What is liver cancer ?
Liver cancer is the uncontrolled growth and spread of unhealthy cells in the liver. Cancer that starts in the liver is primary liver cancer. Cancer that spreads to the liver from another organ (such as bowel or breast) is known as secondary or metastatic liver cancer.

What is the difference between liver tumor and liver cancer ? 
Any mass or nodule in the liver is known as a liver tumor. Liver tumors can be non-cancerous (benign) or cancerous (malignant). The most common type of cancer that originates in the liver is hepatocellular carcinoma (HCC).

What are the causes of primary liver cancer ?
There is no one cause of primary liver cancer. Several factors increase a person’s likelihood of developing liver cancer. Some risk factors for liver cancer include:
Viral hepatitis – Hepatitis B virus (HBV) and Hepatitis C virus (HCV) infections are an important cause for the development of liver cancer. It is estimated that about 5-10 percent of people with HBV or HCV will develop liver cancer.

• Cirrhosis is a progressive disorder that leads to scarring of the liver. Cirrhosis is the end result of all forms of long standing liver damage. Cirrhosis is caused by Hepatitis B, Hepatitis C, alcohol abuse, fatty liver and certain genetic disorders.  5-10 percent of patients with cirrhosis will develop liver cancer.
• Toxins such as Arsenic – Drinking water (usually well water) contaminated with arsenic also increase risk for developing liver cancer. Obesity may increase the risk of liver cancer.
• Diabetes can increase the risk of liver cancer, especially in those who drink alcohol heavily or have chronic viral hepatitis B or C infection.

What are the symptoms of liver cancer ?
Liver cancer usually has no obvious symptoms, and people at risk should be followed regularly to detect cancer at an early stage. The following symptoms might be caused by liver cancer:
Unexplained weight loss
Anorexia (persistent lack of appetite)
Early satiety (feeling very full after a small meal)
Persistent abdominal pain
Increasing abdominal girth (swelling of the “stomach” area) with or without breathing difficulty
Sudden jaundice (yellowness of the skin and eyes)
Sudden deterioration in the overall condition of a patient with cirrhosis
Liver enlargement or a mass that can be felt in the area of the liver

What tests will I have to detect liver cancer ?
If liver cancer is suspected, the doctor will conduct a physical examination and order special tests. Further tests may include alpha-fetoprotein (AFP) blood test, ultrasound scan, computed tomography (CT), magnetic resonance imaging (MRI), angiography, laparoscopy and biopsy. It is important to detect liver cancers early because small cancers in a patient who has minimal symptoms can be treated effectively.

What is liver cancer screening ?
Liver cancer screening is the best way to detect liver cancer early in its course. It is performed to detect small cancers that do not produce any symptoms. Small cancers can be treated more effectively. Patients who have a liver disease that puts them at a high risk of developing liver cancer (such as hepatitis B, any form of cirrhosis) should undergo periodic screening tests. It usually involves a blood test to look for a cancer marker (alpha-feto-protein) and an ultrasound scan of the liver to look for actual cancer. You must understand that screening tests are not 100 percent accurate and your doctor may advise you additional tests if he suspects that you may have a liver cancer.

How is liver cancer treated ?
Liver cancer treatment depends on:
The liver’s condition
The size, location, and number of tumors
If the cancer has spread outside the liver
The person’s age and overall health

Different ways of treating liver cancer are:
Surgery: If the cancer has been found early and the rest of the liver is healthy, doctors may perform surgery to remove the tumor from the liver.
Cryosurgery: Cryosurgery uses a metal probe to freeze and destroy cancer cells.
Radiofrequency Ablation: Radio frequency ablation uses a special probe to destroy cancer cells with heat using special needle. The procedure is performed under ultrasound or laparoscopic guidance.
Chemotherapy or chemoembolization: Chemotherapy uses anti-cancer drugs to destroy cancer cells. In some cases, the chemotherapy can be directly injected into the liver tumor.
Radiation Therapy: Radiation therapy uses radiation (high-energy x-rays) to destroy cancer cells.
Oral chemotherapy drugs : Sorafenib is an oral medication for use in advanced cases of liver cancer.

Can a liver transplant be done for liver cancer ?
Surgery is the most effective therapy for most types of liver cancer, but doctors will usually combine different methods to treat the cancer most effectively. When surgery to remove the cancer itself cannot be performed, your doctor may suggest a liver transplantation in which the cancer along with the entire liver is replaced thus curing the patient.

