DISC DISEASE OR SLIPPED DISC

CERVICAL AND LUMBAR DISC DISEASE

Introduction

Disc is the soft tissue located in between the vertebral bodies.

A picture showing different types of disc problems. 

Disc problems are common in cervical (neck) and lumbar (lower back) regions. Earlier, it was common in older people, due to more degeneration of discs in them. However, now-a-days, we see several younger people, even in their 20s and 30s, who come with disc problems. This is because of sedentary life style, lack of exercises, prolonged sitting (on account of job, computer use, etc), and sports injuries. 

What are the common symptoms of disc diseases?

Disc prolapse or slipped disc can present with several symptoms:

In cervical disc disease, following symptoms are common:

1. Neck pain,

2. Pain in the arm, which may increase on coughing,

3. Tingling or pins and needle sensations in the arm,

4. Numbness in arm,

5. Weakness in the arm.

In lumbar disc disease, the following symptoms may occur:

1. Lower back pain,

2. Pain in the leg, which may radiate from lower back to the leg, also referred to as sciatica,

3. Tingling or numbness in leg,

4. Weakness of leg,

5. Leg pain, numbness or weakness may increase on walking (referred to as claudication), and get relieved on resting. 

How is the diagnosis of disc disease confirmed?

1. Clinical history and examination by a neurologist are useful in suspecting the diagnosis.

2. MRI of spine (cervical or lumbar region, as the case may be) is the confirmatory test for disc disease. 

An MRI scan of lumbar spine showing a prolapsed disc at L5-S1 level

What are the treatment options for disc disease?

Conservative (without surgery): It is useful to note that surgery is not needed in about 90% of cases. 

Several measures are useful in relieving pain in patients with disc prolapse: 

1. Rest- in severe cases, bed rest may be advised. In less severe cases, limited mobility within the house (for toilet and dining purposes) may be permitted.

2. Use of analgesics (such as aceclofenac, etoricoxib) and muscle relaxants (such as mobizox and myospaz forte) may help in relieving pain.

3. Specific medications that help reduce the nerve pain are pregabalin, gabapentin, duloxetine, etc. 

4. Physiotherapy- measures such as IFT, ultrasound, traction, etc help reduce the pain in several people with disc prolapse. 

Surgical options

In 10% of patients, medical treatment fails, then, surgery may be needed. Following are the specific indications for surgery in a patient with slipped disc:

1. Failure of medical treatment to adequately control the pain,

2. Progressive neurological deterioration, such as worsening of weakness or numbness, or bladder/bowel involvement,

Various types of surgeries are:

1. Laminetomy,

2. Discectomy,

3. Spine stabilisation with instrumentation. 

The choice of surgery depends on patient's symptoms, MRI findings and age. 

General advice to patients with disc disease:

1. Avoid forward bending,

2. Avoid lifting heavy weights. 

3. Lose weight, if overweight or obese

What is the prognosis of patients with disc disease?

In general, the outcome of patients with disc prolapse is good and most patients return to normal life after proper treatment. They are able to do their activities of daily living and are gainfully employed.

Surgery is also safe, however, I come across many people who have wrong notions about surgery. They have been mis-informed that after surgery, people get paralysed. In practice, this does not happen. However, if the case for surgery is not correctly chosen, there may not be good relief from pain after surgery also, a condition referred to as "failed back syndrome". 

If you have any further queries, you may get back to me.

Dr Sudhir Kumar MD (Internal Medicine) DM (Neurology)

Senior Consultant Neurologist,

Apollo Hospitals, Hyderabad, India

Phone- 0091-40-23607777

Email: drsudhirkumar@yahoo.com

Online consultation: http://bit.ly/Dr-Sudhir-kumar

MERALGIA PARESTHETICA

MERALGIA PARESTHETICA

Introduction

Meralgia paresthetica is a condition, characterised by sensations of burning, tingling and pain in the upper outer aspect of thigh.

What is the underlying cause of meralgia paresthetica?

It is caused by entrapment or compression of the nerve that supplies sensation to the upper, outer aspect of thigh. The nerve is commonly called as lateral femoral cutaneous nerve of the thigh.

The condition can get aggravated by sitting in one position for a long time, wearing a tight belt, wearing skinny jeans, or compression of nerve by protruding abdomen in an obese person. 

What are the common symptoms of meralgia paresthetica?

The common symptoms include one or more of the following symptoms, affecting the upper/mid thigh region:

• Numbness,
• Tingling,
• Burning, 
• Pain. 

These symptoms occur more on sitting or standing, and get mildly relieved on lying down down. They may be more severe at night.

The picture (shaded area) below shows the location of symptoms over thigh in meralgia paresthetica.

How is the diagnosis of meralgia paresthetica confirmed?

