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Especially in chronic arm and shoulder pain, closed shoulder surgery, that is shoulder arthroscopy, is of great importance. What is Shoulder Arthroscopy? It is an endoscopic (arthroscopic) examination of the shoulder joint. Intra-articular (glenohumeral joint) -Subacromial joint can be examined with shoulder arthroscopy. Gleno cartilage structures, joint relation, conditions that disrupt the integrity of the glenoid (SLAP - Superior Labral Anterior-Posterior), Bankart Lesion (Labrum anterior-inferior insufficiency-with / without capsule), Biceps tendon, rotator cuff tears, ligament injuries, capsule insufficiencies are detected. . Impingement in the subacromial joint and rotator cuff tears can be detected. Rotator sheath repairs can be done. In Which Situations Is Shoulder Arthroscopy Preferred? Shoulder arthroscopy is the gold standard for understanding and treating problems related to injuries or degeneration of the shoulder joint and subacromial joint. It is used for simultaneous repair during endoscopic imaging. How Long Does Off Shoulder Surgery Take? 30-45 minutes optimal time, but the time may be longer depending on the technique while repairing. Before Off Shoulder Surgery? All preparations are made in hospital conditions What is the Recovery Process After the Surgery? If the attempt required repair, detection may be required. Generally, although strong suture materials are used to give early motion, the resting period may vary depending on the severity of the injury. Will It Repeat After Surgery? Re-rupture of the repaired tissue may always occur. This situation is only possible with a new trauma that causes injury and pushes the limits. Daily activities rarely cause recurrence after recovery. How Much is the Surgery Fee? Pricing is made according to the hospital class determined according to the patient's budget.

Degenerative Disc Disease; The word Laser is an abbreviation consisting of the initials of the word (Light Amplification by Stimulated Emission of Radiation). It is in our language with the word LASER. According to this angle, which briefly summarizes the generation of energy, laser; It is the light that emerges when the liquid crystal located between two mirrors with full and semi-reflections is exposed to concentrated energy (amplification). The laser type is named after the substance in the liquid crystal. Degenerative Disc Disease Laser energy application in the musculoskeletal system was first made by Whipple in 1984 with the use of CO2 laser. The classification of the laser according to its optical parameters (wavelength, power and dose) has been questioned in clinical studies after this date. Laser is known to alter cell proliferation, motility and secretion at different doses. Tissue interaction, on the other hand, may be dose-dependent, in the form of breaking up, liquefying, heating and evaporating. Although the type of laser used in the musculoskeletal system is often the ion resonance type, it can be classified as follows: UV Laser (Excimer) Visible Laser (Argon) IR Laser (Ion Resonance) n  CO2 n  YAG: (Yttrium-Aluminum Garnet) l Neodymium (Figure-2) l  KTP Doubled Neodymium (Potassium-titanyl-Phosphate) l  Holmium l  Erbium Argon laser is well absorbed by hemoglobin and acts by releasing heat in the tissue. This effect results in apoptosis by activating oxygen in the cell nucleus. This is the basis of photodynamic therapy. Excimer breaks the bonds of molecules without generating heat, which is why it is called cold laser. High power is obtained at low frequencies with CO2, it is absorbed by water. It achieves its superficial effect without penetration. Nd YAG penetration and coagulation effect is high. Laser energy effect is examined in three stages: Photo-thermal: coagulation, necrosis and evaporation Photo-chemical (Argon, Excimer): It is the change in the bond structures as a result of the absorption of energy at the molecular level. It provides an advantage in the treatment of metabolically active tissues (such as tumors). The photo-mechanical effect is the combination of short wave and low frequencies and the borderline ultraviolet-infrared effect. While the tissue reacts with fast ionization, the "acoustic shock wave" effect occurs. Even cutting-cutting power on bone is provided with this feature.ır. Radiofrequency energy is short wave sound energy. As in light energy, a physical state change occurs in proportion to the tendency of the substance to become unstable, on which the concentrated short wavelength energy is focused. This change, explained by the conversion to heat energy, is the basis of the cooking feature in microwave ovens. The thermal effect of radiofrequency energy is frictional. There are two separate effects: ohmic and dielectric. Ohmic effect develops at frequencies below 500 mHz. If the dielectric effect is above 500 mHz, microwave destructive effect occurs. In the musculoskeletal system, the 1-300 mHz ohmic effect of radiofrequency energy is utilized. With radiofrequency (RF) energy, tissue can be freed from its covalent bonds (relaxation-cutting), completely evaporated or new bonds (wrinkle-pull) can be formed. The ohmic effect achieved by increasing and decreasing the frequency in medical applications allows the clinician to intervene with less complex choices than laser. However, its disintegrating effect is limited in soft tissues. Knowing which energy will be used, how often and how to use it in the musculoskeletal system is possible by knowing the chemical and physical results of these energies in tissues. Penetration is the leading limiting factor in both energies. Preferring Holmium YAG in laser applications in orthopedic surgery is one of the mechanical advantages it provides despite its low penetration effect. Degenerative Disc Disease Although thermal penetration and related necrosis effect decreases with the use of Holmium YAG laser, it can be used with other advantages of energy. In addition to the acoustic shock effect, thermal coagulation, evaporation, wrinkling and bleeding control are achieved by extremely reduced tissue penetration. Its effect is indispensable, especially in minimally invasive endoscopic surgery applications, arthroscopy, tenoscopy and foraminoscopy in areas that cannot be reached with mechanical devices. Thermal therapy, which has been used since Hippocrates, has been revived with laser and radiofrequency applications. The thermal effect is protein denaturation at 40-70 degrees, coagulation at 70-85 degrees, vacuolization at 85-100, evaporation at 100 degrees, carbonization at 400 degrees. Living tissue begins to die at 45 degrees and 45 degrees is the temperature at which the RF effect has just begun. In order for the radiofrequency thermal effect to end with irreversible tissue contraction, energy must be transferred to create 60-75 degrees of heat. This effect occurs 30% in 5 minutes at 60 degrees, 36% at 62 degrees, and more than 50% after 65 degrees. With the thermal effect, the helix structure turns into a gel form with protein denaturation and reduces its volume, the tissue shortens and gives a morphological response. This effect is called "ablation" for short. The functional results of the thermal effect on regenerative tissues are close to perfect. While the capsule contributes to the healing process in ligament and tendinous structures, functional expectations during remodeling occur in the area limited by RF. However, cellular necrosis caused by thermal effect in structures such as cartilage and intervertebral disc is irreversible. For this reason, mechanisms that try to create the energy transfer created at high temperatures with monopolar electrocautery tips that provide coagulation and ablation effect together, with bipolar radiofrequency tips at low temperatures have been developed. For example, the ablative effect occurs with a spark, depending on the probe shape. Spatter-free energy transferred at monopolar tip shape or bipolar tips enables nonablative RF energy application. Bipolar effect providing coagulation and plasma forming ablative effect (nonablative) is coagulation + ablation = coblation. The difference of coblation effect from multipolar radiofrequency is that it provides plasma conversion at low temperature. In this way, it can be called cold ablation. Therefore, there are two different applications of radiofrequency: Monopolar Bipolar: Coblation-plasma effect-cold ablation Coblation is a breakthrough in intradiscal pressure reduction and nucleoplasty treatment, but gives good results in selected cases. Today, the effect created by the intradiscal ring in cervical disc protrusion has taken its place in the first place in the practical applications preferred by clinicians. In cervical coblation, vand provides 2 mm cavity formation and 10% volume reduction with an average application of 10 minutes in four directions (Figure-4C). Coblation-nucleoplasty effect is achieved by opening channels in the lumbar region. Opening an average of 6 channels with coblation may be sufficient to reduce the disc pressure (Figure-4A). The inability to remove the plasma-debris formed in radiofrequency nucleoplasty should be considered as a disadvantage compared to mechanical nucleoplasty, and intradiscal cefazolin should be added to the previous discography. Residual debris can cause discitis. Intradiscal Treatments: Laser treatment in protruse discs, which started with Choy and Asher's reduction of disc pressure