Peripheral Vascular Disease In Lower Limb

PERIPHERAL VASCULAR DISEASE IN LOWER LIMB

BRIEF ARTERIAL ANATOMY OF LOWER LIMB

Case 1

  • Navin Shah 68/M
  • Came with complaints of blackening over left little toe since 2 months
  • He has been to 4 other hospitals where he could not get the satisfactory treatment and was advised lower limb amputation
  • We have taken up the case and after discussions and meticulous planning with the help of available diagnostics and set off for the management
  • H/o DM (Diabetes) / HTN (Hypertension) for the past 25 years
  • H/o CAD-TVD (Coronary artery disease) on medical management
  • H/o chronic smoking +
  • Peripheral angiogram was done which showed ATA/PERONEAL ARTERY total occlusion, Distal Percutaneous Transluminal Angioplasty (PTA) 90% stenosis.
  • He was first treated with POBA and angioplasty (Plain Old Balloon Angioplasty) to ATA / PTA and PERONEAL artery.
  • Subsequently with limited amputation of just the little toe we are able to achieve our goal of limb salvage surgery.

Case 2

  • T Rama Rao 61/m
  • Came with complaints of ulcer over left foot for over 2 months. He is known case of heart disease undergoing treatment
  • History of Diabetes since 25 years
  • Evaluated – complete block of main artery supplying lower limb
  • Treatment – PTA (Percutaneous Transluminal Angioplasty) with 3 stents
  • Debridement and regular dressings has heeled the wound completely

Case 3

  • Prathap Reddy 71/M
  • k/c/o CAD (Coronary Artery Disease)
  • History of HTN + (Hypertension) / DM + (Diabetes)
  • C/o Blackish discoloration of left little toe
  • Peripheral angiogram shows left ATA and PTA – 99% stenosis
  • Treatment – Amputation of left 4th,5th toes followed by

BASICS

  • In peripheral arterial disease there is a decreased or total loss of blood supply to the peripheries (most commonly affects lower limbs)
  • Due to
    • Embolism
    • Atherosclerosis, thrombosis
    • Trauma
    • Complications of peripheral aneurysm

RISK FACTORS

  • Age
  • Gender – Male common
  • Obesity
  • Family history
  • Diabetes
  • Smoking
  • Hypertension
  • Dyslipidemia
  • Hyperhomocysteinemia
  • Race (Asian / Hispanic / black vs white)

STATISTICS

  • Approximately 12% of the adult population has PAD, almost 20% of adults older than 70 years have PAD
  • A new analysis published by THE SAGE GROUP concludes that atherosclerotic peripheral arterial disease (PAD) afflicts over 20 million in India
  • Once PAD has progressed to CLI (Chronic Limb Ischemia), the risks of limb loss and mortality increase. At six months approximately 20% of those with CLI will die; another 40% will experience amputation.
  • Diabetics represent 60% to 80% of CLI patients, we believe that India may unfortunately be on the path to becoming the Critical Limb Ischemia Capital

WHY MORE COVERAGE

  • Under diagnosed, undertreated, and poorly understood even by the physicians and much more common than thought considering the lifestyle and the rise of share of the non communicable diseases like hypertension and diabetes.
  • The diagnosis of PAD should not be overlooked for 2 important reasons. First, patients with PAD may experience many problems, such as claudication, ischemic rest pain, ischemic ulcerations, repeated hospitalizations, revascularizations, and limb loss. These lead to a poor quality of life and a high rate of depression
  • Cardiovascular death and have a higher rate of all-cause mortality compared with patients without PAD.

