NSPC 2010 Newsletter Volume 3

Volume 3 April 2010 Issue 6

Brain and Spine Surgery Neuro-Oncology Neuro-Ophthalmology

Pain Management Dynamic MRI Physical Therapy

NSPCNEUROLOGICAL SURGERY, P.C.

April 2010

NSPCBrain and Spine Surgery Neuro-Oncology Neuro-Ophthalmology

Update

(516) 255-9031 www.nspc.com

Neurosurgeons

Stephen D. Burstein, M.D.

Michael H. Brisman, M.D.

William J. Sonstein, M.D.

Jeffrey A. Brown, M.D.

Benjamin R. Cohen, M.D.

Artem Y. Vaynman, M.D.

Lee Eric Tessler, M.D.

Jonathan L. Brisman, M.D.

Ramin Rak, M.D.

Alan Mechanic, M.D.

Donald S. Krieff, D.O.

Brian J. Snyder, M.D.

Elizabeth M. Trinidad, M.D.

Mihai D. Dimancescu, M.D.

Endovascular

Neuroradiologist

John Pile-Spellman, M.D.

Neuro-Oncologists

Paul Duic, M.D.

Jai Grewal, M.D.

Neuro-Ophthalmologist

Scott Uretsky, M.D.

Epilepsy Neurologist

Alan B. Ettinger, M.D.

Pain Management

Muhammad M. Khan, M.D.

Madan K. Raj, M.D.

Neurophysiologists

Joseph Moreira, M.D.

Marat Avshalumov, Ph.D.

Neuropsychologist

Gad E. Klein, Ph.D.

Top Doctors Join NSPC

Scott Uretsky, M.D.Neuro-Ophthalmologist

Alan B. Ettinger, M.D.Epilepsy Neurologist

Joseph Moreira, M.D.Neurophysiologist

Marat Avshalumov, Ph.D.Neurophysiologist

John Pile-Spellman, M.D.Endovascular Neuroradiologist

Gad E. Klein, Ph.D.Neuropsychologist

For brief biographies of our new specialists see page 2.

For complete biographies for these and all of our experts at

Neurological Surgery, P.C., visit our website.

www.nspc.com

NSPC NewsUpdate 30910.indd 1 4/8/10 12:01 PM

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e Biographies Welcome to NSPC

Scott Uretsky, M.D.Dr. Uretsky is a fellowship trained neuro-ophthalmologist with board certification in neurology (a diplomat of the American Board of Psychiatry and Neurology). Dr. Uretsky perfomed a fellowship in Neuro-Ophthalmology at the Wills Eye Institute and specializes in treatment of optic nerve disorders, visual disturbances and eye movement disorders of nervous system, including neurological, ophthalmic and systemic diseases that impact the visual system.

Joseph Moreira, M.D. Dr. Moreira is a board certified neurophysiologist, certified in Psychiatry and Neurology. He completed his fellowship in electromyography and neuromuscular diseases at Cornell University Medical Center/Hospital for Special Surgery. Dr. Moreira completed his internship and residency at St. Vincent’s Hospital and Medical Center. Prior to coming to NSPC he was Assistant Clinical Professor of Neurology at New York Medical College and Director, Electromyography and Intraoperative Neurophysiology at St. Vincent’s Hospital.

Alan B. Ettinger, M.D.Dr. Ettinger is a national leader in epilepsy who has dedicated his life to helping individuals with seizures and related disorders. Dr. Ettinger is the new Director of Epilepsy at Neurological Surgery, P.C. He completed his neurology and EEG/Epilepsy fellowship training at the Albert Einstein College of Medicine. Dr. Ettinger was the former Director of Epilepy at North Shore-LIJ.

Gad E Klein, Ph.D.Dr. Klein is a neuropsychologist who specializes in the cognitive aspects of various neurological disorders including epilepsy, movement disorders such as Parkinson’s disease, as well as brain tumors and dementia. Dr. Klein completed a fellowship at North Shore-LIJ in Neuropsychology and is also an expert in advanced neuro-imaging techniques such as functional MRI, as well as the intracarotid amobarbital test (Wada test) and electrocortical stimulation mapping. These procedures enable accurate brain localization of motor and sensory function, as well as higher-order cognitive functions such as language and memory in order to minimize post-surgical functional deficits in patients undergoing brain surgery.

Marat Avshalumov, Ph.D.Dr. Avshalumov is a neurophysiologist who specializes in the intraoperative monitoring of spinal cord and brain function during complicated surgical procedures that place the nervous system at risk. Prior to coming to NSPC, Dr. Avshalumov was the assoicate director of the intraoperative monitoring program at Mount Sinai Medical Center. Intraoperative neurophysiological monitoring assists in protecting the brain and spinal cord by providing real time feedback regarding the status of the nervous system to the surgical team.

