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Introduction and Diagnosis of Pain Treatment The most important part of the pain treatment is the correct diagnosis of it. For acute pain problems this is usually straightforward. Acute pain in the limbs, joints and the spine is often related to a sprain consequent to an injury. In severe cases, a muscle, tendon or ligament tear is the reason. In some patients an acute limb pain is from a sudden slipped disc compressing nerve roots. It is in chronic pain that the diagnosis may be more difficult. Proper assessment by a specialist preferably a neurosurgeon or neuro-spine specialist can help determine the root causes. Adjuncts to the physical examination include MRI (Magnetic resonance Imaging) scans, EMG (ElectroMyography) , NCS (Nerve Conduction Studies) and selected blood tests. Medical Treatment Pain can be treated symptomatically with pain medications. Surgical Treatments If back and neck pain treatment is required for a significant slipped or herniated disc, bony spur, spinal or foraminal stenosis, facet degeneration, spinal instability, osteoporotic vertebral body fracture, spine injury or spinal tumor that has not responded to conservative treatment or may potentially cause nerve damage, then a surgical intervention may be necessary. This decision needs to be made by an experienced and qualified neurosurgeon in collaboration with a well informed patient. Minimally Invasive spine treatments for pain relief include (this is not an exhaustive list) epidural steroid and analgesic blocks, facet blocks, nerve root blocks, spinal cord stimulation, nerve root stimulation, laser therapy, nucleoplasty, vertebroplasty, kyphoplasty and others.  In general though these pain relief procedures do not cure the root of the problem which is often spine degeneration . A proper physiotherapy program to strengthen the spine after pain relief is strongly recommended. Multiple pain procedures may be required in some patients. Some patients may be better off treating the root cause of the problem rather than having multiple pain procedures and/or ending up with permanent nerve damage from the root cause of the problem . For example a patient with sciatica and foot weakness from a sequestrated disc herniation may be a better candidate for Microsurgical/Endoscopic microdisectomy than pain relief treatment such as a root block or nucleoplasty. Trigeminal Neuraliga that does not respond to or where the patient cannot tolerate medications can be treated by minimally invasive options that include Radiosurgery (eg Gamma Knife), balloon decompression, Radiofrequency rhizotomy, or Glycerol ganglion injection. MicroVascular Decompression (MVD) is a specific microsurgical procedure to remove a vascular compression from the Vth cranial nerve which is often the cause of Trigeminal Neuralgia. Post-Herpetic Neuralgia that is not relieved by medical therapy can be treated by a microsurgical procedure on the spinal cord called DREZ lesioning. Neuropathic pain syndromes are difficult to treat medically. Brain procedures such as Motor Cortex stimulation, Deep Brain Stimulation (DBS) and others have been used with varying degrees of success.

Cervical Spine artificial disc replacement (Cervical Spine-ADR) is an advanced surgical and Microsurgical technique designed to preserve motion in the cervical spine by replacing damaged or degenerated discs with artificial ones. For the right patients it is an excellent treatment that avoids many of the problems of the older treatment of spinal fusion explains Dr Prem Pillay, a Spine Specialist who is experienced with both spinal fusion and artificial disc replacements. Indications of Cervical Spine Disc Replacement Cervical Spine ADR is typically indicated for patients suffering from: Cervical Disc Herniation When a disc protrudes or ruptures, causing spine nerve and/or spinal cord compression that can cause myelopathy and/or radiculopathy. Patients with myelopathy can have progressive weakness of the arms and legs. Cervical Radiculopathy Pain, weakness, or numbness radiating from the neck into the arms due to spine nerve root compression. Cervical Degenerative Disc Disease Progressive wear and tear of the discs leading to loss of disc height, instability, and pain. The procedure is considered when: Conservative treatments like physical therapy and pain medication have failed.Patients exhibit symptoms such as neck pain, arm pain, numbness, or weakness.Imaging including X-rays, CT Spine and the better MRI of the Spine confirms disc pathology that correlates with clinical symptoms. Materials Used Various materials are employed in the construction of artificial cervical discs: Polyethylene (PE) Often used for the core or bearing surfaces due to its durability and low friction. Cobalt-Chrome (CoCr) Alloys Common in endplates for their strength and biocompatibility. Stainless Steel Less commonly used due to MRI incompatibility but still found in some designs. Titanium (Ti) Alloys Known for their excellent biocompatibility, often used for endplates or as coatings to promote bone ingrowth. Polycarbonate Urethane (PCU) Used in some discs for its cushioning properties. Ultra-High-Molecular-Weight Polyethylene (UHMWPE) A variant of polyethylene with enhanced durability for bearing surfaces. The choice of materials focuses on durability, biocompatibility, and their ability to mimic the natural biomechanics of the cervical spine. Most Neurosurgeons use the best ADRs that have good results and are FDA and/or CE regulated and registered. Techniques The surgical technique for Cervical Spine-ADR involves: Anterior Approach A small incision (1-2 inches) is made on the front or side of the neck to access the cervical spine. Xrays are used for localization. High quality visualization is used with special Spine Microscopes and microinstruments Disc Removal Under the Microscope the Neurosurgeon removes the damaged disc, taking care to preserve the surrounding structures like the posterior longitudinal ligament. Disc Replacement An artificial disc is inserted into the disc space. This can be: Single-piece designs , where the implant is one unit with metal endplates and a polymer core. Two and three-piece designs , with two endplates and a mobile core, allowing for more natural motion. Fixation Techniques to ensure the implant remains stable include keels, spikes, wire mesh, or specialized coatings like hydroxyapatite to promote bone ingrowth. Postoperative Care Unlike fusion, patients typically do not need a cervical collar, or only use it for a short time when out of the home or office, promoting faster recovery, Most patients have a better quality of recover in a shorter time as compared with fusion. Why Cervical Spine ADR is Better than Spinal Fusion Motion Preservation:** C-ADR maintains segmental motion, which can reduce the risk of adjacent segment disease where adjacent discs degenerate faster due to increased stress. Faster Recovery: Patients undergoing C-ADR can often return to work and normal activities sooner than those with spinal fusion due to the lack of bone fusion time. Lower Revision Rates: Studies indicate that patients with C-ADR have lower rates of revision surgery or supplemental fixation procedures compared to ACDF. Improved Clinical Outcomes: Long-term follow-up studies have shown significant improvements in neck disability index scores, pain, and overall patient satisfaction with C-ADR. Reduced Stress on Adjacent Segments: By preserving motion, C-ADR puts less stress on the vertebrae above and below the surgical site, potentially reducing future degenerative changes. Biomechanical Advantage: Artificial discs can mimic the natural disc’s function, allowing for more physiologic motion and potentially reducing the risk of further disc degeneration. In conclusion, cervical artificial disc replacement offers a motion-preserving alternative to traditional spinal fusion with benefits including faster recovery, lower rates of subsequent surgeries, and potentially better long-term health outcomes for the cervical spine. The choice between ACDF (fusion) and ADR (replacement) should be made after a comprehensive evaluation by a Neurosurgeon spine specialist, considering the patient’s overall health, the specifics of their spinal condition, and their lifestyle needs. With many years of experience in treating Cervical Herniated Discs (Slipped Discs) and access to the latest technological advancements, Dr Prem Pillay aims to offer patients the highest standard of care. From accurate diagnosis to tailored treatment plans, our approach aims to ensure the best possible outcomes for individuals affected by this challenging condition. If you or a loved one has been diagnosed with a cervical spine problem, we encourage you to seek consultation with our specialized team. Together, we can develop a comprehensive evidence based and personlized treatment strategy that addresses your unique needs and provides the best chance for a positive outcome.

