A team of neurosurgeons at Fortis Hospitals Mulund led by Dr. Deepu Banerji, Consultant Chief Neurosurgeon brings back 60 year old on his feet by treating severe cervical spondylosis myelopathy and offering him a permanent cure for life long.

Mr. Vilas Panchal, 60, was suffering from neck pain for the last two years. Amidst his routine professional life and personal commitments Mr. Panchal kept ignoring his pain and eventually the pain spread from his spine to his upper extremities. Since December 2009, his symptoms progressed rapidly and he subsequently experienced difficulty in walking. By January 2010 end he was practically bed ridden, requiring two people to support him and help him do his daily chores. As his condition worsened day by day and was affecting his daily life his family decided to take a second opinion and that’s when they consulted Dr. Deepu Banerji at Fortis Hospitals. Upon consultation it was revealed that Mr. Panchal was suffering from an acute case of Cervical Spondylosis Myelopathy affecting cervical spinal cord level (vertebra). Doctor advised him to go for surgery in order to avoid further deterioration of his condition.

Explaining the complexity of the operation Dr. Deepu Banerji, chief neurosurgeon, Fortis Hospitals, said, “Mr. Panchal came to us with an extremely disabled condition. His MRI revealed severe compression of cervical spinal cord against three vertebral levels. A CT Scan further revealed the ligaments in front of spinal cord becoming bony, leading to severe spinal cord compression and deformity of spinal alignment. The simple option of decompression from behind the body i.e. laminectomy was not a good option in view of relative instability and loss of spinal alignment. So the surgery was performed from the front of the body (below the lower jaw) wherein three vertebral bodies were drilled out in the centre to relieve the pressure on the spinal cord. A titanium cage filled with bone was put in to stabilize and support the spine. The cage was fixed with a titanium plate.”

Degenerative disorders of the spine continue to be a significant cause of neck pain in today’s population. Cervical Spondylosis is the age related degeneration of cervical spine where the disks of the spine start becoming dry and less elastic with age. Cervical Spondylosis if left untreated, may lead to permanent disability, as the degeneration has an effect on the nerves that carry messages from the brain to hands and legs.

“Though this type of extensive spinal compression leading to severe disability is not very common but is often seen in the aging population. Usually the fear of surgery causes too much delay in agreeing for surgery and often leads to significant irreversible damage and poor outcome from surgery. It has been established that the result of surgery is better if operated early preferably within 6 month of symptoms” added Dr. Deepu Banerji.

Post surgery, Mr. Panchal’s condition has improved gradually. Today he is completely independent and has started going to his work place. “I am able to walk upright on my legs after the surgery and I feel so confident and relieved. My pain is totally gone and I don’t need to be on pain killers any longer. I am thankful to Dr. Deepu Banerji and the team at Fortis Hospitals to have given me a new perspective to my life and gave me a hope to lead a healthy life at this age after suffering years of pain,” says Mr Vilas Panchal.

Cervical spondylosis is age related degeneration of cervical spine. The disc which is spaced between two vertebral bodies contains approximately 90% water. This helps in absorbing part of the transmitted weight from upper vertebrae and transmitting rest downwards. Disc also allows movement between two vertebrae while maintain stability. From age of 30 onwards as part of degeneration the water content of disc starts reducing causing decreased turgidity in the disc and less ability to absorb pressure and transmitting it down. This puts lot of strain on the vertebrae, small joints, ligaments and muscles. This is the time a person gets pain and stiffness in neck. This is the beginning of spondylosis and slowly progresses with age. Avoiding unnecessary strain, good posture and strong muscles not only protects the spine but delays spondylosis. As degeneration progress the nature tries to stabilise the spine by forming bone along the edges of vertebrae to fuse consecutive vertebrae. Occasionally there is stress and arthritis of small vertebral joints – causing further pain especially on movement of neck. There may also be calcification of the ligaments. These bony growths may either press the exiting nerve root causing pain down the arms or numbness and tingling. If compression is severe it may even cause loss of sensation and weakness of grip and fingers. If these bony projections grow centrally in the spinal canal, it compresses the spinal cord. This along with thickening of intraspinal ligament cause severe narrowing of spinal canal and produce weakness of both upper & lower limbs in various degrees. This leads to progressive difficulty in walking and if left untreated may end up becoming bedridden.

