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What is Electromyography (EMG)? Electromyography (EMG) is a diagnostic procedure used to assess the health of muscles and the nerves that control them. It measures the electrical activity of muscles during rest and movement, helping to identify conditions that affect the muscles or the peripheral nervous system. EMG is commonly used to diagnose neuromuscular disorders, pinched nerves, muscle diseases, and conditions such as carpal tunnel syndrome. Types of Electromyography (EMG) EMG procedures can be classified into two main types, depending on the method used to record electrical activity: Surface Electromyography (sEMG): This non-invasive technique uses electrodes placed on the skin to detect electrical signals from underlying muscles. It is commonly used for general muscle function analysis and in rehabilitation settings. Intramuscular Electromyography: This method involves inserting a thin needle electrode directly into the muscle to record its electrical activity. Intramuscular EMG provides more detailed information and is typically used to diagnose neuromuscular conditions. Benefits of Electromyography (EMG) EMG provides valuable insights into muscle and nerve function, offering several advantages in the diagnosis and management of neuromuscular conditions: Precise Diagnosis:  EMG helps pinpoint the exact location and nature of nerve or muscle abnormalities. Early Detection:  Conditions such as nerve compression or muscle diseases can be detected in their early stages, allowing for timely intervention. Guidance for Treatment Plans:  The findings from an EMG study guide healthcare providers in creating personalised treatment plans. Non-Surgical Assessment:  EMG provides a minimally invasive way to diagnose complex neuromuscular issues without the need for surgery. Symptoms and Conditions Diagnosed with Electromyography (EMG) EMG is commonly used to diagnose a variety of conditions affecting the muscles and peripheral nerves. Symptoms and conditions include: Symptoms: Muscle weakness or fatigue. Tingling, numbness, or loss of sensation in the limbs. Unexplained muscle cramps or spasms. Persistent pain or discomfort in the arms, legs, or back. Conditions Diagnosed: Neuropathy:  Damage to the peripheral nerves, often caused by diabetes or trauma. Radiculopathy:  Pinched nerves in the spine, such as in sciatica or cervical radiculopathy. Muscle Disorders:  Conditions like muscular dystrophy or polymyositis. Carpal Tunnel Syndrome:  Compression of the median nerve in the wrist, causing numbness and pain. Motor Neurone Diseases:  Disorders such as amyotrophic lateral sclerosis (ALS). Diagnosis and Treatment Process Diagnosis: A thorough evaluation using EMG includes several steps to ensure an accurate diagnosis: Medical History and Physical Examination:  A detailed review of symptoms and physical examination to determine the need for EMG testing. Nerve Conduction Study (NCS):  Often performed alongside EMG, this test measures how well electrical signals travel through the nerves. EMG Procedure:  Depending on the type, electrodes are placed on the skin (for sEMG) or inserted into the muscle (for intramuscular EMG). The muscle’s electrical activity is recorded and analysed. Treatment: EMG findings guide the appropriate treatment plan, which may include: Medications: Pain relievers or anti-inflammatory drugs for nerve or muscle inflammation. Anticonvulsants or antidepressants for nerve pain management. Physical Therapy: Tailored exercises to improve muscle strength and nerve function. Ergonomic adjustments to reduce strain on affected areas. Surgical Intervention: In severe cases, such as advanced carpal tunnel syndrome or nerve compression, surgery may be required. Lifestyle Modifications: Weight management and regular exercise to reduce stress on nerves and muscles. Posture correction to alleviate pressure on the spine and nerves. Conclusion Electromyography (EMG) is a powerful diagnostic tool that provides essential information about muscle and nerve health. By accurately identifying the source of neuromuscular symptoms, EMG enables timely and effective treatment, improving the patient's quality of life. If you are experiencing unexplained muscle weakness, numbness, or pain, schedule a consultation with us today to explore how EMG can help diagnose and manage your condition.

Advancements in medical imaging and minimally invasive techniques have significantly improved the accuracy of diagnosing brain and spinal conditions. One such technique is Image-Guided Stereotactic Biopsy , a precise and minimally invasive procedure used to obtain tissue samples from abnormal areas in the brain or spine. This method plays a crucial role in diagnosing conditions such as tumours, infections, and inflammatory diseases while minimising risks associated with traditional open surgery. What is an Image-Guided Stereotactic Biopsy? An image-guided stereotactic biopsy  is a specialised diagnostic procedure that uses advanced imaging technologies such as Magnetic Resonance Imaging (MRI), Computed Tomography (CT), or Fluoroscopy to precisely guide a needle to the target tissue. This technique enables neurosurgeons and interventional radiologists to safely extract tissue samples from deep or delicate areas of the brain and spine. This biopsy method is essential in diagnosing: Brain tumours  (malignant or benign) Spinal lesions  (tumours or infections affecting the vertebrae or spinal cord) Inflammatory or infectious conditions  (such as encephalitis or spinal infections) Neurodegenerative diseases  (when tissue analysis is required for confirmation) Benefits of Image-Guided Stereotactic Biopsy Minimally Invasive : Reduces the need for open surgery, resulting in faster recovery. High Accuracy : Real-time imaging ensures precise targeting of the lesion. Lower Risk : Decreased risk of complications such as infection, bleeding, or damage to surrounding structures. Shorter Recovery Time : Most patients resume normal activities within a day or two. Essential for Diagnosis : Provides definitive tissue analysis to confirm or rule out serious conditions. When is Image-Guided Stereotactic Biopsy Recommended? This procedure is advised when imaging studies reveal an abnormality in the brain or spine that requires further evaluation. Common indications include: Brain Conditions Primary Brain Tumours : Gliomas, meningiomas, and other abnormal growths. Metastatic Brain Lesions : Cancer that has spread to the brain from another part of the body. Inflammatory or Infectious Brain Disorders : Conditions such as encephalitis, abscesses, or demyelinating diseases. Spinal Conditions Spinal Tumours : Both benign and malignant growths affecting the spinal cord or vertebrae. Osteomyelitis and Spinal Infections : Infections of the spine requiring precise diagnosis for targeted treatment. Unexplained Neurological Symptoms : Progressive weakness, numbness, or chronic pain of unknown origin. Diagnosis and Treatment Process Diagnosis: A comprehensive approach is used to determine the need for biopsy and potential treatment options. Steps include: Medical History and Physical Examination Advanced Imaging Studies  (MRI, CT, PET scans) Functional Assessments  (For conditions affecting nerves or blood vessels) Treatment Options After Biopsy: Once a diagnosis is confirmed, a personalised treatment plan is developed, which may include: Targeted Medications : Chemotherapy, immunotherapy, or antibiotics for infections. Stereotactic Radiosurgery (SRS) or Fractionated Stereotactic Radiotherapy (FSRT)  for tumour management. Surgical Intervention : If the biopsy confirms a tumour requiring removal. Conclusion Image-guided stereotactic biopsy is a vital tool in diagnosing brain and spinal conditions with high accuracy while minimising risks. When combined with advanced treatment options like Stereotactic Radiosurgery (SRS) and Fractionated Stereotactic Radiotherapy (FSRT) , patients can benefit from safe and minimally invasive approaches to managing complex neurological conditions. Schedule a consultation with us today to learn more.

