The treatment of brain and spinal tumours has developed greatly in recent years. There are a range of minimally-invasive techniques developed to treat brain and spinal tumours and also promote quicker and less painful recovery. Spinal tumours are of 2 types – Extradural tumours and intradural tumours. Extradural tumours are located outside the dural sac which holds the spinal cord and fluid. These are usually easier to remove as they are not enmeshed with the spinal cord, hence the surgeon can achieve clean resection margins. Intradural tumours are of two types – Extramedullary and intramedullary. Extramedullary tumours are found inside the dura, but not touching the spinal cord. Intramedullary tumours directly affect the spinal cord. In addition to surgical procedures for tumour removal, the doctors may also employ radiation therapy and chemotherapy to treat the cancer.
Craniotomy and excision of all types of brain tumours
A craniotomy is a surgical procedure to remove a portion of the skull to access the brain. Specialised tools are used to cut a bone flap from the skull. After the brain surgery, the skull flap is replaced and the surgical incision is closed. Craniotomies vary in size and complexity. For endoscopic tumour removal, a small hole called a burr or keyhole is drilled in the skull through which instruments and cameras are inserted. More complex tumour removal procedures may require larger bone flaps to be removed. These could require some skull reconstruction surgery.
Brain tumour biopsy
A brain tumour biopsy is the procedure of extracting a sample of the brain tumour tissue for further laboratory testing. The biopsy helps diagnose the type and grade of brain tumour, which will decide the course of treatment. Most brain tumour biopsies can be done through a small hole drilled in the skull. This is known as a burr hole biopsy. The biopsy extraction takes about an hour or two, after which the sample is sent to the lab for analysis. The lab may take 1-2 days to process the sample and release the results. The biopsy is usually performed as an outpatient procedure.
Cerebrovascular Conditions and disorders
The word cerebrovascular refers to blood flow in the brain. Conditions that result in irregular blood flow to the brain include strokes, carotid stenosis, vertebral stenosis, intracranial stenosis, brain aneurysms and vascular malformations. The irregular blood flow could be caused by narrowing of blood vessels, formation of clots, blood-vessel blockages or ruptured blood vessels. Lack of sufficient blood flow to the brain could cause a stroke or permanent intellectual deficits. Doctors will determine the surgical course of treatment for the patient based on a series of diagnostic imaging tests to visualise blood flow through the brain.
Subarachnoid haemorrhage (SAH)
Subarachnoid haemorrhage (SAH) refers to bleeding between the pial and arachnoid membranes in the brain. This is the subarachnoid space where cerebrospinal fluid usually circulates. A haemorrhage in this area could result in a coma, paralysis or even death. A Subarachnoid haemorrhage could occur spontaneously or as a result of a head trauma. Spontaneous subarachnoid haemorrhages are typically linked to brain aneurysms. The most common cause of primary SAH is a berry aneurysm, a berry-shaped cluster of sac-like pouches on a cerebral artery. The aneurysm swells and puts pressure on the walls of the artery. If ruptured, the aneurysm bleeds and forms clots which can result in a coma or even death.
Identifying and repairing the source of the subarachnoid haemorrhage is critical to saving the patient’s life and reducing the possibilities of intellectual deficits. Surgery is performed to clip the aneurysm to ensure it does not bleed again. Endovascular coiling may also be used to reduce the risk of re-bleed.
A brain aneurysm is a balloon-like bulge in the walls or a cerebral artery. As the aneurysm grows, it stretches the walls of the artery and poses a risk of rupture. Ruptures are dangerous and can result in coma or brain death. The goal of surgically clipping an aneurysm is to cordon it off from the rest of the artery without blocking off its blood flow. The patient is placed under general anaesthesia and the surgeon performs a craniotomy to open the skull. The aneurysm is isolated and a small titanium clip is placed at the “neck” of the aneurysm and closed.
An arteriovenous malformation is an abnormal tangle of arteries and veins, which disrupts regular blood flow. Arteries carry blood to various organs and veins return the blood from the organs to the heart. Arteriovenous malformations hinder this process, and as a result, certain parts of the brain may not receive sufficient oxygen. These malformations also weakens the walls of the vessels, increasing the risk of rupture and consequent bleeding.
A vein of Galen defect is a congenital arteriovenous malformation found deep within the brain. A patient with a vein of Galen defect would experience seizures, slow growth, congestive heart failure, swollen veins on the scalp and a build-up of fluid in the brain which would result in an enlargement of the head.
Embolization and sclerotherapy are the most common treatment methods for arteriovenous malformations. During embolization, materials like medical glue, metal coils or plugs are inserted into the arteriovenous malformation through a catheter to cut off its blood supply. Once its blood supply is terminated, the malformation shrinks. In sclerotherapy, a chemical liquid is injected into the arteriovenous malformation to destroy the tangles and encourage scar tissue formation.
Cavernomas are abnormal clusters of vessels with small bubbles filled with blood that makes them look like blackberries. They can vary in size from microscopic to several centimetres in diameter. The cavernomas typically do not have much blood flowing through them. Some cavernomas are congenital and some may develop later in life. They can result in symptoms such as seizure, headaches and haemorrhage. Cavernoma can stay undiscovered and without producing symptoms for many years. Treatment is usually only recommended for cavernomas that have haemorrhaged recently or cause frequent seizures. Cavernomas can be removed using minimally-invasive or open surgical techniques.
