Spondylosis:

The gradual deterioration of the disc between the vertebrae is referred to as Degenerative Disc Disease (DDD) or Spondylosis. Degenerative Disc Disease is very common affecting 40-50% of people over the age of 40 and becomes increasingly common as we age. It is a kind of wear and tear disease similar to osteoarthritis. Although it can occur at any spinal level, it is most common in the lumbar spine (low back). DDD can cause the discs to flatten losing their normal height. This disc height is important as it separates the disc above from the one below. When disc height is lost, the nerve pathways may become narrowed and cause nerve impingement, inflammation, and pain.

As the ‘discs’ degenerate, they become thinner. Sometimes the vertebrae develop small, rough areas which may irritate the nearby nerves. This causes troublesome symptoms like severe neck pain and stiffness and pain down the arms and hands.

Most patients tend to get better with medication and exercises. However occasionally the spondylotic changes can lead to compression of the spinal cord or the nerve roots and this may result in pain, numbness and weakness in the upper limbs (radiculopathy).

Cervical spondylosis is chronic degeneration of the bones of the neck (cervical spine) and the cushions between the vertebrae (inter vertebral disc). The treatment involves removal of worn out discs or bone spurs – depending on the underlying problem. If required the surgeon will fill the gap with a graft of bone or other implants made of metal combined with bone.

Patients have reported their symptoms as being as mild occasional backaches to chronic low back pain that is severe enough to limit their activities at work and play. The pain is typically mechanical in nature. This means the pain increases as more stress or load is placed on the low back. Bending, lifting, and twisting are the types of movement that may exacerbate DDD.
Management

Rarely does DDD require surgery. There are several non-surgical treatments including anti-inflammatory medication, physical therapy and exercise programs. Surgery is only considered when the patient’s symptoms are debilitating; interfere with activities of daily living, and non-surgical treatment has failed after a reasonable period of time, usually at least six months.

Fusion permanently stops the motion of the spine at the level of the degenerated disc. This helps to relieve pain. Fusion for DDD is best when limited to one or two discs. Fortunately we have five discs in the lumbar spine. The un-fused discs take over to provide adequate function of the lower back.

An artificial disc can also be inserted into the space after removing the entire degenerated disc. This surgery is done from the front. This restores disc height, improves spine function, and helps to eliminate debilitating pain.

Spinal Tumors

A spinal tumor or a growth of any kind – whether cancerous or not, can impinge on nerves, leading to pain, neurological problems and sometimes paralysis. The symptoms include loss of sensation or muscle weakness, especially in the legs, difficulty in walking, sometimes leading to falls and loss of bowel or bladder function.

Newer techniques and instruments enable surgeons at Apollo Hospitals, India to reach tumors or treat delicate injuries even in the most inaccessible areas. High-powered microscopes are used during surgery and in some instances even intradural tumors are removed. In select patients, Total Spondylectomy – removal of the entire vertebra is done as a definitive cure.

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Apollo Hospitals

Scoliosis

The spine has normal curves if seen from the sides and is seen as a straight column from the front. But in certain conditions the spine shows curvatures from the front and it is called scoliosis. The abnormal forward bending of the spine is called kyphosis.

Scoliosis is a term taken from a Greek word meaning curvature. During the 19th Century physicians thought poor posture was the primary cause of scoliosis. Today scoliosis is known to be either congenital (present at birth) or developmental and may be hereditary. The disease causes the spine to curve to the side usually in the shape of an “S” or “C”. The curvature is measured in degrees.

Adolescent Idiopathic Scoliosis is the most common type of spinal curvature. It occurs around the onset of puberty in otherwise healthy boys and girls. It is more common in girls. Physical signs may include uneven shoulders, one hip lower than the other, a rib hump when bent over at the waist and leaning to one side.

Whatever the patient’s age, the goal is to stabilize the spine to prevent additional curvature. Some patients with scoliosis are pain free and do not seek treatment until the deformity is noticed. Unfortunately, at that point it may be too late to treat the disease. The size of the curve is measured in degrees on an X-ray. The progression of scoliosis is monitored by periodic x-ray studies. When scoliosis is severe it may cause the spine to rotate, which can cause spinal spacing to narrow on the opposite side of the body.

While minor deformities may be treated non-operatively, more severe and progressive ones require surgery.
Surgical Management of Scoliosis

Surgical treatment of scoliosis is employed if the curvature at detection is of greater magnitude. The aim of surgical correction is to achieve a well-balanced spine in which the patient’s head, shoulders and trunk are centered over the pelvis. This is done by using instrumentation to reduce the magnitude of the deformity and obtaining fusion in order to prevent future curve progression.
Usage of Staples

A more recent development in the treatment of Scoliosis is the use of staples on the convex side of the curve, which correct and maintain the curve till the patient is skeletally mature. These staples allow differential growth to take place i.e. less growing speed on the stapled side than the concave side thereby correcting the curve as the child grows.

