At the recent J. Lawrence Pool Memorial Research Symposium, sponsored by the CUMC Department of Neurological Surgery’s Spine Center, neurosurgeons presented their work on the theme: “Management of Adult Spinal Disorders: Current Controversies and Evidence Update”.  In this video, Dr. Michael G. Kaiser makes a slide presentation entitled “Cervical Spondylotic Myelopathy, Clinical Guidelines”.

According to the Boston Globe early this month, football superstar Peyton Manning just had surgery in Chicago for a pinched nerve in his neck.  While the details of his condition were not released, surgeons at our Spine Center say they routinely see patients for this kind of problem and there are a variety of treatment options.

The nerves that get “pinched” in the neck are usually the large nerve roots that exit the spine through bony tunnels between the vertebrae.  These nerve roots progressively branch out allowing us to move and feel our arms.  Pressure on the nerve roots can cause numbness, tingling, and pain in the neck, arm or hand.

The cause and exact location of a pinched nerve is usually determined by neurological examination and an MRI.  If the problem is new, surgeons usually won’t operate until a course of rest, medications, and physical therapy have been tried.  When the problem persists like it reportedly did for Manning, there are surgical treatments to consider.  The type of surgery done depends on what is causing the problem, where it is, and the extent of the damage.

The most common cause of a pinched nerve is Herniated Intervertebral Disc Disease.  The intervertebral disc is a cushion that sits between the bones of the spine.  With wear and tear, the fibrous outer ring of the disc can become cracked or thinned and the jelly like interior can bulge out or protrude onto nearby nerve roots.

If the disc is the culprit, then something as simple as a Microdiscectomy can be performed.  Here, surgeons remove the offending portion of disc through a small incision in the back of the neck.  The surgery is minimally invasive and the patient often goes home the next day.

When the disc has degenerated more significantly as in Spinal Disc Disease, surgeons may need to remove it altogether.  This surgery, called an Anterior Cervical Disectomy and Fusion/Fixation, is much more involved.  Surgeons operate through the front of the neck, removing the entire disc and some of the bone.  The disc is replaced with a spacer and the whole area is secured with plates and screws.

More recently surgeons have begun to use artificial disc replacements, a surgery that preserves the movement of the neck.  The Spine Center is currently involved in clinical trials for the SECURE®-C Cervical Artificial Disc.

You can’t always blame the disc, however.  The nerve can be pinched because the bony tunnel, or foramen, through which it exits the spine has narrowed with age.  When this is the case, surgeons can perform a laminectomy, where they remove the part of the bone that is crowding the nerve.

Peyton Manning was not treated here at the Spine Center, and while we can’t officially comment on his status, it looks like his surgery went well.  According to the Globe article, he was released from the hospital the day after surgery and,”‘All medical personnel involved believe the issue has been resolved,’ the team said. ‘Peyton fully expects to participate in the Colts’ offseason program this spring.’”

Congratulations to Dr. E. Sander Connolly Jr. from the Cerebrovascular Center for his recent induction into the American Society for Clinical Investigation (ASCI).  In existence for 102 years, the ASCI remains one of the oldest and most prestigious honor societies in medicine.

The ASCI comprises more than 2,800 physician-scientists from all medical specialties elected to the Society for their outstanding records of scholarly achievement in biomedical research. The ASCI represents active physician-scientists who are at the bedside, at the research bench, and at the blackboard. ASCI

Nominations of physician-scientists are taken from all over the world and just about 80 new members are accepted into the ASCI each year.  This year, Dr. Connolly was one of only five neurosurgeons added.  He was specifically recognized for his research on hemorrhagic and ischemic stroke.

Dr. Connolly is also the director of the Cerebrovascular Research Laboratory where you can learn more about the work he is doing.

What appears to be a radical surgery to relieve brain pressure may prove to be the most effective and logical for patients with resistant high pressure conditions like Idiopathic Intracranial Hypertension (IIH).  Drs.  Saadi Ghatan and Neil Feldstein from the Pediatric Neurosurgery Center explained a procedure called Internal Cranial Expansion (ICE) and its effectiveness to their colleagues at this year’s meeting of The American Society of Pediatric Neurosurgeons.

IIH, also called Pseudotumor Cerebri, is a condition where pressure inside the skull is chronically too high and no specific cause can be found.  It is most common in obese females and the symptoms include headaches, nausea, and vomiting.  Also, the increased pressure can damage nerves, particularly those that effect vision in a condition called papilledema.

