What we Treat

Cranial Treatments

The brain is the body's control center. It enables you to think, feel and move with ease and receives and sends information on a never-ending basis. It is protected by a series of 8 bones that form the cranium, a part of the skull. The frontal, parietal, temporal, occipital, ethmoid and sphenoid bones are fused together by immovable joints called sutures that lock the edges of the cranium together, and make the 'cap' of your skull. Penetrating this protective cap and operating inside the body's control center requires a precise knowledge of the brain and nervous system that only a neurosurgeon possesses.

Neurosurgeons study the human nervous system, including the brain, for a minimum of 14 years. Their special knowledge combined with practical experience enables them to treat many illnesses and conditions previously considered to be untreatable. Today, strokes, aneurysms and even brain tumors can often be treated successfully by neurosurgeons

Lumbar spine disorders

The lumbar spine consists of 5 lumbar bones (vertebrae) stacked on top of the sacrum. The body of the vertebra is cylindrical mass of solid bone that is the weight bearing portion of the vertebra. Extending back from each side of the body are pillars of bone called pedicles. Two plates of bone, called laminae, arch between the pedicles, thus enclosing the spinal canal, which contains the nerves that travel to the legs. At the junction between the lamina and pedicle, behind the nerves, are smooth projections called facets, the joints of the spine. Between the vertebrae are discs, or cushions, which act as shock absorbers, and allow for motion and flexibility. Ligaments and muscle are attached to the vertebrae at various points to provide strength and stability and to control motion. The lumbar spine serves three primary functions: 1) to provide support for the body; 2) to protect the nerves that go to the legs, bowels and bladder; 3) to allow motion of the torso in relation to the pelvis.

The lumbar disc has an outer tough ring that encloses a softer, spongy center. As part of normal aging, the disc undergoes a gradual wear-and-tear process referred to as Adegeneration, characterized by the gradual loss of water, decrease in height, stiffening of the disc and bulging of the ring of the disc. This is a normal process that occurs in all adults, and is usually unassociated with any pain. Most adults older than 50, and many in their 40's have some degree of disc degeneration, which appears on an MRI scan as a darker appearance of the disc. Often the only symptom is a gradual loss of range of motion, often unnoticed because it occurs so slowly when you're 80 years old. Your back is not as flexible as when you were 20, but it is not necessarily painful.

Back Pain

Back pain is a common disorder - most people will suffer back pain at least once in their life. Usually it is simply a muscle sprain, and will resolve with a brief period of restricted activity, cautious exercise and over-the-counter medications. Sometimes back pain is more severe, or can last longer than a few days. In these cases, additional treatments may be needed - physical therapy, chiropractic treatment, massage therapy, anti-inflammatory medication such as ibuprofen or naproxen, or muscle relaxants.

There are many factors that can contribute to back pain: muscle and ligament sprains, degenerative arthritis, disc degeneration, spinal instability and compression fractures. Often many of these problems coexist. Complicating the diagnosis and treatment of back pain is the simple fact that virtually all people over 50, and many people over 30, will have changes of degenerative arthritis and disc degeneration on X-ray, MRI or CT imaging of their spines. Most of these people are free of pain. The tendency is to attribute pain to visible findings on X-rays and scans and to assume that correcting these abnormalities with surgery will fix the problem. This approach is too often an expensive failure, particularly if no attention is paid to appropriate conservative treatments, such as exercise and understanding of body mechanics, weight loss, physical therapy, chiropractic treatment, massage therapy and anti-inflammatory medication. However, in some cases of persistent back pain from mechanical abnormalities of the spine, where adequate conservative treatment has failed, surgery may be indicated. Your surgeon will discuss with you whether or not you should consider surgery.

Disc Herniation

When a disc herniates, a fragment of the spongy center of the disc protrudes through the outer ring. This is also referred to as a disc rupture, or a slipped disc. Depending on where the disc herniates, this can cause no symptoms, only back pain, or, if the fragment pinches a nerve, leg pain. When the leg pain radiates into the foot, it is often called sciatica. Sciatica is a syndrome consisting of pain, numbness and weakness radiating into the leg in a specific pattern. Most cases of sciatica will resolve on their own, or with conservative treatment, including temporary restriction of physical activity, exercises, physical therapy or chiropractic treatment. Sometimes steroid injections into the spine will decrease the pain and aid in recovery.

