Treatments

The treatment of brain, spine and peripheral nerve disorders including:

Minimally Invasive Spine Surgery

Microscopic Surgery
The hallmark of the neurosurgeon's surgical tools, the microscope allows the neurosurgeon to operate in very small and delicate places. Neurosurgeons are uniquely trained to use the microscope for procedures ranging form aneurysms to brain tumors to removal of herniated discs in the neck and back. The modern microscopes can be integrated with endoscopes, image guidance technology (stereotaxy) and fluorescent angiography.

Percutaneous Surgery
In surgery, percutaneous pertains to any medical procedure where access to inner organs or other tissue is done via needle-puncture of the skin, rather than by using an "open" approach where inner organs or tissue are exposed (typically with the use of a scalpel). In spinal surgery, screws can be placed into the lumbar spine over a guide wire through small stab incisions.

The percutaneous approach is commonly used in vascular procedures. This involves a needle catheter getting access to a blood vessel, followed by the introduction of a wire through the lumen of the needle. It is over this wire that other catheters can be placed into the blood vessel.

Lumbar Fusion
A spinal fusion surgery is designed to stop the motion at a painful vertebral segment, which in turn should decrease pain generated from the joint. There are many approaches to lumbar spinal fusion surgery, and all involve adding bone graft to an area of the spine to set up a biological response that causes the bone graft to grow between the two vertebral elements and create a fusion, thereby stopping the motion at that segment.

Lumbar Discectomy
Lumbar discectomy encompasses a number of terms, including discectomy, microdiscectomy and laminectomy/discectomy. The typical patient presents with pain down one leg which may radiate from the buttock to below the knee. The usual pain is either to the back of the calf and to the sole of the foot, or to the outside of the shin and top of the foot. Back pain is not usually a feature, however it may initially occur. Lumbar disc problems are exceedingly common and it is important to realize that in the vast majority of cases non-operative management works very well.

Lumbar Laminectomy
Lumbar laminectomy is a surgical procedure most often performed to treat leg pain related to herniated discs, spinal stenosis, and other related conditions. Stenosis occurs as people age and the ligaments of the spine thicken and harden, discs bulge, bones and joints enlarge, and bone spurs or osteophytes form. Spondylolisthesis (the slipping of one vertebra onto another) also can lead to compression.

Cervical Laminectomy/Discectomy
Cervical laminectomy is a procedure to treat spinal stenosis. The back of the spinal canal is removed by cutting the lamina to provide more space for the spinal cord and nerve roots. By relieving pressure on the spinal cord it is the goal of cervical laminectomy to stop the progression of damage to the spinal cord and allow for as much recovery of function as possible.

Vertebroplasty/Kyphoplasty
Kyphoplasty is a newer treatment for patients immobilized by the painful vertebral body compression fractures associated with osteoporosis. Like vertebroplasty, kyphoplasty is a minimally invasive procedure that can alleviate up to 90 percent of the pain caused by compression fractures. In addition to relieving pain, kyphoplasty can also stabilize the fracture, restore height and reduce deformity.

Complex Spinal Surgery and Instrumentation

Cervical Fusion
Anterior cervical spinal fusion surgeries are commonly done in conjunction with an anterior cervical discectomy. For many patients, cervical spinal fusion surgery (fusing one vertebra to another) is often done to eliminate motion at a vertebral segment. Decreasing the motion at a painful motion segment should decrease the pain at that segment. Achieving the fusion also serves to maintain adequate space for the decompressed spinal cord and/or nerve roots. The fusion may also prevent the spine from falling into a collapsed deformity (kyphosis).

Anterior Thoracic and Lumbar Fusion
Anterior lumbar corpectomy and fusion is a special type of spinal decompression and fusion procedure that utilizes an anterolateral (flank or side of the body incision - through the abdominal region) approach to remove bone and tissue that is causing compression of the spinal cord and nerves. However, in order to do so generally involves removing nearly the entire vertebral body and disc, which must be replaced with a piece of bone graft and mended (fused) together to maintain stability. A small metal plate with screws may also be used to add additional stability.

