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.’”

Harry was sent to see Dr. Christopher J. Winfree at the Center for Peripheral Nerve Surgery. With stubborn nerve pain like Harry’s, neurosurgeons like Dr. Winfree consider implanting an electrical nerve stimulating device (ENSD) in the spine for pain relief. Because of the very specific pattern of Harry’s symptoms his doctors could trace the irritated nerves in his feet back to a specific spinal segment where these nerves emerged from the spinal cord.

Dr. Winfree felt that placing the ENSD in the foramen or tunnel where the nerve emerged from the spine would give Harry the most targeted pain relief. An ENSD has a battery powered unit similar to it’s cousin, the pacemaker, that is placed just under the skin. This unit generates electrical impulses that travel through a wire to an electrode that is implanted next to the offending nerve. Using a remote control, the patient can control the intensity of the stimulation and thus his pain. Where and how these electrodes were placed in Harry’s spine was the subject of a paper Dr. Winfree and his colleague Raqeeb Haque, MD published in the July, 2009 issue of the journal Neuromodulation.

They used a new technique called, Transforaminal (meaning through the tunnel on the side of the spine where the nerve comes out) Nerve root (the name for the nerve when it first comes out of the spinal cord) Stimulation. It can be tricky to implant an electrode in this area because the nerve’s exit tunnel or foramen is small and narrow and as a person gets older and the spine degenerates it gets even harder to access.

Dr. Winfree has found a clever way to sequentially use three different shaped probes to guide the electrode into the narrow space. He says it is actually faster, easier, and requires less radiation from guiding X-Rays to access the foramen from the inside out. Here is how he did it.

He started by making a small incision in the skin above the level of the spine where the troublesome nerve was located. He then cut a small segment of bone out of the back to access the spinal canal. Using a slightly curved probe, Dr. Winfree threaded the electrode down the canal and over to the side where the foramen is. Once at the foramen entrance he switched to a highly curved probe to guide the electrode around the corner and into the narrow passage. Then, he switched again to a straight probe that wouldn’t get hung up on the nerve root and pushed the electrode into place. In the end, four electrodes where placed at two levels of the spine to target both Harry’s feet.

To learn more about this case, see the July 2009 Issue of Neuromodulation and look for Dr. Winfree and Dr. Haque’s paper, Transforaminal Nerve Root Stimulation: A Technical Report.

]]> http://www.columbianeurosurgery.org/2009/12/a-new-way-to-give-an-old-vet-relief-2/feed/ 0 http://www.columbianeurosurgery.org/2009/10/surgeons-use-ultrasound-not-to-find-a-baby-but-a-nerve/ http://www.columbianeurosurgery.org/2009/10/surgeons-use-ultrasound-not-to-find-a-baby-but-a-nerve/#comments Sat, 31 Oct 2009 05:10:47 +0000 Department Author http://beta.columbianeurosurgery.org/?p=2127 Dr. Christopher J. Winfree of The Center for Peripheral Nerve Surgery and his colleagues describe in a paper, soon to be published in the journal Neurosurgery, how the innovative use of ultrasound can guide surgeons in the placement of a pain relieving device for a patient with intractable foot pain.

The patient, we’ll call “Mildred”, suffered for years with plantar fasciitis.  This causes pain on the bottom of the foot, especially the heel.  She had extensive physical therapy and two foot surgeries and nothing helped relieve her pain.  When all else fails with a patient like this, Neurosurgeons can place an electrical nerve stimulation (ENS) device in the spine to block the pain.

ENS devices work, essentially by introducing pressure and vibration to mask pain. You are doing the same thing when, after bumping into a coffee table, you rub your shin to make it feel better.  When this kind of stimulation is effective, permanent implantation can be an option.

A neurosurgeon can map which nerve is associated with the pain and place an ENS device on it.  All the nerves in our arms and legs travel to and from our brain. They travel from our brain, like electrical wires coming from a main frame, through our spinal cord and out to their assigned locations. The brain and spinal cord make up what is called the central nervous system, and all the nerves once they exit the spine are called the peripheral nervous system. The central nervous system is more delicate so surgeons prefer to work with peripheral nerves.  The most common place to put an ENS device is in the patient’s back where the peripheral nerve starts.

Mildred had this procedure done four times and it failed four times because of infection.  Surgeons at The Center for Peripheral Nerve Surgery knew they had to find a location further along the nerve pathway.  The perfect location was in the back of her knee.

Typically, surgical placement of an ENS unit there involves opening up the back of the knee, treading through muscles, arteries and veins to find the nerve they are looking for.  At this point in Mildred’s ordeal, however, doctors wanted to limit the amount of trauma they had to put her through so they used an innovative technique using ultrasound.

Most of us know what an ultrasound is; something doctors use to see a baby.  Instead of using it on Mildred’s belly however, they used it on her knee.  Ultrasound images were used like a camera and required only a tiny incision and a hollow needle.  Doctors threaded the ENS unit through the needle and attached it right where they wanted it.  It didn’t take Mildred long to recover and she finally got the relief she needed.

Look for Dr. Winfree and his colleagues’ paper, Ultrasound-Guided, Percutaneous Peripheral Nerve Stimulation: A Technical Note in an upcoming issue of Neurosurgery

What to Expect During a Selective Nerve Root Block
An SNRB generally follows this process:

• The patient lies face down on an x-ray table and the skin is well cleaned with an antiseptic.
• The physician locates a specific spinal nerve root using fluoroscopy, a type of X-ray that provides real-time video imaging of your body.
• Once the nerve root is located, the physician introduces a needle through the skin into the area adjacent to the spinal nerve
• Medication — steroids (to decrease inflammation) and/or a local anesthetic (to numb the area) — is then injected into the area bathing the nerve root.
• If the patient’s pain subsides after the injection, the pain-generating nerve root is presumed to have been identified.
• The procedure normally takes 30 to 60 minutes.

What Causes Spinal Nerve Inflammation?
Spinal nerves can become inflamed due to compression, for example from a damaged disc or from contact with a bone spur. Depending on the location of the inflamed nerves, pain and/or other symptoms (such as numbness, tingling) may be experienced in different areas of the body. Nerve irritation in the cervical spine can cause pain, tingling or numbness in the neck, arm or shoulder. Nerve irritation in the thoracic spine can produce upper back pain or pain along the ribs and chest wall. Irritation of lower back (lumbar) nerves can produce lower back pain, hip pain, buttock pain or pain, tingling or numbness in the leg.

The Center for Peripheral Nerve Surgery is a multidisciplinary center specializing in the diagnosis and treatment of a variety of peripheral nerve problems, including injuries (such as lacerations), entrapments (such as carpal tunnel syndrome), and tumors (such as neurofibroma). Our goal is to maximize function, minimize suffering, and help patients realize their full potential in spite these painful and sometimes disabling disorders. We offer a wide range of proven treatments, including noninvasive therapies as well as surgery. Determination of an appropriate treatment is based on a comprehensive neurological examination that may include electrodiagnostic studies, imaging studies, or nerve biopsy.

Our peripheral nerve surgical team has expertise with a range of treatment procedures, from minimally invasive decompression to complex and lengthy brachial plexus reconstruction and tumor excision. Studies consistently demonstrate that experienced surgeons and practitioners at neuroscience centers of excellence achieve the best possible patient outcomes.