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Date: 12-14 July 2019 Venue: Hyderabad, India - Radisson Blu Plaza Websitesi: http://spineendoscopy.org/ Congress Directors Dr. Sukumar Sura (Hyderabad, INDIA) Dr. Mahesha Kanthila (Mangalore, INDIA) Scientific Advisor Dr. Said G. Osman, MD (Maryland, USA) Program Manager Mr. Naresh Kumar Pagidimarry Congress Topics » Transforaminal Lumbar Discectomy » Transiliac Transforaminal L5-S1 Discectomy » Transforaminal Decompression in Lateral Recess Stenosis » Transforaminal Endoscopic Spine Fusion » Endoscopic Lamino-foraminoplasty » Interlaminar Decompression of Lumbar Canal Stenosis » Interlaminar Lumbar Discectomy » Endoscopic Posterior Cervical Discectomy & Foraminotomy » Endoscopic Thoracic Discectomy » Endoscopic 360 decompression of Spinal Canal Stenosis » Unilateral Biportal Endoscopic Decompression

Is it Effective in Musculoskeletal Tumors? Used in radiotherapy In malignant and invasive benign skeletal tumors, radiotherapy is applied in addition to chemotherapy before / after surgery. Since sarcoma cells are more sensitive than carcinomatous cells and the majority of skeletal tumors have this structure, radiotherapy continues to be used as part of the treatment. Radiotherapy reveals its lethal effect by stopping the division in cells with increasing proliferative rhythm. Since normal cells are also damaged during regeneration in the entire area where the rays are targeted, Proton Beam Therapy has emerged as a result of investigating therapies that focus directly on the tumor area to reduce unwanted effects. Proton beams, without using X-rays like conventional radiotherapy agents, can deliver intense radiation to the tumor area with beams as wide as the size of the tumor, or even very narrow beams. While reaching the tumor, it is a great advantage that it does not pass behind the targeted tissue, although it causes radiation by passing through the normal tissues. This is why proton beams are tried to be applied to the patient as shortly as possible by giving certain positions, since the focusing of the radiation beam, which concentrates only on the tumor area, cannot be performed yet. With a good planning, no matter how deep the tumor is, the most appropriate treatment is planned by selecting the ray trace. In which types of cancer is it effective? Most childhood tumors are extremely sensitive to radiation. Prostate cancers, Brain tumors, Spinal tumors, Skeletal Sarcomas (Muscle / Bone / Cartilage), It is effective in breast cancers and their metastases. How is proton therapy different from conventional radiotherapy? Proton Beam Therapy is known to cause less tissue damage than conventional radiotherapy. It destroys the cancer cells without damaging the surrounding tissues and the tissues behind the tumor. Compared to conventional radiotherapy, the 3-year survival rate is expected to exceed fifty percent. The number of fully healed cases is increasing. Proton beam acquisition is very costly and difficult compared to conventional radiotherapy. It requires the construction of a special building the size of a football field, in this center all waste systems are specially designed. A proton center costs millions of dollars and can be made operational with at least two years of work. Advantage in Orthopedic Surgery Orthopedic tumor surgery results in limb loss in severe cases. Removal of large areas of limbs, especially pelvis and spine tumors, may not be compatible with life. In this case, it is a fact that Proton Beam Therapy and radiotherapy prolong life in cancers that cannot be reached or removed. In treatments that require limb loss, radiotherapy can never be a preference for limb protection, but it helps prevent limb loss. Orthopedic tumor surgery can be given before surgery to reduce the margins. Concomitant chemotherapy is often applied. After surgery, the disappearance of satellite tumors or the spread of the tumor is greatly reduced by radiotherapy. Tumor Treatment in Our Center International algorithms are valid in the approach to orthopedic tumors in our clinic. Treatment is planned after tumor classification and grading of patients diagnosed with or detected masses. Classification of tumor size (T), lymph node extension (N) and metastasis status (M) is the basis of a classical approach, but when the tumor grading depends on the cell structure, biopsy is the basic step of the algorithm after obtaining almost accurate information about the tumor type according to radiological scientific experience. . Biopsy may be needle, excisional, marginal or may include compartment. Limb preserving or treatments that will cause limb loss are not applied before the cell structure is definite. After the cell structure is determined, the surgeon decides whether the cell is in situ and directs it to the treatment, this decision is definitely surgical, it is made in cooperation with the patient in line with the recommendations of the physicians who will form the council (Oncologist, Radiologist, Pathologist, etc.) If complementary or terminating surgery is delayed at such critical stages, not disrupting radiotherapy and chemotherapy will prolong life and prevent metastasis.

