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Say goodbye to back pain

Photo: SHAJU JOHN

Arthritis is a disease that has a serious impact on our lives. There are, moreover, hundreds of different conditions that can be termed as arthritis. Arthritis is a combination of two terms: arth or bone joint and itis or inflammation; hence an infla mmation in bone joint is arthritis. Similarly, if it happens between the vertebrae of the spine, it is termed as spondylitis.

Spondylitis can also be termed a lifestyle problem since it can occur due to wrong sitting posture or extended sitting for long hours. But it has a serious form, which can lead to ankylosing or cementing of vertebrae. In such cases, the joints may lose their functionality and get merged and wedged.

Ankylosing happens in the spine and leads to a condition called “Ankylosing Spondylitis”. It is one form of inflammatory arthritis, in which the joints and ligaments of the spine and sacroiliac joints become inflamed. As the inflammation starts, the body’s self-healing mechanism starts forming new bony outgrowths called syndesmophytes. This leads to fusing of the vertebra causing inflexibility in the spine’s mobility.

The common symptoms are fatigue, chronic pain and stiffness in the neck, lower back and upper buttock area. Usually the most common spot of pain is deep within the buttock: one side or both the sides.

Inflammation which occurs in tendons and ligaments that connect and provide support to the joints can lead to pain and tenderness in the ribs, shoulder blades, hips, thighs, shins, heels and along the bony points of the spine.

The pain is highest in the morning or after a prolonged rest and usually settles down once the body warms up or after physical activity. Early detection may save the patient’s spine from cementing.

As the symptoms may be diagnosed as some other form of arthritis, the examination has to be really thorough. In AS, pain in the spine or lower back pain is accompanied by a lessening of the motion of the spine, which is the main outcome of the disease.

A clinical examination and x-Ray may help in diagnosis. Tests like magnetic resonance imaging (MRI) and tomography give a more precise indication of the exact stage of the disease.

Specialists believe that the origin may be hereditary (or genetically inherited). Also it has been found that people who suffer from this condition are born with a gene- HLA-B27 (in at least 90 per cent of the cases). There are other external conditions that lead to AS; not every person with this gene has the disease.

AS is more common in males than in females, and is typically more diagnosed in people between the age of 15 and 30 years. As a member of the Rheumatic group, it can spread to the other tissues in the body.

Hence, it can affect the joints and organs like the knee joint, ankles, eyes, heart, lungs, kidneys.

Once ankylosing or cementing develops, there may be reduction of or complete end to the pain, but only after a complete loss of motion in the vertebral column. The fused vertebra becomes brittle in nature and becomes highly prone to fracture. Treatment may involve medication to reduce pain and inflammation, exercise and fomentation.

But if this condition is wrongly diagnosed or diagnosed late, it may lead to the total damage of the joint, specially the hip joint because that is the first to be affected after the spine.

In such a case the doctor may recommend a full hip joint replacement. With the latest developments in replacement surgery this has become a treatment option to avoid the spread of AS to other parts of the body.

The writer is a Consultant Orthopaedician based in New Delhi.

Endoscopic spinal surgery is a boon to both doctor and patient.

The human intervertebral disc consists of an inner jelly-like substance (called nucleus pulposus) surrounded by a fibrous structure (called annulus fibrosus). Due to the normal ageing process, tears develop in the fibrous covering and the inner jelly comes out and presses on the nerve root. The resultant pressure and chemical irritation of the nerve roots causes severe pain in the legs (called sciatica) and low back pain. This is called Inter Vertebral Disc prolapse (IVDP).

This association between sciatic pain and disc prolapse was first revealed by Mixter and Barr in 1934, who advised surgical removal of the prolapsed disc. Conventional surgery requires general anaesthesia and involves a large incision and cutting of muscles and bones of the spine to remove the disc. This necessitates significant hospitalisation and post-operative rest.

Even though many changes have occurred over the last few decades, the evolution in spinal surgery has been very slow, due to the higher complexity and the risks. Micro lumbar Discectomy also required cutting the normal structures of the spinal column to access the disc tissue. This can at times further aggravate disc degeneration and may lead to long-term complications. The general anaesthesia required for these procedures also increased the risk including mortality. Often surgery is not advised due to fear of anaesthetic complications.

Endoscopic disc surgery under local anaesthesia is a recent technique that has a solution to all these problems. It involves introducing a one millimetre needle under image intensifier ‘C arm’ guidance into the site of disc prolapse and staining the damaged disc using special intra-vital stain and removing only the damaged disc under endoscopic visualisation.

The endoscope is introduced under local anaesthesia through an eight mm incision. No normal structure is injured or cut or removed and the patient is fully conscious during the procedure. So there is no chance of neurological injury. The spinal canal, which was stenosed, can be enlarged and pressure on nerve root relieved. The torn fibrous annulus can be repaired to prevent a recurrence from the same site. Since there is no general anaesthesia, the patient can walk off. As tissue trauma is very low, the post-operative pain and requirement of medication is also very low and the recovery is of short duration. There are no long-term adverse sequelae and hence no chronic post-operative pain, commonly referred to as Failed Back Surgery Syndrome.

Disc surgery is the commonest endoscopic spine surgery performed, but it has many other applications like spinal fusions, deformity correction and widening of the constricted spinal foramen called foraminoplasty.

DR SREEDHARAN NAMBOOTHIRI P E

endospines@gmail.com

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