The most common symptom of lumbar spine pathologies is low back pain. Truthfully speaking, a large majority of the world’s adult population suffers from low back pain.
Low back pain can radiate to the legs along with paresthesias/abnormal sensations in the legs when the exiting nerves of the leg from the lumbar spine get compressed.
With continued significant nerve compression, the nerve/s may get damaged resulting in slowly progressive numbness, weakness, loss of muscle bulk in the lower limb or rarely even sudden onset of severe weakness/loss of power in a part of the lower limb (most commonly foot drop).
Sudden onset of severe weakness/loss of power in a part of the lower limb (most commonly foot drop) does not carry a good prognosis.
Even more ominous is damage of the bladder/bowel nerves manifest through slow/sudden onset of urinary symptoms such as urinary retention and urinary incontinence.
Therefore, it is imperative that patients undergo MRI of the lumbo-sacral spine when they present with significant back pain/paresthesias radiating to the lower limb to pick up significant nerve compression.
A lumbar disc is a softer structure located between two bony vertebral bodies to allow movement between the two bodies.A lumbar disc prolapse is posterior dislocation of the lumbar disc thereby causing compression on the nerves of the lower limbs and bladder/ bowel nerves exiting from the lumbo-sacral spine.
Other causes of nerve compression are hypertrophied facet joints of the spine and hypertrophied ligaments.
MRI would diagnose correctly the levels, severity, location ofcompression on the nerves of the lumbo-sacral spine.
X-rays in flexion/extension are crucial to rule out instability in the lumbo-sacral spine.
I am a conservative spine surgeon by nature which means I exercise utmost restraint in offering surgery to my patients. I recommend surgery to only a small percentage of my patients.
In my practice, I would normally manage Pure Low back Pain without radiation non-surgically unless X-rays in flexion/extension reveal instability and/or lumbar spondylolisthesis.
Low back Pain/Paraesthesias radiating to the leg- I manageConservatively if MRI does not show significant nerve compression.
Low back Pain/Paraesthesias radiating to the leg- I offer Surgery ONLY if the MRI shows significant compression.
With continued significant nerve compression, the nerve/s may get damaged resulting in slowly progressive numbness, weakness, loss of muscle bulk in the lower limb or rarely even sudden onset of severe weakness/loss of power in a part of the lower limb (most commonly foot drop). Sudden onset of severe weakness/loss of power in a part of the lower limb (most commonly foot drop) does not carry a good prognosis. Even more ominous is damage of the bladder/bowel nerves manifest through slow/sudden onset of symptoms such as urinary retention and urinary incontinence or faecal incontinence.
Therefore, it is imperative that patients undergo identification and surgery at the painful/pareaesthetic stage rather than after developing irreversible nerve damage.
Surgery is done from the back through a tiny incision. Under microscope/endoscope, the surgeon removes all compressing elements on the nerves of the lumbo-sacral spine.
Well-selected patients with severe back pain/paresthesias radiating to the leg have near immediate miraculous disappearance of their pain post-operatively under Dr Sujoy Sanyal. The recovery time is short with most patients walking home the next day.
If too much of bone/joint/ligaments need to be removed to adequately decompress the nerves in the lumbo-sacral spine, the strength and stability of the spine might be hampered. In such situations, screws are inserted in the vertebral bodies and connected to rods to restore strength/stability to the spine. In addition, cages filled with bone graft are placed between the vertebral bodies in order to fuse one to the other over time, thus buttressing the screws-rods in place.
Screws are also required if X-rays in flexion/extension reveal instability in the lumbo-sacral spine which creates a situation called Lumbar Spondylolisthesis.
The traditional method of placing screws in the spine is by a large midline incision. Through the midline, first the nerves are decompressed. Thereafter, the muscles are significantly retracted to the sides and screws are placed in the vertebral bodies and connected to rods. Finally, cages filled with bone graft are placed between the vertebral bodies in order to fuse one to the other over time, thus buttressing the screws-rods in place. This method of placing Screws in the Lumbo-sacral spine is termed Open Pedicle Screw Placement.
