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Anupama Hospital

Multi-speciality Hospital (Pediatrician, Dermatologist & more)

16-31/494 & 495, Phase 6, KPHB Colony, JNTUC Road, Kukatpally, Landmark : Near To JNT University & Adjacent To Malaysia Township, Hyderabad Hyderabad
10 Doctors · ₹200 - 350
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Anupama Hospital Multi-speciality Hospital (Pediatrician, Dermatologist & more) 16-31/494 & 495, Phase 6, KPHB Colony, JNTUC Road, Kukatpally, Landmark : Near To JNT University & Adjacent To Malaysia Township, Hyderabad Hyderabad
10 Doctors · ₹200 - 350
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About

Our goal is to offer our patients, and all our community the most affordable, trustworthy and professional service to ensure your best health....more
Our goal is to offer our patients, and all our community the most affordable, trustworthy and professional service to ensure your best health.
More about Anupama Hospital
Anupama Hospital is known for housing experienced Orthopedists. Dr. Radha Krishna, a well-reputed Orthopedist, practices in Hyderabad. Visit this medical health centre for Orthopedists recommended by 94 patients.

Timings

MON-SUN
09:00 AM - 09:00 PM

Location

16-31/494 & 495, Phase 6, KPHB Colony, JNTUC Road, Kukatpally, Landmark : Near To JNT University & Adjacent To Malaysia Township, Hyderabad
KPHB Hyderabad, Telangana
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Doctors

300 at clinic
Available today
09:00 AM - 09:00 PM

Dr. K K Reddy

MBBS, Diploma in Tuberculosis and Chest Diseases (DTCD)
Pulmonologist
22 Years experience
200 at clinic
Unavailable today

Dr. Chary

Dermatologist
200 at clinic
Available today
09:00 AM - 09:00 PM

Dr. Rajasekhar Reddy K

MBBS, MS - General Surgery, MCh - Neuro Surgery
Neurosurgeon
18 Years experience
350 at clinic
Unavailable today

Dr. Rambhupal Rao

Cosmetic/Plastic Surgeon
300 at clinic
Available today
08:00 PM - 08:30 PM

Dr. Purohith

Cardiologist
200 at clinic
Available today
09:00 AM - 09:00 PM
200 at clinic
Unavailable today

Dr. Nagarjuna

Gastroenterologist
250 at clinic
Available today
09:00 AM - 09:00 PM

Dr. Nagendra Prasad

MBBS, MS - General Surgery, FICS, FIAGES
Pediatrician
19 Years experience
200 at clinic
Available today
09:00 AM - 09:00 PM
300 at clinic
Available today
09:00 AM - 09:00 PM
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Exercises for Sciatic Pain From Piriformis Syndrome

MSPT (Master of Physical Therapy), BPTh/BPT
Physiotherapist, Bangalore
Exercises for Sciatic Pain From Piriformis Syndrome

Exercises for Sciatic pain from Piriformis Syndrome
Sciatica is a symptom. It consists of leg pain, which might feel like a bad leg cramp, or it can be excruciating, shooting pain that makes standing or sitting nearly impossible.

The pain might be worse when you sit, sneeze, or cough. Sciatica can occur suddenly or it can develop gradually.

Symptoms:

  • Pain in the rear or leg that is worse when sitting
  • Burning or tingling down the leg
  • Weakness, numbness, or difficulty moving the leg or foot
  • A constant pain on one side of the rear
  • A shooting pain that makes it difficult to stand up

Sciatica usually affects only one side of the lower body. Often, the pain extends from the lower back all the way through the back of the thigh and down through the leg. Depending on where the sciatic nerve is affected, the pain may also extend to the foot or toes.

For some people, the pain from sciatica can be severe and debilitating might include the inability to bend your knee or move your foot and toes.. For others, the sciatica pain might be infrequent and irritating, but has the potential to get worse.

Causes of Sciatic Pain:

  • Slipped Disc: In majority of cases sciatica is caused by a herniated or "slipped" disc. This is when one of the discs that sit between the bones of the spine (the vertebrae) is damaged and presses on the nerves.
  • Spondylolisthesis (a condition in which one vertebra slips forward over another one)
  • Other causes include spinal stenosis (narrowing of the nerve passages in the spine), a spinal injury or infection, or a growth within the spine (such as a tumor).
  • Other things that may make your back pain worse include being overweight, not exercising regularly, wearing high heels, or sleeping on a mattress that is too soft.
  • Piriformis Syndrome: It is referred as neuritis of branches of the sciatic nerve caused by pressure of an injured or irritated piriformis muscle. Symptoms associated with piriformis syndrome typically consist of buttock pain that radiates into the hip, posterior aspect of the thigh, and the proximal portion of the lower leg.
  • Piriformis syndrome typically does not result in neurological deficits such as decreased deep tendon reflexes and myotomal weakness.


