Thyroid nodules – when to be concerned…

The thyroid gland is situated in the front of the neck like a shield of a warrior protecting the windpipe or trachea which lies behind it. Indeed the word thyroid is derived from the Greek word for shield. The butterfly-shaped gland produces a hormone called thyroxine which is involved in the regulation of a variety of bodily functions. In essence, it controls your ‘metabolic rate’, so patients with low levels of thyroxine feel tired, lethargic and gain weight.

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Whilst those with high levels – a condition called thyrotoxicosis – suffer from ex300 sleeplessness, weight loss, palpitations and tremors.

The thyroid gland is prone to developing small lumps within it which are called nodules. These may appear gradually or suddenly. Occasionally they may be painful. Figure 1 shows a gland with several large nodules – a common condition known as multinodular goitre. About 60% of women will have a thyroid nodule present if they were to have

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an ultrasound scan of the neck. The vast majority of these nodules

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are benign but may require treatment if they cause swallowing or breathing problems. However, 5-10% of nodules may harbour a cancer and therefore require surgical removal. Trying to decide which 200-101 nodules are sinister is challenging.

Figure 1: A large 15 cm multinodular goitre removed from a patient. This had no cancer in it but caused swallowing difficulties

To decide if a nodule has a cancer within it, surgeons frequently use ultrasound scans and then take a small sample of cells from the nodule with a needle. Ultrasound can identify worrying features which signify cancerous change. There are now newer advanced applications such

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as elastography which help identify malignant nodules (see Figure 2). The cells sampled from a needle biopsy are analysed by cytologist to help make a diagnosis (see Figure 3). More recently, special molecular diagnostic techniques which identify point mutations in genes can help in the identification of malignancy. These include mutations in the BRAF and RAS genes.



Figure 2: Ultrasound scan of the thyroid gland utilizing elastography to identify sinister changes


Figure 3: Cells taken from a nodule are examined under a microscope. This is called cytology and gives a quick and accurate diagnosis

Once a nodule is deemed to be of concern, surgery is often advised. Surgical removal of the thyroid gland is known as thyroidectomy. If the nodule is clearly cancerous, the entire gland is removed in an operation called total thyroidectomy. This is a common operation, first performed by Professor Theodor Billroth in the 1860s in Europe. If the nodule has worrisome features based on the ultrasound scan or biopsy, some surgeons may choose to remove just half the gland first in an operation known as hemithyroidectomy or thyroid lobectomy. The nodule may then be sent for further analysis before the surgeon proceeds with further surgery.

The technique of thyroidectomy has evolved substantially. Technology has made this surgery safer and more effective. Amongst the more notable improvements is the use of nerve integrity monitoring which reduces the risk of nerve damage during which may affects the patient’s voice. The harmonic scalpel is another instrument which reduces blood loss from surgery and is associated with less pain following surgery.

The scar following thyroid surgery often heals well. Whilst it may appear unsightly initially, most people heal well and the scar is often imperceptible several months after surgery (see Figure 4).


Figure 4: The scar following thyroid surgery after 6 months

In selected patients, it may be possible to remove the thyroid gland using keyhole surgery (See Figure 5) or robotic surgery (see Figure 6) through the armpit. This clearly avoids the neck incision and is favoured by some women. It is best to seek the opinion of a surgeon if you wish to have this type of surgery.

Figure 5: Endoscopic thyroid surgery through the armpit. The author learnt this technique from Prof Luong (right) who is a leading authority on this approach

Figure 6: Robotic thyroidectomy using the da Vinci S system



Most patients survive thyroid cancer. The well differentiated cancer sub-types such as papillary and follicular thyroid cancer have very good outcomes. Figure 7 is the survival graphs from

a 10 year review of thyroid cancer at the author’s institutional practice. The average follow up period was 42 months. Survival was poorer for the less favourable sub-types such as Medullary and Anaplastic thyroid cancer

Figure 7: Survival outcomes in a review of 152 thyroid cancers treated at Tan Tock Seng Hospital, Singapore where the author is a Visiting Consultant

Preventing Major Amputations in Diabetic Patients without Major Operations



Having to undergo a major amputation like a below-knee-amputation (BKA) or above-knee-amputation (AKA) is one of the feared complications

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of Diabetes.

Patients with diabetes are at higher risk of amputations because of the damaging effects of diabetes on the patient’s nerves, arteries and immune (defense system against infection) system resulting in non-healing wounds can potentially lead to tissue death or gangrene

  1. Nerves: Patient losses sensations on his or her toes, increasing the chance of accidental injury to toes and


  2. Arteries: The blood vessels that bring oxygen and nutrients to the injured parts are often narrowed or blocked in Diabetes, making recovery almost impossible
  3. Immune system: With this affected, the non-healing wound can easily get infected leading to life-threatening infection (Sepsis).



