At Neuroscience & Spine Associates, our primary focus is patient care.  Once we have concluded a comprehensive assessment of the patient’s condition, we can plan a rehabilitative or therapeutic regimen.
In some cases, this plan includes neurosurgery.

Our professional staff includes board certified experienced neurosurgeons for those cases where surgery is the only approach to resolve the patients symptoms.  The range of expertise within our practice enables Neuroscience and Spine Associates to provide the post comprehensive care, working with patients and their caregivers from diagnosis to treatment and ultimately to recovery.

Our neurosurgeons have expertise in all forms of spinal and cranial surgery as well as peripheral nerve procedures.  They specialize in a wide range of treatments for brain tumors as well as spinal instrumentation.

What is Spinal Instrumentation and Spinal Fusion?

Spinal instrumentation utilizes surgical procedures to implant titanium, titanium-allow stainless steel, or non metallic devices into the spine.  Instrumentation provides a permanent solution to spinal instability.  Medical implants are specially designed and come in many shapes and sizes.  Typically these include rods, hooks, braided cable, plates, screws and interbody cages.  Cages are simply structures that support bones (either between bones in place of them) while new bone growth occurs through and around them.

Spinal fusion is a process using bone graft to cause two opposing bony surfaces to grow together.  In medical terminology, this is called arthrodesis.  Bone graft can be taken from the patient (termed autologous bone) during the primary surgical procedure or harvested from other individuals (termed allograft bone).  Another option for some patients is bone morphogenetic protein (BMP).  BMP stimulates the body to make bone.

CRANIEL SURGERY 

Overview
Craniotomy is a cut that opens the cranium,.  During this surgical procedure, a section of the skull, called a bone flap, is removed to access the brain underneath.  The bone flap is usually replaced after the procedure with tiny plates and screws. 

A craniotomy may be small or large depending on the problem.  It may be performed during surgery for various neurological diseases, injuries, or conditions such as brain tumors, hematomas (blood clots), aneurysms or AVMs, and skull fractures. 

Other reasons for a craniotomy may include foreign objects (bullets), swelling of the brain, or infection.  Depending on the reason for the craniotomy, this surgery
requires a hospital stay that ranges from a few days to a few weeks.

   

CARPAL TUNNEL SYNDROME

Definition:
Carpal Tunnel Syndrome (CTS) is a common and often painful condition that can interfere with the normal use of your hands. CTS occurs when the Median Nerve becomes compressed within the wrist resulting in pain, numbness, and weakness. The Median nerve normally supplies sensation to the palmar surface of the thumb, index, middle and half of the ring finger. As this nerve enters into the palm, it must do so via a small canal known as the Carpal Tunnel.

Presentation:
The most common presentation occurs in females from 40 to 50 years of age. It then later reappears in the geriatric population as a result of degenerative joint disease also described as Osteoarthritis. The third most common area of presentation is in those individuals who perform repetitive work or activities with their hands. In this latter category, typist are the most frequent. In men, butchers have a very high prevalence. Generally, temporary CTS is frequently seen in pregnancy, and usually resolves several weeks following delivery. Individuals who are low in thyroid can also present with CTS.

Diagnosis:
Carpal Tunnel Syndrome is often easily diagnosed by its more classical history: Intermittent, but generally worsening numbness of the first three ½ fingers (see figure above), nighttime pain which can be relieved by shaking the hand back to "life", and weakness in ones grip, often followed by atrophy (muscle wasting) of the thumb.

Clinical exam usually confirms the classical pattern of numbness. In addition there is frequently a shock-like sensation elicited by tapping the nerve just proximal to the carpal tunnel at the wrist. This sign is known as a Tinel's Sign. Weakness in opposition of the thumb and little finger is usually present in more severe cases. EMG/NCV tests are diagnostic for CTS in over 90% of individuals. In some early cases, even when pain is significant, the EMG/NCV test may be normal. It generally takes 4 to 6 weeks before nerve damage will show up electrically.

