Endoscopy refers to inserting microscopic cameras into the body through tiny incisions which throw up pictures of the inside of the body onto a screen. Endoscopy has been used for diagnostic purposes since the 1970s. Endoscopy for surgery has become popular from the 1990s.

Endoscopic spine surgery is a state-of-the-art surgery technique which involves micro incisions and minute tubes that cause almost no damage to surrounding tissues and muscles. It is a minimally invasive surgery and it is also called a pinhole surgery.

What are the advantages of endoscopic pinhole spine surgery?

There are a lot of reasons why doctors opt for an endoscopic surgery-

  It is also called Minimally Invasive Spine Surgery (MISS) because it causes little blood loss
  Recovery is almost immediate. A person can resume everyday activities within a week
  Very little pain around the surgery region so minimum pain medication is needed.
  No muscle or bone is removed.
  Since screws and rods are not used, full mobility of the spine can be restored
  The wounds are minute and do not usually require stitches and thus no ugly scars are left after the wounds heal.

What are the characteristics of an endoscopic spine surgery?

  The surgery is performed under local anaesthesia
  The person is discharged within 24 hours of the surgery
  The incisions that are made are microscopic

What are the different types of endoscopic surgery?

Endoscopic discectomy:
It is the least invasive of all spinal surgeries. It is used for treating herniated discs. Endoscopy reveals images of the spine. Through the same tunnel, surgery tools are inserted and the bulging or herniated disc is pulled out with a grasper. The wound does not always require stitches to close it.

Endoscopic Laminotomy:
This a substitute for open laminotomy. The camera helps locate exactly where the target area is. Then an incision is made below and above the lamina to relieve the pressure compressing the nerve.

Endoscopic facet rhizotomy:
With microscopic cameras, the nerves causing pain are identified and then the laser is used to numb these nerves which relieve pain. This type of surgery can also remedy a previously botched spinal surgery, facet joint arthritis or facet joint pain

Endoscopic foraminotomy:
This type of surgery again uses microscopic surgical tools guided by a tiny camera to enlarge a narrowed neuro of spinal nerve root canal to give it more room to move about without being compressed.

Endoscopic Spine Surgery & Pinhole Technique!

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!

A fall or an injury is among the most common causes of a fracture. For a fracture to heal; the bones must be set in the correct position and a cast may need to be worn so as to hold them in place. This allows the bones to grow new tissue and bridge the break. The food you eat can help you speed up this process. Some of the best foods to build strong bones and help a fracture heal are:

Milk: Milk is one of the richest sources of calcium and vitamin D. It is also rich in proteins. These three elements are crucial to building strong bones. Proteins help the body release amino acids which in turn come together and create new tissue for the bones. Calcium is, of course, the building block of our bones. However, it is vitamin D that enables the body to absorb this calcium and utilize it. If you do not like the taste of milk, you could substitute it with yogurt. This dairy product is considered equally rich in proteins, calcium and vitamin D. In addition, it also contains amino acids such as glutamine and lysine that helps the bones absorb calcium.
Kale: Kale is known as a superfood. One of the reasons for this is the amount of calcium it contains. Kale is one of the few vegetables that are rich in this mineral. Thus, lactose intolerant people can get their required calcium from this vegetable. Kale can be eaten raw or cooked. Kale can also be juiced. However, to benefit fully from the vitamins and minerals in this vegetable, it is best to eat it raw.
Spinach: Spinach is another green leafy vegetable that is rich in calcium. It also contains zinc. Zinc helps stimulate the chemical reactions needed to bind calcium and other minerals together to create new bones. In addition, spinach is also a rich source of vitamin K. While this vitamin does not play a direct role in healing bones, it helps speed up the healing process.
Broccoli: Broccoli is a cruciferous vegetable that is rich in vitamin K1. This is very beneficial to your overall health and bone health. Vitamin K1 aids in the mineralization process of fusing broken bones together and building new bone tissue. Thus, it helps the bones set correctly.
Citrus Fruits: Fruits such as oranges are chock-full of vitamin C. This nutrient helps build a strong immune system and aids in the fracture healing process. Vitamin C also helps the body create collagen that surrounds the broken bones and allows it to heal faster.

Food Items That Help You Recover From Fractures!

