Minimally Invasive Spine Surgery


Traditional spine surgery usually requires long incisions. Muscles are cut and moved away from the spine to expose the surgical area. This causes increased pain, long recovery time and impaired spinal function.

With minimally invasive (keyhole) techniques, surgery on the spine can be performed with a wound of only 2-3cm and many of these can be performed as day surgery. Prolapsed intervertebral disc, spinal stenosis and spondylolisthesis are some of the conditions that can be performed with minimally invasive surgery.


In minimally invasive surgery a tubular retractor is used to dilate the muscles and create a tunnel to expose the spine (Fig 1a,b). Using the tubular retractor, procedures to relieve pressure on the spinal cord and to remove the slipped disc can be performed.

In patients who require spinal fusion to stabilize the spine, the metal screws and rods can be inserted through small wounds (Fig. 2).


1. Smaller scars

2. Less tissue trauma

3. Less blood loss

4. Less postoperative pain

5. Shorter hospital stay

6. Faster rehabilitation

7. Quicker return to work and normal activities

Clinical example

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patient with back pain and both leg pain which is worse with walking. Patient underwent minimally invasive surgery to relieve the pressure on the spinal nerves. He had rapid recovery with a small wound.


  1. Benedict Peng. Clinical and Radiological Outcomes of Minimally Invasive versus Open Transforaminal Lumbar Interbody FusionSpine 2009 Jun 1;34(13):1385-9.

Contributing Specialist:

(Spine Surgery)

Island Orthopaedic Consultants
Gleneagles Med Ctr,#02-16,
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What Can You Do To Help Your Back and/or Neck?

In our fast-paced society, we often look for “quick fix” solutions to quickly remove the pain. We need to understand that in many instances, back or neck pain become obvious as a result of years of “neglect” of the spine. Patients with back or neck pain can become sedentary, or become out of shape, gaining weight that places more strain on the low back. Our goal at the Centre for Spine and Scoliosis Surgery (CSS) is to make your back or neck stronger, more flexible, and thus reducing the chance of further injury. Many of these can be achieved by educating you on the structure and function of the spine, and the lifestyle modifications that may accompany.

While a spinal injection or surgery can help relieve symptoms, not maintaining spinal muscle strength and flexibility, or use of good body mechanics can increase your likelihood of future problems. You have to remember that as you get older,

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sure your chair molds properly to your back. If you are too short or too tall for your back to rest properly in your chair, or if your company does not offer ergonomically designed chairs, consider bringing in a rolled-up towel. Place it behind your low back to reduce the amount of stress on the back. While sitting, make sure your feet rest flat on the floor. If this is a problem, use a footstool. Proper foot and leg alignment will ease back stress. While typing on a computer, your forearms and thighs should be parallel to ensure proper shoulder alignment. If necessary, use a pad to support your wrists while typing. The monitor should be at eye-level or slightly below eye-level. Last but not least, always get up and move around every half hour, even if it is just a quick stretch by the side of your desk.

Some jobs require standing for many hours at a stretch. People rarely distribute their weight equally onto both legs while standing. They tend to shift their weight from one side to another, throwing the spine out of

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alignment, which can lead to back strain.

If you have difficulty standing without shifting weight, try standing with one leg on a footrest, periodically switching feet. It is also important to do back stretches now and

then in order to reduce stiffness of the back.

Lifting is a common activity in our daily life. When lifting, maneuver the object close to your body, and use the strength in your legs to get the object off the ground, rather than your low back. Whenever possible, your back should not bend forward when lifting something, however light it may appear.
Contributing Specialist:

Dr Hee Hwan Tak
MBBS, FRCS (Ed), FRCS (Glas), FAMS (Ortho)
Medical Director and Senior Consultant, Pinnacle Spine & Scoliosis Centre
Mobile: 65-98283132
Tel: 65-67370680
Fax: 65-67370522
Emergency: 65-97718964
3 Mount Elizabeth, Mount Elizabeth Medical Centre, #04-07, Singapore 228510
Adjunct Associate Professor, Nanyang Technological University, Singapore
Panel of Medical Experts, The Subordinate Courts of Singapore

Associate Editorial Board Member, The Spine Journal (USA)


Diabetic foot ulcers


A major complication of diabetes are foot ulcers. Majority will heal as long as the blood supply to the foot is good and infection is treated appropriately. However, there are ulcers that persist for many months without healing.


