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.
We have to know that body has enough potential to recover but main issue is a time frame needed for recovery. In case of disc annular tear and the pain coming from the tear it can be eminently treated without surgery and therefore Dr. Satishchandra Gore also would not advise you surgery. In case of disc herniation surgery is advised when the disc herniation is of type 2 or type 3. Let’s know what are these types. Type 1 disc herniation is a soft butter like herniation which is a pure nuclear herniation and in most of the patients it may vanish without much of a problem except causing severe pain for several weeks and after that the fragment may vanish because our body is capable of eating away that fragment. This is type 1 which is Soft nuclear herniation which may be lying free in the canal. Type 2 herniation is herniation of the nucleus with a piece of annulus – that is the coating of the disc – which is generally very hard and the time taken is about 6 to 8 months for that fragment to show some reduction in the swelling and the size of that fragment. So in these patients if the surgery is not done maybe around 6 to 8 months the pain may reduce but there will be 2 limitations which may remain – that is activities of daily life and the uncertainty of the reoccurrence of the pain during activity of daily life remain as a problem mainly because we as surgeons do not have the external control on the behaviour of that fragment. Type 3 herniation is when you have a nucleus, additional coating of the disc that is the annulus, and there could a piece of endplate that is there is a fractured piece of bone with this herniation. These herniations are known to take more than 2 years or so to recover naturally, there again there is uncertainty. Theoretically if you wait for 2 years the problem may resolve but it may not resolve so what we normally do when the patient presents to us with severe symptoms if there is a trend towards reduction of the symptoms over a period of time we definitely see if the nature is helping us to naturally resolving the swelling or the inflammation. If there is a failure of natural resolution that may be an indication for surgery. The other problem is if you do not do the surgery in proper time frame there would be negative effects of not doing the surgery or the effects of the fragment remaining very close to your nerve. Number 1 it can get it can get adherent to the nerve thus limiting the mobility of the nerve and giving severe limitation of your bodily movements. Number 2 there could be additional effects where there may be residual weakness or residual numbness of the leg which may not recover fully. So if you are advised surgery, and if you don’t do surgery it is okay, because it is after all your decision about your body and you have a choice to suffer or you have a choice to get relief of the symptoms in a short and fast way.
For somebody to tell you to live with the pain mainly because of his or her inability to diagnose or treat is not what we want. We are able to diagnose your problem and treat it with Gore system under local anesthesia and in a stitchless surgery so instead of living with the pain and disability coming from that pain and of course the additional changes in your personality getting depression getting mood offs and to the extent that you may not have any meaningful activities or meaningful life is not the right way. We can definitely overcome the pain. Common problem which we have seen is patients have a very severe fear in the mind about surgery. This fear has come from the past stories where there were some very sensational problems where the patients were not able to walk properly again after the surgery or there were complications with anaesthesia and of course in aged people they were told to live with it because the benefits of surgery could not be given to them because of their inability to undergo anaesthesia for the surgery. All these problems have been overcome with the new philosophy of Gore system which is stitchless surgery under local anaesthesia in an awake and aware patient.
This is a very fundamental question which has to be clarified very well. First thing is – Most of the patients only see the skin incision because that is what remains on the back as a scar. So telling you that this scar is going to be only 2 centimetres or 1 centimetre or 8 millimetre or whatever is actually irrelevant. What you do inside is much more important.
In case of open surgery – the open surgery looks more like a cone – that is the top of the surgery on the skin is a small incision but as you go on digging the tissues you realise that you are not able to tackle the tissue by cutting more, so ultimately when you see the surgery it is like a cone where you have a big incision on the skin and a very small cone like narrowing down up to the target. In open surgery the muscles are denervated, they are paralyzed because the nerves are cut, they may undergo scarring, they may undergo changes of reduction in blood supply, there is a lot of bone which is removed from the body and this removal of bone can cause instability or unstable spine which smartly many doctors cover up by telling you to undergo fixation by use of screws and plates and rods. Open surgery also has to be done essentially under general anaesthesia so many times the benefits of surgery cannot be given to the patients who are at an advanced age but having very severe suffering.
Microdiscectomy is definitely an advance over open surgery where a microscope is used to magnify what is seen. Apart from the ability to see the structures better there is no other advantage of microscope used during surgery. The incision becomes smaller at the skin. There are various variations of microdiscectomy or various other additional things like tube assisted or tube and endoscope assisted surgeries where it is very very misleading nomenclature where they also call themselves as minimally invasive surgery. The skin incision is very small but under the skin you will find there’s a large dissection, the same denervation and paralysis of the muscles, there is a cutting of the bone and there is a cutting of the tissues which may make the whole spine unstable. In addition the surgery essentially is done under general anaesthesia, there could be a need for blood transfusion and need for hospitalization. In case of microdiscectomy, as I said it is definitely an advantage and an advancement over open surgery but ultimately the same philosophy is used except that you are seeing the things big so that you can tackle them better.