Brain hemorrhages, particularly intracerebral hemorrhages (ICH) , can be life-threatening and require timely intervention to prevent complications such as brain swelling, increased pressure, and neurological damage. Image-Guided Stereotactic Evacuation of Hematoma  is an advanced, minimally invasive technique used to remove blood clots from the brain with greater precision and minimal disruption to surrounding brain tissue . What is Image-Guided Stereotactic Evacuation of Hematoma? Image-guided stereotactic hematoma evacuation is a minimally invasive neurosurgical procedure  that uses advanced imaging technologies such as Computed Tomography (CT), Magnetic Resonance Imaging (MRI), or Fluoroscopy  to guide the precise removal of a blood clot (hematoma) from the brain. This technique is commonly used for: Intracerebral Hemorrhage (ICH) : Spontaneous bleeding within the brain, often caused by high blood pressure or stroke. Subdural Hematoma : Bleeding between the brain and the skull, commonly resulting from head trauma. Hypertensive Hemorrhage : Bleeding due to chronic hypertension, typically affecting deep brain regions. The goal of this procedure is to reduce brain pressure, prevent further neurological decline, and improve patient recovery while minimising surgical trauma . Benefits of Image-Guided Stereotactic Hematoma Evacuation Minimally Invasive : Requires only a small incision, reducing surgical risks. Increased Precision : Imaging guidance ensures accurate targeting of the hematoma. Lower Risk of Brain Injury : Unlike open surgery, this technique preserves surrounding brain structures , reducing the risk of complications. Shorter Recovery Time : Patients experience less post-operative discomfort and faster rehabilitation  compared to traditional surgery. Suitable for High-Risk Patients : Safer for elderly patients or those with other medical conditions who cannot undergo open surgery. When is Stereotactic Hematoma Evacuation Recommended? This procedure is considered when: The hematoma size is significant  and causing increased pressure in the brain. The patient has neurological deterioration , such as worsening consciousness, weakness, or speech difficulties. The hematoma is located in a deep brain region  where traditional surgery poses high risks. The patient is not a candidate for open surgery  due to medical conditions. In some cases, medication-based management  is initially attempted, but if the hematoma does not resolve or worsens , surgical evacuation is required. Diagnosis and Treatment Process Diagnosis: A multidisciplinary approach is used to determine the best course of action. This includes: Medical History and Neurological Examination Imaging Studies (CT, MRI, Angiography) Blood Tests to Assess Coagulation and Underlying Conditions Treatment Options Following Diagnosis: Once a hematoma is diagnosed, treatment options are tailored based on severity: Medication-Based Management : For small hematomas with no significant symptoms. Stereotactic Hematoma Evacuation : For deep-seated or moderate-sized hematomas causing pressure symptoms. Open Surgery (Craniotomy) : For large, life-threatening hemorrhages requiring immediate decompression. Conclusion Image-guided stereotactic hematoma evacuation is a game-changing, minimally invasive procedure  that offers precision, safety, and faster recovery  for patients suffering from brain hemorrhages. By leveraging advanced imaging and targeted intervention, neurosurgeons can effectively remove blood clots while preserving brain function. Schedule a consultation with us today to learn more.

Advancements in neurosurgery have led to the development of minimally invasive techniques that allow for safer and more precise treatment of brain and spinal conditions . One such breakthrough is Image-Guided Endoscopic Surgery , which combines endoscopic technology with real-time imaging to treat complex neurological disorders with minimal disruption to surrounding tissues. What is Image-Guided Endoscopic Surgery? Image-guided endoscopic surgery  is a minimally invasive neurosurgical procedure  that uses advanced imaging techniques such as Magnetic Resonance Imaging (MRI), Computed Tomography (CT), or Fluoroscopy  to navigate an endoscope, a thin, flexible tube with a camera and surgical instruments, through small incisions in the skull or spine. This technique is used to treat a variety of neurological conditions, including: Brain Tumours : Removal of pituitary adenomas, meningiomas, and other deep-seated tumours. Hydrocephalus : Creating alternative pathways for cerebrospinal fluid (CSF) drainage. Spinal Cord Compression : Decompression of nerves caused by herniated discs or spinal stenosis. Chiari Malformation : Surgical correction of brain tissue pressing into the spinal canal. Ventricular Cysts : Drainage of cystic formations in the brain's ventricles. By integrating image guidance  with endoscopy, surgeons can navigate complex anatomical structures with increased accuracy and reduced risk. Benefits of Image-Guided Endoscopic Surgery Minimally Invasive  – Small incisions result in less pain, reduced scarring, and quicker recovery. Enhanced Precision  – Real-time imaging ensures accurate navigation and targeting. Lower Risk of Complications  – Minimizes damage to healthy tissues and vital structures. Reduced Hospital Stay  – Many procedures allow for faster discharge compared to traditional surgery. Improved Outcomes  – High-definition endoscopy provides clear visualisation, enhancing surgical effectiveness. When is Image-Guided Endoscopic Surgery Recommended? This procedure is recommended for patients who require surgical intervention for conditions that can be treated with a minimally invasive approach, including: Brain Conditions Pituitary Tumours : Removal through the nasal passage without opening the skull. Hydrocephalus : Creating an alternative CSF drainage route using endoscopic third ventriculostomy (ETV). Intraventricular Tumours and Cysts : Removing fluid-filled cysts or small tumours inside brain ventricles. Spinal Conditions Herniated Discs : Removing or repairing discs that are pressing on nerves. Spinal Stenosis : Widening the spinal canal to relieve nerve compression. Spinal Tumours : Minimally invasive removal of tumours affecting the spinal cord. For cases where traditional open surgery carries higher risks or longer recovery times , image-guided endoscopic surgery offers a safer alternative . Diagnosis and Treatment Process Diagnosis: thorough evaluation is necessary to determine if the patient is a candidate for image-guided endoscopic surgery. This includes: Medical History and Physical Examination : Assessing symptoms and neurological function. Advanced Imaging Studies : MRI and CT scans to locate and assess the severity of the condition. Functional Assessments : Evaluating nerve function for spinal conditions. Treatment Process Pre-Surgical Planning : Using advanced imaging and neuronavigation software to plan the surgical approach. Anesthesia and Patient Positioning : Ensuring patient comfort and optimal positioning for endoscopic access. Endoscopic Procedure : A small incision or natural body opening (e.g., nose) is used to insert the endoscope, guided by real-time imaging. Targeted Treatment : The surgeon removes the tumour, repairs damaged tissue, or relieves pressure on nerves. Closure and Recovery : Minimal suturing is required, and patients are monitored for a short period before discharge. Conclusion Image-guided endoscopic surgery is a revolutionary approach that enhances surgical precision, reduces recovery time, and minimizes risks  for patients with brain and spinal conditions. By integrating real-time imaging with minimally invasive techniques, this procedure offers a safer and more effective alternative  to traditional surgery. Schedule a consultation with us today to learn more.

A brain aneurysm  is a weakened area in a blood vessel that bulges out due to increased pressure, potentially leading to a life-threatening rupture. When an aneurysm ruptures, it causes a subarachnoid hemorrhage (SAH),  which can result in severe brain damage or even death. Clipping of aneurysms  is a well-established surgical treatment  that effectively prevents rupture by securing the weakened blood vessel. What is Clipping of Aneurysms? Aneurysm clipping  is an open surgical procedure  performed by a vascular neurosurgeon  to prevent a brain aneurysm from rupturing or to stop further bleeding in the case of a rupture. The procedure involves: Accessing the aneurysm  through a small opening in the skull (craniotomy). Placing a tiny metal clip  at the neck of the aneurysm to block blood flow. Preventing rupture or re-bleeding  by isolating the aneurysm from circulation. Once clipped, the aneurysm shrinks and heals over time , significantly reducing the risk of future complications. This technique has been widely used for decades and remains one of the most effective and durable  treatments for brain aneurysms. Benefits of Clipping of Aneurysms Permanent Solution : The aneurysm is securely closed off, preventing future rupture. Highly Effective : Long-term studies show excellent success rates with minimal recurrence. Lower Risk of Re-Bleeding : Especially crucial for patients with ruptured aneurysms. Preserves Normal Blood Flow : The metal clip does not interfere with adjacent blood vessels. Although minimally invasive endovascular procedures  like coiling  are available, clipping remains a preferred option for specific aneurysm types  and patient conditions. When is Clipping of Aneurysms Recommended? Aneurysm clipping is recommended in the following cases: Ruptured Aneurysms : When an aneurysm has already burst, causing a subarachnoid hemorrhage. Unruptured Aneurysms : If the aneurysm is large, irregular in shape, or at high risk of rupture. Aneurysms Not Suitable for Coiling : Some aneurysms, particularly those with wide necks or complex locations , are better treated with clipping. Younger Patients : Clipping is often preferred for younger patients  due to its long-term durability. Your neurosurgeon will evaluate multiple factors, including aneurysm size, location, and overall health , to determine the best treatment approach. Diagnosis and Treatment Process Diagnosis: A thorough evaluation is performed to confirm the presence, size, and risk of an aneurysm. This typically involves: Neurological Examination : To assess symptoms like headaches, vision changes, or neurological deficits. Imaging Studies Computed Tomography (CT) Scan : Detects bleeding in the brain. CT Angiography (CTA) or Magnetic Resonance Angiography (MRA) : Provides detailed images of blood vessels. Cerebral Angiogram : A gold-standard test to precisely map aneurysm anatomy. Treatment Process: Pre-Surgical Planning : Detailed imaging is used to plan the safest surgical approach. Craniotomy : A small section of the skull is temporarily removed to access the aneurysm. Clipping the Aneurysm : A titanium clip is placed at the aneurysm neck to block blood flow. Closure and Recovery : The skull is secured, and patients are monitored in the ICU for early recovery. Follow-Up and Rehabilitation : Regular imaging is performed to ensure long-term success. Conclusion Aneurysm clipping is a proven, effective, and durable  surgical treatment for preventing and managing brain aneurysms. While less invasive techniques  like coiling are available, clipping remains the gold standard for complex or high-risk aneurysms . Schedule a consultation with us today to learn more.

