Treatment Options
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Spine
Most spinal problems involving the cervical spine, thoracic spine, and or lumbar spine can be treated conservatively without surgery. Time, rest, anti-inflammatory medications, and physical therapy, are often safe and effective in the treatment of common spinal problems. Certain problems may require surgical intervention. The following procedures are commonly used to treat spinal problems refractory to non-operative care.
Minimally Invasive Spine Surgery
Advances in surgical techniques and instrumentation have led to the emergence of the field of minimally invasive spine surgery. We perform outpatient cervical discectomy and outpatient lumbar discectomy with quick patient recovery and return to daily activities. Minimally invasive lumbar decompression surgeries for spinal stenosis have also reduced length of hospital stay and have led to expedient patient recovery.
Cervical Spine
- Anterior Cervical Discectomy and Fusion
- Cervical Laminoplasty
- Posterior Cervical Microforaminotomies
- Cervical Disc Replacement with Prodisc C disc replacement
Lumbar Spine
- Microdiscectomy
- Kyphoplasty and Vertebroplasty
- Lumbar Laminectomy
- Lumbar Spinal Fusion
- Interlaminar Lumbar Instrumented Fusion (ILIF) in the Treatment of Lumbar Stenosis Pain and Radiculopathy
- The XLIF® Surgical Procedure
- Complex Spine Surgery
- X-STOP IPD Implant
- Lumbar Disc Replacement with Synthes Prodisc L
Cervical Spine
Anterior Cervical Discectomy and Fusion (ACDF)
ACDF is a common surgical procedure to treat nerve root and/or spinal cord compression secondary to disc herniation or bone spur formation. This procedure is also used to repair cervical spine injury secondary to trauma. This procedure is used when other non-surgical treatments have failed.
A cervical disc may be injured/damaged or may degenerate which may cause spinal cord or nerve root compression. This nerve root may become inflamed and cause pain, and neurological dysfunction including weakness and numbness.
After general anesthesia, a small incision is made on the anterior surface of the right or left side of the neck in order to reach the spine. The damaged disc is identified with x-ray guidance, and is subsequently removed in order to decompress the spinal cord and nerve roots. Arthritic bone spurs are also removed. The intervertebral foramen, the bone channel through which the spinal nerve exits, is then enlarged with a small instrument giving the nerve more room to exit the spinal canal.
To prevent the vertebrae from collapsing and to increase stability, the open space is often filled with bone graft, or PEEK spacer. The process of the bone graft joining the vertebrae together is called "fusion". Sometimes a titanium plate and or screws are utilized to increase stability during fusion.
The surgery may be performed on an outpatient basis or with a 1-2 day hospital stay depending upon surgeon and patient preferences and requirements. Generally a patient may return to office work in 2-6 weeks, individual restrictions may vary.
The lamina is a flat portion of bone that is the back portion of the vertebra. When the spinal canal has become too small due to injury or disease, the canal may be made larger by use of laminoplasty. This procedure helps to alleviate spinal cord compression. An incision is made down the back of the neck to expose the cervical vertebrae. On one side of the vertebral column, the lamina are partially cut to create a hinge-like movement, much like a door. The lamina on the other side are cut all the way through to, in effect, open the "door." After gently opening the "door" of each vertebra to create more room for the spinal cord and nerve roots behind it, bone wedges and/or titanium plates are inserted to keep the spinal canal open.
Posterior Cervical Microforaminotomy
Often referred to as “Laser Surgery,” this procedure has been available for over 60 years, but has been made less invasive through the use of finer instruments, techniques and the operating microscope. Posterior cervical microforaminoty is for select patients who present with isolated compression of nerve roots exiting the spinal cord in the cervical spine. The technique of posterior microforaminotomy allows for limited and yet effective decompression of nerve roots without committing the patient to a fusion operation. This type of operation is performed from the back of the neck and is associated with significantly less structural modifications of the spine which in the long run lessens the likelihood of accelerated degenerative disc disease and bone spur formation in adjacent levels of the spine. Potential candidates for this surgery need to undergo a thorough neurological evaluation, as not every patient is an appropriate candidate for this type of operation.
Cervical Disc Replacement with Prodisc C disc replacement
This procedure is similar to the anterior cervical discectomy and fusion (ACDF), but no fusion is performed. The damaged disc and offending bone spurs are removed through an anterior approach in order to alleviate pressure on the spinal cord and nerve roots. A synthetic disc is then inserted into the remaining space between the vertebral bodies previously occupied by the damaged disc. The goal of the intervertebral disc prosthesis, is to restore the normal dynamic function of the spine and to significantly reduce pain. This is achieved through the re-establishment of the disc height, as maintained by the prosthesis, which reduces nerve compression. Prior to the development of artificial discs the main surgical option involved fusion, in which adjacent vertebral bodies are “fused together” permanently using implants, bone chips and/or cages. The goal of the intervertebral disc prosthesis is to maintain mobility at the affected intervertebral disc and to reduce the extra loading on the adjacent intervertebral discs. This has been shown to reduce adjacent level degeneration as compared to a cervical fusion.