Treatment:
Where pain and/or mild numbness are the only presenting symptoms, conservative measures will be tried. These include a hand splint to be worn at night and during painful activity. Anti-inflammatory medications such as Advil, Alieve (and stronger prescriptions) may also be of help. It is often noted in the "health-food" literature that Vitamin B6 can improve CTS. It is worth a try, if nothing else.

Splints are designed to keep your wrist in a neutral position., Bending the wrist makes the symptoms worse because it narrows the carpal tunnel increasing pressure on the nerve.

In milder forms, a steroid-type injection may be prescribed. These are often very effective in stopping the pain, but nerve damage often continues because the compression remains.

Surgery:
Surgery may be advised if symptoms continue after conservative treatment, or if you are experiencing severe pain. Surgery is designed to stop further nerve damage, and in over 90% of cases results in significant improvement in neural function.

The surgery is called Carpal Tunnel Release. It takes about 30 minutes to perform and is usually done as an out-patient service. The surgery is performed through a cosmetic one inch incision along the palm's "life-line". As only the ligament over the nerve is released, hand strength is maintained.

Complications which occur rarely, can include continued pain and numbness in cases of prolonged and severe nerve compression.

Follow up:
For the first two days after surgery, whenever at rest, you should try to keep your hand elevated. The bandage is removed the day after surgery. It is recommended that you clean the incision with alcohol or peroxide, and leave it open to air. Keep your hand dry. You may shower, but do not soak your hand.

Our office will call and schedule an appointment for you to be seen 5 to 7 days post-op.

Starting the night of surgery it is recommended to begin gentle exercises. Move and wiggle each finger, and try to touch your fingertips to the thumb. Follow this by making a gentle fist.

Recovery:
Nerves regenerate at approximately ½ to 1 inch per month. Therefore you can expect to see sensory improvement in as far out from surgery as 6 months, and even up to 2 years. If the muscle in the thumb was atrophied (shrunken) before surgery, most likely it will not re-grow. You may get stronger however, in the muscles of the hand which were still functioning prior to surgery.

About a third of patients will experience a soreness in the muscle of the thumb following surgery. It is often described as feeling like a "stone-bruise". This tenderness can last up to three months.

Generally golf is allowed at 6 weeks after surgery. Tennis may have to wait 3 months, but often can be played safely at 6 weeks with a wrist support. You can never use the palm of your hand for a Hammer! Remember the Median nerve is no longer protected by the tough carpal ligament and will be sensitive to direct blows.

MEDIAL BRANCH NERVE BLOCK PROCEDURE

As with many spinal injections, medial branch blocking procedures are best performed under fluoroscopy (live x-ray) for guidance in properly targeting and placing the needle (and for avoiding nerve injury or other injury).

On the day of the injection, patients are advised to avoid driving and doing any strenuous activities, and to get plenty of rest the night before.

The injection procedure includes the following steps:

     • An IV line will be started so that adequate relaxation medicine can be given, as needed.

     • The patient lies on an x-ray table, and the skin over the area to be tested is well cleansed.

     • The physician treats a small area of skin with a numbing medicine (anesthetic), which may sting for a few seconds.

     • The physician uses x-ray guidance (fluoroscopy) to direct a very small needle over the medial branch Nerves.

     • Several drops of contrast dye are then injected to confirm that the medicine only goes over these Medial branch nerves.

     • Following this confirmation, a small mixture of numbing medicine (anesthetic) will then be slowly injected onto each targeted nerve. 

  The injection itself only takes a few minutes, but the entire procedure usually takes between fifteen and thirty minutes.

After the procedure, the patient typically remains resting on the table for twenty to thirty minutes, and then is asked to move the affected area to try to provoke the usual pain.  Patients may or may not obtain pain relief in the first few hours after the injection, depending upon whether or not the medial branch nerves that were injected are carrying pain signals from the spinal joints to the brain.  On occasion, patients may feel numb or have a slightly weak or odd feeling in their neck or back for a few hours after the injection.