Brain aneurysms are potentially life-threatening conditions that occur when a blood vessel weakens and bulges, increasing the risk of rupture and severe bleeding. Endovascular coiling , also known as aneurysm embolisation , is a minimally invasive  procedure used to prevent aneurysm rupture by sealing it off from blood circulation. What is Coiling? Coiling is a catheter-based endovascular procedure  designed to treat brain aneurysms without open surgery. The procedure involves: Inserting a catheter  into a blood vessel, typically through the groin or wrist. Guiding the catheter to the aneurysm  using real-time X-ray imaging (fluoroscopy). Deploying soft platinum coils  into the aneurysm, filling the space and blocking blood flow. Promoting clot formation , which seals the aneurysm and prevents rupture. This technique effectively isolates the aneurysm from circulation , reducing the risk of rupture while preserving normal blood flow in surrounding vessels. Benefits of Coiling Minimally Invasive : No need for open surgery or skull incision. Shorter Recovery Time : Patients typically return to normal activities faster than with traditional surgery. Lower Risk of Surgical Complications : Reduced risk of infection and blood loss. Suitable for Older or High-Risk Patients : Ideal for those who may not tolerate open surgery. Coiling has become a preferred treatment  for many aneurysms, particularly those in deep or difficult-to-access brain regions . When is Coiling Recommended? Coiling is often recommended in the following situations: Unruptured Aneurysms : To prevent rupture in patients with high-risk aneurysms. Ruptured Aneurysms : To stop active bleeding and prevent further complications. Aneurysms with a Narrow Neck : These are well-suited for coiling as the coils remain securely in place. Patients Unsuitable for Open Surgery : Those with medical conditions that increase surgical risks. In some cases, a stent or balloon-assisted coiling  may be required for wide-neck aneurysms to keep the coils in place and maintain normal blood flow. Diagnosis and Treatment Process Diagnosis: A comprehensive assessment is required to determine the best treatment approach. Diagnostic steps include: Neurological Evaluation : Assessing symptoms such as headaches, dizziness, or vision disturbances. Imaging Studies Computed Tomography (CT) Scan : Detects bleeding from a ruptured aneurysm. CT Angiography (CTA) or Magnetic Resonance Angiography (MRA) : Provides detailed images of blood vessels. Cerebral Angiogram : A catheter-based test to precisely map the aneurysm and determine treatment suitability. Treatment Process: Pre-Procedural Planning : Advanced imaging is used to customise the coiling approach. Catheter Insertion : A thin catheter is inserted into an artery in the groin or wrist and navigated to the brain. Coil Deployment : Platinum coils are placed inside the aneurysm, promoting clot formation. Final Evaluation : The neurosurgeon ensures complete aneurysm closure using imaging. Recovery and Monitoring : Patients are monitored closely and may be discharged within a day or two. Conclusion Coiling is a safe, effective, and minimally invasive  option for treating brain aneurysms, offering a faster recovery and lower surgical risk compared to traditional clipping. While not all aneurysms are suitable for coiling , it is often the preferred approach for high-risk patients or aneurysms in delicate locations .

Dr. Prem Pillay, Singapore Senior Consultant Neurosurgeon with super specialty training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA) Brain Arteriovenous Malformations (AVMs) and Dural Arteriovenous Fistulas (DAVFs)  are potentially serious cerebrovascular conditions that can have significant bleeding causing brain damage (strokes) that can result in weakness, numbness, loss of senses, speech problems (aphasia, dysphasia), paralysis, coma and death. This summary will provide an overview of these conditions, including their presentation, diagnosis, treatments, and less invasive treatment methods. Brain Arteriovenous Malformations (AVMs) Presentation Brain AVMs are abnormal connections between arteries and veins in the brain, bypassing the normal capillary bed. They account for 10-15% of all intracranial vascular malformations[1]. AVMs can present with various symptoms, including: – Sudden, severe headaches – Seizures – Neurological deficits (e.g., weakness, numbness, vision problems) – Cognitive changes (forgetfulness and memory problems, loss of focus, difficulty with complex tasks or executive function) However, many AVMs are asymptomatic and are discovered incidentally during brain imaging for other reasons[4]. Diagnosis The diagnosis of brain AVMs typically involves several imaging techniques: Computed Tomography (CT): Often the initial imaging modality, especially in emergency situations[1] as they can show the location of bleeding. Magnetic Resonance Imaging (MRI) Provides detailed images of brain tissue and can show subtle changes related to AVMs[1]. CT Angiography (CTA) and MR Angiography (MRA) These techniques can provide additional vascular details and are often used in conjunction with other imaging modalities[4]. They are less invasive than formal Cerebral catheter Angiography. Cerebral Angiography Considered the gold standard for AVM diagnosis. It provides detailed information about the location, size, and vascular architecture of the AVM[1]. Treatment The treatment of brain AVMs aims to reduce the risk of hemorrhage and alleviate symptoms. Treatment options include: Surgical Resection Involves removing the AVM through open brain surgery. This is often the preferred treatment for accessible AVMs[1]. Smaller openings and  Advanced Microscopes using florescence together with brain mapping and tractography / connectomes identification can allow safer and more accurate surgery. Endovascular Embolization A minimally invasive procedure where embolic agents such as Onyx, PHIL and others are injected through a catheter to block blood flow to the AVM[6]. Stereotactic Radiosurgery A no Surgery Non-Invasive technology; Uses focused radiation to gradually close off the abnormal blood vessels over time[4].The latest systems use Robotics and Micro (MLC) Radiosurgery for higher accuracy and safety. These can often be done as Day Procedures. Conservative Management For some low-risk AVMs, observation and medical management of symptoms may be appropriate[7]. Dural Arteriovenous Fistulas (DAVFs) Presentation DAVFs are abnormal connections between arteries and veins within the dura mater, the protective covering of the brain and spinal cord[8]. Symptoms can vary depending on the location and severity of the DAVF: – Pulsatile tinnitus (rhythmic sound in the ear) – Headaches – Visual disturbances – Neurological deficits – In severe cases, intracranial hemorrhage or seizures[8] Diagnosis The diagnosis of DAVFs involves similar imaging techniques to those used for AVMs: MRI and MRA: Can detect abnormal blood flow patterns and enlarged blood vessels[5]. CT and CTA: Useful for identifying bony involvement and vascular anatomy[5]. Cerebral Angiography: The definitive diagnostic tool, providing detailed information about the fistula’s location, feeding arteries, and draining veins[5][9]. Treatment Treatment of DAVFs depends on their classification (e.g., Borden or Cognard systems) and associated risks. Options include: Endovascular Embolization Often the first-line treatment, involving the injection of embolic agents to occlude the fistula[9]. Microsurgery Used when endovascular treatment is not feasible or unsuccessful[10]. Stereotactic Radiosurgery Can be effective for certain types of DAVFs, especially those in challenging locations[3]. Conservative Management For low-risk DAVFs, observation and symptom management may be appropriate[8]. Less Invasive Treatment Methods Recent advancements have led to the development of less invasive treatment options for both AVMs and DAVFs: Endovascular Techniques Liquid Embolic Agents Modern agents like Onyx, PHIL (Precipitating Hydrophobic Injectable Liquid), and Squid offer improved control and effectiveness in embolization procedures[9]. Detachable Coils Used in combination with liquid embolic agents for more complex cases[9]. Flow Diverters In special scenarios, devices like the Pipeline Embolization Device can be used to treat certain types of fistulas[9]. Stereotactic Radiosurgery (SRS) SRS has emerged as an effective and safe alternative to conventional surgery for some AVMs and DAVFs[3]. It offers several advantages: – Non-invasive procedure – Lower risk of complications compared to open surgery – Effective for deep-seated or surgically inaccessible lesions – Can be used in combination with other treatment modalities Multimodal Approach For complex