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Cordotomy Surgery in India

Cordotomy surgery is a minimally invasive neurosurgical procedure that involves making precise incisions in the spinal cord to disrupt pain signal transmission. The primary goal of cordotomy is to provide long-lasting pain relief, especially for patients who have not found success with traditional treatment options.

Cordotomy surgery comes in two primary types: percutaneous and open procedures. In percutaneous cordotomy, a needle-like electrode administers radiofrequency energy to specific nerve fibers, forming a lesion that interrupts pain signals. Conversely, open cordotomy requires a small surgical incision to access the spinal cord directly and create the necessary lesion for pain relief.

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    The decision between percutaneous and open cordotomy hinges on several factors, such as the location and severity of the pain, the patient’s overall health condition, and the surgeon’s proficiency. Both methods have demonstrated high success rates in alleviating pain; however, the appropriate approach is chosen based on the unique requirements of each patient.

    Benefits of Cordotomy Surgery

    Cordotomy surgery in India presents significant advantages for patients grappling with chronic pain. Primarily, it offers precise pain relief by disrupting the transmission of pain signals within the spinal cord. In contrast to medications, which may entail side effects and offer only temporary relief, cordotomy surgery provides a more lasting solution.

    Furthermore, cordotomy is characterized as a minimally invasive procedure, involving smaller incisions compared to conventional open surgeries. This approach leads to reduced pain, less scarring, and quicker recovery times for patients. Moreover, the procedure carries a lower risk of complications, enhancing its safety and efficacy as a pain relief option.

    In addition, cordotomy surgery can markedly enhance a patient’s quality of life. Chronic pain can be physically and emotionally taxing, restricting daily activities and diminishing overall enjoyment of life. By offering enduring pain relief, cordotomy surgery empowers patients to regain control and enjoy an improved quality of life.

    The Cordotomy Surgery Process

    The cordotomy surgery process typically involves several steps from initial consultation to post-operative care. Here is a general overview of what to expect:

    Initial Consultation: When you consult with a neurosurgeon specializing in cordotomy surgery, they will review your medical history, perform a thorough physical examination, and engage in discussions about your symptoms and treatment objectives. Additionally, they may recommend imaging tests like an MRI or CT scan to further assess your condition and gather essential information for planning your treatment.

    Preoperative Preparation: Before undergoing cordotomy surgery, once it has been determined to be appropriate, you will undergo preoperative preparations. These preparations typically include blood tests, an electrocardiogram (ECG), and other routine assessments. Your healthcare team will give you specific instructions regarding fasting and any medications that need to be stopped before the surgery.

    Surgery Day: On the day of the surgery, you will be admitted to the hospital and prepared for the procedure. An anesthesiologist will administer anesthesia to ensure your comfort and pain relief during the surgery. The surgeon will then proceed with the cordotomy, using either a percutaneous or open approach as previously planned based on your specific needs and condition.

    Recovery and Post-operative Care: After the surgery, you will undergo close monitoring in the recovery room before being transferred to a hospital room. Your medical team will implement pain management protocols to ensure your comfort, and you may receive medication to relieve any postoperative discomfort. Additionally, physical therapy and rehabilitation may be recommended to facilitate your recovery process.

    Follow-up Visits: In the weeks and months after surgery, you will attend scheduled follow-up appointments with your healthcare provider. These visits are essential for monitoring your progress, evaluating pain levels, and addressing any questions or concerns you may have. They play a crucial role in ensuring your recovery is progressing well and in optimizing the long-term success of the surgery.

    Recovery and Rehabilitation after Cordotomy Surgery

    Recovery and rehabilitation following cordotomy surgery are critical for achieving a successful outcome. Although the exact timeline can vary based on individual factors, here are some general guidelines:

    1. Hospital Stay: Following cordotomy surgery, most patients typically stay in the hospital for a few days. During this period, your healthcare team will closely monitor your condition, manage pain effectively, and ensure that you are recovering satisfactorily. They will also provide instructions on post-operative care, including wound care and medication management, to support your recovery process.
    2. Pain Management: After the surgery, you may experience some pain or discomfort in the days following the procedure. Your healthcare team will provide suitable pain medication to ensure your comfort throughout the recovery period. It is crucial to adhere to the prescribed medication schedule and promptly communicate any unusual symptoms or concerns to your healthcare provider for proper management.
    3. Physical Therapy and Rehabilitation: Based on your individual requirements, your healthcare provider may recommend physical therapy and rehabilitation to facilitate your recovery. These therapies are designed to enhance strength, mobility, and overall functionality. Your healthcare provider will develop a customized rehabilitation plan tailored to address your specific condition and recovery goals.
    4. Gradual Resumption of Activities: During your recovery, it’s crucial to gradually reintegrate into your daily activities. Your healthcare provider will offer guidance on when and how to increase your activity levels safely and effectively. Adhering to these instructions is vital to prevent complications and optimize your overall recovery process.
    5. Follow-up Care: Regular follow-up appointments with your healthcare provider are essential for monitoring your progress, addressing any concerns or questions you may have, and ensuring your continued recovery after surgery. During these visits, your healthcare team will assess your pain levels, evaluate your functional outcomes, and make any necessary adjustments to your post-operative care plan. These appointments are critical for achieving a successful recovery and long-term pain relief.

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      Success Rate

      Cordotomy surgery stands out for its remarkable efficacy in alleviating chronic pain, consistently delivering enduring relief to patients. Extensive research underscores its transformative impact on improving patients’ quality of life, with studies consistently showcasing positive outcomes following the procedure.

      Research findings reveal that cordotomy surgery has been highly effective in reducing pain in a significant majority of patients suffering from cancer-related pain, with over 80% experiencing notable relief. Similarly, for individuals with chronic non-cancer pain, the procedure has demonstrated substantial efficacy, with more than 70% reporting improvements in pain management.

      Risks of Cordotomy Surgery

      As with all surgical procedures, cordotomy surgery involves certain risks and potential complications. It is crucial to fully understand these risks and engage in a detailed discussion with your healthcare provider before reaching a decision.

      Moreover, it should be noted that cordotomy surgery may not achieve total pain relief for every patient. The effectiveness of pain reduction can vary based on individual circumstances, and some individuals may still necessitate supplementary pain management techniques. Your healthcare provider will evaluate your unique case and offer practical expectations tailored to your condition.

      Advantages of Cordotomy Surgery in India

      India has become a premier choice for cordotomy surgery, drawing patients globally in search of effective pain relief. Several factors contribute to India’s popularity as a destination for this procedure:

      1. World-Class Medical Facilities: India boasts state-of-the-art hospitals and medical facilities that feature the latest advancements in healthcare technology. These institutions are equipped with cutting-edge equipment and infrastructure, ensuring the highest standards of care and safety for patients undergoing treatment.
      2. Highly Skilled Healthcare Professionals: India is home to a pool of highly skilled and experienced healthcare professionals, including neurosurgeons who specialize in cordotomy surgery. Many of these experts have received international training and are renowned for their proficiency in the field. Patients can anticipate personalized care and comprehensive support throughout their treatment journey.
      3. Cost-Effective Treatment: One of the key benefits of opting for cordotomy surgery in India is its cost-effectiveness. Compared to many Western countries, the expense of medical treatments, including cordotomy surgery, is considerably lower in India. This affordability does not come at the expense of quality, making it an attractive option for patients seeking high-standard care at a more accessible price.
      4. Minimal Waiting Times: In certain countries, patients might experience extended wait times for specialized procedures such as cordotomy surgery. Conversely, in India, patients frequently benefit from swift treatment, significantly reducing the waiting period and enabling quicker relief from chronic pain.
      5. Holistic Approach to Care: Healthcare providers in India often prioritize a holistic approach to patient care, addressing not only the physical but also the emotional and psychological aspects of well-being. This comprehensive strategy ensures that patients receive personalized treatment tailored to their unique needs, fostering overall well-being and aiding in recovery.

      Cost

      The cost of cordotomy surgery in India can vary based on several factors, including the hospital chosen, the surgeon’s expertise, the length of the hospital stay, and any additional medical services needed. Typically, the cost ranges from around $3,000 to $8,000 USD or more.