Movement disorders are characterised by neurological dysfunction associated with co-ordinated movements. This covers the debilitating motor symptoms of Parkinson’s disease, essential tremors, dystonia and focal epilepsy. Deep Brain Stimulation (DBS) is a surgical procedure which has proven effective in the treatment of movement disorders. DBS uses a battery-operated surgical implant called an Implantable Pulse Generator (IPG). The Implantable Pulse Generator is stop-watch size device that delivers electrical stimulation to the brain, similar to the electrical stimulation provided to the heart by a pacemaker. This blocks the abnormal brain signals that cause the movement or tics. Before the procedure, an MRI or CT scan is used to identify and locate the target for surgical intervention in the brain. During the procedure, a thin electrode is inserted into the target location in the brain. The electrode is then attached to an insulated extension cable connecting it to the Implantable Pulse Generator in the collarbone area, chest or abdomen. Once the system is in place, it is tested and activated to help the patient manage their movement disorder.
Deep brain stimulation
Deep brain stimulation is a treatment method for the motor-function loss associated with Parkinson’s disease. This incudes tremors, hand-eye co-ordination, difficulty in walking and stiffness. The procedure involves implanting an electrode in the brain and an implantable pulse generator in the sub-clavicle region, connected to each other by an extension cable. The pulse generator sends small electrical signals to the electrode in the brain to counteract the movement tics associated with Parkinson’s diseases.
Baclofen pump for spasticity
Baclofen is a muscle relaxant medication to decrease spasticity associated with multiple sclerosis and other neurological and spinal cord conditions. Spasticity is a condition in which muscles tighten or contract, preventing normal fluid movement. It is caused by an imbalance between the signals that stimulate and inhibit the spinal cord. This results in jerky, involuntary movements, increased muscle tone and stiffness.
The Baclofen pump is a device implanted in the abdomen, which continuously delivers baclofen to the spine as programmed by the doctor. The baclofen from the pump is delivered to the intrathecal space, the fluid-filled space surrounding the spine. The baclofen pump is recommended only after oral administration of baclofen has lost effectiveness.
Spinal cord stimulator
A spinal cord stimulator is a biomedical implant that sends low-intensity electrical impulses into the spinal cord to relieve chronic back pain. Spinal cord stimulation is often recommended only after non-surgical methods of pain relief have failed. The spinal cord stimulator device consists of a set of electrodes and a small generator. The electrodes are surgically inserted between the spinal cord and the vertebrae. The generator is placed beneath the skin on the buttocks or the abdomen. An external remote controls the electric signals sent to the electrodes by the generator. Some systems are equipped with rechargeable batteries that need to be charged nearly every day. Systems with non-rechargeable batteries will need to be replaced every 2-5 years.
The patient is usually fitted for a spinal cord stimulator in 2 stages – the trial and the final surgical implant. The trial surgery is typically performed as an out-patient procedure. The radiologist inserts a hollow needle into the epidural space between the vertebrae and the spinal cord under x-ray fluoroscopy. The electrode is then inserted and positioned in place over the correct nerves. The electrode is connected to an external generator that can be worn by the patient on a belt. The patient will be instructed on the operation of the device and asked to maintain a log of their pain levels over the course of the next 4-7 days. The trial is deemed successful if the spinal cord stimulator is effective in reducing the patient’s pain by 50%. If successful, the patient is implanted with the long-term spinal cord stimulator.
Epilepsy surgery/ procedures
Epilepsy is a central nervous system disorder characterised by abnormal brain activity resulting in seizures. The symptoms of the seizure can vary in patients, ranging from disorientation and blank staring to full-body twitching and foaming at the mouth. The exact cause of epilepsy is unknown but it is associated with head traumas, strokes and infectious diseases such as AIDS, viral encephalitis and meningitis. Surgical approaches to epilepsy usually involve removal of the part of the brain generating the abnormal electrical activity. Hence surgery is usually only recommended for focal seizures. Surgical treatment for epilepsy is recommended only if drug therapies prove ineffective.
Epilepsy could be treated by a variety of procedures – Multiple Subpial Transections (MST), Laser Interstitial Thermal Therapy (LITT), Resective Surgery, Deep Brain Stimulation, Corpus Callosotomy or Hemispherectomy.
Stereo EEG (Electroencephalography)
Stereo EEG is a minimally-invasive procedure used to determine the source of seizures in the brain. The neurosurgeon places electrodes directly into the brain with the help of a robotic operating surgical assistant. The robotic assistance greatly improves accuracy and reduces pain and recovery time. The patient will be given general anaesthesia during the procedure. The surgeon drills tiny holes into the patient’s skull to insert the electrodes. Once the electrodes are implanted, the patient is under constant observation for about a week to 10 days. In some cases, the patient may be kept under observation for up to a month. The data gathered during the observation period will help surgeons plan a course of treatment for the patient’s epilepsy.
A Hemispherotomy is a procedure used to disconnect the outer cortex of one hemisphere of the brain, where the seizures originate, from the brain stem and the other brain hemisphere. By disrupting the connection between the 2 halves of the brain, seizures originating in only one half of the brain can be controlled. Hemisphereotomies are usually recommended for children with refractory seizures originating in one half of the brain. Refractory seizures are seizures that cannot be controlled by medication.
Anterior temporal lobectomy with amygdalohippocampectomy
An Anterior Temporal Lobectomy is a procedure for the complete removal of the anterior portion of the temporal lobe of the brain. This is recommended for patients who experience frequent seizures originating in this part of the brain. The extent of removal of the anterior temporal lobe varies from case to case and in some cases, only the medial structures of the anterior temporal lobe are removed. This is known as an amygdalohippocampectomy.