IIH is treated in a number of ways primarily using shunts.  These are one way valves that drain fluid off the brain to help reduce the pressure.  In some cases the shunts fail or aren’t enough to relieve the pressure and surgeons need to consider other options.  Ghatan and Feldstein explained to their colleagues how ICE is performed and how a select group of IIH patients responded.

ICE involves four large craniotomies, or removal of bone flaps.  The  calvaria, or underside of the skull bone, is removed or thinned from the bone flaps and along the borders of the craniotomies.  This gives the brain more room and logically, with more room, there is less pressure inside the skull.  Furthermore, with this procedure, surgeons do not have to operate inside the delicate structure of the brain.

Ghatan and Feldstein have had tremendous results, particularly with patients who have had multiple shunting surgeries and those with rapidly progressing visual problems.

In the group of children with IIH who had this procedure, they saw, “Resolution of papilledema within 4 weeks, normalization of Intracranial Pressure (ICP) in all patients, resolution of headaches in four out of five patients, and successful removal of shunts in all patients.”

Based on their experience with this population, Ghatan and Feldstein concluded that, “Internal Cranial Expansion provides lasting normalization of ICP, visual symptoms and papilledema were well treated, but headaches often require multidisciplinary management in the long run.”

To learn more about this procedure see the article, Internal Cranial Expansion Procedure for the Treatment of Symptomatic Intracranial hypertension: Technical note in the Journal of Neurosurgery: Pediatrics.

This article can be found in the journal Neurosurgery: March 2010 – Volume 66 – Issue 3 – p 590–592

At the time of the accident, the man, we’ll call George, was a fit and healthy 65 year old at the beginning of an enjoyable retirement filled with travel and outdoor adventure.  On such an adventure, he flipped his snowmobile and in a split second his life nearly changed forever.  At the emergency room, imaging tests showed that he had broken his sternum (the bone in the center of his chest), a bone in his neck and three bones in his mid back, including a burst fracture in his thoracic spine.

A burst fracture occurs when an immense top down impact causes all or part of the vertebral body to shatter and collapse.  The vertebral body sits adjacent to the spinal canal and this kind of break can shoot bone fragments into the spinal cord.  Miraculously, George showed no neurological signs that would indicate his cord had been injured and the bone appeared to be stable. George was given a back brace, some pain medication and told to rest.  He was told he’d have to have periodic X-Rays to make sure the bone was healing well.

George spent a few weeks resting before going to the Spine Center to see Dr. Kaiser.   Dr. Kaiser took more images and says that the crushed bone wasn’t healing well and was actually creeping into the spinal canal.  He determined that without surgery, George’s spinal cord was in danger and he could face permanent disability.

Dr. Kaiser says that during the surgery, the first thing he did was a laminectomy.  That is, he removed part of the lamina or bone from the back of the fractured vertebrae to expose and take pressure off the back of the spinal cord.  Once inside, he discovered tissue just millimeters from the cord that was swollen and showed signs of injury.  Next, Dr. Kaiser carefully snaked his way around the spinal column and removed the unstable bone fragments from the vertebral body that were pressing on the front of the cord.

George’s spine was then distracted to re-create normal alignment and a titanium cage was inserted where intact bone had once been.  Dr. Kaiser finally performed a Spinal fusion, where rods and screws were used to tighten everything up and ensure stability.  Pieces of bone, removed from the site earlier, were then pressed onto the outside of the fusion.  This bone would eventually grow into the area to further increase stability.  With the surgery complete, George’s spinal cord was finally safe.

Using compassion and expertise, the doctors, nurses and staff at the Spine Center nursed George back to health and he finally went home.  He returned to the Spine Center less than a month later and began a carefully planned regimen of physical therapy with the Spine Center’s Physical Therapy team.  After five months of therapy he had regained enough strength and mobility that he could continue exercising on his own.  A year after the accident, George  was back in the swing of his retirement.  He sent Dr. Kaiser a photo with himself at the helm of a speed boat and the expression on his face clearly reads, “Luckiest man alive!“

The basilar artery is a large blood vessel located at the base of the brain that is formed when two of the major suppliers of oxygen rich blood, the vertebral arteries, come together at the back of the brain.

Because our brain is such a vital structure, the human body has given it a redundant blood supply.  That means that if one vessel in the brain gets blocked off, blood can be automatically re-routed.  This happens basically in two ways.  First, all the major arteries to the brain come together in the middle to form a circle (the Circle of Willis) and collectively can feed the whole brain. This way blood can be re-routed from the other major vessels if one fails.

