Aneurysm: A brain or cerebral aneurysm is a cerebrovascular disorder in which the wall of an artery in the brain becomes weak and balloons outward. The ballooned part of the artery is the aneurysm. An aneurysm has thin walls and can leak or rupture easily. Aneurysms can form in many sizes and can rupture at any time
Complications of a ruptured aneurysm: The rupturing of an aneurysm is called a subarachnoid hemorrhage and causes blood to leak into the fluid-filled space around the brain. This bleeding is very dangerous and can cause:
- Brain damage
Treatment depends on the location of the aneurysm, and may include:
Microsurgical clipping During this surgery, a metal clip is placed at the base of the aneurysm to control the bleeding and to decrease the risk of more bleeding. This procedure often requires a small craniotomy, which is the creation of a window in the skull. This allows the doctor to go around the brain with the help of endoscopes and microscopes to detect the aneurysm and clip it.
Aneurysm coiling may be an option for suitable people. Coiling is used to block the blood vessel supplying blood to the area of the brain with the aneurysm. Metal coils are placed in the aneurysm through a catheter that is inserted in the groin area. This surgery will prevent further bleeding Your neurosurgeons may recommend a combination of surgical and non-surgical approaches to treat aneurysms.
An arteriovenous malformation (AVM) is a congenital defect between the arteries and veins. The condition affects the connection between these blood vessels, and disrupts the flow of blood between them. Although this defect can occur anywhere, AVMs are most common in the brain or spine. It is common for people not to know that they have an arteriovenous malformation for many years — or even until they reach adulthood. You may not know that you have an AVM in your brain until you experience symptoms. A ruptured AVM is a medical emergency.
Possible treatments for an arteriovenous malformation include:
- Microsurgery to remove the AVM
- Some AVMs can be treated by microsurgical resection, where a doctor will:
- Perform a small craniotomy
- Use a microscope to guide the complete removal of the AVM
- Coagulate any feeding arteries
Embolization to block blood flow to the AVM
Endovascular embolization is a minimally invasive procedure that involves the threading of a small catheter or tube through a blood vessel in the groin, which is then navigated to blood vessels in the brain to block blood flow
There are two main types of tumors:
- Noncancerous (benign) — Slow growing tumors that do not spread to other parts of the body.
- Cancerous (malignant) — Faster growing tumors that are more difficult to treat, and usually destroy the surrounding brain tissue.
Cancerous brain tumors can be further classified as:
- Primary tumors originate in the brain and rarely spread throughout the body. They are named from the cells in which they originated, such as astrocytomas, oligodendrogliomas, and ependymomas.
- Secondary brain tumors (or brain metastases) originate from cancer cells in another part of the body and spread to the brain
An abscess is a collection of pus in an enclosed area of the body. Within the brain, abscesses occur as the result of a bacterial or fungal infection. A brain abscess is a serious, life-threatening condition. Ruptured abscesses have a high mortality rate. The goals of treatment for brain abscesses are to reduce intracranial pressure and eliminate the infection. Your neurosurgeons will remove or drain the abscess to relieve the pressure. After treatment, you will need to take a course of antibiotics.
Treatment for a brain abscess includes both:
- Surgery to remove or drain the abscess to relieve the pressure in the skull.
- The surgical approach will vary depending on the location of the abscess.
- Medicine (antibiotics) to eliminate the infection.
- Our neurosurgical team will evaluate you and find the path that is the least disruptive to your brain, critical nerves, and ability to return to normal functioning
Carpal tunnel syndrome is a common problem that affects the use of your hand, and is caused by compression of the median nerve at the wrist. It most often occurs when the median nerve in the wrist becomes inflamed after being aggravated by repetitive movements such as typing on a computer keyboard or playing the piano. It also seems to affect professional artists fairly commonly – in particular, sculptors and printmakers. The "carpal tunnel" is formed by the bones, tendons and ligaments that surround the median nerve. Since the median nerve supplies sensation to the thumb, index and middle finger, and part of the ring finger, and provides motion to the muscles of the thumb and hand, you might notice numbness and weakness in these areas.
If you experience severe pain that cannot be relieved through rest, rehabilitation or nonsurgical treatment, you may be a candidate for one of several surgical procedures that can be performed to relieve pressure on the median nerve. The most common procedure is called carpal tunnel release, which can be performed using an open incision or endoscopic techniques. The open incision procedure or carpal tunnel release, involves the doctor opening your wrist and cutting the ligament at the bottom of the wrist to relieve pressure.
A contusion is a type of traumatic brain injury (TBI) that causes bruising of the brain tissue; a hematoma is heavy bleeding into or around the brain. The severity of a TBI can range from a mild concussion to the extremes of coma or even death.
Each year, minor incidents of TBI happen to over one million people in the United States. These minor injuries result in the treatment and release from hospital emergency departments. Another 230,000 people are hospitalized each year with TBI. Of these people, 99,000 will show a lasting disability.
Age, injury, poor posture, or diseases such as arthritis can lead to degeneration of the bones or joints of the cervical spine, causing disc herniation or bone spurs to form. Sudden severe injury to the neck may also contribute to disc herniation, whiplash, blood vessel destruction, vertebral injury, and, in extreme cases, permanent paralysis. Herniated discs or bone spurs may cause a narrowing of the spinal canal or the small openings through which spinal nerve roots exit.
Cervical stenosis occurs when the spinal canal narrows and compresses the spinal cord and is most frequently caused by aging. The discs in the spine that separate and cushion vertebrae may dry out. As a result, the space between the vertebrae shrinks, and the discs lose their ability to act as shock absorbers. At the same time, the bones and ligaments that make up the spine become less pliable and thicken. These changes result in a narrowing of the spinal canal. In addition, the degenerative changes associated with cervical stenosis can affect the vertebrae by contributing to the growth of bone spurs that compress the nerve roots. Mild stenosis can be treated conservatively for extended periods of time as long as the symptoms are restricted to neck pain. Severe stenosis requires referral to a neurosurgeon.
