Institute of Advanced Spine Sciences

Selective Nerve Root Block

A Selective Nerve Root Block injection is used to diagnose or treat pain in an inflamed spinal nerve. Typically, a medication (an anesthetic or an anesthetic with a steroid) is injected at a specific root nerve. This is done under fluoroscopic or X-ray guidance. If the injection reduces the amount of pain the patient experiences, the source of the pain becomes clear. The procedure could also trigger discomfort and pain and the patient is usually required to be awake during the procedure to explain their symptoms. After the procedure, the patient may feel some muscle weakness but this should fade away in a few hours.

For treatment purposes, steroids are usually mixed with the anesthetic in the selective root block injection. Steroids work to inhibit the actions of certain enzymes that cause pain and block C-fibers in the nerve to reduce transmission of pain. This is useful in treating patients with cut was well as chronic pain.

Transforaminal Epidural Cortisone Injections

Epidural glucocorticoid injections are used to treat leg and back pain non-surgically. The method has been proven to relieve pain, improve mobility and buy time for the body to heal, and become stronger to handle surgery. It is usually suggested only if conventional pain-management methods have been tried and proven ineffective.

During a Transforaminal injection, a small gauge blunt needle is injected into the epidural space through the bony, spinal opening for the existing root nerve. The procedure is performed with the patient lying on their abdomen, under real-time fluoroscopy or X-ray guidance. This helps ensure that the glucocorticoid is placed in the correct location. The patient is sedated but awake during the procedure, as the patient needs to give feedback to the doctor about their pain levels.

A Transforaminal epidural cortisone injection is a safe, minimally-invasive non-surgical technique for pain relief for lower-back or leg pain.

Cervical Medial Branch Blocks

The spine has small bony joints called facets, connecting the different vertebrae. These facets enable movements like bending and twisting and provide stability to the back. These joints can also become arthritic or cause pain in the joints in the arms and legs. The goal of a cervical medial branch block is to determine if the patients back pain originates from the facets of the upper spine.

The Cervical medial branch block is performed by injecting an anesthetic to temporarily block any pain signals from the medial nerves in the upper back. The injection is administered under X-ray to ensure proper placement.

After the procedure, the patient is usually kept for observation for a few hours and then discharged. The patient may be asked to maintain a pain journal to record the time, duration, location and intensity of the pain, as well as when they feel noticeable relief. If the patient experiences relief from this procedure, their pain is likely facet-related and they may be recommended radio frequency ablution therapy for long-term relief.

Discography

A lumbar discography is performed on patients with severe, persistent back pain, to locate it source. It is performed when conventional methods of alleviating back pain, such as medication or physical therapy are ineffective. The procedure is usually performed before a spinal fusion. The advantage of a discography is that it isolates the location of the pain and allows the surgeons to plan a better surgical approach.

During the discography, the radiologist injects a dye into the spinal disc with CT or MRI visualization and observes the patient’s pain response. The patient is awake and responsive during the procedure, and asked to describe their pain level and location. The process is repeated on each of the discs to be examined to isolate the source of the pain.

Discography is designed to replicate the pain the patient usually experiences, so a certain amount of pain is to be expected during the process. The doctor may give patients a mild sedative to keep them calm.

Ortho-biological therapies (PRP)

Platelet-rich Plasma Therapy (PRP) is a cutting-edge therapy, with scientific evidence suggesting it supports accelerated healing of spinal fusions and other bone fusion surgeries. PRP therapy uses the patient’s own platelets to accelerate tissue growth by increasing the concentration of the body’s natural growth factors.

PRP injections are prepared by passing a small amount of the patient’s blood through a centrifuge. This concentrates the plasma and platelets into a clear fluid. This fluid is then injected directly into the site of injury. Injections of PRP in the spine are performed under X-ray guidance to ensure accurate placement at the affected site.

Platelet-rich Plasma Therapy has proven effective in improving recovery rates of patients who have undergone spinal fusion. PRP offers decreased inflammation, shorter recovery time and negligible risk of side effects. While undergoing Platelet-rich plasma therapy, the patient must avoid anti-inflammatory drugs, as these will interfere with the natural healing process.

