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MOST LIKELY Program contents in December [11] 12 to 22, 2024

MSF FELLOWSHIP program under team MSF at Dervan, Walawalkar hospital.

11: welcome lunch dinner and orientation to our set up and program. Evening fire side chat introduction of ppl.

12: Talks : 1 basic of anatomy better understood as 3 z 3w 3 n etc. concept and the universal symptom generators 2 more about nerve domains 3 access to foramen 4 access to canal 5 variations in normal anatomy, pathoanatomy, aging, d f l variations 5 3 d clay modelling to appreciate the v structure 6 revision 7 question answers 8 distribution of books

13: Talks 1 symptom generation what why where how, 2 roles of inflammation, tether and compression in sg 3 role of DRG, 4 algorithms 5 matrix 6 imaging limitations 7 reading an MRI CT PET 8 more on sciatica insights 9 revision of sg targets over 3 z 3w 8 new jargon 10 opd session  revision and q and a

14: talks for 2 hrs.  1 what is a needle 2 how we target foramen upper 3 how we target foramen lower 4 line of sight thinking 5 gores concepts wrt disc and wrt stenosis. Cadaver session day 1 learn

15: Talks for 2 hrs. 1 what instruments we use in disc 2 stenosis 3 laser physics 4 laser safety 5 variations in anatomy wrt d f l 6 ventral dissection  CADAVER Day 2 practice  q and a

16 Monday non spine day 1. Excursion 2. Delegate talks 3. Saamish dinner and liquids 4 more on talking up TFE a complete philosophy for pain disc stenosis and instability 5 visit to campus

17,18 live surgery discs

19 20 live surgery disc and stenosis [subject to availability]

21 revision talks, q and a. advanced : cadaver use of vajra, and laser if not done in live.  Practice  evening certification, feedback, group photo. Gifts.

22 half day examination on cadaver for FMSF q and a and practical session. Post dinner disperse. Till we meet again

Below we compare open post midline or interlaminar surgery and new system SMRUTII surgery? Posterior wall of canal is ligamentum flavum in lower 2/3 of a segment in lumbar spine and IAP lamina is extra ligamentous. It should make us immediately aware that most of bone cutting we do in open surgery is not relevant to target  from intracanal perspective and needs to be rectified. This is shown in detail in 2 videos below one about open surgery for central stenosis and second highlighting my smrutii system basics. 

For transforaminal endoscopy enthusiasts Treatment of central canal stenosis is Not foraminoplasty as we need to go on inside facet and work in central canal , so it is Channelplasty. Below is a video showing differences in f plasty and Ch plasty.

Stenosis or narrowing in lumbar canal is due to changes on its inner walls, it can be foraminal or UZ stenosis, lower zone or root canal or lateral recess stenosis and middle zone or central canal stenosis due to central lateral or posterior [lateral medial] causes. Video Below shows our crystal clear ideas about central canal stenosis on posterolateral walls in form of ligamentum flavum changes. Inside facet joint edge. This will clarify to u why we must stay away from interlaminar bone breaking surgery!

https://media.publit.io/file/crystal-clear-S-M-R-U-T-I-I-system-concept.html?player=MISSIONSPINE  or see below

Subpars Medial Reach Upper Transforaminal Intracanal Intervention : S M R U T I I complements TFE gore system.

Patients present to us with low back pain, leg pain or claudication with varying degree of neurological involvement. Claudication commonly indicates stenosis of path of nerves or thecal sac with added involvement of arteriovenous system. Lumbar canal stenosis is due to narrowing inside canal as a result of degenerative changes around dural sac. In its front, side and back, 360 degrees all around. 3 structures change in lumbar spine degeneration causing stenosis namely disc in front, ventral face of facet and its soft tissue cover posterolaterally and ligamentum flavum at posteromedial face. It is INSIDE the canal walls. Posterior midline does not have causes. NO changes IN BONE are seen after age of skeletal maturity. We have been successfully operating disc and its varied presentations causing pain etc. by gore TFE system using transforaminal access; surgery that is stitch less , under local anesthesia in an awake and aware patient, reaching front and back of the dural sac thru foraminal access. Areas that we were not able to reach easily by TFE now that is inner wall of facets we can and do by smrutii system.

SMRUTII Basis is a new awareness of ligamentum flavum anatomy and use of new MRI protocols that completely change our approach to stenosis. We propose to follow ligament from above down and spare the lamina in stenosis surgery.

I wish we learn thru method, with very precise understanding of anatomy of spine, bony anatomy that does not change much and soft tissue that mainly changes as disc, facet ventral face cover and ligamentum flavum. WE SIMPLY DIVIDE ANATOMY AS UPPER ZONE IN CONFINES OF UPPER BODY EG: L4 AT L45, middle zone behind disc at L45 and lower zone that has occupied lower body. We know now that we have 8+1 total 9 symptom generators in degenerative lumbar spine. plus facet dorsal capsule.  Middle zone stenosis is central canal stenosis affecting thecal sac. Upper zone affects exiting nerve ENR and DRG dorsal root ganglion. The lower zone has traversing nerve root TNR that is ventrally immobile at entry to root canal or lateral recess and may be affected by ventral or dorsal cause. 

Video on left is for UZ middle is MZ and on right is LZ. That is UZ is from disc up to lower border of above pedicle. The MZ is built from lower end plate of disc to its upper endplate of disc. Lower zone is built from lower discal endplate towards mid pedicle across area. It is important to note there is NO posterior midline symptom generator. 

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