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Dr. Prem Pillay , Singapore Brain Spine Nerves Center, Singapore Senior Consultant Neurosurgeon with super speciality training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA) The IASP (International Association for the Study of Pain) defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Chronic Pain is defined as pain that persists for more than 3 months. Chronic discomfort can be either nociceptive or neuropathic. Nociceptive pain is linked with an external stimulus. Neuropathic pain is caused by nerve damage. Neuropathic discomfort occurs in the absence of detectable ongoing tissue damage. Faces – pain scale chart Terms Allodynia Discomfort due to a stimulus which does not normally provoke agony. Analgesia Absence of discomfort in response to stimulation which would normally be painful. Anesthesia Dolorosa  Ache in an area or region which is anesthetic. Causalgia A syndrome of sustained burning discomfort, allodynia, and hyperpathia after a traumatic nerve lesion, often combined with vasomotor and sudomotor dysfunction and later trophic changes. Central Pain Ache initiated or caused by a primary lesion or dysfunction in the central nervous system. Dysesthesia An unpleasant abnormal sensation, whether spontaneous or evoked. Hyperalgesia An increased response to a stimulus which is normally painful. Hyperesthesia Increased sensitivity to stimulation, excluding the special senses. Hyperpathia A painful syndrome characterized by an abnormally uncomfortable reaction to a stimulus, especially a repetitive stimulus, as well as an increased threshold. Hypoalgesia Diminished suffering in response to a normally painful stimulus. Hypoesthesia Decreased sensitivity to stimulation, excluding the special senses. Neuralgia Ache in the distribution of a nerve or nerves. Neuritis Inflammation of a nerve or nerves. Neuropathic Pain Ache initiated or caused by a primary lesion or dysfunction in the nervous system. Neuropathy A disturbance of function or pathological change in a nerve: in one nerve, mononeuropathy; in several nerves, mononeuropathy multiplex; if diffuse and bilateral, polyneuropathy. Nociceptor A receptor preferentially sensitive to a noxious stimulus or to a stimulus which would become noxious if prolonged. Noxious Stimulus  A noxious stimulus is one which is damaging to normal tissues. Pain Tolerance Level The greatest level of discomfort which a subject is prepared to tolerate. Paresthesia An abnormal sensation, whether spontaneous or evoked. Peripheral Neurogenic Suffering initiated or caused by a primary lesion or dysfunction or transitory perturbation in the peripheral nervous system. Peripheral Neuropathic Agony initiated or caused by a primary lesion or dysfunction in the peripheral nervous system. Common Problems Headaches can be caused by muscle tension, migraine, neck problems (cervical disc prolapses) and less commonly by strokes, brain tumors and head injury. Face Pain:  A condition called Trigeminal Neuralgia is caused by pressure on the Vth Cranial nerve next to the brainstem. This is often due to an abnormal position of a blood vessel compressing this nerve. Rarely tumors and arteriovenous malformations can cause this problem. Neck and Back Pain:  This can be caused by slipped discs or herniated discs, spine tumors and spine infection which press on nerve roots in the spine. Other causes include facet degeneration and bony spurs pressing on the nerve roots. Chemicals produced by degenerating discs can also be a cause of such discomfort. Instability in the spine can cause a severe agony. This can be degenerative or subsequent to an injury. Sciatica:  This refers to an ache shooting down a leg. This is often a sign of nerve root compression by a slipped disc. Hand Pain:  This can be caused by herniated discs in the neck or by thickened ligaments pressing peripheral nerves in the wrist – carpal tunnel syndrome (median nerve) or in the elbow-cubital tunnel syndrome (ulnar nerve). Other syndromes:  Reflex sympathetic dystrophy (RSD), fibromyalgia, amputation/phantom pain, post-herpetic neuralgia, brachial/lumbar plexus avulsion pain, T2 syndrome etc. Conclusions It is important to determine the root causes of pain and not just treat the symptoms. There are causes of pain that if not found early could lead to nerve damage and weakness or paralysis. A detailed clinical and neurological examination is needed by a Neurosurgeon and Pain expert. This is followed by selecting the appropriate tests to find the source of the pain. These tests include one or more of the following: X-rays of the spine and/or limbs MRIs (Magnetic Resonance Imaging) of the Spine, Nerves in the limbs, or the Brain Nerve Conduction Tests (NCS) and ElectroMyography (EMG) Blood tests for biomarkers of inflammation, infection or cancer CT (computed tomography) of painful areas Your Neurosurgeon will then determine the pain source and design less invasive or non invasive treatments including more advanced anti pain agents, and day procedures to treat the root cause of the pain.

Dr. Prem Pillay , Singapore Brain Spine Nerves Center, Singapore Senior Consultant Neurosurgeon with super speciality training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA) What is It and How Can You Get it Cured? Arm, shoulder and hand pain is occurring more frequently in modern life. Dr. Prem Pillay a Spine, shoulder-arm-pain Nerve & Pain Specialist  in Singapore, states that this is from several factors including our lifestyle and work style of the 21st Century. This results in stress and strain to the neck, shoulder, arms and hands. Consequently, pain and stiffness and nerve pressure can occur at these locations resulting in difficulty with work and sports activities. The overuse of Computers and Mobile devices including smartphones and iPhones is an important factor in causing arm related pain, states Dr. Prem Pillay. With computer use and poor posture, stress can accumulate in the neck causing cervical spine/neck disc protrusions that can press on or irritate nerves that run down the arm. Neck and arm pain can result. Sports activities like tennis, badminton, golf, weight training, gymnastics, horse riding, martial arts (judo, karate, TKD, jujitsu, kendo, etc.), rugby, football, etc. can also result in arm and neck injuries that can cause arm and hand pain. Even activities like yoga and pilates, if not done correctly, or from incorrect instruction can result in injury. Localized arm pain in the shoulder, elbow or wrist can be from a nerve compression in the arms, elbows or hands; a joint capsule strain or tendon injury or from a Pinched nerve from the neck of the spine called the Cervical Spine. Other causes include a muscle strain or tear. Partial injuries may heal with rest. The principles of treatment include RICE: rest, ice, compression and elevation for an acute injury. Repetitive stress injury (RSI) is associated with office work especially with computers and with some types of manual work even in artists and musicians. When injuries are mild and associated with mild nerve injury or  partial tears, anti-inflammatory pain medications, muscle relaxants, and physiotherapy with heat, ultrasound or lasers can assist recovery states Dr. Prem Pillay. Many people try traditional message, chiropractors and massage therapists for these pains. If the pain does not improve after three visits or becomes more painful anytime during or after therapy you should immediately seek help from a proper Medical Spine and Nerve Specialist. Dr. Prem Pillay states that the proper medical examination and tests can usually accurately determine the cause of the arm pain and whether it is from the Nerves or from the muscles or joints. Nerve problems are potentially more serious and can lead to weakness or paralysis and should be look for carefully by a Spine and Pain expert specialist.  Pain in the shoulder can be from localized problems such as a frozen shoulder, partial tears of the rotator cuff, joint cartilage injuries, and muscle tears/strains. In the elbow, a tennis elbow causing pain on the outside or a golfer’s elbow causing pain on the inside are common. In the hand, a condition called De Quervain’s tenosynovitis can cause pain at the base of the thumb and wrist. Another cause of pain in the hand, wrist and fingers can be caused by nerve pressure on the median nerve in the wrist by thickened ligaments. This is called Carpal tunnel Syndrome. Nerve pressure from a slipped disc in the neck can cause pain in the shoulder, elbow and down the arm to the fingers. Nerve related pain can be quite disturbing and disabling. Dr. Prem cautions that it is important to distinguish pain from a pinched nerve from a muscle sprain. A pinched nerve is often more serious and could spread to more muscles causing not only pain but weakness as the nerve pressure increases. Nerve pain that radiates down the arm is called radiculopathy. Brachalgia is a general term for arm and shoulder pain. Radicular pain can be associated with tingling, and numbness in the area of pain going down the arm to the fingers. Medications and physiotherapy can be helpful once the diagnosis has been confirmed states Dr. Prem Pillay. However if nerve pressure is found, pain relief alone is often not enough. It is important to reduce nerve pressure so that is does not result in weakness or paralysis. If the nerve is compressed severely or for too long, recovery may not occur or be incomplete despite surgery. If the problem is found early, modern methods include laser and superior to laser day treatments without surgery, superior to laser treatments for spine disc problems without surgery through special injections can reduce nerve pressure. For carpal tunnel syndrome endoscopic release or direct microscopic release can be effective. Cervical spine disc problems that are more serious may require Microsurgery including minimally invasive spine surgery techniques to remove the disc protrusion or herniated disc that is pressing the nerves. A disc replacement is often done at the same time. Dr. Prem Pillay, states that modern spine surgery and no surgery (open) Spine procedures can be done safely and effectively if the specialist is experienced, well trained and qualified. With many years of experience in treating arm pain, shoulder pain and hand pain; and access to the latest technological advancements, Dr Prem Pillay endevours to offer patients the highest standard of care. From accurate diagnosis to tailored treatment plans, our approach aims for the best possible outcomes for individuals affected by this challenging condition. If you or a loved one has been diagnosed with this problem, we welcome you to seek consultation with our specialized team. Together, we can develop a comprehensive evidence based and personalized treatment strategy that addresses your unique needs and provides the best chance for a positive outcome.