Click here to view Prodisc C Patient Information
A microdiscectomy removes a disc herniation (herniated disc) to relieve pressure on an adjoining nerve. This procedure allows for shorter hospital stays (mostly outpatient), smaller scars – 18 mm, quicker return to work and normal activities, and less post-operative pain – no muscle cutting.
Who can Benefit
- Lumbar discectomy is the #1 procedure performed on the spine in the United States each year.
- About 250,000 Americans have surgery to relieve herniated discs annually.
- 70 percent to 80 percent of patients requiring herniated disc surgery are candidates for this procedure.
Kyphoplasty and Vertebroplasty
Kyphoplasty and Vertebroplasty are effective treatment options for patients who are suffering from intractable back pain caused by osteoporotic and pathological compression fractures of the spine. For those patients who meet the surgical criteria, these methods of stabilizing the vertebral fractures of the spine have resulted in rapid and significant reduction in incapacitating pain. Potential candidates for this operation must undergo careful screening and diagnostic work-up before surgery. The operation is generally performed on an outpatient basis.
Laminectomy is a spine operation to remove a portion of the vertebral bone called the lamina. There are many variations of laminectomy, including laminotomies, hemilaminotomies, hemilaminectomies, complete laminectomy. Generally, we prefer to remove the least amount of bone possible to accomplish the task of decompressing the spinal cord or nerve roots. This procedure was one of the first type of spinal surgeries performed, but has been refined over the years and remains quite effective in alleviating spinal cord and nerve compression.
In cases of spinal instability secondary to degeneration, spondylolisthesis, trauma or tumors, a lumbar decompressive procedure such as a laminectomy may be combined with a fusion procedure. Spinal fusion is a surgical technique used to join two or more vertebrae. Supplementary bone tissue, either from the patient (autograft) or a donor (allograft), is used in conjunction with the body's natural bone growth (osteoblastic) processes to fuse the vertebrae. This procedure is used primarily to eliminate the pain caused by abnormal motion of the vertebrae by immobilizing the vertebrae themselves. There are two main types of lumbar spinal fusion, which may be used in conjunction with each other:
Posterolateral fusion places the bone graft between the transverse processes in the back of the spine. These vertebrae are then fixed in place with screws and/or wire through the pedicles of each vertebra attaching to a metal rod on each side of the vertebrae.
Interbody fusion places the bone graft between the vertebra in the area usually occupied by the intervertebral disc. In preparation for the spinal fusion, the disc is removed entirely, for example in ACDF. A device may be placed between the vertebra to maintain spine alignment and disc height. The intervertebral device may be made from either plastic or titanium. The fusion then occurs between the endplates of the vertebrae. Using both types of fusion is known as 360-degree fusion. Fusion rates are higher with interbody fusion. Three types of interbody fusion are:
- Anterior lumbar interbody fusion (ALIF)- the disc is accessed from an anterior abdominal incision
- Posterior lumbar interbody fusion (PLIF) - the disc is accessed from a posterior incision
- Transforaminal lumbar interbody fusion (TLIF) - the disc is accessed from a posterior incision on one side of the spine
In most cases, the fusion is augmented by a process called fixation, meaning the placement of metallic screws (pedicle screws often made from titanium), rods or plates, or cages to stabilize the vertebra to facilitate bone fusion. The fusion process typically takes 6–12 months after surgery. During this time external bracing (orthotics) may be required. External factors such as smoking, osteoporosis, certain medications, and heavy activity can prolong or even prevent the fusion process. If fusion does not occur, patients may require reoperation.
Some newer technologies are being introduced which avoid fusion and preserve spinal motion. Such procedures, such as artificial disc replacement, are being offered as alternatives to fusion, but have not yet been adopted on a widespread basis in the US. Their advantage over fusion has not been well established. Minimally invasive techniques have also been introduced to reduce complications and recovery time for lumbar spinal fusion.