Cell therapy is becoming increasingly common in the treatment of knee cartilage problems. Cellular treatments are applied to tissues that do not have the ability to regenerate themselves. The cartilage cell is one of them. Cartilage cannot compensate for tissue loss by multiplying in its location. However, the cell sample can be activated and reproduced outside. And it is transported to the problematic area. Cartilage transplant; Cells taken from the patient’s cartilage are first separated. Intact cells are selected under a microscope after filtration and centrifugation. It is then reproduced in suitable nutrients. This reproduction is then continued by providing a certain distribution on a skeleton called the matrix. When the appropriate volume is obtained, the tissue is ready for transplantation. The area where the tissue will be transferred is prepared adjacent to healthy cells, well-blooded and easy to detect. Dead cells in the patient’s knee are cleaned and opened up to the intact tissue and blood supply is provided. If the tissue is a person’s own cell, it functions as long as it maintains its vitality without going through the remodeling process. And it can begin reproducing the cartilage matrix within 24-72 hours. The tissue takes 3-12 weeks to attach. At the end of 2 years, the tissue skeleton is completely renewed and its continuity with other neighboring cells is ensured. The situation is very different in foreign cells. If the cell is rejected, within 72 hours, the cells are enveloped and killed, leaving only the matrix. And they leave their places to cells that mimic cartilage called fibrocytes.

Physiotheraphy; It deals with all human movements and the structure of the skeletal musculature. It is one of the main treatment methods for those who have spinal problems, including those who suffer from back, waist and neck pain. We collect the physical therapy methods in our body under 4 main headings. 1. Range of motion exercises (ROM exercises) It is very important to bring the movements to their former extent in fixations after orthopedic treatments or after joint surgery. Movements that were previously passive assisted are developed over time to active and resistant exercises. It is very important for this treatment to be regular and efficient in the presence of a physiotherapist. Otherwise, permanent injuries and movement restrictions may develop. 2.Muscle Strengthening and Balance: Even if the joint range of motion is full, it should be very important to have a certain level of muscle strength that creates movement. Muscle atrophy and weakness negatively affect returning to daily life after orthopedic treatment. We practice these kinds of exercises gradually, by following certain programs, accompanied by a physiotherapist. 3.Walking Exercises Walking disorders can occur for various reasons. It is applied when it is necessary to gain normal walking style after orthopedic knee disorders or treatments. Gait analysis is a special test that makes it easy for us to find the cause of gait disorders and to treat the cause. 4. Return to Sports and Athlete Support Exercises Although joint width is provided after orthopedic treatment, bringing muscle strength to the level of daily life is not enough for athletes. Special training programs for returning to sports are carried out in the company of a physical therapy-sports physician and a physiotherapist.

Joint arthroscopy for joint health: Arthroscopy is the process of imaging the inside of the joint with a camera. Using a special camera with a diameter of 1.2-7 mm depending on the size of the joint, the surgeon can diagnose diseases while imaging the joint and intervene by planning the treatment at the same time. Today, with the development of optical systems, by using high resolution cameras, images that are almost close to seeing with the naked eye can be obtained. With such clear images, many situations that cannot be diagnosed by radiological imaging methods can be revealed. Another advantage of arthroscopy is that it is not an alternative to open surgical methods and in most cases it is the only option without an alternative. For example, with hip arthroscopy, it is possible to correct the joint incompatible with arthroscopy and the patient to return to work the next day. Since the same procedure involves great risks with open surgery, it is almost never applied. Arthroscopy in large joints has taken its place in the treatment as the gold standard. Shoulder, elbow, hip and ankle; In the large joint class, the camera system is almost always intervened and successful treatments are widely applied. Joint Arthroscopy "Arthroscopy for Joint Health" Since thin and special camera systems are required for arthroscopy of the wrist, foot and finger joints, middle foot joints in small joints, it can be applied in a limited number of centers. Arthroscopic intervention is possible in the spine and disc area. This intervention, formerly called "arthroscopic discectomy", has been described as "endoscopic discectomy". Disc problems between the vertebrae can be solved by imaging them with a camera even under local anesthesia. Since the areas that arthroscopy can reach and view are very difficult to reach with open surgery, it is not difficult to predict that many surgical methods will be performed arthroscopically in the future. The materials we use for the repair of structures that have been injured and lost their integrity in joint surgery are engineering marvels and complex operations can be performed with a single move. In joint surgery, cartilage repairs, meniscus repairs, ligament repairs, foreign body removal and cellular treatments have all become possible only with arthroscopic treatment. I wish you a healthy and pain-free life, emphasizing that any formations that cause stuck on the joint surface must be treated. It is our freedom of movement!

