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Awake craniotomy with intraoperative monitoring

Intraoperative brain mapping (awake brain surgery) is a procedure performed during brain tumor surgery while the patient is awake but sedated.

It enables the neurosurgeons to remove tumors that would otherwise be inoperable because:

  • They are too close to areas of the brain that control vision, language and body movements
  • Surgery would result in a significant loss of function.

Neurosurgeons perform awake brain surgery for tumors that have spread throughout the brain and do not have clear borders, such as some types of glioma. Awake brain surgery can shrink these tumors.

Minimally invasive spine surgery

Minimally invasive spine surgery (MISS) is sometimes called less invasive spine surgery. In a traditional, open surgery, the doctor makes an incision that is 5 to 6 in. long and moves the muscles to the side in order to see the spine. One of the major drawbacks of open surgery is that the pulling or “retraction” of the muscle can damage the soft tissue.

In minimally invasive spine surgery, doctors use specialized instruments to access the spine through small incisions. This avoids significant damage to the muscles surrounding the spine. In most cases, this results in less pain after surgery and a faster recovery.

Common Minimally Invasive Spine Surgeries are

  • MIS Lumbar Diskectomy
    The surgeon inserts the retractor and removes a small amount of the lamina bone. This provides the surgeon with a view of the spinal nerve and the disk. The surgeon carefully retracts the nerve, removes the damaged disk, and replaces it with bone graft material.
  • MIS Lumbar Fusion
    In an MIS TLIF, the patient is positioned face-down and the surgeon places one retractor on either side of the spine. This approach prevents disruption of the midline ligaments and bone. Using the two retractors, the surgeon can remove the lamina and the disk, place the bone graft into the disk space, and place screws or rods to provide additional support.

Minimally invasive brain surgeries

Minimally invasive neurosurgery utilizes small, flexible, lighted tubes called endoscopes to visualize various parts of the brain, skull base, or spinal cord through small openings. Endoscopes serve as small microscopes, magnifying critical anatomical structures so the surgeon can easily see the various diseased areas requiring repair, removal, or replacement.  A small incision (less than an inch) is needed for a neuroendoscopy. Smaller incisions and bony openings often result in less pain and shorter hospital stays. Because the use of endoscopes is much less intrusive into these anatomical structures than is conventional surgery, endoscopic neurosurgery is referred to as minimally invasive neurosurgery.

Many brain tumor operations that previously required a large scalp incision and large bony opening (craniotomy) can be performed as minimally invasive surgery – using smaller incisions and craniotomy openings.


Endoscopic Procedures

One of the biggest advances in neurosurgery over the past decade has been the development of endoscopic techniques for treating tumors in the skull base and brain. Lesions that formerly required craniotomy and brain retraction are now being accessed directly via natural pathways through the nose and sinuses.

During this procedure, thin tubing that transmits video images of the brain is inserted through one or two small incisions in the skull or through an opening in the body. This tube-like instrument, called an endoscope, contains a small camera that allows the neurosurgeon to see detailed images of the problem area in the brain.

The neurosurgeon will use the images transmitted by the endoscope as a guide for removing the tumor or repair the affected area of the patient’s brain. The removal of the tumor or damaged area is performed with specialized surgical instruments.

What are the Benefits of Endoscopic Brain Surgery?

  • Minimally invasive (results in less pain for the patient)
  • Faster recovery time than open brain surgery
  • Reduced risk of brain trauma
  • Reduced risk of side effects
  • Reduced hospital stay

Spine vascular malformation

What is Spinal Vascular Malformation?

Spinal vascular malformation is a very rare condition. It is an abnormal tangle of blood vessels on, in, and/or near the spinal cord 

Depending on where a malformation is located, it is classified as:an intramedullary arteriovenous malformation (AVM within the spinal cord tissue), a pial arteriovenous malformation (AVM on the surface), a dural spinal arteriovenous fistula (DAVF within the membrane that covers the spinal cord), or an epidural arteriovenous fistula (Epidural AVF on the surface of the membrane that covers the spinal cord).

What are the symptoms?

