Question 1

Doctors who don't perform MISS themselves often face a perception battle when counselling patients. How should they address patient fears?

Dr. SK Rajan · Accepted Answer

In counselling, the greatest confidence comes from seeing patients who have been operated on. The internet helps a great deal here: the Artemis Hospitals website carries many patient testimonials in favour of minimally invasive spine surgery and 3D imaging, showing that they were able to get up the next day. Beyond that, as the technology percolates into more and more centres and results accumulate, the outcomes will speak for themselves. At this point, the main limitation is the availability of technology. When I was growing up in a small town, we heard that Delhi had very good hospitals and technology, and it was hard to imagine what was possible. The same gap exists between India and countries without these facilities, so I understand that it is hard to believe we now perform minimally invasive surgery with walking the next day and 99% safety. But the world has reached there.

Question 2

When we say '99% safe,' patients sometimes read this as '99% chance of a full recovery.' Can you clarify?

Dr. SK Rajan · Accepted Answer

Safety and success have to be separated. Safety is about not worsening the patient; success is about improving the patient. When we say 99% safe, we mean that out of 100 patients, 99 will have no deterioration in their condition. We never say that 99% of patients will get up and walk: if a patient comes to me paralysed, especially after trauma, there is no technology anywhere in the world, including the US, that can make him walk. Safety comes first and success follows, and success differs from person to person. A go-getter who wants to run and go to the gym may not be satisfied if I relieve his pain but he cannot return to the gym. A housebound patient who only wants the freedom to leave home, travel and feel independent will count that much improvement as success. Success depends on the patient's pre-operative condition, how long the disease has been present and its stage on MRI. These points are best clarified in a one-to-one discussion, which is why we hold online OPDs to explain how much each patient is likely to improve.

Question 3

There is often overlap between neurology and spine surgery, with neurologists recommending medication or physiotherapy until deterioration occurs. How is it determined when surgery is right, for example in a 65-year-old who may have 20 years of life ahead?

Dr. SK Rajan · Accepted Answer

In general, a patient who comes with acute pain of short duration, less than about three to four months, with no weakness and quality of life not severely compromised, should be given a trial of medical management: precautions, posture correction, exercises, physiotherapy, medicines and possibly injections. At the other end of the spectrum is a patient who has suffered for a long time and tried all of these without benefit, or whose attacks keep returning, so that they develop weakness of the foot or arm, changes in handwriting, or a poor quality of life: unable to travel, lift their children or lead a normal social life. When that happens and the MRI shows corresponding compression of the nerves, we have to explain that surgical decompression and stabilisation will improve quality of life better than continuing physiotherapy and exercises that are not working. Lifestyle demands also differ. A 70-year-old who lives above their own shop, does not want to travel and is supported by a joint family can be managed medically. The same person with the same problem at the same age who wants to travel the world or stay socially and politically active will need surgery. Treatment is individualised, which is why doctors' opinions vary: some look only at the clinical examination, others at the patient's whole journey and quality of life. It is a very big grey zone, and it will remain one.

Question 4

Many spinal conditions are painful, and pain medicine and non-surgical pain therapies have advanced. Where do pain specialists fit alongside spine surgery?

Dr. SK Rajan · Accepted Answer

Many patients who come to me end up being sent to a pain specialist for injections. If the MRI shows little nerve compression and the pain is not improving with medicine or exercise, that is where the pain specialist has a role. When there is compression, I refer to a pain specialist only if the patient cannot undergo surgery because of medical comorbidity, such as end-stage liver disease, or if the patient wants pain relief for now and is not ready for surgery; an injection can give relief for a few weeks while the pros and cons of both approaches are weighed. Pain medicine and surgery are complementary, not in conflict. Something on the MRI does not mean everyone needs surgery, and many patients at a particular stage benefit more from pain medicine. For an obese patient with relatively poor bone quality who will not exercise and has intense pain, an injection can give some relief; at the same time we start improving bone health and muscle mass with protein supplements, and ultimately take the patient up for surgery. We use pain specialists a great deal in our practice.

Question 5

What hygiene and precautions should be observed after spine surgery?

Dr. SK Rajan · Accepted Answer

I will address it from three angles. First, reducing the chance of infection: make the surgery as minimally invasive as possible, give postoperative antibiotics, and remove the urinary catheter in good time, because urine often becomes a major source of infection. Second, how patients keep themselves clean: regular dressings every second day until day 10, when the sutures are removed; avoiding going out and receiving too many visitors; and sponging to clean the wound and body rather than taking a bath. Third, precautions: for about three months after a simple discectomy or spinal fusion, which is the time healing requires, no lifting weights, no sitting on the ground, no squatting, no bending down and no lifting children. In the first month, the patient should not sit for more than half an hour continuously, or travel for more than half an hour without getting out of the car for a short break. For the first 7 to 10 days, no sitting on a sofa or low seat; an armchair allows the patient to get up with support. The belt should be worn after lumbar surgery and the collar after cervical surgery. We obtain X-rays every month for the first three months, sent to us through the partner or referring doctor, and then every three months up to one year, and the restrictions are lifted as the months go by.