Before the details of Lumbar Shift Surgery, let's give brief information about Lumbar Shift and its symptoms that cause back pain that is difficult to bear. What is a Lumbar Slip? It is the distortion of the alignment of the vertebrae that make up the spine, and it is the displacement forward and rarely back. This condition, which is called spondylolisthesis, is frequently used in communication with patients in folk language, also in cases of herniated disc. What are the Symptoms of Lumbar Shift? As a result of a slipped waist, the hole where the nerves to the legs come out, the hole we call Foramen becomes narrow and the nerve is under pressure, the area where it receives sensation becomes numb, numb, in advanced situations the muscle group it stimulates weakens or even paralysis. How Is A Lumbar Slip Diagnosed? Back and leg pain, numbness, loss of strength, loss of sensation during examination, loss of reflex, and loss of muscle strength are sufficient to determine the level of slippage. Nowadays, although examination seems to have lost its importance as it is easily understood by MRI imaging, examination is essential in order to understand which one causes the complaint in multi-level hernias. What Is The Treatment Process For Lumbar Displacement? In cases where there is no severe loss of nerve function, drug therapy, rest and physiotherapy provide over 80 percent improvement. However, recurrent pains that require bed rest and severe / sudden nerve damage may require urgent surgery. At Which Stage Is Lumbar Slip Surgery Required? Pain affecting daily life, attacks that require bed rest several times a year, severe nerve damage and loss of function require surgery. What Are The Lumbar Shift Surgery Options - How Is It Done - How Long Does It Take? Nowadays, closed endoscopic surgeries are becoming the first choice, microscopic surgery is common. Open surgery is almost abandoned. In cases where bone removal is required after open surgery, fixing it with a screw may prolong the resting period and return to work. In minimally invasive endocopic transforaminal surgery, there is no need for fixation in the region. What is the Recovery Process After Lumbar Slip Surgery? Movement is given within 2 hours after closed endoscopic surgery. In other surgical methods, the time to allow movement may be longer, corset or bed rest period may be required. Will It Recur Again After Surgery? The likelihood of recurrence after surgery is often related to the patient's wrong movement habits. As long as postoperative recommendations are followed, the recurrence rate is less than 2%. How Much Does Waist Shift Surgery Cost? Fees are determined according to the preferred hospital type and class. Treatment options suitable for each patient's budget are necessarily provided.

Our feet are exposed to many traumas while carrying our weight. The heel pain that we see most often in the foot area may be a simple heel fat pad syndrome, or it may cause nerve compression in the ankle region. (tarsal tunnel) Apart from plantar fasciitis problems, nerve knots between the toes (morton neuroma), and nerve entrapments, there are dozens of joints that cause foot pain. Disruption of the foot arch are common reasons for flat foot or dome foot. Problems in the area called sinus tarsi can often be missed. This area, which is difficult to diagnose, achieves great success in arthroscopic intervention.

Before details about Back Hernia Surgery, let's briefly give information about Back Hernia and its symptoms that cause back pain that is difficult to bear. What is Back Hernia? It is the rupture of the wall of the cushions, which we call the disc between the vertebrae in the back region, to herniate outward and put pressure on the nerves. What are the Symptoms of Back Hernia? Unlike waist and neck hernia, it causes pain in the chest and upper abdomen, and gives findings that are confused with organ problems such as stomach ulcer-heart attack, masking back pain, and often examined in other branches. If no other cause for heartburn or chest pain can be found, back hernia should be considered. How Is Back Hernia Diagnosed? MRI imaging and EMG are very helpful with the corresponding level of nerve sensation loss during physical examination. Especially in patients who have gone to cardiology and gastroenterology and have not found a cause of pain, the history is very important in doctor's examination. During the examination, the hernia is investigated at the level of the relevant segment. Excessive reflexes in the legs, which we call myelopathy, and unbalanced muscle contractions, which we call spasticity, are signs of advanced back hernia. In this case, the pain can spread to the legs; balance defects, gait disturbance may be seen. What is the Treatment Process for Back Hernia? Closed endoscopic transforaminal discectomy is applied in case of pain and loss of function affecting daily life. Open surgery can carry risks. Drug therapy - physiotherapy should be initiated in patients diagnosed with back hernia. Surgical treatments can be planned in cases of resistance to treatment. Among the minimally invasive surgical methods, intradisc laser - radio frequency treatments are beneficial in closed disc hernias. If the fragments come out, endoscopic surgery should be preferred. At Which Stage Is Back Hernia Surgery Required? It is planned if the pain affects daily life and requires rest. Surgery should be planned immediately in severe nerve damage such as myelopathy. In case of delay, surgical treatment only eliminates the pain. The healing process may take longer. What are the Back Hernia Surgery Options - How Is It Done - How Long Does It Take? Intra-disc laser, radiofrequency, endoscopic transforaminal discectomy, and open surgeries can be performed from minimally invasive surgeries. While open surgery and microscopic discectomy are gradually decreasing, endoscopic transforaminal surgery is a safe and preferred surgical method. What is the Recovery Process After Back Hernia Surgery? After endoscopic surgery, the patient stands up 2 hours later on the same day and is discharged the next day. Bone removal for decompression in open surgeries may require screw fixation. In this case, bed rest and return to work may be prolonged. Will It Recur Again After Surgery? Back hernia rarely recurs. How Much is Back Hernia Surgery Fee? It varies according to the hospital and packages selected according to the patient's budget.