TREATMENT EARLIER

  • Amputation if wound does not heal and necrosis due to compromised blood supply revised amputation resulting in high morbidity and mortality rates
  • Due to new modalities for diagnosis such as colour doppler, CT angio, DSA, MRA and new interventions like peripheral stenting with advanced stents
  • Level of obstructed supply can be made and appropriate intervention can be done

HOW WE DO IT

  • Depending on the stage of presentation
  • Non healing ulcer – debridement if needed after endovascular technique
  • Gangrene – Infected – Amputate to reduce sepsis – endovascular technique
  • Non infected – endovascular technique – amputate
  • Vasodilators to increase blood supply and anticoagulants and anti platelets for stent patency and anti diabetics, anti hyper lipidemics and anti hypertensives depending on the risk factors and regular dressings and wound care.
  • The goals of therapy are to improve symptoms and thus quality of life and to decrease the cardiovascular event rate (myocardial infarction, stroke, cardiovascular death)
  • Accomplished by establishing a
    • Supervised exercise program and
    • Administering cilostazol or performing a revascularization procedure if medical therapy is ineffective.
    • A comprehensive program of cardiovascular risk modification (discontinuation of tobacco use and control of lipids, blood pressure, and diabetes) will help to prevent the latter

STENT

  • Stent placement is typically used when residual stenosis after PTA is 30% or greater
  • Primary stent placement has become a viable alternative for treating ulcerative lesions that may potentially be the source for embolization
  • Several clinical studies have demonstrated the significant improvements of the new generation of nitinol stents for the SFA lesions: the German Multicenter Experience, the Mewissen trial, the BLASTER Trial, and the SIROCCO trial

TAKE HOME MESSAGE

Watch out for

  • Tingling sensation in the legs
  • Pain after walking a certain amount distance
  • Sudden rest pain
  • Ulcerations
  • Blackening
  • Especially on the background of the above said risk factors
  • Better to get evaluated about the limb and the doctor will decide if your heart status also needs to get evaluated 

MOTTOS

  • Salvaging your precious limb
  • Adding miles to your walk

Pain in the surgical/trauma

1. What is pain?

Pain is an unpleasant physical and emotional response to actual or potential tissue damage or described in terms of such damage.

It is a protective response which ensures that an injured part of the body is carefully handled and further damage is prevented.

2. Why do we feel pain?

There are nerve endings distributed all over our body- from the skin to the intestines. These get activated in response to injuries from varied mechanisms like cuts and bruises, deep pressure, burns, extreme cold etc. Upon activation, signals are sent by the nerve endings to the brain and pain is perceived.

 

3. Why is it important to reduce pain?

Control of pain leads to a better life -Pain is unpleasant. It leads to emotional responses like depression and anger. It imposes a financial burden on the individual as well as society not only because of the expenses of treatment but also because there is loss of productive work-hours in the affected population. Long-lasting pain affects day-to-day functioning. People with pain tend to handle that body part carefully leading to stiffening of the joints and loss of muscle mass due to disuse. The stress leads to lack of control of blood pressure and blood sugar, sleeplessness, increase in acidity and body weight.

In patients undergoing surgery, pain relief leads to early recovery which means the patient walks sooner (Decreasing the chances of blood clots forming in the legs and travelling to the heart). He has better control of blood pressure and blood sugars due to decrease in stress levels and is less prone to stress-related complications like heart failure. All this leads to earlier discharge from the hospital.

 

4. How is pain classified?

There are various ways to classify pain:

There can be more than one type of pain in a patient due to more than one cause. This is important to know because the treatment changes with the cause/type/duration.

  • Based on the duration it can be acute ie immediate or sudden, usually lasting from 3 to 6 months or chronic ie long-lasting-more than 6 months or acute-on-chronic ie sudden pain superimposed upon a pre-existing pain.
  • Based on the site of origin it can be Somatic ie arising from the skin/Bones/muscles or Visceral ie from the internal organs like the intestine or Uterus.
  • Based on the cause of pain it can be Neuropathic ie arising from nerves which are injured or Inflammatory ie due to chemicals released after injury.

 

4. What are the common means of reducing pain?

Pain can be mitigated by non invasive or invasive means. Non invasive methods include oral medicines (Aspirin, Paracetamol, morphine etc.) Hot fomentation, cold compresses, physiotherapy, yoga and so on.

Invasive methods include pain killer injections either into the muscles or veins and more recently blocking nerves causing pain with anaesthetic drugs. Each method has its advantages and disadvantages.

Medicines which are called NSAIDS ( Nonsteroidal anti-inflammatory drugs) include Ibuprofen and Diclofenac. They act by decreasing the inflammation at the site of the pain. But when taken for a prolonged duration they might cause damage to the kidneys. They should also not be taken by those suffering from asthma or heart/bleeding problems.