Pancreatitis

Pancreatitis is serious disease in which there is a swelling in pancreas. The pancreas is a large gland behind the stomach and close to the duodenum. The function of pancreas is to secrete digestive enzymes into the small intestine through a tube called the pancreatic duct. These enzymes help digest fats, proteins, and carbohydrates in food. The pancreas also releases the hormones insulin and glucagon into the bloodstream. These hormones help the body use the glucose it takes from food for energy. Pancreatic disease occurs when the digestive enzymes are activated and begin attacking the pancreas. In very severe cases, pancreatitis can result in bleeding into the gland itself; serious tissue damage, infection and fluid collections may occur. Severe pancreatitis can result in damage to other very important organs such as the heart, lung and kidneys. In approximately 70% of the cases, pancreatitis occurs when person consumes excessive, alcohol for longer period of time. It may happen due to metabolic disorders. It’s rare that patients have chronic pancreatitis that tends to run in families (hereditary pancreatitis). Alcohol damages the pancreas but patient may not show symptoms for many years. It occurs suddenly and patient show severe pancreatitis symptoms, including severe pain and loss of pancreatic function, resulting in digestion and blood sugar abnormalities.
There are two types of pancreatitis. The first category is acute pancreatitis which occurs suddenly and may result in critical complications. According medical data, the majority of patients get well completely from this type of pancreatitis. Chronic pancreatitis is usually the result of longstanding harm to the pancreas from alcohol intake. In chronic pancreatitis, patient complains severe pain and there is loss of pancreatic function.

Causes:

Acute pancreatitis is more common in men than women. Chronic pancreatitis may be due to metabolic, hereditary, or simply the causes are unidentified. Pregnancy can also cause ancreatitis, but in some cases the development of pancreatitis is most likely just a reflection of the hyper triglyceridemia which often occurs in pregnant women. Pancreas divisum, a common congenital deformity of the pancreas may cause some cases of frequent pancreatitis. Gallstones in the gallbladder which is another organ in the abdomen may be a cause of pancreatitis because a gallstone can block the pancreatic duct, trapping digestive juices inside the pancreas. Pancreatitis due to gallstones occurs most often in women who are above 50 years. Other causes are usually due to medications and very rarely, infections, trauma or surgery of the abdomen. Types of trauma can cause acute pancreatitis in rare cases. Trauma can be postoperative trauma (due to surgery), hyperlipidemia (or excessive amounts of fat and fatty substances in the blood), hypercalcemia (or an abnormally large amount of calcium in the blood), Ductal obstruction, Infectious Agents. Other causes, including Tropical pancreatitis, hereditary pancreatitis, hyperparathyroidism, cystic Fibrosis, pancreas Divisum.

Symptoms:

Pancreatitis patient complains pain in the upper abdomen that may last for a few days. The pain may be severe and may become constant just in the abdomen or it may reach to the back and other areas. It may be sudden and severe or start as a mild pain that gets worse when food is eaten. Acute pancreatitis may be a symptom of gallstone disease. The relation between gallstones and acute pancreatitis is the anatomical union of the ducts that drain the gallbladder and pancreas, called the ampulla or major papilla of the duodenum. In mild cases, a person is having problem in eating for 3 or 4 days and he has to receive fluids and pain relievers through an intravenous line. The pain occurs more often and lasts longer. Patient loses weight as the time passes and show symptoms of diabetes, including increased thirst, appetite, urination, fatigue, and weight loss. General symptoms of chronic pancreatitis include Pain, malabsorption of food leading to weight loss or diarrhea, diabetes, nausea, vomiting, fever and increased heart rate.
Patients must seek medical advice when they have intense, persistent abdominal pain, consult doctor to determine whether it is a symptom of pancreatitis or some other medical condition is the cause. It’s important to diagnose pancreatitis early in order to avoid severe and permanent damage to pancreas.

Complications:

Numerous complications may develop in severe cases of acute pancreatitis. A damaged pancreas may become infected with bacteria that spread from the small intestine into the pancreas. Signs of infection include fever, an elevated white blood cell count and, in severe cases, organ failure. Pancreatic infections can be deadly without thorough treatment, including drainage or surgery to remove the infected tissue. Sometimes doctor perform multiple operations. Another complication is pseudocysts. These are collections of pancreatic fluid and sometimes tissue debris that form within pancreas or in an obstructed duct. If the cyst is small, no particular care may be needed, but large, infected or bleeding pseudocysts need instant treatment. Abscess is a collection of pus in or near pancreas that may develop after the inception of acute pancreatitis. Treatment involves drainage of the abscess by catheter or surgery. There may be respiratory failure. Chemical changes in patient’s body can affect his lung function, causing the level of oxygen in blood to fall to severely low levels. Shock usually occurs when blood pressure is very low so that patient’s organs can not carry out their normal functions. Severe shock can cause death within minutes if treatment is not given immediately. Chronic pancreatitis can lead to bleeding because constant inflammation and damage to the blood vessels surrounding the pancreas cause potentially fatal bleeding. Patient may be drug addict. It is due to medical treatments for severe pancreatic pain is not always effectual. Pancreatic cancer. Long-term inflammation of the pancreas increases your risk of pancreatic cancer, one of the most serious of all malignancies.

Diagnosis:

Physicians diagnose pancreatitis by checking the blood for levels of digestive enzymes such as amylase and lipase helps. If the level of these two enzymes is high in the blood then it is diagnosed as acute pancreatitis. As the patient recovers, the digestive enzyme levels will decrease to normal. Chronic pancreatitis generally is assumed when the patient has symptoms and risk factors such as heavy alcohol intake. Diagnosis can be complicated. Doctors use new techniques, including pancreatic function tests and x-ray imaging of the pancreas gland with a CT scan or retrograde pancreatography (ERCP) to diagnose it.