If the leg pain persists more than 4-6 weeks, or if there is significant weakness, surgery may be indicated. A small incision is made in the back, and using the microscope the fragment of disc is removed. This is referred to as a microdiscectomy, or a minimally invasive discectomy. It is usually an outpatient procedure, followed by a few weeks of restricted activity and cautious exercise, with recovery to normal activity in 6-12 weeks. Your surgeon will discuss with you whether an operation is indicated and available alternatives.

Lumbar Stenosis

Narrowing of the spinal canal which can result in compression of the nerves contained within the canal is called spinal stenosis. It is usually a degenerative condition, that is, a condition caused by years of wear-and-tear on the mobile elements of the spine. It is thus a condition associated with aging. Thickening of the ligaments, bulging of the discs and bone spurs arising from the facet joints can all contribute to spinal stenosis. Typical symptoms are pain, numbness and weakness in the legs brought on by standing and walking and relieved by sitting or lying. The condition is often progressive, and can lead to severe disability and inability to walk more than short distances.

Lumbar stenosis is diagnosed by symptoms and imaging studies of the spine (X-rays, CT, MRI) and ruling out other contributory conditions such as vascular impairment or peripheral neuropathy. Mild cases can often be treated with proper exercise and posture. Steroid injections into the spinal canal (epidural injections) are usually helpful for a period of time. Decompressive surgery (laminectomy) is indicated in severe cases unresponsive to conservative management. Often these operations may necessitate a fusion of the spine, depending on the individual circumstances of the condition.

Spinal Fusion

Spinal instability refers to a condition where weakness in the structural components of the spine allows for excessive motion. This motion can result in irritation of the nerves, causing pain, numbness or weakness. Spinal instability can also cause posturally related back pain. Instability can result from trauma, congenital conditions, degenerative changes or surgery. When spinal instability contributes to pain or weakness, or is anticipated because of planned surgical intervention, then your surgeon may recommend a spinal fusion.

Fusion techniques have improved considerably over the last decade with development of better spinal implants and bone fusion technologies. Achieving a good fusion involves two equally important components: 1) Instrumentation to provide immediate structural strength to the spine, and 2) Bone fusion to provide long-term stability by causing adjacent vertebrae to fuse into one solid piece of bone.

Instrumentation techniques are many and varied, depending on the necessities dictated by your individual case. They include pedicle screws, posterior or transverse lumbar interbody fusion (PLIF or TLIF), anterior lumbar interbody fusion (ALIF) or a combination thereof. Historically, bone grafts taken from the hip have been used as a source of fusion bone. However, this is now often replaced by a product called Infuse® which we have used with great success to achieve solid bony fusion, obviating the need for a separate, often painful incision to harvest bone graft.

Cervical Spine

The cervical spine is composed of 7 bones called vertebrae connected to each other by ligaments, discs and joints. The "body" of each vertebra is in the front, connected to a ring of bone behind. The opening in this ring is the spinal canal, through which the spinal cord passes. The discs are between the vertebral bodies and act as little shock absorbers. Each disc has a tougher lining around the outside, with a spongy center. On either side of the spinal canal between the vertebrae are openings for a spinal nerve to leave the spine. The discs, then, are in front of the spinal cord and exiting nerve, while the joints or facets are behind them. Finally, several different ligaments and muscles connect the vertebrae to each other. The muscles, ligaments and joints provide for flexibility and stability, while the bony portions give protection to the spinal cord and nerves and provide overall strength to the spine.

For more information associated with the Cervical Spine click on the links below.

Neck Pain

Neck pain can be due to many different problems, but the most common is a muscle strain. The neck soreness is often accompanied by pain that radiates into the back of the head as well. Most of these cases can be successfully treated for a short time with mild pain medications, neck exercises and attention to proper posture.

Sometimes neck pain is of longer duration. This is often a result of spinal arthritis and degenerative changes in the discs – things that occur in almost everyone by the age of 50, and in about half of those in their 40's. Most people with these X-ray changes do not have any problem at all with their necks, but sometimes the arthritis can be more of a problem, and when painful, can be associated with stiffness and tightness due to muscle spasm. Sometimes this pain can extend into one or both shoulders. After an examination (and sometimes X-rays) to rule out a more unusual problem, the symptoms are treated with non-narcotic pain medications, anti-inflammatory medication, exercises and perhaps physical therapy or chiropractic treatment. Scans are generally not needed at this time. If the problem persists despite these measures, a scan can be done followed by a referral to a neurosurgeon, although even then most do not need surgery.