Dr. Prem Pillay , Singapore Brain Spine Nerves Center, Singapore Senior Consultant Neurosurgeon with super speciality training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA)  Peripheral nerve tumors are a heterogeneous group of neoplasms that arise from or affect nerves outside the brain and spinal cord [4][8]. According to the 2021 WHO classification of the Central Nervous System (CNS), peripheral nerve sheath tumors (PNSTs) comprise a set of unique entities each with specific clinical, anatomical, histological, and molecular features [1]. Broadly, PNSTs can be subdivided into benign and malignant forms, often reflecting differences in their behavior, prognosis, and recommended treatments. Benign Peripheral Nerve Sheath Tumors Schwannoma Schwannomas originate from Schwann cells, which form the myelin sheath of peripheral nerves [1][8]. Most schwannomas are benign and can appear anywhere along peripheral nerves. Variants include plexiform schwannoma, which can arise in superficial or deep sites and may be challenging to distinguish from more aggressive lesions if they show atypical features [1][8]. Multiple schwannomas may be associated with NF1 (Neurofibromatosis). Patients with a peripheral nerve schwannoma may need to have screening of other nerves with MRI of the whole spine and Brain with gadolinium contrast to rule out multiple nerve tumors at other locations. Neurofibroma  Neurofibromas also arise from Schwann cells, typically featuring other non-neoplastic cellular components (e.g., fibroblasts, perineurial cells) [8]. A distinct subtype is the plexiform neurofibroma , often linked to neurofibromatosis type 1 (NF1). Plexiform neurofibromas can transform into malignant peripheral nerve sheath tumors (MPNSTs) and therefore warrant close monitoring [1][8]. Perineurioma and Hybrid Nerve Sheath Tumors  Perineuriomas exhibit differentiation toward perineurial cells, while hybrid nerve sheath tumors can show areas of both schwannoma and neurofibroma (or other) histology [1][8]. These tumors are relatively rare but are increasingly recognized due to improved molecular diagnostics. Malignant Peripheral Nerve Sheath Tumors (MPNST) MPNSTs are aggressive soft-tissue sarcomas accounting for about 10% or slightly more of all peripheral nerve sheath tumors [4][5]. They may arise sporadically or in association with NF1 or prior radiation therapy [1][5]. MPNSTs often present with a high risk of local recurrence and metastasis, with the prognosis highly dependent on complete surgical resection and the tumor’s stage at diagnosis [5][10]. Clinical Presentation and Diagnosis Peripheral nerve tumors can present with: -Localized or diffuse swelling along the nerve path – Neurological deficits such as numbness, pain, tingling, or muscle weakness in an arm or leg – Positive Tinel or Hoffman-Tinel sign , indicative of nerve irritation [4] Imaging studies are central in delineating the location and extent of the tumor: Magnetic Resonance Imaging (MRI)  Considered the gold standard for visualizing peripheral nerve tumors, MRI provides high-resolution images that can define the relationship between the tumor and adjacent structures [1][2][7]. Certain MRI sequences (such as diffusion-weighted imaging) are investigated for differentiating benign from malignant lesions [5]. Computed Tomography (CT) Can be used to further assess bony involvement or complex anatomical regions, supplementing MRI findings [2]. Positron Emission Tomography (PET)  Useful in more complex cases, particularly for detecting malignant transformation and metastatic spread, although its use is often guided by specific clinical scenarios [1][8]. Electromyogram (EMG)  EMG and nerve conduction studies can help assess the functional impact on the peripheral nerve [2]. Biopsy  A core or excisional biopsy is typically performed to confirm histopathology, determine tumor grade, and guide treatment decisions [2][7][8]. Treatment Approaches Watchful Waiting In asymptomatic, slowly growing, small benign peripheral nerve tumors (usually a few mm in size) a watch-and-wait approach (also called “monitoring”) may be considered if they do not threaten function [3][7]. Periodic MRI or other imaging helps track any changes in size or symptoms, and treatment can be initiated if the tumor grows or becomes symptomatic. Surgery Micro-surgical resection remains the mainstay of therapy for most peripheral nerve tumors, both benign and malignant [3][4][7][10]. In benign lesions such as schwannomas or neurofibromas, careful microsurgical removal can often be curative. For MPNSTs, wide surgical margins are crucial for potential cure [10] with nerve grafting where required. However, surgical planning must balance tumor removal with functional nerve preservation. Radiotherapy – Adjuvant Radiotherapy: Often recommended for malignant peripheral nerve sheath tumors with larger lesion sizes or aggressive histological features [10]. It can also be used if resection margins are close to the spinal cord or large nerve plexus or if a tumor is not fully resectable. – Stereotactic Radiosurgery: Precisely delivers radiation to limit damage to nearby structures. It is     used for tumors along cranial nerves or near to the Spinal Cord or if a tumor is not fully resectable without causing functional issues[2][3][7]. Chemotherapy Chemotherapy sensitivity varies among peripheral nerve tumors. MPNSTs , unfortunately, do not respond robustly to conventional chemotherapy, though anthracycline-based regimens may be tried in inoperable or metastatic settings [1][9]. In NF1-associated tumors, chemotherapy or newer targeted agents may be considered, particularly in children with symptomatic plexiform neurofibromas [1][5]. Targeted and Molecular Therapies Research into molecular pathways involved in PNSTs, especially MPNSTs, has propelled the exploration of targeted agents: MEK Inhibitors  Selumetinib is approved for children ≥2 years with NF1-related plexiform neurofibromas that are inoperable or symptomatic, demonstrating tumor shrinkage in some cases [1][5]. Other MEK1/2 inhibitors are under clinical investigation. mTOR Inhibitors Combinations of MEK and mTOR inhibitors are being tested to broaden therapy options and potentially reduce tumor growth [1][5]. Immunotherapy and Other Targeted Pathways  Emerging evidence suggests that immunomodulatory approaches or other molecularly guided treatments may benefit a subset of aggressive MPNSTs, though these remain experimental [5]. Clinical trials continue to assess efficacy. Latest Innovations and Future Directions Molecular Diagnostics : Advanced genetic profiling (e.g., next-generation sequencing) helps distinguish between atypical neurofibromas and early malignant transformation [8]. Improved understanding of tumor biology is critical for identifying actionable targets. Refined