In case of our surgery, the Gore system of surgery we have entirely a different philosophy altogether and our surgery is directed by the pain generator that is the tissue which has undergone breakdown which is reacted by the nerves of the body and the pain is actually generated at that spot. So our surgery precisely targets the pain causing tissue and that too we directly land on the tissue without touching anything else and therefore we are able to tackle this problem in a much more precise way. The main advantage in addition is our surgery can be done under local anaesthesia and since the tube is only 8 millimetres there is no need of stitching. One more important thing is we do not cut any muscle, we do not paralyze any muscle, so the muscle strength and therefore the recovery of function and rehabilitation is much much simpler and much easy after the Gore system of surgery.
Many surgeons are not able to distinguish between the open, the microdiscectomy, the tube assisted surgeries and the surgery done through the foramen under local anaesthesia by Gore system because they get lost in the language, they get lost in the words called as minimally invasive endoscopy and then microdiscectomy, nano this, micro that. We have to remember that the surgery is advised many times to relieve a certain problem. If we are able to target our efforts to directly land on the problem after a precise diagnosis and we do not create new problems like the muscle paralysis or injury to the nerve, cutting open of the dural sac or excessive bleeding and of course additional instability which will need added screws and rods and plates then Gore system should be chosen over all other systems. The main objection then many surgeons would have is that our system that is the stitchless surgery under local anaesthesia by Gore system may have certain limitations and it may not be applicable in all possible problems in the back – this is again a misunderstanding, we are able to do almost all the surgeries which are done open except putting the screws and making the back more stable if it is unstable and causing problems. So we must think of these issues about the surgery and the contents of the surgery the below the skin. If you have something which looks only good at the skin but it hides many other problems inside you should be wary of taking up those choices.
You may also look at the video on https://drgoreonline.com/laminectomy-vs-endoscopy/
The answer is – in case of Gore system you do not need to cut the bone because we are able to navigate ourselves without cutting the bone. There is a misnomer in surgical jargon as bony hypertrophy – what it means is the bone grows and therefore you have to cut – this is absolute misnomer because in any living person after the age of skeletal maturity that is after the age of 18 to 21 the bone does not grow. So bone growth which needs cutting of the bone is absolutely a misnomer. We do not need to cut the bone. There are very exceptional circumstances where the bone may be coming in the way of our access to the pathology or to the cause which is giving us the suffering in which case the bone maybe cut this phone. This may be cut to a large extent in the open surgery, this bone is cut to a little extent in microdiscectomy and tube surgeries.
In case of Gore system the bone is not cut at all or the surface of the bone is only shaved as to take away the tissue which covers the bone which may be hypertrophied or which may be grown as to cause symptoms.
Gore system of surgery essentially is done under local anaesthesia so all the complications related to anaesthesia are not there. Our surgery does not cause paralysis of the nerve.
The stories about paralysis and the patient being bedridden for multiple times or for a long time or for years together where present in the past where the decision making was faulty and the technique was not as refined as it is today. The complications of Gore system are commonly seen to be three. One is there could be an infection at the site of surgery what is called as sepsis at the site of surgery, in our hands it is zero but in the initial part of evolution of our surgery during our learning curve it was close to 1%. The second complication is we can have a lot of irritation of the nerve because the space in which we work is so small that many times the surface of the nerve is rubbed. This rubbing of the nerve can give rise to severe burning in the leg which may substitute the painful area, that is after the surgery the pain is gone but the area may become very sensitive to touch and may give rise to burning – this is called as dysesthesia and this can be relieved on his own or can be relieved nowadays with medications called as gabapentin or similar class of medicines. In very very elderly patients, the patient may get some oozing that is collection of some blood giving rise to some difficulty in walking which again is a self resolving problem and the incidence has been 1 in 10000 or 2 in 10000. The incidence of infections as was mentioned now is zero in my hands but used to be about a percent 1% and the incidence of dysesthesia is again about 1 to 2%. There are around 3 to 5% patients where inspite of doing proper surgery following the best possible traditions and the principles of surgery the patients may still continue to complain of pain – this is because of some other problems like psychological problems and of course there could be an inadequate surgery in certain patients.
In short Gore system surgery is not life threatening, it does not cause any paralysis of the nerves and you can be functional and back to work as before.
Yes of course sure you are eligible for this system of surgery which we do which is stitchless and under local anaesthesia. We need to find out what is causing the pain and why the pain is persisting or what is causing the claudication why is it not going away. Our clinical assessment and our imaging assessment may be a problematic issue because of the implants being present inside and our assessment may be sub optimal because of the implants being inside but since we are doing the surgery under local anaesthesia we can definitely probe the causes which are likely and confirm the cause and then operate if necessary. So yes you can be a candidate for Gore system of surgery inspite of implants being present in your back. One more issue is there are some patients who have had what we call as cages in your back. These cages are made up of polymer and sometimes they may back out, they may move from the normal location and cause very severe pressure and irritation for the nerve. This needs a solution can be given by Gore system where we use our endoscope, go in the foramen and we can literally dissolve the cage by use of laser because cage being a polymer is susceptible, can be treated by use of lase which can ablate the cage.
