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BMP doesn’t show significant reduction in reoperations

BMP has gotten a lot of bad rep lately. This is technology that has its place in spine surgery but it is so powerful must be carefully used.

 

Macrophages on MRI May Flag Unstable Cerebral Aneurysm

 

Checklists as a means to achieve better patient outcomes

http://www.medpagetoday.com/Surgery/Neurosurgery/35683

 

Image Guided and Robotic Surgery in Neurosurgery and Spine Surgery

Dr. Kevin Yoo and his team have been using image guided surgery in his practice for years with BrainLab system. He has started to use Mazor Robotic surgery to assist in spine surgery. These technologies allow Dr. Yoo to point to and understand patient’s anatomy better in the operating room.

 

Coflex – new device for back pain.

Some of you may have heard of a device called Coflex® being used by spine surgeons to treat back problems. Coflex®is a titanium metal implant that helps keep your spine stable after surgical decompression. The Coflex® device also helps maintain the normal height and motion in your spine where the Coflex® was implanted. It’s amazingly strong, yet simple to install, allowing a better range of motion than fused bones.

Because of this, I have begun to use this in my practice. There are many factors when considering a new device or procedure for my patients, but most important among these are the outcomes for my patients. Coflex® has proved itself with superior results on many levels:

•Faster Symptom Relief – At 6 weeks, Coflex® patients showed early relief of their spinal stenosis symptoms compared to fusion patients (90% vs. 77%, measured by ZCQ div-layer with text definition)

•Lasting Symptom Relief – At 2 years, Coflex® patients showed lasting relief of their spinal stenosis symptoms compared to fusion patients (88% vs. 78%, measured by ZCQ div-layer with text definition)

•Patient Satisfaction – At 2 years, Coflex® patients were satisfied with their outcome compared to fusion patients (94% vs. 87%)

•Shorter operating time – Coflex® surgeries were 36% faster compared to fusion surgeries (98 minutes vs. 153 minutes).

•Shorter hospital stay – Coflex® patients spent 40% less time in the hospital compared to fusion patients (1.9 days vs. 3.2 days).

•Less Blood Loss – Coflex® patients had less blood loss during surgery compared to fusion patients (110 cc vs. 349 cc).

•Stability in the Treatment Area – At 2 years, Coflex® patients retained their pre-operative range of motion (within 10%) and translation (within 5%) at the area of treatment.

•More Natural Movement at Treatment Area and Surrounding Spinal Segments – At 2 years, Coflex® patients retained their pre-operative range of motion (within 15%) at the areas below and above the treatment area, and fusion patients saw a 25-50% increase in unnatural motion (this sounds bad, but is it good?) at the areas below and above the treatment area.

What the list above should tell you is that using Coflex® results in a faster relief of symptoms, enables a shorter and easier (and therefore safer) surgery, a shorter recovery period, and lasting results. I am happy to offer Coflex to my patients for whom decompression is appropriate. The results for my patients thus far have been excellent.

 

Glioblastoma Multiforme

Have you or a loved one been diagnosed with glioblastoma multiforme? Do you feel lost hearing this diagnosis? You aren’t alone in feeling this way. The diagnosis of a glioblastoma multiforme often sends people scouring the internet and every possible source for vital information, and that can be overwhelming. We will give you an overview and answer your main questions about this type of brain tumor.

First and foremost, what is glioblastoma multiforme? Glioblastoma Multiforme often referred to as Grade IV astrocytoma or GBM, are cancerous tumors arising from the brain tissue. Hence, they are classified as primary brain tumors. These are by far the most aggressive of the brain tumors, and unfortunately they are also the most commonly occurring brain tumors today. They are considered aggressive, mainly because of the speed at which they spread and infiltrate into the surrounding brain tissue.

These tumors arise from the glial tissue of the brain, hence the name glioblastoma. Glial tissue is the protective covering around your nerve cells present inside your brain and spinal cord. This tissue comes in various forms; however, GBM is usually made up of the star shaped glial cells better known as the astrocytes, hence the name astrocytoma. Although, astrocytomas are divided into four grades depending on the speed at which they infiltrate the surrounding brain tissue and the type of tissue they are made up of, only the Grade IV astrocytomas are considered under the purview of GBM. These tumors are intracranial space occupying lesions in the brain that can develop rapidly within a few days, or gradually over a span of few weeks. They also do not have a stable border or demarcation and are made up of a poorly differentiated heterogeneous mixture of cells, generally affecting the cerebral hemispheres, seldom occurring in the brainstem and the spinal cord.