The brain also has what is called collateral circulation.  Collateral blood vessels are normally closed but when a larger vessel gets blocked they can open up and re-rout the blood between vessels.  Over time these tiny vessels will grow and become permanent.

Sometimes a surgeon needs to block an artery on purpose.  This may be the case when it supplies an oddly shaped or giant aneurysm that is at risk of bursting.  A giant aneurysm  (larger than 2.5 cm in diameter) in the basilar artery can be particularly hard to treat however, because of  its location.  It lies deep in the skull near parts of the brain that control vital functions like breathing and heart rate.

An aneurysm occurs when the wall of a blood vessel grows weak and starts to balloon out.  These enlarged areas of the vessel are at risk of bursting and causing a brain bleed.  They can also be a problem if the increase in size presses on vital brain structures .

A number of surgical methods are used to treat them.  Because they are often balloon like in shape, they can be clipped at the neck and closed off.  Once it is no longer fed with blood, the aneurysm shrinks away.  More recently surgeons have been able to insert a coil into the aneurysm itself using minimally invasive endovascular techniques.

The problem with oddly shaped and giant aneurysms is that they often don’t have a distinct “neck” that can be clipped or they are just too big to be reliably coiled.   Surgeons are seeing that the rate of recurrence of these kinds of aneurysm after these procedures are not always optimal.  When this is the case, clipping off the basilar artery itself can be the most effective and least risky procedure.

Researchers in the Cerebrovascular Center combed through old charts from the last 22 years and found all the patients who had gone through this procedure.  They had records of these patients during the procedure, at their one month and one year follow-ups, and up to 18 years after.  They wanted to see how patients fared over all, especially in terms of neurological symptoms (indications of brain damage) and recurrence of the aneurysm.

The results were exceptional.  At the one month follow-up, 80% of the patients studied had no neurological problems.  Upon long term follow-up (an average of 3.5 years) none of the patients had any lasting deficits.  In fact, one patient who had weakness in his arms and legs before surgery was completely normal by his 2 year follow up.

According to the authors, ”No patients suffered a recurrence of symptoms or necessitated re-operation. No patients suffered a hemorrhage at any point after occlusion, and of the 4 patients who presented with a subarachnoid hemorrhage, none suffered a re-bleed.”

Based on their research, they also outlined a number of patient criteria for optimal outcome.  First of all they said, ”Patients were considered for surgical occlusion of the basilar artery if direct surgical or endovascular intervention was not considered safe.” Then they considered, ” failure of previous treatments, size of the aneurysm, neck to dome ratio, incorporation of major vessels in the neck of the aneurysm, and position of the thalamoperforates (specific surrounding blood vessels).”

It was also critically important, they said, that there was good collateral circulation.  This was tested before surgery using a balloon test occlusion as a kind of trial run. Surgeons get to see if it will be safe to block the vessel by inflating a balloon inside the artery to temporarily block the blood flow and see if it is re-routed.

Overall, the authors concluded that, ”Surgical occlusion of the basilar artery is an effective treatment option offering a high rate of angiographic cure in a single procedure for patients with complex basilar artery aneurysms,” and “for aneurysms of the upper third of the basilar artery, proximal surgical occlusion should be considered as an important treatment option along with direct surgical clipping and endovascular approaches.”

*The authors of this study, Complex Basilar Artery Aneurysms Treated with Surgical Basilar Occlusion: A Modern Series are: resident physicians Christopher P Kellner and Raqeeb Haque;  and from the Cerebrovascular Center, Dr. Philip M. Meyers, Dr. Sean D. Lavine, Dr. E. Sander Connolly, and the Department Chair Dr, Robert A. Solomon.

To learn more about the treatment of aneurysms see our blog, Results From First IML: Aneurysm Coiling V. Clipping Still A Toss Up, and Solomon’s Brain Aneurysm Primer Video.

Every month, over 40,000 patients rate the effectiveness of their physicians.  Of the nations 720,000 active physicians, less then 5 % were accorded this honor by their patients.  Patients took the time to compliment Dr. Feldstein in areas such as: bedside manner, the amount of time he spends with patients and their families, the courtesy of his staff, appropriate follow-up, and their overall opinion of Dr. Feldstein as a physician.   The reviewers told him: “Quite simply, you are one of the best!”

And we wholeheartedly agree!