The cause of pain is normally situated next to the nerve where the nerve is irritated by swelling, or by compression or by adherence of the tissue next to the nerve. The patient may also have associated weakness and numbness of that part of the body. If you have had multiple spine surgeries which unfortunately have not relieved your pain problem we need a detailed assessment and certain injections in the back to confirm the origin of the pain. Gore system will help you in the form that we will confirm and reconfirm the cause of pain or the cause of the problem and once we are sure then only the surgery would be done. Since our surgery is under local you are awake throughout the surgery where you can add to our understanding of your problem by answering certain questions when we try to prove the likely painful structures. This is not possible in traditional surgery done under general anaesthesia. Multiple spine surgeries also normally would be affecting your health in general, your level of fitness and your mental health because that can cause depression and may need counseling from a good psychologist and a good counselor who can tell you about rehabilitation after the surgery. What we have seen is that if you are determined to become better and come back to original function it is definitely possible because we can pinpoint the cause of your pain and relieve it without causing a new problem.
We have to know that your chronological or calendar age may mean something significant or may not mean something significant. What I mean is if you are physically fit, if your heart and your lungs are functioning properly, if your kidneys are supporting the function of your body properly then getting benefit from our surgery which is under local anesthesia and stitchless is definitely possible even at that age. I have personally operated somebody aged 16 to 92, so age is no bar basically because even if the system is aged if you’re mentally motivated and physically fit then we can definitely help you by putting our system to use to relieve your symptoms.
I can assure you that we can do the treatment in 2 stages. In stage 1 we only mask the pain. We put a numbing medicine next to the structure which is giving pain. Once you confirm that the pain is relieved by the injection or masking injection then only we take up the surgery in hand. So we have a double insurance about relief of pain. 1 we know the cause of pain for certain and number 2 it is done under local anaesthesia where you are continuously being monitored in real time for the change in pain. There are certain situations where the pain comes only in certain positions of the body and therefore may not be present all the time but since we have been using this system for years together we do understand what is what and what causes what so there is a very very very high chance of you getting relief with Gore system and because of this philosophy.
If you are not a resident of Pune that is not a problem. You can definitely undergo the surgery and maybe leave the same day or the next day morning back to your hometown. You may travel in a car on the backseat lying with your back touching the seat. You may travel by bus, you may travel by train, you may travel by flight but we must remember that after surgery the disc area is very delicate. The disc area is prone to injuries and the disc area can flare up with added inflammation and swelling if you are too active after the surgery. We must remember that the area which is operated or the annulus normally takes about 4 to 6 weeks of healing. Unless the tissue has healed if you suddenly impact the tissue you can have a recurrence of the symptom or you have a recurrence of the herniation of the disc. Travelling by flight is preferred because it is a short time travel and is generally from Pune you can reach almost all corners of our country or even abroad in a short time. Travelling by bus may be possible but you may have to sit in the front of the bus so that the back seat with a lot of vibrations, back seats are avoided. You can travel by train but again if the travel is long one then it is better that you lie down throughout the travel. Basically after surgery total healing of the tissue is advised and then rehabilitation is induced.
Absolutely no. The Surgery has nothing to do with what you eat as a very basic issue. If you eat vegetarian food, non vegetarian food, whatever it is alright. The only precaution which we advise is anything which you eat, if it is going to cause constipation it should be avoided because when you are constipated the bowel pressure if it increases – since the veins of the bowel are connected to the veins in the spine the pressure in the spine goes up and you may suffer with severe back pain or sometimes the pain radiating down the leg.
The healing essentially is of the coating of the disc which has been opened during surgery. This healing will depend on the tissue which is going to heal. This tissue is normally not having much blood supply so it doesn’t heal and that is why the disc problem goes on and on for a long time. But after surgery since we have created an improved blood supply to that area it will heal. The normal healing time will vary from 4 to 6 weeks but in a patient who is very aged and where the healing tissue is very thin and has very very less fibres which help in healing, then the healing time could be as long as a few months. Normally we have seen people coming back to work – generally around 34-35 years of age – and they are able to go back to work very soon because the healing is faster in that age group. If you are a person who is 65 or who is 70 years old then naturally the tissues are very thin and they may take longer time to heal properly and therefore the return to work or return to activity maybe longer.
The stages of recovery are as we advised –
Post operatively we need rest for about a week where the local healing starts and the local swelling goes down.