Medial Branch Blocks (Facet Joint Blocks)

A medial branch block procedure is performed to diagnose as well as treat persistent back pain due to facet joint degeneration. The procedure is performed by injecting a local anaesthetic to temporarily block any pain signals from the nerves supplying the small joints in the back. The injection is administered under X-ray guidance to ensure proper placement.

After the procedure, the patient is usually kept for observation for a few hours and then discharged. The patient may be asked to maintain a pain journal to record the time, duration, location and intensity of the pain, as well as when they feel noticeable relief. Based on the time taken for the recurrence to occur and its frequency, the doctor will decide on the course of treatment.

Laser

The concept that energy from laser beams could reduce inflammation, improve cell regeneration, relieve pain, relax muscles and stimulate nerve regeneration seems counter-intuitive – but medical science has a significant body of evidence to support laser therapy. During a Percutaneous Laser Disc Decompression (PLDD), lasers are used to remove the masses of tissue compressing the nerve in the disc associated with the back pain. The nerve compressions could be caused by herniated disks, tumors, or any other soft tissue growths.

Less invasive than a traditional open-surgery approach, laser surgery has quicker recovery time and less chances of post-operative infection. Laser spinal surgery is done under local anesthesia. In some cases, the patient may be sedated. It can be performed in an out-patient setting. The patient recovery time varies but is usually about 6 weeks. Additional follow-up surgeries are often to be expected when undergoing a Percutaneous Laser Disc Decompression.

Radio-frequency Ablation

Radio-frequency Ablation (RFA) is a minimally invasive, out-patient procedure that destroys the small nerve fibers carrying pain signals to the brain. It can provide lasting relief for patients with untreatable chronic pain, especially in the lower back, neck and arthritic joints. Radiofrequency ablation, also known as Rhizotomy, uses heat to ablate or “burn” the small nerve endings, eliminating the transmission of pain signals to the brain. The procedure is performed under fluoroscopy or X-ray guidance by a radiologist.

Radio-frequency ablation is recommended to patients who experience pain relief after a diagnostic pain/nerve receptor blocker injection. Before the procedure, the doctor reviews the patient’s medical history and does a series of imaging tests to ascertain the best location for ablation. Patients who are on blood thinners or aspirin must stop taking their medications a few days before the procedure, as advised by the doctor.

Cryotherapy

Cryotherapy is the use old cold therapies to manage acute pain from musculoskeletal injuries. Cryotherapy can be applied in various ways like icepacks, coolant sprays or gels, ice baths or whole-body cryotherapy. Cold therapies are effective in relieving pain as they reduce neural activity, reduce the blood flow to the skin, and thus reduce pain and inflammation. Cryotherapy may be combined with rest, compression and pain medication.

Posture Correction and Biomechanics Clinics

Good posture plays a part in reducing strain on the skeletal system and muscles while performing basic activities like standing, sitting or lying down. Poor posture can cause neck pain, upper and lower back pain, knee pain and poor foot function. The Posture Correction and Biomechanics clinic at Gleneagles Global Hospital in Chennai focuses on addressing this problem.

At the Posture Alignment and Biomechanics Clinic, the root cause of the pain is identified and the related postural imbalances are all corrected. The clinic is equipped with cutting edge imaging and diagnostic tools to assess the posture and alignments of the patient’s body. The doctor will prescribe the relevant postural corrections and exercises to help counter the mis-alignments found. The techniques used may include mobilization, manipulation or Muscle Energy Techniques (MET). All the treatment programs are designed to maximize range of movement and reduce chronic pain.

Kinesiology

Kinesiology, in medicine, is the science of human movement (The literal Greek translation is movement science). Kinesiology is a non-invasive, holistic therapy, combining eastern massage techniques with modern muscle monitoring. The detailed knowledge of muscular anatomy, mechanics and neural physiology that our doctors possess helps them gain deeper insights into mechanical injuries, how they were caused and the corresponding treatment.