Treatment:

Treatment plan for acute pancreatitis is supportive management in the hospital. Generally, patients are given intravenous fluids and pain medication. Medical records, represent that approximately 20 percent of patients, the pancreatitis can be severe. The patient may need to be admitted in the intensive care unit because of damage that has occurred to other important organs such as the heart, lungs or kidneys. In some severe cases, surgery is done to remove permanently damaged parts of the gland. Chronic pancreatitis can be very difficult to treat. Medical doctors try to alleviate pain and improve nutritional and metabolic problems that result from pancreatic function loss. Patients are generally given pancreatic enzymes and insulin to supplement as it is not being secreted or released by the pancreas. In some instances, obstruction of the pancreatic duct would need a surgical drainage procedure.

Prevention:

It is a fact that pancreatitis occurs all of sudden and can not be prevented but patients can some precautions to reduce risk. They must not consume excessive alcohol. Smoking is also risk factor for this disease. Excessive fat intake must be avoided. Eating a high-fat diet can raise blood-fat levels and increase risk of gallstones which can lead to pancreatitis. A healthy diet comprises fresh fruits and vegetables, whole grains, and lean protein, and limits fats, especially saturated fats such as butter. Person must have to develop good habits and modify Lifestyle to avoid this disease. Chronic pancreatitis may have bad consequences such as pain and malabsorption of certain nutrients. It is better to avoid alcohol. Person must eat meals at short intervals. fat intake should be limited in diet. It will help reduce weight and oily stools that result from a lack of pancreatic enzymes. Diet should be rich in carbohydrates. Carbohydrates provide energy to help fight tiredness. Person must obtain most of daily calories from complex carbohydrates found in grains, vegetables and legumes. If he has diabetes, he must consult a dietitian. Dietician can make appropriate diet plan. It is always recommended to drink plenty of liquids.

Patients of pancreatitis may suffer from cause emotional stress. In order to deal with such problems, person must maintain normal daily activities as best he can. He must be in touch with friends and family and continue to do activities that he enjoys. It is to understand that physical health can impact directly on mental health. Denial, anger and frustration are common with chronic illnesses. In this crisis period, person must seek help of professionals such as therapists or behavioral psychologists. They can provide good advice to resolve emotional problems. They can also educate patient how to develop coping skills which include relaxation techniques that may help patient to live better life. If patient is suffering from a chronic illness, he is at greater risk of depression. At this time, it is better for patient to discuss with family, friends and doctor to come out with depression. These strategies will help to fight with disease and patient will relax.

 

 

Signs and symptoms of ovarian cancer:

Ovarian cancer may cause several signs and symptoms. Women are more likely to have symptoms if the disease has spread beyond the ovaries, but even early- stage ovarian cancer can cause them. The most common symptoms include:
a.Bloating
b.Pelvic or abdominal pain
c.Trouble eating or feeling full quickly
d.Urinary symptoms such as urgency (always feeling like you have to go) or frequency (having to go often)

These symptoms are also commonly caused by benign (non-cancerous) diseases and by cancers of other organs. When they are caused by ovarian cancer, they tend to be persistent and represent a change from normal− for example, they occur more often or are more severe. If a woman has these symptoms more than 12 times a month, she should see her doctor, preferably a gynecologist.

Others symptoms of ovarian cancer can include:

1. Fatigue
2. Upset stomach
3. Back pain
4. Pain during sex
5. Constipation
6. Menstrual changes
7. Abdominal swelling with weight loss.

However, these symptoms are more likely to be caused by other conditions, and most of them occur just about as often in women who don’t have ovarian cancer.

Treatments for Ovarian Cancer:

a. Surgery for ovarian cancer

Surgery is the main treatment for most ovarian cancers. How much surgery you have depends on how far your cancer has spread and on your general health. For women of childbearing age who have certain kinds of tumors and whose cancer is in the earliest stage, it may be possible to treat the disease without removing both ovaries and the uterus.

For epithelial ovarian cancer, surgery has 2 main goals:ovarian-cancer-staging and debulking (this is discussed in detail further on). It’s important that this surgery is done by someone who’s experienced in ovarian cancer surgery.

Experts recommend that patients see a gynecologic oncologist for surgery. Gynecologic oncologists are specialists who have training and experience in treating, staging, and debulking ovarian cancer. If your cancer isn’t properly staged and debulked, you may need to have more surgery later. It has been shown that gynecologic oncologists are more likely than general surgeons and gynecologists to stage and debulk ovarian cancer optimally (see below).

For other types of ovarian cancer (germ cell tumors and stromal tumors), the main goal of surgery is to remove the cancer.

