When 23-year-old Towfiq Islam walked into Apollo Hospital on the OMR in Chennai, Senior Spine Surgeon Dr Muralidharan Venkatesan realised he might be facing one of the most difficult cases of his career.
Dr Muralidharan is no stranger to the debilitating effects that a bent spine can have on a person’s life. “We see several cases of scoliosis. Scoliosis is the lateral curvature of the spine, where the spine gets bent to the left or the right,” he says. Most such cases are idiopathic, where the cause is not known, and emerge after the age of 10. But some can also occur at birth.
A life of pain and discomfort
Towfiq, however, was not merely living with scoliosis. Hailing from Dhaka in Bangladesh, Towfiq was born with a rare condition called arthrogryposis multiplex congenita. “This is a rare birth condition where the joints are extremely stiff and contracted. Up until the age of 11, though he was stunted by the bent joints, he was normal in terms of weight and other indicators,” explains the doctor. However, at the age of 11, Towfiq suddenly began losing weight and lost most of his muscle mass. The result was that his arms and legs began to appear like just a layer of skin covering bone.
Despite all these troubles, Towfiq managed to carry on his life and get an education, even entering college. However, in the last six years, Towfiq’s spine had become bent, leaving his torso twisted to the left. While there is reason to believe that Towfiq had an undiagnosed scoliosis problem at birth, says Dr Muralidharan, his underlying conditions had led to his scoliosis becoming significant. “Because of his bent limbs, bent knees and bent hips, his body was forced to be in an awkward position for him to maintain balance when he stood,” explains the doctor. Hence, Towfiq’s spine became twisted to allow him to maintain his centre of gravity.
Due to the bends in his knees, hips and limbs, Towfiq’s spine had become drastically bent too, leaving him in constant pain
But this was putting Towfiq’s chances at a reasonable life in jeopardy. When the young man walked into the consultation, Dr Muralidharan had trouble believing the extent of the problem. At age 23, Towfiq weighed just 27 kg because his bent spine was pushing into his stomach and preventing him from eating properly. His lungs were under similar pressure, making breathing a difficult job. And because the bend was so severe that Towfiq’s ribs were rubbing against his pelvis, he was in constant, debilitating pain.
A complex case
Dr Muralidharan immediately recognised just how urgent and necessary Towfiq’s surgery was, if he was to have a chance at a reasonably normal life. However, any surgical intervention was not without significant risks, given how complex Towfiq’s condition was. “The first question was, can I operate on him?” says Dr Muralidharan. “And if we do, what is the safest way of doing it on this challenging patient?”
A comprehensive set of blood, genetic, neurological, lung function and cardiological tests followed. The primary concern for Dr Muralidharan was to assess whether Towfiq’s body could withstand such a major surgical procedure. But his earlier episode of muscle mass loss was a key concern too, as losing muscle mass after the surgery would lead to further complications. “So, we did genetic screening and muscle biopsies to look for whether there were any signs of known muscular dystrophy,” explains the doctor.
Though all the tests were promising, Dr Muralidharan says that his other colleagues were sceptical of the possibilities of success, raising the risks of wound infections, wound breakdown and paralysis. All of the risks and possibilities were placed before Towfiq and his family when he was counselled before opting for the surgery. Ultimately, they chose to go ahead with the procedure despite the risks, as Towfiq desperately sought relief from the pain that haunted him constantly.
Even before the surgery could take place, Towfiq had to undergo intensive treatments as a first step. For two weeks, Towfiq was placed under halo-gravity traction, where a metal ring is placed around the head and attached via pulley to weights, so that the spine is gradually stretched. He was also prescribed breathing exercises to improve his lung function, and was given protein supplements in his diet to build up his protein levels before the surgery.
A miracle on the surgical table
The procedure itself involved complications at every step, says Dr Muralidharan, due to multiple challenges in Towfiq’s case. “He was wheeled into surgery at 8am. It took us 3 hours just to set up his positioning for the surgery and the neuro-monitoring, which would keep track of any possibilities of neurological damage during the procedure,” explains the doctor. Towfiq’s position during the surgery was crucial because, “we had to be cautious that we did not stretch or break his already flexed, contracted joints, and that his pressure points were protected.”
Similarly, a special kind of anaesthesia had to be used so that the neuro-monitoring was not interrupted. And the dosage had to be carefully calibrated because of Towfiq’s extreme underweight.
The procedure itself lasted for six hours: first, Dr Muralidharan released the tight soft tissues around the spine. Then, the vertebral joints around the spinal curve had to be meticulously broken to allow it to be flexible enough for realignment. Finally, using screws and a rod contoured to the desired shape, Towfiq’s spine was fixed in its new alignment.
Importantly, says Dr Muralidharan, performing such a complex procedure also required him to accept the limits of what Towfiq’s body could take. “Even with a normal flexible curve, we only aim to correct 60%-70%. Some residual curvature remains, and that we have to accept. In Towfiq’s case we felt that if we manage around 40%-50% correction, that is more than enough,” he explains.
In the end, the surgery turned out to be a marvellous success. “Towfiq spent one day in the ICU for observation. By the second day, he was up and about. By the fifth day, he was out of the hospital, and by the tenth day, he had returned home. He recently came back for a follow-up and he is very happy with the shape of his back and all of his pain is gone. He is also breathing much more comfortably. And he has gained 3kg since the surgery, and is able to eat more frequently and eat better. He has happily returned to college life,” says Dr Muralidharan.
This article has been produced by TNM Brand Studio in association with Apollo Hospitals and not by TNM Editorial.