Question 1

Did you talk about scoliosis during your presentation?

Dr. Puneet Girdhar · Accepted Answer

Yes, a large part of the patients I showed had scoliosis, and I also covered revision scoliosis, where an earlier operation has failed. One example was a revision in which a previous lumbar fixation had been left at the apex of the curve and the curve worsened until the Cobb angle reached about 100 degrees. I revised it, brought it down to about 25 degrees and the patient had balanced shoulders. Primary thoracic scoliosis is something we correct routinely. I also showed an angular kyphosis with a hemivertebra, and a cervicothoracic kyphoscoliosis in which the scoliosis was corrected by decompression, a vertebral column resection, an anterior cage and fixation.

I perform three types of osteotomy. The first is all-posterior Ponte osteotomy, with facetectomy, decompression from behind and correction with screw fixation. The second is pedicle subtraction, in which part of the pedicle and a wedge of the vertebral body are removed. The third is vertebral column resection, in which the entire vertebral body is removed from behind with ultrasonic osteotomes and a high-speed drill.

Scoliosis alone is the easier problem, but most of the patients you see also have kyphosis. Kyphosis gives a big hump and can compress the spinal cord, whereas scoliosis alone rarely does, so these are very challenging cases. I remove the hemivertebra, perform a vertebral column resection, place a cage in the front and fix the spine. I use ultrasonic osteotomes to cut the bone precisely, with no hammer or chisel and no cracks, and the bone removed can be used as graft. When the tip touches the dura it stops automatically, so it does not injure the neural elements.

Question 2

How old was the patient you showed, and can the correction still be done in a patient of around 25 years?

Dr. Puneet Girdhar · Accepted Answer

The patient was about 17 or 18 years old. Ideally these patients should come at 4, 5, 6 or 7 years, and not later than that. In an older patient, around 20 or 25 years, the correction can still be done and we have to do it, because we do not have any other option, but the surgical outcomes start getting challenged.

Question 3

Can I seek your consultation for a patient who is the family member of a colleague, and is that feasible?

Accepted Answer

Yes. Share the patient's reports, X-rays and MRI through the WhatsApp group we already have with you. The Jivo team documents the case in a file and shares it with Dr. Puneet Girdhar. Once he has reviewed it and given his opinion, the team coordinates your availability and his, and organises a video consultation on Zoom or Google Meet so that you, as the referring doctor, can be present.

Question 4

Can I invite one of my colleagues, a vascular surgeon, to join the platform?

Accepted Answer

Yes. Your colleague can be invited through the Jivo doctor portal, or you can share the number in the WhatsApp group and the Jivo team will take it from there.

Question 5

Do you manage patients with neurological lesions following transverse myelitis?

Dr. Puneet Girdhar · Accepted Answer

Transverse myelitis is a very different disease. It is more a medical disease than a surgical one, so it is not under the purview of a spine surgeon and is managed by neurophysicians or neurologists. There is a proper protocol that includes cerebrospinal fluid assessment by lumbar puncture, and immunotherapies are now available. Patients often need supportive treatment: rehabilitation if they have weakness, and intensive care support if the illness affects their breathing. It is not a compressive lesion, so it does not need a surgeon.

Question 6

Does your institution offer courses in orthopaedic and spine surgery for foreign doctors, and what are the requirements?

Dr. Puneet Girdhar · Accepted Answer

We have fellows from all over the world. Short-term fellows, who are usually from within the country, come as observers for one week up to three or four weeks. The National Board diplomate programme is a two-year fellowship, but it cannot be offered to overseas doctors because it requires a national passport, a postgraduate qualification recognised by the National Medical Commission and an entrance test, in which one to two lakh postgraduates appear and only 30 are selected.

A short-term observership or fellowship of up to one year is possible. I have had fellows from Russian-speaking countries and from Africa, including Tanzania, who stayed with me for up to a year, but we encourage shorter programmes of 4, 8 or 12 weeks. For hands-on work, registration with the National Medical Commission is needed, which may be an uphill task but can be done. Otherwise we can offer a good observership in which you may scrub, although the surgical part is more observational. It is very informative to see the work in person, because you only understand the effectiveness of a technique once you have seen it.

Question 7

If spine surgery is described as safe, can it also reverse nerve damage that a patient has lived with for years?

Dr. Puneet Girdhar · Accepted Answer

A lot of neurological deficits are not recoverable. In spinal cord injury, surgery has a role in the early stage: it prevents secondary damage, stabilises the spine, reduces the impact of haematoma or compression on the cord and gives the cord the conditions, including oxygen, in which to recover. Some partial injuries may recover over three to six months, and patients may be able to stand up and walk again.

Many patients with a cord transection, an injury that cuts the spinal cord, may have to live with weakness of the legs, or of the legs and arms, for the rest of their lives. They still need rehabilitation to prevent deep vein thrombosis and bedsores. They also need surgical stabilisation so that they have sitting balance, can be turned in bed and can be rehabilitated vocationally, physically and behaviourally. There is a lot that can be offered, but no promise of complete recovery can be made after a cord transection.

Patients often ask, "I had this injury six years back, I have no sensation, no power in the legs and no urine or stool control: can you do some robotic surgery to improve it?" The answer is no. Robotic surgery is for safe corridor surgery, precise implantation and accurate work that prevents neurological injury. It does not restore nerves. Neurological loss from an injury can recover partially if the transection is not complete, but if there is zero power and zero sensation, the possibility of recovery is dismal.

Question 8

How safe is spine surgery today, given patients' fears, now that minimally invasive and robotic options exist?

Dr. Puneet Girdhar · Accepted Answer

At an advanced centre like ours, injuring a nerve or the spinal cord during surgery is a very rare event. In the last ten years I have not seen anybody paralysed because of a surgery. There can be transient deficits, such as hoarseness of voice after anterior cervical surgery, which usually recovers in four to six weeks, and a little numbness here and there. These are mostly in patients who ignored and neglected their problem for a long time, so that the nerves are compressed or the deformity is extreme and the surgery is technically very challenging. The risk is higher in those operations than in the straightforward decompressions and stabilisations we do routinely, which depend on the skill and experience of the surgeon.

Robotics can mitigate the small residual risk because of its precision. You are not eyeballing, the learning curve becomes very small, and fellows can follow the same objective path without depending on their experience, because the robot gives the trajectory. Every technology has its own drawbacks, including a learning curve, but it is very short compared with learning to eyeball and developing hand-eye coordination.

Open surgeries always carry the risk of dural tear and nerve injury. With a minimally invasive, targeted approach you have a magnified view of your nerves and ligaments, and the possibility of injury has gone down substantially. This is what modern techniques and technologies can do: make spine surgery safe, build belief and give reproducible outcomes, and that is what we have been doing for more than 15 years.

Live Discussion with Dr. Puneet Girdhar