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!

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!

Myths about Total Knee Replacement

Myth#1 - Knee replacement is a surgery for old people. “I’m too young for a knee replacement.”
Fact - Candidacy for a knee replacement is not based on age, but on the person’s level of pain and immobility. Living with a painful joint that prohibits you from working or participating in normal life activities is an outdated way of thinking. Age is not necessarily a limiting factor. Often times, a patient is actually fearful about the uncertainty of surgery. Once they are able to resume many of the activities they enjoyed before the surgery, with increased mobility and with less pain, they are very happy they had the surgery. The quality of life one achieves by living without knee pain is priceless.

Myth#2 - “I should wait as long as possible to undergo knee replacement surgery” 
Fact - You don't need to suffer by waiting until the pain is intolerable. The longer life of joint replacements enables people to consider surgery earlier and at a younger age. Osteoarthritis is a degenerative disease that continues to damage the joint and delaying surgery makes both surgery and return to activity more difficult. Delaying surgery lowers a patients’ quality of life not only before the operation, but even for up to two years following surgery.

Myth#3 - “I should continue with medications as long as possible”
Fact - Medicines including painkillers just give symptomatic relief for a temporary duration and prolonged usage is riddled with serious side effects such as renal failure, peptic ulceration  etc. All these medicines are NOT curable.

Myth#4 - Alternative therapies such as acupressure, ozone treatment, massage beds, oils, laser therapy, magnetic therapy; braces will cure my advanced arthritis and knee pain.
Fact - Till date there is NO cure for advanced knee arthritis and these alternate therapies are not backed by established scientific data. All these modalities give temporary pain relief in early to moderate arthritis for some duration only and are NOT curative. Often times, a patient who is actually fearful about the uncertainty of surgery lands up trying these in order to avoid surgery. 

Myth#5 - After a knee replacement, it takes months to recover.
Fact - Depending on the activity, most patients who undergo knee replacement are able to perform routine tasks within a few weeks. A return to rigorous activity takes only a few months. One becomes independent for himself before discharge from hospital. There’s no prolonged best rest required after the surgery.


Myth#6 - After knee replacement, I’ll have to give up some activities and sports.
Fact - You have a high probability of getting back to activities like brisk walking or cycling in 6 to 12 weeks. It will take a bit longer to return to more rigorous activities and contact sports. Squatting and sitting cross legged though possible but at best should be kept to minimal.

Myth#7 - Knee replacement surgery leaves a large scar that is noticeable.
Fact - Scarring is minimal compared to traditional surgery. In fact, the scar is typically only 3 to 5 inches long. As time passes, the scar will fade and become less noticeable.

Myth#8 - Knee replacement is a very painful surgery. There is lots of pain in post operative period.
Fact - With modern day pain management such as in a multimodal approach, ensures that the patient does not feel any pain in post op period and has a smooth recovery.

Myth#9 - Knee replacement is done one at a time.
Fact - Both the knees can be operated at the same time if the patient does not have significant co morbidities and is deemed fit to undergo the procedure by the doctor.

Myth#10 - The new knee lasts for 5-6 yrs. only.
Fact - With modern day precision including computer assisted knee replacement and advancement in biomaterials, the survivorship has increased considerably. Today's joint replacements last 25 years or longer and, for most people, will last a lifetime.

Myth#11 - Knee replacement cannot be done a second time.
Fact - Knee replacement can be done multiple times what is called as a revision joint replacement surgery with good survivorship.

Myth#12 - “I am obese, I cannot undergo Knee replacement surgery.”
Fact - Knee replacement can be successfully done in an obese patient though the recovery is somewhat prolonged and might require additional implants. However, patients who are morbidly obese and have restricted mobility primarily due to obesity are better off after a bariatric procedure.

Myth#13 “I have diabetes or hypertension or heart ailment, so  I cannot undergo Knee replacement surgery.”
Fact  - diabetes hypertension or heart.



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 13 Myths About Total Knee Replacement (TKR), Busted!

Spinal surgery becomes inevitable when back pain cannot be managed with medications and/or exercise. This is a major decision and requires planning for many things before, during, and after the surgery.