Staging epithelial ovarian cancer

Surgery for ovarian cancer has 2 main goals. The first goal is to the cancer − to see how far the cancer has spread from the ovary. Usually this means removing the uterus (this operation is called a hysterectomy), along with both ovaries and fallopian tubes (this is called a bilateral salpingo-oophorectomy or BSO). In addition, the omentum is also removed (an omentectomy). The omentum is a layer of fatty tissue that covers the abdominal contents like an apron, and ovarian cancer sometimes spreads to this tissue. Some lymph nodes in the pelvis and abdomen are biopsied (taken out to see if the cancer has spread from the ovary).

If there is fluid in the pelvis or abdominal cavity, it will also be removed for analysis. The surgeon may “wash” the abdominal cavity with salt water (saline) and send that fluid for analysis. He or she may also remove tissue samples from different areas inside the abdomen and pelvis. All the tissue and fluid samples taken during the operation are sent to a lab to be examined for cancer cells. ovarian-cancer-staging is very important because ovarian cancers at different stages are treated differently. If the staging isn’t done correctly, the doctor may not be able to decide on the best treatment.

Debulking epithelial ovarian cancer

The other important goal of surgery is to remove as much of the tumor as possible − this is called debulking.Debulking is very important in any patient with ovarian cancer that has already spread widely throughout the abdomen at the time of surgery. The aim of debulking surgery is to leave behind no tumors larger than 1 cm. This is calledoptimally debulked. Patients whose tumors have been optimally debulked, have a better outlook than those left with larger tumors after surgery (called sub-optimally debulked).

Sometimes the surgeon will need to remove a piece of colon to debulk the cancer properly. In some cases, a piece of colon is removed and then the 2 ends that remain are sewn back together. In other cases, though, the ends can’t be sewn back together right away. Instead, the top end of the colon is attached to an opening (stoma) in the skin of the abdomen to allow body wastes to get out. This is known as a colostomy. Most often, this is only temporary, and the ends of the colon can be reattached later in another operation.

Debulking surgery might also mean removing a piece of the bladder. If this occurs, a catheter (to empty the bladder) will be placed during surgery. This will be left in place until the bladder recovers enough to be able to empty on its own. Then, the catheter can be removed.

Debulking may also require removing the spleen and/or the gallbladder, as well as part of the stomach, liver, and/or pancreas.

If both ovaries and/or the uterus are removed, you will not be able to become pregnant. It also means that you will go into menopause if you haven’t done so already. Most women will stay in the hospital for 3 to 7 days after the operation and can resume their usual activities within 4 to 6 weeks.

Surgery for ovarian germ cell tumors and ovarian stromal tumors

Most ovarian germ cell tumors are treated with a hysterectomy and bilateral salpingo-oophorectomy. If the cancer is in only one ovary and the patient still wants to be able to have children, only the ovary containing the cancer and the fallopian tube on the same side are removed (leaving behind the other ovary and fallopian tube and the uterus).

Ovarian stromal tumors are often confined to just one ovary, so surgery may just remove that ovary. If the cancer has spread, more tissue may need to be removed. This could mean a hysterectomy and bilateral salpingo-oophorectomy and even debulking surgery.

b. Chemotherapy for ovarian cancer

The General Medicine deals with the prevention, diagnosis and non-surgical treatment of various diseases. It serves as the first point of contact whenever a patient visits the hospital. A general physician conducts a physical examination of the patient and then recommends necessary tests and diagnostic procedures. The results of these tests, the general physical examination and symptoms are then correlated to arrive at a final diagnosis. Depending on the final diagnosis, the general physician gives the necessary treatment (usually medication) to the patient or refers to a specialty department for further treatment.

The department of general medicine provides treatment for the following:

1. All types of fevers
2. Infections affecting different organs of the body
3. All metabolic diseases and endocrine diseases such as diabetes, thyroid, cholesterol, obesity.
4. Blood pressure
5. Tummy aches, infections like vomiting, diarrhea and jaundice
6. Infectious diseases
7. Respiratory diseases like asthma, allergies, lung infection, cough, sinusitis, pneumonia & TB
8. Disease of the joints and limbs, backache
9. Problems like headache, muscular weakness, epilepsy.

There are many different factors that can affect the fertility of both women and men. Even if you are not currently trying for a baby you may be wondering, or have concerns about your fertility health. There are various screening tests that can be done to evaluate fertility for both women and men

TMJ disorders:

TMJ disorders are a family of problems related to your complex jaw joint. If you have had symptoms like pain or a “clicking” sound, you’ll be glad to know that these problems are more easily diagnosed and treated than they were in the past. These symptoms occur when the joints of the jaw and the chewing muscles (muscles of mastication) do not work together correctly. TMJ stands for Temporomandibular Joint, which is the name for each joint (right and left) that connects your jaw to your skull. Since some types of TMJ problems can lead to more serious conditions, early detection and treatment are important.

No one treatment can resolve TMJ disorders completely and treatment takes time to become effective. Our doctors can help you have a healthier and more comfortable jaw.

Trouble with Your Jaw?

TMJ disorders develop for many reasons. You might clench or grind your teeth, tightening your jaw muscles and stressing your TM joint. You may have a damaged jaw joint due to injury or disease. Injuries and arthritis can damage the joint directly or stretch or tear the muscle ligaments. As a result, the disk, which is made of cartilage and functions as the “cushion” of the jaw joint, can slip out of position. Whatever the cause, the results may include a misaligned bite, pain, clicking or grating noise when you open your mouth or trouble opening your mouth wide.