The kinesiologist starts with a consultation with the patient, in which they go over medical history, challenges, lifestyle patterns and needs. The kinesiologist then has the patient lie down on the examination table and works on balancing the stresses indicated during the consultation. Kinesiology operates on an evidence-based treatment model known as active rehabilitation. Progressive therapeutic exercise and a range of motion techniques are used to help overcome injuries.

Prolotherapy

Prolotherapy, also known as proliferation therapy or regenerative injection therapy, is an alternative therapy for pain management, where a dextrose or saline solution is injected into the painful joint. Prolotherapy has been used to treat arthritis of the knees, hips and fingers, degenerative disc disease, fibromyalgia, sprains, strains and muscle aches.

Prolotherapy can help reduce pain and stiffness in the affected joint and improve its strength, function and mobility. Prolotherapy practitioners say the irritation caused by the saline or dextrose solution helps stimulate the body’s natural growth response, leading to the growth of new tissues.

Bracing

A back brace is an external support used to stabilize one or more portions of the spine. It can help relieve pain and pressure on the injured portion of the spine and help to ensure healing in correct alignment after surgery. A back brace may be customized by the doctor or a non-prescription over-the-counter brace may be recommended for purchase.

The back brace is typically designed to provide stability and additional spinal support. It also reduces load on the vertebrae and the discs. A back brace is often an important component of the recovery process.

Traumatic Spinal Cord Injuries – A Comprehensive Management

A traumatic spinal cord injury is a sudden injury leading to major damage to the spinal cord, usually with a spinal fracture and possibly resulting in paralysis. Traumatic spinal cord injuries could be caused by road or industrial accidents, sports injuries and accidental falls. A complete traumatic spinal cord injury occurs across the whole spinal cord width and results in complete paralysis below the trauma. An incomplete traumatic spinal cord injury results in only a partial-severing of the spinal cord, resulting in partial paralysis below waist level.

Patients with traumatic spinal cord injury have their spine immobilized, to prevent further injury from movement. Once stabilized, the patient’s pain is addressed with the appropriate medication. The patient is also kept under regular neurological observation. The doctors attending to the trauma will address and treat the patient as needed, surgically or otherwise. In the absence of any neurological deficits, a conservative approach of bed rest, immobilization, cervical collars, traction and rehabilitation is recommended.

Diet and Nutrition

Diet, nutrition and maintaining a healthy weight are essential components of balanced spinal health, especially in the elderly. The reasons for poor nutrition in geriatric patients could be due to a combination of the physiological, psychological and social changes associated with food intake and body weight as they age. The structures in the spine need correct nutrition to support the body and perform properly. The consumption of calcium, magnesium, vitamin D3 and B12 in the diet is crucial for good bone health. Including lots of leafy greens, eggs, cod liver oil, and meaty proteins in the diet is recommended. The geriatric spine care program covers a comprehensive dietary regimen designed by the in-house nutritionists.

Psychiatric Mental Health Management

Most geriatric patients experience some deterioration in motor function and cognitive abilities as they age. Coupled with the state of being ill and possibly constant pain, the slowing down of functions can cause confusion, depression and hopelessness. This is why the elderly in particular require mental health support. Patients may be unwilling or unable to communicate the extent of their pain. The trauma of having a chronic illness, fear of pain and suffering can take a very large toll on the patient. The presence of good mental health resources is also associated with more effective recovery from surgery.

Fitness Training

As humans age, the requirements of their bodies change and require specialised attention. Geriatric patients are typically afflicted with arthritis, osteoporosis, decreased balance (making them susceptible to falls) or wear-and-tear of the joints. In addition to this, most senior citizens tend to lead a sedentary, inactive life. Geriatric physiotherapy focuses on restoring mobility, increasing fitness and stamina levels, reducing pain and maintaining balance and co-ordination. Fitness training is essential to help geriatric patients maintain their strength and ability to function independently. The training focuses on strengthening the musculoskeletal system as well as the nervous system.