cases, a combination of treatment methods may be employed. For example, endovascular embolization may be used to reduce the size of an AVM before surgical resection or radiosurgery[6]. Conclusion Brain AVMs and DAVFs are complex cerebrovascular conditions that require careful evaluation and individualised treatment planning explains Dr Prem Pillay, an AVM/DAVF expert. While traditional surgical approaches remain important, less invasive techniques such as advanced endovascular procedures and stereotactic radiosurgery have expanded the treatment options available to patients. These newer methods offer the potential for reduced procedural risks and improved outcomes in selected cases. As research continues, ongoing advances in imaging technology, embolisation techniques, and radiosurgery are likely to further refine and improve the management of these challenging vascular lesions. The choice of treatment should be based on factors such as the patient’s age, overall health, lesion characteristics, and the expertise of the treating team. If you or your loved ones have an AVM/DAVF, you are most welcome to contact us for an opinion or guidance from our Expert and his team. We are able to design a personalized treatment that has the highest potential success rate and lowest risk rate based on the latest medical evidence and years of experience. Citations: [1] https://www.mayoclinic.org/diseases-conditions/brain-avm/diagnosis-treatment/drc-20350265 [2] https://www.spandidos-publications.com/10.3892/etm.2014.2122 [3] https://www.e-neurofunction.org/m/journal/view.php?number=354 [4] https://www.msdmanuals.com/home/brain-spinal-cord-and-nerve-disorders/stroke/brain-arteriovenous-malformations-avms [5] https://pubmed.ncbi.nlm.nih.gov/19172609/ [6] https://evtoday.com/articles/2015-feb/cerebral-avms-and-dural-avfs-pathology-and-management [7] https://my.clevelandclinic.org/health/diseases/16755-arteriovenous-malformation-avm [8] https://www.mayoclinic.org/diseases-conditions/dural-arteriovenous-fistulas/symptoms-causes/syc-20364280 [9] https://pmc.ncbi.nlm.nih.gov/articles/PMC7213517/ [10] https://www.pennmedicine.org/for-patients-and-visitors/patient-information/conditions-treated-a-to-z/dural-arteriovenous-fistula

Dr. Prem Pillay, Singapore Senior Consultant Neurosurgeon with super specialty training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA) Causes, Symptoms, Treatments Pain or discomfort in the neck is a common reason for patients to seek medical care. A muscle spasm, brought on by poor posture, sleeping position or stress, is a frequent causes of neck pain. But an aching painful neck can be a symptom of a more serious problem. Disc degeneration, narrowing of the spinal canal, arthritis, spine infection and even cancer in the spine can cause neck pain. If Neck pain is severe or persistent a Spine specialist, such as a neurosurgeon, should be consulted. When To See a Spine Specialist? A doctor should be consulted if neck pain occurs after an injury or blow to the head. Also see a specialist if a fever or headache accompanies the neck pain, if a stiff neck prevents you from touching your chin to your chest, if pain shoots down one arm, if there is a tingling/numbness in your hands, if there is weakness of the arm and/or hands; or if pain does not decrease after a week. You can take a number of steps on your own to alleviate neck pain caused by strain or spasm of the neck-muscles states Dr Prem Pillay, a Spine Expert. Improve your posture and change the way you sleep. Take rest breaks at work instead of silting or standing in the same position. Do exercises to stretch the neck and shoulder muscles. Use hot showers, hot compresses or a heating pad to relax tense muscles. Understanding The Neck The neck is part of a long flexible column of bones and other tissue, often referred to as the spinal column or backbone, that extends through most of the body. The neck region of the spinal column is called the cervical spine, which consists of seven bones or vertebrae that are shaped like building blocks. Intervertebral discs separate the vertebrae from one another. These discs allow the spine to move freely and act as shock absorbers when a person moves. The back of each vertebra forms a tube-like canal of bone that runs down the back. This space is called the spinal canal, through which the spinal cord and nerves travel. The spinal cord is surrounded by cerebrospinal fluid and three protective membranes called the dura, the pia and the arachnoid. A pair of spinal nerves exit each vertebra through small openings called foramina (one to the left and one to the right). These nerves connect to the muscles, skin and tissues of the body, providing sensation and movement to all parts of the body. The delicate spinal cord and nerves are further supported by strong muscles and ligaments that are attached to the vertebrae. The cervical spine needs to be strong because it also holds up the head, which can weigh 10 pounds or more.   Common Disorders Of The Cervical Spine Cervical Disc Disorders The discs in the neck can wear out in the course of aging or can be damaged by sudden movement (whiplash), poor posture or diseases such as arthritis. Neck pain occurs when the herniated disc pinches the nerve or when arthritis progresses to the point where it involves the joints of the spine. Arthritis can lead to degeneration of the disc as well as abnormal bone growths (spurs) next to the joints. These spurs are the result of repetitive movement and can irritate the adjacent nerve and cause pain. Cervical disc disorders are typically marked by intermittent neck pain, followed by severe neck and even shoulder and arm pain. The pain is sufficient to awaken a person from sleep. Irritated nerves also can lead to numbness or weakness in the arm or forearm, tingling in the fingers and coordination problems. Severe nerve impairment or even paralysis can develop if the disorder is left untreated. Pressure on the spinal cord from a herniated disc or bone spur in the neck can also be a very serious problem. Virtually all of the nerves of the body have to pass through the neck to reach their final destination (arms, chest, abdomen, legs). This means that weakness may start in the arms and then involve the lower body and legs with compression of the central spine nerve called the spinal cord. Cervical Spine Stenosis Cervical stenosis is a narrowing of the spinal canal that can pinch the spinal cord. The normal aging process is usually the cause. The discs dehydrate over time, causing them to lose their ability to act as shock absorbers. At the same time, degenerative changes in the vertebrae can lead to the growth of bone spurs that compress the nerve roots. The bones and ligaments that make up the spine gradually thicken and become less pliable. These changes cause the spinal canal to narrow. Symptoms of cervical stenosis are neck pain, numbness and weakness in the hands, inability to walk at a quick pace, deterioration of fine motor skills and muscle spasms in the legs. Diagnosing Neck Problems Your Spine Specialist investigates a neck problem through a medical history, physical exam and diagnostic tests. The physical examination includes an assessment of sensation, strength and reflexes in various parts of the body to help pinpoint which nerves or parts of the spinal cord are affected. The doctor may then order various diagnostic studies to determine more precisely the nature and extent of the disorder. These tests https://singaporespine.org/treatment/spine-checks-and-scans/ include X-Rays, Digital Spine movement Tests, CT Spine Scans, MRI Spine scans and Electrical testing of the Nerves and Muscles (NCS and EMG). Treatment of Neck Pain Patients with neck pain are usually treated conservatively at first. Non-surgical treatments may provide relief. Conservative treatment includes bed rest, reduction of physical activity, physical therapy and wearing a cervical collar, which provides support for the spine, reduces mobility and lessens pain and irritation. Mild cervical stenosis and Disc Disease can be treated conservatively as long as the symptoms are restricted to neck pain. People who experience tingling/numbness, weakness in the arms or legs, pain and numbness/tingling down the arm may require additional treatments. Treatment of whiplash injuries and Disc Injury consists of analgesics, non-steroidal anti-inflammatory drugs, muscle relaxants and aggressive physical therapy. Gentle cervical traction and manipulation are sometimes helpful. Specialized Spine Physiotherapy is needed. When is Surgery Necessary? Are there Less Invasive Options? Surgery such as Disc Replacement ( https://singaporespine.org/treatment/cervical-spine-disc-replacement/ ) may be needed when conservative treatments for cervical disc