If your kid is affected by Duchenne muscular dystrophy (DMD), it is important for you to know about the best ways of dealing with the condition. Muscular dystrophy consists of group of diseases, which result in the weakening of muscles along with reduced flexibility. DMD accounts for being the most common type of muscular dystrophy. It occurs because of flaws in the gene, which controls how your body keeps the muscles healthy. This disease affects boys and the symptoms start appearing from early childhood.

Treatment
There is no specific treatment for DMD. However, there are several ways, including medicines and therapy, to deal with the symptoms and to protect the muscles.

Several steroids such as prednisone help in slowing down muscle damage. Children taking this medicine are able to walk for two to five years longer than they would usually do. Lung and heart functions are also improved.
DMD leads to heart problems and hence, you should take your child to a heart doctor for regular checkups until the age of 10.
In some cases, a surgery may be required to fix their shortened muscles, for straightening the spine, or for treating a heart or lung problem.
Taking care of your child
If your child has DMD, it does not mean that he will have to refrain from activities such as school, sports and spending time with friends. By sticking to the right treatment plan, you will be able to make your child active.

Stand and walk: Being in an upright position will keep your child s bones strong and the spine straight. You can get your child braces or standing walkers, which will help him in terms of balance and mobility.
Eat right: Although there is no special diet for DMD, several food items should be taken for preventing problems related to weight. Your child should eat the proper amount of food with a proper balance of nutrients and calories regularly.
Stay active: You should ensure that your child exercises regularly. Regular stretching exercises help in keeping the muscles and joints limber, which makes him feel better. You can avail the help of a physical therapist for an exercise schedule.
You can look for and join local support groups associated with DMD, as other families living with DMD can be a source of good advice and understanding about life with DMD.

Muscular Dystrophy -  How To Deal With It?

Your shoulders are one of the most important parts of your body, but sadly it is also one of the most neglected parts. People use their shoulders for day to day activities. Without shoulders it would be very difficult to even do a simple activity like lifting a fallen paper from the ground. Like your other body-parts, shoulders also need proper attention and care.

Why is shoulder mobility so important?
Whether it is about moving a growing child, lifting a barbeque table or about moving heavy luggage, actions require shoulder mobility. If you find it difficult to do these activities it is highly probable that you have shoulder impingement syndrome. This syndrome occurs when the rotator cuff muscles become inflamed and irritated and result in severe pain and difficulty while moving one s shoulder. Weak shoulders also make your posture look bad, it can cause grave strains in your neck and back and make you look hunched which is not at all attractive for your appearance.

Different kinds of shoulder injuries and causes of shoulder immobility:

Rotator cuff injury

Frozen shoulder

Onset of arthritis

Shoulder instability

Injury to the tendons and ligaments

Shoulder dislocation

Torn rotator cuff

Impingement   It refers to the excessive friction of the shoulder muscles against the top part of the shoulder blade.

How can you improve shoulder mobility?

You can improve your shoulder mobility with the help of some exercises. For example, stand straight with your hip and feet apart. Move your hands behind your back and try to interlock your fingers, if you face difficulty in doing so, use a towel instead. Hold this position for a minute or so.
Sit and keep your feet and knees straight pointing towards the direction of your eyes. Touch your shoulder blade by bringing your hands backward, touch your elbow with your other hand and bring it upwards. Sit straight, hold your head up and breathe slowly. Hold this position for a minute and then repeat again.
You can also improve your shoulder mobility with the help of yoga. Yoga is all about relieving your tension and stress, hence it is very beneficial to loosen up tight shoulders and it makes you much healthier by improving shoulder mobility. Stand straight with your feet at least four feet apart and then bend your left foot slightly towards to the right. Make your right foot bend 90 degrees. Raise your right arm towards the left and bend your body. Inhale and exhale. Switch sides after taking five breaths.
Physiotherapy For Shoulder Mobility-

Physical Therapy is not just scientific; it is also very thorough and very methodical in its way of healing and remedying clients with many aches and pains. A therapist is well trained and very careful in massaging and handling delicate parts of the body such as the vertebrae, extremities and in cases of temporomandibular joint neuromusculoskeletal dysfunction. Physical Therapy is a distinct specialization in the practice of physiotherapy.

Before patients are treated with the therapy, it is very important that they undergo a preliminary assessment of what ails them. Their dysfunctions are determined and their biochemical systems are assessed as well. The body's posture as well as the placement is analyzed and almost all areas of the entire body in terms of the position and functioning of the musculoskeletal system is considered just to make sure that the root cause of the problem is discovered and treated. 