Before a spinal surgery- This preparation will help in smooth recovery, especially if you do not have a full-time caretaker.

Discontinue pain killers: Discontinue pain killers at least 10 to 14 days before surgery. These are blood thinners and can prolong bleeding during the surgery.

Prepare for blood loss: Most people experience some blood loss, but not excessive.

Use a toilet seat raiser: Sitting and getting up from the toilet seat may be difficult. The seat raiser is used to increase the height, making this movement easy.

Enable easy access to common items: Before heading for the surgery, keep things which are commonly used within easy reach. This will help reduce movement and avoid searching (especially if someone else is going to be doing it).

Stock it up: Cooking may not be feasible during the initial postop period, and so it is advisable to stock up food items (ready to eats, fruits, soups, etc.) which will come in handy.

Slip-ons: Bending down and tying shoes may not be easy, so slip-ons can be used.

Caregiving: It is always advisable to have someone stay over with you during the initial postop days. They could help with regular household chores, cooking, etc.

Lifestyle changes: Ensure you eat well in the days before surgery, quit smoking, quit/use moderate amounts of alcohol, and exercise as advised by your surgeon.

After Surgery- Post surgery, there will be some pain and limitation of movement. It is important to understand that adherence to post-op instructions will improve the success rate of the surgery. Also, recovery time for spine surgery is slightly longer and affects overall quality of life, so psychological preparation is required.

Postoperative medications: These will be given to control infection and pain in the immediate postop period, and should be taken without fail

Rehab: The surgeon will recommend physical therapy and rehab exercises which need to be followed. Complete recovery may take anywhere between 3 to 12 months. During this time, care should be taken to avoid repeat injury.

Support: Adequate back support should be provided using lumbar support and ergonomic chairs, and the right posture should be maintained. Ensure there is no undue strain on the back muscles.

Weight management: With excess weight, there is too much strain on the lower disks. Therefore, weight should be managed to reduce this strain.

Smoking and alcohol should be completely stopped, as healing can be hampered.

With some preparation, spinal surgery can be sailed through smoothly.

What To Expect Before and After Spine Surgery?

Arthritis is inflammation of one or more of your joints. Pain, swelling, and stiffness are the primary symptoms of arthritis. Any joint in the body may be affected by the disease, but it is particularly common in the knee.

Knee arthritis can make it hard to do many everyday activities, such as walking or climbing stairs. It is a major cause of lost work time and a serious disability for many people. There are 2 types of arthritis the knee joint in the human body can get afflicted with. They are:

Osteoarthritis 

The form of arthritis which, with increasing pain, slowly wears down the joint cartilages is called osteoarthritis. This form of arthritis usually affects people after the age 40. The symptoms of osteoarthritis include:

Severe pain in the knee joints
Pain after walking up the stairs and it subsiding once you are on rest
Severe pain after the movement of joints for a long time
Pain that becomes worse in rainy days
Joints becoming stiff after waking up in the morning but they improve in the latter part of the day
Pain which also occurs in the thighs and the genital regions coupled with joints swelling and joints getting stiff after rest.
Rheumatoid arthritis

Rheumatoid arthritis is a chronic form of arthritis caused because of the knee joint inflammations. This form of arthritis can occur at any age. Being an auto-immune disease, its symptoms include, but are not limited to:

Severe pain in the morning
Mild fever accompanying the pain
Joints suddenly becoming swollen, red and warm causing, immense pain
Sudden stiffness of the joints
Pain that increases in cold weather
Mild fever, extreme tiredness and weakening of the muscles
Doctors are still doubtful about what exactly causes the disease; but the deformation of the immune system might cause the damage of the joints, causing people who are already suffering from obesity, smokers, and women, in general, more prone to this disease.

When the knee pain is diagnosed as a form of arthritis, the following treatments are suggested:

If you are overweight or obese, losing some of those extra pounds can go a long way in reducing the pain.
Muscle-stretching exercises are effective in keeping the knee joints flexible.
Dry needling, cupping, taping can help to control the pain and keep the joint supported.
Prescribed dosage of anti-inflammatory drugs such as Tylenol, Motrin, and Advil or injections of hyaluronic acid might relieve your pain.
If regular treatments do not work, you might opt for knee-replacement surgery and osteotomy (the process of cutting a bone with the help of surgery) which might better the alignment of the knee by transforming the bone shapes.