Before giving information about wrist triangular complex problems and arthroscopic treatment, let's briefly talk about the wrist. Our wrist consists of a complex structure connected to each other like eight beads to which the two bones of the forearm (Radius and Ulna) are articulated. This extremely flexible structure, which enables us to resist various strains in daily life, completes the functions of our hands by moving in almost all directions. I compare the architecture of the forearm bones to the sticks used in Far Eastern dishes. While the ulna hinge acts as a joint in the elbow, a radius in the wrist functions similarly. While the radius in the elbow rotates around itself like a shaft, it makes the same situation as ulna on the wrist, they literally cross each other. In this way, they give our hands a unique function that can perform the movements we use in daily life, such as turning keys, screwing, and opening the door handle. As it turns out, in reality the elbow and wrist joints complement each other in this way, but unfortunately they also share their questions. For example, if we have suffered an elbow joint fracture, the key turning function of our wrist is likely to be impaired. Similarly, an injury that causes shortness of the wrist may cause early calcification by causing strain in the elbow joint. This is why, in recent years, the importance of anatomical correction (near-real correction) in wrist fractures, before shortness can be accepted. If shortness occurs, the little finger side of the wrist (Ulna) faces more strains than anticipated in the load distribution. This situation will cause the really complex bone-joint-ligament structure, which we call the Triangular Complex (TAC), to be susceptible to injury. Check out the figures to see this brief briefing. The TAK structure on the wrist allows the ulna, which is shorter than the radius, to join the joint, supports the wrist bones, enables rotational movements. TAK is at risk in wrist sprains. In addition to bone injury, TAK injury is very common in fractures. It can be directly injured, torn or indirectly squeezed between the ulna-wrist bones approaching the joint due to the shortening of the radius bone (abutment syndrome). Arthroscopic Treatment In Arthroscopic Treatment, we can simply divide TAC injuries into rupture and compression. TAC ruptures can be divided into simple wrist looseness-dislocation (instability) and those that do not. Wrist tightness or abutment disease manifests itself with the limitation of joint motion in which pain is at the forefront. We can observe these gates with arthroscopic joint surgery. This procedure can be performed by using a special sling device with the help of a scope with a diameter of about 1.2 mm and only numbing the arm. In the absence of arthroscopy, we opened the joint for treatment and often could not benefit our patients at the macro level. Today, using HD optical cameras and advanced equipment, we can correct the dislocations with extremely practical repair methods, and we can remove the jams with the micromotor, laser and radiofrequency devices we operate inside. Get rid of living with painful joints, Join Life….

Joint pain is one of the main reasons for outpatient treatment for musculoskeletal problems. While MRI (Magnetic Resonance Imaging), one of the advanced diagnostic methods, increases the options for the treatment of joint cartilage lesions, its effect on the accuracy of the options and the decision of timing is limited. Early diagnosis and adequate treatment can prevent the irreversible loss of cartilage tissue. Cartilage tissue is a metabolically active tissue. Except for superficial losses, it does not have the ability to repair itself. Since cartilage cells do not have regeneration capability, losses can only be covered up to 1 mm by cellular migration and matrix production. In superficial losses, if the injury does not reach the subchondral tissue, there is no cellular migration. After hemorrhage in full-thickness injuries, we see that fibrin and mesenchymal cells play a role in shaping. In this case, the repair tissue becomes firocartilage like cicatricial tissue. The hyaline cartilage provides a smooth and smooth surface as well as providing belt fluidity, one of the basic functions of cartilage. Fibrocartilage functions as a filler as a scar tissue and prepares the basis for the inflammatory response with PDGF, TGF- (3 mediators released from mesenchymal cells, which have an important place in arthritis physiopathology. If the cartilage defect creates a mechanical obstacle and the arthroscopic treatment is delayed, the healing may result in the form of excess scar tissue. This will increase the friction and wear and make the treatment unsuccessful. It is a hard osseous healing tissue caused by mesenchymal cells with pluripotent cell characteristics to increase osteophyte formations despite the relief of pain over time, therefore, in addition to acute inflammatory response, the problems in the late period will be in the form of a healing tissue that creates a mechanical obstacle and disrupts lubricity. Viscosupplementation provides the migration of chondral cells and accelerates the formation of new cartilage as well as a mechanical effect in the closure of superficial defects. However, its application alone is controversial in cases where there is a mechanical obstacle. Despite conservative options, the aim in arthroscopic surgery should be to provide acceptable lubricity of cartilage