Do You Have a TMJ Disorder?

• Are you aware of grinding or clenching your teeth?
• Do you wake up with sore, stiff muscles around your jaws?
• Do you have frequent headaches or neck aches?
• Does the pain get worse when you clench your teeth?
• Does stress make your clenching and pain worse?
• Does your jaw click, pop, grate, catch, or lock when you open your mouth?
• Is it difficult or painful to open your mouth, eat or yawn?
• Have you ever injured your neck, head or jaws?
• Have you had problems (such as arthritis) with other joints?
• Do you have teeth that no longer touch when you bite?
• Do your teeth meet differently from time to time?
• Is it hard to use your front teeth to bite or tear food?
• Are your teeth sensitive, loose, broken or worn?

The more times you answered “yes,” the more likely it is that you have a TMJ disorder. Understanding TMJ disorders will also help you understand how they are treated.

Treatment

There are various treatment options that our doctors can utilize to improve the harmony and function of your jaw. Once an evaluation confirms a diagnosis of TMJ disorder, our doctors will determine the proper course of treatment. It is important to note that treatment always works best with a team approach of self-care joined with professional care.
The initial goals are to relieve the muscle spasm and joint pain. This is usually accomplished with a pain reliever, anti-inflammatory or muscle relaxant. Steroids can be injected directly into the joints to reduce pain and inflammation. Self-care treatments can often be effective as well and include:

• Resting your jaw
• Keeping your teeth apart when you are not swallowing or eating
• Eating soft foods
• Applying ice & heat
• Exercising your jaw
• Practicing good posture

Stress management techniques such as biofeedback or physical therapy may also be recommended, as well as a temporary, clear plastic appliance known as a splint. A splint or nightguard fits over your top or bottom teeth and helps keep your teeth apart, thereby relaxing the muscles and reducing pain. There are different types of appliances used for different purposes. A nightguard helps you stop clenching or grinding your teeth and reduces muscle tension at night and helps to protect the cartilage and joint surfaces. An anterior positioning appliance moves your jaw forward, relives pressure on parts of your jaw and aids in disk repositioning. It may be worn 24 hours/day to help your jaw heal. An orthotic stabilization appliance is worn 24 hours or just at night to move your jaw into proper position. Appliances also help to protect from tooth wear.

What about bite correction or surgery?

If your TMJ disorder has caused problems with how your teeth fit together, you may need treatment such as bite adjustment (equilibration), orthodontics with or without jaw reconstruction, or restorative dental work. Surgical options such as arthroscopy and open joint repair restructuring are sometimes needed but are reserved for severe cases.

Our doctors do not consider TMJ surgery unless the jaw can’t open, is dislocated and nonreducible, has severe degeneration, or the patient has undergone appliance treatment unsuccessfully.

TMJ Ankylosis

The temporomandibular joint (TMJ) is the joint that allows mastication and speech. It is a synovial joint formed between the mandibular condyle below and the articular fossa of the temporal bone above. The joint is liable to suffer from a number of diseases,(commonly fractures of the mandible), some of which predispose to TMJ ankylosis. Ankylosis is defined as loss of joint movement resulting from fusion of bones within the joint or calcification of the ligaments around it.

Typically calcification of the ligaments around the joint is not painful, but the mouth can open only about 1 inch or less. Fusion of bones within the joint causes pain and more severely limits jaw movement. Occasionally, stretching exercises help people with calcification, but people with calcification or bone fusion usually need surgery to restore jaw movement.

TMJ ankylosis may be post- traumatic or post-surgery for TMJ disease in a majority of cases. More unusual causes include Rheumatoid Arthritis, Sickle Cell Anaemia and Fibrodysplasia Ossificans Progressiva. Surgical options for treatment include Gap Arthroplasty which is still preferred by some and Interpositional Surgery which is the standard procedure.

The nasopharynx is located behind the nose and above the back of the throat. On each side of the nasopharynx are the Eustachian tubes which connect to the ears. Nasopharyngeal cancer typically arises in the thin lining of the nasopharynx in the space behind the Eustachian tubes. It is more common in Southern China and most often found in men.

Symptoms
Since the tumour grows within air-filled spaces, it may not exhibit symptoms until it is large enough to block passage of air or smell or vision. They include:

• A lump in the neck caused by a swollen lymph node

• A sensation of fullness or pressure in the ear

• Popping noises, hearing loss, and ear infection

• Nasal regurgitation of food and liquids

• Impaired (hypernasal) speech

Tumours of the Pituitary Gland and Skull Base

• Headaches

In advanced cases, infiltration of NPC into the spine can cause

• Stiff neck

• Pain

• Neck instability

The preferred surgical treatment for NPC is the Endoscopic Endonasal Approach ODONTOID PANNUS (Rheumatoid Pannus, Odontoid Synovial Cyst) Odontoid pannus is abnormal tissue that grows in the region of the odontoid process – a toothlike projection at the back of the second cervical vertebra which serves as the pivot for the turning of the head.