Diagnosis:
Sciatica is diagnosed with a medical history and physical exam. Sometimes X-rays and other tests such as magnetic resonance imaging (MRI) are done to help find the cause of the sciatica.

  • X-ray- to look for fractures in the spine
  • Magnetic resonance imaging (MRI) or computed tomography (CT) scan - to create images of the structures of the back
  • Nerve conduction velocity studies/electromyography - to examine how well electrical impulses travel through the sciatic nerve
  • Myelogram using dye injected between the vertebrae - to determine if a vertebra or disc is causing the pain

Treatment:
Primary treatment consists of self-care and non-surgical strategies. The aim is to correct the underlying problem, restore function and prevent re-occurrence.

  • Self-Care: Sciatica may resolve with rest, ice or heat, massage, pain relievers and gentle stretches. Muscle inflammation and pain can be reduced by application of an icepack for 20 minutes several times a day during the initial 2-3 days. Thereafter a hot pad may be applied to relax muscles. If the self-care exercises aren’t working within the first couple of days you must consult your doctor.
  • Medication: Over the counter Nonsteroidal anti-inflammatory drugs (NSAIDs) can bring pain relief. Muscle relaxants may be prescribed for spasms.
  • Physiotherapy: A normal schedule is recommended physical therapy can help you return to full activity as soon as possible and prevent re-injury. Physiotherapists will show you proper lifting techniques / postures, walking techniques, exercises to stretch and strengthen your back muscles.
  • Massage, ultrasound, diathermy, heat and traction may also be recommended for some time.

Facts on Psoriasis

MBBS, DDV
Dermatologist, Mumbai
Facts on Psoriasis

What Is Psoriasis?

Psoriasis is a skin disease that causes scaling and inflammation (pain, swelling, heat, and redness). Skin cells grow deep in the skin and slowly rise to the surface. This process is called cell turnover, and it takes about a month. With psoriasis, it can happen in just a few days because the cells rise too fast and pile up on the surface.

Most psoriasis causes patches of thick, red skin with silvery scales. These patches can itch or feel sore. They are often found on the elbows, knees, other parts of the legs, scalp, lower back, face, palms, and soles of the feet. But they can show up other places such as fingernails, toenails, genitals, and inside the mouth.

  • Who gets Psoriasis?
  • What  causes Psoriasis?
  • How is Psoriasis diagnosed?
  • How is Psoriasis treated?

Who Gets Psoriasis?

Anyone can get psoriasis, but it occurs more often in adults. In many cases, there is a family history of psoriasis. Certain genes have been linked to the disease. Men and women get psoriasis at about the same rate.

What Causes Psoriasis?

Psoriasis begins in the immune system, mainly with a type of white blood cell called a T cell. T cells help protect the body against infection and disease. With psoriasis, T cells are put into action by mistake. They become so active that they set off other immune responses. This leads to swelling and fast turnover of skin cells. People with psoriasis may notice that sometimes the skin gets better and sometimes it gets worse. Things that can cause the skin to get worse include:

  • Infections
  • Stress
  • Changes in weather that dry the skin
  • Certain medicines.

How Is Psoriasis Diagnosed?

Psoriasis can be hard to diagnose because it can look like other skin diseases. The doctor might need to look at a small skin sample under a microscope.For appointments call 9004839333.Clinics at Malad,Juhu and Bandra in Mumbai.

How Is Psoriasis Treated?

Treatment depends on:

  • How serious the disease is
  • The size of the psoriasis patches
  • The type of psoriasis
  • How the patient reacts to certain treatments

Ayurvedic Approach To Vitiligo

MD - Medicine
Ayurveda, Saharanpur

Do not over expose your skin to sun white patches should turn slightly pink and not very red.

White Patches Treatment In Ayurveda

BAMS, CERTIFICATE COURSE IN KSHAR-SUTRA SURGERY
Ayurveda, Jodhpur
White Patches Treatment In Ayurveda

Friends "white spots" in a disease in which the patient remains physically upset win over as it ceases to bother many times mentally makes many feel he hated myself among the people but they know very glad all will our ancient ayurveda possible medical treatment hundred percent of this disease in science to see our ancient ayurvedic stages of the disease by the classical yogaj be disease reliable treatment possible patient if your neighborhood.
If you are worried about treatment from all sides, then definitely tell us about it. We will do our best to free them from this frustrating disease.
Ayurveda is the only way Far too many patients have been rid of the disease.