problems do not provide relief and when there are neurological deficits such as weakness in the arm or hand. This is associated with the MRI showing moderate to severe nerve impingementthat may be caused by a degenerated /prolapsed disc/discs, thickened ligaments, and overgrowth of bone. Surgery may also be needed for those who injure their spines from a road traffic accident, falls, sports injuries where there are spine fractures or burst discs often associated with spinal cord and spinal nerve injury and damage. The choice of treatment and the decision as to when to perform the operation should be determined by a Neurosurgeon, the medical specialist trained in the surgical treatment of disorders of the spine. Less Invasive options including day treatments with no scars are also available such as Specialized Spine Injections, Discoplasty, Nucleoplasty, Annuloplasty, Radiofrequency Ablation, Co-Ablation,Endoscopic and Robotics, Lasers and Superior to Laser technologies. Surgery and Less Invasive Procedures may be advisable if: You miss work because of pain. You are unable to join in family activities because of pain or muscle weakness. Your pain forces you to, spend more time alone, away from friends and family. You feel frustrated or depressed because of your pain. You are otherwise in good health. Factors in determining the type of surgical treatment include what type of disease (herniated disc or bone spurs), whether there is pressure on the spinal cord-or spinal nerves and if the spine is dislocated in addition to pressure on the cord or nerves. Other factors include age, duration of disorder, other medical conditions and previous medical history. Surgery has its limitations. It can’t reverse all the effects of overuse or aging, and it carries risks ; Yet it may be the only way to relieve pain, numbness and weakness and prevent further spine nerve damage that may cause more weakness or even paralysis if the problem has become serious. FAQ About Neck Pain Or Neckache What Are The Causes Of Neck Pain? The roots of neck pain lie in our modern lifestyle. At the workplace, prolonged sitting and many hours of computer use can cause neck pain. Travel with the carrying of hand luggage and laptops all contribute to neck pain. Recreational exercises performed improperly or without adequate warming up, massages with neck manipulation, Injuries to the neck, poor posture etc can cause wear and tear of the cervical spine resulting in neck pain and shoulder discomfort. Most patients with neck pain have varying degrees of spinal disc degeneration. Some patients have arthritis, infection or cancer as the cause of the neck pain. This is why its important to have a Medically qualified Spine Specialist assess your neck pain. How Can I Prevent Neck Pain? Proper Posture is Often the Key Ergonomics This is especially important for those who use computers for long hours. This involves proper placing of the computer monitor such that your head is in a neutral position when viewing the computer screen; a proper chair with lumbar support and an arm rest such that your elbows are resting 90° to your work surface and your keyboard. Stand up and take short breaks every 20 – 30 minutes, doing neck stretches and back stretches before resuming your work. Another bad habit is talking on the phone with the receiver tucked between the neck and shoulder. This should be avoided as it puts a lot of strain on the neck muscles. Invest in a hands free device instead. Text Neck is now a common problem in young people who overuse mobile devices! Neck strengthening exercises help but should be taught to you by a trained physiotherapist. Neck stretching exercises and neck strengthening exercises should be taught to you by trained physiotherapists. Exercising Intelligently Exercising irregularly and without proper warm-up can put a lot of stress on your spine muscles. Jogging or aerobics on a hard ground (high-impact activities) without proper shoes is also stressful to the spine. Remember there is an equal upward thrust on your spine for every downward step. Swimming though a good form of an aerobic exercise, may actually aggravate neck pain especially strokes like the breast stroke and front crawl. In these strokes, the head is moved up and down or sideways to breathe. However, specially designed exercises like Aquatic therapy (by trained physiotherapists ) is beneficial as it is specially designed to strengthen the spinal muscles. Packs, and/or a warm shower can help in relaxing the neck muscles. When Do I Need Seek Medical Attention For Neck Pain? When Does Surgical Intervention Become Necessary? Surgical intervention, such as microsurgery with disc replacement, becomes necessary when pain is not relieved by conservative (non-surgical) treatment or when there are neurological deficits such as weakness in the arm or hand. This is associated with the MRI showing moderate to severe nerve impingement that may be caused by a degenerated /prolapsed disc/discs, thickened ligaments, and overgrowth of bone. The decision for surgery should be made by you and your neurosurgeon. New and advanced technology is available for the replacement of discs but there is no technology available to replace or repair damaged nerves in the spine. We therefore advise patients not to not wait until their nerves are permanently damaged. After a microsurgical intervention, patients will still need to be put through a proper and organized spine therapy program. This is for long term spine strengthening and preventing relapses. We have found in our experience that a combination of aquatic therapy with physiotherapy works best. Surgery may be the treatment of choice if: Surgery may be advisable if: •You miss work because of pain • You are unable to join in family activities because of pain or muscle weakness • Your pain forces you to, spend more time alone, away from friends and family. • You feel frustrated or depressed because of your pain. • Conservative Treatment is not working • Your symptoms are progressive in your arms and legs. • Your hands are becoming more clumsy and weak. • There is difficulty with walking and balance. • It’s preventative – prevents further nerve injury. • You are otherwise in good health. Factors in determining the type of surgical treatment include what type of disease (herniated disc or bone spurs), whether there is pressure on the spinal cord-or spinal nerves and if the spine is dislocated in addition to pressure on the cord or nerves. Other factors include age, duration ofdisorder, other medical conditions and previous medical history Are there less invasive or no surgery options ? Less Invasive options including day treatments often with no scars are also available such as Specialized Spine Injections, Discoplasty , Nucleoplasty, Annuloplasty, Radiofrequency Ablation, Co-Ablation, Endoscopic and Robotics , Lasers and Superior to Laser technologies. With many years of experience in treating Neck Pain from Cervical Spine problems 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 Neck Pain / Cervical Spine problems, we welcome you to seek consultation with our Spine Specialist. 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 Senior Consultant Neurosurgeon with super specialty training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA) Proton therapy is the latest and advanced form of radiation treatment that uses a beam of protons to deliver radiation precisely and effectively to Tumors and Cancers while sparring normal tissues . Proton therapy is a type of radiation therapy that uses a beam of protons to treat cancer and some noncancerous tumors. Protons are positively charged particles that can damage the DNA of cells and stop their reproduction, thus killing them. Proton therapy has some advantages over current types of radiation therapy, such as X-rays, because protons can be more precisely controlled to target the tumor and spare the surrounding healthy tissue. Proton therapy may cause fewer side effects than traditional radiation. It is not widely available except in advanced overseas centers such as MD Anderson Cancer center in Texas, USA states Dr Prem Pillay , a Singapore Neurosurgeon who was a Fellow in Neurosurgical Oncology (Brain and Spine Tumors and Cancers) at MD Anderson Cancer Center and is now practising at the Singapore Brain-Spine-Nerves Center at the Mt Elizabeth Medical Center in Singapore. Fortunately for patients in our part of Asia, Proton therapy is now available at Mt Elizabeth Hospitals, in Singapore. Proton therapy is performed using a particle accelerator that produces a beam of protons. The beam is shaped and directed by magnets and computers to match the size and shape of the tumor. The patient lies on a table that can be moved and rotated to adjust the position of