Special spinal implants made from Nitinol – a titanium based alloy has been studied extensively and is being employed clinically in a few centers in USA and Europe. The staples are in the shape of ‘C’ when they are manufactured at room temperature. When the staples are cooled to below freezing point the prongs become straight but clamp down into the bone in a ‘C’ shape when the staple returns to body temperature providing secure fixation. These are called Shape Memory Alloy (SMA) staples. As no fusion is done the child grows normally and even the residual deformity tends to improve with growth.

This novel procedure was performed for the first time in India at Apollo Hospitals, Chennai, on a 6-yr old girl, from a small town near Madurai, by the senior spine surgeon Dr. Sajan Hegde and his team.

Slipped Disc:

A prolapsed disc is a condition when the inner, softer part of the disc bulges out through a weakness in the outer part of the disc. This bulging disc may then press on nearby nerves which in turn causes discomfort and pain. The symptoms include – back pain, ache in the arm or leg and pinpricks felt in feet, toes and hands.
Management

As a rule, surgery may be considered if the symptoms have not settled after about six weeks or so. At Apollo Hospitals, the spine surgeons may opt for:

Keyhole surgery – Also known as microdiscectomy spine surgery, it is typically performed when there is a prolapsed disc in the lumbar (lower back) region which is pressing against a nerve.

Disc replacement – An artificial disc is a device that is implanted into the spine to imitate the functions of a normal disc (carry load and allow motion). Artificial discs are usually made of metal or plastic-like (biopolymer) materials, or a combination of the two. The disc replacement for prolapsed disc is done in the cervical ( neck) spine.

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Apollo Hospitals

Spondylolisthesis:

Spondylolisthesis is a Greek term meaning slipping of the spine. It is the abnormal forward movement of one vertebra over the vertebra below. Most often, this forward slip of the vertebra occurs in the lumbar area of the spine. This slippage and herniation of the disc causes pressure on the nerve roots associated with the affected vertebrae, causing pain and dysfunction. There are various types of spondylolisthesis.

Type 1 – Congenital spondylolisthesis

An individual is born with the abnormality of the posterior bony arch of the spine, which causes the slippage. This is usually seen at the L5-S1 level and often associated with abnormality of the facet joints. Patients usually present with back pain during the adolescent growth spurt. CT and MRI scans are required to diagnose the dysplasia (abnormal bone formation).

Type 2 – Isthmic spondylolisthesis

Isthmic spondylolisthesis is caused by a defect in a part of the bone called the pars interarticularis. The pars bone connects the upper joint of one vertebra to the lower joint. The defect is usually caused by a stress fracture in individuals with a hereditary predisposition (some minor abnormality or weakness of the pars at birth). In certain individuals a defect may exist without any forward slip, referred to as spondylolysis. This itself can be painful.

Type 3 – Degenerative spondylolisthesis

Degenerative spondylolisthesis is a forward slippage secondary to arthritis of the spine. Spinal stenosis is usually associated with this process. This is due to a long standing degenerative disc leading to weak facet joints in the back of the spine. This is usually seen at L4-L5 level.
Management

In degenerative spondylolisthesis, surgery is indicated if slippage progressively worsens or if back pain does not respond to nonsurgical treatment and begins to interfere with activities of daily living. In the congenital and high dysplastic group, surgery is done at early stages to prevent neurological complications.

cervical disc replacement

The cervical spine is made of seven bones called as cervical vertebrae, which is piled on top of each other in the neck area.

Cervical disc replacement is a surgical procedure which involves in removing a damaged cervical disc and replacing it with an artificial disc. Cervical discs act as the cushion between the bones of the neck. Discs that get damaged due to various reasons can cause a lot of pain since the disc could move out of its original position causing a lot of pressure on the central spinal cord and at each vertebral level. Disc disruption can be a source of neck pain and can also cause neurological problems such as pain, numbness that starts from the neck passing through either the arms or one of it.

The initial treatment for this cervical disc symptom suggested by the doctors would be exercises and medications. But if the pain persists to continue for more than 6-12 weeks it is advisable to consider the option of surgery.
PROCEDURE AND RECOVERY:

The method used by the doctors for cervical disc replacement is an anterior cervical discectomy and fusion technique approach, whereby, they do the incision from the front of the neck which allows them to remove the damaged disc and the protruding disc which gives a great relief to the patient. In this kind of approach, a plate with screws is applied to the front of the spine to provide stability which helps in gaining solid fusion. The patient is under rest for a couple of days till the fusion is healed which is determined by an X-ray.