There are several different surgical procedures which can be utilized, the choice of which is influenced by the severity of your case
- Anterior Cervical Disectomy This operation is performed on the neck to relieve pressure on one or more nerve roots, or on the spinal cord. The cervical spine is reached through a small incision in the anterior (front) of your neck. If only one disc is to be removed, it will typically be a small horizontal incision in the crease of the skin. If the operation is more extensive, it may require a slanted or longer incision. After the soft tissues of the neck are separated, the intervertebral disc and bone spurs are removed. The space left between the vertebrae may be left open or filled with a small piece of bone through spinal fusion. In time, the vertebrae may fuse or join together.
- Anterior Cervical Corpectomy This operation is performed in conjunction with the anterior cervical disectomy. The corpectomy is often done for multi-level cervical stenosis with spinal cord compression caused by bone spur formations. In this procedure, the neurosurgeon removes a part of the vertebral body to relieve pressure on the spinal cord. One or more vertebral bodies may be removed including the adjoining discs. The incision is generally larger. The space between the vertebrae is filled using a small piece of bone through spinal fusion. Because more bone is removed, the recovery process for the fusion to heal and the neck to become stable is generally longer than with anterior cervical discectomy. Your surgeon may select to use a metal plate that is screwed into the front of the vertebra to help the healing process.
- Posterior Cervical Laminectomy This procedure requires a small incision in the middle of your neck to remove bone spur formations or disc material. The foramen, the passage in the vertebrae of the spine through which the spinal nerve roots travel is enlarged, to allow the nerves to pass through.Your neurosurgeon will remove a section of the lamina (the back bony part of the vertebrae) and ligament to find the exact area of the compression. An operating microscope is used to create an opening, and part of the lamina is removed to take pressure off the nerves and spinal cord. If needed, bone spurs, tissue and any disc fragments causing the compression are also removed
Chiari malformations in adults occur when there is a lack of space for the cerebellum, which is the part of the brain that controls balance and coordination. When the space at the bottom back of the skull is smaller than it should be, the cerebellum and the brainstem may be pushed downward. The pressure on the cerebellum can block the flow of cerebrospinal fluid and cause an array of symptoms.
To help diagnose Chiari malformation, our experts will ask about your symptoms and conduct a thorough physical
exam, as well as order MRI imaging. The treatment for Chiari malformation depends on the severity of your condition. For people who show symptoms, decompression surgery is often the best option.
The goals of Chiari malformation treatment include:
- Reducing pressure on the nerve tissue
- Creating normal flow of cerebrospinal fluid around and behind the cerebellum
- Malformations that cause no symptoms should be left alone and do not require surgery. Although medications may ease the pain associated with a Chiari malformation, surgery is the only treatment that will correct functional disturbances or stop the progression of damage.
Surgery to Reduce Pressure
The most common operation for Chiari malformation in adults — called posterior fossa decompression —
involves removing a small section of bone in the back of the skull.
- Neurosurgeons open the covering of the brain (the dura) and sew a patch in place to enlarge the covering.
This provides more room for the brain and relieves the pressure.
- Surgeons treat pediatric Chiari malformation similarly, although the decompression is usually followed at lower
levels to decompress the spinal canal.
Other treatment options may include:
Shunting — Rarely, we may need to use a shunt to drain the cerebrospinal fluid from the brain to the
abdomen to control the problem in adults.
A concussion is an injury to the brain that results in temporary loss of normal brain function. It usually is caused by a blow to the head. Cuts or bruises may be present on the head or face, but in many cases, there are no signs of trauma. Many people assume that concussions involve a loss of consciousness, but that is not true. In most cases, a person with a concussion never loses consciousness. People with concussions often cannot remember what happened immediately before or after the injury, and they may act confused. A concussion can affect memory, judgment, reflexes, speech, balance and muscle coordination. Paramedics and athletic trainers who suspect a person has suffered a concussion may ask the injured person what year it is or direct them to count backwards from 10 in an attempt to detect altered brain function.
Even mild concussions should not be taken lightly. Neurosurgeons and other brain-injury experts emphasize that although some concussions are less serious than others, there is no such thing as a "minor concussion." In most cases, a single concussion should not cause permanent damage. A second concussion soon after the first one, however, does not have to be very strong for its effects to be deadly or permanently disabling.Treatment: The standard treatment for concussion is rest. For headaches, acetaminophen (Tylenol) can be taken. Postconcussive headaches often are resistant to stronger narcotic-based medications.
People who suffer a head injury may suffer from side effects that persist for weeks or months. This is known as postconcussive syndrome. Symptoms include memory and concentration problems, mood swings, personality changes, headache, fatigue, dizziness, insomnia and excessive drowsiness. Patients with postconcussive syndrome should avoid activities that put them at risk for a repeated concussion. Athletes should not return to play while experiencing these symptoms. Athletes who suffer repeated concussions should consider ending participation in the sport.
Degenerative disc diseaseoccurs when spinal discs degenerate, or wear down. The discs of the spine cushion the interlocking vertebrae and act as shock absorbers for the back, allowing it to bend, flex and twist. They break down over time as a natural part of the aging process. Spinal discs are composed of two layers – a tough, firm outer layer and a soft, jelly-like core. Small tears in the outer layer may cause the soft material in the center to leak out, causing a disc to bulge or rupture. This is a leading cause of back pain, primarily in the lower back and the neck. However, not everyone who has degenerative disc disease experiences pain.
Surgery may be considered when patients do not respond to conservative treatment and are severely limited in performing activities of daily life. Spinal fusion can reduce pain by stopping the motion at a painful segment of the spine. The disc is removed from between two vertebrae, then the vertebrae are fused together. This procedure is performed through a single incision in the back.