After a week you can be up and about in the house and start walking around in known areas, that is – where there are ups and downs and dark corners but you are aware of those areas.
Normally around 3 to 4 weeks’ time after the surgery we know that the inside tissue has healed where there is a sealing of the annular opening and there is a complete relief of the swelling of the nerve – which are the stages of healing. The further stage of course is once you are sure that the local operated area has healed we may utilize this information to hasten the further course of physical activity as to bring you back to a fully functional status.
The first factor which affects the healing is activity if you are overly aggressive about activity after surgery since your pain has gone away it may give rise to a flare up and increased inflammation and swelling of the tissue which has been operated which is not advisable. The other factor which helps in a positive was is a good state of nutrition where you may take vitamin supplementations, vitamin D, vitamin B12 and all other vitamins that may be needed. The third factor which normally helps in healing of the tissue is gentle start of exercise as early as 1 to 2 weeks after the surgery. Other things which help are of course being physically fit prior to surgery. Normally we have seen that if a patient is absolutely fit before the surgery which unfortunately cannot be judged or cannot be measured before the surgery because the patient is in pain then the return to work or return to job or activity could be as fast as say about 3 days. Of course we do not advise as a rule for driving before 6 weeks because these surgeries are not to be done again and again. We are not going to do repeat surgeries so healing of the basic tissue is to be achieved and then you can be active and pain free after that for a long long time. Here we must mention that by surgery we are not altering the way your body behaves we’re only altering the local change which has given rise to pain and therefore a person who has a back problem has more likelihood of having the problem again.
Normally after surgery the leg pain goes away as early as a same day or within a day or two once the swelling around the nerve goes away. The pain in the back may linger on till the healing of the annulus is taking place. Normally this healing starts around 4 weeks after our surgery and then the relief of leg pain is generally immediate, the relief of a back pain may take time. We commonly give an example that when you remove a tooth you may have pain in the gums and once you start chewing when the gums pick up strength your pain goes away. So in short the relief of pain in in the leg is pretty early, the pain relief in the back may need certain time and the relief could be as early as same day.
For how many days do I need bed rest after surgery? Normally about a week or so maybe up to 10 days.
Since spine surgery is done can I sleep on my back or my sides after surgery? You can sleep in any position which is comfortable for you.
Is this complete bed rest or can I do certain activities? Normally for the first 10 days we advise you to get up and go to the toilet, take bath and you may sit for the meals. At all other times we advise to lie down in bed so that the quality of healing is much better.
Do I need a specific kind of mattress to sleep on? Absolutely no. The only thing is you should not use a very very thin mattress like a Dunlop mattress because these mattresses are very comfortable but for a long period of time if you sleep in them you may sink in them, there is no resistance to the body therefore the posture is not maintained properly and it may cause pain being very very soft. We normally advice a straight surface to sleep on. It need not be hard, it can be firm, it can be soft but extra soft is also not advisable because it doesn’t really help.
After surgery, we encourage walking within about 3 hours or 2 hours of surgery. Once your high headedness or heavy headedness goes away and you are more comfortable, you can get up and go to the toilet within those first few hours and convince yourself that you are not having much pain or not having any discomfort and you can also go to the toilet on your own and pass urine. Normally this is just to confirm that everything is working well. We do not encourage rigorous walking or brisk walking immediately but it is only to make you comfortable and confident that adequate measures have been taken and your problem has gone away.
You can climb the stairs once you start walking that is within 4 hours of surgery. When you go home if you live upstairs or your house has one or two stories or it’s a duplex house you can definitely go up and down the stairs, it is not a problem. The only thing is it should not be done as a matter of exercise from the day of surgery. You can start exercising as has been mentioned before after 3 to 4 weeks of good healing of the tissue which has been operated. So climbing stars is allowed.
Yes definitely. Normally the healing period which we have observed on an average is about 6 weeks so we advise driving a car after 6 weeks. Riding a bike especially for long distances is a problem of urban life where people need to commute from their house to the work and need to use a two wheeler for a long long distance. This may be possible only after we absolutely confirm that you are free of pain and back has hardened and has healed properly. This normally may take anywhere two and half to three months from the date of surgery. So yes you can ride a bike but after we have made it certain that has healed very well.
We need to understand here that there are three types of exercises – one is to improve the strength, second is to improve the stamina and one is to improve your flexibility. Flexibility and strength are generally required early on after the surgery. We normally advice to start extension exercise that is lying on the belly and raising your chest off the bed which is more to do with flexibility and a little bit of strength at the end of about 3 weeks after the surgery. Other exercises which may be relevant to the type of work which you do can we started after that. We do not consider walking as an exercise we do not consider pranayam as an exercise for the back surgery.