Symptoms usually develop when people are in their 20s, although almost 20 percent of people diagnosed with spinal AVM are under the age of 16.

The emergence of symptoms may be sudden or gradual. Symptoms typically include:

  • Problems with walking or climbing stairs
  • Numbness, tingling or sudden pain in your legs
  • Weakness on one or both sides of your body

As the condition progresses, additional symptoms may include:

  • Sudden, severe back pain
  • Lack of feeling in the legs
  • Difficulty urinating or moving your bowels
  • Headache
  • Stiff neck
  • Sensitivity to light

What are the causes?

The specific cause isn’t known. Most spinal AVMs are present at birth (congenital), but others may occur later in life.

How is a diagnosis made?

  •  Magnetic resonance imaging (MRI)
  • Computed tomography (CT)
  • spinal catheter angiography

What are the treatment options?

Depending on the lesion, the best treatment plan changes. For intramedullary AVMs, partial or palliative treatment is sometimes an option since complete obliteration may carry a much higher chance of causing neurological deficits than conservative management or partial treatment.

The treatment strategy includes catheter embolization, surgical resection, radiation, and/or a combination these modalities.

For pial arteriovenous malformations, complete obliteration may be possible by surgical resection or catheter embolization depending on the anatomy.


Spine tumors

What is spinal tumor?

A spinal tumor is a growth of cells (mass) in or surrounding the spinal cord.

What are the types of spinal tumors?

There are two main types of tumors that may affect the spinal cord:

  • Intramedullary tumors begin in the cells within the spinal cord itself, such as astrocytomas or ependymomas.
  • Extramedullary tumors develop within the supporting network of cells around the spinal cord. Although they don’t begin within the spinal cord itself, these types of tumors may affect spinal cord function by causing spinal cord compression and other problems. Examples of extramedullary tumors that can affect the spinal cord include schwannomas, meningiomas and neurofibromas.

What are the symptoms?

Spinal tumors may cause a variety of symptoms depending on their type, location, and rate of growth.

In general, the most common pattern of symptoms is pain at the tumor site in the neck or back, followed by neurological problems like weakness / numbness in the arms or legs or a change in normal bowel or bladder habits.

In patients already diagnosed with cancer of another area of the body, the new onset of spinal pain may indicate a spinal fracture caused by a metastatic tumor that has weakened a vertebra.

Tumors that arise inside the dura are usually benign and slow growing. Patients with these tumors may have pain for years before any neurological problems occur.

What are the causes?

The cause of primary spinal tumors is unknown. Some primary spinal tumors occur with certain inherited gene mutations.

What treatments are available?

Intradural-Extramedullary and Intramedullary Tumors are usually surgically removed. The goal of treatment is usually to:

  • Totally remove the tumor
  • Preserve neurological function

The spinal cord and nerves are highly sensitive and avoiding damage to these structures is a critical part of surgery. Monitoring techniques may be used throughout the surgery to determine the function of the spinal cord as the tumors are being removed. If the tumor cannot be completely removed (e.g. if it adheres to many spinal nerves), post-operative radiation therapy may improve outcome in some cases. If the tumor is metastatic, chemotherapy may also be helpful.Following the surgery, it may take some time for the nerves to fully heal. Usually rehabilitation and time significantly helps improve a patient’s neurological function.

Disk prolapse

What is disk prolapse?

A disc becomes prolapsed when the soft, jelly-like material that comprises the center of the disc pushes through the fibrous shell and into the spinal column. This condition often leads to neck or back pain when the prolapsed disc comes into contact with a nerve or other soft tissue. 

What are the symptoms?

Nerve compression from a prolapsed disc can cause a variety of symptoms, depending on the pathology and location of the problem. Some common forms of radiculopathy (A disease of the root of a nerve, such as from a pinched nerve or a tumour.)


  • Local, chronic pain in the neck or back
  • Pain that radiates along the affected nerve
  • Unexpected muscle weakness or loss of reflexes
  • A feeling of numbness or tingling in the fingertips or toes
  • The sensation of pins and needles

What are the causes?

