FREQUENTLY ASKED QUESTIONS

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The answer is we need to understand that pain in the back and pain going down the leg can arise from certain specific causes and changes in the back. These changes, if the pain is in the back and then going down the leg are very very commonly related to the disc and its changes. The disc is a shock absorber between the two vertebrae in the back, lower back to be precise and these undergo changes as the time passes with aging and with degeneration. These changes initially are in the form of annular tear. This annular tear locationally can be at the center of the back side of the disc – what we call as posterior annulus or it can be at the corners of the back side of the disc what is called as posterolateral annulus. If there is a tear only then commonly there is a leakage of some chemicals from the disc and this can give rise to pain in the back if the tear is in the middle. If the tear is on the sides, the pain can go down the leg. As these changes progress, we have found that there may be a fragmentation that is breaking down of the nucleus in the disc and one of the fragments can come out of the tear causing what is called as disc herniation. So in addition to the chemical leaking and irritating the nerve, there is now a fragment of the nucleus which can put pressure on the nerve so there is a combination of swelling and pressure on the nerve which can cause pain going down the leg. This pain in general could be because of the swelling alone or swelling and compression by the fragment. In case of swelling alone it is diagnosed precisely by my sign styled as Gore Sign and if it is because of compression we use the test called a straight leg raising test to make out the compression of the nerve. So the nerve may be irritated because of leakage of chemicals from the annular tear and depending on the nerve which is irritated the pain could be in the back, it may travel down up to the hip, it could be only at the hip, it could be at the knee, on the outside of the knee or back of the knee on the outside and it can also be in the heel or around the heel. So this is a very basic distribution of the pain because of disc related changes.

We need to appreciate that God has created these separate segments of the body because these segments represent a different nerve going to different muscles and different joints.

Let us say that we are looking at changes at L3-4 the changes could affect the L3 nerve or the L4 nerve and generally this is present in the form of pain over the front of the thigh around the knee.

If it is L4 it will be pain which will come below the knee along the shin, that is the inside of the leg.

In case of L4-5 the pain could be of L4 where again it will be like around the knee, inside of the knee, going along the shin. At L5 it could be on the side of the thigh, side of the leg, radiating right up to the big toe of the foot.

In case of L5-S1, the same L5 can be affected or the S1 where the pain is normally at the back of the thigh, it could be at the back of the leg, and it could be going right up to the heel or on the little toe of the foot.

So distribution of the pain along certain areas of the leg normally tells us where the pain is originating but in our traditional assessment this distribution is called as dermatomal distribution. Sometimes the distribution is not very classical and there could be a mix up of this distribution where multiple areas of the foot, leg and thigh and hip could be affected, in which case feeling the nerve and understanding Gore Sign will help you in distinguishing the pain coming from L5 or S1 and whether it is because of chemical irritation alone or because of mechanical compression over the nerve.

Basically the pain in the heel almost never comes from the heel unless of course if you have any injury to the heel, you have a fracture of the heel bone or you have an abscess or an infection or of course if you are dealing with ischemia that is reduction in the blood supply, for example in a diabetic patient where the blood supply, the arteries and veins will be affected. We say that if there is no injury, if there is no infection and if there is no ischemia then the pain has to be coming from Neuralgia that is nerve mediated pain. So doing an X-ray of the heel, looking for an overgrown bone and cutting the bone or taking an injection in the heel – do not relieve the cause. Sometimes the injection may relieve the pain for short duration. Many times the patients also opt for change in the foot wear by adding certain support to the arch or adding silicone gel pads under the heel. These things do help in making you more comfortable but the cause of the pain does not go away. Here we need to understand that heel pain is the earlier sign of irritation of the S1 nerve root. If we appreciate the gravity of the situation that you are already having heel pain which means that your S1 root is already getting irritated this is commonly seen in the younger age group. At this juncture we should start working on strengthening our back and making our back more flexible so that this signal which the brain has given you in the form of heel pain is utilised to improve the function and the structure of the back.

