Back Pain/Lumbar Fusion (disk replacement, stabilization)
Back pain from a congenital spinal slippage, degenerative disk disease, or acquired disorder are common problems which are initially treated with exercise, weight loss or injection therapy. Self-care strategies are important and include strengthening your back and stomach muscles and modifying your work habits.
When conservative measures fail to control the pain, either disk replacement or spinal fusion may be recommended. These types of procedures are more involved than simple discectomies or laminectomies, and usually require more recovery time. Lumbar disk replacement requires an anterior approach. Spinal fusion or spinal stabilization requires bone grafting and placement of instrumentation, metal screws and rods. The instrumentation is placed with X-ray guidance and can sometimes be placed with only small, minimally invasive techniques (which shortens the hospital stay and quickens the recovery).
Depending on the type of stabilization you require, a post-operative brace may be required for several months. After a successful fusion or stabilization procedure, you should be able to return to your normal, or slightly modified activity in 3-4 months.
Balance Difficulty/Cervical Stenosis
Frequent falling because of balance problems may be caused by compression on the spinal cord in the neck region. This can also be associated with hand numbness and arm weakness. This is usually a slowly progressive problem for those in the 60 to 80 year old age group. If conservative measures fail, then surgery through either an anterior approach or posterior approach may be recommended.
The posterior approach is either done with a cervical laminectomy (removal of the posterior portion of the bone) in order to relieve the spinal cord compression or through a cervical laminaplasty (widening of the spinal canal). These procedures usually require a one- to two-day hospitalization and 4 to 6 weeks to recover.
If your condition prior to surgery involved significant weakness and/or walking dysfunction then post-operative physical therapy will be ordered as well. Your post-operative pain needs and any additional therapy will be addressed accordingly.
Brain Trauma/Intra-cranial Hemorrhage (bleeding)
Falls, car accidents and gunshot wounds are all mechanisms to potentially injure the brain. Intra-cranial bleeding can also spontaneously occur, especially in the elderly. These types of injuries can be very mild to very severe and possibly life-threatening. The surgical care for these types of injuries can include open brain surgery (craniotomy) to remove bone fragments or blood clots, or simply placing a thin fiber monitor in the brain in order to measure the patient’s intra-cranial pressure. The more severely injured patients may need long periods to recover, which may include transfer to a rehabilitation unit.
Bleeding from ruptured blood vessels in the brain can cause collections of blood (subdural hematoma, epidural hematoma, intra-cranial hematoma) or subarachnoid hemorrhage from a ruptured intra-cranial aneurysm. Intra-cranial bleeding associated with blood thinners (Coumadin) is also common; and those taking Coumadin should be extra careful in avoiding any head trauma. These problems may require the blood to be drained, either through small bur holes or through open procedure (craniotomy). If there is an abnormal blood vessel involved, which can potentially bleed in the future, an angiogram is required and further intervention/possible surgery may be needed. Recovering from a major intra-cranial bleed may take up to one year, and a positive attitude and strong family support are very important in maximizing your recovery.
There are several types of brain tumors that are treated surgically. Brain tumors in adults can cause seizures, headaches, weakness or visual changes. The diagnosis is made by CT scan or MRI. These tumors can be from the brain primarily (glioma), from the meninges or covering of the brain (meningioma) or from another part of the body (metastatic) or tumors associated with the pituitary gland. These are obviously very serious conditions which require prompt attention.
Surgery is used to biopsy, make diagnosis, and hopefully to remove most or all of the tumor. The procedure can be done through a tiny hole in the skull while the patient is awake (stereotactic) if only a biopsy is required, or through open procedure (craniotomy). There are times when intraoperative computer guidance is also required (navigation intra-operatively).
Different types of tumors may require further treatment such as radiation or chemotherapy. Certain tumors can be primarily treated with radiosurgery (gamma-knife), which is a non-invasive procedure done as an outpatient. The more aggressive tumors require multiple specialists helping in your care, and we will monitor and help with organizing the best and most appropriate team to treat your specific case.