John Pile-Spellman, M.D.Dr. Pile-Spellman is a world renowned expert in endovascular neuroradiology. Prior to coming to NSPC he was a Professor of Radiology, Neurology and Neurological Surgery, Vice Chair of Research and Director of Academic Interventional MRI at Columbia University Medical Center. He has been an attending Radiologist and Director of Academic Interventional Neuroradiology at New York Presbyterian Hospital. He completed residencies at Massachusetts General Hospital, as well as fellowships in Neuroradiology at Massachusetts General Hospital and Interventional Neuroradiology at New York University Medical Center.


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www.nspc.comMedical ServicesEndoscopic Pituitary Surgery

The endoscope - like the microscope - is a tool that helps neurosurgeons see the pituitary region better during surgery. The endoscope is a small, rigid rod that provides light and magnification from inside the sphenoid sinus. The surgeon watches a video monitor directly in front of him or her that displays the image that is coming from the endoscope. This is similar to how laparoscopic surgery is done. It is more comfortable for the surgeon and allows other people in the operating room to follow the surgery in detail.

The endoscope is small - between 0.11 and 0.16 of an inch (2.7 to 4 milimeters) in diameter. It can be threaded through the nose while leaving enough room for other surgical instruments to be introduced.

Once the endoscope is in place, it can easily be moved in all directions. This gives the neurosurgeon a wider and more adjustable field of view than the microscope. Other advantages of the endoscope include:

• Excellent vision to the sides

• Excellent vision from above

• Angled lenses that allow a surgeon to see around corners

• The ability to get closer to the pituitary gland and tumors

• Less disruption to the tissues because the instruments are smaller

At the same time, the endoscope has some disadvantages when compared to using a microscope for pituitary surgery. These include:

• Less ability to magnify the area being viewed

• Lenses can get fogged

A surgeon may use both an endoscope and a microscope when doing pituitary surgery.

Removing a Pituitary Tumor

Illustration © Copyright - www.mayoclinic.org


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e Medical ServicesChiari Malformation

Chiari (kee-AR-ee) malformation (CM) includes a complex group of disorders characterized by herniation of the cerebellum through the large opening in the base of the skull (foramen magnum) into the spinal canal. The herniated tissue blocks the circulation of cerebrospinal fluid in the brain and can lead to the formation of a cavity (syrinx) within the spinal cord. There are two main types of CM. CM1, the simplest and most prevalent form, is generally considered to be a congenital malformation, although acquired cases are recognized. (See diagrams at left.) It is rarely detected at birth. CM2 is a more severe congenital malformation, that is apparent at birth and associated with complex defects of the brain and spinal cord, particularly myelomeningocele (an opening of the lower spinal column).

Patients with CM1 may experience no symptoms. When symptoms are present, they usually do not appear until adolescence or early adulthood, but can occasionally be seen in young children. The majority of patients complain of severe headache and neck pain. Other common symptoms are dizziness, vertigo, disequilibrium, visual disturbances, ringing in the ears, difficulty swallowing, palpitations, sleep apnea, muscle weakness, impaired fine motor skills, chronic fatigue and painful tingling of the hands and feet. Because of this complex symptomatology, patients with CM1 are frequently misdiagnosed.

How common is Chiari Malformation?Until recent years, CM1 was regarded as a rare condition. With the increased availability of magnetic resonance imaging, the number of reported cases has risen sharply. Current estimates suggest from 200,000 to 2 million Americans have the condition. Women are affected three times more often than men. Approximately 3,500 Chiari operations are performed each year in the United States.

Understanding Chiari Malformation

Pre-Op, CM Type 1

Post-Op


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Treatment for a Chiari MalformationThere are many ways to treat Chiari malformations, but symptomatic patients usually require surgery. The basic operation is one of uncrowding the area at the base of the cerebellum where it is pushing against the brainstem and spinal cord. This is done by removing a small portion of bone at the base of the skull deep to the neck muscles as well as removing the back of the first spinal segment (C1). The operation may be modified if there is hydrocephalus. Most people who have the surgery do quite well and have an improvement in their symptoms.

Specific treatment for a Chiari malformation will be determined by the physician based on: • the patient’s age, overall health, and medical history • the extent of the condition • the type of condition • specific medications, procedures, or therapies • expectations for the course of the condition • your opinion or preference

Medical management consists of frequent physical examinations and diagnostic testing to monitor the growth and development of the brain, spinal cord, skull, and backbones.