Opiod drugs like Morphine, while very very effective, are the leading cause of addiction in the US and active research is ongoing to find alternate means of pain relief especially in the acute setting of trauma or surgery.

 

 

5. My friend recently had an accident and fractured his thigh bone and has to undergo surgery. What modes of pain relief can she be given?

After an accident there are various factors to take into consideration before pain relief methods can be planned. The treatment differs for young people with no other health issues vis-a-vis older persons with say high blood pressure or diabetes or kidney failure. It will also change with the extent and region of injury, ensuing blood loss, ability of the patient to breathe adequately, neurological status (Drowsy/conscious) and the expertise of the medical personnel.

In all cases no one method is considered superior or enough by itself. A multi-prong approach to pain relief ranging from oral/i.v medicines to blocking the nerves carrying pain from the injured area (Nerve block) helps in lessening the side effects, complications and costs involved.

 

6. What is a nerve block?

A nerve block involves deposition of local anaesthetic drugs near a nerve or a bundle of nerves to temporarily stop them from working. This cuts off pain transmission at the very first step.

For example this patient with a fracture of the thigh bone will have severe pain upon any sort of movement and may be taken up for surgery only after a few days especially if he has other problems like being on blood-thinning medicines or uncontrolled diabetes. In the meantime she will need a Femoral nerve block along with other pain medication. The femoral nerve is present on the front of the thigh near the groin.

 

 

7. How is the nerve block given?

Before giving the nerve block we ensure that the nerve itself is not injured from the accident by testing sensation and muscle movement. If there is any doubt we do not proceed with the block and give alternate means of pain relief.

Nerve blocks are given by qualified Anaesthesia doctors. All nerves in the body have more or less a constant location in humans. They can be identified by means of landmarks eg the Femoral nerve is close to the major artery in the groin whose pulsations are easily felt.

Sometimes the Anaesthetist might use a needle through which very small current pulses are given in order to locate the nerve. These pulses do not cause pain and are felt more like vibrations. When the needle is close to the nerve, the muscles supplied by the nerve show contraction. With the femoral nerve the muscles on the front of the thigh will move. At this point all the drug is given.

Another precise way of identifying the nerve is by using ultrasound where the pulsating artery and the nerve next to it are visible on the screen.

After the drug is injected the patient will get pain relief in 5-10 minutes. If prolonged pain relief needs to be given we leave small tubes called catheters next to the nerves and give a constant supply of the numbing medicine through syringe pumps for as long as needed (Commonly 3-4 days).

 

8. Will I have pain when the nerve block is given?

No, the doctor will first give a small numbing injection on the skin before using the other needle.

 

9. How soon will I get pain relief and how much of relief can I expect? Is there a way to measure pain?

Pain relief usually starts within 10 minutes and depends on the concentration of the drug given. It might take upto an hour for maximum relief.

The extent of relief varies from tolerable pain to sometimes complete relief.

The level of pain perceived is very individual-specific. Some people can bear the pain after Hip replacements and some may cry holy murder while an i.v cannula is being placed.
Most commonly the health care provider uses a visual analogue scale (VAS) to note down the pain level being experienced. This is a scale where the facial expression of the patient is assigned a number ranging from 0 to 10 . Here 0 means a happy face and 10 denotes extreme crying. Similarly, the health care provider or nurse might ask the patient to give a number to the pain being experienced (Numerical scale). Again 0 means no pain and 10 is the worst pain imaginable. The aim for us is usually to bring the pain down to less than 3 denoting mild/tolerable pain.

 

10. Will there be any side effects/complications of the nerve block?

Like any procedure done on the human body there are always chances of complications during nerve blocks. When done by expert hands minor complications are infrequent and major complications rare.
These range from failed blocks with no pain relief, injury to blood vessels/lungs/nerves/other organs, temporary weakness of the muscles supplied by the nerve and very rarely injection of the drug into blood vessels leading to Local Anaesthetic Systemic Toxicity.