Until recently, the doctors use the method known as total disc arthroplasty approved by FDA which is similar to anterior cervical discectomy and fusion except the defect that is created by removing the disc between the two vertebrae is replaced with a disc replacement device. This device allows for free movement among the two vertebrae which is to be maintained and avoids the need of fusion.

The cervical disc replacement is performed on general anesthesia and they are discharged from the hospital on the same day or the next morning based on the surgeon’s advice. Pain from the procedure is very minimal and improves well within a short number of days. Most patients are capable of returning back to work within a couple of week’s time after a good rest.

What is a Thoracic Aortic Aneurysm ?

A thoracic aortic aneurysm, also called TAA, is a bulging, weakened area in the wall of the aorta (the largest artery in the body), resulting in an abnormal widening or ballooning greater than 50 percent of the normal diameter (width).

The aorta extends upward from the top of the left ventricle of the heart in the chest area (ascending thoracic aorta), then curves like a candy cane (aortic arch) downward through the chest area (descending thoracic aorta) into the abdomen (abdominal aorta). The aorta delivers oxygenated blood pumped from the heart to the rest of the body.

An aneurysm can be characterized by its location, shape, and cause. A thoracic aortic aneurysm is located in the chest area. The thoracic aorta can be divided into segments: ascending aorta, aortic arch, and descending aorta, as described above. An aneurysm may be located in one of these areas and/or may be continuous throughout the aorta. An aneurysm called a thoracoabdominal aneurysm involves a thoracic aortic aneurysm extending down to the abdominal aorta.

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Thoracic aneurysms do not occur as often as abdominal aneurysms. The descending thoracic aorta is the most common location of a thoracic aneurysm, followed by the ascending segment, then the arch.

The location of an aneurysm is distinctly connected with the cause, course, and treatment of a thoracic aneurysm.

Types of thoracic aortic aneurysms

The shape of an aneurysm is described as being fusiform or saccular which helps to identify a true aneurysm. A true aneurysm involves all three layers of the arterial blood vessel wall.

The more common fusiform-shaped aneurysm bulges or balloons out on all sides of the aorta. A saccular-shaped aneurysm bulges or balloons out only on one side.

A pseudoaneurysm, or false aneurysm, is an enlargement of only the outer layer of the blood vessel wall. A false aneurysm may be the result of prior surgery or trauma.

Sometimes, a tear may occur on the inside layer of the vessel resulting in blood entering the layers of the blood vessel wall, creating a pseudoaneurysm.

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[ Types of Aneurysms ]

The aorta is under constant pressure from blood being ejected from the heart. With each heartbeat, the walls of the aorta expand and spring back, exerting continual pressure or stress on the already weakened aneurysm wall.

Therefore, there is a potential for rupture (bursting) or dissection (separation of the layers of the thoracic aortic wall), which may cause life-threatening hemorrhage (uncontrolled bleeding) and, potentially, death.

Once formed, an aneurysm will gradually increase in size and there will be a progressive weakening of the aneurysm wall. Treatment for a thoracic aneurysm may include surgical repair or removal of the aneurysm to prevent rupture.

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What causes a thoracic aortic aneurysm to form ?

Thoracic aortic aneurysms may be caused by different disease processes, especially in respect to their location.

Examples of different locations of thoracic aortic aneurysms and their causes may include, but are not limited to, the following : –

Location of Thoracic Aortic Aneurysm Causes Associated with Aneurysm Type
Ascending Thoracic Aneurysm

cystic medial degeneration (necrosis) – breaking down of the tissue of the aortic wall. This is the most common cause of this type of thoracic aortic aneurysm.
genetic disorders which affect the connective tissue, such as Marfan syndrome and Ehlers-Danlos syndrome
family history of thoracic aortic aneurysm with no incidence of Marfan syndrome
atherosclerosis – hardening of the arteries caused by a build-up of plaque in the inner lining of an artery. This is a rare cause of ascending thoracic aortic aneurysm.
infection, syphilis (rare causes of thoracic aortic aneurysm)

Aortic Arch Thoracic Aneurysm

Takayasu’s arteritis – a type of vasculitis that causes inflammation of the arteries
atherosclerosis
continuation of an ascending and/or descending aortic aneurysm

Descending Thoracic Aortic Aneurysm Atherosclerosis is most often associated with descending thoracic aneurysms, and is thought to play an important role in aneurysmal disease, including the risk factors associated with atherosclerosis such as : –

age (greater than 55)
male gender
family history (first-degree relatives such as father or brother)
genetic factors
hyperlipidemia (elevated fats in the blood)
hypertension (high blood pressure)
smoking
diabetes

What are the symptoms of a thoracic aortic aneurysm ?

