Columbia Neurosurgery » neurosurgery

A Place for Brain Surgeons to Debrief

Department Author — Tue, 29 Dec 2009 09:44:34 +0000

Science and technology have advanced by leaps and bounds in the last ten years and no where is this more true than in the field of cerebrovascular surgery. This branch of neurosurgery deals with problems with the blood vessels that supply the brain. New microsurgical and endovascular techniques have enabled these surgeons to help more people and to deal with increasingly complicated problems. New technologies, techniques, and tricks of the trade are fast evolving as each new complication is tackled.

Several years ago physicians, scientists and engineers at the top of this field had the brilliant idea to get together and talk about what they are learning from these complications. They called this meeting the Cerebrovascular Complications Conference (3C Meeting). Part of their mission statement was, “Through open dialogue, 3C hopes to enhance physician education, stimulate progress in the field of cerebrovascular surgery, and improve patient care.”

For this year’s annual 3C meeting in Jackson Hole, Wyoming, our own Dr. Sean Lavine from the Endovascular Center was part of the planning team. About this year’s conference he said, “The conference provided a unique opportunity for both traditional open vascular neurosurgeons and endovascular neurosurgeons to learn from the candid discussion of complications experienced by an international group of neuro-endovascular specialists of all levels of experience.” The conference lasted 3 full days and featured a multitude of case presentations as well as state of the art medical education methods like 3-D anatomy and surgical simulation.

Results from first IML: Aneurysm Coiling v. Clipping Still a Toss up

Department Author — Wed, 23 Dec 2009 13:51:13 +0000

Two years ago at their annual meeting the Congress of Neurological Surgeons (CNS) introduced Integrated Medical Learning (IML), a great new way to make the most of having so many neurosurgeons in the same place at the same time. According to the CNS website, “Integrated Medical Learning® allows participants to define the content and direction of sessions targeted at the most practical and important clinical and scientific questions of the day. Learners evaluate key evidence, interact with faculty, and define current and future practice.” They do this using online surveys before and after the meeting and handheld interactive devices during the meeting.

Dr. E. Sander Connolly from the Cerebrovascular Center and colleagues were involved in this program and were particularly interested in how this large group of neurosurgeons would divide in terms of treatment for brain aneurysms. Their results were presented as one of the top ten abstracts at this year’s CNS meeting.

An aneurysm occurs when part of a blood vessel weakens and bulges or b alloons out. Most of the time this causes what is called a berry aneurysm that is at risk for bursting. When this happens in the brain, surgeons usually treat it one of two ways: Clipping, where, in an open brain procedure, they place a small clip at the base of the aneurysm, or coiling, where they go into the brain using tiny instruments via blood vessels and fill the aneurysm with a flexible coil to keep it from rupturing.

Before the 2007 meeting, attendees were given access to review articles highlighting the latest research on this topic. Then, at the meeting surgeons were presented with 8 patient-cases that could be treated either by coiling or clipping. The surgeons used handheld interactive devices to answer questions about these cases. Specifically they were asked which procedure they would choose to perform in each case. At this year’s meeting Dr. Connolly and his colleagues presented the results: 328 surgeons responded and though individually they tended to have strong opinions one way or the other, the group was for the most part evenly split. A condition known as clinical equipoise.

With the use of IML these researchers took advantage of the coming together of neurosurgeons from around the world to find out the current state of treatment for a very particular problem. This is useful information, especially for those trying to decipher whether one treatment is better than another. IML was an enriching experience for those involved and is a great tool to help further the science of neurosurgery. We look forward to the results from this year’s IML.

To learn more see the article: Community and Individual Equipoise for Ruptured Intracranial Aneurysm Clipping versus Coiling: Results form Integrated Medical Learning. The full article can be found in Neurosurgery volume 65(2), August 2009, p 407

Dr. Robert Solomon, chairman of the Department of Neurosurgery, in a video series on Cerebral Aneurysms.

Galbraith Award Given to New York Aneurysm Study

Department Author — Tue, 15 Dec 2009 18:31:37 +0000

Lead author Dr. Brad Zacharia with Dr. E. Sander Connolly from the Cerebrovascular Center and colleagues received the Galbraith Award at this year’s annual meeting of the Congress of Neurological Surgeons (CNS) for their study of the treatment of brain aneurysms in the State of New York.

An aneurysm is a bulge in a blood vessel that is caused by weakening of the vessel wall. Aneurysms can be life threatening if they burst and often require surgical treatment. There are two types of surgery that are performed and it remains controversial which is best. Clipping has been the treatment of choice for the last 40 years. This involves a craniotomy and placement of a tiny clip at the base of the aneurysm. With the advent of endovascular surgery coiling has become another option. A small flexible coil is passed through blood vessels into the brain where it is placed in the aneurysm to keep it from bursting. Recent studies have suggested that endovascular coiling has a better outcome.

The authors used the New York Statewide Planning and Research Cooperative System (SPARCS) to look at all the patients that were discharged from a hospital in New York State that had a primary diagnosis of brain aneurysm between the years 2005 and 2007. They found about 3,000 patients with that diagnosis, discharged from over a hundred hospitals. They divided the hospitals into high and low volume based on the number of these kinds of patients treated. Then they looked at the general outcome for these patients and correlated it to whether the hospital was high volume or low and to the type of surgery the patient had.

The authors found that between surgical treatments, the best outcome was found in the group that had undergone endovascular coiling. Between high and low volume hospitals they found that more low volume medical centers were performing this procedure but, independent of surgical treatment a better outcome was found in the large volume medical centers.