2nd and 3rd toe gangrene

2nd and 3rd toe gangrene

Above Knee Amputation

Above Knee Amputation








This can be prevented by:

  1. Regular medical follow up with good control of diabetes
  2. Adequate day to day care of the foot with follow up by a Foot and Ankle Surgeon and adequate footwear advice from a Podiatrist.
  3. Screening to make sure the arteries to the foot are not blocked or narrowed. This is done by pressure measurements or ultrasound studies by trained personnel.


Once wounds occur, the body requires good blood supply to allow for healing at the area of injury. If the wound gets infected, antibiotics to fight the infection cannot reach the injured area if the blood vessels that carry them there are blocked.

In order to overcome this, something needs to be done to bring good blood supply to the area of need.

In the past, Vascular surgeons perform a by-pass operation to bring blood across the area of blockage. This is a major procedure requiring long inpatient stay and involving high risk of stroke or heart attack during the operation.


In the past decade, Vascular Surgeons increasingly are replacing this with the process of angioplasty or ‘ballooning’ (Endovascular Surgery). This procedure does not need General Anaesthesia, reducing the operation risks significantly. Patients usually only need to stay overnight for monitoring after the procedure.



Blocked Ankle Artery

Blocked Ankle Artery

Ankle Artery unblocked by Angioplasty

Ankle Artery unblocked by Angioplasty

It is hoped that with this procedure Vascular Surgeons can prevent major amputations in

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patients with less invasive methods

Contributing Specialist:

Dr Cheng Shin Chuen

Consultant Surgeon
FRCS Edin(Gen Surg)
Pacific Vein & Endovascular Centre
290 Orchard Road

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Fax: (65) 6235 0023
Hp: (65) 9626 8748
Email: [email protected]


Treatment of Adolescent Scoliosis

Each case of scoliosis, defined as three-dimensional curvature of the spine, is as unique as the person who has the condition. If the size of the curve is less than 25 degrees in the growing child, periodic observation by us is sufficient. Wearing an orthotic brace is beneficial if the curve reaches 25 degrees or more in a growing child with immature bones. Bracing can come in the form of a traditional TLSO (Boston brace) or dynamic SpineCor brace. The role of physiotherapy or chiropractic manipulation is still controversial. When the curve measures more than 40 to 45 degrees in the growing child, and more than 50 degrees in the skeletally mature patients, surgery may be the best treatment.

Surgical Approaches

Scoliosis surgery aims to arrest the progression of the curve, while at the same time making a curved spine straighter. It

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is important to try to preserve as much of the spine’s natural mobility as possible.

For many patients, scoliosis surgery is done from the back or posterior approach i.e. posterior spinal fusion with instrumentation. Bone is taken from another part of the patient’s body (either local sources, ribs, or the pelvis) and then grafted onto the vertebrae. The bone graft will take at least one year to “harden” to the vertebrae. Nowadays, we routinely take the bone from the ribs so that we can at the same time reduce the rib hump deformity. To stabilize the fusion and hold the vertebrae in place during this time period, two titanium rods are attached to the spine with hooks or pedicle screws or both. For stiff and large curves, we may elect to use cobalt-chromium rods instead, which are stronger than titanium rods.

Sometimes the best approach is from the front, or anterior region. This maybe possible if the patient only presents with one significant curve. In this type of surgery, the incision is made through the chest and/or abdominal cavity. If the curve is in the chest, we may perform thoracoscopic surgery – a type of minimally invasive surgery-to correct scoliosis. This technique is possible because of good images provided by the camera connected to the thoracoscope. This technique results in smaller incisions (four one-half inch incisions on the side of the chest wall compared with one 10-inch incision with traditional front approach, and also avoiding a long scar at the centre of the back compared with the traditional

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posterior spinal fusion and instrumentation). It is particularly suitable for patients who have scoliosis confined to the thoracic spine or where the spine can be reached through the chest cavity. Other requirements include curves which are right sided. In this procedure, the

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patient is placed on her or his side. The right lung is temporarily deflated by the anesthetist for the duration of the surgery. The procedure involves removing the discs between the vertebrae so that the spine becomes “looser”. The spaces are then filled with bone taken from the ribs. Titanium screws will then be inserted under radiographic control. A rod will be used to connect the screws, and by doing so straightens the spinal curve. The picture below illustrates the small incisions used in this form of minimally invasive spine surgery.

There are times when a combined anterior and posterior (from behind) approach is used, if the curve is too big and rigid. Generally, we will first approach the front to “loosen” the spine by removing the discs between the vertebrae. The second stage will

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involve opening the back of the spine, and correcting the scoliosis using a combination of hooks or screws, although the tendency is to use all screws nowadays as they offer better stability than hooks.

