For a Fine Spine

Dr. Raghava Dutt Mulukutla is a leading orthopaedist

Dr. Raghava Dutt Mulukutla is a leading orthopaedist who has specialised in spinal surgery since 1994, so it’s safe to say that he’s partly responsible for putting Hyderabad on the medical map. Dr. Dutt has also shared his knowledge on the surgical aspects of rheumatology and on the biomechanics of the lumbar spine via several publications. You & I caught up with the spinal surgery expert to better understand the risks and benefits of these complex procedures.
 
Tell us about safe spinal surgery.
People in India have a lot of concerns about safe spinal surgery since, by and large, the concept isn’t prevalent. Despite being common the world over, it has yet to enter the Indian system in a significant way. Fifteen to 20 of us started practising in the early 1990s, and the field took off in 1994 or 1995. So you could say that we are some of the earliest fully-trained spine surgeons in the country. These procedures have been conducted for decades; it’s not like we’ve started something new. But today, it’s a dedicated spine surgeon who performs such a surgery.
 
How does one know who to see with spinal problems?
As I said, a spine surgeon does spinal surgery. A neurosurgeon operates on the brain, and an orthopaedic surgeon works on bones and joints. But these surgeries are so vast and complicated that those professionals have no time to specialise in the spine. To call himself a spine surgeon, a doctor must complete five years of training after a master’s in basic orthopaedic surgery. They obtain an M.B.B.S. and then study orthopaedic surgery to become general orthopaedic surgeons. Then they move on to spinal surgery and train for five years to call themselves spine surgeons.
 
What does the discipline cover?
For scoliosis and hunchback patients, surgery must be done by specially trained spinal surgeons. We’ve been doing these in Andhra Pradesh since 1994, for anyone 18 months or older. The oldest patient I have treated was an 86-year-old lady who was partially paralysed, so age is no bar. We have done hundreds of deformity correction procedures for young children in Hyderabad over the past 20 years, and treat people from all strata of society.
 
For a Fine Spine 
 
How long does spinal surgery take?
Some of these operations can be completed in as little as an hour, while others take longer than 12. I’ve done them at both the Udai Clinic and Apollo Hospitals.
 
That sounds gruelling. What are the circumstances in which surgery is advocated?
If the patient has cancer of the spine, paralysis or a fracture, we have to operate. Someone with a major infection on his legs or a severe slipped disc, who cannot attend to the activities of daily life, or who has difficulty walking despite physiotherapy and non-surgical methods also requires surgery. The last demographic is children born with deformities.
 
All medical procedures involve risk. What are the potential side effects of spinal surgery?
There are two side effects that concern patients and doctors alike, and the first is infection. This is common in people with obesity, diabetes, malnourishment or other medical problems. However, the chances of infection are very low in most hospitals across India; about the same as at a hospital in New York or anywhere else in the world. It is a concern but not a big one. The second complication is the risk of nerve damage, and this depends on the type of surgery we do. Sometimes, we break the spine and correct the deformity – these operations are eight to ten hours long and carry a relatively high risk of nerve damage (0.5-8%).
 
What about the success rate?
Following a successful spinal surgery done for leg pain, it’s around 90-94%; for back pain, the figure is 75-80%. When we operate on the spine, there are different units to treat. We operate on some units, and this might cause pain in other ones. But even if we cannot completely cure the pain, we reduce it enough for the patient to carry on with his life. Spinal surgery isn’t like a hysterectomy, where the patient is back to normal soon, or like cataract removal where some eyeglasses rectify the situation. This is a completely different ballgame, and patients need to understand why they’re coming to us.
 
I’d say that 50% of the chance for success depends on the doctor and the other half is up to the patient. If they don’t cooperate with us, there’s no point doing these operations. Weight correction, regular exercise, smoking, control of diabetes, lifestyle changes – all these things are needed in order to get good results. But there are always dangers involved with spine surgery – risk of infection, paralysis, nerve damage and cerebrospinal fluid leakage. We make sure we’re as careful as possible on the operating table, but risk still exists. That’s what every patient should be aware of before they undergo surgery.
 