Spinal fusion is a surgical procedure used to correct problems with the small bones in the spine (vertebrae). It is essentially a “welding” process. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone. Spinal fusion is a treatment option when motion is the source of the pain—the theory being that if the painful vertebrae do not move, they should not hurt. This article focuses on two methods of fusing the lumbar (lower) spine—posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF); Dr Prem Pillay will talk with you about which method is appropriate in your situation. This article discusses only the surgical component of these two procedures. Interbody Fusion An interbody fusion is a type of spinal fusion that involves removing the intervertebral disk from the disk space. In an interbody fusion, the intervertebral disk is removed. When the disk space has been cleared out, your surgeon will implant a metal, plastic, ceramic or bone spacer between the two adjoining vertebrae. This spacer, or “cage,” usually contains bone graft material. This promotes bone healing and facilitates the fusion. After the cage is placed in the disk space, your surgeon may add stability to your spine by using metal screws and rods (usually using the highest grade Titanium) to hold the cage in place. An interbody fusion can be performed using a variety of different approaches. Two common types are posterior lumbar interbody fusion and transforaminal lumbar interbody fusion. Less common are Anterior Lumbar interbody Fusion (ALIF). Posterior Lumbar Interbody Fusion In posterior lumbar interbody fusion (PLIF), your surgeon inserts the spacer or “cage” from the back of the spine. With this approach, your surgeon gains access to your spine by removing the bone (lamina) and then retracting the nerve roots to one side. Then the back of the intervertebral disk can be removed and a spacer inserted. Illustration shows a PLIF procedure. The weakened intervertebral disk is removed. It is then replaced with a spacer or “cage.” Transforaminal Lumbar Interbody Fusion This technique is a variation of PLIF. In transforaminal lumbar interbody fusion (TLIF), your surgeon approaches the disk space slightly more from the side. The advantage of this approach is that it requires less movement of the nerve roots; thus, theoretically, it decreases the chance of nerve injury. In these front and side views of a TLIF procedure, note the screws in the back of the vertebrae. The cage can only be seen by the white metal markers. Bone graft is in the disk space inside and around the cage. (Left)   An x-ray of a TLIF procedure. (Right)   A CT scan of the same patient showing the healed fusion. Note that bone has grown through the cage,  so the cage is not visible. The screws and rods used to stabilize the spine are still in place but cannot be seen from this angle. References and Acknowledgements American Academy of Orthopaedic Surgeons : Patient Information American Assocation of Neurological Surgeons: Patient Information

Robotic Spine Surgical Systems transforms spine surgery from freehand procedures to highly-accurate, state-of-the-art robotic procedures, with less radiation, greater accuracy and precision and less risk. Dr Prem explains that it  is used for procedures including minimally invasive surgery (MIS) for slipped disc or herniated discs, Spine stenosis, Spine Spondylosis, Spine Tumors, Spine Infection, scoliosis and other complex spinal deformities. It is a minimally invasive robotic guided spine surgery system that is used. Why Robotics? Robotic minimally-invasive surgeries are moving from the laboratory to the surgical suite after a long period of testing and validation. In selected patients they can help the Spine Specialist with more accurate implant placement and sagittal balance restoration states Dr Prem Pillay. World wide, robotic assisted spine surgery has been used to successfully performed a wide range of procedures ranging from complex reconstructions on childhood deformities to minimally invasive surgeries for low back disorders.   Clinical Applications This system can be used for a variety of clinical procedures including : Open, MIS [Minimally invasive], and percutaneous posterior thoracolumbar approaches Scoliosis and other complex spinal deformities Pedicle screws – short and long fusions Transfacet screws and translaminar-facet screws Osteotomies Biopsies Sagittal Balance Restoration and correction Advantages Higher accuracy Less radiation Fast learning curve Conventional, freehand MIS presents many challenges. According to literature, in freehand surgery there are instances of misplaced pedicle screws and high levels of radiation are required for intraoperative imaging to assure accuracy. Spinal Robotics’ state-of-the-art technology overcomes these challenges thus redefining the standard of care for MIS.   Spinal Robotics Technology has been successfully used in the placement of over 20,000 implants in the United States and Europe. Numerous peer-reviewed publications and presentations at leading scientific conferences have validated the accuracy, usability, and its clinical advantages. It is now available for Spine procedures in Singapore states Dr Prem Pillay, Spine Neurosurgeon and Robotic Expert.   Recent Advances and Future Directions of Robotic Spine Surgery Expanded Applications Recent advances have seen the expansion of robotic applications beyond thoracolumbar pedicle screw placement to include cervical spine instrumentation, pelvic fixation, and complex tumor reconstruction. Improved Software and Planning Tools Enhancements in imaging software are facilitating better patient registration, error minimization, and trajectory planning both preoperatively and intraoperatively. Integration with Other Technologies The combination of robotics with augmented reality and artificial intelligence is an area of active research and development. Automated and Telerobotic Surgery Future directions for robotic spine surgery include the development of automated surgical procedures and telerobotic capabilities, allowing for remote surgery. Machine Learning and Artificial Intelligence The integration of machine learning and AI algorithms into preoperative planning and intraoperative decision-making processes is a promising area of development. Conclusion Robotic-assisted spine surgery represents a significant advancement in the field, offering improved accuracy, reduced radiation exposure, and potentially better patient outcomes. While challenges such as cost and learning curves exist, ongoing technological developments and expanding applications suggest a bright future for robotics in spine surgery.As the technology continues to evolve, it is crucial to maintain clinical equipoise with established methods of screw placement and to conduct further long-term studies evaluating patient-reported outcomes and cost-effectiveness. Dr Prem Pillay elaborates that the integration of robotics with other advanced technologies, such as augmented reality and artificial intelligence, may further revolutionize spine surgery in the coming years