Generally speaking, scoliosis surgery requires 4 to 5 hours in the operating room and a hospital stay of about 5 to 7 days. Most patients return to school or work 2 to 4 weeks after surgery; sporting activities can be resumed at about 12 months post-surgery.

The pictures below show the x-rays of a patient who had severe scoliosis before and after surgery.










Neurophysiological Monitoring

One of the risks of scoliosis surgery is injury or damage to nerves contained within the spinal cord. Specifically, though unlikely, there is a chance of paralysis. Traditionally, the patient is awakened during surgery to ensure that the nerves are unharmed and movement is normal. We routinely use neurophysiological or intraoperative nerve monitoring, where wire leads are connected from the patient’s foot or leg to the skull. A technician constantly monitors

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the nerve activity, which is detectable through these leads throughout the operation. We also perform the traditional “wake-up” test if required.

Blood product support

Scoliosis surgery potentially involves significant blood loss. During surgery, blood can be conserved by using meticulous technique and state-of-the-art surgical instruments to stop or prevent excessive bleeding. In many cases, blood lost during a surgical procedure can be salvaged and recycled using cell savers. Certain medications maybe administered by our anesthesiologist to reduce intraoperative bleeding e.g. tranexamic

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acid. Occasionally, we will get the patients to donate their blood before the surgery to be re-transfused back to themselves during or after the surgery (autologous transfusion).


For surgeries as complex as those used to correct scoliosis, there’s no substitute for an experienced health care team, from the surgeons who specialize in spinal surgery,nurses in the wards, physiotherapists who provide chest physiotherapy and ambulatory physiotherapy. We

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offer scoliosis patients:

  • Comprehensive counseling before and after surgery.
  • A comprehensive approach to the non-operative and operative treatment
  • Availability of highly qualified spine surgeon to perform the surgery
  • The use of high-quality fluoroscopic (X ray) images during surgery
  • Intraoperative nerve monitoring
  • Excellent post-operative care at our paediatric high-dependency and intensive care unit if required

X rays of a patient who had thoracoscopic fusion and instrumentation of thoracic scoliosis














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)


Facts about Adolescent Scoliosis

Adolescent Scoliosis is a structural three dimensional curvature (C or S shaped) of the spine that occurs at or near the onset of puberty for which no cause has

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officially been proven. Special Occasion Dresses Studies have been done for different probable causes (genetic, brainstem control, hormones such as growth hormone and melatonin) but no firm conclusion was made. There is no evidence to suggest any association with diet, bone density, back posture, or heavy school bags in the causation of the scoliosis. Scoliosis shows up in teenagers

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from ages 10 to 14, and girls over the age of nine are five times more likely to get scoliosis than boys of the same age.


Scoliosis can cause a shortened stature when untreated. Curves more than 80 to 90 degrees are associated with shortness of breath and risks of heart failure and death. Patients with this degree of scoliosis will also have more concern about their cosmetic appearance. The association of pain is controversial still, with some studies showing little difference as compared with normal population, while others reported significant

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increase in back pain with increasing severity of the scoliosis.


Examination is done using Adams test,

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where the patient is asked to lean forward with his or her feet together and bend 90 degrees at the waist. The examiner can then easily observe for any asymmetry of the trunk or any abnormal spinal curvatures. Treatment varies from non-operative (bracing)
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to operative (surgical correction), which aims to keep the patient’s curvature from progressing beyond the important threshold of 50 degrees at maturity. This threshold is important, because once the scoliosis exceeds 50 degrees, there is tendency to increase well beyond adulthood.


For mild cases, the patients require check-ups every 6 to 12 months. Moderate cases will be advised to wear a brace. The standard brace is a Boston brace, although a dynamic brace (SpineCor) maybe an alternative. Studies have shown that full-time bracing is significantly more effective than part-time bracing in the control of scoliosis. Surgical treatment is indicated in scoliosis of more than 40 degrees in a growing child, and in anyone which has scoliosis of more than 50 degrees. Surgery will fuse the affected spinal bones (vertebrae) in a more normal balanced position, and allow remaining growth to proceed normally in the other parts of the spine.


Different surgical approaches (from the back or the front) can be done depending on the characteristics of the scoliosis. Surgery in our institution is accompanied by spinal cord and nerve monitoring which greatly increase the safety of the surgery. Spinal surgery with modern instrumentation significantly corrects the spinal deformity and stops the curve progression. Minimal access technology used in some selected scoliosis cases will allow for improved scar healing with similar outcome. Patients are usually out of hospital in five to six days and back at school in two to three weeks. They are advised to refrain from excessive bending and heavy lifting for three to four months. They can swim after six months, and participate in athletics after 12 months.

In summary, adolescent scoliosis is a progressive curvature of the spine of unknown cause. Treatment will depend on the severity of the curve, and it is important to start treatment early before the scoliosis worsens. Early intervention will ensure a better outcome.

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)


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)

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