The surgical spine

Photo for representational purpose

The outcome of any successful spine surgery depends on choosing the correct patient, operating for the right indication, at the correct level, and on the correct side," I said, attempting to alleviate the furrowed brow of a 50-year-old daughter, who had brought her ailing dad to see me for severe back and leg pain. "Of course, the surgeon also matters, but that's the least important piece in the puzzle," I went on to add, remembering my mentor, who used to say that any monkey could operate.

Rusi uncle was 84 and walked with his torso bent at right angles to his waist, almost parallel to the floor. This position allowed a pinched nerve in his spine to move away from a bony spur that was irritating it. The moment he tried to straighten up, he had lancinating pain. "Dikra, you do whatever you want, without any operation to get me okay. Spine surgery is very risky, and I don't want to be dependent on anyone," he said, with the loving authority of having lived life on his own terms.

I showed him his MRI and emphasised that while there were multiple levels of degeneration in the spine, the sinister element was only one, and could be easily addressed. "We can do a big operation and put in a bag full of screws to treat all the issues that I'm seeing in this MRI, but we are operating on you and not the image," I comforted. "I can say with certainty that your problem is coming from one point, and with a minimally invasive approach, we'll fix you. You'll be the tallest person in the house once again!" I said, assuring him of an upright posture. He reluctantly agreed with a half-smile.

A couple of days later, we made a two-cm incision into his back and drilled off an overgrowth of bone that was jamming the nerve every time he tried to stand straight. I passed a smooth ball tip probe all around the nerve to make sure it was free of any compression. Within the hour, Rusi uncle was awake and walking as straight as a pole. He couldn't believe it, neither could his daughter, and frankly speaking, even I was pleasantly surprised. Ever since I have been at the receiving end of delicious organic fruits from his farmhouse.

At our hospital, we follow an "enhanced recovery after surgery" pathway, commonly called ERAS, which is a multidisciplinary approach to improving the quality of patient care in the immediate postoperative period. Most of our patients are out of bed within a few hours of surgery and discharged home sooner than they expect. A combination of efficient pain management by highly trained anaesthesiologists, aggressive postoperative physical therapy, and skilled nursing allow for even the elderly to go home the next day after surgery.

A 37-year-old woman was a little miffed with me because she was made to walk four hours after spine surgery as opposed to the promised two. "All the others who you have operated upon started walking way before I did," she threw a fit. "Everyone's a little different," I tried to reason, "And everyone heals at their own pace. But a month from now, those two extra hours in bed won't make a difference." In today's pampered existence, patients want a boutique experience to surgery. We are desirous of scar-less incisions, painless injections, gourmet food, and scented rooms. And why not? Anyone who is distressed needs a little mollycoddling - yes, even the doctors.

"I have an upper back pain that does not seem to want to go away," said a 13-year-old boy. He had come in with his stern-faced mother, who was convinced that this was a ploy to stay away from online school. "Studying from home has definitely increased the number of spinal problems we've been seeing," I explained to his mother. "Most often it's only muscular and gets better by correcting one's posture, but look, he's wincing," I demonstrated, pressing on his fourth thoracic vertebrae. I insisted on getting an MRI done and the mother raised her hands in a huff. I think she was hoping I would chide him to get back to work and there I was, ordering tests worth thousands.

Her irritation was instantly transformed into deep concern when she returned with the results. There was a collapse of the fourth thoracic vertebrae, but luckily no compression of the spinal cord. I could have rolled my eyes at her, but refrained. "This looks like tuberculosis of the spine," I said, recognising the pattern, "But we need to do a biopsy to be sure." We were lucky it wasn't a tumour, which is the other possibility when children complain of pain of this nature.

The next day, we stuck a needle into his spine and took out a piece of tissue for testing, the results expectantly revealed tuberculosis. With six months of medication he was pain free, probably avoiding major surgery by not letting the diagnosis pass him by.

Most of the time, pain originating in the spine is because of weak muscles, and hence, strengthening the core and improving posture remain key elements to spine care. Even so, attention must be paid to identify what is remedial and reversible, so that spinal tumours, compression fractures, tuberculosis, and other infections - which can be treated if caught in time - aren't missed. Patients who are undergoing dialysis and complain of back pain should get an MRI to ensure there isn't a bacterial infection of the spine, as is commonly seen with these patients and which can eat up the bone swiftly if not treated in time. Intravenous drug abuse is another common source of spinal infections. Any patient who has a known malignancy, even if it is under remission, and begins to complain of back pain should be investigated with an MRI to rule out a metastatic spread to the spine.

"What's the best thing you can do for your spine?" an interviewer asked me recently on World Spine Day, commemorated on October 16 every year to bring awareness to an estimated 1 billion people in the world, who suffer from spinal pain at any one point. "Keep moving and be kind to your spine," I replied. It really is all you need to do.

The writer is practicing neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals