कुंभमेळा पुण्यपर्वाच्या निमित्ताने: डॉ. श्रीनिवास जनार्दन कशाळीकर

विद्यार्थी: कुंभ मेळ्याच्या वेळी आपल्यामध्ये होणाऱ्या किंवा होऊ शकत असणाऱ्या ह्या बदलांचा आणि अमृताचा काय संबंध?
शिक्षक: ज्यांना हा शोध लागला, त्यांच्या निरीक्षणानुसार, अनुमानानुसार किंवा अनुभवानुसार; हे वैशिष्ट्यपूर्ण बदल आपल्याला; आपल्या खऱ्या “स्व” कडे नेणारे म्हणजेच, सच्चिदानंदाकडे नेणारे म्हणजेच अमर करणारे, म्हणजेच पुण्यदायी, उर्ध्वगामी किंवा मुक्तिदायी पद्धतीचे असतात. त्यामुळे ह्या बदलांना दोन शब्दांत म्हणजेच “अमृत सांडणे” ह्या शब्दांत वर्णन केले गेले.
विद्यार्थी: माझा एक मूलभूत प्रश्न आहे. खरोखर माणूस अमर होऊ शकतो का? की हा एक भ्रम आहे? जर मी मुळात मर्त्य असेन तर अमर कसा होणार? माझ्या अस्तित्वाचा कोणता मर्त्य पैलू अमर होतो? आजपर्यंत अशा तऱ्हेने कोण अमर झाला? उलटपक्षी; मुळात जर मी “अमर असेन” तर, मी “अमर होतो” ह्या म्हणण्याला काय अर्थ आहे?
शिक्षक: तुझा प्रश्न एकदम रास्त आहे! वास्तविक पाहता; आपण पूर्णपणे मर्त्यही असत नाही आणि पूर्णपणे अमर देखील असत नाही! आपल्या अस्तित्वाचा काही भाग मर्त्य असतो आणि काही भाग अमर असतो. पण; आपण मर्त्य भागाशी (जडत्वाशी) तद्रुप होऊन राहिल्यामुळे; अमरत्वाच्या (चैतन्याच्या) अनुभवाला मुकलेले असतो! परिणामी; आपण मर्त्य आणि संकुचित बनून संकुचित ध्येय, संकुचित विचार, संकुचित स्वार्थ यांच्या योगे; मर्त्य आणि संकुचित अवस्थेतच (अमरत्वाच्या अनुभवाविना) मरून जातो!
विद्यार्थी: म्हणजे ह्याची देही ह्याची डोळा; अमरत्वाचा अनुभव येऊ शकतो? कसा असतो हा अनुभव?
शिक्षक: नामस्मरणाद्वारे; किंवा अन्य मार्गाने सद्बुद्धी, सद्विचार, सद्भावना, सद्वासना सत्संकल्प, सत्कार्य (स्वधर्म) ह्याच्या योगे; स्वत:चे आणि इतरांचे सर्वांगीण कल्याण साधत साधत निर्भयपणे स्वस्थ होण्याचा अनुभव. हे आंतरिक स्थित्यंतर असते!
विद्यार्थी: तुमच्या मते; कुंभ मेळ्याचा वेळी त्या त्या ठिकाणी स्नान केल्याने असा चैतन्याचा किंवा अमरत्वाचा अनुभव येतो?
शिक्षक: ते तेवढे सोपे नाही. कारण आपण आपल्यातील जडत्वाशी इतके तादात्म्य पावलेले असतो, की एकदा किंवा अनेकदा निव्वळ स्नान करून आपल्याला अमरत्वाचा किंवा चैतन्याचा अनुभव येईलच असे सांगता येत नाही! पण कुंभ मेळा किंवा इतर तीर्थयात्रा यांचा मूळ हेतू हाच आहे ह्यात शंका नाही!
 

क्षीरसमुद्र म्हणजे काय? डॉ. श्रीनिवास जनार्दन कशाळीकर
विद्यार्थी: क्षीरसमुद्र म्हणजे काय?
शिक्षक: शब्दश: पाहिल्यास क्षीर समुद्र म्हणजे दुधाचा समुद्र. पण माझ्या समजुतीप्रमाणे क्षीरसमुद्र म्हणजे देखील दुसरे तिसरे काही नसून; आपली संपूर्ण मज्जासंस्था किंवा चेतासंस्था असावी. कारण, अगदी वास्तविक दृष्टीने पाहता देखील, मज्जासंस्थेचे आवरण हे पांढरे असते. असो. ह्या ‘अमृतमंथना’च्या प्रक्रियेमधून आपल्या पूर्वजांना एक महत्वाचा शोध लागला असावा.
विद्यार्थी: कोणता बरे हा शोध?
शिक्षक: ह्या घटनेमध्ये; जेव्हां विशिष्ट ग्रहस्थिती ह्या चार ठिकाणी येते, त्या त्या दिवशी, आणि त्या त्या ठिकाणी “अमृत सांडले” असे म्हटले आहे. “अमृत सांडले” ह्या शब्दांतून हा शोध दृग्गोचार होतो!
हा शोध म्हणजे, ठराविक अवधीनंतर; ठराविक जागी, ठराविक ग्रहस्थिती असताना तेथील अणुरेणुंमध्ये उर्ध्वगामी विकासाला (सम्यक विकासाला) अनुकूल असे विशिष्ट फेरबदल घडून येतात.
ज्यांना हा शोध लागला आणि ज्यांनी हे सांगितले; त्यांचा; हे सांगण्यामागे, कोणताही वैयक्तिक स्वार्थ किंवा अहंकार नसल्यामुळे त्यांच्या म्हणण्याला लोकांच्या हृदयात स्थान मिळाले असावे आणि लोकांचा त्यावर दृढ विश्वास बसला असावा. साहजिकच ह्या विशिष्ट ग्रहस्थितीला त्या ठिकाणचा आसमंत पवित्र होतो आणि अमृतत्वाने भरून जातो, अशी धारणा पक्की तयार झाली असावी. विशेषत: तेथील नद्यांमध्ये या दिवशी स्नान केले असता मर्त्य आणि पापी जीवन नष्ट होऊन अमृतत्वाची प्राप्ती होते ही धारणा दृढ झाली असावी आणि ह्या धारणेने लाखो लोक तिथे जमू लागले असावे आणि तेथील नद्यांमध्ये स्नान करू लागले असावे.
विद्यार्थी: विशिष्ट ग्रहस्थितीमध्ये असे काही बदल घडू शकतात?
शिक्षक: हे माझे अभ्यासाचे किंवा संशोधनाचे क्षेत्र नव्हे. पण ज्याप्रमाणे ठराविक काळानंतर दिवस-रात्र होतात आणि ऋतू बदलतात, त्याप्रमाणे वातावरणात ठराविक कालावधीनंतर भूगर्भीय घडामोडी, गुरुत्वाकर्षण, भूचुम्बकीय क्षेत्र किंवा रेडिओलहरींमध्ये देखील वेगवेगळे बदल घडत असू शकतील. अन्य घडामोडी देखील घडत असू शकतील. राहिला मुद्दा शरीरातील बदलांचा. वातावरणातील वेगवेगळ्या बदलांच्याद्वारे आपल्या शरीरातील वेगवेगळ्या रासायनिक, अंतस्त्रावी आणि मज्जासंस्थेमधील घडामोडी बदलतात हे ज्ञात आहे.
वातावरणाच्या परिणामामुळे; शरीरामध्ये अनेक बदल घडतात. वातावरणातील चक्रमय आणि ठराविक काळाने घडणाऱ्या घटनांमुळे शरीरामध्येही ठराविक काळाने चक्रमय (cyclical) पद्धतीने घटना घडतात. अशा घटनाना “जीवशास्त्रीय घड्याळे” (Biological Clocks) म्हणतात.
 

DR. NEERAJ JAIN M.B,B.S., M.D., FIPP (USA)
Interventional Pain Specialist ,Spine & Pain Clinic. RU-23 Pitampura,
& Consultant Incharge, Pain Clinic, Sri Balaji Action Medical Institute, New Delhi.
, 9810033800 (Mobile).

LOW BACK/ NECK PAIN (LBP) is a pandemic disease having 80% of lifetime prevalence, affecting 15-20% population at any point of time, being one of the commonest reason for visit to a doctor & young age morbidity/disability/work absenteeism.
AETIOLOGY OF LBP:
LBP is not just a disease but a symptom, a syndrome with combination of multiple possible abnormalities of anterior & posterior longitudinal ligaments, vertebral body, synovia / chondropathy/ osteoarthritis of articulating facets joints, sacroiliac joint, nerve roots & foramen, paraspinal muscles, related connective tissues eg.- ligamentum flavum , spinal canal, intervetebral disc at annulus ring. It may be due to mechanical, nonmechanical, referred pain, psychological & failed back surgery (FBSS).

PERCUTANEOUS LEAST INVASIVE INTERVENTIONAL
PAIN MANAGEMENT OF LBP:-
It has both diagnostic & therapeutic relevance( as there are significant false positive & negative imaging studies not correlating to symptoms)
Better results are obtained if treatment is started early.
. LESI-lumbar epidural steroid injections::
. interlamminar or transforaminal or caudal approach
- BALLOON NEUROPLASTY
SNRB- selective nerve root block
. Epidural adenolysis or percutaneous decompressive neuroplasty
. Trigger point injection
. Botox paraspinal muscle injection
. Facet joint or pericapsular injection
. Spine Prolotherapy & manipulation
. Facet RF thermal neurolysis
. SI joint injection or denervation
. Piriformis muscle block
. Diagnostic provocative discography
. Intradiscal procedures:-Ozone Discolysis/ Chemonucleolysis
- Dekompressor disc debulking
- IDET-intradiscal electrothermal therapy
- Coblation nucleoplasty
- Laser percutaneous discectomy
. Vertebroplasty & kyphoplasty
. Intrathecal pump neuraxial implants
. Augmentation or neuromodulation spinal cord stimulation
ONCE THE CONSERVATIVE TREATMENT FAILS:-
Early aggressive treatment plan of pain has to be implemented to prevent peripherally induced CNS changes that may intensify or prolong pain making it a complex pain syndrome. Only 5% of total LBP patients would need surgery & 20% of discal rupture or herniation would need surgery. Nonoperative treatment is sufficient in most of the patients, although patient selection is important even then.
Depending upon the diagnosis one can perform & combine properly selected percutaneous fluoroscopic guided procedures with time spacing depending upon pt`s pathology & response to treatment.
Using precision diagnostic & therapeutic blocks in chronic LBP , isolated facet joint pain in 40%, discogenic pain in 25%(95% in L4-5&L5S1) ,segmental dural or nerve root pain in 14% & sacroiliac joint pain in 15% of the patients. This article describes successful interventions of these common causes of LBP after conservative treatment has failed.
LESI : LUMBAR EPIDURAL STEROID INJECTION
Indicated in - Acute radicular pain due to irritation or inflammation.
- Symptomatic herniated disc with failed conservative therapy
- Acute exerbation of discogenic pain or pain of spinal stenosis
- Neoplastic infiteration of roots
- Epidural fibrosis
- Chronic LBP with acute radicular symptoms
ESI TREATMENT PLAN:
Compared to interlaminar approach better results are found with transforaminal approach where drugs (steroid+ LA/saline +/- hyalase) are injected into anterior epidural space & neural foramen area where herniated disc or offending nociceptors are located. Whereas in interlaminar approach most of drug is deposited in posterior epidural space.Drugs are injected total 6-10 ml at lumbar, 3-6 ml at cervical & 20+ ml if caudal approach is selected. Lumbar ESI is performed close to the level of radiculopathy, often using paramedian approach to target the lateral aspect of the epidural space on involved side. Cervical epidural is performed at C7-T1 level .
SNRB- SELECTIVE NERVE ROOT BLOCK.
Fluoroscopically performed it is a good diagnostic & therapeutic procedure for radiculopathy pain if
. There is minimal or no radiological finding.
. Multilevel imaging abnormalities
. Equivocal neurological examination finding or discrepancy between clinical & radiological signs
. Postop patient with unexplainable or recurrent pain
. Combined canal & lateral recess stenosis.
. To find out the pathological dermatome for more invasive procedures , if needed
EPIDURAL ADENOLYSIS OR PERCUTANEOUS DECOMPRESSIVE NEUROPLASTY for EPIDURAL FIBROSIS OR ADHESIONS IN FAILED BACK SURGERY SYNDROMES (FBSS)
A catheter is inserted in epidural space via caudal/ interlaminar/ transforaminal approach
After epidurography testing volumetric irrigation with normal saline/ L.A./ hyalase/ steroids/ hypertonic saline in different combinations is then performed along with mechanical adenolysis with spring loaded or stellated catheters or under direct vision with EPIDUROSCOPE.
FACET SYNDROME:- FACET JOINT INJECTION OR
RF MEDIAL BRANCH NEUROTOMY
It is due to mechanical stress on the Zygapophysial joints or traumatic/anatomical derangement & degenerative facet arthropathy. It is commoner in male of younger age group during active careers . CT/ MRI/ Bone scan show structural pathology, but diagnosis is confirmed by relief of pain with joint injection (1ml of LA+ 20 mg triamcinolone) which has therapeutic value also.After effective facet joint block, fluoroscopic percutaneous radiofrequency(RF) thermal rhizotomy of two level medial branches of dorsal ramus is a safe, effective & long term treatment.
SACROILIAC JOINT INJECTION & DENERVATION:
The only way to make a definitive diagnosis is pain relief with image guided joint injection of depo-steroid with L.A..This can be followed by joint denervation of L4-5 S1-3 branches to this joint providing long term pain relief.
INTRADISCAL PROCEDURES::
PROVOCATIVE DISCOGRAPHY: coupled with CT
A diagnostic procedure & prognostic indicator for surgical outcome is necessary in the evaluation of patients with suspected discogenic pain, its ability to reproduce pain(even with normal radiological finding), to determine type of disc herniation /tear, finding surgical options & in assessing previously operated spines
PERCUTANEOUS DISC DECOMPRESSION (PDD)
After diagnosing the level of painful offending disc various percutaneous intradiscal procedures can be employed:--
OZONE-DISCOLYSIS: Ozone Discectomy a revolutionary least invasive safe & effective alternative to spine surgery is the treatment of choice for prolapsed disc (PIVD) done under local anaesthesia in a day care setting. This procedure is ideally suited for cervical & lumbar disc herniation with radiculopathy. Total cost of the procedure is much less than that of surgical discectomy. All these facts have made this procedure very popular at European countries. It is also gaining popularity in our country due to high success rate, less invasiveness, fewer chances of recurrences, remarkably fewer side effects meaning high safety profile, short hospital stay, no post operative discomfort or morbidity and low cost.
DEKOMPRESSOR: A mechanical percutaneous nucleotome cuts & drills out the disc material somewhat like morcirator debulking the disc reducing nerve compression.

INTRATHECAL (SPINAL) PUMP IMPLANTS:
Opted when oral narcotics provide insufficient pain relief or side effects are troublesome in intractable cancer & chronic pain patients. It delivers drug via an implanted catheter directly into CSF needing a very small dose (1/300 of oral dose). The programmable pump is implanted in ant. lower abdomen. It delivers the drug as per the patients needs. More powerful analgesia & spasticity control is achieved using lower doses, constant relief & fewer side effects as with oral doses eg. Somnolence, mental clouding, constipation, euphoria with decreased chances of drug addiction or misuse.
NEUROMODULATION TECHNIQUES:
SPINAL CORD STIMULATION (SCS) IMPLANTS :
Done for FBSS( failed back surgery syndrome) & CRPS(comlex regional pain syndromes) inUSA. In Europe it is done for chronic intractable angina & pain of peripheral vascular diseases (PVD). The indications are expanding further in chronic pain states. A set of electrodes is placed in epidural space & connected to a pulse generator ( like a cardiac pacing device) that is implanted in upper buttock. Low level of electric impulses replace pain signals to the brain with mild tingling sensation. A trial stimulation is done before permanent SCS lead implant.
PERCUTANEOUS VERTEBROPLASTY / KYPHOPLASTY:
A NEWER APPROACH TO MANAGEMENT OF VERTEBRAL BODY FRACTURES
As life expectancy is increasing so is the incidence of vertebral body (VB) # now being the commonest # of the body. PVP is an established interventional techniques in which PMMA bone cement is injected under L.A. via a needle into a # VB with imaging guidance providing increased bone strength, stability, pain relief, decreased analgesics, increased mobility with improved QOL and early return to work.

Vertebroplasty/Kyphoplasty: A Novel Approach for Treatment of Spine Fractures
Neeraj Jain
Senior Consultant Spine & Pain Specialist, Spine & Pain Clinics & Sri Balaji Action Medical Institute,
Max Hospital, Pitampura, New Delhi, India.
Abstract: As life expectancy is increasing so is the incidence of vertebral body (VB) fractures now being the commonest fracture of the body.
Percutaneous Vertebroplasty/ Kyphoplasty (PVP) is an established interventional technique in which bone cement is injected under local anaesthesia
via a needle into a fractured VB with imaging guidance providing instant pain relief, increased bone strength, stability, decreasing analgesic medicines,
increased mobility with improved quality of life and early return to work in days. In this era of minimally access surgery replacing open surgeries, PVP
is a novel procedure & should be in the first line of management in place of conservatism or major spine surgery for painful uncomplicated compression
fracture spine. PVP is a novel procedure with high benefit to risk ratio, which is highly underutilized in relation to the high prevalence of the vertebral
fractures. Vertebroplasty is a palliative procedure and does not correct the underlying cause of the vertebral fracture. Medical management of
osteoporosis or malignancy must therefore be initiated and continued.

INTRODUCTION
Discovering the fact that fracture /# vertebrae is the commonest # of
body, its incidence >the # hip, it becomes imperative to take it more
seriously. With increasing life span there is more of aged osteoporotic
population, more so due to sedentary indoor lifestyle and post menopausal
osteoporosis. Diabetics, smokers & alcoholics are at higher risk of
developing osteoporosis. I have seen such alcoholic patient developing
six spine fractures in just three months time from a single fracture being
on complete bed rest.
Stable VB # are normally treated conservatively with bed rest, strong
analgesics, removable braces, a programmed progressive ambulation and
physiotherapy. Fractures with > 50% of anterior VB collapse or > 20%
of sagital angulations are potentially unstable and may require posterior
instrumentation and fusion if not cemented in time. For burst # pedicle
instrumentation with extension segmental constructs are required. PVP
is not ideal for # dislocations or # distractions. Spine surgeon has to be
consulted if patient needs operative spine stabilization.
Quick fix of fracture spine makes patient walk back same day instead of
bed rest of months together avoiding morbidity & mortality of prolonged
bed rest, making bedridden patient walk, in a way bringing patient back
to normal life.
VERTEBROPLASTY: AN OVERVIEW
Percutaneous Vertebroplasty (PVP) is an established interventional
technique in which rapidly hardening surgical polymethyl methacrylate
bone cement is injected under local anesthesia via a large bore needle
into a vertebral body (VB) under imaging guidance providing increased
bone strength, stability, pain relief, decreased analgesics, increased
mobility with improved QOL and early return to work. Kyphoplasty has
the added advantage of addressing fracture with spinal deformity and
appears to be associated with fewer instances of bone cement
extravasations.
As per Greek mythology pain was thought to be due to intrusion of particles
into soul, now pain relief is done by intrusion of particles into bone. The
bone of content is to fill bone with content. In this era of MAS replacing
open surgeries, PVP is a novel procedure & should be in the first line of
management in place of painful conservatism or major spinal surgery
with a list of complications in polytrauma settings for painful
uncomplicated VB #; especially when the spine surgery is relatively
complicated or patient refuses due to surgery phobia or cost involved or
there may be comorbid conditions /injuries deterrent for surgery. PVP is
a big help in polytrauma setting when stabilizing spine does lot of good
to the patient’s overall management.
Collapsed 1 year old # Both spine & Implant fractured! # Spine with bowel & bladder
involved
INDICATIONS
Started in 1984 by Galibert PVP is done in host of indications: Senile
osteoporotic compression # remains the commonest Indication (83%).
Both men and women are at risk for spinal fractures, with over 700,000
new fractures occurring every year. In fact, one in four women over 50
will suffer an osteoporosis related spinal fracture. Even more startling,
spinal fractures are twice as likely as hip fractures. And they’re three
times more common than breast cancer. Yet as many as two-thirds of
spinal fractures go untreated.
• Painful new or progressive osteoporotic collapse # refractory to
medical therapy or dosage of analgesia leads to unacceptable side
effects.
• Complicating Co-morbid diseases, on steroids & received transplant.
• To reduce loss of vertebral height and possibility of continued collapse
• Metastatic VB #, Multiple Myeloma VB # (3%). Approximately 30%
of patients with various neoplastic conditions develop symptomatic
spinal metastases during the course of their illness & pain is the
presenting complaint in the majority of cases.
• Aggressive painful VB haemangioma
• Vertebral osteonecrosis
• For strengthening VB before major spinal surgery.
• The benefit has been extended to the traumatic uncomplicated VB
compression # (VCF) (14%) which is commoner in younger age
group with active life profile and prime of their career where strict
bed rest and acute or chronic pain are unacceptable and they are
more demanding for proactive treatment approach so as to be back
to work ASAP.
CONTRAINDICATIONS
• Pre-existing neurological deficit
• Burst fractures (relative C/I)
• Fracture related spinal canal stenosis
• Uncorrectable coagulation disorders
• Allergy against bone cement or contrast media
• Unable to lie prone
LONG-TERM MORBIDITY &
CONSEQUENCES OF VERTEBRAL
COMPRESSION FRACTURES
Whether painful or not, the long-term consequences of VCF can be
devastating and can include:
• Traumatic VB # is painful condition requiring bed rest restricting
daily activities markedly as “spine cripples”.
• Left untreated it can cause DVT, increase osteoporosis, loss of VB
height, respiratory & GI disturbances, emotional & social problems
secondary to unremitting pain, loss of independence with high cost
of rehabilitation.
• High risk of primary or consequential damage to neural, bony or disc
elements.
• Increased wedging, deformity & increase incidence of fall and
adjacent VB #.
• Chronic debilitating pain of kyphosis & altered spine mechanics.
• Uncomfortable braces & sleep disturbance because of pain &
discomfort with its sequels.
• Decreased pulmonary function and increased lung disorders , 9%
reduction in vital capacity per #
• Decreased appetite and potential for malnutrition due to stomach
compression & visceral crowding.
• Five-fold increased risk of future vertebral fractures after the first
and 75-fold increased risk after 2 or more vertebral fractures coupled
with low bone mass
• Increased dependence on family and friends
• 40% Clinical anxiety and/or depression
• Loss of self-esteem and compromised social roles
MORBIDITY & COMPLICATIONS OF SPINAL
SURGERY
• Cost of surgery and hospital treatment
• Cost of implants
• Phobia of surgery
• Prolonged recovery period & Extensive rehabilitation
• Changed spinal mechanics & transition syndrome
• Major surgery & anesthesia with its own complications
• Anaesthesia related • DVT • Mechanical Pulmonary
• Medical morbidity • Infection • Hardware related
Persistent pain
• Implant migration • Spinal cord/nerve injury
Pseudoarthrosis
• Sexual dysfunction • Transition syndrome
PRE-OPERATIVE WORKUP
Detailed history & investigation including coagulation profile.
Neurological battery checkup of motor / sensory / reflexes should be done
pre & post operatively & notified. In neurological deficiency wait for 72
hrs for spinal shock to wean off if there was any and then take decision
accordingly
X-ray spine in A/P & lat view. CT is more informative of bone & #
morphology. MRI is good for soft tissue injuries e.g. spinal cord/ root
damage, hematoma, canal stenosis and ligamentous injury
Ask for pedicle size in all dimensions and construct a 3D image aiming
needle placement and cement filling mentally in scan room itself as
rehearsal of PVP. This reduces operative time & gives better results.
Outcome with risk & complication should be well informed & consented
HOW TO PERFORM PVP STEP BY STEP
Sedate with fentanyl & midazolam. To have a feedback in case of any
eventuality instantly, only sedate the patient. Start oxygen, monitor vitals.
Prone positioning with adequate padding.
Fix fluoroscope view as desired & check for its movements.
Total aseptic precautions of major surgery. Cleaning & fully draping of
the patient and the C-Arm.
Do skin marking & measurements & Give liberal local anaesthesia from
skin up to the bone.
Adjust fluoroscope from P/ A to oblique to see “Scottie dog” with pedicle
in maximum oval view with flattened end plates, hit the superior lateral
quadrant of pedicle oval for transpedicular approach. Alternatively
parapedicular route is used in thoracic region & antero-lateral approach
for cervical vertebra.
• 23-34 % increased age adjusted mortality compared with patients
without VCF
• Women unaware that they have vertebral fractures have a 16%
increased mortality compared to women without fracture
• Nine-fold increased risk of mortality in 4 years, compared with 7-
fold increased risk with hip #
• Women with vertebral fractures are 2-3x more likely to die of
pulmonary causes than those without fractures

Conventionally PVP is done by hammering the vertebroplasty needle
through the bone. Here we used light weight drill to bore through the
vertebra. With drill one can do a graduated drilling starting from smaller
gauze wire, this allows extra scope for maneuvering needle to the desired
most location in VB which is difficult to attain with hammered bone
biopsy needle which by its impact cause unacceptable distraction of #
fragments & intense pain.
It is important to set the needle at exact entry site & side with right
trajectory aiming the # defects
In lateral view needle should go through middle of the pedicle going up
to anterior 1/3 of VB.
In P/A view the needle can be in midline or paramedian depending upon
# & if uni/bipedicular approach is planned
Wash haematoma of VB with saline. Do bone biopsy if there is any doubt
about # lession. Do dye test (vertebral venography). Always wash dye
with saline before injecting cement to have good view of cement flow.
Make cement more radiopaque by adding barium /or tungsten. Then inject
cement with 1 or 2 ml leurlock syringes strictly under fluoroscope in
lateral view & cross checking in P/A view. Stop injecting either there is
adequate filling or at the first sight of ectopic cement leak. Total cement
volume varies as per fracture morphology, osteoporotic cavitation & level
of vertebra. Keep sample cement to see for hardening. Remove needle
with rotational movement before cement hardens.
COMPLICATIONS OF PVP/ KYPHOPLASTY
• PVP is generally safe with low risk.
• Ectopic cement leak is frequent but generally inconsequential..
• Symptomatic cement extravasation incidence depends upon etiology
of fracture.
• Osteoporosis 1-2%
• Neoplasm 5-10%
• Location of ectopic cement leaks
• Epidural
• Foraminal
• Paravertebral
• Disc
OUTCOME
• PVP is a novel procedure with high benefit to risk ratio, which is
highly underutilized in relation to the high prevalence of the vertebral
#.
• Different studies show an immediate pain relief in (85 - 90)% of
patients with low complication rate ranging from (1-5)% depending
upon the type of lesion.
• PVP does augment height of VB but ideal would be kyphoplasty.
• Patient is either off medicine or on reduced doses.
• Patient feels so well that he almost forgets about VB #.
Pain relief is by virtue of different mechanisms postulated :
• Cementing of # fragments
• Thermal neurolysis of VB nerve ending, sinu-vertebral nerve & DRG
due to heat of polymerization
• Washing away of nociceptor chemicals
• Neurolytic action of liquid monomer
• By allowing early ambulation decreasing pains of immobility & bed
rest
NEW DEVELOPMENTS
• Non PMMA cements
• Bioactive glass
• Hydroxyapatite
• Osteoconductive coral granules
• Composite cements
• Ideal cement volumes
• Variations of technique
Kyphoplasty or Balloon Vertebroplasty is cementing the fractured
vertebra after creating cavity, is ideal for collapse osteoporotic # with
Varied Vertebrae Anatomy PVP in lat. view
PVP in A/P view Cross-section of PVP
Vertical collapse All six vertebrae cemented & secured
One & three year old # Cemented with preemptive fill in next Habitual #
osteoporotic patient
# Spine patient ventilated/ Normal after cementing

CONCLUSION
• With rich experience in osteoporotic PVP one can comfortably pass
the benefit to traumatic # where -it is more rewarding & satisfying.
• With PVP you just don’t manage pain rather you treat it. It is also
important to remember to address the underlying condition of
osteoporosis. Improve patients bone health and reduce risk for future
fractures through a combination of medication, diet, exercise and
lifestyle modifications.
• Very few people die of pain, many die in pain and even more live in
pain, some of them are sequel to spine traumatic fractures, a reversible
suffering.
• We have to keep pace with patients needs.
• PVP may be is the future of uncomplicated VCF management.
• kyphoplasty has the added advantage of addressing spinal deformity
and appears to be associated with fewer instances of bone cement
extravasation.
• Pain means punishment, we can avoid the chronic punishment of
VCF with PVP avoiding all D’s of disability, depression, drugs
dependence, deformity, dissociation & dejection.
• In future we are looking for high radiopaque biodegradable or
bioactive bone pastes or cement or glues with more procedural time
relaxation which will strengthen the bone while inducing new bone
growth.
• Vertebroplasty is a viable treatment and possible standard
management of the pain and disability of vertebral fractures needing,
height loss & can be employed in selected traumatic wedge collapse VB
# with height loss.
Balloon kyphoplasty
• Restores vertebral body height
• High pressure ballooning (150-400 psi) followed by cement injection
into cavity created by balloon
• fewer complications resulting from cement extravasation
• reduction in morbidity of kyphosis
Clinical outcome data
• 22 published observational studies
• Retrospective designs
• Short term follow up
• Concurrent treatment modalities
• Three series of >250 patients
• Gangi et al Radiographics 2003(868 patients)
Clinical outcome data balloon kyphoplasty
• Five published case series
• Largest describes 188 procedures in 78 patients with minimum 1
year follow up (Coumans JV et al J Neurosurg2003)
• No comparisons with vertebroplasty or conservative therapy
• Pain relief scores similar to those achieved by vertebroplasty
• Adequate training
• Meticulous technique
• Careful patient selection
• If you don’t take up the job the Robots will take over.
BIBLIOGRAPHY
1. Galibert P, Deramond H, Rosat P, Le Gars D. Preliminary note on the treatment of vertebral
angioma by percutaneous acrylic vertebroplasty [in French]. Neurochirurgie 1987;33:166-168
2. Jensen ME, Evans AJ, Mathis JM, Kallmes DF, Cloft HJ, Dion JE. Percutaneous
polymethylmethacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression
fractures: technical aspects. AJNR Am J Neuroradiol 1997;18:1897-1904
3. Mathis JM, Petri M, Naff N. Percutaneous vertebroplasty treatment of steroid-induced osteoporotic
compression fractures. Arthritis Rheum 1998;41:171-175
4. Chiras J, Depriester C, Weill A, Sola-Martinez MT, Deramond H. Percutaneous vertebral surgery:
techniques and indications [in French]. J Neuroradiol 1997;24:45-59
5. Deramond H, Depriester C, Galibert P, Le Gars D. Percutaneous vertebroplasty with
polymethylmethacrylate: technique, indications, and results. Radiol Clin North Am 1998;36:533-
546
6. Gangi A, Kastler BA, Dietemann JL. Percutaneous vertebroplasty guided by a combination of CT
and fluoroscopy. AJNR Am J Neuroradiol 1994;15:83-86
7. Tohmeh AG, Mathis JM, Fenton DC, Levine AM, Belkoff SM. Biomechanical efficacy of
unipedicular versus bipedicular vertebroplasty for the management of osteoporotic compression
fractures. Spine 1999;24:1772-1776
8. D. H. Choe, E. M. Marom, K. Ahrar, M. T. Truong, and J. E. Madewell
Pulmonary Embolism of Polymethyl Methacrylate During Percutaneous Vertebroplasty and
Kyphoplasty Am. J. Roentgenol., October 1, 2004; 183(4): 1097 - 1102.
9. M. Mathis, A. O. Ortiz, and G. H. Zoarski Vertebroplasty versus Kyphoplasty: A Comparison and
Contrast AJNR Am. J. Neuroradiol., May 1, 2004; 25(5): 840 - 845.
10. D. F. Kallmes and M. E. Jensen. Percutaneous Vertebroplasty Radiology, October 1, 2003; 229(1):
27 - 36.
11. Padovani B, Kasriel O, Brunner P, Peretti-Viton P. Pulmonary embolism caused by acrylic cement:
a rare complication of percutaneous vertebroplasty. AJNR Am J Neuroradiol 1999;20:375-377
12. Belkoff SM, Fenton DC, Scribner RM, Reiley MA, Talmadge K, Mathis JM. An in vitro biomechanical
evaluation of an inflatable bone tamp used in the treatment of compression fracture.
Spine 2001;26:151-156
13. J. M. Mathis, J. D. Barr, S. M. Belkoff, M. S. Barr, M. E. Jensen, and H. Deramond
Percutaneous Vertebroplasty: A Developing Standard of Care for Vertebral Compression Fractures
AJNR Am. J. Neuroradiol., February 1, 2001; 22(2): 373 - 381.
14. K. Kim, M. E. Jensen, J. E. Dion, P. A. Schweickert, T. J. Kaufmann, and D. F. Kallmes
Unilateral Transpedicular Percutaneous Vertebroplasty: Initial ExperienceRadiology, March 1,
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Correspondence: Dr Neeraj Jain, Senior Consultant Spine & Pain
Specialist, Spine & Pain Clinics & Sri Balaji Action Medical Institute,
Max Hospital, Pitampura, New Delhi & Sant Parmanand Hospital, New
Delhi. e-mail: managepain@yahoo.com www.spinenpain.com

Bacterial invasion in subgingival sites especially of gram-negative
organisms are initiators for periodontal diseases. The periodontal
pathogens with persistent infl ammation lead to destruction of
periodontium. In recent years, periodontal diseases have been
associated with a number of systemic diseases such as rheumatoid
arthritis, cardiovascular-disease, diabetes mellitus, chronic
respiratory diseases and adverse pregnancy outcomes including
pre-term low-birth weight (PLBW) and pre-eclampsia. The factors
like low socio-economic status, mother’s age, race, multiple births,
tobacco and drug-abuse may be found to increase risk of adverse
pregnancy outcome. However, the same are less correlated with
PLBW cases. Even the invasion of both aerobic and anerobic may
lead to infl ammation of gastrointestinal tract and vagina hence
contributing to PLBW. The biological mechanism involved between
PLBW and Maternal periodontitis is the translocation of chemical
mediators of infl ammation. Pre-eclampsia is one of the commonest
cause of both maternal and fetal morbidity as it is characterized by
hypertension and hyperprotenuria. Improving periodontal health
before or during pregnancy may prevent or reduce the occurrences
of these adverse pregnancy outcomes and, therefore, reduce the
maternal and perinatal morbidity and mortality. Hence, this article
is an attempt to review the relationship between periodontal
condition and altered pregnancy outcome.
Key Words: Adverse pregnancy outcome, periodontal disease, preeclampsia,
pregnancy, pre-term low-birth weight