Skin Health

General Physician, Tirunelveli
Skin Health

Keep in mind - vitamins, minerals, and herbal supplements can be helpful in getting severe inflammatory acne under control.

Back Pain

Bachelor of Ayurveda, Medicine and Surgery (BAMS), MD- Ayurveda
Ayurveda,
Back Pain

It's observed that we notice back ache at least once in our life time
One in 3 all over world experience this problem
3 major cause we come across in the back ache are:

  • Spondylitis inflammation at spinal canal
  • Spondylolisthesis - slip disc
  • Spondylosis - degenerative change

Ayurveda line of treatment works wonder in all major causes of back ache
It is also packed with patya- diatory intake
Local treatment of panchakarma and also other effective shamanoushadis where you can feel best pain manegment in day to day life style.

Improve Your Posture

Master of Physical Therapy MPT CARDIO, BPTh/BPT
Physiotherapist, Rajkot
Improve Your Posture

A poor posture like sitting or driving in a hunched position for too long can cause strain the neck muscles.

Mam, lumacip plus cream how long time to be used? Then its safe to the oily skin mam?

Diploma in Aesthetic Medicine, MBBS
Cosmetic Physician, Delhi
Mam, lumacip plus cream how long time to be used? Then its safe to the oily skin mam?
Hi lybrate-user, LUMACIP PLUS CREAM contains: Fluocinolone Topical (0.01% w/w, Hydroquinone Topical (4% w/w, Tretinoin Topical (0.05% w/w). Fluocinolone is a topical steroid. It is not recommended to use this on skin for long period of time without medical advice and indication. Your skin may feel better initially with its use but, it can lead to undesirable effects like flaring up of acne/other infection, unusual pigmentation and dependence. It is also not recommended to use Hydroquinone preparations for long periods of time as it can lead to side effects like hyperpigmentation /hypopigmentation too. For improving tone and texture of face, removal of dark spots and for glowing facial skin, I recommend skin lightening creams, Skin lightening capsules/tablets, Chemical peels and Microdermabrasion therapy. You will need a skin lightening cream and good sunscreen initially. I can prescribe you that. For further improvement, advanced treatments can be initiated. I would be happy to help you. Please consult me privately so that I can understand your problem in detail and help you.
1 person found this helpful
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Sir please tell me that ,what is the reason behind for checking bp and sugar before surgery.

BHMS
Homeopath,
Sir please tell me that ,what is the reason behind for checking bp and sugar before surgery.
The basic reason is Raised BP will leads to increased blood loos during surgery, and raised sugar level leads to delayed wound healing after surgery and more chance for infection.
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Respected sir/mam now my baby is 6 weeks old. Please tell me which vaccines are mandatory. And which are optional.

M.D.( Pediatrics), DCH
Pediatrician,
Respected sir/mam now my baby is 6 weeks old. Please tell me which vaccines are mandatory. And which are optional.
DPT /Hib /HepB /IPV..(some include rotateq first dose) Routinely given, you can give PCV in addition to the former. All these are to be given every month for three months. Optional is a misguided word. What it really means is, give it, if you can afford. All recommended vaccines are beneficial and are desirable but for affordability. (I use Rotarix at 10 & 14 wks instead of rotateq 6-10-14 wks. Both schedules are equally good)
2 people found this helpful
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Skin Health

PG Diploma in Emergency Medicine Services (PGDEMS), Bachelor of Ayurveda, Medicine and Surgery (BAMS), MD - Alternate Medicine
Ayurveda, Ghaziabad
Skin Health

Eat 1 or 2 medium sized balls made of neem leaves everyday, it helps in curing skin itching and pimple problems.

5 people found this helpful

My son is 5 years old now a days he is becoming more thin and ziddi he will not listen to my words also even if I beat also he will not listen I consulted a doctor but still same what to do please suggest.

B.Sc.(Hons), P.G.Dietetics
Dietitian/Nutritionist, Gurgaon
Hello lybrate-user, give him his favourite foods - more of fluids & water as it is summers now so it is difficult to solid food much. Give him small & frequent meals, may be after every 2- 3 hours. Give him lassi, juices, ice-creams, watermelon, milkshakes like mango shake, chickoo shake, banana shake. There is no point in scolding or beating. Have patience with your child. If he is active and not dull, there is not much to worry.
1 person found this helpful
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I am suffering from Disc bulge Problem L3-4 ,L4-5.It's been 10 days .i m on medication and going 4 therapy. How much time it gonna take for full recovery.