by vaporization in the nucleus pulposus in 1986, was called “percutaneous laser disc decompression” (PLDD). Complications of endplate thermal necrosis, root injury, and discitis of the laser probe are statistically insignificant in multicenter studies up to a hundred thousand cases. Complications in applications with proper dosage and frequency parallel to the Endplate are almost non-existent in correctly selected cases. However, cases of tetraplegia after cervical application reported by authors such as Martin Knight still brought thermal penetration and radiation safety to the spinal cord into the agenda. PLDD is the transfer of 400-1000 joule Nd YAG laser energy into the disc in 10-30 minutes. In KTP laser, this time is 1-2 minutes. Using Richley Holmium, he transferred 1200-2000 joules of total energy, reporting 88% success. Neodymium has twice the ablation depth, thermal effect compared to Holmium. Excessive water absorption and removal of water from the environment increases the thermal effect and causes carbonization. The thermal effect, correct frequency selection and intermittent timing (relapse time) can be reduced. These parameters, which vary according to the wavelength, are 10-15 watts in Holmium YAG laser, and the repetition time of 10 hertz is 1200 joules in total. Casper recommends 1200j total energy using 13 Watt, 10 Hertz, 5 minutes of relapse and application time. Table-1 recommends the use of accepted doses after multi-center studies. Another residual debris disadvantage caused by thermal effect in intradiscal treatment has disappeared with the introduction of Laser Asisted Spine Endoscopy (LASE) (Figure-5). Annuloplasty was achieved with percutaneous intervention, which provided visual and irrigation as well as laser, and it was possible to remove the debris. Although the distance of laser energy to the annular region does not cause a problem during subannular decompression and annuloplasty in the lumbar region, the distance of 10 mm to the posterior longutinal ligament origin in cervical applications is the operation limit. Sang-Ho Lee et al. They suggest 10 watts max, 10-15 hertz max energy in the cervical area. The same safe range should be preferred in the lumbar region. The nonablative limit is the energy transfer that does not exceed 500 joules at a time with a frequency of 10 hz and the application with 5 sec intervals. Chiu recommends gradual energy application in thoracic disc laser application. It recommends starting with 10 watts in nonablative degrees, decreasing to 5 watts of energy and reducing the transferred power to 300 joules (12 hz). In the first stage, vaporization, in the second stage, only wrinkling and hardening are aimed. Sinovertebral neurolysis and denervation is evidenced by the patient's expression of pain reduction in the second stage. Chiu also recommends mechanically removing the debris and endoscopic control. Intradiscal applications of radiofrequency energy take its place in the market in a range from monopolar RF IDET energy to coblation probes. While subannular heat up to 85 degrees provides annuloplasty and nucleoplasty in IDET treatment, the thermal effect transferred to the tissue was measured as 55 degrees. At the epidural distance, this temperature reaches 30 degrees. Even if the patient is sclerotomal, the pain should be taken into account during the application and the energy should be cut off (Figure-4D). Coblation provides a safer nonthermal effect. Cervical application tips are particularly advantageous. The radiation effect of coblation, which works with mechanical-coblative principles by opening a canal in the lumbar region, is in the foreground. Both radiofrequency effects reduce disc pressure. Table 1: Different doses of laser energy applications according to spinal treatment options Percutaneous Endoscopic Applications Endoscopic laser applications that started in parallel with the definition of percutaneous endoscopic surgery by Hijikata and Kambin and continued with Yeung and Knight enabled the definition of the concept of foraminoplasty. The brutal surgical results of lateral spinal stenosis are inconspicuous in the face of endoscopic detection and elimination of formaninal stenosis. During foraminoplasty, the problem of removing structures such as bone-osteophytes was solved by the shock wave effect of the laser (Figure-7). The destructive effect obtained by the continuous application of 30-40 W 10 Hz energy directly on the bone is not only sufficient to provide decompression, but also eliminates the situations that prevent the appearance such as bleeding-debris formation. The use of radiofrequency energy in endoscopy provides great convenience in stopping epidural hemorrhages by the excision of the annular fibrils and the release of the nucleus fragment. Therefore, the use of both energies is preferred in endoscopic discectomy (Figure-6). In spine endoscopic surgery, the choice of laser or radiofrequency energy should be approached selectively. In intradiscal applications, the coblation method in cervical protrusions is safe and effective, and the same application can be performed, especially in asymmetric localized foraminal lumbar hernias, provided that protrusion is limited. Monopolar IDET application may be preferred in diffuse central and diffuse protrusions. However, laser nucleoplasty can be combined in painful discography. In this application, successful clinical results have been reported by eliminating the annular relaxation and providing pressure reduction with laser plasma effect in the nucleus. Mechanical nucleoplasty is recommended especially in cases with protrusion and minimal extrusion together with annular tears in the lumbar region. Lee et al. reported that they also removed the pressure secondary to plastic annular deformation by applying subannular LASE annuloplasty after mechanical nucleoplasty. In our country, it will be possible to reduce posterior pressure with LASE and selective annuloplasty in the near future. In endoscopic spine surgery, the bipolar RF probe provides great benefits in the excision of tissues holding the extrudate disc together with bleeding control. Cutting these tissues with mechanical tools is not preferred because it disrupts the field of vision with bleeding. On the other hand, after the disc is removed, the treatment is riveted by subannular RF application. During the subannular application of the laser, contralateral protrusion can be intervened as well as annuloplasty, but LASE should be preferred for its safety. In addition, LASE can be a serious alternative to mechanical nucleoplasty, as it allows debris to be removed. In foraminoplasty, the superiority of laser is indisputable in the decompression stage performed by removing osteophytes and cutting the foraminal ligament. Considering that foraminoscopic shaver tips offer limited options and cause bleeding, it is clear that laser application will continue to be an integral part of foraminoplasty. Resources: Abelow SP. Thermal Controversies. 11. Imlas 1. AAMISS meeting Lecture Kongre Özet Kitabı Seul Kore  12-15 Mayıs 2004 Atik OS,  Erdogan D,  Omeroglu S, Dural Mn, Baydar Metin L. Histological Alterations After Holmium:YAG Laser Irradiation. Joint Diseases & Related Surgery  Vol 10 • No 1 • 1999: 30-32 Atik O S, Kanatli U, Guzel V, Daglar B, Ozalay M. Lateral Release And    Medial Shrinkage On Patellofemoral Joint Capsule Using Arthroscopic Laser Surgery (Preliminary Report) Joint Diseases & Related Surgery Vol:9 No:1 1998 Atik OS. Chondroplaty Using the Holmium:YAG Laser. In B. E Gerber, M Knight WE Siebert (Eds) Lasers in the Musculoskeletal System. Springer Neuchatel 2000. Atik OS. Neodmium:YAG contact arthroscopic lase surgery. In Brillhar (Ed)  Arthroscopic Laser Surgery. Springer New York P 1994 Gerber BE. Basic Laser Principles and Research:Introductory Remarks. In B. E Gerber, M Knight WE Siebert (Eds) Lasers in the Musculoskeletal System. Springer Neuchatel 2000. Gerber BE, Knight MTN, Siebert WE. Preface. In B. E Gerber, M Knight WE Siebert (Eds) Lasers in the Musculoskeletal System. Springer Neuchatel 2000. Gerber BE, Basic Laser Principles and Research.  Laser In the Musculoskletal System Ed. Gerber, Knight, Siebert.Springer New YorImhoff AB, Basics Laser Physics and Safety. Laser In the Musculoskletal System Ed. Gerber, Knight, Siebert.Springer New York 200Gerber BE, Knşght MTN, Siebert WE. Preface. Recommeded Surgical Parameters. Laser In the Musculoskletal System Ed. Gerber, Knight, Siebert.SpriChiu J. Endoscopic Lumbar Foraminoplasty.Endoscopic Lumbar Foraminoplasty Chapter 19 Chiu JC. Posterior Lateral Endoscopic Thorasic Discectomy with Laser Thermodiskoplasty. 11. Imlas 1. AAMISS meeting Lecture Kongre Özet Kitabı Seul Kore  12-15 Mayıs 2004 Chiu JC, Clifford TJ, Reuter MW. Cervical Endoscopic Discectomy with Laser Thermodiskoplasty. In The Practice of Minimally Invasive Spinal Tecnique Ed. Savitz MH, Chiu JC, Yeung AT. CSS first edition Ohio 2000 Choy DSJ. Percutaneous Laser Disc Decompression. In  Percutaneous Laser Disc Decompression.Ed Daniel Choy Springer New York 2003 Choy DSJ.  Percutaneous Laser Disc Decompression (PLDD) 352 Cases with an 8 ½ Follow up Arthroplasty Arthroscopic Surgery Vol. 6, No:10 (1-5), 1995 Lee SH. Percutaneous Lumbar Disc Decompression (PLDD) with Laser Assisted Endoscopy (LASE). 11. Imlas 1. AAMISS meeting Lecture Kongre Özet Kitabı Seul Kore  12-15 Mayıs 2004 Reuter MW.Evaluation of Cervical Disc Surgery. 