Anatomy of The Spine Almost everyone will experience low back pain at some point in their lives. A common cause of low back pain is lumbar spinal stenosis. As we age, our spines change. These normal wear-and-tear effects of aging can lead to narrowing of the spinal canal. This condition is called spinal stenosis. Anatomy Understanding your spine and how it works can help you better understand spinal stenosis. Your spine is made up of small bones, called vertebrae, which are stacked on top of one another. Muscles, ligaments, nerves, and intervertebral disks are additional parts of your spine. Vertebrae These bones connect to create a canal that protects the spinal cord. The spinal column is made up of three sections that create three natural curves in your back: the curves of the neck area (cervical), chest area (thoracic), and lower back (lumbar). The lower section of your spine (sacrum and coccyx) is made up of vertebrae that are fused together. Five lumbar vertebrae connect the upper spine to the pelvis. Parts Of The Lumbar Spine Spinal Cord and Nerves These “electrical cables” travel through the spinal canal carrying messages between your brain and muscles. Nerves branch out from the spinal cord through openings in the vertebrae. Muscles and Ligaments These provide support and stability for your spine and upper body. Strong ligaments connect your vertebrae and help keep the spinal column in position. Facet Joints Between vertebrae are small joints that help your spine move. Facet joints are very close to the spinal nerves. Intervertebrae Disks Intervertebral disks sit in between the vertebrae. Healthy Intervertebral Disk (Cross-Sectional View) When you walk or run, the disks act as shock absorbers and prevent the vertebrae from bumping against each other. They work with your facet joints to help your spine move, twist, and bend. Intervertebral disks are flat and round, and about a half-inch thick. They are made up of two components. Annulus fibrosus. This is the tough, flexible outer ring of the disk. It helps connect to the vertebrae. Nucleus pulposus. This is the soft, jelly-like center of the annulus fibrosus. It gives the disk its shock-absorbing capabilities. Description & Cause Spinal stenosis occurs when the space around the spinal cord narrows. This puts pressure on the spinal cord and the spinal nerve roots, and may cause pain, numbness, or weakness in the legs. As we age, the bone in our spines may harden and become overgrown. This can lead to a narrowing of the spinal canal, called stenosis. When stenosis occurs in the lower back. it is called lumbar spinal stenosis. It often results from the normal aging process. As people age, the soft tissues and bones in the spine may harden or become overgrown. These degenerative changes may narrow the space around the spinal cord and result in spinal stenosis. Degenerative changes of the spine are seen in up to 95% of people by the age of 50. Spinal stenosis most often occurs in adults over 60 years old. Pressure on the spinal cord is equally common in men and women, athough women are more likely to have symptoms that require treatment. A small number of people are born with back problems that develop into lumbar spinal stenosis. This is known as congenital spinal stenosis. It occurs most often in men. People usually first notice symptoms between the ages of 30 and 50. Diagnosing Neck Problems A physician 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. Cause Arthritis is the most common cause of spinal stenosis. Arthritis is the degeneration of any joint in the body. In the spine, arthritis can result as the disk degenerates and loses water content. In children and young adults, disks have high water content. As we get older, our disks begin to dry out and weaken. This problem causes settling, or collapse, of the disk spaces and loss of disk space height. When we are young, disks have a high water content (above,left). As disks age and dry out, they may lose height or collapse (above,right). This puts pressure on the facet joints and may result in arthritis. As the spine settles, two things occur. First, weight is transferred to the facet joints behind tghe spinal cord. Second, the tunnels that the nerves exit through become smaller. As the facet joints experience increased pressure, they also begin to degenerate and develop arthritis and can hypertrophy (enlarge). The cartilage that occurs and protects the joints wears away. If the cartilage wears away completely, it can result in bone rubbing on bone. To make up for the lost cartilage, your body may respond by growing new bone in your facet joints to help support the vertebrae. Over time, this bone overgrowth-called spurs-may narrow the space for the nerves to pass through. Degenerative bone spurs narrow the spinal canal Another response to degeneration in the lower back is that ligaments around the spine like the ligamentum flavum (yellow ligament) increase in size. This also lessens space for the nerves. Once the space has become small enough to irritate spinal nerves, painful symptoms result. Severe stenosis can cause weakness and even paralysis in the legs and difficulty with bladder and bowel function. Symptoms Back Pain People with spinal stenosis may or may not have back pain, depending on the degree of degeneration that has developed. Spinal nerves relay sensation in specific parts of your body. Pressure on the nerves can cause pain in the areas that the nerves supply. Pain in the buttocks that radiates down the leg – called sciatica – is caused by this pressure. Burning pain in buttocks or legs (sciatica). Pressure on spinal nerves caaresult i pain in the areas that the nerves supply. The pain may be described as an ache or a burning feeling. It typically starts in the area of the buttocks and radiates down the legs. The pain down the leg is often called “sciatica”. As it progesses, iit can result in pain in the foot. Numbness or tingling in buttocks or legs. As pressure in the nerve increases, numbness and tingling often accompany the burning pain. Although not all patients will have both burning pain and numbness and tingling. Weakness in the legs or “foot drop”. Once the pressure reaches a critical level, weakness can occur in one or both legs. Some patients will have a foot-drop, or the feeling that their foot slaps on the ground while walking. Less pain with leaning forward or sitting. Studies of the lumbar spine show that leaning forward can actually increase the space available for the nerves. Many patients may note relief when leaning forward and especially with sitting. Pain is usualy made worse by standing up straight and walking. Some patients note that they can ride a stationary bike or walk leaning on a shopping cart. Walking more than 1 or 2 blocks, however, may bring on severe sciatica or weakness. This is called pseudo-claudication. Doctor’s Examination & Treatment Doctor Examination Medical History and Physical Examination After discussing your symtoms and medical history, your doctor will examine your back. This will include looking at your back and pushing on different areas to see if it hurts. Your doctor may have you bend forward, backward, and side-to-side to look for limitations or pain . Imaging Tests Other tests which may help your doctor confirm your diagnosis include: X-rays. Although they only visualize bones, X-rays can help determine if you have spinal stenosis. X-rays will show aging changes, like loss of disk height or bone spurs. X-rays taken while you lean forward and backward can show “instability” in your joints. X-rays can also show too much mobility. This is called spondylolisthesis. Magnetic resonance imaging (MRI). This study can create better images of soft tissues, such as muscles, disks, nerves, and the spinal cord. Additional tests. Computed tomography (CT) scans can create cross-section images of your spine. Treatment Nonsurgical Treatment Nonsurgical treatment options focus on restoring function and relieving pain. Although nonsurgical methods do not improve the narrowing of the spinal canal, many people report that these treatments do help relieve symptoms for a while. Physical therapy. Stretching exercises, massage, and lumbar and abdominal strengthening often help manage symptoms. Lumbar traction. Although it may be helpful in some patients, traction has very limited results. There is no scientific evidence of its effectiveness. Anti-inflammatory medications. Because stenosis pain is caused by pressure on spinal nerves, reducing inflammation (swelling) around the nerve may relieve pain.  