lesions without causing erosion on the opposite surface over time. In superficial cartilage lesions, this procedure can be applied to a simple debridement, and in more severe lesions, to cartilage transfer. Simple debridement is based on cellular migration and matrix filling healing, unstable fragments, chondromalastic foci are cleaned and regeneration is given to healthy layers. Although the cartilage healing is hyaline, regional thinning develops and the irregularity continues. Although the belt-like mechanics of the injury area deteriorates due to thinning, the opposite surface wear is prevented. Cartilage transfer is the process of removing cartilage osteochondral graft from a smooth area. When the healing is completed, the surface is covered with hyaline cartilage. Correct treatment of timely, correctly defined cartilage lesion means preservation of long-term joint function. In the treatment, the right option should be determined immediately by targeting eradication. How sensitive and effective is MRI in this choice? Although the answer seems to be in favor of MRI with the developing technology, its sensitivity in superficial lesions is not yet sufficient. Detection of cartilage lesions The problem in diagnosing cartilage injuries or degenerations is that the main complaint and the way pain occurs during daily activity are quite similar to meniscal lesions. Provocation maneuvers during physical examination can often be painful in condylar lesions. In case MRI examination and physical examination findings do not match, which is inevitable in differential diagnosis and treatment planning, the presence of a superficial cartilage lesion should be revealed by questioning the short-term conservative response. Arthroscopic joint examination of pain that does not decrease despite conservative treatment or recurs at the end of treatment is the gold standard in early detection of cartilage lesions. Although rare, cartilage lesions can be reported as cruciate ligament injuries on MRI. In this case, if it cannot be distinguished due to the clinical painful knee, the large cartilage lesion can be missed by the decision of conservative ligament repair (Figure 1). MRI methods and difficulties in the diagnosis of cartilage lesions It is often seen that no special classification is used except for recording the presence of cartilage lesions, facial discontinuity and irregularity, and subchondral edema reported by MRI. Therefore, even if it is possible for the clinician to suspect the presence of a superficial cartilage lesion with a good physical examination, it may not be possible to confirm the lesion. Clinically compatible results and sensitivity of MRI are reduced under 1 Tesla power. Sensitivity to cartilage lesions increases in proportion to magnet power. Digital software support STIR imaging, spin echo T1 / T2 cartilage-specific sequence and gradient settings increase sensitivity, so a wide range of sensitivity between 18-80% is reported in the literature. MR-arthrography is useful in detecting the suspicious lesion after a good physical examination, which is not frequently used, but has not found its place in practice. Detection of superficial erosions is difficult, and the possibility of focal focuses outside of the sections is quite strong. Reaching the surface in the presence of MRI subchondral edema Some side lesions may reveal false positivity in 14%. In addition, false-negative rate has been reported to be higher (16-30%), although it varies depending on sensitivity. When degenerative cartilage lesions are widespread and superficial, they may not be demonstrated by MRI even though they are responsible for a significant part of the findings (Figure 2). Although MRI sensitivity is claimed to be 100% in full-thickness lesions, it may not give any MRI findings (Figure 3). Cartilage in small joints such as ankles Detection of dac lesions can be much more misleading. A full-thickness lesion cannot be detected on MRI scans, and extensive talus edema may be false negative (Figure 4). Fragmented flap-style cartilage injuries, which are clinically extremely noisy, often do not show MRI findings (Figure 5). Similarly, extensive-superficial chronic subchondral inflammation can be missed in lesions whose process is over (Figure 6). 54-year-old female patient, diffuse superficial degenerated cartilage loss and softening 43-year-old male patient with complete focal cartilage lesion without MRI findings and peripheral meniscal separation in return 41-year-old male patient, a full-thickness cartilage lesion on the articular surface of the ankle tibia distal end without MRI findings 34-year-old female patient with MRI findings non-giving flap-style cartilage defect A 34-year-old female patient, an explosive superficial chronic cartilage lesion in the medial femoral condyle. Arthroscopy efficacy Arthroscopic diagnostic approach should be among the options of the clinician under the guidance of physical examination in cases of joint pain that does not resolve despite conservative treatment. Arthroscopic diagnosis can explain the clinic by revealing the cartilage softening with dynamic examination as well as video imaging, even if there is no superficial loss. Arthroscopic classifications of cartilage lesions should reveal the topography of the lesion as a focal, large or kissing lesion and should be able to convey sufficient information depending on whether its depth is superficial, moderate or full. However, we could not use a practical and