1. Dr. Manish Raj MD,DA,FISP,FPM
Minimally Invasive Spine & Pain consultant
Fellow of Interventional spine & pain(Pci-Mumbai)
Fellow of Pain manganement (FPM-Aesculap Germany)
Member- North american spine society(NASS)
-Society of minimally invasive spine surgery(SMISS)

2. • About 85% of Indians experience back trouble by age 50.
• Back problems are the most frequent cause of activity
limitations in working-age adults
• In the long run, surgery, chiropractic care, etc., are
considered no more effective than no treatment in
reducing low back pain…so, prevention is key!
Back facts in general…

3. Overview
Introduction
Anatomy
Causes of LBP
Prevention
 Recent Advances in Treatment

4. BACK & NECK PAIN
 One of the most common chronic conditions in India
 Frequency in men & women are equal
 4 out of 5 Indians will experience LBP or Neck Pain
 Acute:  6 weeks
 Chronic: > 6 weeks

5. Anatomy
 Spine: 33 vertebrae
 7 cervical (neck)
 12 thoracic
 5 lumbar
 5 sacral (fused)
 4 coccygeal (tailbone)

6. INTERVERTEBRAL DISC
 Fibrocartilage
 Functions:
 Absorb shock
 Allows increased spinal range of motion in flexion/
extension

7. NERVES
 Nerves come out of holes between vertebrae

8. MUSCLES & Connective Tissues
 Spine is supported by bones, muscles and connective
tissues

9.  Injury to any structures previously
mentioned in the Spine
region
How do you get low back pain?

10. • Poor body mechanics
• Stressful living & work habits
• General physical fitness decline
• Loss of flexibility
• Loss of strength
Leading Causes of Back
Problems

11.  General joint stiffness
 Acute strains and sprains
 Muscle guarding or spasm
 Disc bulge  herniation
 Degenerative disk disease
 Osteoarthritis
Common Back Disorders

12. A other ause of a k pro le s…
accidents
It is also possible to injure
your back due to accidents.

13. Back Strain/ Sprain

14. Disc Injury
 Discs have sensory pain receptors
 Discs can:
 Degenerate
 Bulge/ herniate
 Most easily injured with flexion
& rotational forces

15. Fractures
 Less common
 Usually occurs with major trauma or as a result of a
pathology
 Fall from a tall height
 Osteoporosis
 Cancer in the bone
 Infection of the bone

16. Risk Factors
 Pregnancy
 Poor physical conditioning
 Poor movement techniques
 Poor posture
 Occupation
 Previous back injuries
 Others – spinal disorders (e.g. scoliosis, osteoporosis,
spondylosis)

17. Causes - Summary
 Any injury to supporting & surrounding structures
 Muscles
 Ligaments
 Joint
 Bones
 Intervertebral discs
 Nerves

18.  Maintain good physical condition
 Ideal weight, maintain good muscle strength,
endurance, and cardiovascular endurance
 Proper diet/ nutrition
 Proper lifting techniques
 Proper posture
 Avoid smoking
 Decreases blood flow
 Maintain good core strength
Prevention

19. Prevention: Posture

20. Prevention: Posture
 Sitting posture

21. Prevention: Posture

22. Prevention: Proper Lifting

23. Prevention: Proper Lifting

24. Disc Herniation

25. Treatment options for Slip disc
-Selective root sleeve transforaminal Epidural steroid
-percutaneous mechanical decompression:
-Decompressor STRYKER
-Nucleotomy
-Hydrodiscectomy
-NUCLEOPLASTY
-Laser Discectomy etc
-ozone discectomy
-IDET(intradiscal electrothermal coagulation)
-Disctrode(Intradiscal radiofrequency)
-Biacuplasty
-ENDOSCOPIC DISCECTOMY
-MIS fusion(percutaneous TLIF)
- Open Surgery(Microdiscectomy,laminectomy,fusion)

26. TFESI (EPIDURAL INJECTION)

27. OZONE DISCECTOMY

28. HYDRODISCECTOMY

29. DECOMPRESSOR DISCECTOMY

30. Intradiscal Electrothermal
coagulation (IDET) & LASER

31. NUCLEOPLASTY

32. Optimal Patient Selection
 Radicular pattern with or without Axial Pain
 Leg pain > back pain
 MRI evidence of contained disc protrusion
 Discography positive, if indicated
 Failed selective nerve root block x 1
 Failed conservative therapy X 3 months
 Axial Back Pain
 Failed conservative therapy X 3 months
 MRI evidence of contained disc protrusion
 Discography positive for concordant pain
 Failed diagnostic injections (facet, nerve, epidural etc)
 Disc height > 75%

33. Exclusion Criteria
 50 % loss of disc height
 Extruded or sequestered disc
 Spinal fracture or tumour
 Moderate to severe spinal stenosis
 Complete annular disruption
 Degenerative instability
33