Non-steroidal anti-inflammatory drugs (NSAIDs) initially provide pain relief.  When used over the course of 5-10 days, they can also have an anti-inflammatory effect. However long term use of NSAIDs and even stronger narcotics is not advisable.  The pain may be relieved but the stenosis and nerve pressure remains. Most people are familiar with nonprescription NSAIDs.  Whether over-the-counter or prescription strength, these medicines must be used carefully.  They can lead to gastritis or stomach ulcers.  If you develop acid reflux or stomach pains while taking an anti-inflammatory,be sure to talk with your doctor. Injections Modern anti-inflammatory injections around the nerves or in the “ëpidural space” can decrease swelling, as well as pain. It is not recommended to receive these, however, more than 3 times. These injections are more likely to decrease pain and numbness but not weakness of the legs. Again they do not take away nerve pressure that can cause weakness and paralysis. Chiropractic manipulation. Care should be taken if a patient has osteoporosis or disk herniation. Manipulation of the spine in these cases can worsen symptoms or cause other injuries. Surgical Treatment Surgery for lumbar spinal stenosis is generally reserved for patients who have poor quality of life due to pain and weakness. Patients may complain of inability to walk for an extended length of time without sitting. This is often the reason that patients consider surgery. There are several surgical options to treat lumbar spinal stenosis: Microsurgical decompression with or without laminectomy, spinal fusion, and posterior dynamic stabilization without fusion. Modern options can result in excellent pain relief. Be sure to discuss the advantages and disadvantages of different surgeries with your doctor. Laminectomy. This procedure involves removing the bone, bone spurs, and ligaments that are compressing the nerves. This procedure may also be called a “decompression”. Laminectomy can be performed as open surgery, where your doctor uses a single, larger incision to access your spine. The procedure can also be done using a minimally invasive method, where several smaller incisions are made. Your doctor will discuss with you the right option for you. Spinal fusion. If spinal degeneration has progressed to spinal instability, a combination of microsurgical decompression and stabilization or spinal fusion may be recommended. In a spinal fusion, two or more vertebrae are permanently healed or fused together. A bone graft taken from the pelvis or hip bone is used to fuse the vertebrae. More options include use of a ceramic cage between the vertebrae with bone promoting material in or around the cage. BMP may be used to aid fusion. Fusion eliminates motion between vertebrae and prevents the slippage from worsening after surgery. The surgeon may also use rods and screws to hold the spine in place while the bones fuse together. The use of rods and screws makes the fusion of the bones happen faster and speeds recovery. Posterior Dynamic Stabilization This is a modern method to stabilize the spine without fusion and is usually used after microsurgical decompression. Rehabilitation After surgery, you may stay in the hospital for a short time, depending on your health and the procedure performed. Healthy patients who undergo just decompression may go home the same or next day, and may return to normal activities after only a few weeks. Fusion generally adds 2 to 3 days to the hospital stay. Your surgeon may give you a brace or corset to wear for comfort. He or she will likely encourage you to begin walking as soon as possible. Most patients do not need physical therapy except to learn how to strengthen their backs. Your physical therapist may show you exercises to help you build and maintain strength, endurance, and flexibility for spinal stability. Some of these exercises will h elp strengthen your abdominal muscles, which help support your back. Your physical therapist will create an individualized program, taking into consideration your health and history. Most people can go back to a desk stop within a few days to a few weeks after surgery. They may return to normal activities after 2 to 3 months. Older patients who need more care and assistance may be transferred from the hospital to a rehabilitation facility prior to going home. Surgical risks There are minor risks associated with every surgical procedure. These include bleeding, infection, blood clots, and reaction to anesthesia. These risks are usually very low. Elderly patients have higher rates of complications from surgery. So do overweight patients, diabetics, smokers, and patients with multiple medical problems. New Surgical Options Interspinous Process Devices Interspinous process devices have been developed as a minimally invasive surgical option for lumbar spinal stenosis. A spacer fits between the spinous processes in the back of the spine. Its role is to keep the space for the nerves open by spreading the vertebrae apart. Interspinous process spacers were approved in 2005. Many procedures have been performed since then. In some studies, success rates are greater than 80 percent. Numerous spacer devices are currently being evaluated. They may be a safe alternative to an open laminectomy for some patients. Limited bone (lamina) is removed with this procedure, and it may be performed under local anesthesia. The key to success with this procedure is appropriate selection of the patients. The appropriate candidate must have relief of buttock and leg pain when sitting or bending forward. The pain returns upon standing. Minimally Invasive Decompression Decompression can be performed using smaller incisions. Recovery is often quicker with minimally invasive techniques. This is because there is less injury to the surrounding soft tissues. With these minimally invasive techniques, surgeons rely more on microscopes to see the area for surgery. They may also take X-rays during the operation. A traditional open procedure requires more direct visualization of the patient’s anatomy, and therefore requires a larger incision. This can be more painful for the patient. The limitation of minimally invasive surgery is the degree of visualization available. If the spinal stenosis extends over a large area of the spine, an open technique is the only method that can address the problem. The advantages of minimally invasive procedures include reduced hospital stays and recovery periods. However, both open and minimally invasive techniques relieve stenosis symptoms equally. Your doctor will be able to discuss with you the options that best meet your healthcare needs.