In the traditional methods of management, they are often only treated with frequent dressing changes. Any ulcer that does not reduce in size by half within 1 month is not likely to heal with further dressing changes. Such a delay in healing can put the patient at risk of getting his or her ulcer infected. This can result in amputations.


If the ulcer is not infected, why does it not heal? The most frequent reason is that the blood supply is poor. Always ask your doctor to examine

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the pulses of your foot. If they are absent, one should consult a Vascular Surgeon.


If your foot pulses are present and the blood supply is good, but still the ulcer does not heal with long periods of dressing, you should see an Orthopaedic Foot and Ankle Specialist. The most common reason is that the diabetes has caused deformities to appear in your

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foot. One severe consequence of this is called the Charcot foot. Diabetes can also cause tendons and muscle to “tighten” causing high pressure areas in your foot that in turn cause the skin to ulcerate.



The above shows a Charcot foot with sagging of the foot and bone destruction in the middle of the foot. Ulcers can form in the bottom of the foot. The bottom xrays show the same foot after reconstruction. The alignment is now restored.

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This topic is courtesy of:

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The Ortho Klinic

Gleneagles Medical Centre

Suite 08-01

6 Napier Road

Singapore ( 2588499 )

Clinic Tel: +65 64738826



Bunion Surgery (Hallux valgus)


Bunions are very common. They cause pain over the big toe. Many severe ones also affect the second and third toes leading to pain in the front of the foot.

Although footwear changes solves the problem for many people. Some still require surgical correction.

There are hundreds of operations described for the correction of bunions. Many date back to the 1950’s and 1960’s. Do check with your surgeon when the surgery was dated. These often require long periods of casting of the foot or usage of crutches and often with pins sticking out of the foot for weeks.

The modern approach to bunion surgery is “WALK IMMEDIATELY” and “NO CRUTCHES”.

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This is made possible by a new procedure called the Scarf osteotomy. With this, even severe bunions can be corrected without sacrificing the important joint of the big toe.

The pictures show a patient with severe bunion deformities that has also involved the 2nd and 3rd toes. The picture below shows correction after a Scarf

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and 3rd toe correction. The final result is pleasant and long lasting with high satisfaction rate. Morever, not a single joint was sacrificed and fused or removed. Every single joint was preserved. This patient could also walk immediately on the following day after surgery.


This topic is courtesy of:

Dr. Chong Keen Wai

The Ortho Klinic

Gleneagles Medical Centre

Suite 08-01

6 Napier Road

Singapore ( 2588499 )

Clinic Tel: +65 64738826



Chronic Ankle Pain – What could be the problem?


The ankle is a very complex joint. There are actually many small joints in the region of the “ankle”. One of which is the subtalar joint

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foot. These too can cause “ankle pain”.


A proper evaluation of ankle pain requires listening to the patient’s symptoms and then performing an examination of all the joints, tendons and ligaments. Sometimes, Xrays or MRI scan may be necessary to assist in confirming a diagnosis.


Treatment of ankle pain has advanced significantly. Many conditions

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which used to be less known and underdiagnosed can now be treated by minimally invasive surgery. The ankle can now be scoped (anterior and posterior ankle arthroscopy) from the front and also from the back. The tendons around the ankle can also be scoped (tenoscopic surgery). The subtalar joint can also be scoped (subtalar arthroscopy). Mini instruments have allowed us to treat many painful ankle conditions through “keyholes”. In my personal experience, the success of such surgery in improving the function of a damaged “ankle” ranges from 85 to 95%.

Ankle arthroscopy showing a “meniscoid lesion”. This is a fibrous “scar” that appears after an ankle injury that can get trapped in the joint, causing pain. Arthroscopic removal results in excellent pain relief.

Tendon scope (tenoscopic surgery) on the ankle. My published personal results

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This topic is courtesy of:

Dr. Chong Keen Wai

The Ortho Klinic

Gleneagles Medical Centre

Suite 08-01

6 Napier Road

Singapore ( 2588499 )

Clinic Tel: +65 64738826