X-LIF and ILIF are two different types of Lumbar Instrumented Fusion developed to overcome the potential shortcomings of standard treatments for lumbar spinal stenosis treatments, using a minimally disruptive surgical technique. To address stenosis, ILIF involves a minimally disruptive decompression procedure called a distraction laminoplasty which involves temporary distraction of the space between the spinous processes, and careful removal of only small sections of bone to relieve the pressure on the spinal cord and nerves. During ILIF, a precision-machined allograft bone is placed between the spinous processes to permanently distract areas that are pressing on the spinal cord and/or nerves, promote fusion between the spinous processes to provide long-term spine stabilization, and provide a protective cover for the spinal cord to help prevent scar tissue from pressing on the spinal cord and/or nerves. A small plate is then attached to both spinous processes to stabilize the segment of the spine and promote fusion, eliminating the need for more extensive surgery.
After you have been positioned, an X-ray will be taken to help your doctor precisely locate the operative space. Next, your skin will be marked at the site where the two small incisions will be made. Your surgeon will use the latest instrumentation to access the spine in a minimally disruptive manner. Disc preparation is the next step. This is done by removing the disc tissue which will allow the bones to be fused together. Several X-rays will be taken during this stage to ensure the preparation is correct. Once the disc has been prepared, the surgeon will then place a stabilizing implant into the space to restore the disc height and enable the spine to once again support necessary loads. Once in position, a final X-ray will be taken to confirm correct implant placement. In the event that further stabilization is necessary, the surgeon may choose to insert additional screws, rods, or plates into the vertebrae.
Anterior and posterior, cervical, thoracic, and lumbosacral instrumented spinal fusion operations are examples of complex spine surgery that we perform on a regular basis. Spinal fusion operations are procedures of choice for a carefully selected sub-group of patients who have progressive and medically intractable back pain. Spinal fusion and instrumentation operations are often effective treatment modalities for spinal instability caused by degenerative processes, spinal infections, tumors and severe trauma to the spine. We have extensive experience and training in complex spinal fusion and instrumentation and treat a large number of patients with these forms of spinal disorders.
Is a minimally invasive surgical procedure designed to alleviate painful symptoms of lumbar spinal stenosis in a select group of patients. This approximately 30 minute procedure is generally performed on an outpatient basis, and is helpful for relieving buttock and leg pain associated with prolonged standing or walking in patients with lumbar spinal stenosis. For more information click here.
With the introduction of total disc replacement (TDR) surgery, surgeons can offer their patients an alternative to spinal fusion surgery for the treatment of symptomatic degenerative disc disease (DDD). The TDR procedure is intended to relieve pain and preserve motion in the spine.
During both TDR surgery and spinal fusion surgery, the pain-generating disc is removed and the normal disc height is restored. During a fusion surgery, the spinal segment is stabilized with an implant and plate and/or rods and screws. Bone graft may be used to promote osseous fusion of the vertebrae. Conversely, during a TDR surgery an implant that allows motion is inserted into the disc space.
Both treatments are usually effective for relieving pain. However, preserving motion at the treated vertebral segment may enable the spine to restore its sagittal balance and maintain more natural mechanics after surgery than fusing the vertebral segment. This may potentially decelerate degeneration in healthy adjacent levels in the spine. Link to Synthes Pro Disc L.Click here to view Prodisc L Patient Information
Spinal cord stimulation is offered for patients with severe claudication, complex regional pain syndrome or causalgia (RSD) or intractable radiculopathy unresponsive to surgery or medication. Class I evidence demonstrating efficacy have been published in the Journal of Neurosurgery and the Neurosurgery journal. Whereas 1 in 10 patients with multiple back surgeries’ history may have relief after repeat surgery, 4 in 10 may have relief after spinal cord stimulation. The majority of spinal cord stimulation is performed by pain management specialists. Dr. Anthony Kim offers paddle placement via laminectomy in patients who have successfully undergone temporary stimulation trial by pain management specialists.
Some brain conditions may be followed with observation, clinical examination, and or serial imaging studies. At OCNA your neurosurgeon will help guide you to the appropriate treatment option. Some conditions of the brain require surgical intervention. Some of the more common treatments are listed below.
- Brain Tumors
- Cyberknife Radiosurgery
- Pituatary Tumors
- Trigeminal Neuralgia
- Hydrocephalus
- Deep Brain Stimulation (DBS) for Parkinson's Disease and Essential Tremor
- Aneurysms
- AVM
The surgical treatment of brain tumors has undergone significant advances in the past decade. We utilize the most up-to-date neurosurgical techniques combined with state of the art intraoperative tumor localization technologies to optimize our surgical outcomes. As a result, we have been performing more accurate and precise tumor resections with shortened post- operative recovery periods. We have extensive experience in the surgical resection of benign and malignant brain tumors.