11. Imlas 1. AAMISS meeting Lecture Kongre Özet Kitabı Seul Kore  12-15 Mayıs 2004 Şatana T, Ergüven M, Pirbudak L. Lomber Dejeneratif Stenoz ve Dejenere Disk Hastalığına Cerrahi Yaklaşım. Aktüel Tıp Artrit ve Osteoporoz Özel Sayısı Nisan 2004 Cilt9 Sayi4 S:39-46 Şatana T, Ergüven M, Pirbudak L, Aldemir Ö. Dejeneratif Disk hastalıklarında Perkutan Endoskopik Dekompresyon ve Minimal İnvaziv Cerrahi Yaklaşımlar. Aktüel Tıp Artrit ve Osteoporoz Özel Sayısı Nisan 2005 S:35-41 Şatana T. Current Concepts in the Laser&Radiofrequency  Technologies for Minimally Invasive Musculoskletal Applications.12 Imlas 2. AAMISS meeting Lecture Kongre Özet Kitabı Istanbul  22-25 Haziran 2005Gerber BE, Basic Laser Principles and Research.  Laser In the Musculoskletal System Ed. Gerber, Knight, Siebert.Springer New YorImhoff AB, Basics Laser Physics and Safety. Laser In the Musculoskletal System Ed. Gerber, Knight, Siebert.Springer New York 200Gerber BE, Knşght MTN, Siebert WE. Preface. Recommeded Surgical Parameters. Laser In the Musculoskletal System Ed. Gerber, Knight, Siebert.SpriChiu J. Endoscopic Lumbar Foraminoplasty.Endoscopic Lumbar Foraminoplasty Chapter 19 Yeung AT, Tsou PM. Posterolateral Endoscopic Excision for Lumbar Disc Herniation Surgical Technique, Outcome, and Complications in 307 Consecutive Case SPINE Volume 27, Number 7, p 722–731 2002 Park J. Pitfalls and Complications of Thermal Capsuloraphy. 11. Imlas 1. AAMISS meeting Lecture Kongre Özet Kitabı Seul Kore  12-15 Mayıs 2004

You can find all the information about UBE Spine Surgery in the treatment of Low Back Pain, Spine Pain and Canal Stenosis (Unilateral Biportal Endoscopic) in this article. (Unilateral Biportal Endoscopic) What is UBE Spine Surgery? Unilateral Biportal Endoscopy (UBE) is an arthroscopic approach to the spine. All operations performed in open surgery performed with a microscope can be performed through two 1 cm holes. Muscle and tissue are not cut, bleeding is less than a teaspoon. The entire surgery is recorded on video like arthroscopy and it is a less invasive surgery that provides 30 times tissue augmentation. In Which Situations Is It Preferred? It is very effective in central canal stenosis, large disc fragments occupying the central canal, facet joint cysts, screw and implant placement with endoscopy. It can be applied to all age groups. How Is It Applied Under Anesthesia? It may be general anesthesia or epidural anesthesia. How Long Does Unilateral Biportal Endoscopy (UBE) Take? (Unilateral Biportal Endoscopy) UBE Spine Surgery takes approximately 1 hour. What is the Recovery Process After the Surgery? Since the muscles and ligaments are not cut in the surgical incision, it is faster than open and microscopic surgery. Does Discomfort Recur After Surgery? The recurrence rate is not different from open surgery. How Much is the Surgery Fee? Pricing is made according to the hospital class determined according to the patient's budget.

Before giving information about Wrist Arthroscopy Treatment, let's answer the question "What is Wrist Arthroscopy Surgery". It is an endoscopic examination of the wrist. Intra-articular ligament structures are the gold standard for imaging problems such as Triangular cartilage, which are very difficult to visualize and diagnose on MRI. It has become indispensable with increasingly widespread special equipment. In Which Situations Is Wrist Arthroscopy Preferred? It is preferred in all arthroscopic thinning in ligament repairs, from the removal of wrist ganglion cysts to the reduction and fixation of intra-articular cartilages. It is even effective in repairing intra-capsular ligaments, which are considered unmanned areas in open surgery, such as scapholunate instability. Triangular fibrocartilage problems are the gold standard in ruptured abutment syndrome How Long Does Arthroscopy Surgery Take? The operation is completed in approximately 30-60 minutes. What Should the Patient Do Before Wrist Arthroscopy? All necessary information is given to the patient before the operation. What is the Recovery Process After the Surgery? Joint movement is given immediately, splint fixation can be done for 3-6 weeks, depending on intra-articular repair situations. Will It Repeat After Surgery? Treatments and recovery will not recur after completion unless there is new trauma. How Much is the Surgery Fee? It is arranged according to the patient's budget.

Spinal degeneration is the result of primary or secondary spondylo-arthritis and disc degeneration (1). Although there are some who associate the onset of degeneration involving the intervertebral disc and facet joints with facet joint arthritis, the general belief is that it occurs as a result of disc degeneration (1,2). The disc structure begins to degenerate in the third decade, water loss occurs in the nucleus pulposus, the disc height decreases with annular tears, the facet joint distance is prolonged, the spine becomes prone to abnormal movement and instability as a result of ligament laxity and becomes open to trauma. With the addition of inflammatory factors to recurrent traumas, cartilage becomes thinner, annular tears grow, facet joint synovitis occurs, cartilage goes to destruction and osteophytes develop. Posterior movement of the disc structures causes narrowing of the spinal canal, hypertrophy develops in the facet joints, and the ligamentum thickens. Result; It is degenerative stenosis (1-3). Disc degeneration Intervertebral disc, which is one of the main reasons for the onset of spinal degeneration, has an avascular structure. It consists of chondrocyte and fibroblast-like cells within the extracellular matrix. Disk; It includes two main regions: nucleus pulposus (NP) and Annulus Fibrosis (AF). While chondroblasts and type-2 collagen are mostly organized in the gelatinous structure of the NP in the inner region of the disc, the basic structure of AF in the lamellar structure is mostly composed of fibroblasts surrounded by type-1 collagen. It synthesizes the appropriate matrix in which both cell groups are located. In the lower and upper parts of the disc (endplate); There are chondrocyte cells that synthesize hyaline cartilage surrounded by a thin cortical bone (1). Disc degeneration is characterized by NP dehydration along with AF rupture and clefts in the endplate area that can turn into fractures. With annulus degeneration, collagen loses its fibril organization and undergoes myxomatous degeneration. The number of lamellae increases, cell distribution deteriorates, and clusters occur. While NP loses water, it loses its height, cavities form and expand posterolaterally. Endplate degeneration progresses with subchondral sclerosis and calcification in the hyaline cartilage. All this causes the disc to become thinner, to lose its elasticity, and to not be able to distinguish between the nucleus and annular region. Disc hernias with the nucleus remaining in the annular ligament (Contained-NP containing) and material protruding out of the disc (noncontained-NP content) It can be divided into. Annular tears are often very large in an uncontrolled hernia. Degeneration is at an advanced stage (1). At the cellular level, disc degeneration begins with increased cellular mating and groupings in the NP region. The distribution of the basic proteins of the cytoskeleton, Actin and Vimentin, is disturbed. The cell loses its shape. Gap connections are reduced with connexins 43 and 45, which provide intercellular connection. In addition to all these mechanical reasons, nutrient and oxygen diffusion in cells is metabolically reduced (1). Diffusion occurs through the posterior and anterior vertebral vessels. Factors such as enplate calcification, narrowing of the lamina cribrosa pores and decreased local blood flow reduce diffusion. Matrix synthesis is disrupted by increasing the amount of lactate by anaerobic metabolism. Martrix degradation increases and gradient molecules accumulate. With the addition of genetic, systemic factors and smoking, necrosis increases, NP becomes hyalinized, the annulus weakens with disorganization, proteoglycan distribution will change, and water retention decreases (1). Matrix proteins undergo changes in the degenerated disc. Proteoglycans provide the viscoelastic structure by holding water and increase the tensile-compressive strength of the disc. Chondroitin sulfate and keratan sulphate are predominant proteoglycan, they aggregate by binding to hyaluronate molecules. Aggrecan, the largest aggregate molecule, is mostly found in AF. Versican, decorin, biglycan, fibromodulin and lumican, which are more in the fetal disc, are also available. Link proteins stabilize proteogiers as glycoproteins. Chondroitin sulfate synthesis is disrupted by degeneration, leaving its place to keratan sulphate. This leads to a decrease in water retention in the NP structure and deterioration of the gel consistency. In addition, water depletion reduces diffusion at the molecular level. Collagen and matrix connections provide the mechanical strength and stability of the disc. Collagen Type 2 increases resistance to compressive forces. This stability, which is protected by cross-links, is disrupted by the replacement of types 1, 2, 3 and 5 collagen by degeneration, by type 1, 4 and X In advanced levels of degeneration, anaerobic respiratory cross-links are disrupted and stability is removed. Fibronectin osteoarthritis is a glycoprotein containing collagen-glycoprotein-integrin and membrane protein binding points with increased itte release. In recent