Question 6

What is the timeline for an athlete who wants to return to active training after spine surgery?

Dr. SK Rajan · Accepted Answer

We see many sportsmen, such as golfers and cricketers, so this is not uncommon. The first priority is spinal stabilisation. For an office worker with a simple slipped disc, I do what is needed. For a sportsman, a gym trainer or an adventure-sports enthusiast such as a climber, where the segment is unstable, I gravitate towards spinal fixation to give the spine good stability, and that is how most sportsmen have returned to active sport. Second, the surgery should be minimally invasive as far as possible, so that the muscle is not damaged much. After surgery, load bearing is built up slowly: returning to active sport takes about one year, of which about nine months is rehabilitation focused on core training, lower back exercises and neck muscles, so that a very strong core can take the load. This is always done under the supervision of sports physical therapists, with protocols varying according to the person's body profile.

Question 7

What are your recommendations for spine health in office workers with long sedentary hours, and for heavy weightlifters? Is there an age dimension?

Dr. SK Rajan · Accepted Answer

Leaving aside extremes such as very obese or very elderly patients, the rules are largely the same between about 30 and 60 years of age. People with long working hours must keep a correct sitting posture: back support, the laptop raised to a higher level, arms well rested and the spine supported, with back support while driving too. The seat should not be low: the angle between the thigh and the lower leg should be more than 90 degrees, obtuse rather than acute, which reduces the load on the spine. Basic exercises are recommended for everyone: pelvic tilts, leg raises, windshield-wiper movements of the legs, the Cobra pose and the Superman pose. These strengthen the lower back and build stamina for long hours of sitting. For heavy weightlifters, much depends on the condition. A lifter with back pain and a largely normal MRI can return to active weightlifting in six to eight weeks, which is more a matter of physiotherapy and exercise. With a prolapsed disc, weightlifting is practically ruled out for the next six to nine months, because the annular tear takes about nine months, sometimes a year, to heal; without that care, there is a very high chance the tear ruptures and the disc comes out. The really elderly must be extra careful to take protein supplements and do resistance training to strengthen their muscles; otherwise they gradually begin to slouch.

Question 8

You mentioned resistance training. Does strengthening the core and back muscles contribute to long-term spine health?

Dr. SK Rajan · Accepted Answer

Definitely. Fifteen or twenty years ago, when we trained as neurosurgeons, we had very little idea why some people develop spine problems and others do not. Over the past couple of decades it has become very clear that the major contributor to spinal problems is the lack of muscular support around the abdomen and lower back. Resistance training helps a great deal. Innumerable patients of mine, at an early to moderate stage, with no weakness and quality of life not badly affected, have been able to avoid surgery by strengthening their core muscles.

Question 9

How do you manage a patient with multiple disc prolapses at both cervical and lumbar levels? Is minimally invasive surgery possible, or is open surgery required?

Dr. SK Rajan · Accepted Answer

In the presentation I showed cases where multi-level thoracic spinal stenosis was managed by minimally invasive laminoplasty, and multi-level lumbar disc disease by minimally invasive surgery with fixation at two or three levels. With navigation and 3D imaging, minimally invasive surgery can now be done not only at one, two or three levels but at four and five levels. Each patient has to be evaluated individually: some cannot tolerate a longer operation, or their bone quality or joint hypertrophy is unfavourable, and then we convert to open surgery or plan it from the start. As a ballpark: one-level and two-level lumbar surgery, minimally invasive without question; for three and four levels, about half our patients have minimally invasive surgery and half open surgery, because of anatomical constraints rather than because minimally invasive surgery is not better. On sequencing: if the patient has cervical myelopathy with cord compression causing weakness, we operate on the cervical spine first, because we do not want the neck in a wrong position during lumbar surgery. If the patient has neck pain radiating into the arm without much compression on MRI and most of the pain comes from the back, we do the lumbar spine first, because that is the complaint the patient wants addressed first. If possible, particularly with fewer than three levels, both are done in the same sitting, and then the order does not matter; in separate sittings, the cervical spine is usually done first.

Question 10

What is the standard treatment for scoliosis with a Cobb angle greater than 10 degrees?

Dr. SK Rajan · Accepted Answer

Anything under 10 degrees is not labelled scoliosis at all; above 10 degrees, the patient has scoliosis. Between 10 and 25 degrees the curve is largely safe and is managed by observation with repeated X-rays over the years. In a child who is still growing, a curve of about 25 to 40 degrees is usually treated with a brace. A Cobb angle of around 40 degrees is usually the tipping point at which we realise the patient will require surgery. If the curve is under about 40 degrees after the spine has finished growing, say at 18 or 20 years of age, we can wait and watch, because such curves rarely progress; it is not a major cause of concern. The second factor, beyond the Cobb angle, is spinal balance: two parallel lines are drawn on either side of the vertebrae to define the median zone of stability. As long as the curve stays balanced within that zone, it is better tolerated. Once it moves beyond it, there is a higher risk of progression and symptoms, and scoliosis correction is more likely to be required.

Live Discussion with Dr. S. K. Rajan