When children are affected, parents are instructed to watch for any changes in normal functioning, including the following:

• breathing problems • degree of alertness • speech or feeding problems • problems walking

Michael H. Brisman, M.D.Stephen D. Burstein, M.D. Jeffrey A. Brown, M.D.William J. Sonstein, M.D. Lee Eric Tessler, M.D.

Ramin Rak, M.D. Alan Mechanic, M.D. Donald S. Krieff, D.O. Brian J. Snyder, M.D.

Resources: www.healthsystem.virginia.edu, www.ninds.nih.gov



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e Medical ServicesAcoustic Neuroma

An acoustic neuroma, also called a vestibular schwannoma, is a benign primary intracranial tumor of the myelin-forming cells of the vestibulocochlear nerve (CN VIII). (Neuroma is derived from Greek, meaning “nerve tumor”.) The term “acoustic” is a misnomer, as the tumor rarely arises from the acoustic (or cochlear) division of the vestibulocochlear nerve. The correct medical term is vestibular schwannoma, because it involves the vestibular portion of the 8th cranial nerve and it arises from Schwann cells, which are responsible for the myelin sheath in the peripheral nervous system. Approximately 3,000 cases are diagnosed each year in the United States with a prevalence of about 1 in 100,000 worldwide. Incidence peaks in the fifth and sixth decades and both sexes are affected equally.

An acoustic neuroma is a skull based nerve sheath tumor that constitutes about 6% of all primary intracranial tumors. They are usually benign and slow growing tumors which arise in the internal auditory canal and can grow into the cerebellopontine angle - a wedge shaped area bounded by the petrous bone, the pons and the cerebellum. Patients usually experience hearing loss which can be sudden or progressive. Other symptoms may include dizziness, ringing in the ears or balance problems.

Who can be treated?In general, all acoustic tumors with an intracranial diameter of up to approximately 3 cm (1 1/4”) qualify for stereotactic radiosurgery, a superfocused radiation treatment. Over the years, larger tumors occasionally have been treated successfully with this technique. However, there is a greater risk that these larger tumors, even before any treatment, interfere with the circulation of the cerebrospinal fluid (CSF), causing hydrocephalus (an excessive accumulation of CSF). In this case, a shunt may be required to divert the CSF. Temporary swelling of a large tumor, induced by the radiosurgery treatment, may occasionally result in hydrocephalus not present earlier. Surgical removal of a large tumor will frequently, though not always, eliminate the need for a shunt.

Treating a Skull Based Nerve Sheath Tumor

©northwesternuniversity

©northwesternuniversity


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www.nspc.com

Patients with large acoustic neuromas-especially older patients-may still prefer radiosurgery or fractionated radiotherapy rather than microsurgical removal.

In fact, there are few reasons why stereotactic radiosurgery should not be considered first instead of microsurgery for the vast majority of acoustic neuroma patients, including young and otherwise healthy ones.

What happens to the tumor?Very few acoustic tumors threaten the patient’s general health initially. The rationale for treating the tumor is to avoid the risk that the tumor might cause serious health problems or even death down the road if left alone to grow. By treating the tumor when it is still small, the risk of complications from treatment is generally smaller. Also, treatment of the tumor while there is still useful hearing allows for the possibility of hearing preservation.

Stereotactic radiosurgery is very different from open surgery. The short-term and long-term risks are very low. The goal of the treatment is to destroy or inactivate the tumor cells so they no longer duplicate. Since acoustic neuroma is a very benign type of tumor, it need not be completely destroyed. Instead, the aim is to stop further growth. An acoustic tumor that does not grow will not jeopardize the patient’s health in the future.

In a benign tumor such as acoustic neuroma, with a very slow cell turnover, it will take some time for the radiation to affect the cells in a way that can be detected clinically or by imaging.

Shrinkage actually is found in the vast majority of tumors when they are followed long enough. One year after the Gamma Knife treatment, (a radiosurgery technique), shrinkage is confirmed in about one-third of the tumors. After four years, two-thirds of the tumors are smaller, and by 10 years, more than 90% have shrunk.

Signs of lack of response to radiosurgery, in general, appear within one to three years of treatment. Failure is extremely unlikely to occur when five years or more have elapsed. This statement may not apply for acoustic neuromas associated with neurofibromatosis 2 (NF2) in which case recurrence may occur later following radiosurgery treatment as well as microsurgery.

Acoustic neuromas sometimes increase in size temporarily as a reaction to the radiosurgery treatment. This is actually a favorable sign indicating a brisk response. Such swelling usually is most obvious between 6 and 18 months after the procedure. It should not be confused with increase due to lack of response in which case the tumor size will not return to the baseline but continue to increase.

