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!“

Click here to learn more about spinal cord injury.

Sometimes a patient with back pain has tried everything, pain killers, physical therapy, injections, even surgery, and still has pain. This is where specialists like Dr. Christopher Winfree from our Pain Center come in.  He can surgically implant a spinal nerve root stimulator (SNRS) to block pain signals to the brain.  Dr. Winfree spoke to neurosurgeons at the World Congress of Neurological Surgeons Annual Meeting 2009 about how to do this.  He gave an overview of several placement methods and their best use.

An SNRS is similar to a pacemaker.  It has a small power unit that attaches to electrodes that deliver electrical impulses.  Patients can control their intensity with a remote. When delivered to a nerve the electrical stimulation can override pain signals. Think of nerves as telephone wires to and from our brain.  If pain is a bill collector on the line, then an SNRS offers a way to turn up the static so we canʼt hear him.  These devices can be placed anywhere along a nerveʼs pathway: at the spinal cord, as it exits the spine, as it travels down the arm or leg, or just under the skin.

Placement on the spinal cord is often a surgeonʼs first choice to immediately relieve pain in the arms or legs.  This technique has a long track record but it has limitations.  Pain specific to the low back, hand, foot, groin and buttock can be harder to target with this approach.   Also, over time, pain can stop responding to the spinal cord stimulation.  For these reasons, surgeons may choose another placement point, initially or supplementally.

Nerves become easier to access specifically, once they come off the spinal cord. Pain that lies within the pathway of a certain nerve can be relieved by placing an SNRS electrode anywhere along that nerve between the spine and the painful area. A couple of techniques have been developed to target nerves as they exit the spinal cord (see our blog, A New Way to Give an Old Vet Relief to learn more). Electrodes can also be placed further along the nerve closer to the area of pain. For example, some nerves in the foot can actually be targeted in the back of the knee (see our Peripheral Nerve Center featured article Surgeons Use Ultrasound, Not to Find a Baby, but a Nerve to learn more).

Targeting nerves in this way can provide significant relief but only when pain falls inside a specific nerveʼs pathway. When it doesnʼt, SNRS electrodes can be placed under the skin, right where it hurts.

Each method has its best use and any one may be just what a patient needs. Patients who end up at the Pain Center sometimes have much more complicated pain patterns and need a combination of methods.  In any case, an SNRS can be a powerful tool that provides long suffering patients with a way to turn up the static when pain calls; in fact, they may not even hear the phone ring.

This year at the annual meeting of the Congress of Neurological Surgeons (CNS) they added pediatrics to their Integrated Medical Learning (IML) program.  Dr. Neil Feldstein from the Pediatric Neurosurgery Center was one of the presenters during a session on the surgical management of Chiari Malformation Type 1 (CM-1).

“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.” CNS Website (To learn more about the IML program see previous Department of Neurological Surgery blog: Results from first IML: Aneurysm Coiling v. Clipping Still a Toss up)

Before the meeting, review articles on the latest developments in the surgical treatment of CM-1 were made accessible (pediatric review articles) to attendees. Surveys were also sent out to poll them in an effort to guide the presentations. The question they determined to address was “What extent of decompression is necessary in the surgical management of Chiari 1 Malformations (CM-1)?”

CM-1 is a congenital (present at birth) condition where bony malformation causes part of the brain to push down into the spinal canal. Sometimes this problem exists without any symptoms, in which case, most surgeons just leave it alone. Sometimes symptoms manifest when the person is well into adulthood. Symptoms can include headaches, stiffness or pain in the back of the neck, difficulty swallowing, and decreased strength or feeling in the arms and legs. Children with this problem may exhibit developmental delays. The treatment of CM-1 is surgical. The goal of which is to take pressure off of the spinal cord and brain by performing a decompression.

The area under pressure is decompressed by removing bone, often from the top of the spine and sometimes from the skull. Traditionally the membrane surrounding the spinal cord, the dura, is also opened up and a graft inserted to make more room for the spinal cord. There is debate among pediatric neurosurgeons as to whether the dura absolutely has to be opened, however.

The dura protects the brain and spinal cord and holds in its surrounding fluid. Deep within the brain a fluid is produced (cerebrospinal fluid) that circulates throughout the brain and spinal cord in a closed system. Pressure within this system is self regulating and because it is closed, the brain and spinal cord are protected from infection. Opening the dura is risky because it can offset the pressure system, let in germs, or introduce a leak. All of which can have serious consequences.

At this years CNS meeting, Dr. Feldstein presented an argument for decompression without dural opening. He presented a number of cases and research studies that support his stance. He conceded that in some rare cases it is absolutely necessary to do, however, for the most part, he and his fellow surgeons at the Pediatric Neurosurgery Center have found that the benefits of adding this procedure don’t always outweigh the risks and therefore do not automatically perform this part of the procedure.

Learn more about Chiari Malformations.

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

In children, head trauma annually results in approximately 600,000 emergency department visits and 95,000 hospital admissions, and is the leading cause of traumatic death in children. One study of children with intracranial hemorrhages found that many children with serious injuries may have only mild symptoms and that those diagnosed early have a better outcome. Follow-up studies have confirmed these findings and have been directed at identifying the signs and symptoms of children who have more serious injuries to enable us to diagnose them as early as possible while avoiding unnecessary tests.