Diffuse axonal injury occurs in about half of all severe head traumas, making it one of the most common traumatic brain injuries. It can also occur in moderate and mild brain injury. A diffuse axonal injury falls under the category of a diffuse brain injury. This means that instead of occurring in a specific area, like a focal brain injury, it occurs over a more widespread area.
In addition to being one of the most common types of brain injuries, it’s also one of the most devastating. As a matter of fact, severe diffuse axonal injury is one of the leading causes of death in people with traumatic brain injury.
Dystonia is a movement disorder, meaning it affects parts of the brain that control body movement (motor function). It causes involuntary muscle spasms (contractions), sometimes repeatedly, that can twist the body and be painful. Dystonia symptoms often start in childhood or early adulthood and can range from mild to severe. In about half of cases, dystonia is a symptom of a disease or a result of being exposed to toxins or certain drugs. In most other cases where dystonia is not linked to a specific illness or problem, it is thought to be hereditary. Many cases of dystonia are temporary, such as those brought on by medication. Although there is no cure for dystonia, several treatment options can help control symptoms and allow people to live independently.
These treatment options include:
- Drugs and medication
- Physical therapy
- Surgery - Deep brain stimulation delivers electrical stimulation to targeted areas in the brain that control movement, blocking the neuronal signals that cause abnormal movement. DBS gives significant benefit in most of the people who undergo the procedure for essential tremor.
Epidural hematoma (EDH) is a traumatic accumulation of blood between the inner table of the skull and the stripped-off dural membrane. The inciting event often is a focused blow to the head, such as that produced by a hammer or baseball bat. In 85-95% of patients, this type of trauma results in an overlying fracture of the skull. Blood vessels in close proximity to the fracture are the sources of the hemorrhage in the formation of an epidural hematoma. Because the underlying brain has usually been minimally injured, prognosis is excellent if treated aggressively. Outcome from surgical decompression and repair is related directly to patient's preoperative neurologic condition.
Epilepsy is a disorder of the brain that causes repeated, unpredictable seizures, generally beginning in childhood or early adulthood. Epilepsy can lead to serious complications, including injury to the brain. Epilepsy means the brain has formed abnormal electrical connections that disrupt normal brain function and cause seizures. It can be caused by an injury or illness that affects the brain, such as a stroke or brain tumor, or its cause can be unknown.In adults, medication can frequently control epilepsy. However, if seizures persist after trying two drugs, our expert neurosurgeons may offer epilepsy surgery
surgical treatment may be considered if your seizures continue after trying two different medications. Your neurosurgeon offers a diagnostic surgery for detection of difficult to localize seizures, also called intracranial EEG monitoring – this is to localize the seizure area and to map brain function. Procedure: A craniotomy is performed and Sterile EEG leads are placed directly on the brain. The bone flap is placed back on the patient and secured. The wound is then closed with the tails of the EEG leads coming out through the wound. These leads are connected to EEG monitors that are available in special rooms in the hospital. The patient is then monitored continuously for several days for seizure activity.
There are several types of treatment surgery for adults:
- Craniotomy: Resection of seizure focus (removing abnormal brain areas)This is considered if
- Your seizures are continuing after trying two different medications.
- Your seizures arise from one site in the brain.
- The site of the seizures has been pinpointed.
- The removal of the portion of the brain causing the seizures will not impair your ability to function.
- Vagus nerve stimulation (placing an implant in the neck to help prevent seizures)
- In rare cases, corpus callostomy (disrupting connections between the two sides of the brain)
Essential tremor is a movement disorder, meaning it affects parts of the brain that control body movement (motor function). It is a type of involuntary shaking movement for which no cause can be identified, and it is often a symptom of another condition, such as:
- Parkinson’s disease
The shaking is very rapid, generally more than five times a second Essential tremor is the most common type of tremor and is mainly found in people over age 65. An essential tremor is not dangerous or life-threatening, but it can be annoying and embarrassing for many people.
In some cases, it may be dramatic enough to interfere with:
Several treatment options can help control symptoms of essential tremor. People whose symptoms have not responded well to medication alone may be candidates for deep brain stimulation Essential tremor, like many movement disorders, can be treated but not cured.
Treatment options depend on:
- The severity of symptoms
- Condition of the person
- Deep brain stimulation delivers electrical stimulation to targeted areas in the brain that control movement, blocking the neuronal signals that cause abnormal movement. DBS gives significant benefit in most of the people who undergo the procedure for essential tremor.
The spinal bones (vertebrae) are separated by discs, which cushion the spine and allow movement between the vertebrae. A herniated disc, often called a slipped disc, occurs when a part of the vertebrae pushes into the adjoining disc, putting pressure on the nearby nerves and causing pain or other symptoms. Discs may move out of place (herniate) or break open (rupture) as a result of an injury or strain. This causes pressure that can lead to pain, numbness, or weakness.
Patient whose symptoms are not improved by conservative therapy may benefit from surgery. Additionally patients who experience progressive muscle weakness from a compressed nerve can get relief from surgery.
- Laminectomy removes some of the bone over the spine and the problem disc. Spinal fusion is a technique in which two vertebrae (back bones) are fused together with bone grafts or metal rods. By fusing the vertebrae, the painful motion is eliminated.
- Microdiscectomy may also be done to remove the fragments of a herniated disc through a small incision.
The term hydrocephalus is derived from two words: "hydro" meaning water, and "cephalus" referring to the head. Hydrocephalus is a condition in which excess cerebrospinal fluid (CSF) builds up within the ventricles (fluid-containing cavities) of the brain and may increase pressure within the head. Although hydrocephalus is often described as "water on the brain," the "water" is actually CSF, a clear fluid surrounding the brain and spinal cord. CSF has three crucial functions: 1) it acts as a "shock absorber" for the brain and spinal cord; 2) it acts as a vehicle for delivering nutrients to the brain and removing waste; and 3) it flows between the cranium and spine to regulate changes in pressure within the brain. Hydrocephalus can occur at any age, but is most common in infants and adults age 60 and older
Hydrocephalus can be treated in a variety of ways. The problem area may be treated directly (by removing the cause of CSF obstruction), or indirectly (by diverting the fluid to somewhere else; typically to another body cavity).