The patient will discuss with the doctor any immediate pain relief.  Ideally, patients will also record the levels of pain relief during the next week in a pain diary.  A pain diary is helpful to clearly inform the treating physician of the injection results and in planning future tests and/or treatment, as needed.

Medial branch nerve block results and follow-up
Patients may continue to take their regular medications after the procedure, with the exception of limiting pain medicine within the first four to six hours after the injection so that the diagnostic information obtained is accurate. 

On the day after the procedure, patients may return to their regular activities.  When the pain is improved, it is advisable to start regular exercise and activities in moderation.  Even if the pain relief is significant, it is still important to gradually increase activities over one to two weeks to avoid recurrence of pain. 

Depending on the amount of pain relief the patient has during the first 6 to 12 hours after the injection, the patient may be a candidate for a radio frequency neurotomy procedure to try and provide longer term pain relief.  Generally, a patient must report at least 80% improvement in their pain during the first 6 to 12 hours after the injection to be considered a candidate for radiofrequency neurotomy

Potential risks and complications of medial branch nerve blocks
As with all invasive medical procedures, there are potential risks and complications associated with medial branch blocks.  However, in general the risk is low, and complications are rare.  Potential risks and or complications that may occur from a medical branch injection include:

     • Allergic reaction.  Usually an allergy to x-ray contrast and rarely to local anesthetic.

FACET RHIZOTOMY INJECTION 

In some low back pain programs, if three facet block injections provide good but temporary relief of the patient’s pain, a facet rhizotomy injection may be recommended.  The purpose of a facet rhizotomy injection is to provide lasting low back pain relieve by disabling the sensory nerve that goes to the facet joint.

In this injection procedure a needle with a probe is inserted just outside the joint.  The probe is then heated with radio waves and applied to the sensory nerve to the joint in order to disable the nerve.  Theoretically, by deadening the sensory nerve to the face joint, a facet rhizotomy effective prevents the pain signals from getting to the brain.

A facet rhizotomy injection is successful in providing lasting pain relief for approximately 50% of patients. 

SELECTIVE NERVE ROOT BLOCK FOR DIAGNOSIS
AND BACK PAIN MANAGEMENT

Another common injection, a selective nerve root block (SNRB), is primarily used to diagnose the specific source of nerve root pain and, secondarily, for therapeutic relief of low back pain and/or leg pain.

When a nerve root becomes compressed and inflamed, it can produce back and/or leg pain.  Occasionally, an imaging study (e.g. MRI) may not clearly show which nerve is causing the pain and an SNRB injection is performed to assist in isolating the source of pain.  In addition to its diagnostic function, this type of injection for pain management can also be used as a treatment for a far lateral disc herniation (a disc that ruptures outside the spinal canal).

In an SNRB, the nerve is approached at the level where it exits the foramen (the hole between the vertebral bodies).  The injection is done both with a steroid (an anti-inflammatory medication) and lidocaine (a numbing agent).  Fluoroscopy (live x-ray) is used to ensure the medication is delivered to the correct location.  If the patient’s pain goes away after the injection, it can be inferred that the back pain generator is the specific nerve root that has just been injected.  Following the injection, the steroid also helps reduce inflammation around the nerve root.

Success rates vary depending on the primary diagnosis and whether or not the injections are being used primarily for diagnosis.  While there is no definitive research to dictate the frequency of SNRB’s, it is generally considered reasonable to limit SNRB’s to three times per year.

Technically, SNRB injections are more difficult to perform than epidural steroid injections and should be performed by experienced physicians.  Since the injection is outside the spine, there is no risk of a wet tap (cerebrospinal fluid leak).  However, since the injection is right next to the nerve root, sometimes an SNRB will temporarily worsen the patient’s leg pain.

