A Lion Roared !!!!!! Extreem Spine Injury !!!

A Lion Roared !!! Extreem Spinal Injury !!!

A very strange mode of injury i saw recently. It happened so that a young boy , who used to work at a zoo as a cage cleaner. He one day while cleaning the cage of an Asiatic Lion forgot to close the divider door. The Lion punched him with a violent paw and look what the lion did to a human spine....

The image shows complete dislocation with a violent separation of vertebral column. Its a very mutilating injury. Looking to the image only one can say that spinal cord will be completely crushed and torn ( a transected spinal cord ). Patient has no control of lower limb with no control of bowel or bladder. Patient has no chance of recovery in such kind of injury to spinal cord with whatever doctors do. But we need to operate upon such patient so that we can allow early rehabilitation of the patient with wheelchair training. We operated upon the patient. Believe me , its a very very very tough job to reduce such kind of dislocation. But , reduction was complete post surgery. see the image...

Myths about Back pain and its management !

During my career as a spine surgeon, i have come across many myths prevailing in community about back pain and spine care... i don;t know who and how many will be reading this blog, but its my humble attempt to let the public know about back and its cry of pain ! I will try to put on this blog details about back and its disease in a scientific format for everyone to understand. I want to take head-on each and every myths prevailing in our country. But first thing comes first... before we can shatter a myth , we need to understand what actually is our back. so today i put forward a brief about human back.

What is Back?

In a broad term , back means entire back from base of the head to the buttock. Back in a medical term is a composite of vertebral column , muscles around back and overlying skin and soft tissue. It doesn't need a rocket scientist to make you understand that any disease or a problem in any of these structures will lead to BACK PAIN.

vertebral column is composed of cervical column ( in neck ), thoracic column ( in chest or mid part of back ) , lumbar column ( low back ) and sacrococcygeal column ( tail bone column).

vertebral column is a tower made up of block like bone pieces with adjoining cushions called disc. see image below.

Block of bone provides structural support and at the same time maintains the shape of human back . The intervening disc provides a delicate balance of support and mobility of back.

Vertebral column is divided into cervical ( made up of 7 vertebrae ) thoracic ( 12 vertebrae ) , lumbar ( 5 vertebrae ) and saccrococcygeal ( 5 fused vertebrae made sacrum and another 3 to 4 makes up for coccyx bone).

On top of this tower our head sits and at the tail end we sit !!!!!

we shall discuss regarding muscles in the next post soon.... we shall also elaborate different region in more detail in next spot.

A Day Care Spine Surgery for Disc Prolapse !

Proudly today i completed my 100th case using tubular minimally invasive Matrix Micro/endoscopic Disectomy. The discectomy is done using tubular retracters. It utilizes only 1" skin incision. The discectomy is done from the tubes.

In normal Microdisectomy , surgeons cut sking , erase muscles from its attachments on the bone of spine. While with the use of tubular retracters there is no muscle damage. On the contrary to dissection, the muscles are dilated using sequential dilaters as shown in the image. The attachments of the muscles are kept intact. Meaning much less damage to normal structures of human back.

The patient does not has to experience a lot of operative pain , as there is minimal dissection done during surgery. Much less blood loss and the patients are up on their feet in just 3 hours post surgery. Not only that, patients can go home without pain in just 12 to 16 hours after surgery. A truly day care spine surgery.

Very Interesting Patient !!!

I came across a very interesting case which i am handling since about a month. Patient ( f/46) presented to me with intense leg pain ( left radicular pain). Her pain was from buttock down upto ankle. She came almost crying with pain.

Examination was uneventful , except Extensor Hallusis Longus/ Extensor Digitorum Longus weakness indicating predominantly L5 root involvement. SLR was restricted. So i thought , surely patient is suffering from acute disc prolapse and ordered urgent MRI. To my surprise MRI could not show any significant neuro-compression.

I put her on conservative management. Started her with anti-inflammatory medicines , rest and gabapentine. Patient did improve but still ws complaining of significant pain.

I took an opinion of my neurologist , he conducted EMG/NCV and concluded to be having L5 root radiculopathy with L5 root weakness. He was of the opinion that one should go for a surgery.

My problem was on MRI, I was not able to find a compressive lession neither intracanal nor foraminal or extraformainal.

So i decided to go for L4 and L5 root blocks. Under image intensifier , i injected local anesthetic. Patient improved in her pain immediately. Its been two days since i have injected her and she is doing extremely fine.

I am hopeful that she shall do good, but if her pain shall recover , mostly I am planning to get a frest MRI and CT scan to detect any compressive pathology.

Will post the Update as and when i have results.

till than Cheers !!!

Pseudocyst of Ligamentum Flavum

Today I operated a very unique case. Patient presented with left sided radicular pain. Pain was intense so much so that patient was tossing in the bed. When MRI was done after due physical examinations, it was found that patient had a fluid filled cyst compressing the left L5 root. At first i thought its a synovial cyst arising from L4-L5 facet.

I posted the patient for Microscopic ( Matrix ) fenestration decompression. When i reached the ligamentum flavum. I found it unusually thickened and hypertrophied. facet capsule were looking relatively in order to the routine degneration.

I performed a laminotomy and could found that ligamentum flavum was getting fused with the L4 lamina. With Neurodrill ( Midas Rex ) , we opened the upper border of the ligamentum flavum. I could not dissect the flavum from dura. there were dense adhesion. I tried to open the flavum from it's lateral attachment. I could feel a cystic lession compressing the root. I punctured it and mucoid fluid drained out. Cyst base was again adhered to the dura. I had to find the cleavage plane from the inferior margin of the dura. Gradually, i could take off the cyst en block from the dura.

I have sent it for histopathological report. But i feel that its Mucoid Degeneration of Ligamentum flavum that has formed the cyst.

That's a relatively rare pathology i feel. Lets see i am waiting for the results and than will plan to upload the snaps.

A lession i learned....

Today came across a very strange MRI. Well i can not say that first in my career but i was almost taken aback by the finding. There was a patent operated for L4-L5 disc herniation about 5 years ago. Since a month she started having leg pain. When i took the xray , the xray was showing disc degeneration at L4-5. Patient was operated with Laminectomy before 5 years. Now, i was suspecting a foraminal stenosis as clinically the picture was L4 and L5 root radiculopathy. But when i took MRI, there was a massive disc at L3-4 on saggital view in both T1 and T2 images. But, when i looked at the axial cuts, i could not identify the disc. When i spoke with my radiologist , he said that because there is complete block , and the print is not as good as the Monitor contrast, i was not able to see it on print images.
So , in other words, there was a massive central and right paracentral disc herniation, to an extent that has completely drained CSF out at that level and there was significant root crowding. A potential patient to develop cauda equina syndrome. i shall put the images soon.

Importance of High resolution MRI in Spine

So far fortunately i have worked in a set up where i have best of the best facilities. Two days back i had a patient who underwent an MRI for Lumbar spine with 0.2 T MRI. At first glance it appeared as if it is just a L5-S1 sequestered disc. But on close examination i could see that the fragment starts from upper border of L5 pedicle. Now, on saggital view i could not see the fragment to the best of its resolution. When i examined the axial cuts more closely i certainly could find that the fragment as such starts from lower border of L4-L5 disc space and down migrates upto L5-S1 disc's upper border. So all in all i want to state that for Spine MRI i would say the requirement should be atleast 0.5 T if you don;t have facility of 1.5T which is the best.