the beam. The treatment usually lasts for several minutes and may be given in small doses (fractionation) daily for a few weeks to improve results and reduce side effects. What cancers and tumors can Proton Therapy Treat? Proton therapy may be used to treat various types of cancer, such as brain, spine, breast, eye, esophageal, head and neck, liver, lung, lymphoma, pancreatic, prostate, sarcoma, chordomas, gliomas. It may also be used to treat cancer in children, who are more sensitive to radiation damage. Proton therapy may be used alone or in combination with other treatments, such as surgery and chemotherapy. Proton therapy may also be used if the cancer remains or comes back after traditional X-ray radiation. Brain tumors that can be treated include Malignant Gliomas such as Glioblastomas, Astrocytomas, Ependymomas,aggressive pituitary tumors, Meningiomas, Brain cancer/metastases that has spread to the brain from the breast , lung, and other primary sites.Skull base tumors such as Chordoma, Chondrosarcoma, adenocarcinoma, squamous cell carcinoma to name a few are can also be potentially treated with proton therapy. Spine tumors and cancer can also be treated. Proton therapy can target t tumors with a sub-millimeter precision while sparring nearby healthy tissues and minimizing side effects. Standard radiation therapy has evolved and improved over the years and is effective in controlling many cancers. However, because X-ray beams are composed of primary photons and secondary electrons, they deposit their energy along the path of the beam, to the targeted tumor and beyond, and deliver radiation to healthy tissues before and after the tumor site. This radiation “exit dose” may cause health issues later because it can damage the normal tissue or organs near the tumor or area of concern. The advantage of proton therapy (also called proton beam therapy) is that the physician can control where the proton releases the bulk of its cancer-fighting energy. As the protons move through the body, they slow down and interact with electrons, and release energy. The point where the highest energy release occurs is the “Bragg peak.” A physician can designate the Bragg peak’s location, causing the most damage to the targeted tumor cells. A proton beam conforms to the shape and depth of a tumor while sparing healthy tissues and organs. How Does Proton Therapy actually work? The best way to understand how proton therapy works is to take a look at the physics and engineering inside the proton accelerator, or the synchrotron, and the beam delivery system. The proton begins its journey at the ion source. Within fractions of a second, hydrogen atoms are separated into negatively charged electrons and positively charged protons. The protons are injected via a vacuum tube into a linear accelerator and in only a few microseconds, the protons’ energy reaches 7 million electron volts. Proton beams stay in the vacuum tube as they enter the synchrotron, where acceleration increases their energy to a total of 70 million to 250 million electron volts, enough to place them at any depth within the patient’s body. After leaving the synchrotron, the protons move through a beam-transport system comprised of a series of magnets that shape, focus and direct the proton beam to the appropriate treatment room. To ensure that each patient receives the prescribed treatment safely and efficiently, the facility is controlled by a network of computers and safety systems. The gantry can revolve around the patient, allowing the beam to be delivered through many angles. As protons come through the nozzle, a custom-made device (the aperture) shapes the beam of protons, and another custom-made device (the compensator) shapes the protons into three dimensions, delivering them to the depth of the tumor. At maximum energy, a proton beam travels 125,000 miles per second, which is equivalent to the two-thirds the speed of light. Pencil beam and intensity modulated proton therapy The team at MD Anderson Proton Therapy Center has continued to expand ways to use proton therapy to benefit patients. The team pioneered pencil beam proton therapy, also called scanning beam, and intensity modulated proton therapy (IMPT). The techniques are now available to other treatment centers said Dr Prem Pillay. Pencil beam technology and IMPT build on the benefits of proton therapy. With a proton beam just millimeters wide, these advanced forms of proton therapy combine precision and effectiveness, offering unmatched ability to treat a patient’s tumor and minimizing the effect on a patient’s quality of life – during and after treatment. They rely on complex treatment planning systems and an intricate number of magnets to aim a narrow proton beam and essentially “paint” a radiation dose layer by layer. Pencil beam is very effective in treating the most complex tumors, like those in the Brain, Spine,eye, and cancers in children, while leaving healthy tissue and other critical areas unharmed. IMPT is best used to deliver a potent and precise dose of protons to complex or concave-shaped tumors that may be adjacent to the spinal cord or embedded head and neck or skull base below the brain or around brain critical structures. For more information on Proton Therapy for Brain and Spine tumors kindly contact us at +6568354325. References: 1.Towards effective and efficient patient-specific quality assurance for spot scanning proton therapyX Ronald Zhu 1 , Yupeng Li 2 , Dennis Mackin 3 , Heng Li 4 , Falk Poenisch 5 , Andrew K Lee 6 , Anita Mahajan 7 , Steven J Frank 8 , Michael T Gillin 9 , Narayan Sahoo 10 , Xiaodong Zhang 11Cancers (Basel) 2015 Apr 10;7(2):631-47.Affiliations : MD Anderson Cancer Center 2.Proton Therapy for Head and Neck Cancer: A 12-Year, Single-Institution ExperienceG Brandon Gunn 1 , Adam S Garden 1 , Rong Ye 2 , Noveen Ausat 1 , Kristina R Dahlstrom 3 , William H Morrison 1 , C David Fuller 1 , Jack Phan 1 , Jay P Reddy 1 , Shalin J Shah 1 , Lauren L Mayo 1 , Stephen G Chun 1 , Gregory M Chronowski 1 , Amy C Moreno 1 , Jeffery N Myers 3 , Ehab Y Hanna 3 , Bita Esmaeli 4 , Maura L Gillison 5 , Renata Ferrarotto 5 , Katherine A Hutcheson 3 , Mark S Chambers 3 , Lawrence E Ginsberg 6 , Adel K El-Naggar 7 , David I Rosenthal 1 , Xiaorong Ronald Zhu 8 , Steven J Frank 1Int J Part Ther. 2021 Jun 25;8(1):108-118.

Fig 1, 2, 3: Image guided high definition Computed Tomograpy of the Spine during the Discoplasty to allow navigation of the Fine Spine Needles with high accuracy and precision to the injured Spine Disc.  A micro device is deployed through the hollow of the needle to deliver a superior to laser energy. Robotics can be used to improve the accuracy of the procedure.     Discoplasty  refers to the treatment of the Spine Disc (the soft gel-like substance between the spine vertebrae or hard bones) without physically cutting it or replacing it .  Discoplasty  refers to a process to reduce dangerous accumulation of pressure within the disc which leads to disc protrusion, extrusion and even a burst part of the disc called sequestration that can damage spine nerves can lead to weakness, numbness and even paralysis. Discoplasty  in the past has been done with chemicals and mechanical disc cutting systems but is currently done through small fine needles placed under high definition Spine Imaging (see images above) into the center of the spine discs; to deploy micro devices that give a special energy to reduce the pressure build up within the disc.  Although lasers have been used, there are now more advanced technologies include superior to laser systems with more controlled energy and less heat as compared with lasers for the treatment.  This includes high frequency Plasma Energy.   Discoplasty  is best done by experienced Spine Specialists such as Neurosurgeons who have had training in Spine, Nerves and Pain diseases, treatments and procedures. Robotic Discoplasty is the latest advance in Discoplasty allowing a higher precision treatment of the Spine Discs. Nucleoplasty  refers to the treatment of the central part of the disc called the nucleus only. Annuloplasty  refers to the treatment of the outer covering of the disc called the Annulus which can be injured or physically stressed resulting in thinning or tears which are associated with back pain or neck pain. This can be done through small needles using focussed energy and can be done at the same time as Discoplasty when indicated. Discoplasty if carried out before the disc wears out significantly or ruptures can give good results in protecting and preserving the function of  the Spine nerves including the spinal cord in patients who present with Neck Pain or Low Back Pain from Spine Disc Disease or Injury; and reducing pain and disability allowing an earlier return to work and activity.

