Dr. Manish Raj MD,DA,FISP,FPM Minimally Invasive Spine & Pain consultant

Fellow of Interventional spine & pain(Pci-Mumbai) Fellow of Pain manganement (FPM-Aesculap Germany)

Member- North american spine society(NASS) -Society of minimally invasive spine surgery(SMISS)

• About 85% of Indians experience back trouble by age 50.

• Back problems are the most frequent cause of activity limitations in working-age adults

• In the long run, surgery, chiropractic care, etc., are considered no more effective than no treatment in reducing low back pain…so, prevention is key!

Back facts in general…

Overview Introduction

Anatomy

Causes of LBP

Prevention

Recent Advances in Treatment

BACK & NECK PAIN One of the most common chronic conditions in India

Frequency in men & women are equal

4 out of 5 Indians will experience LBP or Neck Pain

Acute: 6 weeks

Chronic: > 6 weeks

Anatomy

Spine: 33 vertebrae

7 cervical (neck)

12 thoracic

5 lumbar

5 sacral (fused)

4 coccygeal (tailbone)

INTERVERTEBRAL DISC

Fibrocartilage

Functions:

Absorb shock

Allows increased spinal range of motion in flexion/ extension

NERVES Nerves come out of holes between vertebrae

MUSCLES & Connective Tissues Spine is supported by bones, muscles and connective

tissues

Injury to any structures previously

mentioned in the Spine

region

How do you get low back pain?

• Poor body mechanics

• Stressful living & work habits

• General physical fitness decline

• Loss of flexibility

• Loss of strength

Leading Causes of Back Problems

General joint stiffness

Acute strains and sprains

Muscle guarding or spasm

Disc bulge herniation

Degenerative disk disease

Osteoarthritis

Common Back Disorders

A other ause of a k pro le s…

accidents

It is also possible to injure your back due to accidents.

Back Strain/ Sprain

Disc Injury

Discs have sensory pain receptors

Discs can:

Degenerate

Bulge/ herniate

Most easily injured with flexion

& rotational forces

Fractures

Less common

Usually occurs with major trauma or as a result of a pathology

Fall from a tall height

Osteoporosis

Cancer in the bone

Infection of the bone

Risk Factors

Pregnancy

Poor physical conditioning

Poor movement techniques

Poor posture

Occupation

Previous back injuries

Others – spinal disorders (e.g. scoliosis, osteoporosis, spondylosis)

Causes - Summary

Any injury to supporting & surrounding structures Muscles

Ligaments

Joint

Bones

Intervertebral discs

Nerves

Maintain good physical condition Ideal weight, maintain good muscle strength,

endurance, and cardiovascular endurance

Proper diet/ nutrition

Proper lifting techniques

Proper posture

Avoid smoking Decreases blood flow

Maintain good core strength

Prevention

Prevention: Posture

Prevention: Posture Sitting posture

Prevention: Posture

Prevention: Proper Lifting

Prevention: Proper Lifting

Disc Herniation

Treatment options for Slip disc -Selective root sleeve transforaminal Epidural steroid

-percutaneous mechanical decompression:

-Decompressor STRYKER

-Nucleotomy

-Hydrodiscectomy

-NUCLEOPLASTY

-Laser Discectomy etc

-ozone discectomy

-IDET(intradiscal electrothermal coagulation)

-Disctrode(Intradiscal radiofrequency)

-Biacuplasty

-ENDOSCOPIC DISCECTOMY

-MIS fusion(percutaneous TLIF)

- Open Surgery(Microdiscectomy,laminectomy,fusion)

TFESI (EPIDURAL INJECTION)

OZONE DISCECTOMY

HYDRODISCECTOMY

DECOMPRESSOR DISCECTOMY

Intradiscal Electrothermal

coagulation (IDET) & LASER

NUCLEOPLASTY

Optimal Patient Selection

Radicular pattern with or without Axial Pain Leg pain > back pain

MRI evidence of contained disc protrusion

Discography positive, if indicated

Failed selective nerve root block x 1

Failed conservative therapy X 3 months

Axial Back Pain Failed conservative therapy X 3 months

MRI evidence of contained disc protrusion

Discography positive for concordant pain

Failed diagnostic injections (facet, nerve, epidural etc)

Disc height > 75%

Exclusion Criteria 50 % loss of disc height

Extruded or sequestered disc

Spinal fracture or tumour

Moderate to severe spinal stenosis

Complete annular disruption

Degenerative instability

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Clinical Outcomes After Lumbar Discectomy for Sciatica: The Effects of Fragment Type and Annular Competence EJ Carragee et al., Stanford University , The Journal of Bone and Joint Surgery. Jan 2003

Are Nucleoplasty and Microdiscectomy patients the same?