FACET JOINT BLOCK FOR BACK PAIN MANAGEMENT

In cases where the facet joint itself is the pain generator, a facet block injection can be performed to alleviate the pain.  Similar to SNRB’s, facet block injections are a diagnostic tool used to isolate and confirm the specific source of back pain for the patient.  Additionally, facet blocks have a therapeutic effect as they numb the source of pain and soothe the inflammation for the patient.

The facet joints are paired joints in the back that have opposing surfaces of cartilage (cushioning tissue between the bones) and a surro9unding capsule.  Twisting injuries can cause damage to one or both facet joints, and cartilage degeneration associated with aging may also cause pain.

In a facet block procedure, a physician uses fluoroscopy (live x-ray) to guide the needle into the fact joint capsule to inject lidocaine (a numbing agent) and/or a steroid (an anti-inflammatory medication.  If the patient’s pain goes away after the injection, it can be inferred that the pain generator is the specific facet joint capsule that has just been injected.

If the facet block procedure is effective in alleviating the patient’s low back pain, it is often considered reasonable for the procedure to be done up to three times per year.  There are very few risks associated with this technique.

EPIDURAL STEROID INJECTIONS

The most commonly performed injection is an epidural steroid injection.  In this approach, a steroid is injected directly around the dura, the sac around the nerve roots that contains cerebrospinal fluid (the fluid that the nerve roots are bathed in).  Prior to the injection, the skin is anesthetized by using a small needle to numb the area in the low back (a local anesthetic).

Injecting around the dura sac with steroid can markedly decrease inflammation associated with common conditions such as spinal stenosis disc herniation or degenerative disc disease. 

It is thought that there is also a flushing effect from the injection that helps remove or “flush out” inflammatory proteins from around structures that may cause pain.

An epidural steroid injection
is generally successful in relieving lower back pain for approximately 50% of patients. 

While the effects of the injection tend to be temporary (one week to one year) an epidural can be very beneficial in providing relieve for patients during an episode of severe back pain and allows patients to progress in their rehabilitation. 

There is no definitive research to dictate the frequency of the epidural steroid injections; however, a limit of three injections in six months is generally considered reasonable.  There is also no general consensus in the medical community as to whether or not a series of three injections need always be performed.  If one or two injections resolve the patient’s low back pain, some physicians prefer to save the one or two additional injections for any potential recurrent low back pain.  Generally, there are few risks associated with epidural injections. 

LUMBAR PUNCTURE (LP) 

A lumbar puncture (LP, also known as a spinal tap, is a diagnostic and/or therapeutic procedure performed by a physician.  The procedure is performed by inserting a hollow needle into the subarachnoid space in the lumbar area (lower back) of the spinal column.  The subarachnoid space is in the canal in the spinal column that carries cerebrospinal fluid (CSF) between the brain and the spinal cord.

CSF is a clear fluid that bathes the brain and spinal cord while protecting it, like a cushion, from exterior injury.  The fluid is produced and reabsorbed in the brain on a continuous basis.  CSF is composed of cells, water, proteins, sugars, and other vital substances that are essential to maintain equilibrium in the nervous system.

SACROILIAC JOINT BLOCK INJECTION

Sacroiliac (SI) joint blocks are injections that are primarily used for diagnosing and treating the low back pain associated with sacroiliac joint dysfunction.  The SI joint lies next to the spine and connects the sacrum (bottom of the spine) with the pelvis (hip)

In an SI joint block injection approach, a physician uses fluoroscopic guidance (live x-ray) and inserts a needed into the sacroiliac joint to inject lidocaine (a numbing agent) and a steroid (an anti-inflammatory medication).  It takes a highly skilled and experienced physician to be able to insert a needle into the sacroiliac joint.

An SI joint block injection may be repeated up to three times per year.  For the treatment to be successful, the injection should be followed by physical therapy and/or chiropractic manipulations to provide mobilization and range of motion exercises.