- Ventricuo-Peritoneal Shunt - Indirect treatment is performed by implanting a device known as a shunt to divert the excess CSF away from the brain. The body cavity in which the CSF is diverted is usually the peritoneal cavity (the area surrounding the abdominal organs).
- In some cases, two procedures are performed, one to divert the CSF, and another at a later stage to remove the cause of obstruction (e.g., a brain tumor). Once inserted, the shunt system usually remains in place for the duration of a patient's life (although additional operations to revise the shunt system are sometimes needed). The shunt system continuously performs its function of diverting the CSF away from the brain, thereby keeping the intracranial pressure within normal limits.
- An alternative operation called endoscopic third ventriculostomy utilizes a tiny camera to look inside the ventricles, allowing the surgeon to create a new pathway through which CSF can flow.
Non-traumatic Intracerebral hemorrhage is bleeding in the brain caused by a rupture or leak of a blood vessel within the head. This causes:
- Increased pressure within the skull
- Rapid destruction of tissue
- The result is a loss or impairment of the body functions controlled by the affected part of the brain.
Common cause of intracerebral hemorrhage
- Intracerebral hemorrhage is often caused by damage to blood vessel walls from high blood pressure. This results in a hemorrhagic stroke. Other causes include:
- Ruptured aneurysm
- Arteriovenous malformation
- Head trauma
Treatment for intracerebral hemorrhage depends on:
- The location, extent, and duration of bleeding
- The general condition of the person
- A Craniotomy or a craniectomy may be performed.
- Insertion of an External Ventricular device may be a possibility if the ventricles of the brain are involved.
- An EVD is: the temporary drainage of cerebrospinal fluid (CSF) from the lateral ventricles of the brain into an external collection bag. An EVD system drains CSF by using a combination of gravity and intercerebral pressure. The drainage rate depends on the height at which the EVD system is placed relative to the patient’s anatomy.
- Purpose of EVD
- Relieve elevated intracranial pressure (ICP)
- Drain infected CSF
- Drain bloody CSF or blood after surgery or hemorrhage
- Monitor the flow rate of CSF
Kyphosis is a spinal deformity characterized by a rounding of the back. While some rounding of the back is normal, kyphosis refers to exaggerated rounding of more than 50 degrees. This condition is also referred to as round back or hunchback. Patients may develop kyphosis as a result of developmental problems, bad posture, osteoporosis, spinal trauma, spinal fracture, or arthritis. Kyphosis can affect both children and adults and can start at any age.
Surgery is reserved for severe cases of kyphosis. Surgeons will straighten the spine by fusing the backbones (vertebrae) together. This is done using a metal rod inserted into the spine to straighten it.
Low Back Pain: If you are experiencing low back pain, you are not alone. An estimated 75 to 85 percent of all Americans will experience some form of back pain during their lifetime. Although low back pain can be quite debilitating and painful, in about 90 percent of all cases, pain improves without surgery. However, 50 percent of all patients who suffer from an episode of low back pain will have a recurrent episode within one year.
Causes of low back pain:
- Muscle strain
- Herniated disc
- spinal tumors
- spinal stenosis
When Surgery Is Necessary :
When conservative treatment for low back pain does not provide relief, surgery may be needed. You may be a candidate for surgery if:
- Back and leg pain limits normal activity or impairs your quality of life
- You develop progressive neurological deficits, such as leg weakness and/or numbness
- You experience loss of normal bowel and bladder functions
- You have difficulty standing or walking
- Medication and physical therapy are ineffective
- You are in reasonably good health
Lumbar spinal stenosis may or may not produce symptoms, depending on the severity of your case. The narrowing of the spinal canal itself does not produce these symptoms. It is the inflammation of the nerves due to increased pressure that may cause noticeable symptoms to occur. When present, symptoms may include:
- Pain, weakness, or numbness in the legs, calves, or buttocks
- Pain radiating into one or both thighs and legs, similar to sciatica
- In rare cases, loss of motor functioning of the leg
- In rare cases, loss of normal bowel or bladder function
- Pain may decrease when you bend forward, sit or lie down. Pain may get worse when you walk short distances.
Treatment - Nonsurgical
Anti-inflammatory medications to reduce swelling and pain, and pain medication to relieve pain. Most pain can be treated with nonprescription medications, but if your pain is severe or persistent, your doctor may recommend prescription medications.Epidural injections of cortisone may be prescribed to help reduce swelling. This treatment is not recommended repeatedly and usually provides only temporary pain relief. Physical therapy and/or prescribed exercises may help stabilize your spine, build your endurance and increase your flexibility. Therapy may help you resume your normal lifestyle and activities. If non-surgical techniques do not work then surgery may be recommended.
Treatment - Surgical
- Decomprssive Laminectomy in which the laminae (roof) of the vertebrae are removed to create more space for the nerves. A neurosurgeon may perform a laminectomy with or without fusing vertebrae or removing part of a disc. A spinal fusion with or without spinal instrumentation may be recommended when spondylolisthesis or scoliosis occurs with spinal stenosis. Various devices (such as screws or rods) may be used to enhance fusion and support unstable areas of the spine.
- Foraminotomy: Surgical opening or enlargement of the bony opening traversed by a nerve root as it leaves the spinal canal to help increase space over a nerve canal. This surgery can be done alone or together with a laminotomy.
- Laminotomy: An opening made in a lamina, to relieve pressure on the nerve roots.
- Medial Facetectomy: Surgical procedure to remove part of the facet (a bony structure in the spinal canal) to increase the space.