The doctors giving the nerve blocks are trained to prevent and recognise such complications. They will use full monitoring like Blood pressure, ECG and oxygen saturation in the blood before, during and for 3 to 4 hours after the procedure. You will need to be admitted in the hospital for that duration.

 

11. Why should I undergo a nerve block when there are other means of pain relief?

Different degrees of pain need different methods of treatment.
A simple headache after a sleepless night might subside after an oral painkiller. Pain due to falling on the ground while running might need an injection into your arm/buttock. A fracture pain or one after a surgery will need oral medicines, injectable pain killers like i.v Morphine and yet not lead to adequate relief. It is such pain which benefits from nerve blocks.
In the surgical setting physiotherapy and active movements become easier and less painful if continuous pain relief is given with nerve block catheters. Our patients undergoing total knee replacement generally walk within 4 hours of surgery.

Further most analgesics (Pain-killers) come with their own respective set of side effects. Many of them cannot be used if you have a history of poor kidney function/ Asthma/ Heart attacks/Bleeding tendencies. They can lead to nausea, dizziness, retention of Urine, constipation, breathing difficulty, drowsiness etc.

In the trauma/surgical setting we need to use all methods in order to attack every step of the pain pathway in the body and minimise the overall dose of individual drugs. So you will be getting oral medicines, i.v injections as well as nerve blocks. These have an additive effect and individual doses of each medicine reduce drastically.

 

12. How long does pain last after surgery?

After any surgery maximum pain is felt during the first 3 to 4 days and this gradually decreases over a period of the next 7 days.

 

13. My father has fractured his ribs and finds it difficult to breathe without pain. He cannot afford to take long leave from work. Can nerve blocks help?

Yes. Rib injuries prevent patients from taking deep breathes due to pain. This causes gradual collapse of the small airways in the lungs. The ensuing inadequacy of oxygen in the body and chances of developing Pneumonia will require hospitalisation.

Such patients can be helped by the placement of Erector Spinae or Serratus Anterior plane blocks. A small catheter will be placed in between the muscles of the chest wall or back and a continuous infusion of local anaesthetic medicine will be given from a portable infusion pump which can be taken home. Deep breathing exercises are thus possible and prevent deterioration of the lung and loss of work-hours.

The infusion pumps will contain medicine for upto 48 hours and you will need to get it refilled at the hospital. A week of such treatment will give enough time for the body to heal.

3 out of 10 People are Affected by Hypertension

What is blood pressure?

Blood pressure is simply the physical pressure of blood in the blood vessels. It is similar to the concept of air pressure in a car tyre.

What do the numbers mean?

A common blood pressure might be 120/80 (said as ‘120 over 80’). These values are quoted in units known as millimetres of mercury (mmHg). There are 2 numbers because the blood pressure varies with the heartbeat. The higher pressure (120) represents the pressure in the arteries when the heart beats, pumping blood into the arteries. This pressure is called systolic pressure. The lower pressure (80) represents the pressure in the arteries when the heart is relaxed between beats. This pressure is called diastolic pressure.

Does blood pressure change?

Blood pressure can be quite variable, even in the same person. Blood pressure goes up and down with different normal daily activities. For example, exercise, changes in posture and even talking changes blood pressure. Blood pressure tends to be higher during the day than at night and higher in the winter than in the summer. Blood pressure also rises when we grow older, particularly systolic blood pressure. Before adulthood, blood pressure rises in parallel with height. In adult years, weight and blood pressure are closely related. When weight goes up, blood pressure tends to go up and we can lower blood pressure by losing weight. Blood pressures differ between individuals. Some people have low, some average and some high blood pressure levels.

What is high blood pressure?

There are various definitions of high blood pressure, which is also known as hypertension, but most doctors consider blood pressures of 140/90 and greater to be high. The precise values that doctors might interpret as high blood pressure depend to an extent on individual circumstances. For example, in patients with diabetes, the definition of hypertension is considered by some to be pressures greater than 130/80. The definition of hypertension is used by doctors to help decide which patients would benefit from medical (lifestyle and drug) treatment to lower pressure. The definitions depend on the balance of risk of not lowering blood pressure (heart attack and stroke, etc) versus the risks of treatment (drug side effects, etc). This explains why hypertension is defined at lower blood pressure levels in diabetic subjects. For the same blood pressure, cardiovascular complications (that is damage to the heart, blood vessels and brain) are more likely in diabetics and blood pressure reduction offers benefit even when a diabetic’s blood pressure is not as high as regular definitions of hypertension.