Arm Pain

Pain, numbness, tingling or weakness in the arm often means involvement of a spinal nerve, though other causes must be considered. For instance, muscle spasm in the neck can sometimes cause tingling in the arm, usually toward the little finger. Nerve entrapment in the wrist (carpal tunnel) or elbow (cubital tunnel) can cause pain and numbness in the arm and hand. However, when a nerve is pinched in the neck, the pain will radiate into the arm, associated with numbness and weakness in a specific pattern.

A "pinched nerve" is usually the result of a disc herniation, also referred to as a "ruptured" or "slipped" disc. The disc lining gives way, allowing a piece of the softer center of the disc to push out against the nerve. While this can be due to an injury, more commonly the disc lining has simply become weak over time (similar to a worn tire). In about 80% of cases, the fragment of disc that has ruptured out against the nerve will be dissolved or shrunken by the body's own healing processes, thus relieving the symptoms. For this reason, symptoms from herniated discs will be treated with medication, therapy, and traction for at least 4 to 6 weeks, with the expectation that the symptoms will probably get better. This can occur even in the face of severe, debilitating pain at the onset of the problem. If the arm symptoms persist beyond that time without improvement, then surgery may be recommended. The goal of the surgery is to remove pressure from the nerve. This can be done from the front or from the back, depending on the patient's individual situation. This surgery is often done as an outpatient, or with an overnight hospital stay, followed by a few weeks of restricted activity and cautious exercise.

At times, X-rays and scans will show degenerative changes as well as a disc herniation. These cases can still be treated successfully without the need for surgery. However, there will be times when the pain persists. Usually this type of pain is not intense, and while there may be some numbness or tingling, muscle weakness is uncommon. Cortisone injections in the neck may help, but some of these more chronic cases will ultimately require surgery to achieve pain relief.

Spinal Cord Compression

Sometimes a disc herniation can cause compression of the spinal cord itself, without involving any of the spinal nerves. Fortunately, this is an uncommon occurrence. This is often not painful at all, but can cause numbness in both hands, difficulty with fine movements (buttoning, writing, and typing), hand weakness, and problems with walking. Similar problems can also result from compression of the spinal cord by arthritic bone spurs, though in these cases the symptoms progress much more gradually. Patients with spinal cord compression most often need to have surgery if their symptoms are significant. This problem is generally NOT amenable to conservative treatment. It is important to realize that the surgical procedure relieves pressure on the spinal cord, but does not make the symptoms better; this depends on the body's ability to heal the damage done by the pressure, and is a process that can take weeks of months. The less severe the symptoms are when the surgery is performed, the greater the chance of recovery.

Spinal Instability

Spinal instability refers to a condition where the structural components of the spine have become weakened, allowing for excessive motion and risk of spinal cord or nerve compression. This is a rare situation, but can occur as a result of trauma, infections, tumors, or simply progressive degenerative changes. When the instability threatens the spinal cord or nerves, or causes severe pain unresponsive to conservative treatment, surgery may be indicated. In these cases, a fusion of the spine is usually required to achieve adequate stability of the spine to resolve symptoms or prevent progression. When weakness is rapidly progressive, these cases can be urgent.

Cervical Microdiscectomy

Surgery to remove a cervical disc herniation is called a microdiscectomy, because the operating microscope is used to minimize the length of the incision and to improve the precision of the procedure. It can be performed from the front (anterior) or the back (posterior). When the anterior approach is used, the entire disc is usually removed, and the disc replaced with a graft. Formerly the graft was a piece of bone surgically removed from the hip. This resulted in excellent fusion rates, but the bone graft incision was often a source of significant pain. Now, synthetic grafts combined with a product known as Infuse®, a compound which stimulates bone growth without an actual bone graft, are used with excellent fusion rates, eliminating the pain associated with a bone graft. Usually a thin titanium plate is affixed to the vertebra to lock the graft in position, minimizing the need for wearing a collar around the neck, and allowing early neck mobilization.

When the posterior approach is used, a small opening in the bone is created with a drill, allowing the disc fragment to be removed. This usually does not require a fusion, but does result in more immediate pain after surgery, though this improves during the days and weeks after surgery.

With both of these approaches, the relief of arm pain is usually prompt, and often immediate. Moderate restrictions after surgery are recommended, followed by a few weeks of rehabilitation, often consisting simply of some self-directed exercises.