- Posterior Lumbar Interbody Fusion (PLIF): Removal of the posterior bone of the spinal canal, retraction of the nerves and removal of the disc material from within the disc space, followed by insertion of bone graft and sometimes hardware in order to fuse the bones. This procedure is called an 'interbody fusion' because it is performed between the 'bodies' of the vertebral bones and across the diseased disc space. This procedure typically is performed on both sides of the spine.
- Transforaminal Lumbar Interbody Fusion (TLIF): Removal of the posterior bone of the spinal canal, retraction of the nerves, and removal of the disc material from within the disc space, followed by insertion of bone graft and sometimes hardware in order to fuse the bones. Similar to a PLIF, but frequently performed from only one side.
Myelomeningocele/Lipomyelomeningocele: Tethered spinal cord syndrome is a neurological disorder caused by tissue attachments that limit the movement of the spinal cord within the spinal column. These attachments cause an abnormal stretching of the spinal cord. This syndrome is closely associated with spina bifida. It is estimated that 20 to 50 percent of children with spina bifida defects repaired shortly after birth will require surgery at some point to untether the spinal cord. The lower tip of the spinal cord is normally located opposite the disc between the first and second lumbar vertebrae in the upper part of the lower back. In people with spina bifida (myelomeningocele), the spinal cord fails to separate from the skin of the back during development, preventing it from ascending normally, so the spinal cord is low-lying or tethered. In patients with a lipomyelomeningocele, the spinal cord will have fat at the tip and this may connect to the fat which overlies the thecal sac (a fluid filled sac that the spinal cord “floats” within.) Although the skin is separated and closed at birth, the spinal cord stays in the same location after the closure. As the child continues to grow, the spinal cord can become stretched, causing damage and interfering with the blood supply to the spinal cord.
Untethering is generally performed only if there are clinical signs or symptoms of deterioration. The surgery involves opening the scar from the prior closure down to the covering (dura) over the myelomeningocele. Sometimes a small portion of the bony vertebrae (the laminae) are removed to obtain better exposure or to decompress the spinal cord. The dura is then opened, and the spinal cord and myelomeningocele are gently dissected away from the scarred attachments to the surrounding dura. Once the myelomeningocele is freed from all its scarred attachments, the dura and the wound are closed. The child usually can resume normal activities within a few weeks. Recovery of lost muscle and bladder function depends upon the degree and length of preoperative implications. The combined complication rate of this surgery is usually only 1 to 2 percent. Complications include infection, bleeding, damage to the spinal cord or myelomeningocele, which may result in decreased muscle strength or bladder or bowel function. Many children require only one untethering procedure. However, since symptoms of tethering can occur during periods of growth, 10 to 20 percent require repeated surgery.
Normal Pressure Hydrocephalus results from the gradual blockage of the CSF draining pathways in the brain. The ventricles enlarge to handle the increased volume of CSF, thus compressing the brain from within and eventually damaging or destroying the brain tissue. NPH owes its name to the fact that the ventricles inside the brain become enlarged with little or no increase in pressure. However, the name can be misleading, as some patients' CSF pressure does fluctuate from high to normal to low when monitored.
NPH can occur as the result of head injury, cranial surgery, hemorrhage, meningitis or tumor. Unfortunately, the cause of the majority of NPH cases is unknown, making it difficult to diagnose and understand. Compounding this difficulty is the fact that some of the symptoms of NPH are similar to the effects of the aging process, as well as diseases such as Alzheimer's and Parkinson’s. The majority of the NPH population is older than 60, and many of these people believe their symptoms are just part of the aging process. Unfortunately, many cases go unrecognized, are never properly treated or are misdiagnosed.
- Primary symptoms of Normal Pressure Hydrocephalus (NPH)
- Gait disturbances/imbalance
- Memory problems or dementia
- Bladder control symptoms.
Ventriculo-peritoneal shunt: implanting a device known as a shunt to divert the excess CSF away from the brain. The body cavity in which the CSF is diverted is usually the peritoneal cavity (the area surrounding the abdominal organs). The surgeon makes a hole in the skull and another small surgical cut is made in the belly. A small hole is drilled in the skull. A small thin tube called a catheter is passed into a ventricle of the brain. This can be done with or without a computer as a guide. It can also be done with an endoscope that allows to see inside the ventricle. Another catheter is placed under the skin behind the ear and moved down the neck and chest, and usually into the belly area. Sometimes, it stops at the chest area. The doctor may make a small cut in the neck to help position it. A valve (fluid pump) is placed underneath the skin behind the ear. The valve is connected to both catheters. When extra pressure builds up around the brain, the valve opens, and excess fluid drains out of it into the belly or chest area. This helps decrease intracranial pressure. The valves can be programmed to drain more or less fluid from the brain.
An alternative operation called endoscopic third ventriculostomy utilizes a tiny camera to look inside the ventricles, allowing the surgeon to create a new pathway through which CSF can flow.
Parkinson’s disease: is a progressive disorder that is caused by degeneration of nerve cells in the part of the brain called the substantia nigra, which controls movement. These nerve cells die or become impaired, losing the ability to produce an important chemical called dopamine. Studies have shown that symptoms of Parkinson's develop in patients with an 80 percent or greater loss of dopamine-producing cells in the substantia nigra.
Normally, dopamine operates in a delicate balance with other neurotransmitters to help coordinate the millions of nerve and muscle cells involved in movement. Without enough dopamine, this balance is disrupted, resulting in tremor (trembling in the hands, arms, legs and jaw); rigidity (stiffness of the limbs); slowness of movement; and impaired balance and coordination – the hallmark symptoms of Parkinson's. The cause of Parkinson's essentially remains unknown. However, theories involving oxidative damage, environmental toxins, genetic factors, and accelerated aging have been discussed as potential causes for the disease. In 2005, researchers discovered a single mutation in a Parkinson’s disease gene (first identified in 1997), which is believed responsible for 5 percent of inherited cases.