Adult Scoliosis Surgery
Scoliosis, or a side ways curvature of the spine, is often caught in adolescents. But many adults suffer too. Surgery involving new spine technology can fix the problem.

Direct Lateral Fusion
In this innovative approach, neurosurgeons access the lumbar spine from the side through a minimally invasive approach. Through a 1 to 2 inch incision, using specialized approach devices and continuous neurological monitoring equipment, the disc is removed and a fusion is performed utilizing a specialized spinal implant. This approach is sometimes used in the treatment of adult scoliosis as well as in degenerative disc disease.

Lumbar Artificial Disc Surgery
The artificial disc offers several theoretical benefits over the spinal fusion for chronic back pain, including potentially enhanced clinical success rates (pain reduction) and potential to avoid premature degeneration at adjacent levels of the spine by maintaining normal spinal motion.

Cervical Artificial Disc Surgery
An artificial cervical disc is a device inserted between two cervical vertebrae after an intervertebral disc has been surgically removed in the process of decompressing the spinal cord or a nerve root. The intent of the device is to preserve motion at the disc space. It is an alternative to the use of bone grafts, plates and screws in pursuit of a fusion following such a disc removal, which necessarily eliminates motion at the operated disc space in the neck.

Anterior Cervical Discectomy and Fusion Surgery

Through a small incision in the front of the neck, the neurosurgeon can access the cervical spine, removing the disc and performing a fusion. This procedure can be performed when a disc “slips” and pinches a nerve or when “bone spurs” put pressure on nerves or the spinal cord. The neurosurgeon often will use the microscope during this delicate surgery.

Brain Tumor Surgery

Skull Base Surgery
Traditionally, many tumors at the base of the skull have been inoperable. In the past, surgical techniques simply were not satisfactory, and many patients faced a high risk of neurological problems after surgery. Advances in diagnostic imaging, surgical techniques and instruments, and a better understanding of the skull-base anatomy have allowed neurosurgeons to remove tumors at the base of the skull. Previously inoperable lesions now may be removed with far fewer risks to the patient.

Stereotactic Craniotomy
Stereotactic craniotomy is performed where excision rather than biopsy of a lesion is planned. Stereotactic localization for craniotomy is important in small superficial cortical or subcortical lesions or deep lesions that can be easily missed by conventional means; and also when accurate localization is crucial to excise tumors in highly eloquent areas. This procedure is routinely performed under general anesthesia.

Stereotactic Biopsy
Lumps or abnormalities in the breast are often detected by physical examination, mammography, or other imaging studies. However, it is not always possible to tell from these imaging tests whether a growth is benign or cancerous. In stereotactic breast biopsy, a special mammography machine uses ionizing radiation to help guide the interventional radiologist's instruments to the site of the abnormal growth.

Transphenoidal Surgery
The endoscopic Transsphenoidal approach is performed through the nostrils. A natural passageway exists at the back end of the nose leading into the sphenoid sinus, which can be enlarged so that the endoscope and instruments can pass into this air-filled cavity. From this region the sella turcica is easily accessed which is the location of pituitary adenomas, craniopharyngiomas and rathke's cleft cyst.

Endoscopic Surgery
Endoscopic surgery uses scopes going through small incisions or natural body openings in order to diagnose and treat disease. Another popular term is minimally invasive surgery (MIS), which emphasizes that diagnosis and treatments can be done with reduced body cavity invasion.

Gamma Knife Radiosurgery
In radiosurgery, no incisions are necessary. Doctors use the latest imaging technology to identify abnormal areas in the brain with pinpoint accuracy, so an array of radiation beams can be focused precisely on the target from many different directions. The gamma-knife machine was the first instrument developed for radiosurgery. The instrument precisely focuses 201 beams of gamma radiation on a precisely located area, each beam originating from a slightly different point.

Neurovascular Surgery

AVM Surgery
AVM s can occur in any area of the brain, and may be either small or large. Surgery cures these lesions by totally removing them, thus disallowing them from ever recurring again. The author's personal bias (quite strongly held) is that most AVM's are best cared for with surgical removal. Even with patients who have large and complex AVM's, surgery provides the cure when the malformation is completely removed.