How common is high blood pressure?

Approximately 4 in 10 adults over age 25 have hypertension and in many countries another 1 in 5 have prehypertension. An estimated 9/10 adults living to 80 years of age will develop hypertension. One half of blood pressure related disease occurs in people with higher levels of blood pressure even within the normal range.

Why is blood pressure important?

Blood pressure is important because it is the driving force for blood to travel around the body to deliver fresh blood with oxygen and nutrients to the organs of the body. However, high blood pressure is important because it leads to increased risk of serious cardiovascular disease, with complications such as heart attack, heart failure, stroke, kidney failure and blindness.

Who gets high blood pressure?

High blood pressure is more common is older age groups and in people with a family history of hypertension. It is also more frequent in those who are overweight. However, high blood pressure can affect young thin people with no family history, so no one should consider himself or herself immune from high blood pressure.

Does high blood pressure need to be treated?

It is the goal of good clinical practice to reduce high levels of pressure wherever possible in order to reduce the risk of complications such as heart attack and stroke. Changes to lifestyle such as weight loss, reduced salt intake, reduced alcohol consumption or exercise are often the first line of treatment. If these approaches don’t return blood pressure to acceptable levels then drug treatment is usually required.

How do I know if I have got high blood pressure?

The truth is you cannot know your blood pressure unless you have it measured and every adult should know his or her blood pressure. Although headaches and nose bleeds can be the result of very high blood pressure, there are many more innocent causes for these common ailments.

Can high blood pressure be cured?

Although not ‘cured’ as such, modern therapeutic approaches to blood pressure are very effective and generally very safe. However, if treatment is stopped the high blood pressure usually returns reasonably quickly.

Ref: International Society of Hypertension

 

WHAT IS SPONDYLOLISTHESIS? CONVERSATION BETWEEN PATIENT & DR RAGHAVA

 

in conversation with Dr Raghava Dutt Mulukutla, Orthopedic Surgeon and Chief of spine surgery

Q. Doctor I am suffering from back and leg pain and I am told that my vertebra has slipped forward.

A. You are suffering from a condition called spondylolisthesis. Here one of the vertebra slips forwards over the vertebra below.

Q. How does this happen?

A. There are a number of reasons for this. This could result from anomalies in the spine at birth, some in early childhood and some due to fractures and various diseases and conditions of spine.

The two most common varieties

1. the first variety, when the vertebra slips forwards between 4-6 years of age. This may cause back pain or leg pain during childhood or during adulthood. Sometimes due to extra weight of pregnancy, women come to doctors with back pain and this condition is then diagnosed

2. the second variety is one which is somewhat common in females at about the age of forty. This is due to degeneration (wear and tear) and is more common in women who are overweight.

Q. What are the treatment options for this condition

A. Most patients get better with physiotherapy and medication. Once the pain subsides it is important to start exercise programmes to strengthen back and abdominal muscle. Walking, sports, yoga, swimming all help.

Q. Do I require surgery?

A. Only if the pain does not subside with physiotherapy, restricted activity for a few weeks followed by exercises etc. Surgery is more beneficial in those who suffer from leg pain rather than back pain alone

Q. What is the type of surgery that is done?

A. In children and young adults sometimes repair of the defect in the vertebra .is done to prevent back pain.Mostly screws and rods are placed in the spine and the vertebra that has moved forwarded is brought back to its original position. Cages are also used to maintain the reduction and restore the height between the vertebrae. Fusion is routinely done .

Q. How long do I need to take rest? And what are the precautions to be taken after surgery

A. You will be out of bed 2nd or 3rd day after surgery. You need to stay in hospital for 4-5 days. You will be in ICU for a day. You will be given a brace to support your back for a few weeks.

Q. When can I get back to work?

A. You need 6 weeks time for light duties and 3 months for heavy work.

Q. Do I need to undergo lot of physiotherapy?

A. You hardly require any physio. A few months after surgery physios will teach you a set of exercises which are very easy to follow and can be done at home.