Imaging  Technology and Techniques

Microsurgery for Brain Tumor Treatement:The most commonly usedtechnique is Microsurgery. Microsurgery is the gold standard around which other technical innovations are based and it is the most common form of brain tumor surgery. The skill of the surgeon is paramount and effectively decides the final outcome for the patient. The other major techniques are Sterotaxy and Endoscopic Brain Tumour Surgery. The different types of technology and techniques can beused alone or in conjunction with other methods, for example, Endoscope Assisted MicroSurgery (EAMS).

Microsurgery : This kind of surgery  involves the use of the operating microscope, microinstruments,ultrasonic surgicalaspirator and other adjuncts.

Endoscopic Brain Tumour Surgery: This is the technology and technique that uses specially designed endoscopes and endoscopic instruments for treating brain tumors. Manyapproaches are already in vogue and new approaches are being developed. For certain brain tumors, endoscopic approaches offer a novel, minimally invasive method to excise these lesions effectively. The minimal operative scar, lesser dissection and minimal hospital stay offer an attractive alternative.

The tumors suitable for endoscopic surgery depend on the location and the tumor type

Courtesy:
Dr. DV Rajakumar M.Ch.
Senior Consultant Neurosurgeon
Fortis Hospitals,Bangalore

A team of Neurosurgeons led by Dr. Sunil Kutty, Consultant Neuro & Spine Surgeon operated the dorsal spinal tumour on a 33 year old Mr Ravindra Ghatse, who was experiencing difficulty in walking, numbness & weakness in his legs.

Mr Ghatse was suffering from Neurofibromatosis type 2 (NF2), a genetic abnormality, which he inherited from his mother. Neurofibromatosis is a neurocutaneous syndrome, which gets passed down through the parents’ genes, affects the brain, spinal cord, nerves, skin, and other vital systems in the body. Of the two types of neurofibromatosis – NF1 and NF2, NF1 is more common. NF2 is characterized by the presence of bilateral acoustic neurofibroma (a type of brain tumor) and is rarer, seen in 1 in 45,000 births in India. People with NF2 usually develop benign tumors on the nerves responsible for hearing and balancing in their ears, causing hearing loss, eventual deafness, and problems with balance.

The disease was affecting Mr Ghatse’s, ability to walk and body balance. 3 months ago he had a fall while walking and was not able to get up. He visited Dr. Sunil Kutty at Fortis Hospital Kalyan and was detected to have multiple tumors i.e. a Dorsal cord neurofibroma causing spinal cord compression, a small Cervical neurofibroma, a small asymptomatic acoustic neurofibroma (Brain tumor), Peripheral neurofibroma (in right upper hand) and a tumour on the abdominal wall. This patient thus had five tumors and it seemed that there could be a few more tumors which were undetected or could generate later.

As per Dr. Sunil Kutty, Neurosurgeon at Fortis Hospital, Kalyan, “All the tumors seemed benign and most were not causing symptoms or affecting patients day to day activity hence there was no need to remove them, but the dorsal spinal cord tumor was gradually increasing and had become symptomatic causing him trouble in performing his regular physical activity. Hence we took a decision of removing the dorsal spinal tumour.”

The neurosurgeon talked at length with Mr Ghatse about the need for removal of the dorsal spinal tumor to relieve the compression on the spinal cord, the likelihood of tumor recurrence and the possible need for more surgeries to remove tumors in the future was also discussed with the patient. Patient agreed and was operated at Fortis Hospitals Kalyan with complete removal of the dorsal cord tumor. He was discharged 2 days after the surgery and his physical healing is in progress, he returned to work within a few days.

“The tumour became absolutely unbearable after a certain period of time. I was under tremendous pressure, pain and often used to worry the final outcome and its effect on my job. The surgery has been successful and has renewed my confidence,” said Mr Ravindra Ghatse.

About Fortis Hospitals Kalyan:-

In keeping with the international model of health systems, Fortis Hospitals Kalyan conceived the concept of hospitals situated at convenient locations across the city, bringing high level care within the reach of the neighbourhood.

The hospital is designed to deliver high standards of healthcare services supported by sophisticated technology and experienced medical professionals. The state-of-the-art, 80 bedded, multispecialty hospital has been established to create a centre of excellence with thrust upon Non-invasive Cardiology, Neurology, Neurosurgery, Orthopaedics, Minimal Access Surgery along with other specialties like Urology, Medical and Surgical Oncology, Endocrinology, Gynecology, Critical care, Emergency and Preventive Healthcare.

Fortis Hospitals Kalyan has an expert and experienced team of specialist consultants, technicians, nursing staff and administrators to deliver patient centric services round-the clock. Fortis Hospitals Kalyan is fully equipped with state-of-the-art 2 operations theaters, have dedicated endoscopy suite, 11 bedded patient centered ICU, 4 bedded emergency / casualty department, 24 hrs diagnostic facility and dedicated 24hrs emergency services.