MPT(Neurology), BPTh/BPT
Physiotherapist, Delhi
I am suffering from Disc bulge Problem L3-4 ,L4-5.It's been 10 days .i m on medication and going 4 therapy. How much ...
It might take anywhere from a month to 3 months depending upon the severity of your pain and the area of your pain. If your pain is radiating to leg it might take more time of its only in the back. Do exercises daily to see best results.
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Gall Bladder Stone

Fellowship in Minimal Access Surgery, FACRSI (Colo-Rectal Surgery), Ph. D - Gastrointestinal Surgery, FAIS, DNB (General Surgery), MNAMS (Membership of the National Academy) (General Surgery) , MBBS
Gastroenterologist, Bangalore
Gall Bladder Stone

Gall Bladder Stone

Courtesy -Dr.Kumar Parth (MBBS; MNAMS; FMAS; FAIS; FACRSI (Colo-Rectal Surgery) DNB; FSGE (Surgical Gastroenterology)

(Consultant Surgical Gastroenterologist), drkparth9@gmail.com, www.drparthgastro.com

Definition:   Presence of stones in the gallbladder is referred to as cholelithiasis.               

PredisposingFactors:

  • Genetics , Gender (more in women)
  • Body weight (Obesity), or rapid loss in weight , Fasting
  • Decreased motility (movement) of the gallbladder
  • Diet
  • Drugs : Cholesterol / Lipid lowering drugs , Estrogen
  • Diseases: Diabetes, blood disorder (Hemolytic anemia etc.)

Composition of Gall Bladder Stone:

Cholesterol Stone: Found in western world, causes accounted to diet rich in cholesterol.

Pigmented stone: generally found in diseases related to blood disorder

Mixed stone: Contains Calcium, magnesium, sodium phosphate ( most common type found in Asian population (India).

Symptoms :

  • (70–85%) are asymptomatic or "Silent Gall Stone"
  • Pain in right upper and central part of abdomen (may radiate to inter-scapular region) mostly after half an hour of food (seen more symptomatic after a fatty diet.)
  • post meal fullness, belching, upper abdominal discomfort
  • Jaundice (yellowing of the skin or eyes)
  • Clay colored stools or dark urine

Investigations required:

  • Blood - Liver Function test , Complete Blood Count,
  • Imaging -Ultrasound Of abdomen and if required MRI (MRCP) abdomen.
  • Complications of Gall Stone
  • Infection of gall bladder {Empyema(pus) / Mucocele of Gall bladder}
  • Perforation of gall bladder
  • Stone slipped in Common Bile Duct resulting in obstruction in the passage of bile leading to Jaundice
  • Stone from gall bladder slipped to common bile duct and entering into pancreatic duct through common channel of opening in Duodenum (small bowel) leading to Pancreatitis.

Indications for Surgery:

  • Symptomatic Gall stone with typical history of pain as mentioned above and proven with Imaging (ultrasound)
  • Asymptomatic or Silent gall stone (Found Incidentally during Ultrasound abdomen) - "DOES NOT REQUIRE SURGERY".

Asymptomatic or Silent gall stone requiring surgery in special circumstances are:

  • Pregnant lady diagnosed with gall stone during first trimester (incidental finding)
  • Any blood disorder and patient is going for any abdominal surgery for any reason.
  • Diabetes mellitus - as chances of infection are high on by ground of diabetes
  • Gall bladder polyp (a soft tissue growth in lumen of gall bladder) size > 1 cm or single stone measuring > 3 cms, as risk of Gall Bladder cancer increase by 10 fold in these cases.

Treatment: Surgery - Laparoscopic Cholecystectomy (Key Hole Surgery) is Gold standard worldwide.

  • Safe surgery, there are no side effects of removing of gall bladder as one has to weigh the complication arising from a "symptomatic" gall stone disease.
  • Can be done as a day care surgery
  • Post surgery patients are advised to refrain from fatty meal for a week so as to acclimatize the body to a diluted bile. Normal activity is allowed from day 1 of post surgery.

Parkinson s Disease

MBBS, DNB, Fellowship in Neurosurgery
Neurosurgeon, Kolkata
Parkinson s Disease

Deep brain stimulation in Parkinson’s disease

Abstract: Deep brain stimulation (DBS) is a widely accepted therapy for medically refractory Parkinson’s disease (PD). Both globus pallidus internus (GPi) and subthalamic nucleus (STN) stimulation are safe and effective in improving the symptoms of PD and reducing dyskinesias. STN DBS is the most commonly performed surgery for PD as compared to GPi DBS. Ventral intermediate nucleus (Vim) DBS is infrequently used as an alternative for tremor predominant PD patients.