Q. How painful is the procedure?

A. The procedure is not that painful and you will be given adequate pain relief medication after surgery

Q. can I play games and sports after surgery?

A. Swimming, yoga ,sports are all beneficial. You will be told how to lift weights and also given a set of exercises to strengthen your back.

Q. Will surgery affect my married life?

A. Not at all . You can have a normal married life and women can have babies and undergo normal deliveries

 

HEALTHY EATING by Dr Deepa Agarwal, Nutritionist/ Dietician

Every now and again many of us resolve to improving our health habits and promise ourselves to eating healthier. Follow these tips to treat yourself to healthy eating.

1. Don’t deprive yourself.

Aim to eat nutritious foods your body loves 80 percent of the time. Use that other 20 percent to treat yourself a bit.

2. Graze healthfully.

Tide yourself over between meals with healthier snacks. Whether your thing is sweet or savory, crunchy or chewy, there are plenty of options for snacking smart.

3. Eat fresh produce all year long.

Find out which fruits and veggies are in season even in the winter and stock up at the store and farmers’ markets. Eating fresh means eating the tastiest and most delicious produce around.

4. Indulge smarter.

Chocolate-dipped strawberries? Choco-Nut popcorn? Yes, please. Lower sugar doesn’t have to mean less deliciousness.

5. Understand emotional eating.

There is a link between how we feel and how we eat, particularly when it comes to stress.  Figuring out what kind of eater you are and whether you look to food to comfort you in times of anger, boredom, stress, or sadness will help you formulate a plan for making different decisions when faced with those emotions.

6. Make holidays, birthdays, and special occasions a little healthier.

Holidays and special occasions are always a good reason to enjoy delicious food. Luckily, there are plenty of ways to celebrate without going overboard.

7. Be mindful at meal times…

Staying tuned in to what you’re eating (as opposed to the phone or TV) is a great way to eat until you’re full, but not beyond. Being relaxed and mindful can also help you heed fullness cues.

8. …But don’t overthink it.

Recent research shows that the more time we take to think about whether or not we should eat something, the more likely we are to find a reason to justify eating it.  Checking in with yourself about your mood and are great habits to have, but remember to trust your gut.

9. Start the day right.

Studies suggest that eating a healthy breakfast is linked to sustained weight loss and weight management, particularly when that breakfast is nutritious and fiber-rich and high in protein.

10. Use the buddy system.

Having a partner with the same healthy-eating ambitions has been shown to help both people reach their goals.

What you eat can impact every aspect of your life from your mental health to your sleep and relationships. So go ahead and wholeheartedly commit to developing healthier eating habits this year. Set goals that are simple and tangible. Make time to meal plan to set yourself up for success. But above all else, believe in yourself. This is your year. You can do this!

Dr Deepa Agarwal, is Consultant Nutritionist at Udai Omni Hospital. She has an experience of 10 years having completed MSc and PhD in Clinical Nutrition.

To consult Dr Deepa Agarwal, please email enquiry@udaiomni.com

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Spine Surgery in hyderabad

OH MY BACK! by Dr Raghav Dutt Mulukutla, Chief of Spine Surgery

If you are one of the few lucky ones who have not yet suffered from low back pain, do not be too happy. Second only to common cold, low back pain is increasing in incidence the world over.  Almost 80-90% of population  is affected by this problem in urban areas and  is the commonest cause of  absenteeism from work for people under 45 years of age in the Western World.

Most of us suffer for a few days to weeks and in some it becomes a chronic problem with umpteen visits to various specialists, homeopaths, ayurvedic  massage treatments, acupuncture, magneto therapy, reiki etc.

In India friends, neighbours, barbers, medical shop owners, grand mothers  are all specialists… they  have their own special remedies to offer and stories to tell. And of course that consultation with the foreign doctor – when I went to USA……… and the stories go on!

Who is at risk?