The answer will depend on the type of work which you do but commonly we advise a 3 week period of healing of the annulus. Generally between date of surgery and 3 weeks you are house bound and you are supposed to improve your getting up from bed, standing, walking, doing small things in the house. The first week is absolute rest maximum possible rest. At the end of 3 weeks we start exercises and generally around 4 weeks you can look forward to working. If you are office goer you can go to the office and find out how it suits you on a day or two. If you feel that everything is comfortable sitting especially is comfortable then you can start working around 4 weeks after the surgery. This period would depend on age, your medical conditions, your weight, your body stature, your type of work, etc. but a general thumb rule is you should be able to go back to work between 4 weeks or up to 6 weeks.
The answer to this is unfortunately in human body the healing of annulus cannot be accessed by any particular test or any particular instrument or a gadget. We do not have a machine to tell us whether your annulus has healed or not healed. It’s a matter of judgement of the surgeon and your inputs based on your type of activity and the pain which you get on doing certain things. As a farmer you are likely to be much more manually exacting and stressing your back than a person who is an office goer. In case of a farmer we would suggest about 6 weeks of period would be necessary for healing of the annulus. At the end of 6 weeks we will ask you to do all these activities like bending, sitting, getting up, walking and we will find out what is the time limit which you can achieve when you are doing all these things. For example you are able to sit for 15 minutes, you are able to walk for half an hour, you are able to bend and get up without much of a problem. Then probably around 6 to 8 weeks but extendable up to 12 weeks you will need to completely be ok after healing of the annulus. In some patients at the end of 4 weeks if we find that the pain is not going away as per expectation then we may put in an injection at the site of the surgery to reduce the spelling which is lingering on so that the healing becomes faster. After starting your routine activities you may feel the pain initially because the tissue is hardening and as has been mentioned we cannot really see it from outside or cannot measure it from outside so this would be a simple rule that you can start all your activities with pain as your guide.
A desk job actually is more stressing to the disc because you sit for a long time where your body weight is falling on that disc which is healing. Now when you load the disc which is healing what happens is you may get pain in the back on the sides which may also radiate down to the hip or up to the knee. So what you have to do is you have to take short breaks with during that sitting period. After say half an hour you are supposed to get up and move around a little bit and again you can sit down. This will again go with the same rule as has been mentioned that let pain be your guide. You can do all these things. Specific precautions to avoid pain after resuming work is excessive use of vehicle should be avoided, twisting of the back should be avoided and you should use a chair which will in entirely support your thighs i.e. the seat of the chair should be big and deep enough so that your thighs are fully supported from below when you’re sitting on the chair. Otherwise you can start and you can give a feedback which can tell us what exactly is changing and then fine tuning of activities can be done.
On field job may involve also lifting bags and pushing and pulling etc. so you can start your work generally after 6 weeks of surgery. This of course would vary from 4 weeks to 8 weeks. You can start traveling preferably in a bus or a train wherever you try to avoid excessive vibrations to the back. Using a vehicle is ok after 6 weeks, even a two wheeler can be used after 6 weeks but in all these things you must remember that your body needs time for healing which is not decided by the doctor, it is by it is decided by the speed at which your body works and this is entirely variable from a person to person. You should also eat well, you should also sleep well, you should also take some tonics or supportive vitamin tablets so that the healing process is alright. Normally you should be able to resume work after surgery and start traveling around as I said 6 to 8 weeks. Precautions mainly on the field job is about that lifting bags and weights and long travels without adequate sleep or proper diet that should be paid attention to and you must remember that we are not interested in operating the backs all the time so you should allow the healing properly. Jobs are jobs. They are not lifesavers, so you should first become OK and then look at your job.
Yes absolutely after surgery you can do all these things but we advise that you don’t do these things as a matter of exercise. I mean your day today activity would need you lifting weights. These weights would not be more than say 5 kgs or so. Bending forward to touch something, bending backward to reach something, bending sideways to do something is all fine. You must remember that your body needs healing properly after surgery which could be about 6 weeks. Please try to get a valid advice from a surgeon that everything is healed properly and then start doing all these things. Now after starting doing all these things if you feel that you again getting some pain then you may have to go back in time and may allow more rest so that the thing heels. In some people we have found that after the surgery there is a flare up and there is increased pain at certain locations which may need additional injections or medications. Your body healing is a process which is not directed by the surgeon. It is understood by the surgeon, can be helped by the surgeon but cannot be directed. So we need to understand that it is a shared responsibility of the patient as well as surgeon to do this care after surgery and rehabilitation properly.