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        • Providing a doctor’s opinion and proper quotation
        • Selecting the best hospital and doctor as per your case
        • Arranging a call with the doctor (if the case required)
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        FMRI

        Fortis Memorial Research Institute

        Number of beds:    1000
        ICU Beds:                  298
        Airport Distance:  17 KMs

        Brief About:

        • Fortis Memorial Research Institute was established in 2001.
        • It is an outstanding multi-speciality quaternary care hospital,having the top-notch infrastructure, advanced equipment, highly qualified and experienced medical professionals and super sub-specialists.
        • Fortis Hosptial Gurgaon is an advanced centre of excellence in Robotic Surgery, Neurosciences, Oncology, Renal Sciences, BMT, Organ Transplants, Orthopaedics, Cardiac Sciences and Obstetrics & Gynaecology.

        Dr. Sandeep Vaishya

        Dr. Sandeep Vaishya

        • He has 22+ years of experience in the field & has been associated with some of the best hospitals in India.
        • Dr. Vaishya has completed his MBBS & MS from the well-known G R Medical College, Gwalior. Following which he did his MCh at the prestigious AIIMS, Delhi. Read More

        Dr. Rana Patir

        Dr. Rana Patir

        • Dr. Rana Patir is Chairman – Department of Neurosurgery at Fortis Memorial Research Institute, Gurugram.
        • Dr. Rana Patir, MS (General Surgery), MCh (Neurosurgery), Fellowship in Neurosurgery (UK), is an eminent Neurosurgeon of India with more than 35+ years of experience in the field of advanced Neurosurgery. Read More

        Dr. Praveen Gupta

        Dr. Praveen Gupta

        • Dr. Praveen Gupta is PRINCIPAL DIRECTOR NEUROLOGY at Fortis Memorial Research Institute, Gurugram.
        • Dr. Praveen Gupta has established two departments in his 18 years of career in Neurology in two large corporate hospitals in Paras and Artemis seeing largest no. of OPD (100 Patient per day) and IPD (50 patient per day). Read More
        Dr. Sandeep Vaishya Dr. Sandeep Vaishya
        Specialist:Neurosurgery
        Experience:22+years 
        Hospital:Fortis Gurgaon
        Dr. Rana Patir Dr. Rana Patir
        Specialist:Neurosurgeon
        Experience:35+ years
        Hospital:Fortis Gurgaon
        Dr. Praveen Gupta Dr. Praveen Gupta
        Speciality:Neurologist
        Experience:18 years
        Hospital:Fortis Gurgaon

        BLK_Super_Specialty_Hospital

        BLK-Max Hospital

        Number of beds: 700
        ICU Beds:               175
        Airport Distance: 13 Km

        Brief About:

        • BLK Super Speciality Hospital was established by Dr. B.L. Kapur  in 1959. It was inaugurated by the then Prime Minister of India, Pandit Jawahar Lal Nehru.
        • BLK Super Speciality Hospital was established by Dr. B.L. Kapur  in 1959. It was inaugurated by the then Prime Minister of India, Pandit Jawahar Lal Nehru.
        • BLK has a unique combination of the best in class technology, put to use by the best names in the professional circles to ensure world-class health care to all patients.

        dr rajiv anand

        Dr. Rajiv Anand

        • He has a thriving experience of over 35+ years; he has studied from some of the prestigious institutes in India.
        • Dr Anand has done his MBBS & MD (Neurology) from the eminent GB Pant Hospital, Delhi. He has done his (Medicine) from the prestigious Delhi University. Read More

        dr. atul prasad

        Dr. Atul Prasad

        • Having successfully treated numerous patients, Dr. Atul Prasad is a leading name in the field of neurology. He has been widely acknowledged for his versatile and patient-centric approach.
        • He is currently working as a Director & HOD in the Neurology Department at BLK Super Speciality Hospital, New Delhi India. Read More

        Dr. Vinit Banga

        Dr. Vinit Banga

        • Dr. Vinit Banga is a leading name when it comes to Neurology & Neurovascular Intervention in India.
        • Dr. Vinit Banga has vast experience in treating problems related to the brain, spine, nerves and muscles. Read More
        dr rajiv anand Dr. Rajiv Anand
        Specialist:Neurologist
        Experience:35 years
        Hospital:BLK-Max Hospital
        dr. atul prasad Dr. Atul Prasad
        Specialist:Neurologist
        Experience:31 years
        Hospital:BLK-Max Hospital
        Dr. Vinit Banga Dr. Vinit Banga
        Specialist:Neurologist
        Experience:12+ years
        Hospital:BLK-Max Hospital