Let us understand that the knee pain is one of the commonest pains seen in our patients. If we talk about patients from India then it is much more common to see a patient with knee pain. Let’s again understand that any pain could be pain coming from the knee or the pain felt in and around the knee  where the cause is not inside the knee and the pain is called as referred pain that is the origin of the pain is at a different location and the perception is at the knee. In case of knee pain the first question which we normally ask the patient is where is the pain? What I mean is – is the pain more on the inner side of the knee that is towards the big toe side of the leg, or it is on the outside of the knee that is the outside or back side of the knee – on the side of the patella that is the knee cap and which is normally on the outside of knee -that is the first question.

Number 2, we ask what happens when you sit, when you stand, when you walk and when you lie down. Normally when you sit with your legs crossed that is sitting on the ground, where you bend both your knees and fold your knees and fold your legs and you sit on the ground. This is the time when you have severe pain in the knee coming up which will increase as the time passes – this is because of reduced stretch-ability of the nerve coming from the back which also is inflamed or swollen. Then we ask the patient if the pain increasing with walking. Normally the pain which increases with walking is related to the nerve. If the pain reduces after walking a certain distance it is commonly related to the joint. Pain on standing at the back side of the knee is again indicative of involvement of the nerve.

 

In Indian scenario if someone tells me that I sit cross-legged and I cannot sit more than five minutes or I must make my knee straight or on walking I get pain which goes down the leg, up the leg, up in the thigh or my leg becomes numb or heavy or more painful on walking – all these signs are indicative of knee pain coming from the nerve which is commonly the L5 nerve root.  We need to appreciate here that for L5 nerve root affection the first sign is knee pain. This pain can be diagnosed by utilising my sign, where you feel the end of this nerve in the form of lateral terminal branch of deep peroneal nerve over the roof of the sinus tarsi — that is you feel this nerve going down the leg and in front of the ankle where there is a small depression just below the ankle on the outside of the ankle.  Indirectly what we need again to appreciate is that our brain is giving us a signal that when you have knee pain on the outside – then we need to pay attention to the strength and flexibility of the back. If we utilise the signal to improve our health then it is very very significant help from these signs. Now when you have been in the knee and when you go to a doctor, we also need to understand that the patients instead of telling where is the pain and what is the problem  they try to tell the doctors why they feel the pain is there. Now this is a lot of complicated matter and this is not common sense. We have to allow the doctor to analyse your Symptoms and help you in overcoming the difficulty for which you need to tell the doctor what is the problem without adding why you feel the problem is there. Your logic is likely to interfere with scientific analysis by the surgeon or the physician. So coming back to the whether knee pain needs knee surgery – Yes it will need knee surgery if the pain is coming from the knee and causing sufficient problem in walking, standing and working or sitting cross-legged and knee surgery maybe relieving the pain coming from the knee but if the pain is not coming from the knee apparently the knee surgery will not be of any help. 

Gore Sign is a result of research and thinking and precise analysis of the patients narration seen in thousands of patients in my practice. The thinking about Gore sign essentially started around 1997-1998 and it was first time presented in Cambridge in the meeting of IITS in 1999. It was also presented in an updated and properly studied and researched form in 2006 in the World Congress of Minimally Invasive Spine Surgery, where it received the best clinical study award of 1000 US dollars by the association. The Gore Sign is basically a very simple point that we try to feel the nerve –

coming from the back,

coming from the back to the back of the hip,

to the buttock,

to the back of the hip bone,

and then going down the leg maybe on the side of the thigh or the back of the thigh,

going to the back and the side of the knee, the outside of the knee,

and then going down the leg maybe to the big toe or to the little toe and heel

We feel the nerve along the path and what we have understood is that there are three areas of the nerve which are extremely painful to touch when the patient is talking about the pain in the leg.