Study of microdiscectomy outcomes based on herniation type

Classified herniations into 4 types

Results: contained herniation with no sub-annular fragment performed poorly with microdiscectomy

Conclusion: The ideal Nucleoplasty patient is not a good candidate for microdiscectomy

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Radiology terms Oblique View

Kambins triangle

Correct Needle Placement Same approach as discography for needle placement

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Incorrect Needle Placement 37

Needle entry too far lateral.

Incorrect Needle Placement

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Needle entry too far lateral and shallow.

Lumbar Nucleoplasty Technique 1. Using fluoroscopy, introduce

the needle to the nucleus/annulus junction of the disk (Confirm position using fluoroscopy).

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Lumbar Nucleoplasty Technique 2. Insert the wand through

the needle, and advance the Wand until the Reference Mark is at the needle hub.

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Lumbar Nucleoplasty Technique

3. Using blunt dissection, advance the tip of the DLR into the nucleus, and STOP when the distal annulus is reached. This determines the Distal channel limit.

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Lumbar Nucleoplasty Technique 4. Position Depth Gauge at

the needle hub It will reference the Distal channel limit within the nucleus (this should be confirmed using fluoroscopy).

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Lumbar Nucleoplasty Technique - Final Result

Create additional channels at the 4, 6, 8, and o’clock positions.

Approximately 1/2 cc of tissue removed causing decompression.

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The Procedure-Cervical Nplasty

The surgeon uses the fingers to detect the vertebral space holding the SCM

muscle laterally and the trachea medially.

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Under fluoroscopic control, the introducer needle is inserted using an anterior

lateral approach, medially to the SCM and vessels.

The Procedure

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Needle Placement Check needle placement in A/P projection

Needle should be in line with the midline (spinous process)

A/P Lateral

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Cervical Nucleoplasty Technique

Position needle tip in the posterior 1/3 of the nucleus Anterior-lateral approach

Fluoroscopic guidance

If desired, move the green marker down to skin level.

Unscrew and remove the stylet

Insert the Perc DC SpineWand Only as far as tip remains within end of needle

Do not allow device to protrude from needle

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Cervical Nucleoplasty Technique

Once the device is inserted, withdraw the needle from over the tip of the device monitor deployment of device

beyond end of needle

Lock Perc DC into Needle Hub

Confirm with fluoroscopy

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Cervical Nucleoplasty Technique In ablation mode, rotate device

through 360o for approximately 2 - 3 seconds

Withdraw device 1-2 mm and repeat to make a series of 2-3 voids.

Never maneuver or advance the needle with the device inserted

Unlock SpineWand from needle hub and withdraw into introducer needle before removing.

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3 2 1

3 2 1

The Procedure Ablation mode is performed for three cycles in

withdrawal, rotating the wand 180 in each cycle (8 seconds ablation each)

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The Procedure 51

The wand is unscrewed from the luer lock and removed inside the introducer

needle

ENDOSCOPIC DISCECTOMY

Technique- transforaminal approach

Surgical Approach

SPINE FUSION (MIS)

SPINAL CORD STIMULATOR

Vertebral compression fracture

VERTEBROPLASTY & KYPHOPLASTYPLASTY

VERTEBROPLASTY

Vertebral augmentation-KIVA

Failed Back surgery syndrome (FBSS)

Percutaneous fluoroscopic epidural adhesiolysis.

RF Facet joint denervation & DRG lesioning.

Spinal cord stimulation

Intrathecal drug delivery systems.

ADVANCEMENT ??????????????

Percutaneous Decompressor Discectomy

Hydrocision Discectomy/ Laser Discectomy

Endoscopic Discectomy

Bicuplasty/Ozone Discectomy

Disc Nucleoplasty / Automated Nucleotomy

Neuroplasty/Adhesinolysis

Vertebroplasty/Kyphoplasty

Intradiscal eletrothermal coagulation(IDET)

Spinal Cord Stimulator

Neurotomy/Radiofrequency Ablation

Provocative Discography

Lumbar & cervical Transforaminal epid.inj

Cervical & Lumbar Facet Joint injection/Block

Intrathecal Pump

Mimimal invasive lumbar discectomy(MILD)

MIS Fusion/ TLIF

QUESTIONS?

Dr Manish Raj MD,DA(Gold medal),FISP,FPM Minimally invasive spine & pain Consultant

BENSUPS Cygnus Superspeciality Hospital,Dwarka

CYGNUS Orthocare Hospital ,Safdarjung Development Area

Director-Spinomax pain & spine clinic,Safdarjung Enclave

www.spinomax.com , Email – info@spinomax.com