Disk herniation is most often the result of a gradual, aging-related wear and tear called disk degeneration. As you age, your spinal disks lose some of their water content. That makes them less flexible and more prone to tearing or rupturing with even a minor strain or twist.

Most people can’t pinpoint the exact cause of their herniated disk. Sometimes, using your back muscles instead of your leg and thigh muscles to lift large, heavy objects can lead to a herniated disk, as can twisting and turning while lifting. Rarely, a traumatic event such as a fall or a blow to the back can cause a herniated disk

How is a diagnosis made?

Imaging tests

  • X-rays. 
  • Computerized tomography (CT scan). 
  • Magnetic resonance imaging (MRI). 
  • Myelogram. A dye is injected into the spinal fluid, and then X-rays are taken. This test can show pressure on your spinal cord or nerves due to multiple herniated disks or other conditions.

Nerve tests

Electromyograms and nerve conduction studies measure how well electrical impulses are moving along nerve tissue. This can help pinpoint the location of the nerve damage.

What treatments are available?

Non-Surgical Herniated Disc Treatments

  • Medications
  • Exercise
  • Physical therapy
  • Chiropractic care -Chiropractic is a form of alternative medicine mostly concerned with the diagnosis and treatment of mechanical disorders of the musculoskeletal system, especially the spine. Proponents claim that such disorders affect general health via the nervous system.

Surgery for Herniated Discs

When no improvement is noted after a course of conservative treatment, surgery might be considered.

  • A discectomy is the surgical removal of part or the entire offending intervertebral disc.
  • Percutaneous discectomy- Percutaneous means “through the skin” or using a very small cut. Discectomy is surgery to remove herniated disc material that is pressing on a nerve root or on the spinal cord.
  • Microdiscectomy incorporates the use of a microscope to magnify the surgical field during removal of the disc.
  • Laminectomy and laminotomy are surgeries done to relieve pressure on the spinal cord and/or spinal nerve roots by removing all or part of the lamina. The lamina, the thin part of the bones that make up the spine (vertebrae), protects the spinal cord.

Spine fractures

What are spinal fractures?

A spinal fracture is when you break a bone in your spine—that’s the basic definition. Spinal fractures are different than a broken arm or leg. A fracture or dislocation of a vertebra can cause bone fragments to pinch and damage the spinal nerves or spinal cord.

What causes the fracture?

When an external force is applied to the spine, such as from a fall, the forces may exceed the ability of the bone within the vertebral column to support the load. This may cause the front part of the vertebral body to crush, resulting in a compression fracture. If the entire vertebral column breaks, it results in a burst fracture.

If the compression is mild, you will experience only mild pain and minimal deformity. If the compression is severe, affecting the spinal cord or nerve roots, you will experience severe pain and a hunched forward deformity (kyphosis).

Osteoporosis is the most common risk factor for fractures, as the disease causes bones to weaken.

What are the symptoms?

Symptoms of a spinal fracture vary depending on the severity and location of the injury. They include back or neck pain, numbness, tingling, muscle spasm, weakness, bowel/bladder changes, and paralysis. Paralysis is a loss of movement in the arms or legs and may indicate a spinal cord injury. Not all fractures cause spinal cord injury and rarely is the spinal cord completely severed.

How is a diagnosis made?

  • X-ray
  • Computed Tomography (CT)
  • Magnetic Resonance Imaging (MRI)

What treatments are available?

Medical Treatment

Most fractures are treated with immobilization in a brace or corset for up to 12 weeks. Bracing helps to reduce pain and prevent deformity.

Surgical Treatment

Severe cases may require surgery.

Vertebroplasty is a new surgical procedure that may be used to treat compression fractures. In this procedure, the surgeon inserts a catheter into the compressed vertebra. The catheter is used to inject the fractured vertebrae with bone cement, which hardens, stabilizing the vertebral column. This procedure has been shown to reduce or eliminate fracture pain, enabling a rapid return to mobility and preventing bone loss due to bed rest. However, it does not correct the spinal deformity.