Imaging Techniques : Sophisticated MRI protocols, including diffusion-weighted imaging and contrast-enhanced sequences, improve the detection and characterization of subtle nerve lesions and can aid in surgical planning [1][5]. Minimally Invasive Surgical Techniques : Refined microsurgical instruments and computer-assisted navigation allow safer resections with enhanced functional preservation [7]. Combination Therapies : Ongoing clinical trials are exploring the combined use of targeted drugs (MEK, mTOR inhibitors) and traditional treatments (radiotherapy, chemotherapy) to improve outcomes in MPNSTs [1][5]. Conclusion Peripheral nerve tumors, encompassing benign entities such as schwannomas and neurofibromas and malignant variants like MPNSTs, represent a diverse group requiring careful workup and multidisciplinary treatment. Accurate diagnosis via imaging and biopsy, alongside precision surgical techniques, can often lead to remission in benign lesions and offer the best chance for disease control in malignant ones. Meanwhile, current innovations in targeted therapy, molecular diagnostics, and radiation approaches hold promise for improving outcomes in these rare yet complex tumors [1][5][7][8][10]. Dr Prem Pillay explains that ongoing research and collaboration among neurosurgeons, neuroscientists, and patient advocacy groups are essential to further refine therapies, minimize side effects, and enhance quality of life for individuals with peripheral nerve tumors. With many years of experience in treating peripheral nerve tumors and access to the latest technological advancements, Dr Prem Pillay endevours to offer patients the highest standard of care. From accurate diagnosis to tailored treatment plans, our approach aims for the best possible outcomes for individuals affected by this challenging condition. If you or a loved one has been diagnosed with a peripheral Nerve Tumor , we welcome you to seek consultation with our specialist and his team. Together, we can develop comprehensive evidence based and personalized treatment strategy that addresses your unique needs and provides the best chance for a positive outcome. References: [1] https://pmc.ncbi.nlm.nih.gov/articles/PMC10093509/ [2] https://www.mayoclinic.org/diseases-conditions/peripheral-nerve-tumors/diagnosis-treatment/drc-20355075 [3] https://www.uofmhealthsparrow.org/departments-conditions/conditions/peripheral-nerve-tumors [4] https://pmc.ncbi.nlm.nih.gov/articles/PMC11031624/ [5] https://pmc.ncbi.nlm.nih.gov/articles/PMC9954030/ [6] https://www.ohsu.edu/brain-institute/nerve-tumors [7] https://neurosurgery.weillcornell.org/condition/peripheral-nerve-sheath-tumors/treatment-peripheral-nerve-sheath-tumors [8] https://pmc.ncbi.nlm.nih.gov/articles/PMC3629555/ [9] https://www.cancerresearchuk.org/about-cancer/soft-tissue-sarcoma/types/malignant-schwannoma [10] https://pubmed.ncbi.nlm.nih.gov/25777573/

Dr. Prem Pillay , Singapore Brain Spine Nerves Center, Singapore Senior Consultant Neurosurgeon with super speciality training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA)  Back pain; including neck pain, mid back and low back pain is an increasingIt is normal for those who suffer from back pain to take pain killers. Unfortunately, it is not a good plan to depend on pain relief by taking these medications for too long. Side effects and dependence may occur. NSAIDs are associated with gastritis, esophagitis and gastriculcers and bleeding. Alternatives to pain killers are present in our modern world. It is important though, cautions Dr. Prem Pillay, for those with persistent pain to seek proper medical advice. If physical therapy such as massage, traditional manipulation or treatments are tried and pain relief does not occur satisfactorily by three sessions, you should see a specialist dealing with that problem.  For instance, if back pain is troubling and persists see a medically trained spine specialist explains Dr Prem as we can find the root cause of the pain which could be from Slipped Spine Discs pressing the spine nerves, infection of the spine or even spine tumors including the spread of cancer . The application of the principles of RICE (Rest, Ice, Compression, Elevation) can be used for acute injuries causing pain. For more persistent pain, the use of heat from hot pads and even a hot shower or bath or a hot sauna can relieve pain. In ancient times people traveled to hot springs to relieve their body aches and pains! There are several types of foods that can reduce inflammation or swelling and relieve pain. Ginger has been known for thousands of years as useful for its anti-inflammatory properties. Sage is a herb with anti-inflammatory action as it contains flavonoids. Both ginger and sage can be used in cooking as in the preparation of a chicken dish! One cup of Black coffee in the morning can reduce pain, including headaches. It is rich in anti-oxidants. Tea including green tea is also rich in anti-inflammatory substances including anti-oxidants that can reduce pain. Fish, especially salmon, is rich in omega-3 which can fight inflammation and help with the joints. In general, colorful fruits and plants are more likely to have natural biochemical agents that can reduce pain. This includes cherries, carrots and beetroot. This is not an exhaustive list of foods. There are many others as well as herbs that are helpful. Drinking plenty of water, for example, will hydrate the body including the muscles and reduce muscle tension, states Dr. Prem Pillay. This can reduce neck pain and back pain. Removing bad habits can also reduce pain, states Dr. Prem Pillay. Smoking can make chronic pains, including back pain, worse. For those who have had spine procedures, smoking can obstruct a good recovery by slowing bone and tissue healing. Lack of sleep is also a factor that if corrected can help with pain. A restful 7-9 hours of sleep can reduce pain the next day. Losing weight can reduce stress on the back. A healthy diet with the adequate right exercises not only can help with weight reduction but can also help strengthen postural and core muscles that support the spine, explains Dr. Prem Pillay, a Spine Specialist. Stress is especially common in our modern lives and is an important factor to control to reduce pain. Having a positive outlook, adequate sleep and regular exercise can reduce stress. Even the action of laughing can be positive. There are laughter clubs (first started in India) where people meet and just practice laughing. Being with friends who can make us happy and laugh is perhaps a simpler alternative. Meditation can also reduce stress. It can be done in a non religious way by finding a quiet place, closing your eyes and thinking of a simple pleasant experience. Or by visualizing a point of light like a candle and trying not to let random thoughts interfere.