        Artemis Hospital

        Artemis Hospital Gurgaon

        Number of beds:  600
        ICU Beds:                185
        Airport Distance: 19 Km

        Brief About:

        • Artemis Hospital, established in 2007, spread across 9 acres, is a 600plus bed; state-of-the-art multi-speciality hospital located in Gurgaon, India.
        • Artemis Hospital is the first JCI and NABH accredited hospital in Gurgaon.
        • Designed as one of the most advanced hospitals in India, Artemis provides a depth of expertise in the spectrum of advanced medical & surgical interventions, a comprehensive mix of inpatient and outpatient services.

        dr aditya gupta

        Dr. Aditya Gupta

        • Dr Aditya Gupta, is an accomplished Neurosurgeon, has been a graduate and topper at All India Institute of Medical Sciences (AIIMS), New Delhi.
        • He was later selected to become Faculty, and remained as Associate Professor of Neurosurgery till 2009. Thereafter, he co-founded the Institute of Neurosciences at Medanta, where he worked till mid-2016 as Additional Director, Neurosurgery. Read More

        Dr. SK Rajan

        Dr. Sk Rajan

        • He has, to his credit, an accomplishment of more than 3000 surgeries including some of the most complex spine cases and cases complicated by other surgeons.
        • He has been recognized for utilising Minimally Invasive KeyHole Spine Surgery Techniques for a variety of spine cases like slipped disc, Lumbar Canal Stenosis, Spinal Tumors, etc. Read More

        Dr. Vipul Gupta

        Dr. Vipul Gupta

        • He has a thriving experience of over 22+ years and is amongst the rare full-time neuro-interventionists specializing in endovascular interventions in stroke.
        • Dr Gupta is counted amongst the first few in the country to use a dedicated intracranial stent & 3D-DSA for aneurysm embolization to perform intra-cranial venous sinus stenting. Read More
        dr aditya gupta Dr. Aditya Gupta
        Speciality:Neurosurgery
        Experience:25+ Years
        Hospital:Artemis Hospital
        Dr. SK Rajan Dr. Sk Rajan

        Specialist:Neurosurgery
        Experience:24+ years
        Hospital:Artemis Hospital

        Dr. Vipul Gupta Dr. Vipul Gupta

        Specialist:Neurosurgeon
        Experience:22 years
        Hospital:Artemis Hospital

        max-hospital-saket

        Max Hospital Saket

        Number of beds:   500
        ICU Beds:                 267
        Airport Distance: 13 KM

        Brief About:

        • Max Super Speciality Hospital at Saket is one of the topmost healthcare service
        • Providers in India. The multi-super speciality hospital has a capacity of over 500 beds, 250 functional beds. It is equipped with state-of-the-art facilities, advanced technologies.
        • With the help of over 300 leading specialist Doctors, strong nursing staff, and state-of-the-art innovative medical tools.

        Dr. (Col) Joy Dev Mukherji

        Dr. (Col) Joy Dev Mukherji

        • Dr. Col. Joy Dev Mukherji practices at Max Super Speciality Hospital in Saket, Delhi, Arcus Superspeciality Medicentre in Dwarka, Delhi and Max Hospital in Sushant Lok I, Gurgaon.
        • He completed MBBS from Sambalpur University in 1983, MD – General Medicine from Bangalore University in 1990 and DM – Neurology from PGIMER in 1995 Read More

        Dr. Puneet Agarwal

        Dr. Puneet Agarwal

        • Dr. Puneet Agarwal is the pioneer of initiating Sonothrombolysis in patients suffering from severe stroke in North India as well as in Max Hospital.
        • Dr. Puneet Agarwal is among the first few doctors in India to have studied Inflammatory Genes in Stroke Patients and IV Valproate in Status epilepticus. Read More

        Dr. Rajashekar Reddi

        Dr. Rajashekar Reddi

        • Dr. Rajashekar Reddi practices at Max Super Speciality Hospital Saket. Professional qualifications of the Doctor are MBBS from Christian Medical College in Vellore, MD (Medicine) from Post graduate institute of Medical Education and Research in Chandigarh, DM (Neurology) from Post graduate Institute of Medical Education and DNB (Neurology) and specializes in Neurology. Read More
        Dr. (Col) Joy Dev Mukherji Dr. Joy D. Mukherji
        Specialist:Neurology
        Experience:39+years
        Hospital: Max Saket
        Dr. Puneet Agarwal Dr. Puneet Agarwal
        Specialist:Neurologist
        Experience:21+ years
        Hospital:Max Saket   
        Dr. Rajashekar Reddi Dr. Rajashekar Reddi
        Specialist: Neurology
        Experience:18+years
        Hospital:Max Saket