The CyberKnife® Robotic Radiosurgery System is a non-invasive alternative to surgery for the treatment of both cancerous and non-cancerous tumors anywhere in the body, including the prostate, lung, brain, spine, liver, pancreas and kidney. The treatment – which delivers beams of high dose radiation to tumors with extreme accuracy – offers new hope to patients worldwide.
Though its name may conjure images of scalpels and surgery, the CyberKnife treatment involves no cutting. In fact, the CyberKnife System is the world’s first and only robotic radiosurgery system designed to treat tumors throughout the body non-invasively. It provides a pain-free, non-surgical option for patients who have inoperable or surgically complex tumors, or who may be looking for an alternative to surgery.
The CyberKnife® System is a one-of-a-kind device for several reasons.
First, the CyberKnife System uses image guidance software to track and continually adjust treatment for any patient or tumor movement. This sets it far ahead of other similar treatments. It allows patients to breathe normally and relax comfortably during treatment.
Second, some forms of radiosurgery require rigid head-frames that are screwed into the patient’s skull to minimize any movement. The CyberKnife System does not require such extreme procedures to keep patients in place, and instead relies on sophisticated tracking software, allowing for a much more comfortable and non-invasive treatment.
Third, unlike some radiosurgery systems, which can only treat tumors in the head, the CyberKnife System has unlimited reach to treat a broad range of tumors throughout the body, including the prostate, lung, brain, spine, liver, pancreas, and kidney.
And finally, the CyberKnife System’s treatment accuracy is unrivaled. Its ability to treat tumors with pin-point accuracy is unmatched by other radiation therapy and radiosurgery systems. The CyberKnife System can essentially “paint” the tumor with radiation allowing it to precisely deliver treatment to the tumor alone, sparing surrounding healthy tissue. For more information click here.
What are Pituitary Tumors?
The pituitary is a small, bean-sized gland that is below the hypothalamus, a structure at the base of the brain, by a thread-like stalk that contains both blood vessels and nerves. It controls a system of hormones in the body that regulate growth, metabolism, the stress response, and functions of the sex organs via the thyroid gland, adrenal gland, ovaries, and testes. A pituitary tumor is an abnormal growth of cells within the pituitary gland. Most pituitary tumors are benign, which means they are non-cancerous, grow slowly and do not spread to other parts of the body; however they can make the pituitary gland produce either too many or too few hormones, which can cause problems in the body. Tumors that make hormones are called functioning tumors, and they can cause a wide array of symptoms depending upon the hormone affected. Tumors that don’t make hormones are called non-functioning tumors. Their symptoms are directly related to their growth in size and include headaches, vision problems, nausea, and vomiting. Diseases related to hormone abnormalities include Cushing’s disease, in which fat builds up in the face, back and chest, and the arms and legs become very thin; and acromegaly, a condition in which the hands, feet, and face are larger than normal. Pituitary hormones that impact the sex hormones, such as estrogen and testosterone, can make a woman produce breast milk even though she is not pregnant or nursing, or cause a man to lose his sex drive or lower his sperm count. Pituitary tumors often go undiagnosed because their symptoms resemble those of so many other more common diseases.
Pituitary Tumors - Is there any treatment?
Generally, treatment depends on the type of tumor, the size of the tumor, whether the tumor has invaded or pressed on surrounding structures, such as the brain and visual pathways, and the individual’s age and overall health. Three types of treatment are used: surgical removal of the tumor; radiation therapy, in which high-dose x-rays are used to kill the tumor cells; and drug therapy to shrink or destroy the tumor. Medications are also sometimes used to block the tumor from overproducing hormones. For some people, removing the tumor will also stop the pituitary’s ability to produce a specific hormone. These individuals will have to take synthetic hormones to replace the ones their pituitary gland no longer produces.
Pituitary Tumors - What is the prognosis?
If diagnosed early enough, the prognosis is usually excellent. If diagnosis is delayed, even a non-functioning tumor can cause problems if it grows large enough to press on the optic nerves, the brain, or the carotid arteries (the vessels that bring blood to the brain). Early diagnosis and treatment is the key to a good prognosis. From The National Institute of Neurological Disorders and Stroke.
Pituitary Tumors - Surgical treatment of pituitary tumors - Transnasal (endoscopic and microsurgical approach) - A type of surgery in which micro instruments are inserted through the nose, through the sphenoid bone at the base of the skull and into part of the brain. Transsphenoidal surgery is generally used to remove tumors of the pituitary gland, or anterior skull base. OCNA neurosurgeons utilize a multidisciplinary team approach of treating pituitary tumors in conjunction with Ear Nose and Throat surgeons, and Endocrinologists.