generally accepted classification that defines both features in our clinic. Surface changes Maintaining the habit of defining Outerbridge's popularized cartilage lesions at 4 degrees, we preferred to characterize them topographically as focal, large and kissing lesions. Discussion Irle et al. He found 100% efficiency and sensitivity of MRI in injuries extending to the subchondral region, but insufficient in superficial lesions. Similarly, Ochi et al. Increasingly determined the sensitivity in softening, fragmentation, erosion and full thickness lesions as 14.3%, 57.3%, 75% and 100%. Potter et al., In a series of 600 cases, obtained more sensitive results by using the MRI spin echo technique in arthroscopic images according to the Outerbridge classification. In this study, sensitivity was 87%, specificity was 94% and accurate diagnosis was 92%. On the other hand, they found false positive 15% and false negativity 14%. Spiers et al. A prospective study of 58 patients found inadequate physical examination efficacy in terms of MRI in terms of meniscal lesions. In this series, it is significant to emphasize that MRI reduces diagnostic arthroscopy by 29% at the stage of diagnosis and the sensitivity is reported as 68%. Bradella et al. Reported a sensitivity of 64-80% in cartilage lesions. Although Friemert et al found increased sensitivity with the STIR technique in addition to the spin echo technique, the increase in sensitivity in superficial cartilage lesions is not significant. In the study of Macarini et al, it is highly specific to emphasize that the sensitivity may change according to the localization of the cartilage lesion. The similarity between the cartilage injury in the medial femoral condyle and the anterior cruciate ligament rupture in our series is a good example of this study. Emphasizing that the sensitivity may change to magnet power and echo-gradient choices, these studies reveal the importance of clinical evaluation. Result Treatment of superficial cartilage losses, whether traumatic or degenerative, should relieve pain and increase functional capacity by creating a slippery joint surface. In conservative treatment, symptoms rapidly regress as long as the lesion remains within the regeneration limits of the tissue. If there is no significant improvement in functional capacity despite conservative treatment, the findings in the MRI examination should be considered false negative. Otherwise, arthroscopy performed after false positive is not a loss. Subchondral edema in joint contusion that occurs after trauma may mislead the extent of the lesion reaching the surface. False positivity is extremely low compared to false negative results in all series. Therefore, arthroscopy should not be avoided at an acceptable rate. Resources Cain EL, Ciancy WG. Treatment algorithm for osteochondral injuries of the knee. Clin Sports Med 2001 Apr;20 (2):321-42 Chen FS,_Frenkei SR, Di Cesare PE. Repair of articular cartilage defects: port IL Treatment options, Am J Orthop 1999 Feb;28 (2):88-99 Duchow J, Hess T, Kohn D, Primary stability of press-fit implanted osteochondral grafts influnce of graft size, repeated insertion and harvesting tecnique. Am J Sports Med 2000 Jan-Feb;28(1):24-7 Morelli M, Nagamori J, Miniaci A. Management of chondral injuries of the knee by osteochondral autogeneous transfer. J Knee Surg 2002 15(3):185-90 Sanders TG, Mentzer KD, Miller MD, Morrison WB, Campbell SE, Penrod BJ, Autogenous osteochondral plug transfer for the treatment of focal chondral defects, Skeletal Radiol 2001 Oct;30(10):570-8 Takahashi S, Oka M, Kotoura Y, Yamamuro T. Autogeneous callo-osseous graffs for the repair of osteochondral defects. J Bone Joint Surg Br 1995 Mar;77(2):194-204 lrie K, Yamada T, Inoue K. A comparison of magnetic resonance imaging and arthroscopic evaluation ofchondral lesions of the knee Orthopedics, 2000 Jun;23(6):561-4. Potter HG, Linklater JM, Ailen AA, Hannafin JA, Haas SB Magnetic resonance imaging of articular cartilage in the An evaluation with use of fast-spin-echo imaging. J Bone Joint Surg Am. 1998 Sep;80(9):1276-84. Spiers AS, Meagher T, Ostlere SJ, Wilson DJ, Dodd CA, Can MRI of the knee affect arthroscopic practice? A prospective study of 58 patients. J Bone Joint Surg Br. 1993 Jcin;75(1):49-52, Bredella MA, Tirman PF, Peterfy CG, Zarlingo M, Feller JF, Bost FW, Belzer JP, Wischer TK, Genant HK, Accuracy of T2-weighted fast spin-echo MR imaging with fat saturation in detecting cartilage defects in the knee: comparison with arthroscopy in 130 patients, AJR Am J Roentgenol, 1999 Apr;172(4):1073-80, Kuikka PI, Kiuru MJ, Niva MH, Kroger H, Pihlajamaki HK Sensitivity of routine 1.0-Tesla magnetic resonance imaging versus arthroscopy as gold standard in fresh traumatic chondral lesions of the knee in young adults, Arthroscopy. 2006 Oct;22(10):1033-9. Macarini L, Murrone M, Marini S, Mariano M, Zaccheo N, Moretti B, MR in the study of knee cartilage pathologies: influence of location and grade on the effectiveness of the method. Radiol Med (Torino). 2003 Apr;105(4):296-307, Ochi M, Sumen Y, Kanda T, lkuta Y, ltoh K. The diagnostic value and limitation of magnetic resonance imaging on chondral lesions in the knee joint Arthroscopy. 1994 Apr;10(2): 176-83, Friemert B, Oberlander Y, Schwarz W, Haberle HJ, Bahren W, Gerngross H, Danz B. Diagnosis of chondral lesions of the knee joint: can MRI replace arthroscopy? A prospective study. Knee Surg Sports Traumatol Arthrosc. 2004 Jan;12(1):58-64. Epub 2003 Aug 5.