Deep brain stimulation:
Neurosurgeons relieve the involuntary movements of conditions like Parkinson's by operating on the deep brain structures involved in motion control – the thalamus, globus pallidus and subthalamic nucleus. To target these clusters, neurosurgeons use a technique called stereotactic surgery. This type of surgery requires the neurosurgeon to fix a metal frame to the skull under local anesthesia. Using diagnostic imaging, the surgeon precisely locates the desired area in the brain and drills a small hole, about the size of a nickel. A deep brain stimulating electrode is implanted which delivers electircal stimulation to the targeted area, blocking the neuronal signals that cause the abnormal movements; thereby helping to relieve the symptoms associated with Parkinson's.
The pituitary is a small gland attached to the base of the brain (behind the nose) in an area called the pituitary fossa or sella turcica. The pituitary is often called the "master gland" because it controls the secretion of hormones. A normal pituitary gland weighs less than one gram, and is about the size and shape of a kidney bean. The function of the pituitary can be compared to a household thermostat. The thermostat constantly measures the temperature in the house and sends signals to the heater to turn it on or off to maintain a steady, comfortable temperature. The pituitary gland constantly monitors body functions and sends signals to remote organs and glands to control their function and maintain the appropriate environment. The ideal "thermostat" setting depends on many factors such as level of activity, gender, body composition, etc.
The pituitary is responsible for controlling and coordinating the following:
- Growth and development
- The function of various body organs (i.e. kidneys, breasts and uterus)
- The function of other glands (i.e. thyroid, gonads, and adrenal glands
Treatment – surgical
The transsphenoidal approach involves making an incision in the upper gum line or nasal cavity and accessing the tumor through the base of the skull. This approach is usually the procedure of choice because it is less invasive, has fewer side effects, and patients generally recover more quickly. Patients can often leave the hospital as early as two to four days after surgery.
The transcranial approach through the upper part of the skull is used for larger tumors that cannot be safely removed through the transsphenoidal approach.
Endonasal Endoscopic surgery: is a newer, minimally invasive approach which allows neurosurgeons to utilize a tiny endoscope with a camera on the end. A tiny endoscope inserted through the nostril is placed in front of the tumor in the sphenoid sinus, and the tumor is removed with specially designed surgical tools. Postoperative discomfort is usually minimal. Endoscopic brain surgery is another surgical option for removing pituitary adenomas, but can only be utilized in certain cases.
Pseudotumor cerebri occurs when the pressure inside your skull (intracranial pressure) increases for no obvious reason. Symptoms mimic those of a brain tumor, but no tumor is present. Pseudotumor cerebri can occur in children and adults, but it's most common in obese women of childbearing age.
When no underlying cause for the increased intracranial pressure can be discovered, pseudotumor cerebri may also be called idiopathic intracranial hypertension.
The increased intracranial pressure associated with pseudotumor cerebri can cause swelling of the optic nerve and result in vision loss. Medications often can reduce this pressure, but in some cases, surgery is necessary.
Subdural hematomas are usually the result of a serious head injury. When one occurs in this way, it is called an "acute" subdural hematoma. Acute subdural hematomas are among the deadliest of all head injuries. The bleeding fills the brain area very rapidly, compressing brain tissue. This often results in brain injury and may lead to death.
Subdural hematomas can also occur after a very minor head injury, especially in the elderly. These may go unnoticed for many days to weeks, and are called "chronic" subdural hematomas. With any subdural hematoma, tiny veins between the surface of the brain and its outer covering (the dura) stretch and tear, allowing blood to collect. In the elderly, the veins are often already stretched because of brain atrophy (shrinkage) and are more easily injured.
Spasticity is a condition in which certain muscles are continuously contracted. This contraction causes stiffness or tightness of the muscles and can interfere with normal movement, speech, and gait. Spasticity is usually caused by damage to the portion of the brain or spinal cord that controls voluntary movement. The damage causes a change in the balance of signals between the nervous system and the muscles. This imbalance leads to increased activity in the muscles. Spasticity negatively affects muscles and joints of the extremities, and is particularly harmful to growing children.
Spacticity can occur in the following conditions:
- Traumatic Brain Injury
- Multiple Sclerosis
- Cerebral Palsy
- Physical and Occupational therapies: therapy for spasticity is designed to reduce muscle tone, maintain or improve range of motion and mobility, increase strength and coordination, and improve comfort. Therapy may include stretching and strengthening exercises, temporary braces or casts, limb positioning, application of cold packs, electrical stimulation, and biofeedback.
- Dantrolene sodium
- Botulinum Toxin (BTA) Injections: have proven effective when used in tiny amounts, by paralyzing spastic muscles. Injection sites are carefully determined based on the pattern of spasticity.
- Intrathecal Baclofen pump: In severe cases of spasticity, baclofen can be administered through a pump that has been surgically implanted in the patient’s abdomen. By delivering baclofen directly to the spinal fluid, a much more powerful reduction in spasticity and pain can be achieved, with fewer side effects. ITB has been found to be extremely effective in treating spasticity in the lower and upper extremities.
- Selective Dorsal Rhizotomy: the neurosurgeon cuts selective nerve roots (rhizotomy), the nerve fibers located just outside the back bone (spinal column) that send sensory messages from the muscles to the spinal cord. SDR is used to treat severe spasticity of the legs that interferes with movement or positioning. By cutting only the sensory nerve rootlets causing the spasticity, muscle stiffness is decreased, while other functions remain intact.
Spinal Stenosis is a narrowing of the spinal canal that compresses the nerves traveling through the lower back into the legs. While it may affect younger patients due to developmental causes, it is more often a degenerative condition that affects people age 60 and older. The discs may become less spongy as you age, resulting in reduced disc height and bulging of the hardened disc into the spinal canal.