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          We offers these Services

          • Providing a doctor’s opinion and proper quotation
          • Selecting the best hospital and doctor as per your case
          • Arranging a call with the doctor (if the case required)
          • Visa assistance, Providing Visa Invitation Letter (VIL)
          • Providing full guidance how to get Visa from your country
          • Providing total cost including treatment, air tickets, accommodation, and food
          • Assitance to book flight ticket from your country
          • Arranging airport pick up/ drop
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          • Booking accommodation and guest house as per your budget/ prefrence
          • Providing help in money exchanging
          • Providing local sim card
          • Arranging video consultation with specialist doctor if case requires

          Medanta-Hospital-Gurgaon

          Medanta The Medicity Hospital

          Number of beds:  1250
          ICU Beds:                300
          Airport Distance: 18 KMs

          Brief About:

          • Medanta – The Medicity is amongst India’s largest and most renowned multi-super speciality healthcare centre with 1250 beds, 29 super speciality units and more than 800 accomplished doctors.
          • Supported by state-of-art infrastructure, all the departments in the hospital are fully equipped with cutting-edge technology, modular Operation Theatre and modernized monitoring systems in ICUs.
          • The panel of doctors from Medanta, headed by A.S.Soin performed the first successful intestinal transplant in India.

          Dr. Arun Garg

          Dr. Arun Garg

          • Dr. Arun Garg is one of the most respected & renowned neuromuscular surgeons, and currently working as head of the stroke neurology at Medanta, the Medicity.
          • With a thriving experience of over 26+ years and primary focus on stroke, he is famed for developing a three-tier system in north India, where primary and secondary brain rescue centres are connected to hub hospital, Medanta-The Medicity, Gurgaon through network of ambulances and telemedicine.  Read More

          Dr. Sudhir Dubey

          Dr. Sudhir Dubey

          • Currently associated as the Assistant Director at Neurosciences department of MedantaHospital, Gurgaon.
          • Specializes in Endoneurosurgery (Endoscopic Neurosurgery) andhas developed these techniques for brain, skull base and spine. Read More

          Dr. V. P. Singh

          Dr. V. P. Singh

          • He has received Prize for best student in Anatomy, MBBS; second position in Delhi University, B.Sc.; Best paper award at the 4th Annual Indian Epilepsy Association Conference; Best paper award at the 7th Annual Indian Epilepsy Association Conference and Diploma of merit for an excellent poster at 3rd Asian Conference of Neurological Surgeons Nagoya.
          • He is credited with starting Gamma Knife Unit and epilepsy surgery program at AIIMS, New Delhi. Read More
          Dr. Arun Garg Dr. Arun Garg
          Specialist:Neurologist
          Experience:26+ years
          Hospital:Medanta Gurgaon
          Dr. Sudhir Dubey Dr. Sudhir Dubey
          Specialist:Neurosurgeon
          Experience:16+ years
          Hospital:Medanta Gurgaon
          Dr. V. P. Singh Dr. V. P. Singh
          Specialist:Neurosurgeon
          Experience:31+ years
          Hospital:Medanta Gurgaon

          indraprastha apollo hospital

          Indraprastha Apollo Hospital

          No. of beds: 900
          ICU Beds:     262
          Airport:        20kms

          Brief About:

          • Indraprastha Apollo Hospital is a flagship hospital of India’s foremost healthcare groups,the Apollo Group. It is a highly renowned multi-speciality facility that offers tertiary and quaternary care services to domestic and international patients.
          • The 900 bedded hospital is outfitted with the most modern technology for diagnostics as well as therapeutic purposes.
          • A team of highly trained medical professionals work under all the 52 specialities at the hospital.