Regardless of race, age and gender, it was determined that 80% of each individual suffered from back and neck pain that requires bed treatment at least once in their life. Neck hernia. Although spinal pain is so common, disc-based pain is 27%. The disc structures between the vertebrae have elastic deformations during the transfer of weight, standing upright and during movement. It provides this dynamic effect with the nucleus (nucleus) in its structure and the annulus structure surrounding it. Like a horizontal automobile tire, the disc absorbs the load during bending and loading, reduces and transfers the weight by spreading, then returns to its original state. This suspension effect continues thousands of times during the day. The aim is to maintain the relationship and stability between the vertebrae, apart from meeting the load. While the discs keep the distance between the vertebrae constant at a certain height, the muscle-ligament and nerve structures remain at a certain tension and provide dynamic stability. As a result of the structural changes of the matrix proteins in the disc structure with aging, their water retention properties decrease. With decreasing disc elasticity, water retention ability decreases. Decrease in diffusion feeding increases the matrix cracks, and plastic deformations occur in the fragile disc with reduced elasticity over time, with the permanent structural changes. The height of the disc decreases, the joint structures are eroded by excessive movement, even the disc wall is torn and the nucleus moves and presses on the nerve structures. And as a result, spinal pain occurs. Medical Treatment Requirement does not exceed 8.3% among disc-related pain, while those with outpatient treatment are 2.7%. The number of inpatients in the world is 9 million (0.45%), the group that receives surgical treatment is only 1 million per year in the world. This number includes all open surgical fusion and discectomies. Low back pain treatment is multidisciplinary. Multidisciplinary Approach »Physical therapist " Neurology expert " Physiotherapist »Algologist »Spinal surgeon It is possible with the cooperation of physicians working in their branches. Progressive (algorithmic) treatment principles require anti-inflammatory therapy in primary care and bed rest not exceeding 3 days. In resistant and chronic cases, algologists apply block-pain treatments, physical therapists apply physical therapies. All treatments are supported by muscle strength-posture discipline-ergonomic measures with the support of physiotherapists. Surgical compression of the neural structures is the last step of choice in recurrent resistant cases due to osteoarthritis, significant loss of disc height. Open surgery indications: » Cauda equina syndrome »Progressive neurological deficit »Failure of conservative treatment »Paresthesias that are not obvious but affect life »Pains that progress with attacks and require more than three rest times a year can be counted. The indication for minimally invasive (closed endoscopic) surgeries differs at this stage. Prominent neurological deficit, cauda equina may be a contraindication. Endoscopic surgery has a place in cases requiring bed rest more than three times a year, but without an absolute surgical indication. PAIN, which does not respond to conservative treatment that reduces the quality of life, is NOT THE FATE OF THIS POPULATION: it is a treatment that is purely aimed at improving the quality of life. Open Surgical Treatments »Lumbar Microdiskectomy »Hemilaminotomy / discectomy »Laminectomy / discectomy »Fusion »Nonfusion »Total Disk Replacement » Nucleus Replacement While surgery is moving towards less invasive methods, it is the fastest return to daily life after treatment. Surgical evolution has tended to increase disc height by regenerating the nucleus. While less invasive methods (LESS Invasive) surgeries broke new ground with percutaneous (piercing the skin) fusion (freezing) surgeries with screws, they also tried to increase the height by renewing the disc core with semi-open methods, on the other hand, they tried to reduce pain with external supports that open the disc space. Table-1 Open Surgery Fusion Nonfusion Disc prosthesis Nucleus Replacement Less Invasive Surgery Fusion PLIF-TLIF Nonfusion Xstop vs Nucleus Replacement PDN MISS Surgery Minimal Invasive Intradiscal Discectomy Selective Discectomy Anulus Repair Nucleus Replacement Hippocrates “First, Harmful” (Primum Nil Nocbbere) approach is the current approach. Ideal treatment for surgery progressing towards more and more harmless treatments »Respectful to anatomical structures »Harmless »For the cause »Increasing the quality of life »There should be a treatment that can return to normal life in a short time. Minimally Invasive - Closed Endoscopic Surgery History: » 1857 Virchow begins with his description of disk protrusion. 1901 Horsley applied the first decompression, 1911 Goldthwait cited annulus rupture and nucleus pulposus extrusion as the cause of pain. »1913: Elsberg treated pain with laminectomy treatment used for years in open surgery. »1922 Siccard and Forestier sprinkled the first seeds of minimally invasive techniques that applied the first provocative discography technique using lipiodol. With this examination method, disc pathology could be revealed on x-ray. The pathological level gave pain during the procedure. » 1934: Peet and Echols differentiated between disc herniation and root compression »1937: Defining it as the first endoscopic intervention (MYELOSCOPY) modified from the pool otoscope, the first endoscopy was performed. »1939. Love applied the interlaminar microdiscectomy technique without resecting the bone with a mini incision. »Until 1955 Male Binocular Microscopic Discectomy technique was developed, wars