Dr. Prem Pillay , Singapore Brain Spine Nerves Center, Singapore Senior Consultant Neurosurgeon with super speciality training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA)  instability (CCI) refers to excessive movement or instability at the junction between the skull and the upper cervical spine. This condition can occur in adults and children. The common symptoms include neck pain, headaches, dizziness and neurological symptoms. This condition can arise from congenital malformations, and connective tissue disorders such as Ehlers-Danlos Syndrome (EDS),  Down syndrome, Morquio syndrome. CCI/CVI is associated with a range of neurological and musculoskeletal symptoms Symptoms and Signs Common Symptoms Severe headache especially at the back of the head and neck pain are hallmark symptoms, often accompanied by neurological complaints including numbness, muscle weakness, difficulty in coordination and gait problems. Cervico-medullary symptoms such as vertigo, dizziness, imbalance, and walking difficulties are frequently reported. Cognitive difficulties include memory problems, Brain Fog, and concentration difficulties. Lower cranial nerve deficits may manifest as speech difficulties, dysphagia, sleep apnea and tinnitus. Spinal cord and nerve compression (Myelopathy and radiculopathy) can present as weakness, numbness, and sensory loss in the arms and legs. Autonomic symptoms like syncope, nausea, and orthostatic intolerance (fainting spells) are also described. Medical Evaluation and Diagnosis is best carried out by a Neurosurgeon with expertise in this condition. It may be overlooked, misdiagnosed or ignored until the condition is more severe. Clinical Signs Weakness in arms and legs (Quadriparesis) or quadriplegia in severe cases. Abnormal head posture (torticollis) and abnormal neurological examination findings. .Myelopathy may show up as gait imbalance, muscle tightness and weakness and increased reflexes (hyper-reflexia). In some cases, the clinical exam may be normal but an experienced Neurosurgeon can order the right and appropriate tests to find radiological evidence of instability Diagnostic Tests Imaging Modalities Dynamic X-rays and CT scans are primary tools for detecting instability, especially with flexion and extension views. MRI is used to assess spinal cord integrity and compression, and can be performed in weight-bearing, flexion, and extension positions for more detailed evaluation. Radiographic Parameters: The most frequently used measurements for diagnosis and surgical decision-making include: Clivo-axial angle (CXA) Harris measurement Grabb–Mapstone–Oakes measurement Angular displacement of C1 to C2. Atlanto-dental interval and basion-axial interval are also assessed, with recent research providing normative data for these measurements in healthy populations to improve diagnostic accuracy. Treatment Options Non-Surgical Management Observation and regular imaging are recommended for asymptomatic patients especially those without much radiological instability. Spine rehab management including physiotherapy and cervical collars may be used in select cases, particularly in children or adults with mild symptoms. Spine injections including nerves and facets injections to reduce inflammation and pain can be used for select patients. Surgical Treatment Occipito-cervical fusion (OCF) or C1-C2 fusion are the main surgical interventions for patients with clear radiographic instability and concordant symptoms. Open reduction and stabilization are performed to correct deformity and restore stability, often using autografts for fusion. Surgical outcomes: Studies report significant improvements in pain, neurological function, and quality of life following surgery, with high patient satisfaction and low surgical morbidity. Special Considerations Syndromic patients (e.g.,EDS,  Down syndrome, Morquio syndrome) require close neurological and radiological screening, with annual exams and imaging recommended for early detection. Sports participation: Patients without instability or neurological symptoms can participate in sports, while those with instability may require preventive stabilization. Conclusion Cranio-cervical instability is a complex condition with diverse symptoms and significant diagnostic challenges states Dr Prem Pillay. Dynamic imaging and specific radiographic measurements are essential for accurate diagnosis. No surgery treatment can be used for selected patients with mild symptoms. Surgical intervention, particularly occipito-cervical fusion, offers substantial benefits for appropriately selected patients. Early recognition and diagnosis remains an important issue as this condition is often overlooked by most doctors. With many years of experience in treating Cranio-Cervical Instability  including complex forms and access to the latest technological advancements, Dr Prem Pillay endeavours to offer patients the highest standard of care. From accurate diagnosis to tailored treatment plans, our approach aims for the best possible outcomes for individuals affected by this challenging condition. If you or a loved one has been diagnosed with Cranio-Cervical Instability, we welcome you to seek consultation with our specialized team. Together, we can develop a comprehensive evidence based and personalized treatment strategy that addresses your unique needs and provides the best chance for a positive outcome.

Dr. Prem Pillay , Singapore Brain Spine Nerves Center, Singapore Senior Consultant Neurosurgeon with super speciality training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA)  Laser spine surgery and procedures refers to the use of a variety of technologies including lasers and Super Laser : superior to laser energy to treat spine disorders. The Spine Conditions that may be treated include: Spine Disc disease, Disc bulges, Disc protrusions, Herniated Spine Discs, Spine Disc Extrusions. Spine Spondylosis and Stenosis and tears of the Annulus. Spine Tumors such as Spine Metastases, Neuromas, Schwannomas, Ependymomas,and others. The different types of Laser Spine Surgery and Procedures may include: Percutaneous Needle and Micro-Needle Laser and Super Laser Discoplasty, Disectomy , Nucleoplasty, Annuloplasty(PLD, PLN) Percutaneous Endoscopic Laser Discetomy (PELD) Percutaneous Endoscopic Laser Foraminoplasty (PELF) Microsurgical Laser Disectomy (MLD) Microsurgical Laser Discoplasty (MLDO) Microsurgical Laser Nucleoplasty (MLN) Microsurgical Laser Spinal Tumor Resection (MLSTR) There are several different types of Laser systems that include: Holmium Lasers Thulium Lasers Nd-Yag Lasers4. CO2 Lasers There are also some new “Super Lasers” (Potentially superior to Laser Energy devices) that can be used that include: Plasma Energy EMF-PAL Energy In general the use of Laser spine surgery and superior to Laser spine procedures in a minimally invasive fashion allows spine surgery and no surgery spine procedures to be done quickly, often as a day procedure with return home the same day, frequently with no stitches required because of the small openings, much less pain and post-operative discomfort and lower surgical exposure risks. These treatments can also be quite effective for treating a variety of spine disorders

Dr. Prem Pillay , Singapore Brain Spine Nerves Center, Singapore Senior Consultant Neurosurgeon with super speciality training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA)  Advantages Over Fusion Lumbar spine disc replacement (TDR) is increasingly recognized as a viable and excellent alternative to spinal fusion for treating degenerative disc disease (DDD). One of the primary advantages of TDR over fusion is the preservation of spinal motion, which can reduce the risk of adjacent segment degeneration—a common issue with fusion procedures. TDR has been shown to result in higher patient satisfaction and lower reoperation rates compared to fusion. Additionally, TDR patients often experience greater improvements in disability indices and back pain scores. Indications and Contraindications TDR is typically indicated for patients with single-level lumbar DDD who have not responded to conservative treatments. It is most suitable for patients without significant facet joint arthritis or spinal deformities. Contraindications include severe osteoporosis, spinal infections, and significant spondylolisthesis (grade 2 or higher). Patients with multi-level DDD or severe facet joint degeneration may not be ideal candidates for TDR. Types of Implants Several types of artificial discs are used in TDR, including the Charité, ProDisc, and Flexicore discs. Each has unique design features aimed at mimicking the natural motion of the spine discs. The Charité disc has been shown to be non-inferior to traditional fusion methods in terms of clinical success. The ProDisc has demonstrated statistically significant effectiveness compared to lumbar circumferential fusion. The choice of implant often depends on the specific anatomical and clinical needs of the patient. Implants are made from several different types of materials including high grade titanium, Cobalt Chromium alloys, Ceramics, Polyethylene, PVA-BC composites. Success Rates The success rates of TDR are generally favorable, with many studies reporting outcomes comparable to or better than those of fusion. For instance, TDR has been associated with higher rates of clinical success and patient satisfaction at both 2-year and 5-year follow-ups. However, the overall success rates can vary depending on the specific implant used and the surgical technique. Future Innovations Future innovations in TDR may focus on improving implant materials and designs to enhance durability and mimic natural disc biomechanics more closely. There is ongoing research into posterior-based motion-preserving options that address both disc and facet joint pathology, potentially expanding the indications for TDR. Additionally, advancements in surgical techniques and imaging technologies may improve the precision and outcomes of TDR procedures. Conclusion Lumbar spine disc replacement offers several advantages over traditional fusion, including motion preservation and reduced risk of adjacent segment degeneration. While TDR is not suitable for all patients, it provides a promising alternative for those with specific indications. Continued research and innovation are likely to expand the applicability and success of TDR in the future. References Comparison of Lumbar Total Disc Replacement With Surgical Spinal Fusion for the Treatment of Single-Level Degenerative Disc Disease: A Meta-Analysis of 5-Year Outcomes From Randomized Controlled TrialsTotal disc replacement (TDR) offers several clinical advantages over fusion for lumbar degenerative disc disease, such as greater likelihood of success, patient satisfaction, and lower risk of reoperation. 