The diagnosis is made on the basis of clinical symptoms and signs and no tests are often necessary. However, nerve conduction studies of femoral nerve can be done in some cases. In atypical cases, MRI of lumbo-sacral spine may be required to exclude pinching of nerves in the lower back.

How do we treat meralgia paresthetica?

The treatment is with medications such as pregabalin, gabapentin, duloxetine, etc, which are very effective in reducing nerve-related pain, burning and tingling.

In addition, if the person is obese/overweight, then, weight reduction is advised. Prolonged sitting should be avoided.

In 90% of cases, the above treatment would succeed. However, in 10% of cases, symptoms do not improve with medical treatment, and surgery may be required.

The surgical options include decompression of the nerve or division of the nerve. Division of the nerve may leave numbness in the affected region.

What is the outcome of meralgia paresthetica?

Most people do well with treatment and no long-term residual symptoms or disability occurs in patients suffering from this condition.

I hope this article would help patients suffering from this condition, and also enrich the knowledge of readers. I would be pleased to answer any queries related to this condition. My email is drsudhirkumar@yahoo.com 

Dr Sudhir Kumar MD (Internal Medicine) DM (Neurology)

Senior Consultant Neurologist,

Apollo Health City, Hyderabad

Phone: 0091-40-23607777

email: drsudhirkumar@yahoo.com 

Online consultation: http://members.tripod.com/sudhirkumar_5/neurologist/id6.html

MYASTHENIA GRAVIS

MYASTHENIA GRAVIS

Introduction

Myasthenia gravis is an uncommon auto-immune disease, characterised by muscle weakness.

Common symptoms of Myasthenia Gravis

Myasthenia gravis presents with symptoms due to weakness of various muscles. 

Common presentations of this include:

1. Drooping of one or both eyelids (usually, there is a difference in the degree of eyelid drooping). Drooping of eyelid is also called as ptosis. 

2. Double vision, on looking up, down, left, right or sideways.

3. Slurring of speech or nasal twang in voice,

4. Difficulty in chewing food,

5. Difficulty in swallowing food, or nasal regurgitation of liquids, 

6. Weakness of arms or legs,

7. Breathing difficulty,

8. Difficulty in holding neck straight (tends to droop forwards)

Please note

The sensations are normal in the affected parts of body.

Urinary and bowel control is preserved. 

Please also note

1. Symptoms may vary at different times of day, most often they are worse in evenings,

2. There is fatiguability, symptoms get worse on repeating the same movements,

3. There may be periods (days to weeks) of remission, when all symptoms seem to disappear, only to return back later. 

The following factors may trigger or worsen exacerbations:

• Bright sunlight
• Surgery
• Immunization
• Emotional stress
• Menstruation
• Intercurrent illness (eg, viral infection)
• Medication (eg, aminoglycosides, ciprofloxacin, chloroquine, lithium, phenytoin, beta-blockers, statins)

How do we confirm the diagnosis of myasthenia gravis?

1. Clinical symptoms, as described above make us suspect a diagnosis of MG, 

2. Tensilon test- where tensilon (edrophonium) injection is given, after which there is temporary improvement of symptoms such as ptosis,

3. Repetitive nerve stimulation- This test in done in the electrophysiology laboratory, where the muscle fatigue is shown (by seeing reduced amplitude with repeated stimulation of muscles),

4. Anti-Acetylcholine receptor antibody levels are elevated in about 80% of people. These antibodies are supposed to be released from thymus gland (located behind the upper chest wall in the centre). These antibodies prevent the action of acetylcholine on the muscles, making them weak. 

5. CT scan of chest is done to look for enlargement or tumor in thymus gland. 

6. Other less common antibodies seen in some patients with MG are anti-straited muscle antibody, anti-MuSK antibody, and anti-striational antibody.

What is the medical management of Myasthenia Gravis?

The medical management is classified into two categories:

1. Symptomatic treatment- to improve the symptoms. Pyridostigmine is commonly used.

We usually start a dose of 60 mg two times daily, and the maximum dose can be unto 720 mg per day.

Common side effects include increased salivation, abdominal pain and cramps, diarrhoea, muscle twitchings, etc.

2. Definitive treatment- is used to suppress the antibodies.

Steroids are commonly used. 

Other agents used are azathioprine, mycophenolate, cyclosporine, methotrexate, and cyclophosphamide.

3. In patients with myasthenic crisis (severe disease requiring feeding tube due to swallowing problem), or requiring mechanical ventilation (due to respiratory distress), PLASMAPHERESIS (blood is purified, and antibodies are removed, something similar to dialysis) or IV IMMUNOGLOBULINS (injections are given by drip over five days) are required.