The most common course of surgical intervention for epilepsy is to remove the portion of the brain from where the seizures originate. This is called a focal resection. Before focal resection can be c0nsidered, the doctors will need to conduct a series of diagnostic imaging tests to pinpoint the origin of the seizures in the brain. The surgeons will use advanced brain mapping techniques to avoid resecting important parts of the brain used for critical functions like speech, language, movement or memory.
A corpus callosotomy surgery is a procedure to separate the two hemispheres of the brain by severing the corpus callosum, a band of nerve fibers that relays messages between the 2 halves. The corpus callosotomy surgery stops seizure signals from passing between the 2 hemispheres. After surgery, the patient’s seizures reduce in intensity, because the seizure is restricted to the hemisphere in which it originated. Corpus callosotomy procedures are usually recommended for patients who experience atonic seizures. That means that the patient loses muscle control and strength during the seizure, resulting in collapses.
Neurological problems in children are often complex and difficult to treat. The GGHC Paediatric Neurosurgery Program covers a comprehensive range of brain, spine and peripheral nerve disorders. Our doctors are also experienced in treating brain tumours, cerebral palsy, congenital brain malformations, hydrocephalus, skeletal dysplasia, spine bifida, tethered cord syndrome and Chiari malformations.
Cerebrospinal Fluid diversions for hydrocephalus
Hydrocephalus is the excess build-up of cerebrospinal fluid in the ventricles deep within the brain. Cerebrospinal fluid normally flows through the ventricles of the brain, washing over the brain tissue and spinal tissue. However, when this fluid starts to build up in the brain, the excess pressure is harmful and can cause neurological deficits. Hydrocephalus could be cause by infection, lesions or brain tumours, stroke or head trauma. Hydrocephalus can occur at any age but is most common in children and patients above 60 years of age.
Hydrocephalus is usually treated by removing the cause of the obstruction, or diverting the cerebrospinal fluid indirectly. Diversion is the more common method of treatment used. A shunt is an implant consisting of a catheter, a flexible tube and a valve to ensure unidirectional flow. The shunt channels the built-up cerebrospinal fluid from the brain to the heart or the abdomen, where it can be more easily re-absorbed by the body.
Surgery for spinal dysraphism
Spinal dysraphism is a broad term used to describe congenital defects of the spine, spinal cord and nerve roots. All forms of spinal dysraphism are a result of an early event in embryonic development. In about the third week of development, the neural plate folds over and forms a neural tube. When one end of the tube does not close completely, it causes the range of deformities that comprise spinal dysraphism. Spinal dysraphism includes open spina bifida, spina bifida occulta, split cord malformation, spinal cord lipoma, dermal sinus tract, tight filum terminale, and tethered spinal cord. Surgical correction for spinal dysraphism is decided according to the nature of the deformity.
A Chiari malformation occurs when the indented, bony space at the base of the skull is abnormally small or misshapen. This presses on the brain and forces brain tissue to grow downwards and occupy space in the spinal canal. This creates structural changes in the cerebellum, the part of the brain located at the base of the skull, affecting balance. Chiari malformations form during the initial stages of foetal development and could be caused due to genetic mutations or maternal malnutrition.Chiari malformations are of various types – Type I is the most commonly observed in children. The lower part of the cerebellum extends into the foramen magnum, a small opening in the skull through which usually only the spinal cord passes. Type I Chiari malformations progress and show symptoms as the brain develops, so sometimes it is only discovered in adolescence. Type II is seen in children born with spina bifida, and is diagnosed in utero or soon after birth. Type III is also diagnosed in utero or soon after birth and is the most sever type of Chiari Malformation. The cerebellum extends through an abnormal opening in the skull and can cause permanent neurological deficits.Chiari malformations may not show symptoms in some cases. Asymptomatic cases require no treatment other than routine monitoring and MRIs. Symptomatic cases are treated with corrective surgery. The most common corrective procedure for Chiari malformations is called Posterior Fossa Decompression. The surgeon removes a small portion of bone from the lower back of the skull. This relieves pressure on the on the brain.
Craniosynostosis is a congenital defect in which one or more of the fibrous joints between the infant’s skull bones are prematurely fused. As the baby’s brain continues to grow, the skull may become misshapen. Early diagnosis of the condition is key to retaining full neurological function. Good cosmetic reconstruction may also be achieved when the condition is treated early. The various types of craniosynostosis are named according to the bone suture affected – Saggital, Coronal, Metopic and Lambdoid craniosynostosis.
Mild cases of craniosynostosis may not require surgical intervention. The doctor may recommend a special moulded helmet to correct the shape of the skull and allow for optimum brain development. For most cases however, surgical correction of the skull is required. The aim of the surgical intervention is to relieve pressure on the brain, create room in the skull for the brain to grow and also to cosmetically correct the shape of the baby’s skull. The surgery is usually performed by a craniofacial specialist in partnership with a neurosurgeon. The procedure can be performed using open techniques or minimally-invasive surgical techniques. Both approaches have produced good results in terms of patient’s neurological development and cosmetic appearance.
Pediatric brain tumours
Pediatric brain tumours are abnormal masses or growths that occur in the child’s brain and the tissues and structures around it. There are various types of pediatric brain tumours – some are cancerous and some are non-cancerous. The course of treatment and patient outcome are dependant on the type of tumour, its location, extent of the tumour, the patient’s age and their general state of health.
If the tumour is located in a zone that makes it accessible to surgical intervention, the doctor may suggest a surgical removal of the tumour. Small tumours with distinct edges are easier to surgically remove without affecting the surround tissue and neurological function. In case the tumour is in a sensitive area of the brain, or has spread and cannot be removed without affecting the surrounding tissue, the surgeon may remove the tumour partially. Even removing a portion of the tumour can improve the child’s condition significantly. Radiation therapy, proton beam therapy, and chemotherapy have also proven to be effective in the treatment of pediatric tumours.