Cervical (Neck) and Arm Pain
Disk herniations or bone spurs commonly can press on cervical nerves, causing pain and numbness in the arm. This pinched nerve type of problem may worsen and cause pressure on the spinal cord with subsequent balance and possible urinary difficulties. Conservative care for these types of ailments includes analgesics, therapy, injections and neck traction.
If your pain doesn’t respond to these measures or you have significant arm weakness or walking dysfunction, surgery will likely be discussed and can be done through either an anterior or posterior approach. The anterior approach requires disk replacement or one grafting, which usually requires implantation of instrumentation, being either a thin metal plate or a metal cage. This procedure usually requires an overnight stay in the hospital and several weeks to recover.
Cervical disk replacement is a new procedure in the United States and will likely be used more frequently in the future. Surgery for these types of problems which do not respond to conservative measures is very successful with 95% of patients having good-excellent results. Your post-operative pain needs will be addressed but, other than a sore throat for 3-4 days, the post-operative discomfort is usually minimal.
Functional Intervention/Spinal Cord Stimulation/Radiosurgery
Certain chronic pain and movement disorders are best treated by either stimulating or lesioning the nervous system, also known as Functional Neurosurgery. These syndromes include reflex sympathetic dystrophy, trigeminal neuralgia and failed back syndrome. After the more conventional treatments and medications have failed, these types of functional neurosurgical procedures are considered. These treatments are minimally invasive and can offer the patients with very difficult problems some measure of relief.
Spinal cord stimulation is applying a low voltage stimulation to the posterior portion of the spinal cord to block the pain pathway with a pleasant tingling sensation. This procedure is done initially as a trial, enabling the patient to test the stimulation prior to any permanent implantation.
Radiosurgery for facial pain (trigeminal neuralgia) and tremor is a one-day procedure with virtually no recovery. It requires placement of a stereotactic frame to the skull during the procedure.
Hand/Upper Extremity Numbness from Peripheral Nerve Compression
Peripheral nerve compression from either carpal tunnel (at the wrist), ulnar neuropathy (at the elbow) or thoracic outlet syndrome (under the clavicle) is a common problem affecting those of all different ages. Other, less common, peripheral neuropathies can affect the lower extremities as well (peroneal, lateral femoral cutaneous nerves). Using a wrist splint and changing your repetitive activities usually help these symptoms and problems.
The operative procedures done for these problems use small incisions and are done as an outpatient with a minimal recovery required. EMG and nerve conduction studies must be done prior to being evaluated for these ailments in order to document the severity of nerve compression. Thoracic outlet syndrome may be associated with certain shoulder problems or can arise after multiple shoulder surgeries, and sometimes requires additional diagnostic studies.
Anterior scalenectomy (dividing the anterior scalene muscle through an incision just above the clavicle) is sometimes recommended in severe cases of thoracic outlet syndrome, which have not responded to conservative measures. The recovery from most peripheral nerve operations is usually minimal and the success rate very high.
Hydrocephalus (spinal fluid buildup in the brain)
Hydrocephalus (increased amounts of spinal fluid in the brain) is commonly seen in infants and older folks in their 60s to 90s. In the adult population, hydrocephalus can be associated with other congenital abnormalities including Arnold-Chiari Malformation. In the older population this is usually a slowly progressive problem affecting balance, urination and memory, and is known as NPH (normal pressure hydrocephalus). The diagnosis is made by CT or MRI and sometimes requires additional diagnostic studies including spinal tap or cisternogram.
If the symptoms progress, a shunt procedure is recommended in order to stop the progression of symptoms and hopefully reverse some or all of the symptoms. A shunt is a very thin plastic tube which drains the spinal fluid from the brain into the abdomen. The tube is all under your skin, and after it’s placed you can return to your normal activities and you are not aware of its functioning. This procedure requires a one- or two-day hospital stay with minimal recovery.