years, it has been found that while decreasing proteoglycan synthesis in NP in degenerate disc, it increases proteoglycan synthesis with an adverse effect in AF and its release is high in annulus repair. It has been observed that fibronectin fragments inhibit chondrocyte-derived aggrecan production and increase metalloproteinases responsible for cartilage breakdown. A link between polymorphism in the Aggrecan gene and disc degeneration has been determined. Sequence differences in protein chains are held responsible in degenerate discs. Chondromodulin-1 (ChM-I) is thought to have a role in chondroprotective effect by preventing vascularization and fibrosis change in early degeneration of the disc. This molecule is secreted during the gestational period, the growth plate due to cartilage provides the development of chondrocytes. It is thought to be secreted also in mature NP and AF cells. Inflammatory such as nitric oxide (NO), interleukin-1B (IL-1)., Interleukin-6 (IL-6)., Tumor necrosis factor alpha (TNF-oc)., Prostaglandin E2 (PGE2)., Matrix metalloproteinase (MMP) Other tissues are also affected by the spontaneous increase of mediators in disc cells. Proteoglycan synthesis is inhibited in joint cartilage. Cartilage degradation begins with the increase in IL1. While MMP increases this degradation, exogenous NO, IL-6 and PG-E2 increase inflammation. Phospholipase activation by migration of CD68 cells during neovascularization is the main cause of pain and destruction at this stage. This mechanism may explain the inflammatory mechanism of disc-induced facet joint degeneration (1). Mechanical effects in disc degeneration cause endplate damage, increased intra-disc hydrostatic pressure to increase NO amount and decrease proteoglycan synthesis and decrease water retention. Vibration reduces the amount of intracellular aggrecan. The related increase in MMP-1 causes matrix degradation. In addition, vibration disrupts ATP controlled flow in Ca channels. Result; disruption of cell nutrition, reduction of martyx production, degradation and degeneration (1). Externally, the effect of growth factors on degeneration has been demonstrated. These effects are of varying intensity at different stages from apoptosis to matrix organization. The presence of LacZ and Luciferase markings in degenerated discs has shown that genetic transition in degeneration can occur regardless of age and gender. It is claimed that gene transfers with adenoviruses may eliminate the genetic factors, perhaps the main cause, of disc degeneration in the future. Masuda et al, recombinant human osteogenic protein-1 (rHOP-1) increased cell and matrix proteoglycan synthesis on the radar with its mitogenic effect. Because of the similar effects of growth factors, they may be used in treatment (1). In short, disc degeneration develops due to extrinsic, intrinsic and genetic reasons. Deciding the stage of this condition resulting in stenosis in the spinal functional subunit should constitute the main framework in determining treatment options. Pathological anatomy of the lumbar degenerated spine Spinal canal stenosis may develop in the central, lateral dead-end and pedicular regions in the coronal plane (Figure 1). Figure 1: Schematization of the anatomical localizations of degenerative stenosis. While lateral stenosis is classified as subarticular, foraminal and extraforaminal, central stenosis may occur at the pedicular disc and intermediate levels. (Inspired by Kuslich (27)). In the sagittal plane, narrowing may be at pedicular, intermediate and disc levels (3,4). Lateral stenosis; It can occur in three stages, including the entrance of the spinal nerve to the foramen (subarticular), foramen and exit (extraforaminal). The first part described is the most cephalic located, superior articular facet medial and inferior location. It has only anterior and posterior osseous wall. Medial and lateral are normally open. The middle part contains the foramen, under the pars interarticularis of the lamina and the pedicle. The anterior wall forms the vertebral body. Pars interarticularis makes the posterior wall, pedicle lateral wall. The medial wall opens into the spinal canal and is normally open. The exit part is surrounded by the intervertebral foramen. The disc is located in the anterior, and the lower part of the facet joint is located laterally. (3-5). Anatomical classification of the degenerative spine made the therapeutic classification necessary with the growing need for planning treatment. Hansraj stenosis; It handles in two parts as simple or typical and complex. In the typical definition of stenosis, cases without instability or with first-degree spondylolisthesis and scoliosis of less than 20 degrees are understood. These patients often only benefit from decompression therapy. Complicated cases may need to be combined with decompression therapy, as well as fusion and instrumentation (5,6). Clinic It usually becomes symptomatic in older ages. It is more common in women. L3-4, L4-5 levels are the most frequently affected segments. Cervical involvement is detected in 5% of the patients (2). Patients describe hip, thigh, leg, foot pain along with back and waist pain. Bilaterate involvement is common. Neurological claudication, increased pain when walking and standing, decreased pain when lying down and extending the legs, and increased pain with concussion are typical. Posture is slightly flexed. With the increase in pain, functional capacity gradually decreases and walking distance becomes shorter. Daily business starts to disrupt. Pain can be questioned with various scales. Visual analog pain grading system VAPS is one of the most widely accepted scales (7). Work disability can be scored by the work disability score (WL-26). Under the Deyo core set title, he gathered the interrogation suggestions targeting spinal diseases in six groups and created a useful system. In recent years, the numerical expression of the impact on functional capacity in spinal diseases can be made using disability scoring systems such as Oswestry. Scores such as SF-36 that question general health status are useful before surgery (6,7). These applications should be queries that the patient can easily understand. Roland disability questionnaire, which has been translated into Turkish and its validity has been determined statistically, is a specific and sensitive test for low back pain (8). The need for analgesics and response to analgesics should be recorded. This can give an idea about the degree of stenosis. Bladder functions must be questioned. Flattening, paravertebral spasm, increased pain with movement and decreased range of motion in extension can often be detected in lumbar lordosis. Flexion width has decreased but is accompanied by pain. The straight leg raising test is usually negative. Decrease in motor power can be detected in provocative tests. Although sensory impairment can sometimes be selective in the relevant dermatome, it is generally not sensitive because minor sensory changes are expected at these ages (6-9). Diagnosis Radiologically, disc space reduction, osteophytes, facet hypertrophy are pathognomonic. The defect in the pars interarticularis should be noted in terms of spondylolysis and narrowing of the pedicle spaces in terms of congenital stenosis. The borders of the foramina should be examined, the hypertrophy of the facet joints and the relationship of osteophytes on the wing should be evaluated. must. The presence of scoliosis, kyphosis, hyperlordosis, sacralization and lumbalizations that disrupt the spine mechanics should be questioned in flexion-extension and standing dynamic radiographs. It is involved in the etiology of foraminal stenosis of a fibrocartilage-like structure in spondylolysis. Listesis rate should be graded by standard indicators. The psoas shadow and the robustness of the pedicles should be noted (9,10). Tomographic evaluation maintains its importance in understanding osteophyte organization. Lateral dead-end and foraminal structures limited by bony structures can be clearly evaluated. Magnetic resonance imaging (MRI) has greatly reduced tomography and myelographic examinations. With MRI, the channel relationship of disc structures, intradiscal pathologies and fibrous tissues that cause foraminal stenosis can be evaluated better. MRI is the most sensitive evaluation method in disc degeneration. However, CT-myelogram is as valuable as MRI for preoperative planning in cases with metal implants and MRI application is contraindicated (5,9-11). In laboratory tests, neuroflament specific to nerve injury and proteins such as 5-100 have been shown to increase in the cerebrospinal fluid (CSF) and blood. It was found that the amount of total protein, albumin, IgG, IL-8 increased in CSF and the amount of ApoE increased in both CSF and plasma (5). Discography is the most effective diagnostic method that enables a dynamic decision to clarify the disc pathology and to plan the treatment. Discography provides the clinical relationship of the location of the annular tear and point targeting convenience in the treatment of complicated radicular symptoms. Anesthetic agent and steroid injection into the disc can provide therapeutic effect and assist the physician in differential diagnosis. White and Pancabi measured the disc pressure and showed the effects of pathological loads on the disc. Disc pressure dynamic measurement can be used as a reference in elucidating mechanical problems. The objective