Spine Surgery/ Peripheral nerve surgery
Spinal and Peripheral Nerve Surgery consists of surgical strategies and procedures to minimise pain and restore maximum range of motion in patients with spinal and peripheral nerve conditions such as degenerative disc disorder, traumatic spinal injury, herniated disc, spinal stenosis (narrowing) and spinal cord tumours. Surgical intervention can help minimise chronic pain, address spinal instability and help improve the patients range of movement and quality of life. Spinal surgery consists of a range of techniques such as decompression, spinal fusion, laminectomy etc. In most cases, these procedures can be performed using open or minimally-invasive technologies.
Anterior Cervical Discectomy and Fusion (ACDF)
Anterior Cervical Discectomy and Fusion is a surgical procedure used to repair a herniated or degenerative disc in the spine. The surgery aims to relieve pressure on the spinal cord or root nerves and reduce the consequent pain, numbness or tingling sensations. The procedure is commonly performed to treat symptomatic cervical herniated discs and cervical degenerative disease. It is also used to remove bone spurs caused by arthritis and alleviate symptoms associated with spinal stenosis.
The Anterior Cervical Discectomy and Fusion Surgery has 2 parts – The first part is the Anterior Cervical Discectomy, in which the cervical spine (neck) is accessed via a frontal (anterior) incision in order to remove the degenerated disc from in between the vertebral bones. The second part of the procedure is a Fusion Surgery to stabilise the cervical spine. This involves placing a bone graft in the intra-vertebral space previously occupied by the degenerated disc, to provide strength and stability. As the surgical site heals, the bone graft grows and provides stability and strength to the neck.
The Anterior Cervical Discectomy and Fusion Approach is advantageous because it allows direct visualisation and access to the cervical discs. The approach is relatively uncomplicated and hence results in less post-operative pain and lower chances of comorbidities.
Artificial Disc Replacement
An artificial disc is a biomedical implant placed in the intravertebral space, in place of a degenerated disc. The degenerated disc is surgically removed before the artificial disc is implanted. The goal of this procedure is to relieve back pain and recover a more normal range of motion, giving the patient a chance at a better quality of life. Artificial disc implants are effective at maintaining a better range of motion as compared to an anterior cervical discectomy and fusion (ACDF). Artificial disc replacements also typically have a lower recovery time compared to ACDF procedures.
During the artificial disc replacement procedure, the surgeon approaches the spine through an incision in the abdomen, moving the abdominal organs aside. This approach is favoured because the spinal nerve roots suffer minimal disturbance. The surgeon then removes the problematic disc and inserts the artificial disc in its intravertebral space. The artificial disc implant usually consists of a nucleus (core), and annulus (outer ring) and a mechanical device to stimulate spinal function.
Cervical/ Lumbar Laminectomy
The word “Lamina” refers to the back of the vertebra that covers the spinal cord. A Laminectomy is a procedure wherein a part of the lamina is removed to create an expanded space for the spinal cord and nerve roots. The aim of the procedure is to relieve pressure on the spinal cord. I It is also called a spinal decompression surgery. A laminectomy may be used to treat a traumatic spinal injury, herniated disc, spinal stenosis (narrowing of the spinal canal) and spinal cord tumours. The procedure is also used to remove bony spur formations on the vertebrae of the spine as a result of arthritis.A Laminectomy procedure is only recommended if conventional methods, such as drug therapies, physical therapies and injections, have failed to address symptoms; or if symptoms rapidly worsen.A laminectomy is a surgical procedure performed under general anaesthesia. The surgeon makes an incision on the back, along the affected vertebrae and retracts the back muscles away for better visualisation of the bones. Specific portions of the lamina are removed to relieve pressure on the spinal cord. If the disc is herniated, it is removed and replaced with a bone graft or artificial disc as decided by the physician in charge of the case. Laminectomies are performed in the cervical spine (neck) and the lumbar spine (lower back).
Lumbar decompression and fusion (PLIF, TLIF)
Lumbar spinal stenosis is a common cause of lower back and leg pain. Lumbar decompression and fusion surgeries are the most common procedures employed to treat this condition. The procedures involve 2 steps – Decompression, in which the bony structure constricting or pinching the spinal cord is removed to relieve pressure; and Fusion, in which a bone graft is placed to fuse the vertebrae adjacent to the decompression site for increased strength and stability of the spine.
There are multiple types of lumbar decompression and fusion procedures, based on the nature of the graft and the incision approach taken.
Posterior Lumbar Interbody Fusion (PLIF) is a lumbar decompression and fusion technique in which the spine is approached through an incision in the back and the graft used is an interbody graft. This type of graft is characterised by the metal spacer/cage (inside which the bone graft is placed) used to maintain the height of the vertebrae.
Transforaminal Lumbar Interbody Fusion is a variation of the PLIF technique, in which the approach is slightly tweaked, to approach the spine from the side, to minimise incising the back muscles and the nerve roots emerging from the spine. TLIF also uses an interbody fusion device as the bone graft implant.
Minimally invasive spine surgery (MISS)
Minimally invasive spinal surgery techniques are an alternative to conventional open surgical techniques. Minimally invasive spinal surgery is advantageous because of the quick recovery time, lower chances of comorbidities and reduced post-operative pain. Minimally invasive techniques are used to treat degenerative disc disease, herniated disc, spinal stenosis, spondylolysis, and scoliosis. With minimally invasive procedures , there is sometimes the option of performing certain spinal procedures on an out-patient basis as well.