I have stopped placing Open Pedicle Screwsfor the last 15 years because I find large midline incisions and retraction of the muscles to the sides grotesque in this era and age. I have placed every screw in the last 15 years percutaneously through tiny stab incisions. I use meticulous pre-operative planning to ensure exact placement of the screws. Such meticulous pre-operative planning helps exact placement of percutaneous pedicle screws without expensive gadgets such as Neuronavigation/O-arm and also decreases x-ray exposure for both the patient as well as the operating theatre personnel. A small midline incision is used to relieve pressure on the nerves and all necessary screws are placed through tiny stab incisions.
Lumbar Spondylolisthesis is slippage of one lumbar vertebra over the other and happens due to instability. Since the spine is unstable, the slippage continues to progress over time.
The initial manifestation of Lumbar Spondylolisthesis is Low Back Pain/Paresthesias with/without radiation to the legs.
With continued slippage, the weight-bearing capacity of the lumbo-sacral spine gets lowered and lowered, finally result in a bed-bound condition.
With continued significant nerve compression, the nerve/s may get damaged resulting in slowly progressive numbness, weakness, loss of muscle bulk in the lower limb or rarely even sudden onset of severe weakness/loss of power in a part of the lower limb (most commonly foot drop). Sudden onset of severe weakness/loss of power in a part of the lower limb (most commonly foot drop) does not carry a good prognosis. Even more ominous is damage of the bladder/bowel nerves manifest through slow/sudden onset of urinary symptoms such as urinary retention and urinary incontinence.
Therefore, it is imperative that patients undergo X-rays of the lumbo-sacral spine in flexion and extension when they present with significant back pain to diagnose Lumbar Spondylolisthesis.
MRI would diagnose correctly the grade/level of spondylolisthesis andlevels, severity, location ofcompression on the nerves of the lumbo-sacral spine.
X-rays in flexion/extension would diagnose correctly the grade/level of spondylolisthesis and further instability in the lumbo-sacral spine.
CT would delineate the bony dislocation better and the cause of the instability.
Minor Lumbar Spondylolisthesis with no instability may be conservatively managed.
Significant Lumbar Spondylolisthesis with/without instability needs surgery.
All cases with instability on flexion/extension x-rays need surgery.
The standard method of surgery is by a large midline incision. Through the midline, first the nerves are decompressed. Thereafter, the muscles are significantly retracted to the side and screws are placed in the unstable vertebral bodies and connected to rods after bringing the vertebral bodies in alignment as much as possible. Finally, cages filled with bone graft are placed between the slipping vertebral bodies in order to fuse one to the other over time, thus buttressing the screws-rods in place.
This is a path-breaking technique devised to fully reduce the spinal dislocation and fix the unstable lumbo-sacral spine using small laparoscopy-style incisions for relief of pressure on the nerves and placement of all the hardware required to fix the dislocated unstable spine in proper alignment.
I find large midline incisions and retraction of the muscles to the sides grotesque in this era and age. I use meticulous pre-operative planning to ensure accuracy of the surgery. Such meticulous pre-operative planning helps safelyfix the dislocated unstable spine in proper alignmentthrough tiny incisions without expensive gadgets such as Neuronavigation/O-arm.
Small incisions and minimal muscle retraction translate into quick post-operative recovery.
Patients with severe back pain/paresthesias with/without radiation to the leg have near immediate miraculous disappearance of their pain post-operatively under Dr Sujoy Sanyal. The recovery time is short with most patients walking home within a couple of days.
Devised an unique pre-operative planning paradigm to improve accuracy and safety of Percutaneous Pedicle Screw placement.
This is a path-breaking technique devised to fully reduce the spinal dislocation and fix the unstable lumbo-sacral spine using small laparoscopy-style incisions for relief of pressure on the nerves and placement of all the hardware required to fix the dislocated unstable spine in proper alignment.
Large midline incisions and retraction of the muscles to the sides are grotesque in this era and age. Meticulous pre-operative planning helps safelyfix the dislocated unstable spine in proper alignment through tiny incisions without expensive gadgets such as Neuronavigation/O-arm.
Small incisions and minimal muscle retraction translate into quick post-operative recovery.