Patient selection is critical in achieving good outcomes. Differential diagnosis should be emphasized as well as neurological and nonneurological comorbidities. Good response to a levodopa challenge is an important predictor of favorable long-term outcomes. The DBS surgery is typically performed in an awake patient and involves stereotactic frame application, CT/MRI imaging, anatomical targeting, physiological confirmation, and implantation of the DBS lead and pulse generator. Anatomical targeting consists of direct visualization of the target in MR images, formula-derived coordinates based on the anterior and posterior commissures, and reformatted anatomical stereotactic atlases. Physiological verification is achieved most commonly via microelectrode recording followed by implantation of the DBS lead and intraoperative test stimulation to assess benefits and side effects. The various aspects of DBS surgery will be discussed.

Key words: deep brain stimulation (DBS); Parkinson’s disease(PD),  stereotaxis

Introduction

Parkinson's disease is a slowly progressive, neurodegenerative disease characterized by tremor, rigidity, bradykinesia and postural instability. It is the most common movement disorder in middle or late life with a prevalence of about 0.3% of the general population, rising to 1% in people over 60 years of age. Approximately 130 000 people suffer from it in the UK and it presents an increasing burden in our ageing population. Pathological findings in Parkinson's disease demonstrate greatly diminished neuromelanin pigmented neurons in the substantia nigra of the basal ganglia with associated gliosis, and Lewy bodies present in many remaining neurons.

James Parkinson, in his original 1817 Essay on The Shaking Palsy, gave an account of six patients in which he noted signs of tremor, festinating gait and flexed posture.  Nearly two centuries from Parkinson's observations, and almost four decades after Cotzias' dramatic demonstration of levodopa's efficacy, the limitations and complications of levodopa treatment for Parkinson's disease have become well documented Five years after initiation of therapy, a majority of patients develop medication related motor complications, namely levodopa induced dyskinesias (LID) and motor fluctuations. Deep brain stimulation (DBS) has been developed primarily to address these treatment related motor complications and therapeutic failures.

Pathophysiology of PD

The loss of dopaminergic neurons in the substantia nigra, the main functional characteristic of PD, affects the circuit described above and leads to the cardinal motor symptoms of PD. While the exact mechanism of this process is unknown, animal research as well as human recordings have provided functional and biochemical evidence that bradykinesia in PD results from excessive activity in the STN and the GPi. This leads to an exaggerated beta (10-30 Hz) synchronization within and between structures in the basal ganglia circuitry  that could also contribute to rigidity and akinesia.

The pathophysiology of rest tremor in PD is less clear and probably more complicated. This symptom most likely results from a dysfunction of both the striato-pallidal-thalamocortical and the cerebellodentato-thalamocortical circuits, with hyperactivity and hypersynchronization between central oscillators.

Possible mechanism of action of DBS

DBS acts through delivering an electrical current in a specific target area of the brain. This current can be modulated through modification of voltage, frequency and duration of each electrical pulse delivered. The delivered energy creates an electrical field of variable size and shape according to the parameters used for stimulation. Although initially believed to stimulate the target, thus the name of the whole process, it seems that

DBS actually excites the neuronal fibers, but inhibits the neural cells. In fact, GPi DBS decreases the GPi mean firing rate back to a normal range in animal models as well as PD patients, and high frequency DBS has a similar effect as dopamine replacement therapies, and promotes faster (about 70 Hz) nonhypersynchronous activity in the basal ganglia, correlated with clinical improvement. This might be achieved through stimulation of bypassing inhibitory pathways, synaptic inhibition, depolarizing blockade, synaptic depression, and simulation-induced disruption of pathological network activity. Overall, this leads to modifications of the firing rate and pattern of neurons in the basal ganglia, as well as local release of neurotransmitters such as glutamate and adenosine. In addition, it seems that DBS also increases blood flow and stimulates neurogenesis. Over the last few years, functional imaging, specifically functional magnetic resonance imaging (fMRI), positron emission tomography (PET) and single-photon emission computed tomography (SPECT), has been used in an attempt to clarify the mechanism of action of DBS. In fMRI, blood-oxygen-level-dependent (BOLD) signals are acquired, and oxygenated blood marks areas of neural stimulation or inhibition. On the other hand, PET and SPECT allow for imaging of multiple activity markers, such as blood flow, glucose and oxygen metabolism. While fMRI is less powerful than nuclear medicine techniques, it provides a much better spatial and temporal resolution. Because of the suspected inhibitory DBS effects in electrophysiological studies, reduced STN blood flow or glucose metabolism would have been expected on functional imaging. However, the opposite has been found to be true in an overwhelming majority of imaging studies to date. In addition, BOLD activation in the area surrounding the electrode has been reported, despite the electrode imaging artifact preventing direct observation of the STN around the electrode. This discrepancy between apparent STN inhibition in single-cell studies and activation in imaging studies might be explained by a few hypotheses. First, electrophysiological recordings identify short neuronal modulation (in the order of milliseconds) while neuroimaging methods may reflect the summed activity changes over seconds to minutes. Second, non-neuronal contributions to the change in blood flow and/or glucose metabolism cannot be excluded, and could confound the results of neuroimaging.