The patient is usually given general anaesthesia before the procedure. The vital signs are carefully monitored throughout. The surgery is performed percutaneously or through micro-incisions in the skin. A tubular retractor is placed in the incision and endoscopic surgical tools and cameras are manoeuvred through it. Once the required repair is complete, the surgical incision is closed with stitches, surgical glue or staples.
Spinal cord tumours
Spinal cord tumours are small growths or masses of cells that form on the spinal cord, in the spinal canal or in the vertebrae. Spinal cord tumours are classified into various types depending on where they occur. A vertebral tumour is one that occurs on the bony vertebrae protecting the spinal cord. Extramedullary tumours grow in the membrane surrounding the spinal cord or in the nerve roots emerging from the spine. These growths can cause compression on the spine and other associated problems. Examples of extramedullary tumours are meningiomas, neurofibromas, schwannomas, and nerve sheath tumours. Intramedullary tumours occur in the core tissue of the spinal cord, like gliomas, astrocytoma and ependymomas. Tumours originating in other parts of the body, such as the abdomen, can also metastasise to the vertebrae and the spinal cord.
The course of treatment for spinal cord tumours is carefully decided based on the type of tumour, location, extent of spread and the general health of the patient. Non-surgical treatment options include radiation therapy and chemotherapy, both of which have proven effective in treating spinal cord tumours. For primary tumours in the spinal cord, complete surgical removal could be curative. In the case of metastasised tumours (tumours that have spread from another part of the body), removal may be only palliative, with the goal of preserving neurological function, reducing pain and stabilising the spine. For cases where the surgical removal of the tumour is possible, pre-operative embolization is recommended to make resection easier. During embolization, a catheter is inserted into tumour under fluoroscopy guidance, and a glue-like embolic agent is injected into the tumour. This compound blocks the blood supply to the tumour, effectively killing it. This helps control bleeding during surgery.
Peripheral nerve tumours
Peripheral nerve tumours are small masses of cells in the nerves that transmit signals from the spine to the various parts of the body. Peripheral nerve tumours could occur anywhere in the body. They are usually non-cancerous but nonetheless cause pain and loss of function . Peripheral nerve tumours are primarily classified into two types based on location – Intraneural tumours, which grow from within the nerve tissue, and Extra neural tumours, which grow on the tissue surrounding the nerve and exert pressure on it. Examples of benign peripheral nerve tumours include schwannoma, neurofibroma, ganglion cysts, lipoma and perineurioma.
The course of treatment for the peripheral nerve tumour depends on its type, whether it is symptomatic, and the extent of spread. If the tumour is small, grows slowly and doesn’t cause any symptoms, the physician may elect to just keep it under observation and monitor it regularly. Larger, fast growing tumours that cause symptoms need surgical intervention. The aim of the surgical intervention is to remove the entire tumour without damaging the adjoining healthy tissue or affecting nerve function. Depending on the location and size of the tumour, surgical removal could cause some neurological deficits. The advantages and disadvantages of the surgical approach will be weighed carefully by the physician before deciding on a course of action. The doctor may recommend stereotactic radiosurgery to remove the nerve tumour. In this procedure, the surgeon delivers gamma radiation in a targeted manner to the tumour without making an incision in the skin.
Spinal vascular malformations
Spinal vascular malformations are a relatively rare condition in the spine and spinal dura, in which abnormal connections are formed between the arteries and veins, forming a tangle where oxygenated and deoxygenated blood mix. Spinal vascular malformations, also called spinal arteriovenous malformations, deplete the surrounding tissue of oxygen and cause neurological damage. The various types of spinal vascular malformations are spinal dural arteriovenous fistulas, spinal arteriovenous malformations, juvenile arteriovenous malformations and pial spinal arteriovenous malformations.
The appropriate course of treatment depends on the type of malformation in question will be decided upon by the surgeon in charge of the case. Most cases are treated with surgical removal or embolization. Surgery usually involves resecting the tangle of vessels and connecting the arteries and veins back correctly. This can usually be achieved with fairly low risk to the patient, subject to its exact location in the spine. Embolization is an effective technique used to treat certain types of lesions. The procedure involves inserting a catheter into the lesions under fluoroscopy guidance, and injecting an embolising agent. The chemical closes the capillaries, like a glue, and stops blood supply to the lesion. This helps control blood loss during the surgery.
Spinal infections are rare, but occur in the spinal column, intravertebral discs or the vertebrae of the spine. These infections are usually bacterial in nature and are transported to the site of infection through the bloodstream. The infection can affect the structural integrity of the vertebrae if it progresses. The infection could cause an inflammation of the discs, causing discitis.
Spinal infections are typically treated with long-term intravenous antibiotic or anti-fungal therapies. The exact drug therapy is chosen after the organism causing the infection is identified. The drug therapy is typically administered for 6-8 weeks to rid the patient of the infection completely. If non-surgical interventions are ineffective, or if spinal stability is compromised, then surgery may be recommended. The goals of surgical interventions for spinal infections are to debride the infected tissue, restore blood flow to the affected area to promote healing, restore spinal stability and to limit the degree of neurological impairment.
Skull Base Surgery
The base of the skull is a sensitive zone, where the skull meets the neck. It houses the cerebellum, an important part of the brain. Tumours in this area could affect a range of functions including balance, hearing, facial paralysis and speech impairment. If the cervical spine is immobilised, traction could be effective in reducing and re-aligning the neck. If traction is ineffective, surgical decompression may be recommended, to relieve pain and reduce pressure. This may be done via an anterior or posterior approach, depending on the specifics of the case. At this time, fusion surgery, with a bone graft or an interbody device may also be done.