34. Clinical Outcomes After Lumbar Discectomy for Sciatica:
The Effects of Fragment Type and Annular Competence
EJ Carragee et al., Stanford University , The Journal of Bone and Joint Surgery. Jan 2003
Are Nucleoplasty and Microdiscectomy patients the same?
 Study of microdiscectomy outcomes based on
herniation type
 Classified herniations into 4 types
 Results: contained herniation with no sub-annular
fragment performed poorly with microdiscectomy
 Conclusion: The ideal Nucleoplasty patient is not a
good candidate for microdiscectomy
34

35. Radiology terms
Oblique View
Kambins
triangle

36. Correct Needle Placement
Same approach as discography for needle placement
36

37. Incorrect Needle Placement
37
Needle entry too far lateral.

38. Incorrect Needle Placement
38
Needle entry too far lateral and shallow.

39. Lumbar Nucleoplasty Technique
1. Using fluoroscopy, introduce
the needle to the
nucleus/annulus junction of
the disk (Confirm position
using fluoroscopy).
39

40. Lumbar Nucleoplasty Technique
2. Insert the wand through
the needle, and advance
the Wand until the
Reference Mark is at the
needle hub.
40

41. Lumbar Nucleoplasty Technique
3. Using blunt dissection,
advance the tip of the DLR
into the nucleus, and
STOP when the distal
annulus is reached.
This determines the Distal
channel limit.
41

42. Lumbar Nucleoplasty Technique
4. Position Depth Gauge at
the needle hub
It will reference the Distal
channel limit within the
nucleus (this should be
confirmed using fluoroscopy).
42

43. Lumbar Nucleoplasty Technique - Final Result
 Create additional
channels at the 4, 6,
8, and o’clock
positions.
 Approximately 1/2 cc
of tissue removed
causing
decompression.
43

44. The Procedure-Cervical Nplasty
The surgeon uses the fingers to detect the vertebral space holding the SCM
muscle laterally and the trachea medially.
44

45. Under fluoroscopic control, the introducer needle is inserted using an anterior
lateral approach, medially to the SCM and vessels.
The Procedure
45

46. Needle Placement
 Check needle placement in A/P projection
 Needle should be in line with the midline (spinous process)
A/P Lateral
46

47. Cervical Nucleoplasty Technique
 Position needle tip in the posterior 1/3 of the
nucleus
 Anterior-lateral approach
 Fluoroscopic guidance
 If desired, move the green
marker down to skin level.
 Unscrew and remove the
stylet
 Insert the Perc DC SpineWand
 Only as far as tip remains within end of needle
 Do not allow device to protrude from needle
47

48. Cervical Nucleoplasty Technique
 Once the device is inserted,
withdraw the needle from
over the tip of the device
 monitor deployment of device
beyond end of needle
 Lock Perc DC into Needle
Hub
 Confirm with fluoroscopy
48

49. Cervical Nucleoplasty Technique
 In ablation mode, rotate device
through 360
o
for approximately
2 - 3 seconds
 Withdraw device 1-2 mm and
repeat to make a series of 2-3 voids.
 Never maneuver or advance the
needle with the device inserted
 Unlock SpineWand from needle
hub and withdraw into introducer
needle before removing.
49
3 2 1

50. 3 2 1
The Procedure
 Ablation mode is performed for three cycles in
withdrawal, rotating the wand 180 in each cycle (8
seconds ablation each)
50

51. The Procedure
51
The wand is unscrewed from the luer lock and removed inside the introducer
needle

52. ENDOSCOPIC DISCECTOMY

53. Technique- transforaminal approach

54. Surgical Approach

57. SPINE FUSION (MIS)

58. SPINAL CORD STIMULATOR

59. Vertebral compression fracture

60. VERTEBROPLASTY & KYPHOPLASTYPLASTY

61. VERTEBROPLASTY

62. Vertebral augmentation-KIVA

63. Failed Back surgery syndrome (FBSS)
 Percutaneous fluoroscopic epidural
adhesiolysis.
 RF Facet joint denervation & DRG
lesioning.
 Spinal cord stimulation
 Intrathecal drug delivery systems.

64. ADVANCEMENT ??????????????
 Percutaneous Decompressor
Discectomy
 Hydrocision Discectomy/
Laser Discectomy
 Endoscopic Discectomy
 Bicuplasty/Ozone
Discectomy
 Disc Nucleoplasty /
Automated Nucleotomy
 Neuroplasty/Adhesinolysis
 Vertebroplasty/Kyphoplasty
 Intradiscal eletrothermal
coagulation(IDET)
 Spinal Cord Stimulator
 Neurotomy/Radiofrequen
cy Ablation
 Provocative Discography
 Lumbar & cervical
Transforaminal epid.inj
 Cervical & Lumbar Facet
Joint injection/Block
 Intrathecal Pump
 Mimimal invasive lumbar
discectomy(MILD)
 MIS Fusion/ TLIF

65. QUESTIONS?

66. Dr Manish Raj MD,DA(Gold medal),FISP,FPM
Minimally invasive spine & pain Consultant
BENSUPS Cygnus Superspeciality Hospital,Dwarka
CYGNUS Orthocare Hospital ,Safdarjung Development Area
Director-Spinomax pain & spine clinic,Safdarjung Enclave
www.spinomax.com , Email – info@spinomax.com