Blood pressure, diabetes, heart disease, thyroid problems and other problems are not an issue as far as our surgery is concerned as we operate under local anaesthesia and we do a stitchless surgery. We need to assess you before surgery as to find out your level of fitness for surgery. Now mind you, fitness for surgery and physical fitness are two different things except the word fitness is common. Your heart, your lungs, your kidney, etc. should be working fairly normal within limits which makes you fit for surgery that doesn’t mean that you are fit as in physically fit person. Now being physically fit makes your recovery after surgery very fast within about 4 to 6 weeks but with all these comorbidities the recovery period could be almost double. Complications are more likely with all comorbidities because for a person with diabetes chance of infection is very high, for a person with heart disease and hypertension some complications during surgery like more bleeding is common or even an irregular heartbeat during the surgery is also likely. Thyroid problems normally do not make any issue because they are under control with medications. If there are other problems they need separate consultation and separate attention, normally they should not interfere with the physical act of operating on the back and recovery from that surgery.
After the surgery yes the disc can re-herniate, what I mean is the fragment of nucleus can come out of the annular opening and can give rise to similar complaints. The chances of recurrence in our type of surgery are as low as 2% to 4%. Now why does this occur – number 1 the nucleus that is the central part of the disc can re-fragment that is there could be a break in the nucleus again, which is something again which is mechanical and not because of surgery but the opening in the annulus which is done for the surgery can allow the fragment to come out so the precaution to be taken to avoid recurrence is to allow a proper healing of that tissue which could be 4 to 6 weeks. Many times we have seen that patients are extremely aggressive after the surgery because the pain is relieved and do not listen or do not follow the advise given about the activities after the surgery and the chances of recurrence becomes more. Starting very early activity before the annulus has healed can definitely add to a higher chance of recurrence. If there is a recurrence, the recurrence can be treated by the same surgery that we do before. There is another problem the recurrence can also be because of some residual material inside the disc which is left behind during the first surgery where it has not been removed when it should have been removed. The chances of that in our surgery with the scope going inside the disc are very very low. It doesn’t happen that way. So in addition we are doing our surgery with irrigation with a lot of the saline is put inside the disc to wash out all small fragments which may remain behind. So chances of recurrence after Gore system stitchless surgery under local anaesthesia are very low but we need to take caution of the healing of the annulus and aggressive activity after the surgery.
Back muscles are primarily involved in helping us bend backwards at the same time when we bend forward these are the muscles which help us in maintaining our balance. There are 2 sets of muscles which need to be strengthened after any back surgery. The first set of muscles is called paraspinal muscles and these are strengthened by lying on the belly, keeping the arms by the side and raising the chest off the bed where these muscles are acting against gravity and they become strong if this movement is done repeatedly, so this is the first exercise. The second set of muscles is called as latissimus dorsal and these are the muscles which form the backside wings which you can see in the body builders when they pose after the exercise and bodybuilding. These muscles can be strengthened by chain pulley exercises in the gymnasium or by using weights in your hands and by rotating the weight around your head and shoulder where these muscles become more strong. So these two sets of exercises are essential for strengthening your back.
As a matter of abundant precaution to keep the problem under control any exercise which involves twisting of the back should be avoided. Any exercise where you lie on your back and try to raise your legs straight up should be avoided because the movement has the fulcrum at the area which is causing the pain, so it should be strictly avoided. Other exercise which involve bending in the front and having weights in your hands and getting up from bending position should also be avoided. Normally it has been observed that exercises which have been done without understanding the purpose of exercises. We should understand that the purpose of exercises is to improve your co-ordination of muscles and to rehabilitate the back towards recovery and going back to work. Many times the exercise which are done to prevent progression of pain and when the pain is not very severe and when the patient is not operated but the patient is taking non operative treatment we need to understand that these exercises should help us in controlling the pain and not increasing the pain. Exercises like pranayama and surya namaskar are not relevant to the pain especially the back pain. Normally the exercise is side specific and therefore exercise related to the back related to the neck should be done. Commonly exercises to improve the flexibility the best exercises are yogasans out of which the yogasans done while on the belly are the best for the back pain. Exercises to improve the strength normally involve using the weights and going to the gym and exercises to improve the stamina would include going for hill climbing, for brisk walking, cycling, swimming, etc.
The disc problem in 50 percent of the patients is genetically pre-determined, that is, if your parents have this problem then you are very likely to have this problem early in life. About 30% causes are related to your body stature, weight, posture, type of work, use of vehicles and all other factors. About 20% our related to accidents, sudden jerks to the back, sudden loading of the back, sudden twisting of the back, etc. So apparently doing yoga, going to the gym, walking long distances regularly have nothing to do with the causation of the back pain. At the most what can happen if you’re doing yoga regularly and gym regularly you may delay the process which can give her rise to back pain. At the same time you may have better tolerance to back pain and you will have a better potential to recover from back pain.