Description Back pain in children is not like back pain in adults. Compared to an adult, a child with a backache is more likely to have a serious underlying disorder. This is especially true if the child is 4 years old or younger or if a child of any age has back pain accompanied by: Fever or weight loss. Weakness or numbness. Trouble walking. Pain that radiates down one or both legs. Bowel or bladder problems. Pain that keeps the child from sleeping. More serious causes of back pain need early identification and treatment or they may become worse. Always see a doctor if your young child’s back pain lasts for more that several days or progressively worsens. Doctor Examination Your doctor will begin by learning about how the problem developed. Then, he or she will conduct a physical examination of your child. Medical History/Symptoms Your doctor will ask general questions about your child’s overall health and more specific questions about the pain. The questions and physical examination will allow your doctor to determine which of a number of conditions is responsible for your child’s back pain. Your doctor will want to know when the pain began, if it was associated with injury or demanding activity, and whether it has improved or worsened. He or she will ask if there is anything that makes it worse, and what your child does to make it less painful. It will be important for your doctor to kow exactly where the pain is felt, how severe it is, and how much it interferes with the child’s schooling and activities. If the pain shoots into a leg it could mean that there is pressure on a nerve. Physical Examination During the physical examination of your child, your doctor carefully examines the muscles, bones and nerves. Your doctor will be checking the following: The spine. Your doctor feels each vertebra and looks for deformities in the alignment and mobility of the spine. Increased roundness of the back or a curve to the side could be important. Your doctor will check posture and walking gait; the ability to bend over to touch the toes; and bending to the right and left. Difficulty with movement may indicate that there is a problem with the joints of the spine. Nerves in the back. Disk problems can cause pressure on the nerves that exit the spine, so your doctor will perform specific tests for that. With your child lying face up, your doctor will raise the legs (straight leg raising test) and may also raise the legs with your child lying face down (reverse straight leg raising test). Testing reflexes and feeling in the legs will be done for the same reason. Muscles. The muscles in the back and legs are tested. Tightness of the back muscles or the hamstring muscles at the back of the thigh will show that your child is trying to protect himself or herself from movements and positions that might be painful. Tenderness of the muscles will indicate a muscle injury, such as a strain. Balance, flexibility, coordination, and muscle strength. Other tests will be done to be sure the back pain is not part of a bigger picture. Investigations / Tests Imaging Tests The doctor may use one or several diagnostic imaging tools to see inside the body. Xrays. X-rays of the spine will show the bones and may show fractures, displacements, or other problems within the bones. Bone Scans. This test involves injecting a substance into the vein and then using a special camera to see where it is picked up. It can pinpoint inflammation, infections, tumors, and fractures. Since the anatomy of the spine is very complicated and since these processes are not always visible on x-ray, the bone scan can be very useful. Computed Tomography (CT) scans. This is a special computerized x-ray technique that provides a three-dimensional image and allows your doctor to see things that are not visible on two-dimensional x-rays. It is particularly useful in the spine to understand the complex anatomy. Magnetic Resonance Imaging (MRI). This technique is very valuable because it shows tissues other than bone. It can be used to see the spinal cord, nerve roots, disks, or other soft tissues that can be very important in back pain. Laboratory Tests Blood tests, including the complete blood-cell count (CBC), or erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP), can all be changed in the presence of inflammation or infection. Common Back Pain Conditions In Children Muscle Strain and Imbalances Musculoskeletal strain is most often responsible for back pain in children and adolescents. Poor posture and a modern lifestyle with computer, laptop, and ipad use for long periods of time can be factors causing this. This type of pain frequently responds to rest, anti-inflammatory medications, and an exercise program. Many teenagers may have more persistent back pain. This is often related to tight hamstring muscles and weak abdominal muscles. These children seem to improve with a physical therapy program that stresses hamstring stretching and abdominal strengthening. Rounded Back In adolescents, rounded back, also called Scheuermann’s kyphosis, is a common cause of pain in the middle of the back (the thoracic spine). Vertebrae become wedged, causing a rounded, or hunched, back. The curved part of the back may ache and pain may get worse with activity. Picture on the Right: An Adolescent Female Presents With Excessive Roundback Localized To The Thoracic Spine. The Severe Kyphosis Is Most Obvious When She Bents Forward. Stress Fracture of the Spine Spondylolysis, or stress fracture, may cause lower back pain in adolescents. Stress fractures may occur during adolescent growth spurts or in sports that repeatedly weist and hyperextend the spine, like gymnastics, diving, and football. Pain is usually mild and may radiate to the buttocks and legs. The pain feels worse with activity and better with rest. A child with spondylolysis may walk with a stiff legged gait and only be able to take short steps. Slipped Vertebra In this drawing of spondylolisthesis, a lower back vertebra has shifted forward. A slipped vertebra, or spondylolisthesis, occurs when one vertebra shifts forward on the next vertebra directly below. It usually occurs at the base of the spine (lumbosacral junction). In severe cases, the bone narrows the spinal canal, which presses on the nerves. Infection In young children, infection in a disk space (diskitis) can lead to back pain. Diskitis typically affects children between the ages of 1 and 5 years, although older children and teenagers can also be affected. A child with diskitis may have the following symptoms: Pain in the lower back or abdomen and stiffness of the spine. Walking with a limp, or simply refusing to walk. Squatting with a straight spine when reaching for something on the floor, rather than bending from the waist. Tumor On rare occasion, tumors, such as osteoid osteoma, can be responsible for back pain. When they occur, tumors of the spine are most often found in the middle or lower back. Pain is constant and usually becomes worse over time. This pain is progressive; it is unrelated to activity and/or happens at night.

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) What Is Scoliosis? 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.  This is one of the problems with scoliosis. This condition of side-to-side spinal curves is called scoliosis. On an X-Ray, the spine of an individual with scoliosis 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. Who Gets Scoliosis? This is a condition that affects approximately 2% of the population. If someone in a family has scoliosis, 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 this hereditary condition. 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 it can occur in children with cerebral palsy, muscular dystrophy, spina bifida, and other miscellaneous conditions, most scoliosis is found in otherwise healthy youngsters. Adults Scoliosis usually develops during childhood, but it also can occur in adults. Adults suffering with this condition 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. In other instances, 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. If allowed to progress, severe instances of adult scoliosis can lead to chronic severe back pain, deformity, and difficulty in breathing. 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 the family physician, a pediatrician, or a spine specialist (Neurosurgeon or Orthopaedist). 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, a spine expert 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 scoliosis will remain small and need only to be periodically assessed by a spine specialist 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. Electrical muscle stimulation, exercise programs, and manipulation have not been found to be effective treatments for scoliosis. 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. 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 orthopaedic techniques have made scoliosis a highly manageable condition. Spine doctors who are specialists in diseases of the muscles and skeleton, are the most knowledgeable and qualified group of physicians to diagnose, monitor and treat scoliosis.