were unorthodox to use medical treatment to improve the quality of life. »1960 Rhizotomies were activated, pain transmission from painful segments was interrupted. » 1974 Shealy performed Rhizotomy by applying Percutaneous (piercing the skin) Radio Frequency procedure. While intra-discal treatments are becoming popular, chymopapapin and Choy laser powered discectomies »1973 Kambin launches endoscopy application » 1977 Hijikata performed Percutaneous Endoscopic Discectomy, 1978 Williams Microscope used in classical discectomy »1980 Anthony Yeung introduced the endoscope specially prepared for spinal endoscopy (Wolf: YESS) to today's surgery. After more than one hundred thousand successful procedures since 1980, Miss Family Tree is gradually branching out. Family tree »Hijikata-Kambin »A. Yeung (Wolf-Yess) »MT. Knight (EKL-Kiss) »H. Leu (Storz-Leu) »T. Hoogland (Joimax-Thessys) »Martin Sawitz, John Chiu, Sang-Ho Lee, Akira Dezava CISS advantages: Patient-centered After minimally invasive surgery, the hospital stay rarely exceeds one day. Returning to work after the procedure is limited to a few days. Recovery is very fast as it does not damage normal tissues. Therefore, specific hospitals with a low number of beds will restore a large number of patients to their health. Short hospital time lowers the cost. The result is excellent for the patient-centered Hospital-Insurance-Employer triangle. Minimally Invasive Surgery Concepts 1. Central Decompression: a. Chemonucleosis: It aims to liquefy and reduce the pressure by injecting chymopapain into the disc. Its indication is limited and it is almost abandoned. b. Nucleotomy: It is one of the standard treatments in the disc. It is the emptying of the disc using mechanical tools. (Figure-1) Figure-1: Nucleoplasty Figure-2: Taken from the Clarus Medical catalog. c. Automatic Nucleotomy: It is the vacuum evacuation of the disc with the help of a motor. (Figure-2) D. Radiofrequency nucleoplasty: It is the denaturation and wrinkling of the nucleus using radiofrequency. (Figure-3) to. Laser ablation: It is the evaporation of the nucleus with laser energy. (Figure-4) f. LASE: Laser assisted endoscope: It provides camera-assisted laser application into the disc with a special very thin probe. It has made a breakthrough in treatment. (Figure-4) 2. Subanular decompression and Annuloplasty a. Subanular decompression: This is the beginning of endoscopic surgery. The disc is removed from the torn annulus from a subanular safe distance. (Figure-5) b. Annuloplasty: The annulus is repaired using laser or radiofrequency energy. (Figure-3-4) 3. Selective Discectomy: It is the last stage. Only the compressing fragment is removed, the disc and annulus are repaired. It will be possible to apply a nucleus portal. a. Foraminoscopy (Figure-6) b. Epiduroscopy (Figure-6) Surgical Technique For lumbar hernia; Under local anesthesia, it is worked from the side in the prone or lateral lying position, the back hernia from the side in the slightly lateral lying position, and the neck hernia from the front. The hernia is reached without damaging the normal anatomical structures by using 5-7 mm special working channel cameras by perforating the skin 0.5-1 cm (Percutaneous). Only the part pressing on the nerve is removed. Disc structure is preserved and its recovery is provided. By Percutaneous Spinal Endoscopy, without cutting normal anatomical structures or bleeding, »Percutaneous endoscopic lumbar discectomy (PELD) (Lumbar Hernia) - Lumbar foraminoscopic - Extraforaminal far lateral - Interlaminar » Percutaneous endoscopic thoracic discectomy (Back Hernia) »Percutaneous endoscopic cervical discectomy (Neck Hernia) Advantages of Percutaneous Endoscopic Surgical Treatment »Local anesthesia is used, the patient does not receive general anesthesia. »The procedure is applied through normal anatomical holes, normal structures are not damaged in order to reach the disc. Therefore, the bleeding is very less. »Selective fragmenttectomy (only the pressing fragment is removed-the disc is preserved) »The disc is protected, the healing of the periphery (Annulus) is stimulated, increasing the healing capacity »In-disc decompression can be made. »With a provocative examination, the level can be determined precisely in multi-level lumbar hernia. »Root inspection (probing) » Foraminoplasty (enlargement of the nerve exit hole) is possible. » Epiduroscopy (examination of the spinal canal) is possible. »Extraforaminal and far lateral examination is possible. Extra-canal compression of the nerve can be easily diagnosed. »Safe percutaneous intradiscal treatment portal Contraindication »Morbid Obesity »Cauda Equina »Complicated hernias (adherent-sequestered) »Open Surgery recurrence » Non-compliant patient »Bleeding Diathesis Future Treatments Percutaneous treatments provide advantages in reaching the disc in the epidural region, the addition of advanced new instruments, genetic advances and robotic surgery, preserving normal tissues and a healthy life will be possible. From emerging treatments; »Anulus repair » Percutaneous nucleoplasty (Injection) »Percutaneous intradiscal stem cell infusion are just a few of them.

Our joints get stronger and stronger as we move. A balanced diet rich in protein and regular exercises are beneficial. Excessive weight gain should be avoided. On the joint, it can be caused by sprains, reverse loading and weakness of muscle strength. Exercises to increase muscle strength should be done. The type of exercise should be appropriate for your level. It is inevitable that you will be injured while running on the treadmill if you have not walked on a straight track. If the items you use around you are in harmony with you (ergonomic), it will reduce your risk of injury. Adapt your surroundings to yourself.