Osteoporosis

Elderly patients with osteoporosis often do not discover the condition until they experience a fall. The weakened muscles and bones can lead to severe injuries resulting in vertebral fractures. Fractures in geriatric patients have a high morbidity rates, so this is of concern. Timely screening for osteoporosis and regular check-ups can help to prevent the onset of this condition

Vertebroplasty/Kyphoplasty

A Vertebroplasty is a minimally invasive procedure used to stabilize an osteoporotic vertebral compression fracture. The doctor performs the procedure by injecting a cement mixture into the fractured bone, under the guidance of fluoroscopy or X-ray imaging. Kyphoplasty achieves the same objective, but by inserting a balloon catheter into the crushed vertebrae to create a hollow under fluoroscopy, into which surgical cement is injected.

Vertebroplasty and Kyphoplasty procedures are effective in the treatment of vertebral compression fractures, vertebral compression due to a malignant tumour or osteoporosis due to long-term steroid use or a metabolic disorder.

Percutaneous pedicle screws

Percutaneous pedicle screw fixation is a minimally invasive surgical procedure to implant rods and screws in the vertebrae to stabilize the spine. The pedicle screws are inserted into the spine through very tiny surgical incisions in the skin. This technique is sometimes used during a spinal fusion surgery in which a fragment of transplanted bone is used to encourage the vertebral fusion. Percutaneous pedicle screw fixation is performed under general anaesthesia. Modern techniques use navigation or robotic assistance and fluoroscopy to place the screws accurately. The percutaneous technique is advantageous as infection rates are lower compared to traditional open surgery.

Endoscopic Suture-Less Spine Surgery

• Spine Surgeries

Endoscopic suture-less spine surgery is a cutting-edge minimally invasive technique where the spinal cord is operated on through a small incision. This ensures only the target area is affected during surgery and no unnecessary trauma is caused to the surrounding vertebrae, muscles and ligaments. While endoscopic surgical techniques have been prevalent in the treatment of other organs, like the gastrointestinal system, the advancement of spinal imaging technologies has brought this technique to the forefront in the field of spinal surgery. Endoscopic surgical techniques are not the same as other minimally-invasive spinal surgery techniques – It involves the use of small tubular retractors and an endoscope through a micro-incision (smaller than an inch). Minimal muscle damage, minimal scarring, negligible blood loss, minimal need for pain medication and fast recovery to active life are major advantages of Endoscopic spine surgery.

• Disc Prolapse

A spinal disc is said to be prolapsed or herniated when the outer fibres of one of the intervertebral discs are injured and the soft nucleus pulposus bulges out of place. The nucleus pulposus could can enter the spinal canal and compress the spinal cord and the spinal nerves. This could result in pain, partial numbness and tingling of extremities. Prolapsed discs can occur in any part of the spine; however cervical and lumbar disc prolapses are more common than thoracic disc prolapses. Intervertebral disc prolapses could be caused by sudden trauma or blunt-force impact to the buttocks and lower back. Trying to lift a heavy object without bending at the knees could also cause similar traumas which are known as acute disc prolapses. In some cases, the damage to the outer fibers of the disc happens gradually, over the course of many years. About 80% of cases with prolapsed discs resolve themselves naturally in 6-8 weeks without major medical interventions. Acute prolapsed discs are always treated conservatively at first, with pain medication and physiotherapy. If the patient doesn’t respond to the medication and physiotherapy, surgical interventions may be considered by the doctor.

• Canal Stenosis

Spinal stenosis is an age related narrowing of the canal within the spine, causing excessive pressure on the spinal nerves. Spinal stenosis is typically caused by wear-and-tear in the spine, associated with osteoarthritis. Spinal stenosis is most common in the lumbar and cervical parts of the spine. Cervical spinal stenosis causes neck pain, numbness or tingling in an arm or foot and difficulty with balance. In extreme cases, the patient may experience incontinence. Lumbar spinal stenosis causes back aches, numbness or tingling in an arm or foot and leg pain and cramps. Canal stenosis may be caused by the formation of bone growth spurs due to osteoarthritis, herniated discs, thickened ligaments around the vertebrae or spinal injuries.

Motion Preservation Surgeries

The primary objective of motion preservation surgeries is to maintain normal or near-normal levels of movement in the spine while reducing complications and the need for a second surgery. Near-normal mobility of the spine is maintained by decompressing spinal nerves, stabilizing the vertebrae and balancing vertebral alignment. Motion preservation surgeries attempt to closely replicate normal spinal biomechanics. This is more complicated in the spine than in the joints as the functional unit of the spine is more complicated.