Spinal Tumor is an abnormal mass of tissue within or surrounding the spinal cord and spinal column. These cells grow and multiply uncontrollably, seemingly unchecked by the mechanisms that control normal cells. Spinal tumors can be benign (non-cancerous) or malignant (cancerous). Primary tumors originate in the spine or spinal cord, and metastatic or secondary tumors result from cancer spreading from another site to the spine. Spinal tumors may be referred to by the area of the spine in which they occur. These basic areas are cervical, thoracic, lumbar and sacrum. Additionally, they also are classified by their location in the spine — anterior (front) and posterior (back). Clinically, they are divided into three major groups according to location: intradural-extramedullary, intramedullary and extradural.
Non-surgical treatment: Nonsurgical treatment options include observation, chemotherapy and radiation therapy. Tumors that are asymptomatic or mildly symptomatic and do not appear to be changing or progressing may be observed and monitored with regular MRIs. Some tumors respond well to chemotherapy and others to radiation therapy. However, there are specific types of metastatic tumors that are inherently radiation resistant (i.e. gastrointestinal tract and kidney), and in those cases, surgery may be the only viable treatment option.
Surgical Treatment: Indications for surgery vary depending on the type of tumor.
- Primary spinal tumors may be removed through a resection for a possible cure. See laminectomy.
- metastatic tumors, treatment is primarily palliative, with the goal of restoring or preserving neurological function, stabilizing the spine and alleviating pain. Generally, surgery is only considered as an option for patients with metastases when they are expected to live 12 weeks or longer, and the tumor is resistant to radiation or chemotherapy.
- Indications for surgery include intractable pain, spinal-cord compression and the need for stabilization of impending pathological fractures
Spondylolisthesis is a condition of the spine in which a vertebra slips out of alignment, moving forward on the vertebra below. The condition is usually caused by degenerative disease, such as arthritis. Other causes include bone diseases, trauma, and stress fractures.
A decompression laminectomy removes bony spurs in the spinal canal, freeing up space for the nerves and spinal cord. Spinal fusion is a technique in which two vertebrae (back bones) are fused together. This provides stronger support for the spine
Stroke: is an abrupt interruption of constant blood flow to the brain that causes loss of neurological function. The interruption of blood flow can be caused by a blockage, leading to the more common ischemic stroke, or by bleeding in the brain, leading to the more deadly hemorrhagic stroke. Ischemic stroke constitutes an estimated 87 percent of all stroke cases. Stroke often occurs with little or no warning, and the results can be devastating.
It is crucial that proper blood flow and oxygen be restored to the brain as soon as possible. Without oxygen and important nutrients, the affected brain cells are either damaged or die within a few minutes. Once brain cells die, they generally do not regenerate, and devastating damage may occur, sometimes resulting in physical, cognitive, and mental disabilities.
There are two types of stroke
- Thrombotic (cerebral thrombosis) is the most common type of ischemic stroke. A blood clot forms inside a diseased or damaged artery in the brain resulting from atherosclerosis (cholesterol-containing deposits called plaque), blocking blood flow.
- Embolic (cerebral embolism) is caused when a clot or a small piece of plaque formed in one of the arteries leading to the brain or in the heart, is pushed through the bloodstream and lodges in narrower brain arteries. The blood supply is cut off from the brain due to the clogged vessel.
- Subarachnoid Hemorrhage: bleeding that occurs in the space between the surface of them brain and the skull. A common cause of subarachnoid hemorrhagic stroke is a ruptured cerebral aneurysm, an area where a blood vessel in the brain weakens, resulting in a bulging or ballooning out of part of the vessel wall; or the rupture of an arteriovenous malformation, a tangle of abnormal and poorly formed blood vessels (arteries and veins), with an innate propensity to bleed.
- Intracerebral Hemorrhage: bleeding that occurs within the brain tissue. Many intracerebral hemorrhages are due to changes in the arteries caused by long-term hypertension. Other potential causes may be delineated through testing.
Transient ischemic attack (TIA):
This is a warning sign of a possible future stroke, and is treated as a neurological emergency. Common temporary symptoms include difficulty speaking or understanding others, loss or blurring of vision in one eye, and loss of strength or numbness in an arm or leg. Usually these symptoms resolve in less than 10 to 20 minutes, and almost always within one hour. Even if all the symptoms resolve, it is very important that anyone experiencing these symptoms call 911 and immediately be evaluated by a qualified physician.
When a brain aneurysm ruptures, it causes bleeding into the compartment surrounding the brain, the subarachnoid space and is therefore also known as a subarachnoid hemorrhage (SAH). Often the aneurysm heals over, bleeding stops, and the person survives. In more serious cases, the bleeding may cause brain damage with paralysis or coma. In the most severe cases, the bleeding leads to death.
A synovial cyst is a fluid-filled sac that develops as a result of degeneration in the spine. Because a synovial cyst develops from degeneration it is not often seen in patients younger than 45 and is most common in patients older than 65 years old. The fluid-filled sac creates pressure inside the spinal canal and this in turn can give a patient all the symptoms of stenosis of the spine. Spinal stenosis is a condition that occurs when degeneration in the facet joint causes pressure on the nerves as they exit the spine. It is typically a process that only happens in the lumbar spine, and it almost always develops at the L4-L5 level (rarely at L3-L4). The pain probably comes from the venous blood around the nerves not being able to drain and this leads to pain and irritation of the nerves. Sitting down allows the blood to drain and relieves the pressure.
Traumatic brain injury (TBI) is defined as a blow to the head or a penetrating head injury that disrupts the normal function of the brain. TBI can result when the head suddenly and violently hits an object, or when an object pierces the skull and enters brain tissue. Symptoms of a TBI can be mild, moderate, or severe, depending on the extent of damage to the brain. Mild cases may result in a brief change in mental state or consciousness, while severe cases may result in extended periods of unconsciousness, coma, or even death.
