Mobility for a person is very important, and when you look through, the hip is a very important component to this. It connects the upper and lower parts of the body and helps in movement. It is a ball and socket joint, where the hip bone provides a socket, into which the upper part of the thighbone (femur) sits into, allowing for free movement.

Like any other human organ, the hip also is prone to damage. Be it natural ageing, infection, injury, or diseases, hip movement can be affected, leading to limited movement and increased pain and stiffness. For these people, being able to get back a hip which will allow them to be back on their feet is a boon for sure. It helps in relieving pain and improving mobility, almost giving people a second lease of life.

Reasons for hip replacement:

With natural ageing, the hip joint can lose its ability to move, due to normal wear and tear of the hip and thigh bones
Diseases of the hips (infectious or autoimmune) can also lead to hip replacement
Injury or trauma is another major cause that requires hip replacement
Joint problems, leading to repeated dislocations
Tumours of the relevant bones
Understanding the procedure in detail

The affected bones (whether diseases or worn out) are replaced with a prosthesis which is compatible with the normal body tissue.
While some materials fuse to the natural bone, others do not and are simply placed as a separate unit
This is a surgery which requires hospitalisation and stays for up to 5 days depending on patient s overall health condition
The entire procedure may take a couple of hours and is usually done under general anaesthesia
An incision is made through the side of the hip
Both the hip and the thigh joints are prepared, diseased tissue removed, re-shaped, etc. to make way for the prosthesis
The prosthesis is introduced through the same incision and positioned into place
As noted earlier, there are two types. The ones which fuse to the bone have pores in them into which normal bone eventually grows.
The other variety is the cemented version, and a glue is used to keep it in place
Most doctors now use a combination, that is cement a porous prosthesis, into which bone will grow, and the incisions are closed
The patient stays in the hospital for 1 to 4 days depending on overall health
Once discharged, infection and pain control are continued
Exercise and physiotherapy play a major role in restoring normal function
Weight management is also very important

Hip Replacement - Understanding The Procedure In Detail!

When you experience any kind of bone and joint pain, you may be wondering what the best remedy might be to get relief. Some people ignore the pain, and it worsens, while others take over-the-counter medicines. However, the best remedy for bone and joint pain is to visit a pain management specialist. The field of pain management has evolved over the last twenty years. Nowadays, there are dedicated pain management specialists who are experts in treating bone and joint pain.

Here are 3 reasons to consult a pain management specialist for bone and joint pain:
1. Pain management specialists are trained especially for understanding any kind of bone or joint pain. They undergo special training based on bone and joint pain management and thus know how best to recognize and treat such pains.

2. Pain management specialists have a multidisciplinary approach towards treating bone and joint pain. The aim of pain management is to provide overall treatment and pain management specialists know about the best ways to take care of joint and bone pains. Pain management involves interventional procedures, psychological therapies, medication management and physical therapies. Pain management specialists also provide you with lifestyle modification remedies and assign you exercise schedules and diet plans. Alternative medicines like acupuncture and massage therapies are also provided by pain management specialists.

3. Pain management specialists cooperate with you and come up with the best solution for your bone and joint pain. Pain is such an aspect, which has no fixed cure and the remedy varies from person to person and depends on the nature and severity of the pain. Thus everyone should receive a personalized treatment, which is most suitable to cure the pain that has occurred to them. Pain management specialists work with patients, discuss a lot and come up with the best treatment procedure, which would complement the patient. For example, a neurostimulation device can be prescribed to a patient who suffers from complex regional pain syndrome and did not have success with other treatment procedures. In many patients with a shattered spinal disc, pain management specialists prescribe injections, which work effectively to give relief and treat the condition.

A pain management specialist can make the best assessments on bone and joint pain. Being trained especially in bone and joint pain management, you can bank upon pain management specialists to receive the best treatment for your bone or joint pain.

3 Reasons to See a Pain Management Specialist for Bone and Joint Pain

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!

The human spine has 33 vertebrae. However, some conditions can fuse these vertebrae. Ankylosing Spondylitis is one such condition. This disease may also be known as AS or Bechterew's disease. It is an inflammatory disease that can make the spine less flexible by fusing the vertebrae of the lower back together. In some cases, it can also affect the rib cage and make it difficult to breathe. This disease typically affects more men as compared to women. Most patients begin showing symptoms in early adulthood.

Ankylosing Spondylitis affects the sacroiliac joints. These joints are located just above the tailbone. It causes inflammation of the spinal bones that in turn cause pain and stiffness. With time, this inflammation spreads to the entire spine and the vertebrae begin fusing together. This can make movement difficult and painful. In severe cases, it can also lead to the development of a hunchback. This disease also affects the other tissues of the body. For example, it can affect other joints and aggravate arthritis or affect organs such as the kidney, heart, lungs, and eyes.