Instrumented Fusion Surgeries

Instrumented spinal fusion surgeries are a set of procedures in which the surgeon uses instruments such as plates, rods and screws to fuse the vertebrae back together. It is performed on adult and paediatric patients with spinal trauma, degenerative spinal diseases or deformities like a scoliosis or kyphosis. The objective of the instrumented fusion is to create a “bone bridge” connecting the segments of the spine above and below the injury. To create this “bridge” the surgeon places bone grafts along the injured portion of the spine.

The instruments used in instrumented spinal fusion procedures are made of titanium, stainless steel or cobalt chrome. The implants provide immediate strength and stability, but will not continue to keep their strength long-term. Long-term spinal stability is achieved by good fusion of the bone grafts over the length of the injury.

• Minimally Invasive Spine Surgery (MISS)

Minimally-invasive Spine Surgery (MISS) is a type of spinal surgery performed using a series of smaller incisions compared to traditional open surgery. This method causes less harm to surrounding tissue and results in less pain and a quicker recovery. Minimally invasive spinal surgeries are performed using tubular retractors. The tubular retractor is inserted in the incision, and creates a “tunnel” to the affected region of the spine, through which other surgical instruments can reach the targeted area.

• Minimally invasive – Transforaminal Lumbar Inter body Fusion (MISS-TLIF) – Transforaminal Lumbar Inter body Fusion is a technique of spinal fusion, performed through micro—incisions in the sides of the spine that align with the Foramen, where the nerves exit the spine and travel to other parts of the body. This technique is primarily used to stabilize the spine and relieve pressure on the spinal nerves.
• Oblique Lumbar Inter body Fusion (OLIF) – An Oblique Lumbar Inter body Fusion is performed to correct issues caused by degeneration in a spinal disc. The surgeon carefully removes the damaged disc, and implants an inter body device in its place. The inter body device is packed with a bone graft, and it lifts the vertebrae into proper position and alignment. Then additional instruments such as plates, rods and screws are used to stabilize the spine. As the patient heals, a solid bone fusion forms over the inter body device and the instruments. The oblique lateral approach to the spine enables placement of a large inter body graft on the strongest part of the vertebrae.
• Anterior Lumbar Inter body Fusion (ALIF) – Anterior Lumbar Inter body Fusion is a spinal surgery that takes an anterior (front) approach through the abdomen. The procedure can be performed using minimally invasive techniques. The anterior approach allows the surgeon to remove the degenerative disc completely and place the interbody graft in compression, resulting in better fusion.

• Open Spine Surgery

Open spine surgery is a traditional approach to spinal surgery, where the surgeon operates through a large incision in the back or abdomen. The surgeon creates an incision and retracts the surrounding muscles to gain direct visualization of the spine. While minimally invasive techniques have gained popularity in recent years due to quicker recovery time and fewer co-morbidities, the open approach is still required to perform procedures that cannot yet be performed with minimally-invasive techniques.

• Pedicle Screw Fixation – A pedicle screw is a spinal implant used to grip different spinal segments together. The screws act as anchor points that can be connected with a rod. The rods temporarily stabilize the spine. The surgeon also implants spinal grafts that will grow around the injured spine segments. This is known as spinal fusion. An inter body fusion is performed typically when there is disc herniation. The herniated disc is removed and an inter body cage with bone grafts is inserted and placed in its position. The bone graft gains strength and creates the spinal fusion.
• Transforaminal Lumbar Inter body Fusion (TLIF) – Transforaminal Lumbar Inter body Fusion is a spinal fusion surgery performed via a 6-inch incision in the lower back. It is performed to remove a degenerated spinal disc and repair it with an inter body cage fused with a bone graft. This technique is primarily used to stabilize the spine and relieve pressure on the spinal nerves.
• Anterior Lumbar Inter body Fusion (ALIF) – Anterior Lumbar Inter body Fusion is a spinal surgery that takes an anterior (front) approach through the abdomen. The procedure is performed through a 3 to 5-inch incision in one side of the lower abdomen and the abdominal muscles are retracted to access the spine. The anterior approach allows the surgeon to remove the degenerative disc completely and place the inter body graft in compression, resulting in better fusion.