However, they can be easily visualized with a computed tomography or magnetic resonance imaging of the brain. So, if your doctor suspects such a tumor, he or she may order one or both of these tests to confirm the diagnosis. In the United States alone, 60% of all brain tumors are gliomas. Statistically, GBM projects a rather bleak survival rate even after the patient has undergone surgery. You may feel disheartened looking at statistics and figures; however, a quick diagnosis and appropriate medical measures introduced early on can greatly improve your outcome. Hence, it is important to educate yourself about the causes, symptoms, treatment, and other lesser known facts of GBM to prepare yourself.

Another question that often comes to mind with such a diagnosis is:  what could have caused these tumors in my brain? Unfortunately, the causes of these tumors are not known yet, apart from an underlying genetic tendency that commonly causes them to develop. So, what we know for certain is that these tumors sometimes run in families, with almost 5% of them being associated with genetic and familial tendencies. You are also more likely to develop these tumors if you suffer from certain disorders such as, neurofibromatosis, Turcot syndrome, and Li-Fraumeni syndrome, as they account for another 1% of GBMs. Use of mobile phones, N-nitroso compounds, head injury, occupational hazards and electromagnetic field exposure have also been implicated as causative factors of GBM, although studies done with regards to these causes have proven inconclusive.

Symptoms of Glioblastoma Multiforme:

These tumors are very rightly classified as acute primary brain tumors. Acute, because they typically appear suddenly and progress rapidly. Although, they sometimes develop over a few weeks, often GBMs are seen to develop and spread within days. Besides, these tumors present with a combination of general and neurological symptoms. Hence, it is very likely that most unsuspecting individuals diagnosed with GBM are caught off-guard. Nevertheless, understanding its symptoms is important for rapid diagnosis and appropriate medical intervention. If you have a glioblastoma multiforme, you are likely to experience a few or all of the following signs and symptoms.

• Motor weakness, which leads to weakness of muscles and weak movements.

• Headaches, nausea, and vomiting due the pressure the tumor exerts on the surrounding brain tissue and skull.

• Cognitive impairment which includes memory loss, impaired thinking and judgment, and personality changes.

• Depending on the site of the tumor, hemiparesis or one-sided weakness of the body, visual loss, sensory loss, and aphasia may be seen.

• Seizures.

Treatment:

GBM is difficult to treat or cure. However, the good news is that palliative therapy often improves the outcome of these tumors. Currently the line of treatment adopted for GBM is surgical removal as much of the tumor as possible. You will also require radiotherapy and/or chemotherapy along with the surgery to improve your chances of survival. However, in patients above 70 years of age, radiation alone is preferred. Surgery is avoided in such elderly patients, as they may not tolerate the more aggressive treatment methods.

Prognosis:

The outcome of GBM tumors is not very promising, mainly due to their tendency to spread and increase in size rapidly, in addition to the absence of a well-demarcated border. The average survival rate with standard palliative measures is 15 months, although 3-5% of these patients do survive up to 3 years. It is important to remember that advances in all fields of medicine are happening at a rapid pace, bringing improved treatment options to a whole host of conditions on a continuous basis.

Resources:

1. Harrison’s Principles of internal Medicine, 18th edition

2. http://brain.oxfordjournals.org/content/130/10/2596.full

3. http://emedicine.medscape.com/article/283252-overview

4. American Cancer Society, Inc.  http://www.cancer.org 

 

Cervical Disc Herniation

Cervical disc herniation is basically a protruding, slipped, or displaced intervertebral disc in the region of your neck. Herniation caused by the rupture or breaking open of the intervertebral discs is another type of frequently occurring disc abnormality. Under normal circumstances, these discs are placed between your vertebral bones to enhance flexibility of movements and decrease friction. Hence, such herniated discs defeat the purpose of flexibility, and are likely to exert pressure on the surrounding nerve roots emerging from your spinal cord leading to symptoms like pain and tingling in the neck, arms, and shoulders. As a result, they are often referred to as slipped, herniated, or bulging discs, and pinched nerves. Although, herniated discs have a higher incidence along the neck and lower back, they can come about anywhere along your spine. Herniated cervical discs are responsible for almost 25% of cervical radiculopathies that are disorders of the nerve roots around the cervical spine. There are in total 7 cervical vertebrae and 5 intervertebral discs between them that support your neck. An abnormality in any one of these discs can result in neck pain. However, herniated discs most commonly affect the C6 and C7 cervical nerve roots in the neck region. Disc herniation between C7 and T1, which is the connection between your cervical and thoracic spine is quite rare. The major cause of cervical disc herniation is trauma to the cervical spine, especially in the younger age group of 30-50 years. On the other hand, older people have an increased chance of suffering from herniated discs due to age related changes such as cracks in a disc leading to its rupture and subsequent bulging out of the jelly-like material inside it. The increased friction and loss of joint fluids with age often lead to herniated cervical discs too. These herniated discs can be visualized with cervical radiograms as well as CT scans, however CT scans are much more accurate in their diagnosis. Hence, if your doctor suspects a herniated cervical disc as the cause behind your neck pain and other symptoms, it is likely that he/she will order a CT scan to come to a final diagnosis.