Hybrid surgery is a combination of transforaminal endoscopy that is Gore system of surgery stitchless and under local anesthesia with putting the screws to stabilize the unstable segment of the spine. So yes it is partly open surgery but the main difference is in open traditional surgery the midline of the back is opened which makes the back very unstable or weak. In hybrid surgery the opening maybe the side and that too only to put the screws inside. So normally on one side you have 2 cuts which normally need 1 or 2 stitches and on one side you have a little longer cut which may need 3 stitches. Apart from that there 2 more cuts on the side which do not need a stitch which involve the endoscopic access to the spine. This surgery is needed especially because we are trying to stabilize the segment which is affected and this stabilization necessarily has to be done by the use of implants which need to go through the skin inside the bone.
There are various types of implants which can be used for hybrid surgery. One is stainless steel implants which are cheaper but which are a magnetic material so a MRI scan can never be done after the surgery. The other implants are made up of titanium but these are expensive because titanium is an alloy which is very light in weight but very very strong as compared to stainless steel. We commonly use implants which are made up of titanium. These are expensive but the surgeries are done in elderly people and the implant should last for whole life, we don’t have to revise them and if at all we do have to an MRI scan later on in life it should not interfere with this imaging. So the implants which are used are titanium implants in hybrid surgery. Commonly we use 4 screws 2 rods and a polymer cage. The cage is like a coin like structure which goes between the vertebral bodies. These cases are made up of polymer and are put between the vertebral bodies through a opening on the side.
Hybrid surgery is a bit more morbid than stitchless surgery under local anesthesia done by Gore system. Normally we have a tube in the back called as epidural catheter. This catheter is put prior to the surgery and its used to give local anesthesia or epidural anesthesia during the surgery. The specialty is we use a medication called as ropivacaine where the patient is able to move the legs even during the surgery if necessary. After the surgery the tube continues to be the in the back for at least a day or two to control the pain of the surgery. Normally the first 24 to 48 hours the pain is quite a bit and it needs use of this epidural anelgesia that is pain killing effect for that duration. When the pain reduces considerably generally by the third day morning we make the patient walk and once the patient is able to walk without much difficulty then we send the patient home. After going home the patient has to be in bed for most of the time. The patient may get up to go to the toilet sit for the meal time otherwise the patient is expected to lie in bed and rest. After a week or so when the patient gets enough confidence to walk around and is painless then the patient can be up and about, can move, can stand, can sit and go around the house in unlimited way. In general, the implants or the screws and plates which are put inside need time to become strong. This time could be as long as 12 weeks or about 3 months from the date of the surgery during which period the patient is allowed to walk but he or she should not strain the back. Exercises are normally started after a month or so after the surgery. Generally patients are back to their usual routine within about 3 months of the surgery when the implants and the bone bone graft and the cage which has been put inside consolidates, solidifies and becomes one with the surrounding bones.
The healing period as has been mentioned is close to 3 months from the date of surgery where the bone grafts which are put inside the time to consolidate and unite with the parent bone that is the vertebral bone or the fusion or the stabilization is complete. This can be confirmed by use of x-rays or CT scan after the surgery. Normally the time period is an average time period so it may extend anywhere up or down but commonly it is about 3 months. It is very common to observe that in female patients the quality of bone is not good, the bone is porous or there is osteoporosis in which case we supplement our surgery with an injection of teriparatide which is parathyroid hormone which improves the strength of the bone, strength and solidity of the bone. It is necessary to have the bone very solid otherwise the implants which are put inside the bone may loosen very fast and may be ineffective and the surgery may not help the patient in overcoming the problems.
The investigation which we do before surgery are commonly – 1. We ask for the x-ray of the lumbar sacral that is a lower part of the back which tells us about the quality of the bone, which tells us about the stability of the spine whether there is any need for hybrid surgery, etc. 2. We need to have a MRI scan if not done before as to confirm the location, the type and the extent of the problem in the back be it disc herniation or an annular tear or instability of the back in addition to a lumber canal stenosis where the measurement of the canal can be done in the MRI scan. We have to note here that many times the MRI scan reports are misleading because them MRI scan specialist does not examine the patient and does not treat the patient so the significance of what is seen in the MRI and whether it should be treated or not treated and how it should be treated is entirely decided by the clinician. Investigation no. 3 is normally a post void residual urine estimation on an ultrasound. What we mean is a patient goes to the toilet and passes urine as usual. Commonly the patient has a lumbar spine problem there may be weakening of the nerves which control the emptying of the bladder and therefore some urine may be left behind in the bladder. This amount is estimated by ultrasound after the patient has been to the toilet. In a female patient – 60 ml and in a male patient – 100ml in absence of any prostrate pathology is taken as a significant amount of post void residue which indicates that the nerves functioning for the bladder are weak. This weakening may worsen around or after the surgery so the patient is cautioned for the need for a catheter prior or after or during the surgery. Investigation number 4 which is commonly done is an EMG and a nerve conduction study. This indicates the voltage pattern of the nerves which are involved which come down from the back to the leg or from the neck to the upper limb and estimation of the voltage of the nerve and velocity of conduction of the nerve tells us about the functional effect of the legion or the problem which we see in the back. This functional estimation helps us further in estimating the amount of surgery, the likely outcome of the surgery, etc. It also helps us in distinguishing between common person who is non-diabetic and a person who maybe having diabetes of a long duration. In patients of diabetes of long direction there’s a distinct entity which could be a proximal weakness of the muscles or polyneuritis that is multiple nerves involved with the swelling which may affect the nerves and which may give rise to numbness in the foot, and other changes in the skin, in the hair pattern, in the sweating pattern etc. So distinguishing diabetic neuropathy from a normal patient is also important. The other investigations which are done prior to the surgery are to find out the patient’s ability to breathe properly and the heart function which is normal so it may include an echo cardiography, x-ray of the chest and routine lab investigations to confirm that the blood sugar etc. is normal.