Microvascular Decompression (MVD) is a neurosurgical procedure used to treat trigeminal neuralgia, a pain syndrome characterized by severe episodes of intense facial pain.
In 1891 Sir Victor Horsley proposed the first open surgical procedure for the disorder involving the sectioning of preganglionic rootlets of the trigeminal nerve. Walter Dandy in 1925 was an advocate of partial sectioning of the nerve in the posterior fossa. During this procedure he noted compression of the nerve by vascular loops and in 1932 proposed the theory that trigeminal neuralgia was caused by compression of the nerve by a blood vessel[2] With the advent of the operative microscope, Peter Jannetta was able to further confirm this theory in 1967 and advocated moving the offending vessel and placing a sponge to prevent the vessel from returning to its native position as a treatment for trigeminal neuralgia[3]
Patients most likely to benefit from a microvascular decompression have a classic form of trigeminal neuralgia. The diagnosis of this disorder is on the basis of the patients' symptoms and from a neurological examination. No blood test or genetic marker exists to diagnosis the disease. An MRI scan can help eliminate other diagnosis. Newer MRI techniques may allow for the visualization of vascular compression of the nerve. Patients who improve with an MVD are likely to have pain which is episodic rather than constant. The pain typically has an electrical quality to it and is intense. The pain can usually be triggered. Common triggers include light touch, eating, talking or putting on make-up. Most patients whose face pain improved with an MVD also improved at least temporarily with medication.
In addition to having the proper type of pain, candidates for an MVD must also be healthy enough to undergo surgery. The risk of surgery may increase with increasing patient age.
Patients are put to sleep using general anaesthesia and are positioned on their back with their head turned or on their side with the symptomatic side facing up. Electrical monitoring of facial function and hearing is often used. A straight incision is made two fingerbreaths behind the ear about the length of the ear. A portion of the skull the size of a half-dollar is removed exposing the underlying brain covering known as the dura. The dura is opened to expose the cerebellum. The cerebellum is allowed to fall out of the way exposing the side of the brainstem. Using a microscope and micro-instruments, the arachnoid membrane is dissected allowing visualization of the 8th, 7th and finally the trigeminal nerve. The offending loop of blood vessel is then mobilized. Frequently a groove or indentation is seen in the nerve where the offending vessel was in contact with the nerve. Less often the nerve is thin and pale. Once the vessel is mobilized a sponge like material is placed between the nerve and the offending blood vessel to prevent the vessel from returning to its native position.
After the decompression is complete, the wound is flushed clean with saline solution. The dura is sewn closed. The skull is reconstructed and the overlying tissues are closed in multiple layers. The patient is allowed to wake up and is taken to an intensive care unit or other close observation unit.
The largest reported series of MVD's published in the New England Journal of Medicine in 1996. The initial success rate was 82% for complete relief with an additional 16% having partial relief for a combined initial success rate of 98%. At 10 year follow-up, 68% had excellent or good relief. 32% had recurrent symptoms. Other series report similar or better results.
Serious complications from an MVD include Death (.1%), Stroke (1%), Hearing loss (3%) and facial weakness (.5%). Other complications include leakage of spinal fluid and wound infection (1%). Most patients will have transient neck pain and stiffness from the surgical incision and from seeding of the spinal fluid with small amounts of blood
What is hydrocephalus?
Hydrocephalus is an excess buildup of cerebrospinal fluid (CSF) in the ventricles (reservoirs) of the brain. This fluid, which protects, nourishes and cleanses the brain and spinal cord, is manufactured daily in the ventricles. Buildup occurs when the fluid cannot flow freely throughout the ventricles and the central nervous system due to various forms of blockage. Except in very rare cases, it is a life-long condition that can only be controlled, not cured, through medical intervention.
Normal Pressure Hydrocephalus (NPH) is a neurological condition that affects the elderly. It is characterized by a triad of symptoms including difficulty walking, poor bladder control, and mild dementia. NPH is a difficult-to-diagnose disease, since the symptoms often mimic those of other conditions among the elderly — Alzheimer's and Parkinson's. NPH is a condition that cannot be cured, but it can often be effectively treated.
NPH is characterized by a triad of symptoms including difficulty walking, poor bladder control, and mild dementia. The symptoms of NPH may not all occur at the same time, and sometimes only one or two symptoms are present. Some patients experience a mild form of the symptoms, while others become more impaired as the condition progresses.
Treatment options for Hydrocephalus
Endoscopic Third ventriculostomy- (ETV) is a surgical procedure in which an opening is created in the floor of the third ventricle using an endoscope placed within the ventricular system through a burr hole. This allows the cerebrospinal fluid to flow directly to the basal cisterns, thereby shortcutting any obstruction. It is used to treat certain forms of obstructive hydrocephalus, such as aqueductal stenosis.