2017·69Citations·J. Zigler et al. · Global Spine Journal Total disc replacement surgery for symptomatic degenerative lumbar disc disease: a systematic review of the literatureTotal disc replacement surgery has no clinical relevant differences with lumbar fusion techniques, and overall success rates in both treatment groups were small. 2010·221Citations·K. D. van den Eerenbeemt et al. · European Spine Journal Lumbar disc replacement surgery—successes and obstacles to widespread adoptionLumbar disc replacement surgery has shown satisfactory long-term results. 2017·62Citations·S. Salzmann et al. · Current Reviews in Musculoskeletal Medicine Advanced meta-analyses comparing the three surgical techniques total disc replacement, anterior stand-alone fusion and circumferential fusion regarding pain, function and complications up to 3 years to treat lumbar degenerative disc diseaseTotal disc replacement (TDR) is considered the most appropriate surgical technique for treating lumbar degenerative disc disease, followed by anterior lumbar interbody fusion (ALIF). 2021·9Citations·Susanne A.J. Lang et al. · European Spine Journal Total disc replacement compared to lumbar fusion: a randomised controlled trial with 2-year follow-upTotal disc replacement (TDR) was superior to spinal fusion in clinical outcome one year after surgery. 2009·169Citations·S. Berg et al. · European Spine Journal A Novel Lumbar Total Joint Replacement May be an Improvement Over Fusion for Degenerative Lumbar Conditions: A Comparative Analysis of Patient-Reported Outcomes at One Year.A novel, posterior-based lumbar total joint replacement (LTJR) showed significant improvement in back and leg pain at one year compared to TLIF for degenerative lumbar conditions. 2020·12Citations·J. Alex Sielatycki et al. · The spine journal : official journal of the North American Spine Society A meta-analysis of artificial total disc replacement versus fusion for lumbar degenerative disc diseaseTDR does not show inferiority for the treatment of lumbar DDD compared with fusion. 2010·88Citations·Wu Yajun et al. – European Spine Journal Lumbar Disc Replacement Versus Interbody Fusion: Meta-analysis of Complications and Clinical Outcomes.Both lumbar disc replacement (LDR) and interbody fusion (IBF) procedures offer similar results in managing lumbar disc disease, with LDR showing slightly superior back pain improvement. 2024·1Citations·Mohammad Daher et al. · Orthopedic reviews Artificial total disc replacement versus fusion for lumbar degenerative disc disease: an update systematic review and meta-analysis.TDR is superior in improved clinical success, reduced pain, shortened hospital stay, and operating time compared to fusion, but does not benefit from blood loss. 2018·38Citations·Yu-Zhe Li et al. · Turkish neurosurgery Comparison of Total Disc Replacement with lumbar fusion: a meta-analysis of randomized controlled trials.Total Disc Replacement (TDR) shows significant superiority for the treatment of lumbar Degenerative Disc Disease (DDD) compared to lumbar fusion at 2 years. 2015·31Citations·Hong-fei Nie et al. · Journal of the College of Physicians and Surgeons–Pakistan : JCPSP

Dr. Prem Pillay , Singapore Brain Spine Nerves Center, Singapore Senior Consultant Neurosurgeon with super speciality training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA)  Dr Prem Pillay , a Spine Specialist states that everyone’s spine has natural curves. These curves round our shoulders and make our lower back curve slightly inward. Some people have spines that also curve from side to side. Unlike poor posture, these curves cannot be corrected simply by learning to stand up straight.  Scoliosis is one of the biggest offenders. This condition of side-to-side spinal curves is called scoliosis. On an x-ray, the spine of an individual with such a condition looks more like an “S” or a “C” than a straight line. Some of the bones in a scoliotic spine also may have rotated slightly, making the person’s waist or shoulders appear uneven. If the curve is from back to front, or bent forwards it is called a Kyphosis. Who gets a crooked back? Dr Prem states that Scoliosis affects approximately 2% of the population. If someone in a family has this condition, however, the likelihood of an incidence is much higher-approximately 20%. If anyone in your family has curvature of the spine, you should be examined for scoliosis. Children Most scoliosis is “idiopathic,” meaning its cause is unknown. It usually develops in middle or late childhood, before puberty, and is seen more often in girls than boys. Although scoliosis can occur in children with cerebral palsy, muscular dystrophy, spina bifida, and other miscellaneous conditions, most scoliosis is found in otherwise healthy youngsters. Kyphosis is children can be from spine infections like Tuberculosis (TB) or from spine tumors. Adults Scoliosis usually develops during childhood, but it also can occur in adults. Adult scoliosis may represent the progression of a condition that actually began in childhood and was not diagnosed or treated while the person was still growing. What could have started out as a slight or moderate curve may have progressed in the absence of treatment. Dr Prem Pillay also states that adult scoliosis can be caused by the degenerative changes of the spine. Other spinal deformities such as kyphosis or round back are associated with the common problem of osteoporosis (bone softening). As more people in the United States and Singapore reach the age of 65 years or older, the incidence of scoliosis and kyphosis is expected to increase. A sudden fall in an older person can result in a spine fracture causing sudden kyphosis says Dr Prem. This may require urgent treatment using small needles to introduce a medications to repair the spine fracture. This can be done without open surgery as a day procedure. If allowed to progress, severe instances of adult scoliosis and kyphosis can lead to chronic severe back pain, deformity, and difficulty in breathing. This may require spine surgery to correct and to prevent nerve damage. The Importance of Early Detection: Tips For Parents Idiopathic scoliosis can go unnoticed in a child because it is rarely painful in the formative years. Therefore, parents should watch for the following warning signs of scoliosis when their child is about 8 years of age: Uneven shoulders Prominent shoulder blade or shoulder blades Uneven waist Elevated hips Leaning to one side Any one of these signs warrants an examination by a Spine specialist states Dr Prem. Some schools sponsor scoliosis screenings. Although only a physician can accurately diagnose scoliosis, school screenings can help alert parents to the presence of the warning signs in their child. Treatment In planning treatment for each child, Dr Prem Pillay states that as a Spine expert he will carefully consider a variety of factors, including the history of scoliosis in the family, the age of the child when the curve began, and the location and severity of the curve. Most spine curves in children with this condition will remain small and need only to be periodically assessed for any sign of progression. If a curve does progress, a spine brace can be used to prevent it from getting worse. Children undergoing treatment with spine braces can continue to participate in a full range of physical and social activities. Modern spine braces allow more mobility than the older rigid ones and can be custom made and modified as the child grows. If a scoliotic curve is severe when it is first seen, or if treatment with a spine brace does not control the curve, surgery may be necessary. In these instances, surgery has been found to be a highly effective and safe treatment for scoliosis and massage therapy or manupilations has not been shown to be effective. Summary Scoliosis is a common problem that usually requires only observation with repeated examination in the growing years. Early detection is important to make sure the curve does not progress. In the relatively small number of patients who require medical intervention, advances in modern spine techniques have made scoliosis a highly manageable condition. Kyphosis can occur suddenly in older people with osteoporosis and may need special spine injections and medications to treat effectively says Dr Prem Pillay.