We generally use the most modern shunt/valve which enables us to regulate the amount of fluid being shunted. With this new technology, most headache problems and other post-operative complications can be avoided. The results from shunting are improved if the pre-operative changes have only been present for 3-4 months and dementia is not present; therefore, the quicker the evaluation and potential treatment is initiated, the better it is for the patient and the better the results can be achieved.
Kyphoplasty is an outpatient procedure used to treat painful compression fractures in the spine. In a compression fracture, all or part of a spine bone collapses. The procedure is also called balloon kyphoplasty.
Kyphoplasty is done in a hospital or outpatient clinic.
- You may have local anesthesia (awake and unable to feel pain). You will likely also receive medicine to help you relax and feel sleepy.
- You may receive general anesthesia. You will be asleep and unable to feel pain.
You lay face down on a table. The health care provider cleans the area of your back and applies medicine to numb the area.
The doctor places a large needle through the skin and into the spine bone. Real-time x-ray images are used to guide the doctor to the correct area in your lower back.
A balloon is placed through the needle, into the bone, and then inflated. This restores the height of the vertebrae. Cement is then injected into the space to make sure it does not collapse again.
Source: Medline Plus: http://www.nlm.nih.gov/medlineplus/ency/article/007511.htm
Lumbar Disk Herniation
A disk herniation in the lower back occurs when the inner, gel-filled cushion of material ruptures through the outer covering of the disk. This can cause pressure on the nerves and subsequent back pain, lower extremity pain (sciatica), lower extremity numbness and, in severe cases, lower extremity weakness can occur. The diagnosis of lumbar disk herniation is usually made with an MRI or CT scan; in some cases myelograms are still required.
Conservative management, utilizing a team approach of medication, physical therapy, pain management and injection therapy is successful in approximately 75% of cases, and patients can return to normal activities within six weeks. If your leg pain doesn’t improve with conservative care, more aggressive measures such as epidural steroid injections or surgery may be recommended.
Surgery for lumbar disk removal can be done as an outpatient or an overnight stay in the hospital. Surgery requires general anesthesia, a small incision in the middle of the lower back and removal of a small portion of bone in order to remove the herniated portion of the disk, which is pressing on the nerve root. Eighty-five percent of patients with this type of surgery have very good to excellent results and are able to return to normal activities within 4 to 6 weeks. If your disk herniation is recurrent or is associated with spinal instability or with a significant amount of back pain, a more extensive surgery and recovery may be required. A positive approach and attitude along with appropriate and timely treatment help make success rates and return to work percentages very high.
This is usually a degenerative, progressive process affecting those over 50 years of age. The spinal canal narrows, pinching the nerves that pass by, and causes leg pain and numbness, especially with walking (neurogenic claudication). Vascular problems in your legs or hip problems can mimic the symptoms of lumbar Stenosis and need to be evaluated prior to any discussion of lumbar surgery.
When symptoms interfere with your normal daily activities and conservative measures have failed, surgery is considered. The operative procedure to treat lumbar stenosis is usually lumbar laminectomy. Recently smaller, less invasive procedures (X-ray device) are being used to treat mild to moderate stenosis. The smaller, less invasive procedures require small incisions with implantation of a small inner-transverse process device which improves the symptoms of spinal stenosis without requiring a laminectomy.
The lumbar laminectomy procedure removes the compressing bone and requires 1-2 days in the hospital and 3-4 weeks to recover and return to normal activities. If the spinal stenosis is associated with slippage of the spine, a fusion or spinal stabilization procedure may be required along with the lumbar laminectomy. This obviously requires more time to recover. Laminectomy-type procedures have excellent results in improving/eliminating lower extremity symptoms and increasing your ability to walk greater distances.
Minimally Invasive Surgery (MIS)
Stereotactic radiosurgery, Kyphoplasty, Spinal Cord Stimulation, Minimal Exposure Spinal Surgery and Percutaneous Spinal Fusion all involve using precise X-ray guided techniques in order to achieve results which in the past required large incisions and long hospitalizations and recoveries. Minimally invasive techniques are less traumatic, have less blood loss and less post-operative pain.