These areas are in our language called as the nerve which is common peroneal nerve or the nerve which is on the side and just at back of the knee

and there are two points over the ankle – the front of the ankle and the back of the ankle, where we feel the L5 and the S1 nerve respectively.

The common presentation of knee pain coming from L5 affection is because the knee is supplied by this nerve – common peroneal nerve by giving 3 branches called as superior, inferior, and recurrent genicular branch of this nerve.

What we need to understand again is the pain could be because of information or swelling alone of the nerve or it could be in addition to the swelling of compression of the nerve. One of the biggest and most vexing problem, which is all clinicians face in their practice is how to distinguish if the pain is because of inflammation alone or because of compression. If the pain is because of inflammation alone then when we press the nerve at the ankle – the pain will temporarily stop and if we inject a sodium channel blocker at that site of pain – in the front of the angle or at the back of the ankle then the pain will stop for a long long time. If the pain stops for a long time or if the pain is relieved to large extent for a longer time then it is definitely because of inflammation, not because of compression. And generally the pain which responds to an injection distally, commonly can be treated without surgery. The pain thus can be accurately be diagnosed as pain because of swelling. A straight leg raising can help us in finding out the cause because of compression of the nerve. We have seen that there are multiple patients with multiple painful spots in the leg or in the arm and these painful areas are not diagnosed by clinicians routinely. The main difficulty being the clinicians are totally clueless about where is a pain coming from and why is it persisting.

We feel that the Gore sign can help you in distinguishing … number 1 –  whether the pain is because of neuralgia – that is nerve mediated where the nerve is tender, painful and the pain is relieved by use of only injection at the distal part. Number 2 –  where the pain is because of inflammation or swelling or it is because of pressure on the nerve and in addition this test also would help you when you are being managed without surgery. As the time passes when your pain increases or decreases where you feel better or worse, actually the nerve is changing in its function which can be easily accessed by feeling the nerve under Gore Sign. It is a very important sign in the management of leg pain and sciatica in patients who are suffering with disc related causes or otherwise.

The answer is very simple. You do not need an MRI or an x-ray for routine diagnosis and treatment because anyway it may not be relevant to your narration. You must get an MRI and x-ray when an intervention that is something which will be more than medication planned for your treatment. This may involve an injection in the back. An injection the leg of course does not need an MRI or a X-ray. An injection in the back or if a surgery that is the stitchless surgery under local anaesthesia is being planned for you then you will definitely need an MRI and a X-ray. In patients where we have the Red flags, that is, injuries, fractures, infections and tumours, we definitely need an MRI and a X-ray even though may be treated without surgery in those patients. Images do lead us to some significant conclusions and shared decision making but images and symptoms do not match in about 30% of the patients.

As has been mentioned the MRI films would be very important because they would depict the actual charges in your body as are seen by this technology of nuclear magnetic resonance. The MRI report is a subjective report of the person who has done this MRI examination and there are 2 main limitations – No. 1 that person never ever listens to you or examines you and never treats a patient in whole life so the report does not carry much meaning unless it has been written by  a clinician who was examined you.

There are certain exercises which are known to reduce the pain or stop the pain over a period of time. Two of them are very important.

 

Number 1 is a shoulder raising and shrugging exercise which is normally advised for pain in the shoulder area or in the periscapular area that is the upper part of the back and painful spots around the triangular bone of the back. The 2nd exercise in which I commonly advice is called as McKenzie’s exercise where when you lie on your belly and try to raise your chest off the bed, the pain may be felt in the back and in the leg may stop, or may travel up towards the back. If this exercise is done repeatedly over 2 hours 20 times like this for a day or two, many times the pain may settle dramatically and the patient can be relieved of the pain. Normally exercise alone does not relieve the pain in other conditions. You need to understand that exercises are important also to improve your coordination the strength of the muscle and strength for the bone. Medications are normally to take care of the swelling of the tissue. Some medicines which are vitamins or maybe tonics will help you in improving the strength and there are some medicines which may be needed as for the cause which may be associated with the symptom.