Dr. Prem Pillay , Singapore Brain Spine Nerves Center, Singapore Senior Consultant Neurosurgeon with super speciality training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA)  Spinal degenerative conditions have been treated mainly by routine physical therapy and analgesics. Patients who have failed conservative treatment have been treated with surgery including discectomy and fusion. Unfortunately, the overall results of such treatments has not been good enough; although perhaps acceptable in the 20th century. There are now modern and technologically more advanced options for our patients with degenerative disc disease, spinal stenosis and segmental instability. In our own practice, one advance has been the development of a multidisciplinary spine and pain center. In this one stop center, the patient has access to the full range of specialties needed for successful spine treatment. This includes neurosurgery, orthopedic surgery, pain management, neurology, neuro-radiology, neuroanesthesiology, physiotherapy, pharmacetics / pharmacology and psychology. In the initial stages for patients with milder problems, the proper selection of pain medications together with more advanced physiotherapy including aquatherapy/aquaphysio is recommended. Patients who do not benefit from the initial spine therapy program will be reviewed by the team and additional tests or MRIs may be done. Selected patients may then benefit from pain procedures, such as nerve blocks (epidural, facet, nerve root, etc.). There is also a group of patients who may benefit from disc interventions such as Discoplasty / Nucleoplasty. These interventions are carried out under local anesthesia as needle procedures with image-guidance including biplanar fluoro and 3D CT guidance. For those patients in whom surgery is felt to be the better option, there are less invasive options as well. Microsurgery, Endoscopic Microsurgery and Microsurgical Spinal Decompression which can relieve and release spinal cord/nerve root/cauda equine pressure can now be supplemented by non-fusion technologies to strengthen the spine. Fusion can be avoided in an increasing number of surgical candidates. Fusion at any one level of the spine has been shown to increase stress and degeneration at adjacent segments. Fusion disease is also difficult to treat. Dynamic implants are now an important part of spine surgery and allow a return to more normal spinal dynamics. Intraoperative image guidance and neuro-monitoring together with advances in microsurgery (including now robotics) are also making contributions to better results and increased safety in spinal surgery. Dr. Prem Pillay is a Senior Consultant Neurosurgeon at Singapore-Brain-Spine-Nerves Center of Mount Elizabeth and Gleneagles Medical Centers, Singapore. For more information about this, visit  neurospine.blogspot.com .

Dr. Prem Pillay , Singapore Brain Spine Nerves Center, Singapore Senior Consultant Neurosurgeon with super speciality training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA)  Causes of Spinal Cord Injury Spinal cord injuries (SCIs) can result from both traumatic and non-traumatic events. Traumatic SCIs are most commonly caused by: Motor vehicle accidents: These are the leading cause, accounting for nearly half of new SCIs each year[6]. Falls: Particularly prevalent in individuals over 65 years old[6], but it can also be a cause in young adults. Acts of violence: Including gunshot and knife wounds[6]. Sports and recreation injuries: Football, diving, motorsports, skiing, bicycling/motorcycling, mountaineering and other high-impact sports are notable contributors[2]. Non-traumatic causes include infections, tumors, degenerative diseases, ischemia-reperfusion injuries, and congenital conditions[5]. The spinal cord, a critical conduit for nerve signals between the brain and the rest of the body, when damaged, can lead to significant loss of function and mobility[4]. Diagnosis and Classification Diagnosis of SCI typically involves: Physical Examination : To assess motor and sensory function. Imaging Studies: X-Rays of the Spine, MRI and  CT scans are used to visualize the extent of damage. MRI is particularly useful for detecting lesions, ischemia, and hemorrhage[7]. Classification of SCIs is based on: Level of Injury: Cervical, thoracic, lumbar, or sacral, which determines the extent of paralysis or loss of sensation. Completeness: Complete injuries (Tetraplegia, Paraplegia )result in total loss of function below the injury site, while incomplete injuries (Tetraparesis, Paraparesis) allow some function to remain[2]. Treatment Options Immediate Care and Surgery Spine Surgery Including Minimally Invasive Surgery and Microsurgery is often necessary to remove bone fragments, foreign objects, or to stabilize the spine. Procedures like spinal fusion, laminectomy, or decompression aim to prevent further injury and stabilize the spine[4][8]. Unstable Spine Fractures need surgery with implants to fix the Spine and prevent further Spine Nerve / Cord damage and to allow healing and a better chance of recovery explains Dr Prem Pillay, a Neurosurgeon and Spine Injury Expert. Spine and Spinal Cord (Nerve) Rehabilitation Physical Therapy: Focuses on improving motor function, preventing contractures, and enhancing overall mobility[2]. Occupational Therapy: Helps in adapting to daily activities with assistive devices[1]. Speech Therapy: For those with cervical injuries affecting speech or swallowing. Medications Used to manage symptoms like pain, spasticity, and autonomic dysreflexia[4]. Adaptive Equipment Wheelchairs, braces,  communication devices, Functional Neurological Electrical Stimulation and now Robotics are crucial for increasing independence[4]. Complications of SCI SCIs can lead to numerous complications: Chronic Pain: Often in areas with sensory loss[4]. Respiratory Issues: Particularly with thoracic injuries affecting breathing muscles[4]. Spasticity: Increased muscle tone causing stiffness[4]. Autonomic Dysreflexia: A life-threatening condition in injuries above T6[4]. Cardiovascular Issues: Including high blood pressure and poor circulation[4]. Bladder and Bowel Dysfunction: Common due to loss of control over these functions[4]. Syrinx Detection and Treatment Post-Traumatic Syringomyelia (PTS): A delayed complication where a syrinx (fluid-filled cavity) forms within the spinal cord. Detection involves MRI, often with dynamic imaging to observe CSF flow[1]. Treatment: Conservative management for stable cases, surgical decompression for symptomatic progression, including shunting to drain the syrinx[1] where indicated (Syringo-Subarachnoid Shunt, Syringo-Peritoneal Shunt). Latest Advances in SPINAL CORD INJURY (SCI) Treatment Robotics: Robotic exoskeletons are being developed to assist with walking and rehabilitation, enhancing mobility and reducing complications like pressure ulcers[3]. Spinal Cord Stimulation: Techniques like epidural stimulation have shown promise in restoring some motor function by activating neural circuits below the injury site[3]. Stem Cell Therapy: Research into stem cells aims at promoting regeneration and repair of damaged spinal cord tissue. Early trials have shown potential in reducing syrinx size and improving clinical symptoms[1]. Neuroprotective Strategies : Advances in understanding the secondary injury mechanisms have led to treatments aimed at reducing cell death, controlling inflammation, and promoting regeneration[3]. Precision Medicine: Utilizing biomarkers and advanced imaging to tailor treatments to individual patients, potentially improving