Many patients with moderate or severe head injuries are taken directly from the emergency room to the operating room. In many cases, surgery is performed to remove a large hematoma or contusion that is significantly compressing the brain or raising the pressure within the skull. After surgery, these patients are usually observed and monitored in the intensive care unit (ICU). Other head-injured patients may not go to the operating room immediately, but instead are taken from the emergency room to the ICU. Contusions or hematomas may enlarge over the first hours or days after head injury, so some patients are not taken to surgery until several days after an injury. Delayed hematomas may be discovered when a patient's neurological exam worsens or when their ICP increases. On other occasions, a routine follow-up CT scan that was ordered to determine if a small lesion has changed in size indicates that the hematoma or contusion has enlarged significantly.
At the present time, there is no medication or "miracle treatment" that can be given to prevent nerve damage or promote nerve healing after TBI. The primary goal in the ICU is to prevent any secondary injury to the brain. The "primary insult" refers to the initial trauma to the brain, whereas the "secondary insult" is any subsequent development that may contribute to neurological injury. For example, an injured brain is especially sensitive and vulnerable to decreases in blood pressure that might otherwise be well tolerated. One way of avoiding secondary insults is to try to maintain normal or slightly elevated blood pressure levels. Likewise, increases in ICP, decreases in blood oxygenation, increases in body temperature, increases in blood glucose, and many other disturbances can potentially worsen neurological damage. The prevention of secondary insults is a major part of the ICU management of head-injured patients.
Various monitoring devices may assist healthcare personnel in caring for the patient. Placement of an ICP monitor into the brain itself can help detect excessive swelling of the brain. One commonly used type of ICP monitor is a ventriculostomy, which is a narrow, flexible, hollow catheter that is passed into the ventricles, or fluid spaces in the center of the brain, to monitor ICP and to drain CSF if ICP increases. Another commonly used type of intracranial pressure monitoring device involves placement of a small fiberoptic catheter directly into the brain tissue.
External ventricular drain (EVD) a catheter is inserted into a lateral ventricle which will allow drainage of CSF (cerebral spinal fluid). A hole is drilled through the skull. The catheter is inserted through the brain into the lateral ventricle. This area of the brain contains liquid (cerebrospinal fluid or CSF) that protects the brain and spinal cord.
Intracranial pressure (ICP) monitor: Intracranial pressure monitoring uses a device, placed inside the head, which senses the pressure inside the skull and sends its measurements to a recording device. Normal measurement are between 0-20mm Hg.
Brain injury types:
- Subdural hematoma: collection of blood between the dura mater and the arachnoid layer, which sits directly on the surface of the brain.
- Epidural hematoma: collection of blood between the dura mater (the protective covering of the brain) and the inside of the skull.
- cerebral contusion is bruising of brain tissue. When examined under a microscope, cerebral contusions are comparable to bruises in other parts of the body. They consist of areas of injured or swollen brain mixed with blood that has leaked out of arteries, veins, or capillaries
- intracerebral hemorrhage (ICH) describes bleeding within the brain tissue, which may be related to other brain injuries, especially contusions. The size and location of the hemorrhage helps determine whether it can be removed surgically.
- Subarachnoid hemorrhage (SAH) is caused by bleeding into the subarachnoid space. It appears as diffuse blood spread thinly over the surface of the brain, and is seen commonly after TBI. Most cases of SAH associated with head trauma are mild. Hydrocephalus may result from severe traumatic SAH.
- Diffuse Axonal injury refers to impaired function and gradual loss of some axons, which are the long extensions of a nerve cell that enable such cells to communicate with each other even if they are located in parts of the brain that are far apart. If enough axons are injured in this way, then the ability of nerve cells to communicate with each other and to integrate their function may be lost or greatly impaired, possibly leaving a patient with severe disabilities.
- Another type of diffuse injury is ischemia, or insufficient blood supply to certain parts of the brain. It has been shown that a decrease in blood supply to very low levels may occur commonly in a significant
Trigeminal neuralgia: The pain typically involves the lower face and jaw, although sometimes it affects the area around the nose and above the eye. This intense, stabbing, electric shock-like pain is caused by irritation of the trigeminal nerve, which sends branches to the forehead, cheek and lower jaw. It usually is limited to one side of the face. Although trigeminal neuralgia cannot always be cured, there are treatments available to alleviate the debilitating pain. Normally, anticonvulsive medication are the first treatment choice. Surgery can be an effective option for those who become unresponsive to medications or for those who suffer serious side effects from the medications.
There are several effective ways to alleviate the pain, including a variety of medications.
- Other medications include gabapentin, clonazepam, sodium valporate, lamotrigine and topiramate.
If medications have proven ineffective in treating trigeminal neuralgia, there are several surgical procedures that may help control the pain. Surgical treatment is divided into two categories: percutaneous (through the skin) and open.
- Microvascular decompression involves microsurgical exposure of the trigeminal nerve root, identification of a blood vessel that may be compressing the nerve and gentle movement of the blood vessel away from the point of compression. Decompression may reduce sensitivity and allow the trigeminal nerve to recover and return to a more normal, pain-free condition.
- Percutaneous stereotactic rhizotomy treats trigeminal neuralgia through the use of electrocoagulation (heat). It can relieve nerve pain by destroying the part of the nerve that causes pain and suppressing the pain signal to the brain. The surgeon passes a hollow needle through the cheek into the trigeminal nerve. A heating current, which is passed through an electrode, destroys some of the nerve fibers.
- Percutaneous balloon compression utilizes a needle that is passed through the cheek to the trigeminal nerve. The neurosurgeon places a balloon in the trigeminal nerve through a catheter. The balloon is inflated where fibers produce pain. The balloon compresses the nerve, injuring the pain-causing fibers. After several minutes, the balloon and catheter are removed