The aim of the therapy is to alleviate pain, strengthen the body, and improve movement and usability of the limbs as well as the other areas of the body through the use of the hands. The therapy also utilizes various work-out regimens as well as a home carry over system to make sure that the intervention plan will work as expected. More than just treatment, physical therapy is a means of assisting a patient to recover body movement, strength and function, therefore the need to have a strong determination to improve from the patient is definitely required. Here are some physical exercises to improve shoulder mobility-

First step is to provide adequate rest to the shoulder. Avoid using the affected arm too much. Keep it in a comfortable position. Do not strain the arm.

Cold compressions can help to ease pain and swelling. Alternate applications of hot and cold compressions help to reduce inflammation and provide quicker relief.

Keeping the arm elevated in a swing is recommended. It helps to drain the fluid or oedema and reduce pain.

Other exercises recommended are basic shoulder strengthening exercises. Example of one such exercise is gently pulling an elastic tubing attached to a door knob, towards your body. These can be performed twice daily, starting five times with each arm.

Wall push exercises are those that strengthen shoulders, forearms, biceps and triceps. You must stand at least a feet away from the wall and push against the wall, for a count of 5 to 10.

Shoulder press ups are exercises that can be comfortably done while sitting on a chair. Keep your arms on the armrest of the chair. Instead of putting the weight on your feet, rise up slowly by putting the weight on your hands. Repeat this 5 times twice or thrice daily.

There are isometric shoulder mobility exercises that involve muscle contraction and movement of limbs. It involves strengthening the muscles through extension, contraction, rotation and flexion of shoulder joint.

There are lateral rotation abduction exercises, lateral shoulder raises, lateral shoulder pull down.

There s a range of scapula squeeze exercises that involve strengthening and stabilising the shoulder blades.

Medicine balls and lightweight dumbbells can be used as props to exercise the shoulders.

A bad shoulder not only results in a bad posture but also prevents you from doing day to day activities. Hence it is necessary to take care of your shoulders and exercise daily to improve the mobility.

Shoulder Mobility - How You Can Improve it?

Cervical spondylosis is a disorder that affects the joints and disc around the cervical region or neck. Earlier, it was believed that spondylosis can occur in old people only and is an age-related disorder. However, it is not true nowadays. Today, even youngsters complain of pain in the neck region due to cervical spondylosis. It occurs mostly to people who spend longer hours sitting and working on the computer. It is caused due to damage of cartilage and bones in this region. Symptoms of cervical spondylosis include chronic pain and stiffness around the neck.

Causes for cervical spondylosis-

A number of factors can be responsible for cervical spondylosis. Following are the common causes for the disorder:

1. Overgrowth of bones in the neck region: this can hamper the sensitive areas around the spine.

2. Drying of fluid: the spinal bone is made up of disc-like structures. There is fluid present in between the disks. Spondylosis is often caused due to the drying up of this fluid.

3. Herinated disks: in some cases, cracks get developed on the disks. This causes leakage of fluid in between them. Consequently, the nerves in this region get damaged.

4. Injury: if you have had an injury to your neck, such as during a fall or car accident, this can accelerate the aging process.

Homeopathic medicines to cure cervical spondylosis-

There are homeopathic medicines, which can cure cervical spondylosis over a period of time. However, the dosage of these medicines must be administered properly to get rid of the disorder. Some of these useful medicines have been listed below:

1. Conium: this medicine is prescribed for patients suffering from vertigo. If a patient feels pain or vertigo while turning the head sideways or lying down on bed, this medicine can prove helpful. Other symptoms that should be taken into account while prescribing this drug include feeling of tightness in the temporal region and pain in occipital area.

2. Gelsemium: if the pain in the neck region extends to the back of the head, one may be given doses of gelsemium. The patient complains of having the pain at the centre of the occipital region. Besides, the patient will feel inactive, dull and dizzy most of the times.

3. Kalmia latifolia: this is given when the pain spreads upto the arm region and fingers. The pain can also be felt around the shoulder blades. The patient suffers from frequent nausea. The pain increases when the patient tries to look down.

4. Silicea: when the pain is felt on eyes or forehead, this medicine is prescribed. It is also useful in treating spine curvature. These patients cannot adjust with cold weather. They feel chilly most of the times. The get quick relief by warm fomentation.

5. Calcarea phos: this is useful for treating patients who have developed spondylosis due to the overgrowth of bones in the cervical region or bone spurs.

Homoeopathic Remedies for Cervical Spondylosis

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