This membrane of granulated tissue forms most often as a result of rheumatoid arthritis, in which the condition is called a rheumatoid pannus. Odontoid pannus may also develop due to severe trauma to the neck at the second cervical vertebra.

A similar (although rarely diagnosed) condition which has similar symptoms and treatment is the odontoid synovial cyst.

Rheumatoid pannus
Rheumatoid arthritis (RA) is a progressive auto-immune disease that causes chronic inflammation of the joints. When it attacks, it usually begins in the synovium – a kind of tissue that lines the joint capsule. Cells in the synovium begin to grow and divide abnormally (synovitis) causing a thickening of the synovium resulting in an inflamed and swollen joint.

As it progresses, the synovium can grow larger and form an inflamed, granulated sheet of tissue called rheumatoid pannus. This tissue will spread from the synovial membrane, causing considerable destruction as it invades the subchondral bone.

Symptoms of cervical–spinal abnormalities develop in approximately 60% to 80% of patients with rheumatoid arthritis. When RA invades the cervical spine, the resulting extension of pannus into the spinal canal may compress the brain stem, spinal cord and vertebral arteries causing severe pain and disability.

Left untreated rheumatoid pannus can even result in sudden death.

Treatment
An instability of the joints results in progressive deformity. Generally, in order to stabilise the joints, cranio-cervical fusion is recommended.

If the patient suffers from compression of the spinal cord or brainstem, surgery to decompress them is recommended. In these cases, the Endoscopic Endonasal Approach is best.

Developmental Dysplasia of the hip (DDH)

What is Developmental hip dysplasia?

Developmental hip dysplasia or DDH is a term used to describe a spectrum of conditions where the hip joint fails to develop properly in childhood. In the past terms such as congenital hip dislocation or CDH were used, though the current preferred term is DDH. The term Hip dysplasia is also commonly used. All of the above terms refer to the same condition.

Before we can understand what DDH is, it is perhaps useful to know a little bit about the hip joint itself. The hip is the largest joint in the body and consists of a ball (femoral head) and a socket (acetabulum). The bones are held together by strong ligaments. Being a ball and socket joint, the hip is freely mobile in all directions. There are numerous muscle groups around the hip that provide stability and movement.

As mentioned above, DDH represents a spectrum. On the less severe end of the spectrum is a slightly shallow acetabulum (or socket) but with the femoral head (ball) still inside the socket. This is a dysplastic hip which typically goes unnoticed during childhood but sooner or later will cause arthritis in the hip because of the poor articulation between the ball and socket. Patients with mild dysplasia present for the first time as adults with end-stage hip arthritis and need a hip replacement. These cases are however rare (no more than 10% of cases).

The more common scenario is where the hip is shallow at birth and during the first few months to years of life the hip joint gradually dislocates out of place. In developed countries (UK, USA and Europe) where babies are screened by clinical examination or ultrasound scanning, DDH may be diagnosed at birth or in the first few weeks of life. Diagnosis at an early age makes treatment much easier and the use of strapping around the hip (called a Pavlik Harness) cures the problem in most babies.

In India, there is no uniform protocol amongst obstetricians or paediatricians to screen for hip dysplasia in the neonatal period (first 4 weeks of life). DDH therefore goes unnoticed and the child presents at a much older age when surgery is the only option to treat the problem.

On the most severe end of the spectrum are the so-called Teratologic hip dislocations. Such dislocations occur when the baby is still developing in the womb. They are usually associated with genetic conditions such as Arthrogryposis (multiple joint contractures). Teratologic hips are difficult to treat and typically need surgery even at an early age.

What causes DDH?

There is no specific cause for DDH that happens in every child with the condition. However, there are many known risk factors that increase the statistical probability of a baby having DDH. These include

• First born female child
• Twins
• Oligohydramnios (where the amount of fluid around the baby is less than normal)
• Family history of DDH in first degree relatives
• Breech presentation
• Postural foot deformities (such as metatarsus adductus and calcaneovalgus feet)
• “Moulded baby syndrome” refers to a combination of DDH, Torticollis (Wry neck), foot deformity and plagiocephaly (flattened appearance to the back of the head). This is thought to result from abnormal pressure on the baby (moulding) within the womb.

A child with DDH may not have any of the above risk factors and the first indication may be a limp that is noticed when the child starts to walk. In India, we routinely see children as old as 10 years with dislocated hips, largely due to a failure to diagnose the problem at an early stage.

A significant number of all babies have shallow hips at birth (probably the result of developing in a cramped space within the womb) but the hips spontaneously become normal within the first 6 weeks of life as the baby starts to move the legs freely. In a small proportion of children, this process fails to occur and these hips gradually dislocate over a period of time.

What are the symptoms of DDH?

There are a wide variety of symptoms that vary with age of the child at diagnosis.

0 – 1 year:

• No symptoms are apparent, though observant parents sometimes notice that the legs are different lengths.
• In severe dislocations, it may be difficult to open the legs (called hip abduction) to change nappies. At this age, DDH is diagnosed by doctors during examination or by ultrasound scanning.