Fortis Hospitals Kalyan has a corporate support cell to cater the growing demand of an organizational healthcare system for corporate. This cell, apart from helping the hospital empanelment for medical services, also provides information and assists corporate on various corporate health plans of Fortis, thereby enabling access to employees to quality medical care.

Imaging Technology

Digital Subtraction Angiography: (DSA) This is commonly used to study the anatomical pattern of cerebral vasculature. It is the preferred standard for detecting Aneurysms and Arterio-venous malformations(AVMs).

Microsurgery for Brain Tumor Treatement:The most commonly usedtechnique is Microsurgery. Microsurgery is the gold standard around which other technical innovations are based and it is the most common form of brain tumor surgery. The skill of the surgeon is paramount and effectively decides the final outcome for the patient. The other major techniques are Sterotaxy and Endoscopic Brain Tumour Surgery. The different types of technology and techniques can beused alone or in conjunction with other methods, for example, Endoscope Assisted MicroSurgery (EAMS).

Microsurgery involves the use of the operating microscope, microinstruments,ultrasonic surgicalaspirator and other adjuncts.

Endoscopic Brain Tumour Surgery: This is the technology and technique that uses specially designed endoscopes and endoscopic instruments for treating brain tumors. Manyapproaches are already in vogue and new approaches are being developed. For certain brain tumors, endoscopic approaches offer a novel, minimally invasive method to excise these lesions effectively. The minimal operative scar, lesser dissection and minimal hospital stay offer an attractive alternative.

The tumors suitable for endoscopic surgery depend on the location and the tumor type

Courtesy:
Dr. DV Rajakumar M.Ch.
Senior Consultant Neurosurgeon
Wockhardt Hospitals,Bangalore

By Dr Deepu Banerji, Consultant Neuro Surgeon Fortis Hospitals Mulund, Mumbai

Stroke – sometimes called a “Brain Attack” or “Cerebrovascular accident” is a syndrome of symptoms & signs of loss of cerebral function caused by disruption in the flow of blood to part of the brain.

What causes stroke?

A stroke occurs when a blood vessel carrying oxygen and nutrients to the brain is blocked by a clot or bursts, causing the brain to starve. If deprived of oxygen for even a short period of time, the brain nerve cells will start to die. Once the brain cells die due to lack of oxygen, the part of the body that the section of the brain controls; is affected through paralysis, language, motor skills or vision disturbances.

There are two types of stroke:

-          Blood Clots that block the artery are ischemic (is KEM-ik) strokes and is the most common type causing between 70-80 percent of all strokes.

-          When a blood vessel ruptures, it causes a bleeding or hemorrhagic (hem-o-RAJ-ik) stroke. Such strokes are usually the result of a ruptured blood vessel or an aneurysm, a weakened area of a blood vessel that bulges or balloons out.

There are also “mini-strokes” known as TIA’s (transient ischemic attacks). People who have one TIA are likely to have another one. TIAs cause brief stroke symptoms that go away after a few minutes or hours. People often ignore these symptoms, but they are an early warning sign and 35 percent of those who experience a TIA will have a full blown stroke if left untreated. TIAs should be taken as seriously as stroke.

A leading cause of stroke and TIA is carotid artery disease (CAD). In CAD, a substance called plaque builds up over time in the carotid arteries, the large blood vessels on either side of the neck that supply blood to the head and brain. The buildup of plaque is a silent disease, until small particles break away and are carried to smaller arteries, where they block the flow of blood. The nature and severity of symptoms depend on how large an area of the brain is affected and whether the blood supply to the brain is completely or partially blocked.

What are the symptoms of stroke?

The most common symptoms of stroke are:-

• Sudden numbness or weakness in the face, arm and / or leg, especially on one side of the body.
• Sudden confusion, trouble speaking or understanding speech.
• Sudden trouble seeing, including double vision, blurred vision or partial blindness, in one or both eyes.
• Trouble walking, dizziness, loss of balance or coordination.
• Sudden severe, headache with no known cause.

If you experience any of these symptoms, even if they go away quickly, seek immediate emergency help.

Every minute counts. Although starved of oxygen, brain tissue does not die in the minutes following a stroke. If blocked blood vessels can be opened within three to six hours, the chances of recovery are greatly improved.

What are the risk factors for stroke?

People who are at higher-than-average risk for stroke include those who have:

• High blood pressure
• High Cholesterol
• Heart disease

Atherosclerosis: when the carotid arteries, the major blood vessels that supply blood to the brain, become clogged with atherosclerotic plaque, the risk for stroke goes up.