Craniovertebral junction anomalies
The craniovertebral junction consists of the occiput, the foramen magnum and the first two cervical vertebrae that are part of the neck. Craniovertebral junction anomalies can be congenital, developmental or as a secondary symptom of an acquired disease. These abnormalities can cause neck pain, neurological deficits associated with the spinal cord, cerebellum and the lower cranial nerves, and vertebrobasilar ischemia.
If the neural structures of the spine are compressed, the neck is immobilised and then reduced with traction. This helps re-align the cranio-cervical junction and reduce pressure on the neck. Surgical interventions for craniovertebral junction anomalies are recommended if traction is ineffective. The surgery aims to relieve neural pressure and realign the vertebrae correctly. The decompression is usually done via an anterior (front) or posterior (back) approach. If the instability persists after decompression, further stabilisation with implants, like rods, screws etc., are used to correct the junction.
A Vestibular Schwannoma, also known as an Acoustic Neuroma, is a non-cancerous tumour that develops on the vestibular nerve, connecting the inner ear to the brain. It is usually a slow growing tumour that primarily affects hearing and balance. The tumour is formed due to an overgrowth of Schwann cells, which make up the protective, insulating sheath of the vestibular nerve. Vestibular schwannoma can also affect the facial nerves and cause paralysis on the side of the tumour. As the tumour grows, it may begin to press on the cerebellum and the brain stem and turn fatal.
The vestibular schwannoma can be treated with radiosurgery (the “gamma” knife) or with surgical removal of the tumour. If the tumour is small, it may be easier to remove the tumour whilst preserving hearing abilities, balance and normal facial control. As the tumour grows, removal becomes more complicated and could end up resulting in neurological deficits. Early diagnosis is key to a good outcome with surgery. Alternatively, radiosurgery may be used to shrink the tumour. This could make it easier to operate on.
A Meningioma is a tumour that forms on the three meninges or membranes surrounding the brain matter and spinal cord, just within the bony structures of the skull and the vertebral column. They usually grow slowly and are non-cancerous. Sometimes meningiomas cause no symptoms and they require no treatment. However, the growth of benign meningiomas can still be dangerous, as they compress various parts of the brain and begin to affect normal neurological function. They can cause seizures, numbness, headaches, blurred vision and speech impairments.
A craniotomy procedure is usually performed to remove a symptomatic meningioma. A piece of the skull is opened and the tumour is partially or completely removed. The location of the meningioma will determine the surgical approach taken. If the tumour cannot be reached surgically, it may be treated with radiation therapy. In case of partial surgical removal of the tumour, radiation therapy could be used to stop the remaining portion of the tumour from growing back.
A Craniopharyngioma is a rare brain tumour that occurs near the pituitary gland. The pituitary gland secretes hormones that control key bodily functions and the craniopharyngioma affects these functions. The tumour may occur at any age but is most common in children and geriatric adults. Patients with craniopharyngioma may experience dizziness, headaches, fatigue, excessive urination and changes in vision.
Surgical intervention to remove all or most of the tumour is usually recommended for most patients with craniopharyngioma. Total tumour removal is desirable; however, due to the presence of important structures adjacent to the pituitary, this may not always be possible. The procedure may be performed using the open craniotomy technique or a minimally-invasive transsphenoidal (via the nose) technique. Radiation therapy and chemo therapy may also be used, in case of partial removal of the tumour, to kill any remaining tumour cells.
A head injury is any trauma to the scalp, skull, or brain. Acute head injuries are of the utmost priority and must be given immediate medical attention. Head injuries usually result in internal brain bleeds or hematoma, a possible skull fracture, a concussion or bruises (contusions) on the brain. Common causes of these injuries are road accidents, sports or adventure sports accidents, falls and physical assault. First aid for a person who has had a head injury requires that their airway, breathing and circulation to be checked. The neck and the head are then stabilised, and any bleeding through the skull is brought under control.
The treatment for head injuries depends on the type and the severity of the injury. Minor head injuries can be treated with pain medication alone. In case the head injury has caused a hematoma, excess pressure on the brain or a skull fracture, surgical intervention is required.
An Epidural Hematoma or an Extradural Hematoma is a collection of blood pooling between the skull and the membranes of the brain. Head trauma or injury could cause a jolt inside the skull, ripping the membranes of the brain and causing internal bleeding. The hematoma could put pressure on the brain and cause swelling and pain. This could affect vision, speech, movement or sensation, leading to permanent neurological deficits if left untreated.
In most cases, surgery is the recommended course of treatment for extradural hematomas. An open craniotomy is usually performed to drain the hematoma. Alternatively, the doctor may perform an aspiration procedure, in which a hole is cut in the skull and suction is used to remove the hematoma. Aspiration is usually recommended for smaller hematomas. Physical therapy and rehabilitation are usually required after surgery to regain strength and mobility.
A Subdural Hematoma is a collection of blood between the inner dura of the brain and the meninges in the arachnoid space. It is a type of bleed that occurs outside the brain matter, but is contained within the membranes of the brain. Subdural hematomas are the result of a head injury that has resulted in tearing of a blood vessel in the brain, usually a vein. If the bleeding is slow, the body may be able to reabsorb the blood back into the body.
Subdural hematomas need immediate treatment, or they can result in paralysis, seizures, breathing problems and coma. Subdural hematomas are usually treated with decompression surgery which is done by drilling holes in the skull, through which the hematomas are drained. Follow up procedures may be required to remove clots that form after the decompression surgery. The surgeon may, in some cases, elect to leave a shunt or drain in the skull to continue to drain the blood from the hematoma for a few days after the procedure.
