After four weeks of excruciating pain in his neck and arms, 36-year-old Vikul Rastogi could bear it no longer. The Delhi-based senior manager (marketing) with Siemens had consulted at least four orthopaedic specialists, and gone through countless physiotherapy sessions with no relief. It was then that he met spine surgeon Dr Bipin Walia who told him that one of the discs in his cervical spine had prolapsed as a result of which his nerves were getting compressed. Surgery was the only option.
On 10 March, Rastogi elected to go in for a cervical disc replacement surgery. The procedure he opted for—implanting an artificial titanium ceramic disc in place of his degenerated disc—is only at the clinical trials stage in the US and awaiting FDA approval. This procedure is, however, certified for clinical use in Europe. In India, it is already available in five cities (see box). Within a few hours, Rastogi was out of surgery and has already gone back to work, which involves a long commute from Delhi to Gurgaon.
Till a few years ago, the only surgical option available to those like Rastogi would have been to remove the offending disc and fuse the adjacent vertebra. While it would have offered an immediate cure to his problem, the spinal fusion procedure has its limitations. Dr Walia is senior consultant, Neurosurgery & head, Spinal Surgery, at the Max Institute of Neuro Sciences, Delhi. He describes how in 30% of patients it causes stress on the disc above and below, eventually leading to degeneration of these. Also, a bone graft is required for the fusion method and the area from which the graft is taken takes its own time to heal. And immediately after the surgery, the patient has to wear a cervical collar.
In 2001, a new technique called Bryan’s Cervical Disc Prosthesis was introduced in India, whereby instead of fusing the vertebrae, an artifical disc was implanted in place of the damaged disc. This procedure was used successfully by neurosurgeons in the Indian Army, who have done the largest volume of this procedure, though eminent neurosurgeons like Dr A.K. Singh, director, Neurosciences at Fortis Hospital, Noida (formerly with G.B. Pant), and centres such as the Indian Spinal Injuries Centre in Delhi have handled a good number of procedures, too. But now, using the same principle as Bryan’s, an even newer procedure, the Prestige LP, which uses a ball and socket design and thereby provides greater mobility, has arrived.
Clearly, these are exciting times for neurosurgeons specializing in managing cervical disc problems. If sophisticated imaging techniques such as the MRI, which arrived in the ’80s, are contributing to the advances in this area, technology in this field has progressed greatly, too. Companies manufacturing medical equipment, which for long had regarded this area as a neglected one, suddenly spotted the big opportunity and improved their product offerings. As Dr Walia, who was formerly with the Indian Army, says, “It’s the decade of neurosurgery.”
Indeed, spine surgeons predict that just as hip and knee replacement surgeries are becoming routine practice for orthopaedic surgeons these days and offering a better quality of life to osteoarthritic patients, the new cervical disc surgery will soon become par for the course for those suffering from a severe form of degenerative disc disease.
Of course, an important clarification first—not everybody with a degenerated disc needs surgery. Almost every individual suffers from disc degeneration, points out Dr A.K. Singh, one of the first in the country to perform the artificial cervical disc implant surgery. But only 1% require surgery, he says. Five% would require non-surgical interventions like physiotherapy, traction and medical management, while the rest can solve the problem through rest or even remain blissfully unaware that degeneration has taken place.
As Bangalore-based orthopaedic specialist Dr Deepak Sharan points out, numerous studies have been done where people were picked at random for X-rays or MRI scans. Degenerative changes or disc bulges in the cervical spine were seen in up to 40% of the adult population and their frequency reached 90% by the age of 60. Yet most of these subjects did not complain of pain or discomfort.
Essentially, as Dr Walia clarifies, surgery is recommended only in cases where in addition to the radiological findings of disc degeneration, there are severe neurological symptoms such as muscle weakness, heaviness in the legs, a sensation of pins and needles and so on. Or in cases where conservative treatment has failed to provide relief. A prolapsed, or a slipped disc as it is also known, is usually an advanced form of degenerative disc disease (DDD).
Fifty-three-year-old K.S. Ramsinghaney—who is regional director, operations, at Max Healthcare—was one such patient. His problem began on 8 December last year, while he was at his office desk. Suddenly, like a whiplash, pain struck his arms and shoulder. “It was as though somebody was caning me,” he recalls. The painkillers the doctors prescribed offered no relief. He went through three MRIs—for the neck, brain and shoulder—and was told that two of his cervical discs had degenerated into jellies.
While the doctors did advise surgery, they also told him he was free to explore physiotherapy and see if that could solve his problem. “But the more I did the traction, the more the pain increased,” says Ramsinghaney, recalling the gruelling days when he could barely sit up for a few minutes as the pain was so acute.
He went in for surgery on 3 January and by 15 January was back at his office desk. “The way my pain vanished was like magic. I came out of surgery at 1pm. By 2pm, I was conscious, could see lights and feel no pain,” he says. The next day he was back home.
This is certainly a far cry from the old days when postsurgery, patients took a long time to recuperate and where if more than one disc had degenerated, it would mean another surgery. Today, in one procedure, even three-level disc replacements can be done, and indeed have been performed in India.
According to Dr Singh, who has performed both the Bryan’s and the Prestige cervical disc prosthesis, the newer offering is more surgeon-friendly unlike Bryan’s which is a complicated affair. It also cuts down the operation time. Also, the quality of the artifical implant has improved so much that the patient can get almost the same mobility in the spine as the original human disc (120 degree neck movement) and it’s good enough to last you at last 40 years.
Of course, compared to the old fusion method, costs are also about Rs50,000 higher. The whole procedure set back Rastogi by about Rs3.25 lakh. The cost of the artifical disc alone is around Rs1.25 lakh.
But, for those for whom the cost is not a constraint, or who are covered by insurance, the benefits—increased mobility, very little recuperative time, lower risks—do seem to far outweigh the costs.
The only limitation that Dr Singh sees in Prestige is that Bryan’s had a better shock-absorbing capacity. But he predicts that given the rapid advances in technology, there will soon come a day when the good points of both can be married, offering an even better solution. And, of course, as he points out, there’s always the next stage to look forward to—regeneration therapies involving stem cells!
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