin helps in mineralisation of the bone so that they may fuse with each other and form a new mass. One can have up to one cup of this green vegetable per day for a quick and effective fracture recovery process. Other ingredients like cheese and raw dairy products are known to have plenty of this vitamin as well.
Green Bell Peppers: High on vitamin C which helps in producing the skin and tissue structuring element called collagen, green bell peppers are an excellent ingredient that can help you in your fracture healing process. Vitamin C can also be found in citrus fruits like oranges, strawberries as well as tomatoes.
Milk: While milk has plenty of calcium, it also has another important ingredient called vitamin D. When calcium and vitamin D come together, the bones tend to heal much faster as vitamin D helps the bones in absorbing the calcium at a much high rate.

Recovering from Fracture - 6 Foods You Must Consume

Spinal fusion is a surgery in which two or more vertebrae in the vertebral column or back are fused or joined to treat a slew of spinal problems and diseases, which cause debilitating back pain. This surgery helps to remove bone and tissue that are narrowing the spinal canal, squeezing the spinal cord and nerves, reducing pain and improving function.

There are many different causes of back pain like injury, poor posture, age, osteoarthritis, herniation of disc between two vertebrae, degenerative disc disease, narrowing of spine called stenosis, and spondylosis or lessening of space between the vertebrae- most of these can be treated using spinal fusion.

All of these causes put tremendous pressure on the vertebrae and pinch spinal nerves that pass through the back and radiate out into the arms, legs and torso. Apart from the pain, patients experience nerve and muscle weakness and irreversible damage affecting normal life.

Spinal fusion started off as just a treatment for fractures but now it has become the surgery of choice for a number of spine problems. Though it can be done anywhere in the spine, it is very effective when done in the lower part of the spine called lumbar spinal fusion or arthrodesis.

Spinal fusion is done by forming a direct bony connection between the vertebrae surrounding the painful discs, the cushioning between the vertebrae. Pain is stopped by stopping the motion of the painful discs.

There are different methods of spinal fusion each with its own advantages and limitations.

Techniques include fusion approached from the front, the back, or both of the vertebral column. Sometimes surgeons decide to use intervertebral cages or metal screws to provide internal structural support while the bone fuses. These cages may be placed between the vertebrae and packed with bone graft material taken from the patient or constructed out of synthetic materials.

What to expect?
Spinal fusion is not a risk-free procedure. It is a major surgery lasting several hours and carrying a number of risks like-

Failure of the vertebral fusion and breaking of metal implants
The vertebrae above and below the fusion can wear away aggravating problems
Blood clots may be formed that can travel to lungs causing embolism
Injury to spinal nerves causing permanent weakness in legs and problem with bladder and bowel function
Infections and blood loss
Heart attack or stroke during surgery
The patient has to be kept in hospital for a couple of days for post-operative care after which he will have to undergo rehabilitation for months. Hence, one should really think before going for spinal fusion. And when it is recommended, seek a second opinion before making a decision. 

Spinal Fusion Surgery - What To Expect?

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