          Dr. Ravi Bhatia

          Dr. Ravi Bhatia

          • He received the LifeTime Achievement Award from Neurological Society of India in 2010.
          • He was initiated into neurosurgery by Professor Jacob Chandy at CMCH, Vellore. Later he received successful training under Prof. P.N.Tandon at AIIMS and later under the late Prof. Kristian Kristiansen at Oslo (Norway). He also worked with Prof. Ansgar Torvik in Neuropathology and Prof Lars Leksell in Stereotactic Surgery during his stay in Scandinavia. Read More

          dr veena kalra

          Dr. Veena Kalra

          • With an experience of over 37+ years, he has guided over 50 theses.
          • Dr Kalra has done her MBBS from the prestigious Delhi University and MD from the eminent AIIMS, Delhi. Read More

          Dr. Mukul Varma

          Dr. Mukul Varma

          • Dr. Mukul Varma is a Neurologist with 35+ years of experience.
          • Dr. Mukul Varma is a member of Neurological Society of India, Indian Epilepsy Association (IEA), Indian Medical Association (IMA), Indian Menopause Society (IMS), Delhi Medical Association (DMA) and American Academy of Neurology – AAN. Read More
          Dr. Ravi Bhatia Dr. Ravi Bhatia
          Specialist:Neurosurgeon
          Experience:50 years
          Hospital:Apollo New Delhi
          dr veena kalra Dr. Veena Kalra
          Speciality:Ped. Neurologist
          Experience:38 years
          Hospital:Apollo New Delhi
          Dr. Mukul Varma Dr. Mukul Varma
          Specialist:Neurologist
          Experience:35+ years
          Hospital:Apollo New Delhi

          Manipal Hospital

          Manipal Hospital Dwarka

          Number of beds:  380
          ICU Beds:                 118
          Airport Distance: 8 Km

          About Hospital:

          • Manipal Hospital Dwarka is a prominent multi-speciality and quaternary care providing hospital with first-rate healthcare services and integrated facilities.
          • The world-class medical centre is a part of Manipal Education and Medical Group (MEMG), one of India’s forerunner healthcare groups.
          • The group started with one flagship hospital in 1991 and now has bloomed into a network of 15 hospitals with a significant presence in Malaysia.

          Dr. (Lt Gen) CS Narayanan

          Dr.(Lt Gen) CS Narayanan

          • He is among the finest neurosurgeons in India with 33 + years of experience.. Due to his clinical excellence, he has been bestowed with scores of awards.
          • He bagged the Vishisht Seva Medal, Chief of Army Staff commendation, Captain Foundation National Award, and was appointed as the honorary surgeon to the President of India Read More

          Dr. Anurag Saxena

          Dr. Anurag Saxena

          • Dr. Anurag Saxena is a well-known Neurosurgeon practicing for more than 20 years.
          • He holds expertise in Microneurosurgery, Minimally invasive brain/spine surgeries, Hydrocephalus treatment (Endoscopic and CSF diversion), Paediatric neurosurgery (brain, spine and CVJ craniofacial), Neuro-Oncology (brain and spine tumors), Cerebrovascular Surgeries, Functional & complex spine surgeries, Motion preservation spine surgeries, Endoscopic brain/spine surgeries. Read More

          Dr. Khushbu Goel

          Dr. Khushbu Goel

          • Dr Khushbu Goel is a well-known Neurologist practicing for more than 15 years.
          • She holds expertise in treating Epilepsy, Parkinson’s Disease, and many more. Read More
          Dr. (Lt Gen) CS Narayanan Dr. CS Narayanan
          Specialist:Neurosurgeon
          Experience:33+ years
          Hospital:Manipal Dwarka
          Dr. Anurag Saxena Dr. Anurag Saxena
          Specialist:Neurosurgeon
          Experience:20 years
          Hospital: Manipal Dwarka
          Dr. Khushbu Goel Dr. Khushbu Goel
          Specialist:Neurologist
          Experience:15 years
          Hospital:Manipal Dwarka

          Get Opinion From Doctor

            We offers these Services

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            • Selecting the best hospital and doctor as per your case
            • Arranging a call with the doctor (if the case required)
            • Visa assistance, Providing Visa Invitation Letter (VIL)
            • Providing full guidance how to get Visa from your country
            • Providing total cost including treatment, air tickets, accommodation, and food
            • Assitance to book flight ticket from your country
            • Arranging airport pick up/ drop
            • Providing professional language interpreter
            • Booking accommodation and guest house as per your budget/ prefrence
            • Providing help in money exchanging
            • Providing local sim card
            • Arranging video consultation with specialist doctor if case requires
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