4. THYMECTOMY- the best and permanent treatment for MG is thymectomy operation. In this, the thymus gland located behind the sternum bone (chest wall) is removed by operation. This removes the source of antibodies and the disease gets cured in most people.

What is the outcome of myasthenia gravis after treatment?

Earlier, the disease had a high morbidity and mortality, as treatments were not available. However, now, with good treatments available, more than 95% people do well and are fully cured.

I hope this articles helps people with myasthenia gravis as well as their caregivers. I would be pleased to answer any further queries. 

Please send email at drsudhirkumar@yahoo.com 

If anyone prefers ONLINE CONSULTATION, please visit http://bit.ly/Dr-Sudhir-kumar

DR SUDHIR KUMAR MD (INTERNAL MEDICINE) DM (NEUROLOGY)

SENIOR CONSULTANT NEUROLOGIST

APOLLO HEALTH CITY

Phone (for appointment): 0091-40-23607777 (extension 6634/3011)

Email: drsudhirkumar@yahoo.com 

Online consultation: http://members.tripod.com/sudhirkumar_5/neurologist/id6.html

TREMORS OR SHIVERING OR SHAKING

TREMORS OR SHAKING OR SHIVERING

DR SUDHIR KUMAR MD (INTERNAL MED.) DM (NEUROLOGY)

SENIOR CONSULTANT NEUROLOGIST

APOLLO HOSPITALS, HYDERABAD

1.  What are tremors?

A: Tremors are commonly referred to as shaking or shivering also. They are involuntary movements (occurring without one’s control) of a part of body.

2.  What are the common causes of tremors?

A: The most common causes of tremors are:

·      Physiological or normal

·      Essential or familial

·      Parkinson’s disease

3.  What are physiological tremors?

A: We all remember shivering of our hands during oral or viva examinations, or while learning to drive, or during any state of anxiety. Such tremors occurring during stress or anxiety is referred to as physiological. Most often, only hands are affected. Since, these affect most people at some time in life, they are also called as normal (or exaggerated normal). These do not require any treatment.

4.  What are familial or essential tremors?

A: These are probably the most common cause of tremors, which are pathological (abnormal).

·      They often start in adolescence or early adulthood.

·      Hands are most often affected, leading to difficulty in writing, signing, drinking tea or coffee, buttoning or unbuttoning, opening a lock or anything that requires fine finger movements.

·      Head may also be affected, with either side-to-side or front-to-back movements.

·      Voice tremors are also common.

·      These occur in families and so are supposed to be of hereditary origin.

·      Severe disability is uncommon with these tremors.

·      Good medications are available to treat them. These include beta-blockers, clonazepam, primidone, and botox injections. Consulting a neurologist would help you choose the best medicine.

PARKSINSON’S DISEASE has already been described in one of my previous blog articles. This can be found at http://bestneurodoctor.blogspot.in/2013/03/parkinsons-disease_12.html

If you have any further queries on tremors or shaking, please send an email: drsudhirkumar@yahoo.com

For online consultation with Dr Sudhir Kumar, please click http://members.tripod.com/sudhirkumar_5/neurologist/id6.html

MULTIPLE SCLEROSIS

DIAGNOSIS AND TREATMENT OF MULTIPLE SCLEROSIS

1. What is multiple sclerosis?

Multiple sclerosis is a demyelinating disease of central nervous system-CNS (brain and spinal cord), which is characterized by involvement of “multiple” parts of CNS.

The disease is also characterized by remissions (improvement of symptoms) and relapses (occurrence of new symptoms) over a period of time, causing “multiple” episodes of symptoms.  

Multiple sclerosis is an autoimmune disease, which means the antibodies produced in the body attacks own healthy tissues.

2. What is the meaning of demyelination or demyelinating illness?

Nerves in central nervous system are like “electric wires”, that is, they have a central core surrounded by an insulation or covering. This covering of the nerves is called “myelin sheath”.

A disease, where the myelin sheath is affected or damaged is called a demyelinating disease or illness, and the process is called as demyelination. Multiple sclerosis is one of the most common demyelinating diseases of the CNS.

3. Who are the common people affected by multiple sclerosis?

·        Multiple sclerosis is commonly seen between the ages of 10 and 60 years, which means, it is uncommon in children below 10 years and those adults who are above 60 years of age.

·        Multiple sclerosis is typically more common in young women (between the ages of 18-36 years),

·        Multiple sclerosis is seen all over the world, probably more common in the West, as compared to Asian countries.

·        Also, the severity of multiple sclerosis seems to be lesser in Asians, leading to lesser degrees of disability, which has led some people to label Asian multiple sclerosis as relatively “benign form” of multiple sclerosis.