Spinal Deformity Correction

Spinal deformity correction surgeries are complicated procedures with a high complication rate. This is due to the unique approach and delicacy each case requires. A spinal deformity is any variation in shape or structure of the spine, when compared to the typical form. Scoliosis is an abnormal sideward curvature of the spine while Kyphosis is an abnormal forward bending of a section of the spine. Often there may be a combination of scoliosis and kyphosis in a patient.

• Paediatric Spinal Deformities

Children may experience a range of spinal deformities such as scoliosis, kyphosis, and spondylolisthesis. Common symptoms of paediatric spinal deformity include asymmetrical appearance of trunk, walking with a “waddle” or the growth of a “hunch-back” or sometimes pain. Paediatric spinal deformities require delicate and skilled treatment and correction.

• Growth rod – Shilla

The Shilla technique is beneficial because it allows the spine to grow naturally, while still correcting the trauma or misalignment. The Shilla is like a track-and-trolley system. The implant rods are partially fixed to the spine segments, allowing the implant to “grow” with the spine. As the spine grows and lengthens, the rods are intended to break. Once the rods break, the patient may be fitted with a new Shilla or be recommended a spinal fusion procedure.

• MAGEC rods – Magnetic growing rods

MAGEC rods are Magnetic Expansion Control Rods used in the treatment of spinal curvatures, in very young children. The MAGEC system combines the idea of traditional growing rods with an extendable, magnetic technology. With traditional rods, the paediatric patient would outgrow it very quickly, requiring revision surgery every 6-12 months. However, that is avoided with MAGEC rods. The MAGEC rods are made of magnets, with a built-in motor that allows extension to occur. The doctor uses a powerful external magnet to control the MAGEC rods in the patient’s spine, extending it as needed.

• Navigation assisted spine surgery

Navigation assisted spinal surgery is a group of technologies which allow the surgeon to obtain real-time scans and 3D imaging of the spine to enable the correct location of the surgical instruments. The goal of navigation assisted spine surgery is to provide the surgeon with as much visualization as possible to increase accuracy of the surgical intervention. With a sensitive organ like the spine, this is path-breaking. The benefits of this technique include safer and more accurate surgical interventions and reduced surgery time.

• 3D Printing

3D printing has revolutionized medical prosthetics. 3D printing technology allows the surgeon to design a prosthetic that perfectly fits the patient. 3D printed implants are especially useful in the treatment of spinal deformities, where each deformity is unique. In such cases, reconstruction using standard implants is difficult.

• Intra Operative Neuromonitoring

Intra Operative Neuromonitoring (IONM) is the use of electrophysiological methods like EEG, EMG etc. to monitor the function of integral neural structure like the spinal cord, important nerves and parts of the brain during surgery. Intra operative neuromonitoring reduces the risk of damage to the nervous system during surgery, and helps surgeons get better visualization and real-time patient-status.

Spinal Cord Stimulator

Spinal cord stimulator is a biomedical device implanted in the spine that emits low-level electronic signals to relieve pain. The implant is controlled by an external remote that the patient can use when they feel pain. Many patients describe the sensation of the spinal cord stimulator as a slight tingling sensation that replaces the pain. Spinal cord stimulators are usually recommended to patients with severe back pain, for whom conservative, non-surgical treatment options have not produced significant relief. Spinal cord stimulators can greatly improve a patient’s quality of life and reduce dependence on pain medication.

Complex Spinal Tumour Surgeries

Spinal tumours are abnormal growths of tissue in the spinal column. Tumours in the spine may be malignant or benign. Depending on the location and nature of the tumour, the treatment may include chemotherapy, radiation therapy and surgical removal of the tumour. Surgery is usually recommended if spine stabilization is needed or if there is nerve compression. The surgeon may perform a partial or complete tumour resection. Once the tumour is removed, the surgeon may use a spinal fusion to stabilize and reconstruct the spine.

• Rehabilitation Medicine
• Physiotherapy
• Occupational Therapy