contribution of the EMG test, which is the most commonly used electrodiagnostic test, is indisputable. It fully reveals the radicular level of the lesion. Working with evoked sensory potentials is more sensitive. Electrodiagnostic tests do not show the decompression or treatment site. However, the surgical intervention area should be decided by comparing it with other diagnostic tests. The perop must be repeated to confirm the diagnostic discography intervention site. Selective root blocks can be used to separate the cause of pain in multi-segment stenosis (5,9-12). The diagnostic algorithm guides in planning treatment. The flow chart should primarily separate low back pain and non-mechanical pain due to medical diseases. Conservative treatment and pain that does not respond to rest necessitate re-initiation of differential diagnostic steps. Differential diagnosis Disc hernias should be evaluated very well in differential diagnosis. Usually in the stenotic degenerated spine the disc shows a slight overflow. Symptoms should not be attributed to disc disease and limited to discectomy or medical therapy. The medical evaluation flow chart that separates medical and non-mechanical low back pain should be followed carefully (9). If cauda equina syndrome develops acutely, extensive disc herniation may be considered. Spinal cord tumors, primary and metastatic bone tumors, infections and fractures should be considered in the differential diagnosis (2). It is the vascular claudication, which is the most clinically involved condition. This type of pain increases with walking, in contrast to stenosis, when lying down, and decreases when standing. A careful vascular examination makes diagnosis easier. EMG is required for differential diagnosis in patients with diabetic neuropathy (2). Treatment Anti-inflammatory therapy is the first step in degenerative lumbago. Treatment for reflex muscle spasm supported by muscle relaxants can be combined with physical therapy. In resistant cases, epidural steroids and anesthetics may facilitate transition to functional therapies (13,14). Combinations of gababentin or amiltriptyline give significant results in cases where epidural injection is applied (13). Successful results of calcitonin use in degenerative luminopia have been reported (10). Cases who do not respond conservatively, have neurological dysfunction (bladder, radicular motor deficit, etc.), and whose functional disability is found to be low, may be referred to surgical treatment. Surgery should reduce pain, increase mobility and prevent neurological deficit. Adequate decompression and preservation of joint and pedicle structures to ensure stability are the basis of treatment. Today's surgery can be summarized as maintaining anatomical integrity, providing decompression and avoiding fusion as much as possible. Minimally invasive procedures meet these needs with increasingly developing techniques. Strictures that can be treated with wide bone resections with percutaneous surgeries and scopic interventions can be easily reached, vital vascular nerve structures Decompression and fusion can be applied through. Open surgical decompression operations were performed under spinal anesthesia, reducing pulmonary complications. However, the occurrence of conditions that will increase the possible CSF pressure (coughing, etc.) may lead to large and difficult dural tears (11). Surgical treatment: 1. The location of the stenosis, 2. the number of involved segments, 3. stability, 4. degenerative spondylolisthesis, 5. previous surgical treatments, recurrence and iatrogenic reasons, and 6. accompanying scoliosis and kyphosis are regulated by evaluating parameters. Surgical treatment flow chart is summarized in Figure 2 (11). Non-fusion techniques and disc surgery Disc degeneration and reduced disc height are the main causes of spinal degeneration. Maintaining the disc height before facet joint involvement occurs can prevent lumbar degeneration. It is possible to reduce disc damage and pain due to injury by repairing the damage. Various treatment methods are used for the annulus and nucleus (15,16). The first attempt to target the nucleus in disc surgery was performed in 1963 by Lyman W. Smith with kimopapain injection. After the injection of chymopapain into the nucleus, it decomposes the proteoglycans contained in the nucleus, decreasing its volume and providing decompression. However, it has a damaging effect on neural tissues. Deaths due to transverse myelitis, paraplegia, and anaphylactic shock have been reported (11,15). Techniques targeting the nucleus in disc herniations containing nuclei can be grouped under the heading Nucleoplasty. In the early 1990s, laser discectomy and nucleotomy, which were popular with local anesthesia, became one of the safe and effective treatments with a short rehabilitation period (17). Using similar equipment and energy in annuloplasty, this time it was aimed to evaporate the nucleus water content. In this way, the pressure in the posterior annulus is reduced. It is necessary to be more selective than annuloplasty in patient selection. Arthrocare Perc-D Coblation device, one of the options in nucleoplasty, vaporizes the nucleus with bipolar radioenergy by mechanically giving localized energy. Approximately six channels are opened to the nucleus to provide decompression. The nucleus turns into plasma form with its water content and is taken out of the cannula (17-20). The use of thermal energy in nucleus decompression has been provided by radiowave Radionics probes. In short, in the treatment referred to as PIRFT, the heat effect of the energy is utilized. Unlike annuloplasty in nucleoplasty, the temperature reaches 70-80 degrees. The contribution of this energy to annular denervation is controversial and the pain reduction mechanism has not been explained yet (17,19). In laser nucleoplasty technique, the evaporation effect of energy and the heat effect are reflected on the nucleus as ° rent. The nucleus is broken down by laser energy. Intradiscal electrothermal therapy (IDET) is a treatment intervention for annulus. It is referred to as "annuloplasty" as it is aimed to treat annulus rupture in this way. In 1997, Saal and Saal treated the tears in annular defects with the help of thermal wire. The basis of treatment should be stabilized collagen fibrils as in arthroscopic capsulography. Thermal effect can be obtained from electrothermal, radio wave or laser energies. Symptoms regress with thermal effect, collagen stabilization and annulus denervation. When 42 ° C is exceeded in heat therapy, neural structures are damaged (17). "The narrowing of the disc space is the beginning of the process in the degenerative spine." his discourse has revealed his materials replacing the disc. Facet instability, foraminal narrowing and subsequent degenerative conditions are secondary to narrowing of the disc space. Artificial nucleus replacements Artificial Nucleus Replacement (ANR) have been tried to regain this distance. Injection of polymethylmethacrylate and silicone materials into the nucleus cavity resulted in disappointment. The metal nucleus results he described Fernstrom in 1966 are still controversial. It has been observed that reactive bone formation and resorption continue in the silicon-dacron composite implant in Urbaniak chimpanzees. The ideal material described by Edeland in 1981 should have vital functions such as water permeability as well as nucleus-like skin-sil responses. A nucleus-like effect was created by using hygroscopic thixotropic gel such as hyaluronic acid with high molecular weight polyethylene fiber encapsulated impregnated with ray and gobbin polymeric material. The cadaver biomechanical studies of the horseshoe shaped lumbar intervertebral disc prosthesis (LIDP) implanted by Hou et al anterior paramedian retroperitoneal intervention have been completed. The elastomer reinforced polyurethane nucleus modified by Sulzer Spine-tech company, the Hydrogel nucleus developed by Rao and Higham in 1991 that can be sent from the 5 mm cannula, and finally the Ray modification (Prosthetic Disc Nucleus PDN), which includes a hydrogel polyethylene sheath. Its main purpose is to provide physiological response of the nucleus to the loads, as well as the disc height. The most important technical problem in disc prostheses is the sizing difficulty. If the disc prosthesis is smaller or larger than normal, it will cause problems (17,19). Decompressive attempts It is planned according to the development area of ​​the stenosis. The aim is to eliminate the pressure without disturbing the stability of the spine. Interventions that will create instability should be determined by fusion applications (Figure-2). Central canal stenosis: The stenotic segment is treated with decompressive lumbar laminectomy. Decompression starting from the maximum constriction zone should be extended caudally and cephalicly. Instability should be prevented by protecting the medial facet joint. Decompression is terminated by making sure that the nerve root is relaxed. If there is any sensation in the dura, superior facet medial can be included in the excision (4,10,11,16,18,20). In lateral canal stenosis, the nerve root can be treated with unilateral laminotomy. Stenosis at the entrance requires medial facetectomy. Facetectomy should be sufficient to provide 1 cm medialization of the nerve. In the stenosis of the middle part, the dorsal root is under pressure. Decompression can be performed by