When we talk about a disc which is degenerated or damaged it is because of certain changes in the outline of the disc, in the coating of the disc or the inside of the disc without apparently no change in the outline. The other discs can be damaged in future because the disc changes on genetically predetermined in addition to your habits and the switch we need to take to avoid for the damage is number one you must keep your body more flexible and the environments. The precaution which we need to take to avoid further damage is you must keep your body more flexible and more powerful. You need to keep it more flexible basically because when you do exercises to improve the flexibility our posture improves and this sensation what is called as posterior column sensation, that is sensation of pressure and sensation of position is very important. If we maintain a better posture then it will help. There are other precautions to be taken. We need to understand that in addition to genetic factors, the other factors are accidents the back, and improper eating, bad posture, use of vehicle, type of work, etc. So these things could be pain attention to improve the back health.

Absolutely no. We have seen that the rate of surgery is about 8 to 10% of the patients which I commonly see. What happens is with seniority and with expertise generally nowadays the patients who need surgery or need a second opinion about the need for surgery come to me so maybe the proportion of patients who see me and proportion of patients who are adviced surgery is slowly changing with seniority and expertise. But commonly in a spine surgeons work the need for surgery is not more that 10% of the patients.  There would be another 10% who need injections and what we call as pain management that is masking the pain for sufficient length of time where you become more comfortable and need for surgery goes away.

Ok this question is very important and the answer is pretty simple. You will need surgery if you have a cause which is not settling down with time. You have a cause which is not only inflammation or swelling of the nerve but there is gross compression of the nerve so much so that your nerve has started behaving in a fashion where there is a deficit in a form of loss of sensations or loss of power and when your activities of daily life are hampered because of the pain that a simple act of sitting for the toilet, standing at one place, walking a certain distance or lying in bed even supine or on the side causes pain. Traditionally surgery is advice for weakness of the nerve especially where it is progressive. Times have changed, our economics have changed and our aspirations and expectations also have changed. If you ask us as spine surgeons our working has changed where we initially used to treat the patients only for weakness or loss of sensation. Nowadays we have started treating patients for pain also because the pain is so very bad and interferes with everything what you need to do in life, that it is very very difficult to carry on with the pain. Surgery essentially first answers the question where is the pain coming from and why is it not going away. That why it is not going away is an important point where commonly we find there is a chronic – that is longstanding inflammation which needs rectification so surgery helps in that fashion. Treatment of back pain and leg pain can also be done by medication, physical therapy and injections in selected cases. Injections may be needed where the pain is because of swelling of the nerve even though it may be very severe and injection can relieve the pain for a long long time. Physical therapy prior to any other intervention may help if the pain is coming from weakness of the back muscles or bad posture or certain activities which are overdone and they cause pain. Physical therapy also would help by soothing feeling coming out of hot fermentation or steam bath or going to a spa. Medication suppresses the pain and many times the medication also helps in getting a few hours of good sleep in presence of pain. But we have to remember that we must analyse the cause and then think whether we need medication, physical therapy and injections alone or surgery may be needed.

 

Commonly, the answer which we give scientifically to the question do I need surgery is if you do a McKenzie’s test – that is your lie on your belly and try to raise your chest off the bed – if the back pain or the leg pain centralizers that is the pain comes towards the back rather than going down the leg and if the nerve is very painful and tender and you are able to inject the ending of the nerve which is very painful.  If there is relief of pain by injection, if there is centralization of pain on the raising your shoulders off the bed then surgery may not be needed. So this is a simple test to confirm the need or no need for surgery.

