Question 1

What are the selection criteria for doctors in our network who want to join your fellowship or observership programme?

Dr. Puneet Girdhar · Accepted Answer

Practically there is no selection criteria for an observer. At best we make you scrub and observe. You cannot participate in performing the procedure, but it is a great experience in today's world. We can accommodate visitors for one week, or for as long as eight to ten weeks if they can make that space in their practice. There are two ways a department can engage: senior surgeons already in practice who come for three to five days or a week to refine techniques and understand the finer nuances, and the students working with them, who can come for longer periods. None of this is accredited by any national board; the credential we can provide is a certificate from our own hospital, signed by myself and our management. All certified courses happen through national exams, a minimum two-year course, and there are also Spine Society of Delhi and Spine Society of India fellowships of one to three months, one of which runs for a year, but these are not available to overseas trainees, fellows or visiting surgeons.

Question 2

Does an observership need to be limited to specialists, or can general practitioners take part, and who benefits most?

Dr. Puneet Girdhar · Accepted Answer

Anybody can come in. It depends on their interest, whether they are doctors or paramedics, and I also get technicians who want to learn from our technicians how the equipment can be used more efficiently. Any doctor is welcome: if they have an outpatient or clinic practice where a lot of spine patients come and they want to refer them, they need to be updated on what is done, and when you see it, your belief becomes stronger. Until you have seen it, it is very difficult to fathom and to convince your patient what the procedure will achieve. Surgeons who want to elevate their practice have to come and observe the procedures more closely, and over time we can develop a long-term relationship, help them set up their centres and tackle more cases themselves, and they can always refer complex cases to us.

Question 3

A young man has a diffuse L4-L5 disc bulge compressing both traversing nerve roots, a left paracentral L5-S1 disc protrusion narrowing the left lateral recess, and spinal canal stenosis of 9.5 millimetres. He is exhausted by medication and physiotherapy but afraid of surgery. What would you recommend?

Dr. Puneet Girdhar · Accepted Answer

If there is no significant back pain and no instability, we prefer a decompression procedure: either biportal endoscopy, through two incisions of 4 to 5 millimetres to 1 centimetre at two different places, or an MIS tubular approach through a single 2.5 centimetre incision, with a discectomy at the same time if there is a large disc. If the patient has significant back pain and the dynamic X-ray shows instability, or there is a lysis or discal collapse with foraminal stenosis, he will require a TLIF: a cage and screws to stabilise the segment and restore disc height, decompression of both foramina, and restoration of spinal balance. If he is already exhausted by medication and physiotherapy and not getting better, I know he is afraid of surgery, but I am sure he needs surgery; he is suffering, which is why he keeps going back to his doctors wanting treatment.

Question 4

How is minimally invasive surgery done in practice, for surgeons whose setting does not yet perform it?

Dr. Puneet Girdhar · Accepted Answer

I would request that we spend time together: if you are planning to come to India, please come to Delhi to our centre. I tried my best, but that is all you can cover in 45 minutes or an hour, when it represents twenty years of work with a lot of technology. You have to observe more, and that would allow you to move on to minimally invasive surgery. It is not difficult, but everything new you start in your practice is always uphill, a steep curve, yet very much achievable, looking at the number of MIS centres in the world today.

Live Discussion with Dr. Puneet Girdhar

What are the selection criteria for doctors in our network who want to join your fellowship or observership programme?

Does an observership need to be limited to specialists, or can general practitioners take part, and who benefits most?

How is minimally invasive surgery done in practice, for surgeons whose setting does not yet perform it?

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In This Series: Indications for Spine Surgery & Advances for Safer Outcomes