Finally, it is possible that PET and fMRI actually detect the increased activity in the axons, rather than in the cell bodies. Complicating matters further, some imaging studies after STN DBS have showed increased

activity in the GPi while others reported decreased activity in that nucleus. In summary, it is still unclear how exactly DBS affects the firing rate and pattern of neurons and how these changes actually modify the symptoms of Parkinson’s disease. DBS is presently more of an empirically proven treatment in search of physiological explanation.

The effect of DBS on the cardinal symptoms of PD have been established in three randomized controlled clinical trials --- 

TABLE 1

Author, year

 

No of patients

Follow up

Target

Results

Deuschl et al., 2006

156

6 months

BL STN

QOL better with DBS, motor symptom better with DBS

 

Weaver et al., 2009

255

6 months

BL STN or GPi

Dyskinesia free ON time better with DBS

 

Williams et al., 2010

366

12 months

BL STN  or GPi

QOL better with DBS

 

 

PATIENT SELECTION for DBS in PD

Patient selection is a critical first step as poorly chosen candidates may not have optimal benefits and have increased morbidity. Several factors must be considered before determining if a patient is an appropriate candidate for DBS surgery. A multidisciplinary approach involving the neurosurgeon, neurologist, and neuropsychologist is important to determine the appropriate surgical candidate. It is also important that the diagnosis of idiopathic PD be confirmed prior to proceeding with DBS surgery. Key to this assessment is evaluating the surgical candidate in both the on and off medication states with a corroborating levodopa challenge. Perhaps the best prognostic indicator of a patient’s suitability for DBS surgery is their response to levodopa.In general, a levodopa challenge following a 12-hour medication withdrawal should provide at least a 33% improvement in the motor section of the Unified Parkinson’s Disease Rating Scale (UPDRS).

                     In our institute, we follow a simple chart(below) for screening of patients for DBS in PD.

 

 

  1.  

Age<75 years

 

  •  

No

  1.  

Idiopathic PD ( No PSP/MSA/NSD etc)

 

  •  

No

  1.  

Levodopa responsive  

                      

  •  

No

  1.  

Poor/adverse response to drug          

 

  1.  Increased off period                                                              

 

  1. Disabling dyskinesia                                                              

 

 

  1. Disabling motor fluctuations                 

 

 

Yes

 

Yes

 

 

Yes

 

 

No

 

No

 

 

No

  1.  

Degree of disability(UPDRS part III score)>25

 

  •  

No

  1.  

Neuropsychology, MMSE>24

 

  •  

No

  1.  

LEVODOPA CHALLENGE RESPONSE POSITIVE                                                   

 

(30% improvement in UPDRS after 12-hours off medication)

 

  •  

No

  1.  

Advanced  co-morbidity

 

Yes

  •  
  1.  

long term anticoagulation

 

Yes

  •  
  1.  

Willing for surgery and programming

 

  •  

No

 

 

PREOPERATIVE MANAGEMENT

A full medical assessment is a necessary part of the preoperative evaluation, as advanced PD patients tend to be elderly with significant comorbidities. Major issues are---

 

Anticoagulation/antiplatelets--- The risk of discontinuing medications that affect anticoagulation and

platelet aggregation should be weighed against the potential benefits in the quality of life offered by DBS surgery. However, timely discontinuation of these latter medications is mandatory for stereotactic surgery since intracerebral hematomas are the most serious of all potential complications from DBS. Any anticlotting medications, including aspirin, ticlopidine, clopidogrel, and all nonsteroidal anti-inflammatory drugs should be discontinued at least 7 to 10 days preoperatively to ensure the return of normal blood clotting function.

Arterial hypertension can also increase the risk of intracranial bleeding during stereotactic procedures and must be controlled in the weeks prior to surgery.

A prolonged discussion on the short- and long-term effects of DBS on Parkinson’s disease should be carried out with the patient, family, and caregivers.

The night prior to DBS surgery, the antiparkinsonian medications are typically held to pronounce the Parkinson’s symptoms at the time of surgery to see the clinical effects on symptoms during surgery and the families must be counselled regarding their role in facilitating the patient.