The answers are many. We have to realize that 50% is genetically predetermined. If your parents have suffered from this problem you are more likely to suffer and then of course diet, exercises, posture, type of work, use of vehicle, associated diseases can add to the incidence and prevalence of pain because of changes in the disc. Chronological age and the degeneration that is structural changes in the disc do not necessarily match. Degeneration is characterized by certain structural changes which our nervous system or vascular system reacts to at the level of the disc and then if the changes are such that they need further intervention then we have to analyse it much better. We have found that there are who are 19 years old, who would have gross degeneration, or patients  who are 90 years old and may not have degeneration. Unfortunately in practice both these words, that is – aging and degeneration are used as synonymous but they are not synonymous and ageing is a change where there is a change in the nutrition of the disc or the tissues and degeneration is the breakdown of the tissue with symptoms. Ageing is without symptoms.

The answer is yes, your pain can be treated traditionally but ultimately we have to see what is effective in the long run which can relieve you and which can bring back the activity pattern or the lifestyle which were hoping for. Taking medication can stop the pain for certain time. Doing exercises can improve the flexibility and ability to work and move around and of course the physical therapy in the form of heat and massage, etc. can also help. Age alone is not the factor. Our treatment is not primarily decided by the age as has being mentioned the degeneration can be seen at the age of 19 or may not be seen at the age of 90. So if the cause deserves the treatment in the form of surgery that would be the best option. We also need to understand that there are certain arguments done by people who do not know the real mechanics and the effectiveness of surgery. They make argument or a statement that at the end of 2 years everything is the same. I mean they say that if you operate or if you don’t operate at the end of 2 years both of them are same. This is a fallacious argument. The argument should actually be like this that what a person can achieve in one day of surgery especially nowadays with stitchless day care surgery under local anesthesia takes 2 years by the natural forces.  We are not denying the relief of symptoms by natural forces but we need to remember the dimension of time. If you live in a place or you live in a style when you can afford to exercise, eat well and take care of you back and your health in general there is no harm in not doing the surgery. Surgery is not mandatory unless there are gross sensory motor that is nerve function changes. So coming back to the point that do I need surgery because I’m so young – the point is not your age. There are certain situations which will take a long long long time to recover naturally which can be hastened by surgery. So we do advise and normally the decision to operate or not to operate is a shared decision. We always give the free choice to the patient to exercise and say that ok I need surgery. If a patient says I do not need surgery they suddenly do not become our enemies. We as doctors and consultants are here to help you in making a better decision, an informed decision and a shared decision.

What has happened with the advent of MRI scan we are able to localize the problem in the back to the level of 1 millimetre. Because of our development of Gore sign and philosophy of transforaminal access to the pain generator – that is a change in the disc or in the back giving rise to the pain – this ability to access that sub-centimeter target makes us do the surgery now in a stitchless way under local anesthesia. What we do is we make the patient lie on the table and under the x-ray control, we pass a needle from the side of the back to the centre of the disc or just below the posterior annulus. And we can tackle the target which is causing the pain. This surgery is extremely precise and it does not touch any other tissue except the tissue which is causing the pain. So the morbidity is very very less, return to function is very high, time taken to return function is very small and the body is not damaged anywhere except where we operate where we take care of the cause. There are few more advantages of this technology – that aged population which have varied medical comorbidities this cannot be tackled by traditional surgery but our surgery can tackle it. So our surgery in short is a stitchless surgery under local anesthesia in a patient who is awake and aware and therefore we can give them the maximum benefit.

Absolutely NO.  In fact Dr. Satishchandra Gore and his teacher Dr. Anthony Yeung have submitted a literature review of last 30 years or more than 30 years and have proven that we have the best solution to the treatment of back pain and sciatic pain. What has happened that since this is a surgery that is extremely precise and needs understanding of the pain generators and has high technology with various modalities of treatment like RF that is radio frequency and laser, etc. it is not very popular or your next door spine surgeon may not be able to do it because you need a very very specific training in doing this precise surgery. So is it experimental? Absolutely no. The problem is, it is not popular because everyone cannot do it. There is ultimately your surgeon factor in doing Gore system surgery. All spine surgeons are not same. All of them do not have the same level of expertise. All of them do not have the ability to understand the issue at hand in the same fashion. So our system is not experimental. It is a validated, published system which can be used to treat people without causing morbidity in a stitchless and under local anaesthesia format.