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) Having a Crooked Back: What are the Solutions 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. This condition of side-to-side spinal curves is called scoliosis. On an x-ray, the spine of an individual with scoliosis 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 scoliosis(crooked back) , 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 scoliosis 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 manipulations 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 Senior Consultant Neurosurgeon with super specialty training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA) Tethered cord syndrome (TCS) in adults represents a rare yet significant neurological condition characterized by the spinal cord’s abnormal fixation within the spinal canal, leading to a variety of symptoms due to the stretching or tension of the spinal cord. This article explains the clinical features, diagnostic methods, treatment options, and prognosis of adult tethered cord syndrome based on many years of experience and the latest medical research. Clinical Features: Adult Tethered Cord Syndrome often presents differently compared to its pediatric counterpart. While pediatric TCS is typically associated with congenital defects, the adult onset can be due to congenital or acquired reasons, including trauma, tumors, or spinal surgery causing scar tissue. Common symptoms in adults include: Pain Persistent lower back pain, often radiating to the legs, hips, and sometimes to the genital or rectal area. This pain is frequently exacerbated by specific movements like bending over, sitting cross-legged, or holding weight (the “3-B sign”: bending, Buddha-sitting, baby-holding). Neurological Deficits Muscle atrophy, numbness, weakness, and sensory disturbances in the lower extremities. These can be patchy rather than following a specific dermatome pattern. Bladder and Bowel Dysfunction Including urinary frequency, urgency, incontinence, and fecal incontinence, though these symptoms are less common than in children. Other Symptoms In rare cases, upper body symptoms like chest or upper back pain have been reported, which complicates diagnosis due to the atypical presentation. Diagnosis Diagnosing TCS in adults can be challenging due to its rarity and non-specific symptoms. Key diagnostic tools includes: Clinical Examination Observing the patient’s posture, gait, reflexes, and any skin abnormalities like dimples or hairy patches over the spine. MRI The primary imaging modality, revealing a low-lying conus medullaris (below L2) and often a thickened filum terminale. MRI is essential for confirming the diagnosis. X rays are not accurate in determining TCS. Electromyography (EMG) and Nerve Conduction Studies To assess nerve function, particularly useful in patients with advanced stages of the syndrome. It should be noted that many of the symptoms of adult TCS are also caused by more common problems like Lumbar Spine slipped discs or Herniated Discs, and/or Facet degeneration causing Back Pain, Leg Pain and Bladder problems. This is the more important diagnosis to assess first and treat first before assuming TCS as the cause; particularly if the MRI does not show a low-lying conus. Treatment The main treatment for TCS is surgical intervention, although the approach varies based on the underlying cause: Conservative Management For patients with mild symptoms, observation might be recommended, especially considering the potential risks of surgery. Surgical Detethering Involves opening the spinal canal to release the tethered cord. Techniques now include minimally invasive microscopic and endoscopic approaches to minimize muscle trauma and Neuro-monitoring of the nerves during surgery.  Surgery aims to relieve tension on the spinal cord and halt the progression of neurological deficits. Postoperative Care Follow-up care is crucial due to the risk of retethering, where the spinal cord can reattach to the spine. Prognosis   The prognosis for adult TCS is variable: Improvement After surgery, many patients experience stabilization or improvement in pain, motor functions, and sometimes bladder control. However, outcomes can be less favorable if there’s a long duration of symptoms before surgery or if there are complex malformations like lipomyelomeningocele . Complications These include potential neurological deterioration, wound issues, CSF leaks, and a risk of retethering. The risk of complications increases with age, particularly in older patients or those with co-morbidities. Long-term Early surgical intervention tends to yield better outcomes. Patients with shorter symptom durations before surgery often experience significant relief from pain and improved neurological function. In conclusion, adult tethered cord syndrome requires an experienced specialist approach to diagnosis, treatment, and follow-up care states Dr Prem Pillay. While surgery offers the best chance of halting disease progression and potentially reversing some symptoms, patient selection is critical, considering that similar symptoms are often from more common causes of back and leg pain such as slipped / herniated discs in the spine, the heterogeneity of outcomes influenced by factors like the duration of symptoms, the presence of complex malformations, and the patient’s age at the time of intervention. Continuous research and advancements in surgical techniques are enhancing the management and outcomes for this condition, emphasizing the importance of early diagnosis and timely surgical intervention.

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) What are Chiari malformations? Chiari malformations (CM) are structural defects in the base of the skull and cerebellum, the part of the brain that controls balance. Normally the cerebellum and parts of the brain stem sit above an opening in the skull that allows the spinal cord to pass through it (called the foramen magnum). When part of the cerebellum extends below the foramen magnum and into the upper spinal canal, it is called a Chiari malformation (CM). Chiari malformations may develop when part of the skull is smaller than normal or misshapen, which forces the cerebellum to be pushed down into the foramen magnum and spinal canal. This causes pressure on the cerebellum and brain stem that may affect functions controlled by these areas and block the flow of cerebrospinal fluid (CSF)—the clear liquid that surrounds and cushions the brain and spinal cord. The CSF also circulates nutrients and chemicals filtered from the blood and removes waste products from the brain. What causes these malformations? CM has several different causes.  It is caused by structural defects in the brain and spinal cord that occur during development or in later life from injury, tumor, disease or infection. The chiari that occurs in early life  can be the result of genetic mutations or a maternal diet that lacked certain vitamins or nutrients. This is called primary Chiari malformation. It can also be caused later in life if spinal fluid is drained excessively from the lumbar or thoracic areas of the spine either due to traumatic injury, disease, or infection. This is called acquired or secondary Chiari malformation. What are the symptoms of a Chiari malformation? According to Dr Prem Pillay, an Expert in the field of Neurosurgery and Chiari Malformations, Headache is the hallmark sign of Chiari malformation, which can be aggravated by sudden coughing, sneezing, or straining.  Symptoms may vary among individuals and may include: Headache Neck Pain hearing or balance problems muscle weakness or numbness dizziness difficulty swallowing or speaking vomiting ringing or buzzing in the ears (tinnitus) curvature of the spine (scoliosis) insomnia depression problems with hand coordination and fine motor skills. People with Chiari Malformation may have a combination of some or all of the above symptoms.  