Almost 90%  have a mechanical reason for their back pain, and in 10% various diseases and disorders are responsible for low back pain. Many risk factors have been identified  :  lifting weights  beyond a workers physical capability, repeated bending and twisting in awkward positions , prolonged sitting especially in slouched position  is well known to produce low back pain. Obesity, cigarette smoking, lack of physical exercise, weak abdominal and back muscles  are some of the very potent factors  in causing low back pain.

What causes back pain?

The very fact that we are born as humans – our upright posture places tremendous stress and strain on the back.

  1. bad posture
  2. prolonged sitting : IT industry/ executives
  3. weak abdominal and back muscles
  4. weak bones ( osteoporosis )
  5. smoking
  6. driving 2 wheelers with bad shock absorbers
  7. over weight
  8. lack of exercises during and after pregnancy
  9. un-accustomed bending forwards and lifting weights

Let’s get to know some of the common conditions that cause low back pain:

The slipped disc: The human spine consists of individual bones called vertebrae separated by  discs-  which simply put  is a  jelly surrounded by fibrous tissue. When the discs get damaged or degenerated, it slips backwards and presses on the spinal cord and nerves causing pain in the lower  back or along the leg – known typically as sciatica.

Non surgical management: 

Over 90% of patients with slipped discs do not require surgery and get better with rest, physiotherapy and medication. You do not have to sleep on floor or hard beds. A firm bed is all that is required,  and rest for more than one week is not advisable. There is no need  for strict bed rest and you can move about  if pain permits.  Exercises should be commenced after the pain subsides and your physiotherapist would be the best person to teach you the exercises  to strength the back  and  abdominal muscles.

The surgery

Traditional surgeries such as laminectomy have no place in the management of disc prolapse. Surgeries such as Fenestration, Microscopic surgery or  Endoscopic microdiscectomy(Key hole surgery) offer the best results. The minimally invasive surgeries do not weaken the back muscles  and return to work is much quicker.

Spinal stenosis:

As we get older , the spinal canal  gets narrowed  due to arthritis and degeneration of tissues in the spine-resulting in pressure on the nerves. Typically  the patient may experience  low back pain, buttock pain and leg pain. Patients find it difficult to walk for long distances and have to rest after  walking for a few minutes. He/she can resume walking once the pain subsides. Majority of the patients get better with change in life styles, physiotherapy and epidural steroid injections in to the spinal canal. Modern surgical techniques once again give lasting relief  in those who do not get better  with non operative treatments.

Spondylolisthesis: This is slipping of one vertebra over the other, resulting in pressure on the nerves and again is responsible for back pain and sciatica. In those who do not get better with non operative measures, surgery offers good relief from pain.

Osteoporosis:  Again a common condition in women, is responsible for significant back pain and vertebral fractures. Exposure to sunlight, physical exercise, balanced diet,  go a long way in managing this problem. In those who suffer from fractures, minimally invasive procedures such as vertebroplasty – which is injection of synthetic material (bone cement) under local anaesthesia gives excellent results.

Other conditions: Curvature of spine (hunch back-scoliosis, TB, cancers and tumors and a variety of disorders can affect a human spine. Prompt consultation  and investigations would  help in diagnosis and treatment.

Who should be consulted for spine surgery?

Orthopaedic  surgeon or  Neuro surgeon? That is the doubt in almost everyone’s mind. Traditionally both operate on Spines.Today we have a sub-speciality  – Spine Surgery. Spine surgeons are specially trained to perform spine surgeries and it would not be too long  when Neuro surgeons would be operating only on Brain and Orthopaedic Surgeons on bone and joints and  Spine surgeons alone would be performing Spine surgeries.

Information on the Internet: Beware! Not all information on the net is accurate and current. Newer technologies that appear on the net, are like fashions that keep changing and  are industry driven.

Are spine surgeries safe?

Spine surgery is complicated and needs expertise. One need not worry too much about the complications and a well planned and well executed surgery in an understanding and cooperative patient gives excellent results.

Is there an age limit?

No! Today spine surgeries are performed in infants. Age certainly is no bar.

The second opinion?

When in doubt take a second opinion. But seeing too many doctors is quite confusing.

