Meet Dr. Timothy Link from Columbia Neurosurgery on Vimeo.

Learn more about this series and see our first one here: Meet Dr. Michael Sisti on Video 

Stay tuned for our next video…

Dr. Paul McCormick

Dr. Paul McCormick and Dr. Michael Kaiser from the Spine Center recently returned from Illinois where they taught residents from around the country the finer points of spinal stabilization.

This annual three day meeting is sponsored by the American Association of Neurological Surgeons (AANS) and is held just outside of Chicago at the North American Spine Society ’(NASS) training facility. This year Dr. McCormick was the honored guest.

Dr. Michael Kaiser

Dr. Kaiser, who has participated every year since the meetings began in 2006, tells us, “We like to refer to it as ‘spine camp’ with 40 residents selected from around the country to attend.  It is a relatively rigorous course – we start the days between six thirty and seven AM and work until five PM.  The day is split between didactic sessions and cadaver labs to provide residents a hands-on opportunity to apply the concepts learned during lectures.”

In addition to teaching residents, the meeting is an opportunity for national leaders in spine to discuss current events, policy initiatives, and academic endeavors.

Dr. Hani Malone

Resident Dr. Hani Malone and Dr. Michael Kaiser from the Spine Center are currently conducting clinical research to determine the optimal treatment strategies for patients presenting with cervical spondylotic myelopathy (CSM), a degenerative process of the neck that can lead to neurological deficits and impaired quality of life.

Dr. Kaiser is currently chairman of the Guidelines Committee for the AANS/CNS Joint Section of Spine and Peripheral Nerve Disorders, the function of which is to establish standardized treatment paradigms for various spinal disorders based on the best available medical evidence.

Dr. Hani Malone is one the rising stars in the Columbia University neurosurgical residency program, who had developed a strong interest in spine surgery and promises to be a future leader in this field.

CSM is the most common cause of myelopathy (injury to the spinal cord) in adults older than 55 years, often causing progressive disability and compromising the patient’s quality of life. Patients will often present with hand numbness, loss of dexterity, gait instability, and compromised urinary control.

The goal of surgery for CSM is to relieve pressure on the spinal cord and prevent further injury, while maintaining spinal stability.  Surgeons have developed a number of different approaches to treat CSM, but the optimal surgical approach for a given patient remains an area of debate.

In order to establish the best treatment alternatives, Drs. Malone and Kaiser have been reviewing the clinical experience of the Columbia University spine surgeons over the past 8 years, where over 500 patients with CSM have been treated.

Development of a prospective patient database has become a national initiative, with the hope that such data will define specific patient characteristics that can be used to determine the optimal surgical approach.

This is particularly true with CSM since there are a number of surgical alternatives that may be considered. In addition to stabilizing and improving neurological function, maintaining and/or restoring the optimal spinal configuration is a major surgical objective to minimize chronic pain, prevent progressive deformities, and maximize quality of life.

Dr. Michael Kaiser

This research is ongoing and Drs. Malone and Kaiser will be submitting the preliminary work presentation at upcoming national neurosurgical meetings, including the AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves and the AANS Annual Meeting.

Dr. Paul McCormick, the Spine Center’s Head, spoke at two Plenery Sessions, one on high-risk carotid artery surgery and another on Spinal Tumors.  Dr. McCormick also introduced the Rhoton Family Lecture speaker, Dr. Christopher M. Loftus, for his lecture on “High-Risk Carotid Surgery 2010″ and was Discussant for the Robert Florent MD Award for “Accuracy of ICD-9-Based and Retrospective

Assessments of Perioperative Adverse Events: Comparison with a Prospective Assessment of Complications in Spine Surgery”.  In addition to sharing his knowledge of medical subjects, Dr. Paul McCormick supports the work of Neurosurgeons in his many roles at AANS, including Executive Committee Treasurer of the the AANS Board of Directors;

Finance Committee Chair; Annual Meeting Committee Ex-Officio; Neurosurgery Research and Education Foundation (NREF) Executive Council Ex-Officio; American Board of Neurological Surgery Vice-Chair; NeurosurgeryPAC Treasurer; NeuroPoint Alliance Treasurer; Drugs, Technology, and Devices Committee Ex-Officio; and is a member of the Strategic Planning, Awards and Honors, Development, and NREF Educational Grants Committees.