Some individuals with CM may not show any symptoms. Symptoms may change for some individuals, depending on the compression of the tissue and nerves and on the buildup of CSF pressure. Infants with a Chiari malformation may have difficulty swallowing, irritability when being fed, excessive drooling, a weak cry, gagging or vomiting, arm weakness, a stiff neck, breathing problems, developmental delays, and an inability to gain weight. How are CMs classified? Chiari malformations are classified by the severity of the disorder and the parts of the brain that protrude into the spinal canal. Chiari malformation Type I Type 1 happens when the lower part of the cerebellum (called the cerebellar tonsils) extends into the foramen magnum. Normally, only the spinal cord passes through this opening. Type 1—which may not cause symptoms—is the most common form of CM. It is usually first noticed in adolescence or adulthood, often by accident during an examination for another condition. Adolescents and adults who have CM but no symptoms initially may develop signs of the disorder later in life said Dr Prem Pillay. Chiari malformation Type II Individuals with Type II have symptoms that are generally more severe than in Type 1 and usually appear during childhood. This disorder can cause life-threatening complications during infancy or early childhood, and treating it requires surgery.In Type II, also called classic CM, both the cerebellum and brain stem tissue protrude into the foramen magnum. Also the nerve tissue that connects the two halves of the cerebellum may be missing or only partially formed. Type II is usually accompanied by a myelomeningocele—a form of spina bifida that occurs when the spinal canal and backbone do not close before birth. (Spina bifida is a disorder characterized by the incomplete development of the brain, spinal cord, and/or their protective covering.) A myelomeningocele usually results in partial or complete paralysis of the area below the spinal opening. The term Arnold-Chiari malformation (named after two pioneering researchers) is specific to Type II malformations. Chiari malformation Type III Type III is very rare and the most serious form of Chiari malformation. In Type III, some of the cerebellum and the brain stem stick out, or herniate, through an abnormal opening in the back of the skull. This can also include the membranes surrounding the brain or spinal cord.The symptoms of Type III appear in infancy and can cause debilitating and life-threatening complications. Babies with Type III can have many of the same symptoms as those with Type II but can also have additional severe neurological defects such as mental and physical delays, and seizures. Chiari malformation Type IV Type IV involves an incomplete or underdeveloped cerebellum (a condition known as cerebellar hypoplasia). In this rare form of CM, the cerebellum is located in its normal position but parts of it are missing, and portions of the skull and spinal cord may be visible. What other conditions are associated with Chiari malformations? Hydrocephalus is an excessive buildup of CSF in the brain. A CM can block the normal flow of this fluid and cause pressure within the head that can result in mental defects and/or an enlarged or misshapen skull. Severe hydrocephalus, if left untreated, can be fatal. The disorder can occur with any type of Chiari malformation, but is most commonly associated with Type II. Spina bifida is the incomplete closing of the backbone and membranes around the spinal cord. In babies with spina bifida, the bones around the spinal cord do not form properly, causing defects in the lower spine. While most children with this birth defect have such a mild form that they have no neurological problems, individuals with Type II Chiari malformation usually have myelomeningocele, and a baby’s spinal cord remains open in one area of the back and lower spine. The membranes and spinal cord protrude through the opening in the spine, creating a sac on the baby’s back. This can cause a number of neurological impairments such as muscle weakness, paralysis, and scoliosis. Syringomyelia is a disorder in which a CSF-filled tubular cyst, or syrinx, forms within the spinal cord’s central canal. The growing syrinx destroys the center of the spinal cord, resulting in pain, weakness, and stiffness in the back, shoulders, arms, or legs. Other symptoms may include a loss of the ability to feel extremes of hot or cold, especially in the hands. Some individuals also have severe arm and neck pain. Tethered cord syndrome occurs when a child’s spinal cord abnormally attaches to the tissues around the bottom of the spine. This means the spinal cord cannot move freely within the spinal canal. As a child grows, the disorder worsens, and can result in permanent damage to the nerves that control the muscles in the lower body and legs. Children who have a myelomeningocele have an increased risk of developing a tethered cord later in life and therefore need follow up said Dr Prem Pillay. Spinal curvature is common among individuals with syringomyelia or CM Type I. The spine either may bend to the left or right (scoliosis) or may bend forward (kyphosis). How common are Chiari malformations? In the past, it was estimated that the condition occurs in about one in every 1,000 people. However, says Dr Prem , the increased use of diagnostic imaging for the Brain and upper Spine such as MRI (Magnetic Resonance Imaging ) has shown that Chiari malformation may be much more common. Complicating this estimation is the fact that some children who are born with this condition may never develop symptoms or show symptoms only in adolescence or adulthood. Chiari malformations occur more often in women than in men and Type II malformations are more prevalent in certain groups, including people of Celtic descent. How are Chiari malformations diagnosed? Currently, no test is available to determine if a baby will be born with a Chiari malformation. Since Chiari malformations are associated with certain birth defects like spina bifida, children born with those defects are often tested for malformations. However, some malformations can be seen on ultrasound images before birth. Many people with Chiari malformations have no symptoms and their malformations are discovered only during the course of diagnosis or treatment for another disorder. According to Dr Prem a Neurological examination includes a physical exam and checking the person’s memory, cognition, balance (functions controlled by the cerebellum), touch, reflexes, sensation, and motor skills (functions controlled by the spinal cord). The Neurosurgeon may also order one or more of the following diagnostic tests: Magnetic resonance imaging (MRI) is the imaging procedure most often used to diagnose a Chiari malformation. It uses a powerful magnetic field to painlessly produce either a detailed three-dimensional picture or a two-dimensional “slice” of body structures, including tissues, organs, bones, and nerves. X-rays use electromagnetic energy to produce images of bones and certain tissues on film. An X-ray of the head and neck cannot reveal a CM but can identify bone abnormalities that are often associated with the disorder. Computed tomography (CT) uses X-rays and a computer to produce two-dimensional pictures of bone and blood vessels. CT can identify hydrocephalus and bone abnormalities associated with Chiari malformation. How are Chiari malformations treated? Some CMs do not show symptoms and do not interfere with a person’s activities of daily living. In these cases, said Dr Prem , we may only recommend regular monitoring with MRI. When individuals experience pain or headaches, we may prescribe medications to help ease symptoms. However some people continue to have headaches and may also develop pain, numbness and weakness related to progressive damage to the central nervous system and or spinal cord. These patients will need to consider surgery. Surgery / Microsurgery In many cases, surgery is the only treatment available to ease symptoms or halt the progression of damage to the central nervous system. Surgery can improve or stabilize symptoms in most individuals. The most common surgery to treat Chiari malformation is a Microsurgery :posterior fossa decompression. It creates more space for the cerebellum and relieves pressure on the spinal cord. The surgery involves making an incision at the back of the head and removing a small portion of the bone at the bottom of the skull (craniectomy) using fine Micro drills. In some cases the arched, bony roof of the spinal canal, called the lamina, may also be removed (spinal laminectomy). The surgery should help restore the normal flow of CSF, and  be enough to relieve symptoms and prevent neurological deterioration in most people. Next, the surgeon may make an incision in the dura, the protective covering of the brain and spinal cord. If the brain and spinal cord area is still crowded, the surgeon may use a procedure called Bipolar cautery or a Laser to remove/reduce the cerebellar tonsils, allowing for more free space. These tonsils do not have a recognized function and can be removed without causing any known neurological problems. The final step is to sew a dura patch to expand the space around the tonsils, similar to letting out the waistband on a pair of pants. This patch can be made of artificial material or tissue harvested from another part of an individual’s body. Infants and children with myelomeningocele may require surgery to reposition the spinal cord and close the opening in the back. Findings from the National Institutes of Health (NIH) show that this surgery is most effective when it is done prenatally (while the baby is still in the womb) instead of after birth. The prenatal surgery reduces the occurrence of hydrocephalus and restores the cerebellum and brain stem to a more normal alignment. Hydrocephalus may be treated with a shunt (tube) system that drains excess fluid and relieves pressure inside the head. A sturdy tube, surgically inserted into the head, is connected to a flexible tube placed under the skin. These tubes drain the excess fluid into either the chest cavity or the abdomen so it can be absorbed by the body. An alternative surgical treatment in some individuals with hydrocephalus is third ventriculostomy, a procedure that improves the flow of CSF out of the brain. A Brain Endoscope is used to enter the Lateral Ventricle and a small hole is made at the bottom of the third ventricle (brain cavity) and