This is a very important question distinguishing my system of surgery from other traditional surgeries. Other traditional surgeries are done where the decision to operate is based on analysis of the patient’s narration and imaging alone. The thinking of the surgeon stops at the stage of imaging. There is no further analysis of the symptoms and therefore there are likely to be higher chances of failure because inherently the images and the symptoms of the patients do not match in 30% of the cases. The images may look normal but a patient is suffering and images may look abnormal and patient doesn’t have any pain whatsoever.  In patients who have symptoms and who need surgery, operating them under local anaesthesia have several advantages.  The first and the most important advantage is the diagnosis is not based on images alone and the decision to operate also is not based on images alone. We go a step further than the images and we are able to see what is causing the pain. When I put my scope in the back – I am able to see what is causing pain. This is published under the heading of in vivo visualisation of the pain generators in the lumbar spine and this is a Paradigm shift in the thinking in spine surgery. What we have achieved over last several years is that instead of going ahead with the dumb images which do not tell you anything and attaching undue meaning to the images we can put a scope in the back and look at the problem which is causing the pain. If the problem is severe enough and the symptoms are debilitating then the advantage is you are able to get a feedback from the patient when you are looking at the pathology and probing the pathology to confirm the origin of the pain. Doing it under local anesthesia also adds a very very important dimension to the surgery in that the surgery even at advanced age and as all of know in today’s world where patients may have diabetes, cardiac problems, hypertension and many other medical issues which sometimes make surgery under general anesthesia impossible. There have been several patients who we have treated who have been told that you have to live with this pain or the surgery would be so risky that you have risk of dying during surgery – this is not a part of our surgery. We can operate patients without the risk to life and we don’t want anyone to live with the pain. We can relieve the pain very very precisely.

Basically both the surgeries are done under local anesthesia and are stitchless. The entry in to the area of the spine from the side is through the space between the two bones of the back called as the foramen. The symptoms of back pain and leg pain that is sciatica can arise from the changes in the disc or the changes in the joints of these two bones at the back that is the facet joints. When the changes are more related to the disc and there is a fragment of the disc which has broken and has come out and gives rise to pain in leg, the surgery commonly done is called as discectomy where the fragment could be in the middle, on the side, in the foramen, outside the foramen or it might have moved up or down called as upmigrated or down migrated fragment. And this can affect right from D12 – L1,  L1 – 2, L2 – 3, L3 – 4, L4 – 5, L5 – S1 levels. When the changes further are enhanced by changes in the facet joints that is changes behind the spinal cord which are more commonly seen with aging population the surgery may not be discectomy alone. In addition the symptoms where the patient has pain and inability to walk, in addition numbness in the leg on walking what is called as claudication – that is the patient is unable to walk or stand for longer time and the pain and the numbness increases as you walk more and more so much so that after certain distance you have to sit down and take rest before walking further. This sort of symptom comes from a change which is titled as Lumbar Canal Stenosis that is narrowing of the canal and since it is narrowing of the canal, the canal has to be made bigger so this surgery is called as foraminoplasty – that is we go through the foramen and we improve the size of that area where the nerve is situated and we make the nerve free from all possible pressures from the side and therefore relieve the symptoms. This is a little more technically demanding surgery where there’s a lot of bone which may have to be tackled and a lot of soft tissue which has to be removed. So foraminoplasty is a little more time taking and commonly indicated in an advanced age but remember that both the surgeries are under local anaesthesia and are stitchless.