EMG is Electromyography which is similar to an ECG which is done for the function of the heart. Electromyography tells us about the function of the muscle which is supplied by a nerve. You can understand that if your back has a problem and the nerve coming down from the back to the leg is affected then it is very likely that this nerve may – the affection of the nerve may give rise to weakness of the muscle and slowing of the conduction of the nerves which can be easily detected by the EMG – NCV test. As mentioned before this test also helps us in distinguishing between a back problem and diabetes and it also localizes the back problem that is if there are multiple levels in the spine like L1, L2, L3, L4, L5 which are affected by the spinal element then to distinguish which is the one which is causing the major problem can be done by doing this EMG which can tell us that the nerve at L4-5 is affected the most.
Our bladder holds urine inside our lower part of our belly and when we go to the toilet and pass urine and the urine comes out where the bladder becomes totally empty in a normal person. In the person where the nerves are affected, some of the nerves which control the bladder also may be affected where they may become weak and this weakening of these nerves may make the bladder function in a very slow fashion where even after going to the toilet and passing the urine the whole amount of the urine may not come out, some urine may remain inside the bladder – this is called as post that is after void that is passing urine residue that is remaining urine. So we estimate this amount of urine by doing a USG that is ultrasound examination. Now Ultrasound examination is a non invasive examination, it does not need any cutting or any injection or anything, it is very commonly available. So any person who is above the age of 65, we normally send for an estimation of the post void residue. If the post void residue is above 60 cc in a female patient or above 100 cc in a male patient it also helps us in conveying to the patient that the surgery or the intervention that you have thinking is urgent because if we do not do the surgery in time it is very likely that the patient may worsen. Sometimes this worsening of the bladder related nerves may not recover in spite of surgery. So to decide whether the surgery should be done now or later and to know whether the surgery is going to affect function of the bladder further or the bladder function is going to worsen further this test is necessary. If the post void residue is very high then there’s a very very common chance but the patient may need a catheter inside the bladder prior, during and after the surgery and it may have to be put for a long long time for which the patient has to be mentally ready. In the past this investigation was not done and many times it so happened that the patient underwent the surgery and after the surgery the nerves became weak or further weak and the patient needed a catheter after the surgery because the patient could not pass urine. This then was blamed on the surgery whereas the problem was present even before the surgery. So it is necessary to be sure that we are dealing with a status which is normal or with a problem.
The answer is in a society everyone is not the best. If we go by standard deviation out of 100 people – 80 people are average, 10 people are below average and 10 maybe above average. The surgery which we do with our system is essentially very very above average and it would need a special training to use this system. Unfortunately as this system has evolved from private practice of Dr. Gore and his seniors this system is not taught in the medical schools as yet in spite of repeated efforts by Dr. Gore from institutions like All India Institute of Medical Sciences to various medical colleges in the country mainly in the south and also in the north. The common work which is done by the spine session for ages has been open spine work and there is a gross industry dominance in the decision making where most of the surgeons are under the effect of thinking where the use of screw is taken as a given. In addition our surgery the decision making is a shared decision making shared between the surgeon the patient or the counselor and the patient not based entirely on the MRI scan. Decisions based on the MRI scan which is normal for the traditional open surgery under general anesthesia. So this surgery will be taking up by somebody who understands the limitations of tradition surgery, who is open enough to overcome those limitations and who has courage and who has devotion and focus enough to pick up the new system of surgery which is not a very common and which is not seen as yet in everyone. The number of surgeons who have been taught about this in our country are more than 600 and as of today as per our knowledge there are more than 100 people who are doing this surgery routinely in our country. World over this is a very popular type of surgery especially in Germany, in Korea and in USA. We need to understand that technology is changing and we are trying to understand the suffering of the patient in a better fashion and we are absolutely sure that our technique and technology and philosophy is the best today to alleviate the problems of the patient.
This surgery is developed by Dr Gore after he learnt from Dr Yeung. It is in vogue for more than 44 years but is eveolving. In its present form it is available in india for last 20 years, since it is still not taught in med schools it is not widely availble.