Spine Surgery in Kerala —
Harvard-Trained Spine Surgeon at Caritas Neuro Sciences

Intervertebral disc disease is the most common cause of back and neck pain requiring neurosurgical intervention. When the soft inner nucleus of a spinal disc pushes through its outer ring (annulus fibrosus), it can compress adjacent nerve roots or the spinal cord itself, causing pain, numbness, weakness, and in severe cases, loss of bladder or bowel control.

Dr. Bahuleyan offers a complete spectrum of surgical treatment for disc disease, ranging from minimally invasive microdiscectomy — which removes only the herniated fragment through a small incision — to anterior cervical discectomy and fusion (ACDF) for cervical disc herniations. For appropriate candidates, Dr. Bahuleyan is ProDisc® certified to perform artificial disc replacement, a motion-preserving alternative to fusion that replaces the damaged disc with a mechanical prosthesis, maintaining natural spinal movement and potentially reducing the risk of adjacent segment disease over time.

The surgical approach is tailored to each patient's specific pathology, disc level, severity of compression, and overall spinal alignment. All procedures are performed with the aid of the operating microscope and intraoperative neuromonitoring (SSEP/MEP) for maximum precision and safety.

Spinal canal stenosis refers to the narrowing of the spinal canal, which places pressure on the spinal cord and/or nerve roots. It most commonly affects the lumbar and cervical spine and is a leading cause of pain, numbness, and progressive weakness in adults over 50. Lumbar stenosis typically presents with neurogenic claudication — leg pain and heaviness that worsens with walking and improves with sitting or leaning forward. Cervical stenosis can cause myelopathy, a serious condition involving clumsiness, balance difficulties, and progressive loss of fine motor skills.

Surgical treatment aims to decompress the neural elements while maintaining or restoring spinal stability. Dr. Bahuleyan performs a range of decompression procedures including laminectomy, laminoplasty (particularly for cervical stenosis to preserve range of motion), and minimally invasive tubular decompression which achieves the same surgical goals through smaller incisions with less tissue disruption. When stenosis is accompanied by spinal instability, instrumented fusion may be combined with decompression to ensure long-term structural integrity.

Every patient undergoes comprehensive preoperative evaluation with advanced neuroimaging (MRI, CT myelogram when needed) and detailed neurological assessment to determine the optimal surgical strategy.

Spondylolisthesis occurs when one vertebra slips forward over the vertebra below it, causing spinal canal narrowing, nerve root compression, and mechanical instability. It can result from degenerative disc disease (most common in older adults), a pars interarticularis defect (isthmic type, common in young athletes), congenital vertebral anomalies, trauma, or pathologic weakening of the bone from tumours or infection.

Surgical treatment is indicated when conservative management fails to relieve symptoms, when there is progressive neurological deficit, or when the degree of vertebral slip is significant. Dr. Bahuleyan performs a variety of fusion procedures tailored to the specific type and grade of spondylolisthesis, including transforaminal lumbar interbody fusion (TLIF), posterior lumbar interbody fusion (PLIF), anterior lumbar interbody fusion (ALIF), and lateral interbody fusion approaches. Pedicle screw fixation is used to provide rigid stabilisation while the fusion heals.

Minimally invasive fusion techniques are used whenever appropriate, employing percutaneous pedicle screws and tubular retractors to reduce muscle damage, blood loss, and postoperative pain while achieving equivalent fusion rates to open surgery.

Spinal injuries encompass a wide spectrum of traumatic conditions from simple compression fractures to devastating spinal cord injuries with complete neurological deficit. They most commonly result from road traffic accidents, falls from height, sports injuries, and in the elderly, osteoporotic vertebral fractures from even minor trauma.

Dr. Bahuleyan manages the full range of spinal trauma including cervical fractures and dislocations (which carry the highest risk of spinal cord injury), thoracolumbar burst and chance fractures, sacral fractures, and cauda equina syndrome — a surgical emergency requiring immediate decompression. Surgical options include posterior fixation with pedicle screws and rods, anterior vertebral body reconstruction, vertebroplasty and kyphoplasty for compression fractures, and combined anterior-posterior approaches for complex unstable injuries.

The Caritas Neuro Sciences spine trauma service operates with 24/7 emergency neurosurgical coverage, dedicated neuro-ICU facilities, and intraoperative neuromonitoring capability, ensuring that patients with acute spinal injuries receive time-critical surgical intervention with the highest safety standards.