Walking age (1 – 16 years):

• Limping is the commonest symptom. It is typically a painless limp and can be difficult to spot.
• Pain is a relatively late symptom and indicates the onset of damage to the hip (tear of a cartilage ring in the hip joint called the labrum) or early arthritis. The pain may be sharp and worse with certain hip movements or just a “dull ache” after activity. Clicking or “giving way” of the hip can also occur.

How is DDH diagnosed?

The investigation of choice depends on age of the child.

0 – 4 months of age: Ultrasound scanning of the hips using the Graf method. Alpha and Beta angles have to be calculated and these angles guide treatment. The Graf method is precise and has been standardised to a high degree. Specific training in ultrasound scanning for hip dysplasia is necessary in order to obtain good quality ultrasound scans.

Children older than 4 months: A good quality AP pelvis x-ray will clearly demonstrate the problem. Various lines are drawn on the x-ray by orthopaedic surgeons but these are probably of little interest to parents.

Arthrogram: This is a dye test which requires a general anaesthetic. In babies and young children up to the age of 18 months, a large part of the ball of the hip joint is made of cartilage not bone. The cartilage is not visible on x-rays and some contrast agent on the outside is required to outline the entire ball (cartilage + bone). An arthrogram also provides useful information to the surgeon about whether the hip can be put back in place without the need for open surgery.

CT Scans: are obtained post-operatively after a body cast (Hip spica) has been applied. X-rays performed through a spica are difficult to interpret. A CT scan clearly shows whether the operation to reduce the hip has been successful. Most good paediatric orthopaedic centres would insist on a CT scan prior to discharging the patient from hospital.

A CT scan is also sometimes obtained to visualise the hip in 3-D where the anatomy is abnormal or unusual. It is a good investigation in cases where previous surgery has been performed.

MR scans/ MR arthrograms: These tests are of use in teenagers or adults with symptoms suggestive of damage to acetabular labrum. Labral tears can be quite painful and restrict activities particularly sports.

In most cases, a simple x-ray of the hips is sufficient to confirm DDH.

What are the treatment options?

Treatment of DDH is entirely dependent on the age of the child. The younger the child at diagnosis, the less the intervention required. It is therefore important that the diagnosis is made soon after birth.

A proportion of babies have dislocated or dislocatable hips at birth. In most modern hospitals, paediatricians or obstetricians will examine babies for DDH. In certain developed countries, all babies have a hip ultrasound scan a few weeks after birth to rule out DDH. This system is obviously ideal in picking up all cases of DDH but it is expensive, difficult to implement and “over-treats” the problem. Remember that a proportion of babies with shallow hips get better by themselves. If the hip remains abnormally shallow at 3 months of age or if the hip is frankly dislocates, treatment is mandatory.

If your child has any of the risk factors mentioned previously, the safest course of action is to obtain an ultrasound scan of the both hips performed in accordance with the Graf method.

Pavlik Harness:

This is the least invasive method and therefore the most preferred by parents (and surgeons!). The harness can be used from birth to the age of approximately 4 months, though it can be difficult in children older than 3 months. It is a system of straps that is applied to both legs and keeps the legs opened (called hip abduction). The baby can kick both legs freely within the harness and it does not interfere with normal growth of the baby.

Once the baby has been placed in a harness, ultrasound scans must be repeated every week until the hip is anatomically located back in the hip joint. This may take 2 – 4 weeks. A further 6 weeks in the harness is necessary. If the baby grows out of the initial harness, it can be changed easily for a larger size. Average time in the harness is likely to be between 10 and 12 weeks.

In the vast majority of babies under 3 months (90% or more), treatment with the Pavlik harness is the only treatment that is necessary. There is good evidence to suggest that the hips become entirely normal when assessed at 5 years of age.

In summary, early diagnosis (soon after birth) and Pavlik harness treatment should be considered as the gold standard in managing hip dysplasia. Complications are minimal and it is effective.

Please click here for instructions on how to look after your baby in a Pavlik harness.

Closed Reduction and hip spica application:

If the child is older than 3 months at diagnosis, Pavlik harness is not appropriate. In this group (3 months to 12 months), an arthrogram will be necessary.  A short general anaesthetic is given. The hip is examined when the child is fully relaxed. A radio-opaque dye is also instilled into the hip joint to provide contrast. If the hip can be put back in place without undue force, a hip spica is applied. The term closed reduction refers to reducing a dislocated joint without the need for an incision. This is in contrast to an open reduction where an incision is necessary.

A post-operative CT scan is necessary to confirm that the hip is concentrically reduced, meaning that the ball is sitting in the centre of the socket. Sometimes the ball can appear on x-rays to be sitting well but the CT scan shows otherwise. Some centres use an ultrasound scan rather than a CT.

The hip spica is changed at 3 months under general anaesthesia. The total period in the spica is 6 months. This may seem a long time to some parents but children have not started walking at this age and there are no long-term adverse effects that result from hip spica treatment.