Stereotactic radiosurgery is a way of treating different brain disorders with a precise, single dose of radiation in a one-day session. Treatment involves the use of multiple radiation beams delivered to a specific area of the brain. Radiosurgery, one-session treatment, has such a traumatic effect on the target lesion that the changes are considered “surgical.” Through the use of three dimensional MRI computer assisted planning, the treatment leads to minimal radiation exposure to normal brain structures. Stereotactic radiosurgery is routinely used for smaller tumors, facial pain (trigeminal neuralgia), abnormal intracranial vessels and movement disorders. It may be used as a primary treatment or alone with open surgery or conventional radiation treatments. Stereotactic radiosurgery is done with the help of the radiation therapy team.
Kyphoplasty is a percutaneous way to treat vertebral compression fractures (VCF). VCF are common in patients with osteoporosis, vertebral tumors and traumatic fractures, and had been treated with bracing and medication which can be slow, time-consuming and sometimes unsuccessful. Kyphoplasty injects bone cement it its liquid phase under X-ray guidance in order to treat the fracture instantly with no recovery required and only an overnight hospital stay.
Physician Assistants (PAs) are healthcare professionals licensed to practice medicine with physician supervision. As part of their comprehensive responsibilities, Pas conduct physical exams, diagnose and treat illnesses, order tests, assist in surgery and write prescriptions. Because of the close working relationship the PA has with the physician, they are educated in the medical model designed to complement physician training.
PAs are trained in intensive education programs accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA). Upon graduation, physician assistants take a national certification examination developed by the National Commission on Certification of PAs in conjunction with the National Board of Medical Examiners. To maintain their national certification, PAs must log 100 hours of continuing medical education every two years and sit for recertification every six years. Graduation from an accredited physician assistant program and passage of the national certifying exam are required for state license.
At Atlanta Neurosurgical Associates, our PA is considered an important part of our team and exercises autonomy in medical decision-making and provides a broad range of diagnostic and therapeutic services.
Stereotactic radiosurgery is a way of treating different brain disorders with a precise, single dose of radiation in a one-day session. Treatment involves the use of multiple radiation beams delivered to a specific area of the brain. Radiosurgery, one-session treatment, has such a traumatic effect on the target lesion that the changes are considered “surgical.” Through the use of three dimensional MRI computer assisted planning, the treatment plan minimizes radiation exposure to normal brain structures.
Stereotactic radiosurgery is routinely used for smaller brain tumors both primary to the brain and metastatic, facial pain (trigeminal neuralgia), abnormal intracranial vessels and movement disorders. It may be used as a primary treatment or alone with open surgery or conventional radiation treatments. Stereotactic radiosurgery is done with the help of the radiation therapy team.
If surgery is being recommended, our physicians/staff will discuss the reason for the surgery and what the surgery entails as well as the potential risks. Different surgeries have different potential complications. There are some general surgical-type complications which the patient can help avoid with some simple maneuvers.
Deep Vein Thrombosis (DVT) occurs when blood clots form in the lower extremities causing leg pain and swelling, which can extend into the lungs in severe cases. Keeping your pulsatile stocking on during your hospitalization, elevating your legs while in bed and getting out of bed and walking quickly after surgery are the best ways of avoiding this complication.
Lung collapse (atelectasis) occurs because patients do not breathe as deeply during the post-operative period because of pain. This atelectasis can lead to pneumonia in severe cases. Walking and getting out of bed, avoiding over-sedation and using the incentive spirometer in order to take deep breaths and keep the lungs open are simple ways of avoiding atelectasis. You should take the incentive spirometer home with you and use it for the next week to 10 days.
Constipation is very common after surgery and can be avoided with ambulation, stool softeners and avoiding too many analgesics. Also patients need to have realistic expectations with all types of surgery, should not undergo elective surgery if depressed or unstable emotionally, and should have good relaxation techniques and a positive attitude in order to maximize your outcome.