A specific cause has not yet been identified for Ankylosing Spondylitis. However, studies show that genetic factors can be a trigger. In particular, the presence of the HLA-B27 gene increases a person s risk of developing symptoms pertaining to this condition. However, it is important to note that merely the presence of this gene does not make Ankylosing Spondylitis inevitable. Other genes that are associated with this disease are ARTS1 and IL23R. These genes influence the functioning of the immune system. While it can affect people of all ages, adults are at a higher risk of suffering from this condition.

In many cases, the initial inflammation of the spine is due to a bacterial infection of microbial infection. Though the infection itself may be treated and cured, it may cause the immune system to react and trigger inflammation. Once activated, if the immune system cannot be turned off, this inflammation will continue and can trigger Ankylosing Spondylitis. In each case, the disease presents a unique pattern of progression.

There is presently no cure for this condition, but with an early diagnosis and treatment, the symptoms can be managed and progression can be slowed. This treatment usually takes the form of medication to relieve pain, inflammation and discomfort and physical therapy. Surgery cannot be used to treat Ankylosing Spondylitis but in cases where it has caused severe joint damage, surgery may be advised to replace the damaged joint.

Ankylosing Spondylitis - What Are The Causes?

Hip replacement is a surgery in which a specialist doctor surgically removes an agonizing hip joint afflicted with arthritis and replaces it with a man-made joint usually produced using metal and plastic elements. It is usually done when all other treatment choices have been tried and have proven unsuccessful in providing satisfactory pain alleviation. The technique is to mitigate the pain in ahip joint, in order to make walking and other physical exercises easier.

The surgical procedure is as follows:

Hip replacement surgery can be performed generally or by utilizing what is called a non-obtrusive method. The primary difference between the two methodologies is the number of entry points needed for the surgery.
During standard hip replacement surgery, you are given general anesthesia to relax your muscles; this will keep you from feeling any pain during the surgery or being awake during the surgery. A spinal sedative might be given to counteract pain as an add-on option.
The specialist will then make a cut at the edge of the hip and move the muscles connected to the highest point of the thighbone to uncover the hip joint.
Next, the ball part of the joint is taken out by cutting the thighbone with a saw. At this point a fake joint is attached to the thighbone using a material that allows them to stay intact.
The specialist then readies the surface of the hipbone - evacuating any harmed ligament - and joins the substituting attachment to the hipbone.
The new ball part of the thighbone is then embedded into the new joint part of the hip. The specialist then reattaches the muscles and shuts the entry point.
There are some things you need to keep in mind and be attentive about, post the surgery. These are as follows:

You will probably remain in the healing facility for four to six days and may need to remain in bed with a pad between your legs to keep the new hip joint set up.
A seepage tube will be set in your bladder to help you urinate without having to walk to the bathroom.
Non-intrusive treatment usually starts the day after surgery and within the days you can go around with a walker or a walking stick.
You will continue with the non-intrusive treatment for quite a long time which could be a number of months post the surgery.
For anywhere in the range of six to twelve months after hip replacement surgery, rotating or putting pressure on the operated leg needs to be limited to a great extent. You need to likewise not cross the operated leg past the midline of the body nor turn it inwards.
You cannot twist the hip past ninety degrees. This includes both twisting forward at the abdomen and crouching.
Your physical advisor will tell you the methods and equipment that will help you comply with the above rules and precautionary measures while performing every day exercises.

Hip Replacement - Things You Must Keep In Mind!

The intervertebral discs are made-up of two concentric layers, the inner gel-like Nucleus Pulposus and the outer fibrous Annulus fibrosus. As a result of advancing age, the nucleus loses fluid, volume and resiliency and the entire disc structure becomes more susceptible to trauma and compression. This condition is called as degeneration of the disc. The disc then is highly vulnerable to tears and as these occur, the inner nucleus pulposus protrudes through the fibrous layer, producing a bulge in the intervertebral disc. This condition is named as herniated disc. This can then cause compression to the spinal cord or the emerging nerve roots and lead to associated problems of Sciatica radiating pain from back to legs in the distribution of the nerve. Other symptoms could be a weakness, tingling or numbness in the areas corresponding to the affected nerve. Sometimes bladder compromise is also present, which is made evident for urine retention and this need to be taken care as an emergency.
Excessive weight, bad postures, undue movements, improper weight lifting and other kinds of traumas may weaken the intervertebral discs. When this occurs the pulpous nucleus will bulge against the annulus, or even be squeezed through it (extruded disc).

The first steps to deal with a herniated or prolapsed lumbar disc are conservative. These include rest, analgesic and anti-inflammatory medication and in some cases physical therapy. At this point, it is convenient to have some plain X-rays done, in search of some indirect evidence of the disc problem, as well as of degenerative changes on the spine.

If in a few days these measures have failed, the diagnosis has to be confirmed by means of examinations that give better detail over the troubled area, as the MRI, CT which will show the disc, the space behind it and in the first case, the nerves. In some instances, the EMG (electromyography) is also of great value, as this will show the functionality of the nerves and muscles.