Carotid Endarterectomy
Carotid endarterectomy is an operation during which your vascular surgeon removes the inner lining of your carotid artery if it has become thickened or damaged. This procedure eliminates a substance called plaque from your artery and can restore blood flow.

Gamma Knife Radiosurgery
In radiosurgery, no incisions are necessary. Doctors use the latest imaging technology to identify abnormal areas in the brain with pinpoint accuracy, so an array of radiation beams can be focused precisely on the target from many different directions. The gamma-knife machine was the first instrument developed for radiosurgery. The instrument precisely focuses 201 beams of gamma radiation on a precisely located area, each beam originating from a slightly different point.

Functional & Interventional Pain Management

Spinal Cord Stimulators
Spinal Cord Stimulator (SCS) or Dorsal Column Stimulator (DCS) is an implantable medical device used to treat chronic pain of neurologic origin. An electric impulse generated by the device near the dorsal surface of the spinal cord provides a paresthesia ("tingling") sensation that alters the perception of pain by the patient.

Pain Pumps
Intrathecal drug delivery, or "pain pump," is a method of giving medication directly to your spinal cord. The system uses a small pump that is surgically placed under the skin of your abdomen and delivers medication through a catheter to the area around your spinal cord - similar to an epidural that women may have during childbirth. A pain pump may be a treatment option if all other traditional methods have failed to relieve your long-term symptoms.

Baclofen Pumps
An intrathecal pump is a medical device used to delivery very small quantities of medications directly to the spinal fluid of a human being. Medications such as baclofen, morphine, or ziconotide may be delivered in this manner to minimize the side effects often associated with the higher dosages commonly found in oral medications of the same type.

Peripheral Nerve Surgery

Carpal Tunnel Surgery
During open carpal tunnel release surgery, the transverse carpal ligament is cut, which releases pressure on the median nerve and relieves the symptoms of carpal tunnel syndrome. An incision is made at the base of the palm of the hand. This allows the doctor to see the transverse carpal ligament. After the ligament is cut, the skin is closed with stitches. The gap where the ligament was cut is left alone and eventually fills up with scar tissue.

Ulnar Nerve Surgery
Ulnar nerve entrapment occurs when the ulnar nerve in the arm becomes compressed. When this happens, the nerve does not function normally. Most often, the surgery is done around the elbow, but it can be done at the wrist, if that is the place of the compression. Sometimes, the nerve is compressed in both places, so surgery is done at both the elbow and the wrist.

Vagal Nerve Stimulators
Vagus nerve stimulation involves the implantation of a generator that stimulates the vagus nerve and thus reduces seizure activity. The vagus nerve is one of 12 pairs of cranial nerves (i.e., nerves that originate in the brain). It has motor functions in the larynx (voice box), diaphragm, stomach, and heart, and sensory functions in the ears and tongue. It has both motor and sensory functions in the pharynx (sinuses) and esophagus. Stimulation of the vagus nerve is thought to affect some of its connections to areas in the brain that are prone to seizure activity.

Breathing Pacemakers
A breathing pacemaker can provide ventilatory support for patients with chronic respiratory insufficiency whose diaphragm, lungs, and phrenic nerves have residual function. Typically, these patients have high spinal cord injuries, central sleep apnea or other central neurological disorders, or a paralyzed diaphragm.

Nerve Stimulators
A nerve stimulator supplies electrons to depolarise a nerve. The number of electrons supplied per stimulus equals the current. To make sure that the nerve is completely depolarised we keep winding up the stimulating current until the muscular response does not increase any more, then we add another 10%. This is called the supra-maximal stimulus. At this point we assume that the nerve supplying the muscle is completely depolarised. As a result the muscle must be maximally stimulated by the nerve. The muscle contraction that results must also be maximal. (The contraction is also called a twitch). The muscle response to the stimulus is called a twitch. The amount or strength of movement is called the twitch height. (From the height of the trace on a recorder.) To allow comparison of twitches it is essential that this current remains constant to ensure the nerve is always completely depolarised.