the CSF is diverted there to relieve pressure. Similarly, in cases where surgery was not effective enough, doctors may open the spinal cord and insert a shunt (Syringo Subarachnoid shunt or syringo-peritoneal shunt )to drain a syringomyelia or hydromyelia (increased fluid in the central canal of the spinal cord). What research is being done? Genetics The NIH and other research entities are researching the genetic factors that increase the risk of developing Chiari malformation and related brain disorders. Recent studies have identified gene mutations in the PI3K-AKT signaling pathway that cause brain overgrowth that may accompany hydrocephalus, CM, and other brain disorders. To better understand the genetic factors responsible for Chiari I malformation, NINDS scientists are looking for other gene mutations that could act through PI3K-AKT signaling and other pathways. These studies could lead to new diagnostic tests and better treatments options for Chiari malformations and other developmental brain disorders. Brain mechanisms Certain signals at the midbrain-hindbrain (MHB) boundary tell the brain to properly develop the cerebellum and other parts of the brain. However, how these brain regions are initiated, formed, and maintained is not well understood. Neuroscientists are studying zebrafish embryos in order to gain a better understanding of how the MHB forms. This will provide valuable insights into human brain development, particularly the cerebellum. Other investigators are studying the expression of different growth factors on the development of the brain, skull, spine, and spinal cord. Interference with normal gene function through gene mutation or environmental factors may influence the development of CM. Conclusions Chiari Malformations can now be better diagnoses and treated. The use of more advanced MRI technology, Computer Image-Guided Microsurgery with Microinstruments , together with Electrical/Electronic monitoring of the central nervous system during surgery , computer aided Neuronavigation has made this possible states Dr Prem Pillay. References National Institute is Health – USA : InformationThe Cleveland Clinic Foundation : Protocols and InformationSingapore Brain Spine Nerves Center : Protocols and Information

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) Soft Bones Can Cause Pain & Disability: Recognize It Early & Solve It Soft Bones are associated with a condition called Osteoporosis. This is a problem where the bones in the body become more porous, soft and can fracture easily, states Dr. Prem Pillay. Loss of calcium and bone matrix is the reason. This can occur slowly over years before a problem happens. Who Is Affected? People with this problem are usually above 50. More women than men are affected. There is information that almost half of all women and one quarter of all men above 50 will break a bone due to osteoporosis. More than one in five people with hip fractures associated with osteoporosis die within a year from a Singapore study. Asian and white women are also more prone to this problem states Dr. Prem Pillay. In both women and men lower levels of hormones such as estrogen in women and androgen or testosterone in men is a factor. Secondary Osteoporosis and Risk Factors Another reason called secondary osteoporosis is from excessive loss of calcium in the urine, Vitamin D deficiency and thyroid problems. Studies in Singapore indicate that more Asian men may have secondary osteoporosis then previously thought. Hypercalciuria was found as a cause in about one fifth of this group in a Singapore study. A reason could be the high salt content in Asian food which can cause leaking or leaching of calcium from the bones and then excreted in the urine states Dr. Prem. Hidden Dangers and Risk of Fractures Osteoporosis can be silent and unknown until a fall occurs and a bone breaks. Even a minor stress like bending over and coughing could cause a fracture in people with severe osteoporosis. The hips, spine and wrists are the danger area for broken bones, states Dr. Prem. Pain and Diagnosis Osteoporosis can cause pain in the spine. It can also cause pain in the bones. Sudden severe pain can occur with a minor fall or accident. Tests that are done include simple X-rays to assess fractures and DEXA scanning to assess bone density. Hormone tests and urine tests are also useful in finding out the possible causes. Treatment Options Those people with osteoporosis from aging and post menopausal bone loss can be treated with calcium and vitamin D supplements. They may also need medications to slow down bone loss and/or stimulate bone production, states Dr. Prem. If a spine fracture occurs and causes pain it can be treated now without surgery. Advanced Injection Therapies There are advanced spine injection type treatments including vertebroplasty and the more modern kyphoplasty to treat the injured vertebral body of the spine. Either a balloon or a spine wand energy treatment is also used during the treatment. Spine related pain can be reduced in the majority of patients as a day procedure. Subsequent physiotherapy and medications can help return people to a normal life and reduce the chance of future fractures, states Dr. Prem Pillay. Prevention Is Key Early detection and awareness remains important and prevention of this silent disease has more of an impact, emphasizes Dr. Prem.

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) Soft Bones Can Cause Pain & Disability: Recognize It Early & Solve It Soft Bones are associated with a condition called Osteoporosis. This is a problem where the bones in the body become more porous, soft and can fracture easily states Dr. Prem Pillay. Loss of calcium and bone matrix is the reason. This can occur slowly over years before a problem happens. The earlier stage is called osteopenia. Who is Affected? People with this problem are usually above 50. More women than men are affected with this condition. There is information that almost half of all women and one quarter of all men above 50 will break a bone due to osteoporosis. More than one in five people with hip fractures associated with osteoporosis die within a year from a Singapore study. Asian and white women are also more prone to this problem states Dr. Prem Pillay. In both women and men lower levels of hormones such as estrogen in women and androgen or testosterone in men is a factor. Causes of Secondary Osteoporosis Another reason called secondary osteoporosis is from excessive loss of calcium in the urine, Vitamin D deficiency and thyroid problems. Studies in Singapore indicate that more Asian men may have secondary osteoporosis then previously thought. Hypercalciuria was found as a cause in about one fifth of this group in a Singapore study. A reason could be the high salt content in Asian food which can cause leaking or leaching of calcium from the bones and then excreted in the urine states Dr. Prem. He has seen younger men in their late 30s and 40s with osteoporosis although this is not common emphasizes Dr. Prem. The Silent Danger of Osteoporosis Osteoporosis can be silent and unknown until a fall occurs and a bone breaks. Even a minor stress like bending over and coughing could cause a fracture in people with severe osteoporosis. The hips, spine and wrists are the danger area for broken bones states Dr. Prem. Osteoporosis can cause pain in the spine. It can also cause pain in the bones. Sudden severe pain can occur with a minor fall or accident. Diagnosis and Case Example Tests that are done include simple X-rays to assess fractures and DEXA scanning to assess bone density. Hormone tests and urine tests are also useful in finding out the possible causes. A typical person is like Mrs. C, a lady in her 70s who had a minor stumble at home and landed on her buttocks. From that time she had severe mid and lower back pain that did not improve much with pain medications and massage. Testing including DEXA, X-rays and MRI scans showed a wedge compression fracture of the upper lumbar spine and lower thoracic spine vertebrae. A specialized day procedure through a spine injection method called Vertebral Body Augmentation (VBA, Vertebroplasty, kyphoplasty) was done under sedation as a day procedure. She had excellent pain relief and was walking the next day. Treatment and Prevention Those people with osteoporosis from aging and post menopausal bone loss can be treated with calcium and vitamin D supplements. They may also need medications to slow down bone loss and/or stimulate bone production states Dr. Prem. If a spine fracture occurs and causes pain it can be treated now without surgery. There are advanced spine injection type treatments including vertebroplasty and the more modern kyphoplasty to treat the injured vertebral body of the spine. Either a balloon or a spine wand energy treatment may also be used during the treatment. Spine related pain can be reduced in the majority of patients as a day procedure. Subsequent physiotherapy and medications can help return people to a normal life and reduce the chance of future fractures states Dr. Prem Pillay. Early detection and awareness remains important and prevention of this silent disease has more of an impact, emphasizes Dr. Prem.