performing total facetectomy to include the pars area. Fusion and instrumentation are required to ensure stability. Hypertrophic facet welding in the exit section! ' There is compression of osteophytes and osteophytic margins around the disc. The Witse paraspinal approach is used for decompression of this area with open techniques. The area is reached with transverse protrusion excision. The success and patient satisfaction of minimally invasive techniques such as foraminoscopy is higher. Mr Knight et al. Provides fusion decompression in minimally invasive foraminoscopic decompression treatments. (4,10,11,16,18,20). Knight et al. It reports successful results by applying annuloplasty and nucleoplasty in the same session as well as decompression with the combined use of laser and radiowave energies (12). Multiple laminotomies can be performed at multiple levels in mild to moderate stenosis, preserving structures such as Spinoz protrusion in the midline. Expansive Lumbar Laminoplasty provides decompression by preserving the technical stability applied for the first time by Tsuji et al. (11). In distraction laminoplasty, the lumbar canal is decompressed by preserving the maximum bone. The medial facet and inner regions of the lamina are removed with the aid of distraction instruments (11). Distraction devices such as spinous protrusion x-stop and PEEK reduce compression in the area of ​​constriction caused by the ligamentum flavum by indirect decompression. It can be applied under local anesthesia (11). Dynamic intervertebral disc prostheses are a developing technique as an alternative to fusion from non-fusion techniques. Since Edeland, there are disc prostheses anchored to the bone, designed either constrained or nonconstrained, such as total joint prostheses that allow movement. The main purpose of these implants, whose validity is discussed with animal and biomechanical experiments such as the caustic design, is to protect the spine motion by preserving the disc height (21). Fusion surgeries These are interventions that maintain stability by providing arthrodesis. It is applied in posterior instrumentation, pedicle screw fixation, wide decompression causing instability and multi-level laminectomies. It is used to provide a corrective effect and prevent progression in the presence of spondylolisthesis and mechanically impaired spine such as scoliosis. Distraction and alignment correction after extensive decompression may contribute to decompression. Arthrodesis reduces pain and prevents progression. Since the fusion will be achieved by rigid fixation, it can be combined between the posterior elements as well as the vertebral bodies. The necessity of the integration is to ensure fusion and maintain the stability until fusion. Various studies comparing pseudoarthrosis rates advocate that pedicle screw fixation should leave its place to selective fusion other than spondylolisthesis, scoliosis and multi-segment decompression (2-4,10,11,22). Interbody fusion It can be applied posteriorly or anteriorly. It provides selective fusion opportunity. Apart from open surgery, it can be applied scocopically (10,11,22). In addition to being popular especially in scopic decompression surgeries that require fusion, it has become one of the indispensable techniques combined with posterior applications with wide decompression. Lumbar interbody fusion (LIF) technique, which has developed rapidly since Cloward (1950), can be applied to the posterior and anterior. Posterior LIF is classified according to the entrance corridor: Paramedian intervention (PLIF), transforaminal intervention (TL1F) (23). Both techniques can be applied as percutaneous, minimally invasive or open (4,22,24,25). Implant; It is a titanium cylinder with a cancellous-like structure like the Bagly and Kuslich design (BAK), which is called cage (4). Transforaminal application with grade 1-2 spondylolisthesis neurolo It is the ideal treatment option in cases without jik deficits (25). Provides disc height in the foraminal area and reduces foraminal stenosis. Anterior LIF can be performed transperitoneally or paramedian retroperitoneally or laparoscopically (26-29). AL1F scope application is advantageous compared to PLIF applications in terms of not causing dural damage. While PLIF allows decompression and fusion together, the dura and nerve damage risk is higher. Like posterior applications, ALIF restores disc height and provides decompression in the formaninal region following discectomy, but it is considered as a disadvantage that facet nipertrophy and osteophyte organizations do not 'eliminate' (27): Result Back pain is resolved despite treatment at the rate of ° / 087. Any treatment that starts without defining the stage of the pathology may increase the symptoms of the patient. Therefore, physiopathological staging should be done very well. Decompressive attempts to cause instability in a stable spine may cause the symptoms to worsen. Fusion surgery can also reduce patient satisfaction when not performed on site. The limits of minimally invasive interventions are clear. In cases that require extensive decompression, traditional surgical methods should not be avoided (30). After making sure that the degenerative spine is responsible for pain and dysfunction, the degree of lumbar degeneration and disc pathology should be established. Degeneration is a progressive process but can be slowed down. Conservatively or surgically recovered healthy disc distance will delay stenotic spine disease. Stenosis surgery has now been demonstrated with its clear benefits and harms. The current approach should be to discuss conservative, genetic, and surgical, especially minimal invasive techniques that preserve disc distance before degeneration begins. Current Medical Journal (April 2004-Volume 9 Issue: 4) Resources Chung SA, Khan SN, Diwan AD. The molecular basis of intervertebral disk degeneration. Orthop Clin N Am 2003;34: 209-19. Whiffen JR, Neuwirth MG. Spinal stenosis in Spinal surgery. Ed Bridwell KH, DeWald RL. Vol 2 (25). Lippincott Co Philadelphia; 1991,S:637-656. White AA, Pamjabi MM. Clinical Biomechanics of the spine. Part 4 349-362 Lippincott Co Philadelphia; 1990 Kuslich SD. Lumbar degenerative disc disease-axial back pain Posterior In Vaccaro AR, Albert T] ed. Master Cases Spine Surgery. Thieme NewYork; 2001, 5:93-99. Brisby H. Nerve root injuries in patients with chronic low back pain. Orthop Clin N Am. 2003;34: 221-30. Boden SD. Outcome assesment after spinal fusion. Orthop Clin N Am. 1998;29(4).: 717-28. Schaufele MK, Boden SD. Outcome research in patients with chronic low back pain. Orthop Clin N Am. 2003;34: 231-7. Küçükdeveci AA, Tennant A, Elhan AH, Niyazoglu H. Validation of the Turkish Version of the Roland-Morris Disability Questionnaire for Use in Low Back Pain. Spine 2001; 26(24)., 2738h- McCowin PR, Borenstein D, Wiesel SW. The Current Approach to the Medical Diagnosis of Low Back Pain. Orthop Clin N Am. 1991;22 (2). 315-25. Spivak MJ. Degerenative Lumbar Spinal Stenosis. (Current Concepts Review).. J Bone Joint Surg . 1998; 80-A Sengupta DK, Herkowitz HN. Lumbar spinal stenosis treatment strate­gies and indications surgery. Orthop Clin N Arn. 2003;34: 281-95. Knight M, Goswami A. Management of isthmic spondylolisthesis with posterolateral endoscopic forarninar decompression. Spine 2003;15; 28(6).: 573-81. Pirbudak L, Karakurum G, Satana T, Karadasli H, Topalhan M, Oner U, Gulec A. Epidural Steroid Injection and Amitriptyline in The Management of Acute Low Back Pain Originating frorn Lumbar Disc Her­niation. Arthroplasty Arthroscopic Surgery 2003;14(2).:89-93. Freedman MK. Axial low back pain. Nonoperative approach. In Vac­caro AR, Albert TJ ed. Master Cases Spine Surgery Thieme NewYork; 2001,5:78-83. Herkowitz Current status of percutaneous discectomy and chemonucleolysis. Orthop Clin N Ara 1991;22(2). 327-32. Hasea RJ. Lumbar spinal stenosis:surgical considerations. J South Ort­hop Assoc 2002 11(3). 127-34. Sagi HC, Bao QB, Yuan HA. Nucrear Repracement Strategies. Orthop Clin N Am 2003;34: 263-67. Kwon BK, Vaccaro AR, Grauer JN, Beiner J. Indications, techniques and outcomes of posterior surgery for chronic low back pain. Orthop N Anı 2003;34:297-308. Davis TT, Sra P, Furier N, Bae H. Lumbar intervertebral thermat ther­ Orthop Clin Am 2003;34:255-62. McCuiloch JA. Lumbar spinal stenosis without instability. in Vaccaro AR, Albert TJ ed. Master Cases Spine Surgery Thieme NewYork; 2001,S:100-8 Kostuik JP. Alternatives to spinal fusion. Orthop Ciin N Am 1998;29(4).: 701-14. Brislin B, Vaccaro AR. Advances in posterior lumbar interbody fusion. Orthop Clin N Am 2002;33: 367-74. Moskowitz A. Transforaminal lumbar interbody fusion. Orthop Clin N Am 2002;33:359-66. Mathews HH. Percutaneous interbody fusions. Orthop Clin N Am 1998;29(4).: 647-63. Moskovitz PA. Minimal invasive posterolateral lumbar arthrodesis. Orthop Clin Am 1998;29(4). 665-78. Burkus (K. Intervertebral Fixation: CIinical results with anterior cages. Orthop Clin N Am 2002; 33: 349-57. Kuslich SD. Lumbar Degenerative disc disease-axial back pain an­terior approach. In Vaccaro AR, Albert T] ed. Master Cases Spine Surgery Thieme NewYork; 2001,85-92 Silcox III HD. Laparoscopic bone dowel fusions of the lumbar spine. Orthop Clin N Am 1998; 29(4).: 665-693. Zdeblick TA. Laparoscopic spinal fusion. Orthop Clin N Am 1998;29 (4). 635-45. Diwan AD, Parvartaneni H, Cammisa F. Faifed degenerative lumbar spine surgery. Orthop Clin N Am 2003;34: 309-324.