Cerebral contusions are areas of bleeding, similar to bruises, on the surface of the brain. They usually occur when the outer surface of the brain strikes the ridges and edges of the skull. Cerebral contusions usually occur along with subdural or extradural hematomas, caused by the same traumatic head injury. Cerebral contusions can cause dangerous swelling, so the main aim of treatment is to keep swelling under control. The patient is given drug therapies to reduce brain swelling. If intracranial pressure increases, surgical intervention may be required to bring it down. The surgeon performs a craniotomy, making a trap door in the skull to relieve pressure.
Diffuse axonal injury
Diffuse axonal injury is a severe form of traumatic brain injury, in which rapid acceleration and deceleration of the brain inside the skull results in shearing of the long, connecting fibres called axons. This sudden injury usually causes a loss of consciousness, as it affects multiple parts of the brain. The immediate course of action is to reduce swelling in the brain using drug therapies to try to retain maximum neurological function. However, once the onset of diffuse axonal injury has occurred, there is little that can be done to completely cure patients. They can be kept comfortable and provided with supportive care to minimise further neurological damage.
A skull fracture is any break or crack in one of the cranial bones. A skull fracture is usually caused by an impact injury to the head. Such a fracture could be accompanied by a brain injury as well. Skull fractures could cause symptoms such as swelling, facial bruising and bleeding from the ears or the nose. In case of mild cases , the patient may just be prescribed bed rest and pain medication to give the skull time to heal. However, if there is brain damage or neurological deficits, surgical intervention may be required to correct the damage, following which reconstructive surgery may be done. Depressed skull fractures may require cosmetic surgery to correct the skull shape. Depressed skull fractures also put pressure on the brain, and hence require surgical repair.
Pain relieving surgery/ procedures
Chronic pain is a difficult symptom to manage and live with. Its effects on the patient’s lifestyle and ability to function is debilitating. Neurological conditions like trigeminal neuralgia, glossopharyngeal neuralgia and carpal tunnel syndrome cause instant, easily-triggered pain that can be frustrating, excruciating and embarrassing. These conditions are usually caused due to a swelling or mass pressing on the nerve, triggering the pain. Surgical intervention is recommended to remove the mass or swelling. Microvascular decompression is a technique that is recommended for this purpose.
Microvascular decompression for Trigeminal neuralgia
Trigeminal neuralgia is a rare neurological disease that causes episodes of sudden, intense, stabbing pain in the face, along the branches of the trigeminal nerve. It is usually caused when the trigeminal nerve is compressed by an artery or vein. Trigeminal neuralgia is often misdiagnosed as a dental issue or a psychological disorder in the initial stages, before the correct diagnosis is made. Trigeminal neuralgia is worsened by stimuli to the skin, such as shaving, tactile pressure, chewing, brushing or a strong breeze. It is considered one of the most painful conditions afflicting a person, and is treated on priority. Initially, a small dose of an antiepileptic or antineuralgic drug can provide significant relief.
Microvascular decompression is the most common surgical procedure used to treat trigeminal neuralgia. The surgical approach is decided based on the location of the compression. However, the typical approach is via an incision next to the ear. The blood vessel pressing the nerve is moved away from the nerve and a Teflon felt pad is placed as a barrier. This is usually effective at relieving pain and symptoms.
Hemifacial spasms are facial spasms restricted to one side of the face. They are caused by a nervous system disorder in which a blood vessel touches a facial nerve, causing compression and the consequent involuntary muscle twitching. Hemifacial spasms could also be caused by traumatic injury to the facial nerve or a tumour. Hemifacial spasms are not dangerous on their own, but they can be frustrating to experience and could be symptomatic of more serious neur0logical problems that require attention.
Botox injections or oral muscle relaxers are used to treat hemifacial spasms. If these medications are ineffective at relieving symptoms, the doctor may recommend surgical decompression of the facial nerve. The Microvascular decompression technique may be used to treat hemifacial spasms.
Glossopharyngeal neuralgia is a rare neurological condition characterised by episodes of intense pain in the back of the throat, the tongue or the ear. The episodes feel like intense bursts of electric shock-like pain that occur without warning, or which may be triggered by swallowing. Glossopharyngeal neuralgia is caused by a blood vessel compressing a nerve inside the skull. It can also occur in people with throat cancer, due to compression from the tumour. Medication can be used to achieve pain relief. However, for a more permanent cure, a surgical intervention is required.
Microvascular decompression is effective in decompressing the nerve triggering glossopharyngeal neuralgia. Percutaneous radiofrequency stereotactic rhizotomy and stereotactic radiosurgery have also proven effective in treating glossopharyngeal neuralgia.
Carpal Tunnel Syndrome
The Carpal Tunnel is a narrow passageway in the palm, surrounded by ligaments and bones. This tunnel allows the median nerve and tendons to pass through it, connecting the hand to the forearm. Carpal Tunnel Syndrome occurs when there is excessive pressure on the median nerve, in the carpal tunnel. It may be caused by repetitive hand movements, and is common in office workers. Patients usually experience tingling, numbness and a lack of strength in the wrist and hand.
In the early stages, carpal tunnel syndrome can be reversed by strengthening the wrists, and practising better hand posture while working. Non-surgical treatment options include a splint, and medication for pain. Surgical intervention may be required if conservative treatments are ineffective. Carpal Tunnel Syndrome is treated surgically by severing the tendon in the carpal tunnel to relieve pressure on the median nerve. The procedure can be performed using endoscopic or open surgical techniques. Endoscopic techniques may result in lower recovery times and less post-operative pain. The decision on which technique to use is up to the surgeon, who will make the decision based on a thorough study of the patient’s condition.