Ventriculoperitoneal Shunt (VPS) diverts the CSF from the ventricles in the brain to the peritoneal cavity in the abdomen where the fluid is reabsorbed into the
bloodstream. The one-way valve is placed next to the ventricle in the brain and the proximal catheter is placed in the ventricle while the distal catheter runs from the valve down to the peritoneal cavity. A catheter is an extremely narrow piece of tubing used for drainage purposes. "Proximal" refers to the catheter placed in the area to be drained, while "distal" refers to the catheter placed in the area accepting the CSF to be absorbed.
For more information click here.
Deep Brain Stimulation (DBS) for Parkinson's Disease and Essential Tremor
Activa Parkinson's Control Therapy and Essential Tremor Therapy uses one or two surgically implanted medical devices, similar to cardiac pacemakers, to deliver electrical stimulation to precisely targeted areas of the brain. Continuous stimulation of these areas blocks the signals that cause the disabling motor symptoms of the disease. As a result, many patients achieve greater control over their body movements, or have a significant reduction of tremors.
The Activa System consists of three implantable components: lead, extension, and neurostimulator. The neurostimulator which is placed in the chest wall, generates electrical pulses that are delivered through the extension to the lead to the defined target in the brain. In select patients with Parkinson’s Disease or Essential Tremor , DBS has been shown to be a beneficial procedure.
For more information click here.
A brain aneurysm, also called a cerebral aneurysm, is an abnormal bulge or ballooning in a blood vessel supplying your brain (cerebrum). The weakened area forms a sac or small balloon that fills with blood. Usually brain aneurysms occur at branching points of arteries.
Brain aneurysms can rupture and cause bleeding into your brain. Usually this occurs in the area between your brain and the surrounding membrane (the arachnoid), called the subarachnoid space, causing a subarachnoid hemorrhage. Many small brain aneurysms, especially those located on the arteries in the front part of your brain, have a low risk of rupture. However, ruptured brain aneurysms can lead to stroke and death.
Your doctor will evaluate you and discuss your symptoms. Your doctor may use tests to diagnose a ruptured or unruptured brain aneurysm and determine its size, location and other characteristics, and assess the aneurysm's risk of rupture. Radiologists who specialize in brain imaging conduct imaging tests.
Tests may include:
- Cerebral arteriogram. In a cerebral arteriogram (also called cerebral angiogram), a doctor inserts a long thin tube (catheter) into an artery in your leg and guides it through your blood vessels to the arteries in your neck that lead to your brain. A specialist injects dye into the arteries, which creates a map of your arteries and the aneurysm on X-rays.
- Cerebrospinal fluid examination. If your doctor suspects a subarachnoid hemorrhage, but the hemorrhage doesn't appear on a CT scan, your doctor may examine fluid from your spinal column (cerebrospinal fluid) for the presence of blood. A doctor will insert a needle into your lower back to withdraw a small amount of spinal fluid in a procedure called a spinal tap or lumbar puncture.
- Computed tomography (CT) scan. A CT scan uses a series of X-rays to create a detailed, three-dimensional image of your brain. CT scans can help detect bleeding in your brain. CT scans reveal blood flow in your brain and show the aneurysm's location. Sometimes a doctor may inject a dye into a vein to highlight blood flow in your arteries and veins (CT angiogram) and provide additional detail regarding the appearance of the brain aneurysm.
- Magnetic resonance imaging (MRI). An MRI uses powerful magnets and radio waves to create detailed images of your brain and show the aneurysm's location. Sometimes your doctor may inject a dye into a blood vessel to view the arteries and veins, highlight blood circulation and locate an unruptured or ruptured brain aneurysm (magnetic resonance angiogram).
Screening for brain aneurysms
If you have a significant family history of brain aneurysms or if you have autosomal dominant polycystic kidney disease, you're considered to be at high risk for an aneurysm, and your doctor may recommend screening. Common screening tests include magnetic resonance angiography or computed tomography angiography.
Your treatment team will work closely with you to develop an individualized treatment plan to prevent a brain hemorrhage based on your brain aneurysm's location, the aneurysm's risk of rupture and your medical condition. We treat brain aneurysms in many ways, including procedures using minimally invasive techniques.
- Monitoring. If doctors determine your brain aneurysm has a low risk of rupture, they may recommend monitoring your condition with regular follow-up appointments. The size and location of a brain aneurysm affects the risk of a brain hemorrhage. As a result, we will consider these and other factors in determining your risk of rupture, and review options for long-term management.