outcomes[3]. Conclusion Spinal cord injuries pose significant challenges due to their complexity and the profound impact on an individual’s life. While the prognosis for regaining lost function remains guarded, advancements in surgical techniques, rehabilitation strategies, and emerging therapies like robotics, and Spinal Cord Stimulation treatments offer hope for better management and potential recovery. Continuous research and clinical trials are essential to further understand and treat this debilitating condition, aiming to enhance the quality of life for those affected by SCI. With many years of experience in treating Spinal Cord Injury and access to the latest technological advancements, Dr Prem Pillay offers patients the highest standard of care. From accurate diagnosis to tailored treatment plans, our approach aims for the best possible outcomes for individuals affected by this challenging condition. If you or a loved one has been diagnosed with a Spinal Cord Injury, we welcome you to seek consultation with our specialized team. Together, we can develop a comprehensive evidence based and personalized treatment strategy that addresses your unique needs and provides the best chance for a positive outcome. References and Citations: [1] https://now.aapmr.org/post-traumatic-syringomyelia/ [2] https://pmc.ncbi.nlm.nih.gov/articles/PMC4303793/ [3] https://pmc.ncbi.nlm.nih.gov/articles/PMC11278467/ [4] https://www.novahospital.co.in/overview-of-spinal-cord-injury/ [5] https://www.nature.com/articles/s41392-023-01477-6 [6] https://www.mayoclinic.org/diseases-conditions/spinal-cord-injury/symptoms-causes/syc-20377890

Dr. Prem Pillay , Singapore Brain Spine Nerves Center, Singapore Senior Consultant Neurosurgeon with super speciality training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA)  Syringomyelia is a chronic neurological disorder characterized by the formation of a fluid-filled cavity or cyst, known as a syrinx, within the spinal cord[1][3]. This condition can progressively expand over time, compressing or destroying surrounding nerve tissue and leading to a wide variety of symptoms depending on the size and location of the syrinx[1]; including muscle weakness, numbness, pain, headaches and bladder/bowel incontinence explains Dr Prem Pillay a Syringomyelia Expert and Neurosurgeon. If syringomyelia extends upwards to the brainstem its called Syringobulbia. Such patients have difficulty in swallowing, facial weakness, speech problems, giddiness and unsteady gait [20]. Definition and Overview Syringomyelia occurs when cerebrospinal fluid (CSF), which normally flows around the outside of the brain and spinal cord, collects inside the spinal cord itself[4]. The resulting cyst can grow larger over time, potentially causing damage to the spinal cord and leading to pain, weakness, and stiffness[4]. This condition is most common in adults between the ages of 20 and 40, with men being more susceptible than women[3]. The terminology used to describe syringomyelia can be complex. It may also be referred to as hydromyelia, syringohydromyelia, or Morvan disease[3]. Some cases are classified as congenital (or communicating) syringomyelia, while others are considered acquired (or primary spinal/noncommunicating) syringomyelia[3]. Causes Of Syringomyelia The exact mechanisms behind syringomyelia development are not fully understood. However, several factors have been identified as potential causes: Chiari Malformation: The majority of syringomyelia cases are associated with Chiari malformation, particularly Type I[1][3][20]. This congenital condition causes the lower part of the brain to protrude into the spinal canal, disrupting normal CSF flow[3][4][20][21]. Spinal Cord Injury (SCI): Trauma to the spinal cord such as a sports injury or vehicular injury can lead to syringomyelia, sometimes months or years after the initial injury[3][4][20]. Spinal Cord Tumors: Tumors such as astrocytomas, ependymomas, spinal cord metastases and other spine tumors can interfere with the normal flow of CSF, potentially leading to syrinx formation[4][20]. Meningitis with or without Encephalitis: Inflammation of the membranes surrounding the brain and spinal cord can contribute to syringomyelia development[4]. Tethered Spinal Cord: This congenital condition or acquired syndrome, where tissue attachments such as a short and thick filum terminale can limit spinal cord movement,  and can cause syringomyelia[4][20][22]. Idiopathic Cases: In some instances, no clear cause can be identified[3]. Symptoms of Syringomyelia of the Spinal Cord Syringomyelia symptoms typically develop slowly over time, although they can appear suddenly after an accident[3]. Symptoms depend on the location and extent of the syringomyelia. Some patients may only have cervical spinal cord (neck) syringomyelia and have predominantly upper body and arms/hands symptoms. Common symptoms include: – Pain in the neck, shoulders, arms, and hands– Muscle weakness and wasting, particularly in the hands, arms, and shoulders– Numbness or decreased sensation, especially to hot and cold– Stiffness in the back, shoulders, arms, and legs– Uncoordinated movements (ataxia)– Scoliosis (abnormal curvature of the spine)– Changes in bowel and bladder function– Headaches– Horner syndrome (in cases where the cyst affects nerves controlling eye muscles)[3][20] Diagnosis of Spinal Cord Syringomyelia Diagnosis of syringomyelia typically involves the following steps: Medical History and Physical Examination: The Neurosurgeon will review the patient’s symptoms and medical history, and perform a thorough neurological examination[4][20]. Magnetic Resonance Imaging (MRI): This is the primary diagnostic tool for syringomyelia. MRI can provide detailed images of the spinal cord and any syrinx present[4]. MRI may also be done of the brain to look for Chiari Malformations, and also syringomyelia affecting the brainstem (syringobulbia)[20]. Computed Tomography (CT) Scan: While less commonly used, CT scans may be employed in some cases[4][20]. Electromyography (EMG)/Nerve Conduction tests (NCS): This test can help assess muscle and nerve function[4][20]. In some cases, syringomyelia may be discovered incidentally during tests ordered for other medical reasons[5]. Treatment of Spinal Cord Syringomyelia The treatment approach for syringomyelia depends on the severity of symptoms and the underlying cause. Options include: Monitoring : For mild cases without significant symptoms, regular monitoring through MRI scans and neurological examinations may be sufficient[5][20]. Surgery/ Microsurgery : Surgery/ Microsurgery : When symptoms are severe or progressive, surgical intervention is often necessary. The main goals of surgery are to relieve pressure on the spinal cord and restore normal CSF flow[4][5][20]. Surgical options include: Chiari Decompression: For cases associated with Chiari malformation, this surgery involves removing a small portion of the skull with or without a duropolasty ; creating more space for the cerebellum and tonsils to reduce pressure and improve CSF flow[5][20]. Syrinx Drainage: A shunt may be inserted to drain fluid from the syrinx[5]. These shunts include syringo-arachnoid (SA) shunts and syringo-peritoneal (SP) shunts. This reduces the syrinx pressure on the spinal cord so that nerve recovery may occur. Obstruction Removal: Surgical removal of tumors or bone protrusions that obstruct CSF flow[5]. Correction of Spinal Abnormalities : Procedures to address issues like tethered spinal cord[5]. Microsurgical release of the tethered cord may also relieve the syringomyelia. Pain Management : Medications may be prescribed to manage pain associated with syringomyelia[4]. Physical Therapy : This can help maintain muscle strength and function [4]. Latest Innovations and Research Recent advancements in syringomyelia research and treatment include: Stem Cell Therapy: A case study reported successful treatment of syringomyelia using uncultured umbilical cord-derived mesenchymal stem cells (UC-MSCs). This approach showed promise in alleviating pain and potentially reducing syrinx size[2]. However this type of treatment is still experimental and needs more clinical work to know whether it will be useful in the future.