A Rhizotomy is a surgical procedure used to sever the nerve roots from the spine. This is done to curb chronic back pain and back muscle spasms. Two common types of rhizotomy procedures are Radiofrequency Ablation and Endoscopic Rhizotomies. During Radiofrequency Ablation, the doctor uses heat to disable nerve roots in the back that transmit pain signals to the brain. This is a percutaneous procedure, performed using a needle injected into the target nerve through the skin, under X-ray fluoroscopy guidance. An Endoscopic Rhizotomy makes use of a micro camera inserted through a small incision in the skin, to provide visualisation of the nerve roots. The target nerve roots are then severed using specialised surgical instruments.
Neuro-endoscopy is a set of minimally-invasive surgical procedures that operate on tumours in the brain, skull or spine. Neuro-endoscopy is performed using an endoscope, which is a small camera, and specialised surgical instruments. Using neuro-endoscopy techniques, the surgeon can access and remove tumours inside the skull without harming surrounding tissues or having to open the skull. The use of neuro-endoscopic techniques also reduces patient recovery time, post-operative pain and scarring.
Endoscopic Third Ventriculostomy (ETV)
Endoscopic Third Ventriculostomy is a surgical procedure to create a by-pass for cerebrospinal fluid in the brains of children and adults with obstructive hydrocephalus. Usually, a shunt or a small flexible tube is placed to divert built-up cerebrospinal fluid from the brain to a different body cavity, where it may be easier for it to be reabsorbed. This is called a CSF diversion procedure. However, this procedure has its some disadvantages, as shunts are foreign, mechanical objects placed in the body.
An endoscopic third ventriculostomy is a minimally-invasive technique, effective at treating hydrocephalus caused by obstructions in the ventricles. The procedure is performed via a micro-incision, using a small endoscopic camera. The most common site of obstruction is the third ventricle of the brain. A small incision or by-pass is made through the floor of the third ventricle so cerebrospinal fluid can drain into the fluid chambers below the base of the brain.
Endoscopic Endonasal Excision of Pituitary Adenomas
Pituitary adenomas are abnormal growths or masses of tissues that develop on the pituitary gland. Pituitary adenomas may cause an increase or decrease in the production of important regulatory hormones in the body, leading to imbalance. Pituitary adenoma could cause fatigue, weight loss, slow growth, irregular periods in women, sexual dysfunction, and rapid or irregular heartbeat. Most pituitary tumours are slow-growing and non-cancerous. However, as they grow, they can put pressure on the pituitary gland and surrounding structures.
With microadenomas, medication to shrink the tumour may be sufficient to provide relief from symptoms. For larger tumours, surgical removal with endoscopic techniques may be recommended. The endoscopic camera and instruments are inserted via a small incision in the nose. This is known as the transsphenoidal approach. This technique is advantageous because it allows the surgeon to access the pituitary gland without opening the skull. Radiation therapy may also be recommended to shrink aggressive pituitary adenoma.
Coiling of Aneurysm
A brain aneurysm is a bulge in the wall of an artery in the brain, causing that part of the artery to weaken. With excess pressure, the aneurysm could rupture resulting in an internal brain bleed and a haemorrhagic stroke. Endovascular coiling is a procedure performed to block blood flow into the aneurysm. This reduces pressure on the aneurysm walls and keeps it safe from rupture. Endovascular coiling or embolization is a minimally invasive technique that doesn’t involve opening the skull. A catheter is inserted into a micro-incision in the groin area, and threaded up to the location of the embolization. This is done under X-ray fluoroscopy guidance. A platinum coil is inserted through catheter, and placed at the opening of the aneurysm. An electric current detaches the coil from the catheter once it is in place. The coil is left in place as a permanent implant. The platinum material induces clotting or embolization and prevents pressure from being exerted by the blood on the weakened walls of the arterial aneurysm.
Embolization of Arteriovenous Malformations
Arteriovenous malformations are a relatively rare condition in the brain, spine or spinal dura, in which abnormal connections are formed between the arteries and veins, forming a tangle where oxygenated and deoxygenated blood mix. Embolization of the malformation reduces the number of abnormal connections and allows oxygenated blood to flow to vital parts of the brain. Embolization is usually not a permanent solution. It is done to reduce the chances of bleeding during surgical removal of the arteriovenous malformation. During the embolization procedure, a catheter is navigated through a small incision in the groin, up to the location of the arteriovenous malformation. This is done under X-ray fluoroscopy guidance. Once the catheter is in place, an embolising agent is injected into the malformation through the catheter. The embolising agent triggers clotting in the malformation, blocking it and preventing blood flow.
A “Stent” is a small tube inserted in a blocked artery to maintain an opening for blood flow. It is usually made of either plastic or metal. Some stents may be coated in medication to prevent recurring blockages. Stents are useful in preventing the rupture of aneurysms, by strengthening the thinning arterial walls. The insertion of a stent is usually performed using minimally-invasive techniques. The surgeon typically y inserts the stent using a catheter through a small incision in the arm or groin area. This is done under X-ray fluoroscopy guidance.
Flow Divertor Stents
Flow divertor stents are special brain stents that channel blood flow away from aneurysm, while reinforcing the arterial walls. Flow divertor stents have a two-fold purpose – embolization and stenting. Although they were initially only used in the treatment of large brain aneurysms that could not be treated with coil embolization, flow divertor stents are now the standard procedure used to treat a broader range of aneurysms.
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