- Endovascular embolization. In endovascular embolization, a doctor inserts a long thin tube (catheter) into an artery in your groin and guides it to your brain using X-ray imaging. Your surgeon then guides detachable platinum coils through the catheter, placing the coils in the aneurysm (aneurysm coiling). The coils fill the aneurysm, which reduces blood flow into the aneurysm sac and causes the blood to clot. Your surgeon also may insert a balloon or tube (stent) in the artery to keep it open and then perform the aneurysm coiling.
Doctors often use endovascular therapy to treat ruptured and unruptured aneurysms and may offer it as an alternative to surgery. Endovascular procedures sometimes need to be performed again. You'll have regular follow-up appointments with your doctor to monitor for any changes.
- Surgery. During the surgery, done under general anesthesia, your surgeon makes an incision in your scalp, creates a window in your skull, locates the brain aneurysm and places a metal clip across its neck to prevent rupture and stop the blood flow to the aneurysm. If the aneurysm is large, your surgeon may use a piece of an artery from another part of your body to connect your blood vessels and bypass the aneurysm.
Surgical techniques have greatly reduced the risks of this surgery. Your risk depends on the size, location, and other characteristics of your brain aneurysm, and your age and medical history. The possibility of an aneurysm recurring after surgery is low.
For more information (The Brain Aneurysm Foundation)
A brain AVM (arteriovenous malformation) is an abnormal connection between arteries and veins that interrupts the normal flow of blood between them. An AVM, which is present at birth (congenital), can develop anywhere in your body but occurs most often in the brain or spine. A brain AVM, which appears as tangles of normal and dilated blood vessels, can occur in any part of your brain. The cause isn't clear. Doctors believe that a brain AVM develops during fetal development. Why this occurs for some babies and not others is unknown.
You may not know you have a brain AVM until you experience symptoms, such as headaches or a seizure. In serious cases, the blood vessels rupture, causing bleeding in the brain (hemorrhage). Once diagnosed, a brain AVM can often be treated successfully.
Normally, your heart sends oxygen-rich blood to your brain through arteries, which branch into smaller arterioles and subsequently to capillaries, the smallest blood vessels. Oxygen is removed from blood in the capillaries and used by your brain. The oxygen-depleted blood then passes into small venules and then into larger veins that drain the blood from your brain, returning it to your heart and lungs to get more oxygen. If you have a brain AVM, blood passes directly from your arteries to your veins via abnormal vessels. This disrupts the normal process of how blood circulates through your brain.
A brain AVM (arteriovenous malformation) often causes no signs or symptoms until the AVM ruptures, resulting in bleeding in the brain (hemorrhage).
Signs and symptoms of a brain AVM include:
- Seizures
- A whooshing sound (bruit) that can be heard on examination of the skull with a stethoscope
- Pulsing noise in the head (pulsatile tinnitus)
- Headache
- Progressive weakness or numbness
When bleeding into the brain occurs, signs and symptoms can be similar to a stroke and may include:
- Sudden, severe headache
- Weakness or numbness
- Vision loss
- Difficulty speaking
- Inability to understand others
- Severe unsteadiness
A bleeding brain AVM is life-threatening and requires emergency medical attention.
Symptoms may begin at any age, but you're more likely to experience symptoms before age 50. Brain AVM can damage brain tissue over time. The effects slowly build up, sometimes causing symptoms in early adulthood. Once you reach middle age, however, brain AVMs tend to remain stable and are less likely to cause symptoms.
For women, pregnancy may start or worsen symptoms because of the increased blood flow and blood volume during pregnancy.
Treatment options for brain AVM involve a number of procedures and depend on the size and location of the abnormal blood vessels. Medications may also be used to treat related symptoms, such as headaches or seizures.
Surgical removal (resection)
Surgical treatment of a small brain AVM is relatively safe and effective. A section of skull is removed temporarily to gain access to the AVM. The neurosurgeon, aided by a high-powered microscope, seals off the AVM with special clips and carefully removes it from surrounding brain tissue. Sometimes this is done with a laser. The skull bone is then reattached, and the scalp is closed with stitches.
Resection is usually done when the AVM can be removed with acceptable risk to prevent hemorrhage or seizures. AVMs that are in deep brain regions carry a higher risk of complications. In these cases, other treatments are considered.
Endovascular embolization
During this procedure, a long, thin tube called a catheter is inserted into a leg artery and threaded through the body to the brain arteries. The catheter is positioned in one of the feeding arteries to the AVM, and small particles of a glue-like substance are injected to block the vessel and reduce blood flow into the AVM.