Thoracic aortic aneurysms may be asymptomatic (without symptoms) or symptomatic (with symptoms). Symptoms of a thoracic aneurysm may be related to the location, size, and growth rate of the aneurysm. Severe onset of pain associated with a thoracic aneurysm may be a sign of a life-threatening medical emergency.

Symptoms of an ascending thoracic aneurysm may include, but are not limited to, the following : –

pain in the chest, neck, and/or back
swelling of head, neck, and arms as a result of pressure on large blood vessels
heart failure – an ascending aneurysm may affect the heart valves, causing blood to back up into the heart

Symptoms of an aortic arch aneurysm or a descending thoracic aneurysm may include, but are not limited to, the following : –

wheezing, coughing, or shortness of breath as a result of pressure on the trachea (windpipe)
coughing up blood (hemoptysis)
hoarseness as a result of pressure on the vocal cords
difficulty swallowing (dysphagia) due to pressure on the esophagus
pain in the chest and/or back

The symptoms of a thoracic aortic aneurysm may resemble other conditions. Consult your physician for a diagnosis.

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How is a thoracic aortic aneurysm diagnosed ?

In addition to a complete medical history and physical examination, diagnostic procedures for a thoracic aortic aneurysm may include any, or a combination,

of the following : –

Computed tomography scan (Also called a CT or CAT scan.) : – A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than standard x-rays.

Magnetic resonance imaging (MRI) : – a diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body.

Echocardiogram (ECG/EKG) : – a procedure that evaluates the structure and function of the heart by using sound waves recorded on an electronic sensor

Transesophageal echocardiogram (TEE) : – a diagnostic procedure that uses echocardiography to assess the presence of an aneurysm, the condition of heart valves, and/or presence of a dissection (tear) of the lining of the aorta. TEE is performed by inserting a probe with a transducer on the end down the throat.

Chest X-ray : – a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.

Arteriogram (angiogram) : – an x-ray image of the blood vessels used to evaluate various conditions, such as aneurysm, stenosis (narrowing of the blood vessel), or blockages. A dye (contrast) will be injected through a thin flexible tube placed in an artery. The dye makes the blood vessels visible on an x-ray.

Treatment for thoracic aortic aneurysm

Treatment may include : –

routine MRI or CT : – to monitor the size and rate of growth of the aneurysm

controlling or modifying risk factors : – steps such as quitting smoking, controlling blood sugar if diabetic, losing weight if overweight or obese, and controlling dietary fat intake may help to control the progression of the aneurysm

medication : – to control factors such as hyperlipidemia (elevated levels of fats in the blood) and/or high blood pressure

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Surgery : –

Thoracic aortic aneurysm open repair

The type of surgical repair of a thoracic aortic aneurysm will depend on several factors: the location of the aneurysm, the type of aneurysm, and the patient’s tolerance for the procedure.

For an ascending or aortic arch aneurysm, a large incision may be made through the breastbone (median sternotomy). If an ascending aneurysm involves damage to the aortic valve of the heart, the valve may be repaired or replaced during the procedure.

For a descending aneurysm, a large incision may extend from the back under the shoulder blade around the side of the rib cage to just under the breast (thoracotomy).

These approaches allow the surgeon to visualize the aorta directly to repair the aneurysm.

Endovascular aneurysm repair (EVAR)

EVAR is a procedure which requires only small incisions in the groin, along with the use of x-ray guidance and specially-designed instruments, to repair the aneurysm by inserting a tube, called a stent-graft, inside the aorta.

Asymptomatic aneurysms may not require surgical intervention until they reach a certain size or are noted to be increasing in size over a certain period of time.

Parameters considered when making surgical decisions include, but are not limited to, the following : –

aneurysm size greater than 5.5 to 6 centimeters (greater than two inches)
aneurysm growth rate 0.5 centimeters (slightly less than one-fourth inch) over a period of six months to one year
presence of genetic disorders or familial history of thoracic aneurysms
patient’s ability to tolerate the procedure

What is aortic dissection ?

An aortic dissection begins with a tear in the inner layer of the aortic wall, usually in the ascending or descending thoracic aorta. The aortic wall is made up of three layers of tissue.