Personal History of stroke or TIA

• Lifestyle risk factors. Smoking, excessive alcohol consumption and being overweight are all significant risk factors for stroke.
• Age, gender and race. The risk of stroke goes up with age & is higher in males.
• Family history of stroke or TIA.
• Diabetes.

How to diagnose stroke?

There are a number of diagnostic exams that can be performed to determine if someone has had a stroke or is at risk for having one.

Computed Tomography (CT). The first diagnostic test performed in the emergency room is usually a (T scan. (T uses computers to generate detailed pictures of the brain, and can confirm the diagnosis of stroke and tell whether the stroke is caused by a hemorrhage in the brain.

Magnetic Resonance Imaging (MRI) is a diagnostic test which may be performed to identify and further localize the site of the stroke and find the source. It may be able to quickly identify the area deprived of sufficient blood flow & guide further therapy.

Angiography. An angiogram is an X-ray in which a contrast agent, or dye, is injected into a vein to highlight the blood vessels. With this exam, radiologists can pinpoint the exact location of blockage or bleeding in the brain. Angiography also is used to guide thin tubes called catheters to the site of the problem and administer treatments.

How can stroke be prevented?

In patients at high risk of having a stroke, the narrowed section of artery may be reopened by an interventional radiologist through angioplasty and reinforced with a stent, thereby preventing the stroke from occurring. Vascular stents are typically made of woven, laser-cut or welded metal that permits the device to be compressed onto a catheter and delivered directly into the hardened artery. In addition to diagnosing and treating those at risk for stroke, interventional radiologists use their expertise in imaging, angioplasty and stenting to treat those having an acute stroke.

Preventive measure:

• Stop smoking
• Controlling high blood pressure
• Lowering cholesterol levels
• Maintaining healthy weight
• Exercising
• Utilizing appropriate medications like aspirin
• Treating unruptured cerebral aneurysm or arteriovenous malformation.

How is stroke treated /managed?

For those having a stroke, it must first be determined which kind of a stroke the patient is having so the proper treatment can be given.

Treatment to Dissolve Blood Clots: If the stroke is due to a blood clot, a clot-busting drug, TPA (tissue plasminogen activator) can be given intravenously to break up or reduce the size of blood clots to the brain. This technique must be performed within three hours from the onset of symptoms.

Other important medical therapies: These include anti platelet drugs for ischemic stroke, drugs for control of blood pressure & blood sugar in diabetes. Treatment also includes prevention of complications like increased intra cranial pressure, chest infection etc. At approved stroke centers interventional rediologists (IR) that specialize in neurological procedure can provide intra-arterial thrombolysis treatment.

Treatment to Open Narrowed Carotid Arteries: If a stroke is the result of narrowing of the carotid arteries, follow-up treatment may be needed to open the narrowing and prevent another stroke. These treatments also are used to prevent stroke in people who have been diagnosed with significant blockage in the carotid artery, usually as a result of atherosclerosis, in which plaque builds up overtime in the artery.

• Carotid Endarterectomy Surgery. The most common treatment for narrowing of the carotid arteries involves a surgeon making an incision in the neck, opening the carotid artery and scraping out the built-up plaque.

•Carotid artery angioplasty and stenting. In this technique, a catheter is inserted through a nick in the skin, usually in the groin, and threaded under X-ray guidance to the carotid artery. A balloon is inflated to compress the plaque against the wall of the blood vessel and open up the artery. Usually, a tiny wire cylinder called a “stent” is inserted and acts like a scaffolding to keep the artery open.

Interventional radiologists use X-rays to guide the placement of small, wire mesh cylinders (stents) to hold open clogged arteries.

Post Stroke rehabilitation:

Rehabilitation is a critical part of recovery for many stroke survivors. The effects of stroke may mean that you must change, relearn or redefine how you live. Stroke rehabilitation helps you return to independent living.

Rehabilitation doesn’t reverse the effects of a stroke. Its goals are to build your strength, capability and confidence so you can continue your daily activities despite the effects of your stroke.

Rehabilitation depends on your need to become independent. You may work to improve your independent in many areas.

These include:

• Self-care skills such as feeding, grooming, bathing and dressing
• Mobility skills such as transferring, walking or self-propelling a wheelchair
• Communication skills in speech and language
• Cognitive skills such as memory or problem-solving
• Social skills for interacting with other people

Under your doctor’s direction, rehabilitation specialists come together to provide a treatment program specifically suited to your needs