When the ball of the hip joint is dislocated, the socket also becomes quite shallow. Keeping the hip joint well reduced in a spica promotes development of the socket (remodelling) and improves stability of the hip. Children less than 1 year of age possess considerable remodelling capacity and it is important to harness this potential.

Medial open reduction:

This is a minimally invasive procedure undertaken in children under 18 months of age. There are numerous advantages with this procedure compared to a traditional “anterior open reduction”. The operation is performed through a small incision in the groin and therefore not visible to the outside. There is minimal blood loss and less postop pain.

The medial open reduction is also referred to as “assisted closed reduction” or “relaxed closed reduction”. This term is used because a forcible closed reduction causes damage to the blood supply of the femoral head and poor long-term results.

Medial open reduction is followed by immobilisation in a hip spica cast for 4 – 6 months. This will depend on a number of factors including ease of reduction, age of the child and progress of hip development within the spica.

Long-term results of medial open reduction have proven that this is a minimally invasive procedure that is safe and effective.

Anterior Open Reduction with femoral and pelvic osteotomy:

This procedure is typically used in children older than 18 months who have been walking for a period of time on the dislocated hip. A thick membrane called the capsule surrounds all joints of the body. When a child walks on a dislocated hip, the capsule enlarges and becomes quite lax. This enlarged capsule needs to be tightened up in order to prevent the hip from re-dislocating after surgery. The anterior open reduction procedure is designed to address this particular problem of a capacious and redundant capsule.

The anterior open reduction is performed through a “Bikini” incision. There are several tight structures (muscles, tendons and ligaments) that are divided or lengthened. The hip joint is relocated and the capsule repaired to keep the joint in place. Typically, the shallow socket (acetabulum) is also corrected by means of a pelvic osteotomy wherein the socket is divided and reset in the correct alignment. In addition to the pelvic osteotomy, the thigh bone may also need to be divided and reset, called a femoral osteotomy. Pelvic osteotomies sometimes need to be stabilised with a pin. Femoral osteotomies require plate and screws to maintain the bone in place during the healing process.

The child is placed in a hip spica for a period of 10 weeks after surgery. During this time, the hip joint stabilises and the osteotomies heal. On removal of the spica in the out-patients, the child is referred for a course of physiotherapy to improve hip movements and to encourage progressive weight-bearing. It may be up to 3 months from surgery before the child is able to walk normally.

If pins or metal plates have been used to secure an osteotomy, these require removal approximately 6 – 12 months later.

Who is at risk of DDH? How can DDH be prevented?

There is no way to prevent DDH from occurring but if your child has any of the risk factors mentioned above, obtaining an ultrasound scan of the hips by a trained sonologist and consulting a paediatric orthopaedic surgeon as soon as possible after birth will facilitate early treatment of the condition, typically without the need for any surgery.

 

What is a Spinal Fracture?

The spine is composed of blocks of bone called vertebrae stacked one above the other with an intervening soft shock-absorber like tissue called a disc lying between each pair of vertebrae.

What causes it?

Normal vertebrae can fracture due to falls from a height, road traffic accidents and other high velocity accidents. Vertebrae can lose their strength due to osteoporosis and these osteoporotic vertebrae are susceptible to fractures from low velocity injuries. Massive injuries to the spine can result in a loss of the normal alignment of the spine – dislocations. Depending on the extent of the initial damage to the spinal cord, some spinal cord injuries are permanent whereas others recover over time.

What are the symptoms/effects?

Fractures and dislocations of the spine can lead to spinal cord and nerve root injury causing varying degrees of muscle paralysis, sensory alterations and loss of bladder and bowel control.

How are they diagnosed?

Fractures and dislocations are diagnosed by a thorough clinical examination, followed by x-rays, CT scans and MRI scans. The CT scan reveals the extent of the bony injury whereas the MRI scan provides information regarding spinal cord compression and ligamentous injury.

What are the treatment options?

There are two issues here – a) bone and ligamentous injury and b) neural injury. Many spinal fractures can be managed without surgery as bony injuries heal over time. However, in the presence of a massive ligamentous injury (e.g. fracture dislocations) operative stabilisation is advisable.

Complete damage to the spinal cord results in permanent paralysis and surgery does not alter the neurological outcome. However, surgical stabilisation in this instance may permit early institution of rehabilitation. Incomplete injuries may recover over time and there is a role for surgical decompression and stabilisation in this instance.

Who is at risk?/How can I prevent it?

Adhering to occupational health and safety rules and regulations, following traffic laws and avoiding excessive speed while travelling on the road will reduce the incidence of spinal cord injuries.

Following a Myocardial infraction or heart attack, the area of infraction often leaves behind by a nonfunctional scar. This can leads to a dilatation of the heart over a period of time and change its shape from a normal elliptical one to a globular one resulting in reduction of heart function and can lead to heart failure. By an operation called Linear Endoventricular Patch Plasty or commonly called Modified Dor’s Procedure, the elliptical shape of heart is restored, thus restoring its normal pump function. The procedure is done in isolation or along with the routine CABG.