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.

What is Spinal Stenosis?
Spinal stenosis is a general term for narrowing of the spinal canal or where the spinal nerves come out of the spine. Our spines are made up of bones (vertebrae) that stack up on top of each other from our tailbone to our neck. There is a canal that runs through all these bones and inside is the spinal cord. The spinal cord sends branches or nerve roots out through exit holes in the spine. These nerve roots further branch out to become the nerves in our arms legs and the rest of our body. Spinal stenosis is when the canal or the exit holes get blocked and put pressure on the spinal cord or nerve roots. The blockage can happen for lots of reasons but the most common one is changes in the spine that happen with old age. In fact, most spinal stenosis patients are over 65 years old (Cheney is 68). The symptoms of spinal stenosis in the low back can include, pain in the back or legs, numbness and tingling in the legs, or loss of motor control of the legs. Usually these symptoms are made worse with standing up straight or walking.

What surgery can be done?
First of all, surgery is typically not the first line of treatment. Patients are usually given physical therapy, anti-inflammatory drugs, and pain management. If these more conservative treatments fail then surgery is considered. The most likely surgical procedure is called a decompressive laminectomy. What that means is that pressure is taken off the spinal cord and or nerve roots. This involves removing part of the bone called the lamina ( + ectomy means to remove -hence the name) behind the spinal cord and or cleaning out the exit holes we mentioned. The procedure is done under general anesthesia, and usually requires a brief hospital stay. Patients are encouraged to walk the day after surgery.

To learn more about spinal stenosis and its treatment options at the Spine Center check out these links: Spinal stenosis and laminectomy and physical therapy.

For people with spinal stenosis it is more comfortable to sit. Standing or walking usually makes their symptoms worse.

Photo from HuffingtonPost.com

Related basic science projects include an active collaboration with Dr. Carol Troy seeks to understand novel mechanisms of caspase-mediated post-ischemic neuronal cell death/survival.  In addition, recent laboratory studies are underway to study the role of the complement cascade, programmed cell death, and neurogenesis in spontaneous intracerebral hemorrhage, as well.

We have recently begun recruiting patients for an FDA-funded multicenter, phase II clinical trial aimed at assessing the safety of tiopronin in patients with aneurysmal subarachnoid hemorrhage(aSAH) and also to obtain preliminary data on the efficacy of tiopronin versus placebo in reducing serum and CSF 3AP levels in this stroke patient population. Collaborating principle investigators participating in this trial include Dr. Brian L. Hoh and Dr. J. Mocco from the Neurosurgery Department at the University of Florida, and also Dr. Louis J. Kim from the Neurosurgery Department at the University of Washington.

Other clinical research efforts include those concerning vascular re-activation of large and small cerebral vessels through the effects of subarachnoid hemorrhage and other trauma, and the auto-regulation of vessels in relation to arteriovenous malformations and other pathological vascular conditions.  In collaboration with Dr. Eric Heyer (Anesthesiology), the lab has also shown that possession of the ε4 allele of the ApoE gene (originally characterized in Alzheimer’s Diseases) is a risk factor for neurocognitive decline following carotid endarterectomy.  Researchers in the laboratory also play a pivotal role in the international effort to identify genes responsible for the formation of cerebral aneurysms.