Physiotherapy for knee arthritis

Physiotherapy treatment is aimed at improving the symptoms of the disease (i.e. knee pain, swelling, stiffness), and you should begin to notice a positive difference within one or a few physiotherapy sessions. The main goals of physiotherapy for your knee arthritis are:

Reduce your knee pain and inflammation.
Normalise your knee joint range of motion.
Strengthen your knee: esp quadriceps (esp VMO) and hamstrings.
Strengthen your lower limb: calves, hip and pelvis muscles.
Improve your patellofemoral (knee cap) alignment and function.
Normalise your muscle lengths.
Improve your proprioception, agility and balance.
Improve your technique and function eg walking, squatting.

How Physiotherapy Helps To Manage Arthritis?

The joints and bones of the body are connected by fibrous band of tissue called as a ligament. When these ligaments are over stretched or are subjected to any injury that could cause tearing of the ligament and a sprain of the ligament happens. Sprains usually occur at the ankle joint, knee joint or the shoulder, since these areas have a connection of bones at a joint. 

During movement, the ligament functions to stretch or expand and move back to its original position. However, sometimes due to an over-stretch of the ligament, it gets pushed or expands beyond its usual position. A sudden twisting movement of the ligament can also cause a sprain. 

While walking, any abnormal movement of the leg can cause a sprain, hence, the ankle joint is the most common location affected by a sprain. Sports injuries are a common causative factor of sprains. In accordance to the body part involved frequently in playing sports, a wrist sprain or an ankle sprain is a common finding. 

Dancers are also prone to frequently sprain their ligaments. If a sprain occurs at the wrist joint, it can also lead to cause the Carpal tunnel syndrome, which leads to the numbness of the wrist joint. Moderate to severe pain around the affected joint, presence of bruising in cases of an injury, swelling around the affected joint and difficulty in movement are the common symptoms of a sprain.



There can be a popping sound heard during an injury to the joint, which indicates a sprain. Sprain of the joint can cause other complications too. If there is an involvement of the nerve in the injury, there can be an associated numbness and tingling sensation at the affected area. A physician performs physical inspection of the area while looking for the symptoms of sprain. If the injury involves a larger surface area and is causing severe pain, an MRI or X-ray can be ordered to detect for the ligament or bone involvement, respectively. 

Classification of sprain can be enlisted as follows: 

Grade 1 sprain (mild): Slight stretching and little damage to the fibers of the ligament. 
Grade 2 sprain (moderate): Includes partial tearing of the ligament.  
Grade 3 sprain (severe): Includes complete tearing of the ligament.  Prevention of a sprain can be achieved with certain measures. Specific exercises that can be targeted for sprain prevention can be learnt from the physical therapist.
Stretching exercises and muscle training are important in prevention of a sprain. Sprain preventing measures are as follows: 

1. Before beginning an exercise routine, it is essential to do warm up exercises. Slight jogging can be done to activate muscle movement. 

2. Stretching before and after an exercise routine is necessary. It ensures that the muscles around the joint are in a relaxed position. It helps in minimizing the risk of an injury. 

3. Some specific exercises that help to strengthen the muscles around ankles should be done. Heel raise exercise is beneficial in strengthening the ankle muscles. 

4. Exercises that target the improvement of overall body s balance should be done on a regular basis. These exercises help in preventing twisting of ankles during walking or moving down the stairs. 

5. In case of a previous ankle injury, it is recommended to wear an ankle brace to prevent any twisting caused by a dis-balance. 

Treatment of the sprain is done by following the RICE procedure. This procedure includes the protocol of rest, ice, compression and elevation. Analgesics can be taken for pain relief. Ice pack application helps in reducing the swelling. Using a compression bandage helps in immobilizing the injury.

Sprain - Effective Tips To Prevent It!

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