What is Endoscopic Microdiscectomy? Microdisectomy refers to the technology of using a dedicated operating microscope with superfine instruments/microinstruments during spine surgery to remove damaged parts of the discs in the spine. These damaged parts of the disc (prolapsed discs, sequestrated discs, herniated discs) often are mechanically pressing on nerves and are the cause of back and limb pain. This surgery allows a smaller/keyhole opening to be made by an experienced neurosurgeon with potentially better results and less damage to normal spine structures (bone, muscle, facets, ligaments) than normal open spine surgery. This can allow a faster recovery with less post surgery pain. If you have tried other procedures or holistic treatments to no avail, then this might be a viable option for your spinal treatment.  Having a consultation with a well known and highly experienced neurosurgeon can help you determine if this surgery is a good option for your condition. Types of Endoscopic Microdiscectomy Endoscopic microdiscectomy procedures may vary depending on the location of the herniated disc and the surgical technique used. Common types include: Transforaminal Endoscopic Microdiscectomy: This technique involves accessing the herniated disc through the foraminal space (a natural opening where nerves exit the spine). It is commonly used for herniations in the lumbar spine. Interlaminar Endoscopic Microdiscectomy: Used for lower lumbar herniations near the midline, this approach involves accessing the disc between the vertebral laminae. Cervical Endoscopic Microdiscectomy: For herniated discs in the neck (cervical spine), this procedure removes the damaged portion of the disc while preserving surrounding structures. Thoracic Endoscopic Microdiscectomy: A less common approach for herniated discs in the upper and mid-back (thoracic spine). Benefits of Endoscopic Microdiscectomy Endoscopic microdiscectomy offers numerous advantages compared to traditional open surgery, including: Minimally Invasive Access:  Small incisions minimise muscle and tissue damage, leading to less postoperative pain. Reduced Recovery Time:  Patients typically recover more quickly and return to their daily activities sooner. Preservation of Spinal Stability:  The procedure removes only the damaged portion of the disc, leaving the rest of the spine intact. Lower Risk of Complications:  Smaller incisions and reduced tissue disruption lower the risk of infection, bleeding, and other complications. Outpatient Procedure:  Many cases can be performed on an outpatient basis, reducing the need for extended hospital stays. Symptoms and Conditions Treated with Endoscopic Microdiscectomy Endoscopic microdiscectomy is commonly used to treat conditions that cause nerve compression and associated symptoms. These include: Herniated Discs:  Discs that bulge or rupture, pressing on nearby nerves and causing pain, numbness, or weakness. Sciatica:  Pain that radiates down the leg due to nerve compression in the lower spine. Radiculopathy:  Nerve irritation or inflammation resulting in pain or tingling radiating into the arms or legs. Spinal Stenosis:  Narrowing of the spinal canal that compresses nerves, particularly when caused by herniated discs. Diagnosis and Treatment Process Diagnosis: A thorough diagnostic evaluation is necessary to determine if endoscopic microdiscectomy is the right option. Steps include: Medical History and Physical Examination:  To identify symptoms and assess nerve function and mobility. Imaging Studies:  MRI or CT scans are used to confirm the presence of a herniated disc and locate the affected area. Nerve Function Tests:  Electromyography (EMG) may be performed to assess the extent of nerve involvement. Treatment: The endoscopic microdiscectomy process involves the following steps: Preoperative Planning:  Imaging studies are used to create a detailed surgical plan tailored to the patient’s anatomy and the location of the herniated disc. Surgical Procedure:  Through a small incision, an endoscope is inserted to visualise the affected area. Specialised instruments are used to remove the herniated portion of the disc, relieving pressure on the nerve. Postoperative Care:  Patients typically receive a personalised rehabilitation plan, including physical therapy, to restore mobility and strength. Recovery is usually quicker and less painful compared to traditional surgery. Conclusion Endoscopic microdiscectomy is a highly effective, minimally invasive solution for patients suffering from herniated discs and related symptoms. By utilising small incisions and advanced visualisation, this procedure minimises recovery time, reduces pain, and preserves spinal stability. If you are experiencing back pain, sciatica, or other symptoms of a herniated disc, schedule a consultation with us today to explore your treatment options. Let us help you find relief and regain your quality of life.

In general, the goal of minimally invasive spine (MIS) surgery is to stabilize the vertebral bones and spinal joints and/or relieve pressure being applied to the spinal nerves — often a result of conditions such as spinal instability, bone spurs, herniated discs, scoliosis or spinal tumours. As opposed to open spine surgery, minimally invasive surgical approaches can be faster, safer and require less recovery time. Because of the reduced trauma to the muscles and soft tissues (compared to open procedures), the potential benefits are: Better cosmetic results from smaller skin incisions (sometimes as small as several millimeters) Less blood loss from surgery Reduced risk of muscle damage, since less or no cutting of the muscle is required Reduced risk of infection and postoperative pain Faster recovery from surgery and less rehabilitation required Diminished reliance on pain medications after surgery In addition, some MIS surgeries are performed as outpatient procedures and utilize only local anesthesia — so there is less risk for an adverse reaction to general anesthesia. As with any surgical procedure, no matter how minimal, there are certain risks associated that include, but are not limited to: Possible adverse reaction to the anesthetic Unexpected blood loss during the procedure Localized infections, no matter how small the incision area And, though uncommon, there is always a small chance that the initial MIS surgery cannot be completed, requiring either a second procedure or full open surgery. Conditions Treated Using MIS Procedures Degenerative disc disease Herniated disc Lumbar spinal stenosis Spinal deformities such as scoliosis Spinal infections Spinal instability including spondylolisthesis Vertebral compression fractures Spinal tumors How Minimally Invasive Spine Surgery Works Because the spinal nerves, vertebrae and discs are located deep inside the body, any approach to gain access to the spinal area requires moving the muscle tissue out of the way. In general, this is facilitated by utilizing a small incision(s) and guiding instruments and/or microscopic video cameras through these incisions. Removal tools include diamond drills, Special fine Microtools such as rongeurs, Ultrasound, lasers and next generation superior to Laser technologies. A number of methods can be used to minimize trauma during MIS surgery. Some of the more common techniques are outlined here. Using a Tubular Retractor This technique involves progressive dilation of the soft tissues, as opposed to cutting directly through the muscles. By using tubes to keep the muscles out of the way, the surgeon works through the incision without having to expose the area widely. Sometimes, the surgeon will also utilize an endoscope or microscope focused down the tube to assist with performing the surgery through a minimal access strategy. Once the procedure is complete, the tubular retractor can be removed, allowing the dilated tissues to come back together. Depending on the extent and type of surgery necessary, incisions can often be small. Percutaneous Placement of Screws and Rods Depending on the condition of the patient, it may be necessary to place instrumentation, such as rods and screws, to stabilize the spine or to immobilize the spine to facilitate fusion of the spinal bones. Traditional approaches for placement of screws requires extensive removal of muscle and other tissues from the surface of the spine. However, percutaneous (meaning “through the skin”) placement typically involves inserting rods and screws through relatively small skin incisions without cutting or dissecting the underlying muscle. With the aid of x-ray images, guidewires are placed through the skin and into the spinal vertebrae along the desired paths for the screws. Then, screws are placed over the guidewires and follow the path of the wires. These screws have temporary extenders that extend outside of the skin and are subsequently removed after helping to guide passage of rods to connect and secure the screws. With the use of spinal navigation and robots , spinal instrumentation is being placed more safely and accurately. Direct Lateral Access Routes In some cases, especially those involving the lumbar spine, approaching the spine from the side of the body results in reduced pain, due to the limited amount of muscle tissue blocking the way. This approach is typically performed with the patient on his or her side. Then, a tubular retractor docks on the side of the spine to enable access to the spine’s discs and bones. Thoracoscopic Access Route Depending on the patient’s condition, it may be necessary to access the front portions of the thoracic spine, located in the chest and surrounded by the heart and lungs. Traditional access approaches often involve opening the chest through large incisions that may also require removal of one or more ribs. However, thoracoscopic access relies on multiple small incisions, through which working ports and cameras can be inserted to facilitate surgery. Common MIS Surgery Treatment Options A number of specific techniques have been deployed for MIS surgery. Though the field continues to develop, the list below highlights some of the most common options. Discectomy Spinal discs are essentially elastic rings with soft material inside that serve as cushions