We need to remove the hard part of the disc in patients who have disc herniation for a length of time and we need to remove a lot of hypertrophic tissue which may be present at the tip of the facet in the foramen and we may also have to remove the bone itself to make way for going in the canal in patients with severe stenosis or we may need to remove the bone which is formed and called as osteophytes. These hard tissues cannot be removed by our instruments alone because remember that our instrument is 7 millimeter in outer diameter. It has a working channel, my Gore system has a scope which has a working channel of 3.6 to 5 millimeters. Our instruments are commonly 3 or 3 .5 millimeters and you can imagine they are very delicate and very expensive instruments. So if we are tackling a stone or a bone which is a very hard tissue, we cannot really tackle that tissue by using a very delicate piece of instrument, therefore we need a drill to shave off the grown portion of the bone or the hardened tissue from the disc. We also use laser because laser is a very very precise instrument of use for surgeon. Laser basically is a form of energy which generates heat where the laser is pointed. Laser is invisible, what we see is called as a guide light which is commonly a helium neodymium that is He Ne Light and the Laser as you know is very very precise. All of us have seen laser pointers which even at a distance of hundred feet still remain a point, they do not spread, they remain a point. So this precision is useful in our surgery. Lasers essentially are used in patients where the space to work is very very small and the laser which we use is a side firing Holmium Yag laser. This laser has a penetration of only 0.4 millimeters on the surface. So theoretically if you want to remove a hard tissue more superficially especially when you’re working very very close to the nerve then laser is absolutely dramatically effective. If you have some space to work and can use the mechanical means then the drill is better. In case of laser,  physics as we know is when we heat a solid it becomes liquid, when a liquid is heated it becomes steam and when we heat the steam it becomes plasma. In case of laser, when we point the laser on a substance a solid is directly converted to plasma and it evaporates and is ablated. So removal of hard tissue in a short time in the precision way without causing any other problem is possible with laser. We can use laser under water also so it suits our requirement. Laser is inherently compatible with MRI so in advanced  setups were some surgery sound on side in my surgeries are done inside the MRI machine a laser is a very simple and compatible modality of energy which can be used for the surgery.

You see, our surgery starts generally on one side because we’re able to reach most of the causes of pain from one side. Sometimes the problem is situated exactly in the midline and then it can also be very large herniation. Then it may be very difficult to reach it just by one sided approach because you are not able to visualize and work with your instruments very properly because of the size and location of the herniation. In which case we put our scope from one side and we may put our instruments from the other side but mind you, both sided approach is against stitchless and under local anaesthesia. So there is no more problem or there is no more morbidity than what is seen with single side approach. Sometimes bi-portal approach is also needed in Foraminoplasty because of changes because of advanced age are present on both sides and one sided approach may not relieve it totally. So if the problem locationally is and intensity wise severe we may consider bi-portal approach.

PRP is platelet rich plasma. We deal with patients who have an annular tear and a leak from the tear and swelling of the nerve around, which gives very severe pain. This pain can be relieved by injection of anesthetic or injection of steroid but in some patients especially in diabetic and some patients at advanced age using steroid may not be a good idea. In some patients they would also be some other factors which will make us reconsider the use of steroids or other medicines. We normally take blood from the patient and we centrifuge it and we separate the platelets and then use the platelet rich plasma. This has an excellent inflammatory property. It also has growth factors which help in healing of the tissue where it is injected. So it is one of the better ways after treating non surgically a patient who has early presentation of the pain from annular tear. A PRF is a platelet rich fibrin plug which we call as Der1 plug because it was used first time in Derwan where all of us work in our charitable hospital. Der1 plug is prepared again by centrifuging the blood from the patient and allowing sufficient time for the plug to form. We have to know that when we do an endoscopic surgery there is an annular tear which is being treated because it is causing severe pain and problems. Second is, we make an opening in the disc to go inside the disc to put our scope and our instruments because otherwise there’s no place to work there. It is not like laparoscopy or arthroscopy you have a big cavity like the belly cavity where you’re putting the scope. This opening in the annulus done for the surgery and an annular tear which is being treated both of them can be plugged, can be sealed by use of PRF Der1 plug. This plug also has several growth factors and also has a very strong anti-inflammatory potential. Studies are on the way which are yet unpublished where we want to see, study and support to use of PRF because it has a positive effect on the regeneration of the disc.