For a healthy back

  1. Correct your posture – do not slouch
  2. Get out of your chair every 20 minutes- stand or walk for a few minutes
  3. Getting out of chair is more important than buying expensive chairs
  4. Exercise regularly: yoga/walking/swimming/sports
  5. Quit tobacco

Dr.Raghava Dutt Mulukutla is  consultant orthopaedic and chief spine surgeon at Udai Omni Hospital. He has an experience of over 35 years, his expertise includes spinal deformity surgeries, scoliosis and back pain management.

To consult Dr Raghava Dutt Mulukutla, please email enquiry@udaiomni.com

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Video Sukhibhava – Dr Raghava Dutt Mulukutla addresses various issues related to relieving back pain in children and young adults.

 

Dr Raghava Dutt Mulukutla, Director and Chief Spine Surgeon at Udai Omni Hospital specializes in back pain and correction of spine as a result of  scoliosis and other spinal deformities. In this program, Dr Raghava Dutt addresses various issues related to relieving back pain in children and young adults. He advises parents that school going  children should  have proper support for the back and be  encouraged to have healthy food habits and lead an active lifestyle.

To consult Dr Raghava Dutt, please email enquiry@udaiomni.com

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Total-and-compartmental-300x180

BLOG – TOTAL KNEE REPLACEMENT versus PARTIAL KNEE REPLACEMENT by Dr Udai Prakash, Orthopaedic Consultant Hip and Knee specialist

If you have been recommended a knee replacement then you may be a candidate for a partial (uni compartmental) knee replacement.You may be a good candidate for a partial or uni compartmental knee replacement if your arthritis is confined to a single compartment of the knee.

Your knee is divided into three major compartments: The medial compartment (the inside part of the knee), the lateral compartment (the outside part), and the patella femoral compartment (the front of the knee between the kneecap and thigh bone).

Partial Knee Replacement

In a partial knee replacement, only the damaged compartment is replaced with metal and polyethylene (a surgical grade plastic). The healthy cartilage and bone in the rest of the knee is left alone.

Total Knee Replacement is also a highly successful procedure. More than 600,000 knee replacements are performed in the US annually and this number is set to reach 4 million by 2030. Similarly, in India it is thought that over 30,000 are being performed annually and this number is increasing by 15% annually.

Partial knee replacement numbers are much smaller as not all patients are suitable for this type of conservative surgery and not all knee surgeons are trained in performing this surgery.


Dr Udai Prakash, is chief joint replacement surgeon at Udai Omni. He has over 20 years of experience and specialises in primary and revision hip and knee surgery.

To consult Dr Udai Prakash, please email enquiry@udaiomni.com

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BLOG – WAYS TO GET RID OF YOUR BACK ACHE by Dr Raghava Dutt Mulukutla, Orthopaedic Consultant & Spine specialist

Top ways to get rid of your back ache


1. Reduce your weight

      • Cut off that fat from your diet
      • Less weight on your spine means less pain

2. Get out of that chair

      • Change the way you work, not your job
      • Get up every 20 minutes. Either just stand up or take a few steps

3. Exercise

      • Regular exercise tones up your back muscles
      • Healthy muscles take the stress and strain and protect your spine

4. Quit Smoking

      • Stop smoking. It damages your spine
      • Avoid all tobacco products

5. Consult a Physiotherapist

      • Core strengthening exercise programmes are very helpful
      • Get advise on how to sit/lift weights/posture etc.
      • Learn stretches

6. Use a desktop

      • Use large desk top monitors, and they should be at eye level
      • Do not use laptops and tablets at work places. Restrict their use

8. Have a healthy body & mind

      • Keep diabetes, cholesterol (lipid profile ), blood pressure, thyroid and other medical conditions in good control
      • Avoid excessive worry about back pain


9. Physical activity

      • Brisk walking/ swimming / yoga /sports are essential for a healthy back
      • Indulge in physical activity that you like and enjoy


10. If nothing works

 

      • See a spine surgeon

Dr. Raghava Dutt Mulukutla is Consultant Orthopaedic and Spine Surgeon. His expertise includes spinal deformity surgeries, scoliosis and back pain management. Here he advises on that lingering backache that one needs to get rid off.

To consult Dr Raghava Dutt Mulukutla, please email enquiry@udaiomni.com

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