Chiari malformations are structural defects at the base of the skull where the cerebellum extends into the spinal canal, disrupting the normal flow of cerebrospinal fluid (CSF). There are four types, each varying in severity. Chiari Type I is the most common, involving downward displacement of the cerebellar tonsils through the foramen magnum, often presenting in adolescence or adulthood with headaches, neck pain, balance problems, and numbness. Chiari Type II (Arnold-Chiari) is nearly always associated with myelomeningocele and involves displacement of both the cerebellum and brainstem. Chiari Type III is a rare, severe form where the cerebellum and brainstem herniate through a defect in the back of the skull. Chiari Type IV involves incomplete or underdeveloped cerebellum.

Syringomyelia — the formation of a fluid-filled cavity (syrinx) within the spinal cord — is a common and serious complication of Chiari malformation. The syrinx can progressively expand, causing worsening weakness, sensory loss, and pain. Left untreated, it can lead to permanent neurological damage.

The primary surgical treatment for symptomatic Chiari I is posterior fossa decompression (foramen magnum decompression) with or without duraplasty, which creates more space for the cerebellum and restores normal CSF flow. In cases with associated syringomyelia, the decompression often leads to gradual resolution or reduction of the syrinx. When the syrinx persists or progresses despite decompression, direct syrinx shunting may be required. Dr. Bahuleyan's combined neurosurgical training across brain, spine, and paediatric conditions provides comprehensive expertise for managing these complex craniocervical junction pathologies.

Spinal tumours can arise from the vertebral column, the membranes surrounding the spinal cord (meninges), the nerve roots, or the spinal cord itself. They are classified by their anatomical location: extradural tumours (outside the dura, often metastatic or arising from bone), intradural extramedullary tumours (inside the dura but outside the spinal cord, such as schwannomas and meningiomas), and intramedullary tumours (within the spinal cord itself, such as ependymomas and astrocytomas).

Surgical treatment of spinal tumours requires precision microsurgery to achieve maximum tumour removal while preserving the spinal cord and nerve roots. Dr. Bahuleyan performs all spine tumour surgeries under the operating microscope with continuous intraoperative neuromonitoring (SSEP, MEP, EMG) to track the functional integrity of the spinal cord and nerve roots in real time throughout the procedure. This dual safety approach significantly reduces the risk of new neurological deficits.

For metastatic spine tumours causing spinal cord compression or structural instability, surgical decompression and stabilisation can relieve neurological symptoms and restore quality of life. Complex cases involving vertebral body tumours may require en-bloc spondylectomy or vertebral body replacement combined with posterior instrumentation. All spine tumour cases are reviewed in a multidisciplinary board alongside medical oncology, radiation oncology, and radiology to ensure comprehensive treatment planning.

Vascular disorders of the spine include spinal arteriovenous malformations (AVMs), spinal dural arteriovenous fistulas (AVFs), cavernous malformations, and spinal cord infarction. Spinal dural AVFs are the most common spinal vascular malformation, causing progressive myelopathy through venous congestion of the spinal cord. Spinal AVMs are abnormal tangles of blood vessels that can present with sudden haemorrhage, progressive neurological decline, or both.

Cavernous malformations of the spinal cord are clusters of thin-walled blood vessels that can bleed repeatedly, causing stepwise neurological deterioration. Spinal cord infarction, while less common, represents a vascular emergency requiring prompt diagnosis and management.

Treatment of spinal vascular disorders requires specialised microsurgical techniques and often a combined approach with interventional neuroradiology. Surgical excision of spinal dural AVFs involves identifying and interrupting the fistulous connection, which is curative in the majority of cases. Spinal AVMs and cavernous malformations are managed with microsurgical resection, sometimes preceded by preoperative embolisation to reduce blood flow. All vascular spine surgeries are performed with intraoperative neuromonitoring and the operating microscope to ensure precise identification and preservation of critical spinal cord vasculature.

Congenital spinal disorders arise from abnormal development of the spine and spinal cord during embryonic life. These conditions include spina bifida (ranging from occult to open myelomeningocele), tethered spinal cord syndrome, diastematomyelia (split cord malformation), dermal sinus tracts, lipomyelomeningocele, and spinal lipomas. Many of these conditions are diagnosed in infancy or childhood, but some — particularly tethered cord syndrome and occult spinal dysraphism — may not present until adolescence or adulthood with progressive symptoms.