\ Natural History Study: The National Institute of Neurological Disorders and Stroke (NINDS) is conducting a five-year study to better understand the factors influencing syringomyelia development, progression, and treatment response[6]. Cell Damage Reversal: NIH-funded scientists are exploring ways to stop and reverse cell damage caused by spinal cord injuries, which could have implications for syringomyelia treatment[6]. Advanced Imaging Techniques: Ongoing research aims to improve diagnostic accuracy and treatment planning through enhanced MRI protocols and other imaging modalities[12][20]. Postural Stability Research: Studies are being conducted to quantify postural stability in pediatric patients with Chiari malformation, which is closely associated with syringomyelia[12][21]. In conclusion, syringomyelia remains a complex neurological disorder with varied presentations and causes. While microsurgical interventions are currently the primary treatment for severe cases, ongoing research into stem cell therapies, advanced imaging techniques, and the natural history of the disease offers hope for improved diagnostic and therapeutic approaches in the future. As our understanding of the condition grows, so too does the potential for more effective and less invasive treatments for those affected by syringomyelia. With many years of experience in treating syringomyelia including complex forms and access to the latest technological advancements, Dr Prem Pillay endeavours to offer patients the highest standard of care. From accurate diagnosis to tailored treatment plans, our approach aims for the best possible outcomes for individuals affected by this challenging condition. If you or a loved one has been diagnosed with Syringomyelia, we welcome you to seek consultation with our specialized team. Together, we can develop a comprehensive evidence based and personalized treatment strategy that addresses your unique needs and provides the best chance for a positive outcome. References [1] https://rarediseases.org/rare-diseases/syringomyelia/ [2] https://pmc.ncbi.nlm.nih.gov/articles/PMC9136562/ [3] https://www.webmd.com/brain/what-is-syringomyelia [4] https://www.mayoclinic.org/diseases-conditions/syringomyelia/symptoms-causes/syc-20354771 [5] https://www.singaporebrain.org [6] https://www.ninds.nih.gov/health-information/disorders/syringomyelia [7] https://www.nyp.org/ochspine/syringomyelia [8] https://www.mayoclinic.org/diseases-conditions/syringomyelia/diagnosis-treatment/drc-20354775 [9] https://www.cedars-sinai.org/health-library/diseases-and-conditions/s/syringomyelia.html [10] https://www.mountsinai.org/health-library/diseases-conditions/syringomyelia [11] https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/syringomyelia [12] https://asap.org/current-research/ [13] https://www.healthline.com/health/neurological-health/syringomyelia [14] https://www.nyp.org/ochspine/syringomyelia/treatment [15] https://my.clevelandclinic.org/health/diseases/6126-syringomyelia [16] https://www.neurosurgery.columbia.edu/patient-care/conditions/syringomyelia [17] https://neurochirurgie.insel.ch/en/diseases-specialities/spinal-disorders/syringomyelia [18] https://www.ncbi.nlm.nih.gov/books/NBK537110/ [19] https://www.medlink.com/handouts/syringomyelia [20]   https://www.singaporespine.org [21]   https://www.singaporespine.org/treatment/chiari-malformations/ [22]   https://www.singaporespine.org/treatment/tethered-cord-syndrome-in-adults/

BRAIN TUMORS ARE ONE  of the most frightening forms of cancer as they damage the soft sponge, packed inside the skull, that controls our lives. Symptoms include headaches, seizures and problems with memory, speech and communication. Often treatment can only slow the spread of the tumor — the odds for survival are bleak. “Most people are dead within six months of diagnosis,” says Dr. Prem Pillay, a neurosurgeon in private practice in Singapore. But there is a glimmer of hope from a radical new treatment which doubles survival time and may increase the survival rate. Usually the first step in treatment is surgery to remove as much of the tumor as possible. Next comes a course of chemotherapy and radiation to try to destroy the remnants and roots of the tumor. This traditionally involves taking drugs orally or by injection. In the new procedure, called interstitial chemotherapy, six to eight biodegradable disc-shaped wafers, soaked with the anti-tumor drug, are placed in the affected area of the brain. This is done during the surgery, after the accessible part of the tumor has been removed. The drug is slowly released from the discs — each just 14mm in diameter and 1mm thick — over several weeks. The wafers were developed at the Massachusetts Institute of Technology and went into use in 1996. “This is the first major new treatment for brain tumors in 22 years,” says Pillay. In the U.S., brain tumors are the second-fastest-growing form of cancer in those over 65 and the No. 2 cause of cancer death among children under 15. Unlike the treatment now, in which the drugs run through the body to the brain, the medicated wafers attack the tumor directly. This circumvents the main obstacle to conventional brain-tumor chemotherapy — the blood-brain barrier, which filters out harmful substances before they reach the brain. This natural defense mechanism reduces the amount of medication able to reach the tumor. The new procedure minimizes the side-effects associated with conventional chemotherapy. These side-effects, which arise when the drugs flow through the body, include anemia, severe nausea, hair loss and a drop in white blood cell count. And with direct application no drug is lost along the way, so the dosage can be reduced. Patients with lower tolerance for chemotherapy can particularly benefit. Last year, Pillay performed the procedure for the first time in Asia. His two patients had advanced malignant tumors. Nine months later and more than two years after their initial diagnosis, both are recovering well. One has returned to work. But Pillay cautions that interstitial chemotherapy is not a one-stop cure-all. “This is a supplement to other treatments, not the sole method,” he says. In European trials some 63% of patients were alive one year after surgery compared to 19% who did not get the wafers. The wafer, essentially an innovative “on-site” delivery system for drugs, could also be effective with other types of cancers, as well as other diseases whose treatments have bad side-effects from chemotherapy. Says Pillay: “I expect that other agents can be introduced into the brain in a similar fashion to treat not only brain tumors but conditions like Alzheimer’s disease, Parkinson’s disease and epilepsy. “Though the front-end costs of wafers are higher, says Pillay, they “actually end up cheaper.” To those diagnosed with a brain tumor, the cost may not be important. The treatment may buy them something priceless: more time and perhaps an eventual cure. — By Andrea Hamilton