Kyphoplasty involves inserting a tube into the vertebral column under X-ray guidance, followed by the insertion of an inflatable bone tamp. A tiny incision is made in the back. Once inflated, the tamp restores the vertebral body back toward its original height, while creating a cavity to be filled with bone cement. The cement seals off cracks and cavities, and prevents the vertebra from re-collapsing. After the cavity is filled, the tube is removed and the incision stitched.

Stabilization can also be achieved by removing broken vertebra and replacing them with a plate, screws, or cage.

Navigation assisted procedures

Computer assisted surgery (CAS) is nothing short of a surgical breakthrough. By utilizing an infrared navigation camera, wireless Smart Instruments, and intuitive software, this technology improves a surgeon’s ability to visualize a patient’s anatomy, track instruments, and deliver greater surgical precision.

Head Injury

What is head injury?

A traumatic brain injury, also referred to an acquired brain injury, occurs when someone suffers a sudden trauma that causes damage to the brain. When the head suddenly and violently hits an object, a traumatic brain injury may occur. If an object pierces the skull and enters brain tissue, a TBI may occur.

What are the causes of head injuries?

• A blow to the head resulting from a fall, a traffic accident, an accident at work, or a sports injury.
• Damage to Brain tissue following a stroke, Brain surgery, or Brain tumour.
• A viral infection.
• Lack of oxygen to the Brain during a heart attack.

What are the signs and symptoms of Head injury? 

An individual suffering from a traumatic brain injury can feel dizzy, nauseous, confused, or depressed. Headaches, memory loss, difficulty in sleeping (or sometimes, oversleeping or feeling sleepy during inopportune times), increased sensitivity to noise or light, and memory and concentration problems are also common symptoms among people suffering from a traumatic brain injury.

Danger Signs in Adults

In rare cases, a person with a concussion may form a dangerous blood clot that crowds the brain against the skull. Contact your health care professional or emergency department right away if you experience these danger signs after a bump, blow, or jolt to your head or body:

  • Headache that gets worse and does not go away.
  • Weakness, numbness or decreased coordination.
  • Repeated vomiting or nausea.
  • Slurred speech.

The people checking on you should take you to an emergency department right away if you:

  • Look very drowsy or cannot wake up.
  • Have one pupil (the black part in the middle of the eye) larger than the other.
  • Have convulsions or seizures.
  • Cannot recognize people or places.
  • Are getting more and more confused, restless, or agitated.
  • Have unusual behavior.
  • Lose consciousness.

Danger Signs in Children

Take your child to the emergency department right away if they received a bump, blow, or jolt to the head or body, and:

  • Have any of the danger signs for adults listed above.
  • Will not stop crying and are inconsolable.
  • Will not nurse or eat.

How is traumatic brain injury identified and treated?

How traumatic brain injury is treated very much depends on the severity of the trauma. If the traumatic brain injury is mild, then headaches or neck pain can be treated with medication or physiotherapy. If the trauma is severe, swelling or haemorrhages often occur and these frequently require surgery. So that the degree of severity and the injuries can be defined, various diagnostic steps are carried out. The most important examinations are the CT scan where the patient’s head is X-rayed or imaging using an MRI scan. Skull fractures and haemorrhages in the brain are easy to detect.


Medications to limit secondary damage to the brain immediately after an injury may include:

Diuretics – causing increased passing of urine.

Anti-seizure drugs-to treat epileptic seizures.

Coma-inducing drugs. to cause a temporary coma or a deep state of unconsciousness.


Emergency surgery may be needed to minimize additional damage to brain tissues. Surgery may be used to address the following problems:

  • Removing clotted blood (hematomas). Bleeding outside or within the brain can result in a collection of clotted blood (hematoma) that puts pressure on the brain and damages brain tissue.
  • Repairing skull fractures. Surgery may be needed to repair severe skull fractures or to remove pieces of skull in the brain.
  • Opening a window in the skull. Surgery may be used to relieve pressure inside the skull by draining accumulated cerebral spinal fluid or creating a window in the skull that provides more room for swollen tissues.


Most people who have had a significant brain injury will require rehabilitation. They may need to relearn basic skills, such as walking or talking. The goal is to improve their abilities to perform daily activities.