Tethered spinal cord syndrome occurs when the spinal cord is abnormally attached to the surrounding structures, preventing it from moving freely within the spinal canal as the child grows. This progressive stretching of the cord can cause back pain, leg weakness, sensory changes, scoliosis, and bladder dysfunction. Surgical detethering involves releasing the abnormal attachments, most commonly a thickened or fatty filum terminale, to prevent further neurological deterioration.

Myelomeningocele repair is one of the earliest neurosurgical interventions performed in the neonatal period, typically within 24-48 hours of birth. Dr. Bahuleyan's combined training in spine surgery and paediatric neurosurgery equips him to manage the full spectrum of congenital spinal conditions from the neonatal period through adulthood, ensuring continuity of care as patients grow and their needs evolve.

Spinal cord stimulation (SCS) is an advanced neuromodulation therapy for chronic pain that has not responded to conventional treatments. A small device implanted near the spinal cord delivers mild electrical impulses that modulate pain signals before they reach the brain, providing significant pain relief for conditions such as failed back surgery syndrome (FBSS), complex regional pain syndrome (CRPS), chronic radiculopathy, and neuropathic pain.

Dr. Bahuleyan's Pain Management Fellowship at the Cleveland Clinic provided specialised training in the selection, implantation, and management of spinal cord stimulators. The procedure involves two stages: first, a trial stimulation period where temporary leads are placed to assess pain relief (typically requiring at least 50% improvement to proceed); followed by permanent implantation of the stimulator leads and implantable pulse generator (IPG) if the trial is successful.

Modern SCS systems offer multiple stimulation paradigms including traditional tonic stimulation, high-frequency stimulation, burst stimulation, and dorsal root ganglion (DRG) stimulation for more targeted pain relief. The Cleveland Clinic fellowship equipped Dr. Bahuleyan with expertise in selecting the most appropriate stimulation modality for each patient's specific pain condition and optimising programming for maximum therapeutic benefit.

Intrathecal drug delivery systems (pain pumps) deliver pain medication directly into the intrathecal space surrounding the spinal cord, providing potent analgesia at a fraction of the oral dose. Because the medication bypasses the systemic circulation and acts directly on spinal cord receptors, intrathecal delivery can achieve superior pain control with significantly fewer side effects than oral opioids — often using 1/300th of the equivalent oral morphine dose.

This therapy is indicated for patients with severe chronic pain — both cancer-related and non-cancer pain — who have failed to achieve adequate relief from conservative treatments, oral medications, nerve blocks, and spinal cord stimulation. Conditions commonly treated include cancer pain, failed back surgery syndrome, complex regional pain syndrome, and chronic neuropathic pain syndromes.

The procedure involves implanting a programmable pump (typically in the abdominal wall) connected to a catheter that delivers medication into the intrathecal space. The pump is refilled periodically through the skin and can be programmed externally to adjust dosing. Dr. Bahuleyan's Cleveland Clinic pain fellowship provided comprehensive training in patient selection, trial catheter placement, permanent pump implantation, dose titration, and long-term pump management including refill protocols and troubleshooting.

Intrathecal baclofen (ITB) therapy delivers baclofen — a powerful muscle relaxant — directly into the cerebrospinal fluid surrounding the spinal cord. This targeted delivery provides dramatically more effective spasticity control than oral baclofen, which often causes drowsiness and cognitive side effects at doses high enough to control severe spasticity. Intrathecal delivery uses approximately 1/1000th of the oral dose, concentrating the medication precisely where it is needed with minimal systemic effects.

ITB therapy is indicated for patients with severe, disabling spasticity from conditions such as cerebral palsy, spinal cord injury, multiple sclerosis, traumatic brain injury, post-stroke spasticity, and dystonia. It can significantly improve quality of life by reducing painful muscle spasms, improving mobility and positioning, facilitating rehabilitation, and making daily care easier for patients and caregivers.

Before permanent implantation, a trial dose of intrathecal baclofen is administered via lumbar puncture to assess the patient's response. If the trial demonstrates significant spasticity reduction, a programmable pump is implanted in the abdominal wall with a catheter tunnelled to the intrathecal space. The pump delivers a continuous infusion that can be precisely programmed and adjusted to each patient's needs. Dr. Bahuleyan manages ITB therapy from initial assessment and trial through pump implantation, dose optimisation, and ongoing refill management.