Symptoms of cervical disc herniation:

A herniated cervical disc may seldom occur due to reasons other than trauma to the neck. Nonetheless, its symptoms usually begin spontaneously, sometimes almost a few days or weeks after the date of trauma. However, a history of trauma with symptoms persisting for more than 6 weeks points towards a disc herniation. The symptoms of a cervical disc herniation are similar to those of cervical spondylosis and carpel tunnel syndrome, and can lead to a missed diagnosis. In any case, a closer look at your symptoms and a confirmation with a cervical CT scan are enough to diagnose a disc herniation. If you have a cervical disc herniation, you are likely to experience some or all of the symptoms listed below depending on the nerve roots involved.

• Your neck pain may come up on moving your neck, or you may experience pain around your shoulder blades. But, the herniated disc often causes the pain to radiate down your arm, forearm, and fingers.

• Cervical disc herniation pains are usually limited to a single side of your body, and in principle the nerve root affected by the herniated disc decides the location of your pain. However, due to functional overlapping between adjacent nerve roots since we are all wired differently, the location of the pain seldom gives an accurate indication of the site of the herniated disc.

• Numbness along your shoulders, arms, forearms, and fingers, sometimes accompanied by tingling is another indication of a cervical disc herniation.

• However, your symptoms may vary slightly depending on the site of herniation along your cervical spine. Sometimes, these variations help the neurologist pinpoint the location of the disc herniation even before the arrival of the CT scan and radiology images. But, it’s still important to note that we cannot depend on the symptoms alone for such a diagnosis. Here’s a table explaining the different symptoms according to the site of herniation to help you understand your condition better.

Location Symptoms
C4 – C5 (C5 nerve root)
  • Weakness in the upper arm.
  • Numbness or tingling is usually absent.
  • Occasionally shoulder pain may be present too.
C5 – C6 (C6 nerve root)
  • Weakness around the front of the upper arm and wrist.
  • Numbness and tingling along with pain radiating along the thumb side of the hand on the affected side.
C6 – C7 (C7 nerve root)
  • Weakness around the back of the upper arm that extends to the forearm and fingers.
  • Numbness, tingling, and pain that radiate down along the triceps and the middle finger.
C7 – T1 (T1 nerve root)
  • A weak handgrip.
  • Numbness, tingling, and pain radiating down the arm to the little finger.

Treatment:

The treatment for cervical disc herniation is pretty straightforward. If you suffer from a mild to moderate herniation, a little bit of rest, modification of activities, NSAIDs for pain, and physical therapy should do the trick. Physical therapists will help you improve your posture while you sit, walk, or dress without exerting pressure on your cervical spine. They also provide appropriate muscle strengthening exercises for your neck. But, it is also recommended that you avoid exercising your neck muscles or lifting heavy weights while the pain lasts or for the first 6 weeks since the beginning of your symptoms. In fact, most people undergoing such conservative management find relief quickly, although the tingling and numbness may take a while to go, and once rid of the pain it seldom returns. Some people require additional corticosteroid injections and/or traction, when conservative management fails to improve their symptoms. In such a scenario, your doctor may give you steroid shots in the region of the herniated disc to reduce pain and inflammation. On the other hand, traction puts some amount of pressure on your cervical spine through gentle pulling at the head to spread the vertebrae slightly, as a result relieving pressure on the affected nerve roots. However, these treatments are not curative as they cannot reverse the herniation, but they can certainly provide palliative relief from the pain and discomfort.

If these measures fail to relieve your complaints, or if the herniated disc puts enough pressure on your spine to cause weakness or severe and constant pain, you may require Discektomy surgery to remove a small part or the entire wayward disc. The eliminated disc may or may not be replaced with an artificial one. Nonetheless, let your doctor decide what’s best for you.

Prognosis:

The prognosis of a mild to moderate disc herniation is quite good, with most of the patients improving with treatment. However, slight pain may resurface occasionally in the long run. But, to regain the ability to perform all of your normal activities may take several months. Although, surgery is a necessity in some cases it does not always guarantee a better outcome in comparison to conservative management.

Resources:

• Harrison’s Principles of Internal Medicine, 18th edition, Chapter 15- Back and Neck pain.

• http://www.nlm.nih.gov/medlineplus/ency/article/000442.htm" target="_blank" style="border: 0px; vertical-align: baseline; outline: none; color: rgb(74, 28, 82);">http://www.nlm.nih.gov/medlineplus/ency/article/000442.htm