When a tear occurs in the innermost layer of the aortic wall, blood is then channeled into the wall of the aorta separating the layers of tissues. This generates great pressure in the aortic wall with a potential to rupture (burst). Aortic dissection can be a life-threatening emergency.

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[ Aortic Dissection ]

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What causes aortic dissection ?

The cause of aortic dissection is still under investigation.

However, there are several risk factors associated with aortic dissection, such as : –

hypertension (high blood pressure)
connective tissue disorders, such as Marfan’s disease, Ehlers-Danlos syndrome, and Turner’s syndrome
cystic medial disease (a degenerative disease of the aortic wall)
aortitis (inflammation of the aorta)
atherosclerosis
existing thoracic aneurysm
bicuspid aortic valve – presence of only two cusps, or leaflets, in the aortic valve, rather than the normal three cusps
trauma
coarctation of the aorta (narrowing of the aorta)
hypervolemia (excess fluid or volume in the circulation)
polycystic kidney disease (a genetic disorder characterized by the growth of numerous cysts filled with fluid in the kidneys)

What are the symptoms of aortic dissection ?

The most commonly reported symptom of an acute aortic dissection is severe, constant chest and/or upper back pain, sometimes described as “ripping” or “tearing.” The pain may be “migratory,” moving from one place to another, according to the direction and extent of the dissection.

How is aortic dissection diagnosed ?

In addition to a complete medical history and physical examination, diagnostic procedures for an aneurysm may include any, or a combination,
of the following : –

computed tomography scan (Also called a CT or CAT scan.) : – a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional images (often called slices), both horizontally and vertically, of the body.

A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.

transesophageal echocardiogram (TEE) : – a diagnostic procedure that uses echocardiography to assess the heart’s function and structures. A transesophageal echocardiogram is performed by inserting a probe with a transducer down the esophagus.

By inserting the transducer in the esophagus, TEE provides a clearer image of the heart because the sound waves do not have to pass through skin, muscle, or bone tissue.

The physician will determine the most appropriate examination. When a diagnosis of aortic dissection is confirmed, immediate intervention, such as surgery, is usually performed.

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NH

Preventive and Wellness Unit

The Preventive and Wellness Unit, provides services to screen patients to detect diseases and accordingly advice on any lifestyle modifications. In an era, where the silent killer diseases such as Hypertension, Diabetes and Ischaemic Heart Disease have taken centre stage due to unhealthy lifestyles and eating habits, the choice of undergoing regular screening tests and health checks is very important.

Kshema Jeevana’s scope includes dealing with all patients who want to avail the services of a family physician. If the person is found to be hypertensive or diabetic during examination, then appropriate medicines are prescribed. Specific investigations are advised depending on the clinical condition of the person. Information leaflets are also given to the patients depending on their condition.

At BBH we offer 15 health packages which can be availed by people. Additional tests can be added to the package at a discounted rate.

“The choice of a right decision today leads to a happy and healthy tomorrow.”

Genetics:

Medical Genetics :

The Division of Medical Genetics provides state-of-the-art evaluation, diagnosis, treatment and counseling for the variety of genetic disorders.

Patients are evaluated by a multi-disciplinary team of physicians and nurses who specialize in genetics, syndrome identification, metabolic diseases and birth defects.

In order for you to receive the most comprehensive and coordinated care, our staff works closely with other medical and surgical specialist.

Genetics is an upcoming branch of medicine, with growing applications in clinical practice. Today it is important and will become even more important as our understanding of human genome evolves. Online Mendelian Inheritance In Man (OMIM) is a continuously updated catalog of human genes and genetic disorders. There are thousands of genes and genetic disorders. Each genetic disorder has its own guidelines to diagnose, manage and counsel. There are many genetic tests available. There are few genetic disorders in which effective treatment options are available. In future treatment will be available for many more genetic disorders. Currently there are many other modalities to manage genetic disorders, there by patients and family gets help and support. The myth that nothing can be done for genetic disorders has to go. Our aim is to integrate good genetic practice for quality health care system. We have both clinical genetics and related laboratory services.
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NH

Anaesthesia

The Department of Anaesthesia focuses on providing high-quality medical care, clinical care, training, research, and education within the scope of anaesthesia and pain medicine.

Our range of anaesthesia services are extended to patients of General Surgery, Orthopaedics, ENT, Urology, Plastic Surgery and also include:

Paediatric anaesthesia
Neuro-anaesthesia
Regional anaesthesia
Day care anaesthesia
Labour analgesia
Thoracic anaesthesia
Anaesthesia in remote locations
Anaesthesia for vascular surgeries
Acute pain services
Fiber-optic Intubation
Obstetric anaesthesia
Patient controlled analgesia