Target selection

The two main targets considered for DBS in PD are the STN and the GPi. current tendency is to prefer targeting the STN because of a greater improvement in the OFF phase motor symptoms as well as a higher chance to decrease the medication dosage and a lower battery consumption linked to the use of lower voltage in the STN compared to the GPi DBS. GPi can be the preferred target if LID is the main complaint. GPi DBS might be preferred for patients with mild cognitive impairment and psychiatric symptoms. Because STN DBS might have a higher rate of cognitive decline and/or depression and worsening of verbal fluency in some studies.

Surgical technique

The basic components of DBS implantation surgery involve frame placement, anatomical targeting, physiological mapping, evaluation of macrostimulation thresholds for improvement in motor symptoms or induction of side effects, implantation of the DBS electrode and implantable pulse generator (IPG).

Head-frame placement

The CRW frame is the most commonly used followed by the Leksell frame. Placement of the frame is done under local anesthesia unless anxiety or uncontrollable movements necessitate the use of sedation or general anesthesia.

Leksell stereotactic frame  placed over the head of a patient showing the correct method for placement of the Leksell head-frame. The frame should be placed parallel to orbito-meatal line in order to approximate the AC-PC plane. It is attached to the patient’s head using four pins under local anesthesia.

Imaging and anatomic targeting

Computerized Tomography (CT) scans and MRI are the two main imaging modalities used for targeting when performing DBS implantations. A thin cut stereotactic CT (_2 mm slices with no gap and no gantry tilt) is obtained after frame placement and is then fused with the stereotactic MRI on a planning station (Stealth station). The advantage of fusing the CT with MRI is the ability to avoid image-distortions inherent to MR imaging adding to the stereotactic accuracy. To better define the STN, T2-weighted images (TR 2800, TE 90, flip angle 90˚, slice thickness 2.0 mm) were obtained.

The AC and the PC were marked and the centre of the AC–PC line determined. The next step is planning the entry point and trajectory. The strategy here is to avoid surface and sub-cortical vessels. After trajectory planning, the patient is placed supine on the operating table and the frame attached to the table using an adaptor. Prophylactic antibiotics are given at least 30 min prior to incision. The head is prepped and draped in a sterile fashion. Under local anesthesia, a burr-hole is placed on the calculated entry point marked on the skull. The entry point is determined by the calculated arc and ring angles. Hemostasis is achieved with bone wax and bipolar cautery.

A Medronic Stim-Loc anchoring device (Medtronic, Minneapolis, MN) burr-hole base ring is then placed on the burr-hole and secured with two screws which are used at the end of the procedure to anchor the DBS electrode.

The dura is then cauterized and opened exposing the underlying surface of the brain. The microdrive is then assembled and cannulae inserted 10 mm above the target to avoid lenticulostriate vessels found deeper. Gel- foam and fibrin glue is applied on dural hole to minimize cerebrospinal fluid (CSF) loss and air entry into the skull. Subsequently, microelectrode recording and stimulation is undertaken.

Microelectrode recording/ Mapping

Microelectrode mapping is used to precisely define the target STN and its boundaries as well as nearby critical structures. We believe microelectrode mapping is crucial in order to give one the best chance for optimal placement of the DBS lead given anatomical inaccuracies due to image distortion and intraoperative brain shifts secondary to CSF loss, and pneumocephalus that can lead to inaccuracies in defining the initial target coordinates and shifts in the target itself once the skull is opened. Microelectrode mapping is performed using platinum-iridium glass coated microelectrodes dipped in platinum black with an impedance of around 0.3–0.5 Mo. These platinum-iridium microelectrodes are capable of recording single unit activity and can also be used for micro-stimulation up to 100 mAwithout significant breakdown in their recording qualities.

As the recording electrode was advanced, entry into the STN was identified by a sudden increase in the density of cellular discharge, with the characteristic irregular pattern of discharge—spikes of different sizes, occurring at random intervals. On coming out of the STN a quiet period (background noise) was seen followed by recording from the substantia nigra if the recording was continued far enough, described as high frequency (50–60 spikes/s) discharge pattern.11 Characteristic STN recordings (visual and audio) were identified and the depth of the STN activity was noted. Identification of STN activity was only based on the visual identification. The centre of the point of best electrical activity was selected as the final target. The microelectrode was replaced with a permanent quadripolar macroelectrode (Medtronic electrode no. 3389) to target the centre of the STN electrical activity. The proximal part of this electrode consists of four nickel conductor wires insulated with a polytetrafluoroethylene jacket tubing. The distal part has four metallic noninsulated contacts of 1.5 mm spaced at 0.5 mm intervals. The diameter of the distal electrode is 1.27 mm. Based on the clinical response any of the four contacts can be used for stimulation. Macrostimulation using the DBS electrode itself is then used to determine benefits and side effects. In most cases lateral skull x rays were obtained at this point with image intensifier carefully positioned to locate the target point in the centre of the Leksell-G frame rings.