Dr. Michael Kaiser was a panelist in a session where he spoke about his experiences with Cervical Spondylotic Myelopathy.

Dr. Alfred T. Ogden was a faculty member in a course specifically designed for nurses and physician assistants.  He spoke about the decision making challenges that can arise in the care of Spine patients.  He was also a faculty member in a hands-on Clinic that covered the most current minimally invasive spinal surgery techniques.

Dr. Peter D. Angevine was a Co-director in another hands-on clinic on Spinal Fusion.  This course covered the state-of-the-art techniques and instrumentation used to fuse different levels of the spine.

Take this quiz to find out.

1. Would your mother tell you to sit up straight if she saw you working on your laptop?

2. Do you communicate with your friends from your laptop more than in real life?

3. Do your neck and shoulders ache?

4. Do you find time disappears when you are on your laptop?

5. Does your laptop travel with you most places?

6. Do you read the news on your laptop more than in the paper?

7. Do you get crumbs on your laptop keyboard?

8.  Do you get headaches if you work at your laptop too long?

9.  Do you have tingling in your fingers sometimes?

10. Are you reading this article on your laptop right now?

If you answered yes to five or more of these questions you may be a laptop slouch potato.  Not to worry though, the Spine Center has some great tips for you.

Laptop at home or in your Office.

Get a cheap external keyboad and mouse so that you can set your laptop up on books or a laptop holder so the screen is at eye level.  Follow the same principles of ergonomics as at a regular computer station. That is feet on the floor, elbows supported, wrists straight and top of the screen at eye level.

OSHA recommends sitting in a recliner or chair that will lean back while working with your laptop on your lap.  This way your eyes will be closer to the height of your screen, and your back and arms are supported.

Laptop in a Coffee Shop

Many of us use our laptops out of the home or office (that is why we have laptops) and can’t be as ergonomic. Here are a couple of tips for when you use your laptop in a coffee shop, for example.

Zoom in so you don’t have to lean in too close to see what is on the screen.  If you are using a PC hit the Control key and the + key at the same time.  On a Mac hit the open-apple/command key next to the space bar and the + key at the same time.

Tip the screen away from you and sit on the edge of your chair then as you look up and over at the screen your back will be much straighter.

Put your bag or a book under the back of your laptop on the table so it is tipped up then lean back in your chair.

Having said all that, no matter where you work on your laptop, one of the best things you can do is to take breaks. It is the endless working in a bad position that leads to more problems than anything.  So, get up and get a glass of water, stretch, or better yet go out and get some exercise.

See the Spine Center’s Posture and Computer Station Tips and Helpful Exercises for your Back

In Ardi we catch a glimpse of one of the earliest moments in human evolution. More specifically, we see the beginning of bipedalism or upright walking. Scientists know that Ardi walked upright because her bones tell them. In particular, the hole in her skull where her spine connects is on the bottom. This shows that her head rested on top of her spine like ours does. A hole closer to the back of the skull would indicate that her head was positioned in front as with present day apes or our knuckle walking ancestors.

Over the last four million years, natural selection expertly tinkered with the mechanics of posture to bring us what we often take for granted today: our long, gently curving, upright spine. Wang, et al in the Journal of Human Evolution described our spines this way, “The vertebral column of humans takes a forward bend in the lumbar (lower) region and a backward bend in the thoracic (upper) region. Without the lumbar curve, the vertebral column would always lean forward, a position that requires much more muscular effort for bipedal animals. With a forward bend, humans use less muscular effort to stand and walk upright.”