What is Stromal Vascular Fraction (SVF)? He knows that the cells obtained after liposuction (lipoaspirate), which is popularly known as a stem cell source, have rejuvenating (regenerative) properties. A cellular product SVF obtained by the isolation of these cells does not only contain fat cells. It is the direct application of the 100 cc fat layer taken from the patient or following the liposuction operation immediately to the patient. Adipose tissue does not cause tissue rejection in autologous use. In this respect, it is an easily accessible cellular regeneration product. The difference from PRP obtained from blood is that it contains cells that are not yet differentiated from the main cell, but differentiated from the mesenchymal stem cell of the bone marrow cell and capable of transforming into any connective tissue. In this respect, although not as much as stem cells, it contains cells that are more prone to direct transformation into fiborsite in the joint, forming cartilage-like tissue. It is not possible for SVF cells to turn into phantom cartilage cells. The cartilage cell can only be produced from the main stem cell under laboratory conditions with special stimulants. Such laboratories cannot operate without a government permit, and yet there are very few centers of this nature working on an experimental, legal basis. In this respect, SVF is not a form of stem cell treatment like PRP.

A fracture is when a bone is injured by overload or high-energy impacts and loses its integrity. Great forces are required to break the bone except for reasons such as diseases that reduce its strength (Osteoporosis, Osteogenesis imperfecta, cancers and cysts). Fractures caused by the weakening of the bone with diseases are defined as “pathological fractures”. Long and flat bones respond differently to external forces and are injured differently. Long bones are most resistant to loads in the longitudinal direction of transport. Its bending strength is relatively low, but it is weak against shear forces. Although flat bones are more resistant to shear forces, they do not show resistance like long bones during carrying and bending. Fractures; It can be simple (one-piece), segmental and multi-part. If the fracture line comes into contact with the external environment together with skin injury, it is defined as an open fracture. Open fractures are graded according to the size of the wound and the type of contamination. The dirtiest and most difficult-to-treat injuries were reported as agro-manure-related open fractures. In penetrating-explosive injuries such as high-energy or firearms, sudden loads in all three directions cause comminuted fractures. The type of fracture is important in planning the treatment. Simple fractures can be corrected mostly by manual correction (closed reduction) and with plaster-wrap fixation after the fracture ends meet. In cases where the fracture ends cannot be brought together, which prevents the union, the fracture ends are surgically combined and fixed in various ways. If there is a dirty wound in open fractures, surgical cleaning and surgical treatment may come to the fore. Types of Fracture Treatment with Outlines Closed correction and Plaster fixation: Broken ends are manually corrected and brought face to face. It is followed with a maximum angulation of 15 degrees from the direction of movement without at least 50% contact and rotation. While this angulation is considered to be in the upper limits in children, high angulations in adults are directed to surgery since they do not have a chance to reshape. Traction correction: Segmented closed fractures, large bone fractures that cannot be controlled with strong muscles, or spine fractures with dislocation are placed under traction for alignment. Traction is the principle of directly seating the fracture with weights suspended over the wire inserted into the bones. In traction, the ends of the fractures should be brought face to face for up to 72 hours by balancing the muscles. If the procedure is successful, it can be continued until the union is achieved or plaster and other external fixations (external fixator) can be passed. Surgical Methods Closed correction and percutaneous screw-wire-nail fixation: It is the most preferred surgical treatment method today. It can be planned in cases of unstable after fixation, fractures in the muscle-ligament attachment sites, fractures involving the joint, and in cases where movement is required. Open correction and internal-external fixation: If soft tissue enters between the fracture ends and prevents contact, open surgical treatment and fixations are applied in cases of joint-related fractures, growth cartilage fractures, intra-articular fractures and vascular-nerve lesion, in order to remove foreign bodies in open fractures. Metal fixations are not applied in dirty wounds, external methods (fixators) are preferred. Dislocation; It is the deterioration of the relationship of the surfaces forming the joint with each other. Joints are compatible, intertwined sphere-bowl relationship (hip), as well as mostly incompatible structures or structures that do not have sufficient bone coverage. In this way, the joint becomes more mobile but prone to dislocation and vulnerable to external forces. Joint limits are limited by ligament structures, harmony is ensured by meniscus structures and cartilage-like structures surrounding the joint, which we call the labrum. But the most important support is provided by the structure we call the joint capsule. While it provides lubricity with liquid in the joint, it approaches the surface like a suction cup with the negative pressure effect of the closed airtight structure of the capsule and resists extrusion. As a result of dislocation of the joint, forcing the boundaries of the joint, the rupture of the joint capsule, rupture of the ligaments and the structures that provide the joint harmony are destroyed. When the joint is dislocated, it can break the bones that make up the joint. In this case, fracture-dislocation is mentioned. Joint dislocations should be placed in the first 24 hours. It is placed on the joint with special maneuvers closed and fixed with dressing-bandage-plaster. At least 3 weeks of fixation is planned according to the characteristics of the joint. Fractured dislocations, dislocations associated with joint fractures, late-intervented dislocations, dislocations with vascular-nerve lesions and structures that interfere with placement are treated surgically. Whether for fracture or dislocation, the primary goal in modern orthopedic surgery should be prompt detection and early movement. The socio-cultural structure of the patient can also change the way of treatment. Painless, fully mobile joint and healthy limb are the main goals in treatment.

In general, Mesotherapy (intradermal therapy) is a medical procedure applied by a physician with known efficacy in many medical conditions. The first applications started in France in the 1950s. Mesotherapy technique is widely used in dermatology, physical therapy and orthopedics all over the world. The technique is paid within the scope of the French Social Security system. Mesotherapy application includes targeted minimal drug application. To the target of the medical problem; amino acids, minerals, vitamins, vasodilators, anti-inflammatory, analgesic and anesthetic substances are administered by microinjection method. Thus, drug toxicity that may occur with systemic drug administration is avoided and at the same time, direct administration of the drug to the target increases the effectiveness of the treatment. Much more effective results are obtained with combined therapies. This application varies from 2-3 months to a year depending on the area taken to the treatment, the size of the problem and the personal response to the treatment. All of the substances applied in mesotherapy are commercial products used today in the health sector. Although mesotherapy is used in the treatment of many diseases, it is widely used especially in the following areas: Joint pain, osteoarthritis and osteoarthritis-related pain, spinal column pain, osteoporosis-related pain, carpal tunnel syndrome, trigger finger, sports injuries, sprains, tendinitis, fractures and after the effects of orthopedic surgery, muscle aches, headache, migraine, neuralgias, anxiety and stress, cellulite, aging of the skin, hair loss. Mesotherapy technique is applied in all countries by medical doctors trained on this subject, using manual or mesotherapy guns.