4. What are the common symptoms of multiple sclerosis?

Common symptoms of multiple sclerosis include:

• Sudden onset diminished vision in one or both eyes, which may get worse over a few days,
• Numbness of arm or leg on one or both sides of body,
• Weakness of arm or leg on one or both sides of body,
• Imbalance while walking,
• Bladder symptoms,

Less common symptoms of multiple sclerosis include

·        Memory disturbances,

·        Seizures or fits,

·        Depression

It is important to note that a patient with multiple sclerosis may have only one or more than one symptom described above at one point of time, or different symptoms may occur during multiple episodes of the disease.

5. How is the diagnosis of multiple sclerosis confirmed?

A person who has one or more symptoms suspicious of multiple sclerosis should consult a neurologist. A neurologist would take history and do a clinical examination to ascertain the number of episodes of illness, and also to identify the affected the parts of central nervous system.

After that he would order for investigations to confirm the diagnosis of multiple sclerosis.

6. What are the important investigations for confirming a diagnosis of multiple sclerosis?

• MRI (Magnetic resonance imaging) of brain and spinal cord- this is the most important investigation. MRI shows the involvement of different parts of brain and spinal cord. The white matter of brain and spinal cord are typically affected in multiple sclerosis. The diseased part of brain and spinal cord are also referred to as “lesions” or “plaques”. A new or active lesion shows enhancement on MRI with contrast dye injection. In addition, there may be swelling around the active lesions. MRI is also able to distinguish new versus old lesions, and is useful to monitor the disease progression or improvement and also the effectiveness of treatment.

• CSF (cerebrospinal fluid) analysis- CSF is removed by lumbar puncture (LP) by inserting a needle in lower back. In multiple sclerosis, the CSF protein is elevated; however, the number of white blood cells (WBCs) is either normal or only slightly elevated. CSF sugar is often normal. CSF is also tested for the presence of oligoclonal bands (OCBs), the presence of which indicates an active disease.
• Evoked potential studies may be ordered to look for involvement of optic nerve (visual evoked potential or VEP) or spinal cord (somatosensory evoked potential).
• Blood tests (such as ANA, Anti-dsDNA, ANCA, etc) may be ordered to exclude other diseases that can mimic multiple sclerosis.

7. What are the current treatment options for multiple sclerosis?

Treatment of multiple sclerosis can be divided into two categories- treatment of acute episodes and treatment to prevent future relapses of disease.

Treatment for acute episodes:

Steroid injections are the preferred treatment options. The drug of choice is methylprednisolone given as injections in the veins over 3-5 days. Then, steroid tablets are given for 15-20 days.

Treatment to prevent relapses of disease:

The most preferred treatment is interferon injections (such as avonex, relibeta and rebif in India). Avonex and relibeta are given as injections in the muscles, once a week, whereas rebif is given as injections underneath the skin three times a week.

Other FDA-approved treatment options to prevent relapses of disease in multiple sclerosis are:

1. Glatiramer acetate (copaxone)- given as injection underneath the skin, once a day.

2. Fingolimod- oral capsule (0.5 mg) once daily

3. Mitoxantrone- given as infusion in the vein, every three months (maximum 8-12 doses over two-three years),

4. Natalizumab (tysabri)- given as infusion in the vein, once every four weeks.

5. Dimethyl fumerate (tecfidera)- twice a day oral capsules.

6. Teriflunomide (Aubagio)- once daily tablets. 

 8. Is Multiple sclerosis curable?

As of today, there is no cure for multiple sclerosis. However, with current treatments, the disease can be kept under control and new relapses can be prevented.

9. Is multiple sclerosis always disabling?

Multiple sclerosis does cause disability in a significant number of people. However, more than two-thirds of patients suffering from multiple sclerosis are independent for their activities of daily living and are gainfully employed in a job. The good outcome depends on proper treatment as well as physical & occupational therapies.

10. Is multile sclerosis contagious or genetic?

Multiple sclerosis is not contagious and does not get transmitted from one affected person to another.

There may be genetic predisposition to get multiple sclerosis but it is not a genetic disease in a strict sense, as most patients with multiple sclerosis do not give a positive family history.

11. Is multiple sclerosis fatal or lethal?

In more than 95% of patients with multiple sclerosis, it does not lead to death. However, in a minority (less than 3%) it may lead to death either due to the direct effect of the severe disease or another complication such as pneumonia or deep vein thrombosis.

I hope this article is useful for hundreds of patients with multiple sclerosis as well as their caregivers. In addition, if someone is looking for information on multiple sclerosis (MS), it should be useful.

For any additional information, please email me at drsudhirkumar@yahoo.com

DR SUDHIR KUMAR MD (Internal Medicine), DM (Neurology)

Senior Consultant Neurologist

Apollo Hospitals, Hyderabad, India

Phone: 0091-40-23607777/60601066

drsudhirkumar@yahoo.com