Endovascular embolization may be done alone, before other treatments to reduce the size of the AVM, or during surgery to reduce the chance of bleeding during the operation. In some large brain AVMs, endovascular embolization may reduce stroke-like symptoms by redirecting blood back to normal brain tissue.
Stereotactic radiosurgery
This treatment uses precisely focused radiation to destroy the AVM. The radiation causes the AVM vessels to slowly clot off in the months or years following the treatment. This treatment works best for small AVMs and for those that have not caused a life-threatening hemorrhage.
Peripheral neuropathy is the term for damage to nerves of the peripheral nervous system, which may be caused either by diseases of or trauma to the nerve or the side-effects of systemic illness.
The four cardinal patterns of peripheral neuropathy are polyneuropathy, mononeuropathy, mononeuritis multiplex and autonomic neuropathy. The most common form is (symmetrical) peripheral polyneuropathy, which mainly affects the feet and legs. The form of neuropathy may be further broken down by cause, or the size of predominant fiber involvement, i.e., large fiber or small fiber peripheral neuropathy. Frequently the cause of a neuropathy cannot be identified and it is designated idiopathic. More common causes include diabetes, alcohol abuse, toxin exposure, vitamin deficiency, infections, chemotherapy, and many others. Peripheral neuropathy is mostly treated by Neurologists rather than Neurosurgeons.
Median neuropathy and ulnar neuropathy are often secondary to entrapment or direct compression and are often amenable to surgical repair.
Ulnar neuropathy is a disorder involving the ulnar nerve. Ulnar neuropathy may be caused by entrapment of the ulnar nerve at the elbow or wrist with resultant numbness and tingling into the fourth and fifth fingers. More advanced cases are associated with hand weakness. Ulnar Nerve Decompression is an outpatient procedure utilized to treat ulnar neuropathy. This procedure involves making a small incision on the medial aspect of the forearm above the elbow, and subsequently releasing the fibrous compression of the nerve.
Carpal Tunnel Syndrome (CTS) is idiopathic median neuropathy at the carpal tunnel. The pathophysiology is not completely understood but can be considered compression of the median nerve traveling through the carpal tunnel. The risk factors for CTS are primarily genetic rather than environmental, although repetitive use has been shown to play a role in aggravating carpal tunnel syndrome.
The main symptom of CTS is intermittent numbness of the thumb, index, long and radial half of the ring finger. The numbness usually occurs at night because we tend to sleep with our wrists flexed and is relieved by wearing a wrist splint that prevents flexion. Long-standing CTS leads to permanent nerve damage with constant numbness, atrophy of some of the muscles of the thenar eminence, and weakness of palmar abduction.
Surgery is often indicated for moderate to severe carpal tunnel syndrome refractory to medical management. During carpal tunnel release surgery, the transverse carpal ligament is incised, which relieves pressure on the median nerve. The outpatient surgery is done through a small 2 cm incision under local anesthesia and takes approximately 25 minutes.
Thoracolumbar and pelvic surgery for deformity and scoliosis:
In the last decade, neurosurgeons have taken the lead in not only nerve and spinal cord decompression but correction of adult deformity. Deformity may occur from recent or remote trauma; falling forward progressively into "kyphosis" due to infection, trauma, cancer, or other causes; progression of rheumatologic disorder, e.g., due to rheumatoid arthritis; progression of congenital disorders, such as Becker's muscular dystrophy; development of abnormal fractures in the setting of ankylosing spondylitis; acceleration or progression of adolescent scoliosis; or, development of abnormal curvatures from prior surgery. Combining the skill sets of complex neurosurgery and complex orthopedic scoliosis correction, we are able to provide a wide array of correction options tailored to each patient. Some options include:
1. Custom recommended bracing
2. Anterior cervical and lumbar corpectomies and anterior releases
3. Posterior transpedicular kyphectomies
4. Pontes and Smith-Peterson osteotomies
5. Posterior en bloc spondylectomies
6. De-rotation of vertebral bodies
7. Coronal deformity correction
8. Expandable cage technology
9. Vertebral augmentation of instrumentation for osteoporosis
Patients who are preparing for scoliosis surgery undergo a rigorous preoperative evaluation, including cardiac clearance, GI emptying studies, pulmonary function testing, endocrine and rheumatologic evaluation.
Postoperatively, patients spend anywhere between 5 days to 30 days in hospital care. Some patients' surgery will be staged over days. Classically, an Intensivist, a Hospitalist, a critical care specialist, a pain management specialist, and a physiatrist will also be involved in the patient's hospital care. It does take a village to help a patient with scoliosis regain his or her life.