When upright, the shape and position of our spine is efficient and requires little effort to hold. As the bones in our spine line up, so too do the muscles, nerves and other soft tissues surrounding it. The problem is that we don’t keep our spine in its natural alignment much of the time. With the advent of the chair and then later the computer, we began to slouch. In a seated slouch our heads are positioned in front instead of on top of our spine, our upper back becomes more rounded and the curve in our lower back disappears. Our head is no longer on its base and an imbalance of tissues occurs. Our muscles have to work harder and other tissues have more stress on them. If we stay like this for too long, sitting apelike at our computers, we push these tissues beyond their limit and that leads to problems, like pain, headaches, numbness and tingling in our limbs. Doing this day after day, these problems can become chronic.

So, what is the answer? We need to keep our heads up and maintain the natural curves of our spines especially when we are sitting. The best way to do this is to use ergonomics; that is, to change our workstations to fit our bodies instead of the other way around. We also need to keep our spine strong and supported in its natural alignment through exercise.

So, lets keep our heads up and remember Ardi and the progress our species has made in becoming upright. We will be honoring nature’s glorious design and in the meantime saving ourselves a whole lot of neck and back pain.

Watch this short video about Ardi’s spine:

http://dsc.discovery.com/videos/ardipithecus-a-bipeds-vertebrae.html

Check out the Spine Center’s info on:

• Posture at your workstation
• Exercises for your back

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/2009/12/what-are-they-a-bunch-of-neurosurgeons-yes-and-theyve-got-the-papers-to-prove-it/ http://www.columbianeurosurgery.org/2009/12/what-are-they-a-bunch-of-neurosurgeons-yes-and-theyve-got-the-papers-to-prove-it/#comments Mon, 14 Dec 2009 16:38:42 +0000 Department Author http://www.columbianeurosurgery.org/?p=3328 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.

If you watch the video of the game where Kuroda is hit by the ball (see link below) you will see him pitch a ball that comes back at high speed and hits him on the right side of his head. He falls to the ground on this left and there is a brief moment where his head can be seen ricocheting toward the ground and back. This is likely where his neck injury started. This moment is an example of a side-impact “whiplash.” “Whiplash” itself is not an official diagnosis, but a term used when the head is flung too far in any one direction, and too abruptly. This most often occurs in an auto accident, but also when you get hit in the head by a ball going 90 miles per hour. This kind of injury, not uncommonly, leads to a herniated disc in the neck. Why does this happen? That requires a brief description of what a disc is and what does it mean when it herniates.

Our neck (or cervical spine) has seven bones called vertebrae stacked on top of each other. In between these bones is a cushion we call the disc. The disc is kind of like a stale jelly doughnut. It is firm on the outside and gooey in the center. This makes it great for shock absorption. When you tilt your head to the left, for example, you are putting more pressure on the left side of the disc. Now if you do it like Kuroda did, really really really fast, imagine how much more force is going to go into the disc. Probably more force than it can handle and it is likely to be damaged. So, what happens when the outside of a jelly doughnut, gets damaged? The jelly oozes out. That is essentially what a herniation is. This can be very painful when it puts pressure on the large spinal nerve root nearby.

Why, then, was it weeks later, while running, that Kuroda suffered such intense neck pain? A likely scenario is that the disc was damaged significantly when he was hit by the baseball but didn’t completely rupture. Not until, the bobbing of his head while running, last-straw-like finished it off.

Treatment for this injury varies depending on severity. Some times simple rest is recommended, other times Physical Therapy is prescribed and when conservative treatment fails, surgery can be done. Luckily for Kuroda, he is young, his disc injury was small, and he is back in the game.

To learn more about Herniated Discs, how they are diagnosed and treated click this link: http://www.cumc.columbia.edu/dept/nsg/ct/hidd.html.

Read the USA Today article: Kuroda hit by Line Drive

Photo by Ross D. Fanklin, AP

Here is a great Animated Video about the Cervical

Spine. You can see that as the head rocks side to side pressure on the disc shifts from right to left.