In pursuit of immortality, Gilgamesh is that the brutal real death he encounters in search of the herb of immortality cannot be stopped. Humanity, which has been pursuing immortality like Gilgamesh for thousands of years, is still in pursuit of the healing it has lost to the snake. The discipline of medicine, on the other hand, ironically symbolizes the snake, exalted as it cures the diseases that cause death. While humanity survived by hoping for empirical treatments was protected against diseases, on the other hand, it was inevitable that it was defeated by aging and death. Today, local physicians define death as a chromosomal program that develops at the cellular level with the concept of “apoptosis” and even genetically triggered it, creating the concept of stopping aging. It’s like everyone had a biological clock that suddenly all cells were ordered to die. There must have been a grass that stopped this clock. Speaking of the cell, the chromosomal structure is detailed. DNA and ribosomes encode, progenitors chase the clock. The result is hopeless for now. But genetic engineering was born, and tissue engineers were also waiting at the door. The cure for immortality would be found. Genetic science and human genetic mapping, cloning made the masses believe that the utopian dreams in the Jules Verne novels were real. So much so that science fiction scenarios are almost the most interesting ones; There were those who evoked immortality and demonstrated the convincing and possible results of recent scientific advances. The experiments for the unethical scenarios of the rich people who cloned themselves in the movie Ada are based on a sheep named Dolly, which was cloned in 1996. The idea that humanity could replicate itself, and even the idea that this copy could be perfect, created another nightmare that was more terrifying than the serpent in seeking immortality. In Hollywood scenarios, the “terminator” icon was immediately cloned, in Galactica the Cylons were conceived as clones of common intelligence, and even an esoteric god was created with the Avatar. So much so that the opinion of the public began to be inaccessible, expensive, imaginary and even immoral treatments. Cellular therapies are banned and restricted in many countries. In reality, what was done in the health field was not very inaccessible. Genetics and tissue engineering continued to evolve rapidly. Masses circulating between us in multiple babies that have become commonplace like IVF (invitro fertilization = in vitro fertilization) technology, those who come back to life with stem cells taken from bone marrow, and those who live with their sibling’s organs have always been among us. Organ donations were encouraged, and those who came back to life with organ transplants continued to make headlines in the newspapers. Another hope arose for Gilgamesh, who lost the weed when cloning was banned before it could replace the herb of immortality; “Stem cells”… but they too faced serious resistance, starting empirical treatments that would cause public controversy. Because the treatment success was low, the behavior of cells was unpredictable, it could be associated with cancer, and failure was brutally criticized. Those who were investigated were those who were dismissed from the profession. Cloning is not legally possible today. The use of stem cells is restricted or prohibited in many countries. However, by producing tissue, treatment can be performed without straining ethical limits. Tissue production can be autologous or allogeneic. The basic principle is that living cells are similar or identical to the characteristics of the original tissue and are placed in the host’s relevant tissue or in an environment where it can survive. Since the person’s own tissue is produced and applied to himself, it can be easily applied in medical treatments within the limits of ethical rules. The cell source may be stem cells. However, the process of differentiation into muscle, cartilage, nerve or any tissue to be developed from stem cells is a very expensive and long process. Pluripotent (multipotent differentiation) cell sources can be used for cells that form nerve and muscle tissue that have completed their differentiation. Such cells decrease gradually as the bone marrow ages and it is very difficult to enrich. The richest source of pluripotent stem cells is in cord blood and blood taken from the embryonic side of the placenta. Taking and keeping these cells is very important in this respect. The cells that complete their differentiation (muscle and nerve cells) cannot multiply by dividing and cannot be renewed by the body when damaged. The obstacle to the production and regeneration of cartilage from cells that have partially completed their differentiation but have the ability to transform into another cell is due to their inactivity in different matrix structures. The ability of bone, fibrous tissue and epithelial cells to renew themselves rapidly may be a hope for immortality. When it comes to epithelium, not only skin and organ surfaces should come to mind. Hormone and enzyme-supplying glands that have highly differentiated proliferative abilities but cannot be reproduced in the body are also of the same origin as epithelial cells. For example, pancreatic islet cells are of ectodermal origin, such as dopamine secreting cells that play a role in the formation of Parkinson’s in its absence, and epithelial cells of the adrenal glands. Today, tissue engineering seeks to differentiate these cells and produce them from stem cells or to reproduce them directly. The relatively problematic tissue in the musculoskeletal system, other than muscle, is cartilage tissue. The reproduction of the cartilage cell is possible by removing it from the lacunae in which it is imprisoned and placing it in an environment where it can be fed again. When the appropriate matrix structure is provided according to the cartilage structure to be produced, there will be a ready-to-use cartilage tissue. After the source cell (ear, joint surface) from which the cartilage tissue will be produced is taken from the donor area, production is started. Since the appropriate medium will also be the tissue to be transferred, the matrix will give the character of the tissue. The tissue produced according to the type of cartilage must bear the character of the tissue to which it is transferred as much as possible in order to maintain its vitality during the remodeling process in the body. Otherwise, the cells may be removed during remodeling and leave their places to non-functional fibrous tissues, which we can call “wildcard”. That is why one of the most important issues that tissue engineering focuses on is “biocompatibility”. Well, we produced your texture, everything is ready and can we apply it to you? The answer to this question will reveal the concept of “host suitability”. In this case, your biological clock should be at times to adapt the new tissue to your body. The young cells that are transferred cannot survive alongside the old cells that surround them whose metabolism has fallen. In the area to be transferred, it should be biologically active and at a level to remove high metabolism. At this level, the snake is in the hands of the clinician. Ensuring that the host is suitable for cellular therapy will perhaps be more challenging than producing cells. Technological developments, tissue engineering will bring many developments in the future. We will surely find and even find the herb of immortality, but the important thing is to know how to use it without getting caught by the snake.

We can divide Recessive Drug Treatments into five. 1. Anti-inflammatory Treatment Surgical incisions or skeletal injuries heal with the tissue reaction we call inflammation. Pain is a perception caused by inflammation. We cut the pain and the unwanted effects of inflammation with anti-inflammatory drugs. Steroids are the strongest known anti-inflammatories. We do not use steroids unless it is absolutely necessary. The drug group we use most frequently are non-steroidal anti-inflammatories (NSAIs). 2.Antibiotics We apply prophylactic antibiotic treatment before surgery or for therapeutic purposes due to infection. 3. Antiembolic Therapy During orthopedic treatments, preventive antiembolic treatments, that is, blood thinners, are frequently used because of immobility and the effect of limb circulation. When embolism occurs, treatment is applied with the relevant branch physicians in hospital conditions. 4. Supportive Treatments Elements including protein, collagen and matrix structure needed by the musculoskeletal system are taken orally. Glucosaminoglycans, collagens are recommended orally. Complements the treatments. 5. Conservative Treatments It is the support treatment package that we recommend before the injury to prevent skeletal injury or wear on the cartilages of the person.

The biggest problem of patients with pain in this area is not being able to sit. Most describe a seated fall story and believe or be made to believe that the deformities in the X-ray films are the cause of the pain. In fact, fractures of the coccyx can heal without sequelae like other fractures and rarely require surgical intervention for angular knee disorders. In this case, it is very useful to investigate hernias in the lumbar region of the patient and to reveal the nerve traps. In our clinical experience, we have determined that the pain felt around the coccyx is mostly due to herniated disc or canal stenosis, and we have achieved successful results by continuing our treatments in that direction. After eliminating the causes directly originating from the coccyx (tumor, infection, fractures), the pain that will be reflected in this area should be investigated. If the dry socket pain is not caused by herniated disc, the source is much more serious.

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.