between the vertebral bones. If the elastic ring becomes weakened, the soft tissue inside can extrude — or herniate — outside of the elastic ring. The herniated disc material can compress the nerves passing by, thus causing pain. If surgical treatment is recommended to trim or remove the herniated disc, it may be possible to perform this procedure with MIS surgery using tubular dilators and a microscope or endoscope. Spinal decompression Spinal stenosis, which is a narrowing of the vertebral canal, is a common condition that can result in compression of the nerves. This can produce a variety of symptoms, including pain, numbness and muscle weakness. If surgery is recommended, it may be possible to remove the bone and soft tissues causing the nerve compression through an MIS approach using tubular dilators and a microscope or endoscope. The more common decompressive procedures include laminectomy and foraminotomy. Transforaminal Lumbar Interbody Fusion (TLIF) This is a MIS technique that is performed for patients with refractory mechanical low back and radicular pain associated with spondylolisthesis, degenerative disc disease and recurrent disc herniation. The procedure is performed from the back (posterior) with the patient on his or her stomach. Utilizing two small incisions, screws and rods are placed between two or more vertebral levels. The intervertebral disc is removed and a cage filled with bone is placed in that void with the goal of stabilizing the levels affected. Candidates for MIS Surgery A doctor will be able to tell which MIS surgeries, if any, might be an option for treating a spinal condition. In some situations, MIS surgery may not be as safe or effective as traditional open surgery. If so, the doctor will be able to inform you about the relative risks and benefits. In addition, there are some conditions that are not truly treatable with MIS surgery. Glossary of Select Spine-Related Surgical Terms Bone spur Bony growth or rough edges of bone (a.k.a. osteophyte). Decompression A surgical procedure performed to relieve pressure and alleviate pain caused by the impingement of bone and/or disc material on the spinal cord or nerves. Disc degeneration Degeneration or wearing out of a disc. A disc in the spine may deteriorate or wear out over time. A deteriorated disc may or may not cause pain. Discectomy The surgical removal of part or all of an intervertebral disc, performed to relieve pressure on a nerve root or the spinal cord. Excision Removal by cutting away material, as in removing a disc. Facet A posterior structure of a vertebra which articulates (joins) with a facet of an adjacent vertebra to form a facet joint that allows motion in the spinal column. Each vertebra has a right and left superior (upper) facet and a right and left inferior (lower) facet. Foramen A normal occurring opening or passage in the vertebrae of the spine through which the spinal nerve roots travel. Foraminotomy Surgical opening or enlargement of the bony opening traversed by a nerve root as it leaves the spinal canal, to help increase space for that nerve. Herniated disc A condition, also known as a slipped or ruptured disc, in which the gelatinous core material of a disc bulges out of position and puts painful pressure on surrounding nerve roots. Intervertebral foramen An opening between vertebrae through which nerves leave the spine and extend to other parts of the body. Also known as neural foramen. Kyphosis A condition in which the upper back curves forward, sometimes leading to the appearance of a hump in the back. Kyphosis may result from years of poor posture, spine fractures associated with osteoporosis, trauma or developmental problems. Lamina The flattened or arched part of the vertebral arch, forming the roof of the spinal canal. Laminectomy Surgical removal of the rear part of a vertebra in order to gain access to the spinal cord or nerve roots, to remove tumors, to treat injuries to the spine or to relieve pressure on a nerve root. Laminotomy An opening made in a lamina, to relieve pressure on the nerve roots. As opposed to laminectomy (where the entire lamina is removed), a laminotomy typically involves removal of just half the lamina (the side where a patient is having symptoms). Lordosis Lordotic curves refer to the inward curve of the lumbar spine. In some patients, this may represent a spinal deformity, also called swayback, which occurs when the lower back curves inward more than normal. Pathologic or excessive lordosis may be caused by osteoporosis or spondylolisthesis. Obesity, congenital disorders or overcompensation for kyphosis may contribute to this condition. Medial facetectomy A procedure in which a part of the facet is removed to increase space in the spinal canal. Nerve roots The initial portion of a spinal nerve; the nerve root is an extension of the central nervous system that begins at the spinal canal and ends in the extremities (fingers, toes). Its purpose is to send sensory information from the extremity to the brain and motor commands from the brain to the extremity. Pedicle The bony part of each side of the neural arch of a vertebra that connects the lamina (back part) with the vertebral body (front part). Percutaneous Effected, occurring or performed through the skin. Pseudarthrosis The movement of a bone at the location of a fracture or a fusion resulting from inadequate healing of the fracture or failure of the fusion to mature properly. This can also result from a developmental failure. Scoliosis Lateral (sideways) curvature of the spine. Spinal stenosis Abnormal narrowing of the vertebral column that may result in pressure on the spinal cord, spinal sac or nerve roots arising from the spinal cord. Spinous process A slender projection of bone from the back of a vertebra to which muscles and ligaments are attached. Spondylitis Inflammation of vertebrae. Spondylolisthesis The forward displacement of one vertebra on another. Spondylosis Degenerative changes in the spine, most commonly affecting the intervertebral discs as well as the facet joints. Device Technology Endoscope A thin, fiberoptic tube with a light and lens, used to examine the interior of the patient’s body; provides minimally invasive access for diagnostic and surgical procedures. Fluoroscope An imaging device that uses x-rays to view internal body structures on a screen, intraoperatively. Laparoscope An instrument that enables visualization of specific structures within the body. A small surgical incision is made through which the laparoscope is placed. An array of tubes can be guided through the same incision, or other small incisions, permitting the use of probes and other instruments. Minimally invasive tubular retractor (MITR) Muscle-splitting technology first introduced in 1995 in conjunction with microendoscopic discectomy. The tubular retractor is used to create a tunnel down to the spinal column and can come in a variety of sizes, even as small as 1.4 cm in diameter (about 1/2 of an inch). A “muscle splitting” approach is employed, in which the tubular retractor is passed through a tunnel in the muscles of the back, rather than stripping the muscles away from the spine, as is done in open procedures. This approach limits damage to the muscles around the spine and decreases blood loss during surgery. Portals Devices that provide a passage through which the surgeon operates during endoscopic procedures. After the incision is made, dilators are used to reach the area of the spine that the surgeon is working on. Fluoroscopy is used to locate the right level at time of surgery. During the procedure, instruments are used to continue the dissection through the portal. When the portal is removed, all the tissue falls back into place. In order to avoid damaging the tissue by moving instruments in and out of the passage, the portal or tubular retractor is placed into the incision to hold the tissue apart and left in place throughout the procedure. There are open and sealed portals. The portals used in the thoracic spine are usually 11 to 12 mm, while portals used in the abdominal cavity tend to be larger. All of the instruments and implants must be designed to fit through these small passages and perform surgical functions, once they reach the site. Spinal Fusion Spinal fusion is an operation that creates a solid union between two or more vertebrae. This procedure may assist in strengthening and stabilizing the spine and may thereby help to alleviate severe and chronic back pain. Almost all of the surgical treatment options for fusing the spine involve placement of a bone graft between the vertebrae. Bone grafts may be taken from the hip or from another bone in the same patient (autograft) or from a bone bank (allograft). Bone graft extenders and bone morphogenetic proteins (hormones that cause bone to grow inside the body) can also be used to reduce or eliminate the need for bone grafts. Fusion may or may not involve use of supplemental hardware (instrumentation), such as plates, screws and cages. This fusing of the bone graft with the bones of the spine will provide a permanent union between those bones. Once that occurs, the hardware is no longer needed, but most patients prefer to leave the hardware in place rather than go through another surgery to remove it. Fusion can sometimes be performed via smaller incisions through MIS techniques. The use of advanced fluoroscopy, endoscopy and navigation has improved the accuracy of incisions and hardware placement, minimizing tissue trauma while enabling an MIS approach. MIS Fusion Procedures Minimally Invasive Lateral Interbody Fusion Minimally Invasive Posterior Lumbar Interbody Fusion (PLIF) Minimally Invasive Transforaminal Lumbar Interbody Fusion (TLIF) Minimally Invasive Posterior Thoracic Fusion MIS Non-Fusion Procedures : Artificial Disc Replacement The latest advance in Spine disc treatments is replacement of the Disc with an artificial disc replacement (ADR). This can be done with minimally invasive techniques for both cervical spine and lumbar spine discs. References Protocols of the American Association of Neurosurgeons (AANS) Protocols of the North American Spine Society (NASS) Protocols of the Neuro Spine and Pain Center Singapore