Once the diagnosis has been confirmed, one of the best alternatives existing today is the Ozone Discolysis as the results obtained are excellent and practically has no complications. This novel treatment avoids the use of surgery in 80% of those who needed it. In most patients left with painkillers as the only treatment, the symptoms eventually disappear, only that this could take weeks to months. Ozone speeds up these developments, see the same result in a few weeks. The problem has to be seen and approached integrally and frequently the combination of therapies has to be used, most frequently physiotherapy. Also, it has to be known that those who had a herniated disc have 10 times more chances of having another herniation than the rest of the population.

If despite the ozone therapy the symptoms persist, Drill Discectomy/ Laser Discectomy are good alternatives before open surgery (Discectomy) which has to be contemplated in those true emergencies, as mentioned above, this is possibly the first choice.

Once the conservative treatment fails:

Early aggressive treatment plan of pain has to be implemented to prevent peripherally induced CNS changes that may intensify or prolong pain making it a complex pain syndrome. Only 5% of total LBP patients would need surgery & 20% of discal rupture or herniation would need surgery. Nonoperative treatment is sufficient in most of the patients, although patient selection is important even then.

Depending upon the diagnosis one can perform & combine properly selected percutaneous fluoroscopic guided procedures with time spacing depending upon pt`s pathology & response to treatment.

Using precision diagnostic & therapeutic blocks in chronic LBP, isolated facet joint pain in 40%, discogenic pain in 25% (95% in L4-5&L5S1), segmental dural or nerve root pain in 14% & sacroiliac joint pain in 15% of the patients. This article describes successful interventions of these common causes of LBP after conservative treatment has failed.

LESI: Lumbar Epidural Steroid Injection

Indicated in   Acute radicular pain due to irritation or inflammation.

Symptomatic herniated disc with failed conservative therapy
Acute exacerbation of discogenic pain or pain of spinal stenosis
Neoplastic infiltration of roots
Epidural fibrosis
Chronic LBP with acute radicular symptoms
Epidural- lumbar injection
ESI Treatment Plan

Compared to interlaminar approach better results are found with a transforaminal approach where drugs (steroid+ LA/saline +/- hyalase) are injected into anterior epidural space & neural foramen area where herniated disc or offending nociceptors are located. Whereas in interlaminar approach most of drug is deposited in posterior epidural space.Drugs are injected total 6-10 ml at lumbar, 3-6 ml at cervical & 20+ ml, if caudal approach is selected. Lumbar ESI is performed close to the level of radiculopathy, often using paramedian approach to target the lateral aspect of the epidural space on involved side. Cervical epidural is performed at C7-T1 level.

SNRB- Selective Nerve Root Block 

Fluoroscopically performed it is a good diagnostic & therapeutic procedure for radiculopathy pain if

There is minimal or no radiological finding.
Multilevel imaging abnormalities
Equivocal neurological examination finding or discrepancy between clinical & radiological signs
Postop patient with unexplainable or recurrent pain
Combined canal & lateral recess stenosis.
To find out the pathological dermatome for more invasive procedures, if needed
Intradiscal Procedures 

Provocative Discography - Coupled with CT

A diagnostic procedure & prognostic indicator for surgical outcome is necessary for the evaluation of patients with suspected discogenic pain, its ability to reproduce pain(even with normal radiological finding), to determine type of disc herniation /tear, finding surgical options & in assessing previously operated spines.

Percutaneous Disc Decompression (PDD)

After diagnosing the level of painful offending disc various percutaneous intradiscal procedures can be employed

Ozone Discolysis: Ozone Discectomy a revolutionary least invasive safe & effective alternative to spine surgery is the treatment of choice for prolapsed disc (PIVD) done under local anaesthesia in a daycare setting. This procedure is ideally suited for cervical & lumbar disc herniation with radiculopathy. The total cost of the procedure is much less than that of surgical discectomy. All these facts have made this procedure very popular at European countries. It is also gaining popularity in our country due to high success rate, less invasiveness, fewer chances of recurrences, remarkably fewer side effects meaning high safety profile, short hospital stay, no postoperative discomfort or morbidity and low cost.

Dekompressor: A mechanical percutaneous nucleosome cuts & drills out the disc material somewhat like morcirator debulking the disc reducing nerve compression.

Epidural Adhenolysis or Percutaneous Decompressive Neuroplasty for Epidural Fibrosis or Adhesions in Failed Back Surgery Syndrome (FBSS)

A catheter is inserted in epidural space via caudal/ interlaminar/ transforaminal approach. After epidurography testing volumetric irrigation with normal saline/ L.A./ hyalase/ steroids/ hypertonic saline in different combinations is then performed along with mechanical adenolysis with spring loaded or stellated catheters or under direct vision with epiduroscope.

Procedures That Can Help Treat Slip Disc & Sciatica!

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