Initial programming is always refined by using intra-operative macrostimulation data and a mono-polar review to identify the thresholds of stimulation for improvement in parkinsonian motor signs as well as the thresholds for inducing side effects at the level of each contact. The four variables that are used in programming are choice of contacts (0, 1, 2 or 3 used either as the cathode or anode), frequency of stimulation (hertz), pulse-width (ms) and amplitude (voltage).

POSTOPERATIVE MANAGEMENT

In the immediate hours after surgery, it is important to keep arterial blood pressure in the normal range. In addition, the patient’s preoperative drug regimen should be restarted immediately after surgery to avoid problems with dopaminergic withdrawal. Patients should undergo postoperative CT scans and/or MRI scans to assess the electrode location and intracranial status. In addition, plain X-rays are obtained to assess the location and geometry of the leads and hardware. Parkinson’s medications may need to be adjusted depending on the patient’s status. Cognitive and behavioral changes may occur in the postoperative period, particularly in older patients. Patients can be discharged as early as 24 hours after surgery, depending on their neurological and cognitive status.

Conclusion

For the last 50 years, levodopa has been the cornerstone of PD management. However, a majority of patients develop motor fluctuations and/or LID about 5 years after the initiation of therapy. DBS of the STN or the GPI grant to patients with PD improved quality of life and decreased motor complications, and has been approved as such by the Food and Drug Administration in the US in 2002. We reviewed the experience and available literature on DBS for Parkinson’s disease over the last decade and arrive at the following understandings.

The success of DBS surgery depends on the accurate placement of the leads and meticulous programming of the stimulation. Therefore, it is best accomplished by an experienced team of neurosurgeon, neurologist, and support staff dedicated to the treatment.

Reports of surgical complication rates and long-term side-effects of DBS are very variable, so benefits and potential adverse results should not be under- or over-emphasized.

While essentially equal in improving the motor symptoms of PD, STN and GPi might have their own benefits and risks, and the choice of the target should be individualized and adapted to the patient’s situation.

Knowledge to further improve DBS treatment for Parkinson’s disease, such as a more scientific and reliable protocol on programming, strategies to minimize cognitive and psychiatric complications, and the better

long-term maintenance of the implanted device, are still lacking.

Data on the impact of DBS on non-motor symptoms affecting the quality of life of PD patients, such as pain, speech or gastro-intestinal complaints, are still scarce. Further research in these areas will help make this useful treatment even more beneficial.

My problem is hair fall. I'll try many shampoo madice but didn't change this problem. Please help.

BHMS, MD - Alternate Medicine
Homeopath, Nagpur
My problem is hair fall. I'll try many shampoo madice but didn't change this problem. Please help.
Hair fall may happen due to many reason like anaemia, nutritional deficiency, skin disorder, mental and physical trauma. In homoeopathy, a huge no. Of wonderful medicines are present that are used to tackle hair fall. You have to maintain your diet, avoid strong chemical effects, styling tools and remove the cause first and also follow the step. If needed we can provide you the hair care regimen, totally natural, free from artificial fragrances and colors which can stop the hair fall naturally.
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I have fatty liver as per report but some doctors say it is common at this age. Is it?

BHMS
Homeopath,
I have fatty liver as per report but some doctors say it is common at this age. Is it?
Yes it is common thing, and what you have to do is mild regular exercise and fatty and oily food restrictions. Do periodical chekup to know the further developments.
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I am getting itchy feeling from almost 15 days and it is becoming more day to day.

Bachelor of Ayurveda, Medicine and Surgery (BAMS)
Ayurveda, Bhopal
I am getting itchy feeling from almost 15 days and it is becoming more day to day.
hello itching is cause of fungal infections avoid oily spicy foods, apply coconut oil+camphor twice a day on effected area further consult
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Hello doctor, I have tonsil problem in my neck my voice is also down what can I do ,today is 7 day to face this problem.

BHMS
Homeopath, Secunderabad
If it does not get better then get it examined by a doctor. Keep gargling with salt water daily 3-4 times. Avoid chilled water or oily food. Have more fruits and soups. Revert back after the that. You can take Homeopathy if it does not get better.
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I am suffering from few days to pain in my shoulder bones. I want to consult with a doctor. Please suggest me a doctor in my locality or medicine to get relief.

MPT - Orthopedic Physiotherapy, BPTh/BPT
Physiotherapist, Noida
I am suffering from few days to pain in my shoulder bones. I want to consult with a doctor. Please suggest me a docto...
posture correction must. physiotherapy treatment and shoulder stretching exercises. avoid computer work and heavy weight
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