You see, there’s no point in lying to them. Anything as simple as a B-complex injection can kill a person, so as long as patients accept that there may be complications, we get good results. The other thing is that patients, especially in India, lack medical knowledge about the spine. Or worse, they get it from the Internet, which is the wrong source. So they don’t come forward in the initial stages, instead delaying so much that nerves are more damaged when we operate. This can lead to poor results.
 
Is recovery tough?
Today, no one is given bed rest; they’re up and about on the second or third day after surgery. After major surgeries that last longer than 10 hours, patients are back at school or work in two or three months. For a slipped disc, you’re back at work within 14 days on average. Abroad, they’re sent back to work in about a week, but because of our bad roads and lack of lifts, we give patients extra time.
 
Do you have any recommendations for post-op rehabilitation?
I’ve hardly any. Patients can do some simple exercises at home after spinal surgery, even the most uneducated person.
 
What about the financial side of spinal surgery?
Thankfully, we are better off as a nation, because these are expensive surgeries. When I first moved back to India in 1994 after training, people weren’t as wealthy as they are now, nor was insurance a popular concept. Today, the government also helps. The state government has a very good scheme called the Chief Minister’s Relief Fund, which sanctions healthy amounts for these surgeries. They’ve never denied any patient if we write a letter to them, so the government has been very supportive. Some of us have some schemes and trusts in our hospitals to help poor patients, including completely free treatment for major operations that normally cost Rs. 3-4 lakh.
 
Can lifestyle issues necessitate spinal surgery?
There is no doubt that lifestyle can influence and even cause these problems. Barring medical deformities, cancer and fractures, most backache is of lifestyle origin. Few of us exercise nowadays; we’re all sitting in front of computers. Because of work pressures and the way cities are being developed, there are no parks or places to exercise. Everyone is working 12 hours a day with no time for recreation, and this has played a huge role in causing many more back problems.
 
If someone opts to undergo spinal surgery, what else should he know?
Patients have to understand that there are a lot of unnecessary spinal surgeries going on in both India and the developed world (Europe and North America). With a case of a disc collapse in the lumbar spine, 90% pf patients get better without surgery. Also, every person who opts for any medical treatment has a fundamental right to a second opinion. Doctors are also human, so we don’t necessarily have to be right all the time. It’s always good to get another opinion from a second, well-regarded spine surgeon – one who spends time with the patient, answers all his questions, and gives scientific reasons for why he requires surgery. It’s very important to know that a good spine surgeon doesn’t mean he has good clientele. Instead, he’s the one who attends conferences and meetings, publishes his work, does presentations, and is in the hierarchy of the associations of spine surgeons at both the state and national levels. Those are the ones from whom you should take a second opinion. Don’t hurry into operations, excepting in situations where immediate surgery is needed.
 
Tell us about some of the technological developments in the field.
Lots of new technology has come in, and we’re moving towards robotic surgeries. We have a system called navigation, where the computer helps us put screws into the spine; this is now an established technique. Today, we all do minimally invasive surgeries where we don’t damage the muscles or remove bone. Lots of pinhole surgeries take place using an insertion as small as one or two millimetres.
 
Previously, we’d make insertions of about 6-8 inches; today, we can do it with one inch. The use of endoscope cameras has also gone up, with lots of monitors in the operation theatre. We also have a lot of new materials to help us infuse the spine. If we have to fuse two segments, bone morphogenic protein helps enhance the fusion; other additions are artificial synthetic calcium substances.
 
And instead of titanium, there’s an even better alloy like grade-five titanium. And there’s new software for MRIs called tractography, where we see exactly what has happened to the nerve – if there is any damage, to what extent, etc. We can analyse it on the scan and even do a 3D reconstruction.                                                                                                                   ..... as told to Anahita