When they compared the data during this three year period (2005-2007) to a previous five year period(1995-2000) they actually found no overall improvement in outcome despite the fact that the use of endovascular coiling (the procedure with a better outcome) had increased since 1995. The authors surmised that this is likely because more low volume centers (which overall had poorer outcomes regardless of procedure) are performing this kind of surgery. This result is of concern and the authors recommended that more research be done to look into this further.

A poster presentation of this research: Trends in Outcome for the Treatment of Intracranial Aneurysms in New York State: A 3-year Population Based Study

This study can be found in the August 2009, Vol. 65, issue 2 of Neurosurgery

More about Brain Aneurysms and their treatment.

What are They, a Bunch of Neurosurgeons? Yes, and They’ve Got the Papers to Prove it

Department Author — Mon, 14 Dec 2009 16:38:42 +0000

Like a lot of smart people, neurosurgeons know that it is important to keep learning. The Congress of Neurological Surgeons (CNS) Meeting is a week-long event where neurosurgeons from around the world get together to teach and learn from each other. Many of the doctors from the different Centers at the Department of Neurosurgery attended and spoke at this year’s meeting in New Orleans. They talked about the work they are doing and presented a number of recently published papers.
Their papers are published in journals like Neurosurgery and the Journal of Neurosurgery and serve as an important form of communication between those in the field when not attending conferences like the CNS meeting. The conferences provide a good forum for researches to get feedback from their peers and it is also a good place to talk about what is coming down the pike. A lot of which is still under investigation, and for which papers have not yet been written.
At the CNS meeting this year, members on the editorial board of the above mentioned journals conducted a special seminar on what makes for good research. Dr. Paul McCormick, Director of the Spine Center co-directed this course. Dr. Peter Angevine also from the Spine Center, and Dr. E. Sander Connolly from the Cerebrovascular Center were among the faculty.
They, along with their colleagues at the Neurological Institute have a long track record of publishing papers and they know that if the research method is bad then even the best idea will be discredited. In this course, the faculty critically reviewed recently published papers to better inform neurosurgeons on how to get the most out of their research and how to best communicate their results. They each highlighted different aspects of study design and presentation to consider.
For example, Dr. Angevine talked about how the outcome of any new treatment has to be thoroughly investigated in terms of cost versus benefit to the patient. One way to do this is to use graded questionnaires about daily living before and after a procedure. Costs to the patient must include, not only direct costs like hospital and doctor fees but also indirect costs like how much is lost in wages from time off work or what is the impact on a family when a primary care-giver is out of commission.
Developments in neurosurgery are moving fast, those in the field need to attend conferences like the CNS meeting and when they can’t, they need to read their colleagues’ papers to keep up. The research presented in these papers needs to be done well for their benefit to be realized. When research is thorough, and the method is sound, then the cream rises to the top, what is truly bad gets thrown out, the field moves forward, and ultimately it is the patient that benefits.

Pediatric Neurosurgery Center

Neurosurgery Webmaster — Wed, 25 Nov 2009 02:52:22 +0000

Feldstein Shares Expertise at Congress of Neurosurgeons

Brigitte Matsuoka — Sun, 15 Nov 2009 23:30:24 +0000

Dr. Neil Feldstein went to New Orleans last week to share his expertise in two sessions on Chiari I malformations at the annual Congress of Neurological Surgeons meeting. The Chiari I malformation is a congenital disorder in which the lower part of the brain is displaced into the cervical spinal canal. Dr. Feldstein discussed key considerations for treating pediatric patients, and also presented innovative, minimally invasive decompression techniques. The Congress of Neurological Surgeons is dedicated to the scientific advancement of the field of neurosurgery, and its annual meeting is attended by neurosurgeons from all over the world.

Surgeons Use Ultrasound, Not to Find a Baby, but a Nerve

Department Author — Sat, 31 Oct 2009 05:10:47 +0000

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

Zachary L. Hickman, M.D.

Neurosurgery Webmaster — Sat, 24 Oct 2009 16:04:31 +0000

Education
Columbia University College of Physicians & Surgeons, M.D. 2007
Chemistry/Microbiology, University of Victoria, Canada, B.S. 2001

Honors/Awards:
Alpha Omega Alpha, Columbia University College of Physicians & Surgeons, 2007
1st Place “Outstanding Clinical Science Poster Presentation”, 32nd Annual Eastern-Atlantic Student Research Forum, 2006
Graduated with Distinction, University of Victoria,2001

Marc Otten, M.D.

Neurosurgery Webmaster — Sat, 24 Oct 2009 16:00:48 +0000

Education
Weill Medical College of Cornell University, M.D. 2006
Philosophy, Princeton University, B.A. 1999

Honors/Awards
George G. Reader Prize in Public Health, Weill Medical College of Cornell University, 2006
Alpha Omega Alpha, Weill Medical College of Cornell University, 2006
Russek Fellow, American College of Cardiology NY Cardiovascular Symposium, 2004

Professional Memberships
American Association of Neurological Surgeons, Resident Member
Congress of Neurological Surgeons, Resident Member

Omar N. Syed, M.D.

Neurosurgery Webmaster — Sat, 24 Oct 2009 15:41:23 +0000

Education:
Medical School: New York University School of Medicine, M.D. 2005

College: Sophie Davis School of Biomedical Education, City University of New York, B.S. 2002

Honors/Awards:
Graduation with Honors, New York University School of Medicine, 2005
Summa Cum Laude, City University of New York, 2002

Professional Memberships:
American Association of Neurological Surgeons, Resident Member
Congress of Neurological Surgeons, Resident Member

Current Position:
Fellowship: Minimally Invasive Spinal Neurosurgery at Semmes-Murphey Neurologic and Spine Institute, Memphis, TN