A definite assessment should be made two years after the treatment: was the swelling merely temporary or did the tumor fail to respond to the treatment? In any case, resection should usually not be considered during this two-year wait.

Resource: www.IRSA.org

©Leksell.com

The Doctors at Neurological Surgery, P.C. who specialize in the treatment of acoustic neuroma include Dr. Michael Brisman, Dr. Jeffrey Brown, Dr. Lee Tessler, Dr. Ramin Rak, and Dr. Alan Mechanic.


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Trigeminal NeuralgiaMedical Services

Without warning, the excruciating, electric-shock-like pain that pierced the right side of Mary Worth’s* face would immobilize her. Occasionally, the piercing jab erupted without apparent cause; more often, it was triggered when she brushed her teeth, applied makeup, chewed food, encountered a soft breeze or even smiled. “I even became afraid to shower because sometimes the water would set off the pain,” said the 46-year-old eastern Long Island mother of three. “It would feel like someone was stabbing me in the face. Until it went away, I couldn’t move. I was always anxious and scared the pain would hit out of nowhere.”

She was suffering from Trigeminal Neuralgia (TN) — a neuropathic disorder of the trigeminal nerve that plagues victims with intermittent severe facial pain, which can interfere with daily life. Over time, it can lead to severe anticipatory anxiety, depression and life-threatening malnutrition. “TN is considered among the most severe types of pain anyone can experience, ”explained Michael Brisman, MD, Winthrop’s Chief of Neurosurgery and a TN specialist. Affecting thousands of Americans each year, TN usually occurs when a small blood vessel comes into contact with the fifth cranial nerve, applying pressure at the point where the nerve joins the brain stem. TN can also be caused by Multiple Sclerosis (MS) or small tumors pressing against the Trigeminal nerve. It is diagnosed after taking a detailed history, performing a neurological examination, analyzing Magnetic Resonance Imaging (MRI) scans and ruling out other possible causes of facial pain, including dental problems, migraine headaches and tumors.

Treatment Options“Most TN sufferers get temporary help from pain relievers or anticonvulsant medications such as Tegretol® or Neurontin®, ” said Dr. Brisman. “But, after a while, the pain attacks typically grow more frequent and severe, requiring higher dosage and more continuous usage of medication. As are result, many patients, whose pain was initially well controlled with medication, find that they must increase their dosage to toxic levels in order to get relief.” If patients cannot tolerate medication because of side effects, or have pain despite medication, surgical intervention is indicated.

That is when Robert Kent* — at his wit’s end because of unrelieved facial pain and untenable side effects from his medications — heard about the treatment for TN offered by Dr. Brisman at Winthrop’s Institute for Neurosciences. The 47-year-old New Jersey resident had been suffering with the condition for 10 years, with pain often set off when he shaved, frowned or laughed. “At first, the episodes were mild and alternated with pain-free periods over a couple of months,” explained Mr. Kent. “Then I’d be totally okay for a while. Each time, I kept hoping the remissions would be permanent, but that didn’t happen. In fact, the quiet periods got shorter, and the pain became more severe. Finally, after seven months without relief, I felt I couldn’t deal with it anymore. I had heard about Dr. Brisman, and decided a visit was worth the trip from New Jersey.”

Dr. Brisman explained that there are several surgical options. Most are based on interrupting the pain by damaging the trigeminal nerve fibers. These “nerve-injuring” procedures include glycerol rhizotomy, which entails injuring the nerve with an injection of sterile glycerol and using balloon compression, which involves inflating a tiny balloon in the base of the skull with enough pressure to damage the nerve and block pain signals; electric current and sterotactic radiosurgery can also be used to selectively destroy the nerve’s fibers.

While these procedures alleviate the condition, they can cause temporary or permanent facial numbness, and the pain can return. The nerve-injuring procedures are outpatient procedures, which are preferred for TN patients who are elderly, have significant medical problems or have MS.

* Patient’s name has been changed in order to comply with HIPAA regulations.

Microvascular Decompression Surgery


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Hitting the Root Cause with MVDAccording to the literature, the only non-destructive procedure that reliably eliminates TN symptoms is microvascular decompression (MVD), which aims to remove the identified cause of the condition by relocating or removing the blood vessel pressing on the nerve and causing the pain. The procedure is not intended to damage or destroy any part of the trigeminal nerve.

About 95 percent effective with a low risk of pain recurrence or side effects, such as facial numbness, MVD offers the best potential for long-term relief or cure of TN pain. As such, MVD is the preferred procedure for TN patients who are young, healthy and do not have MS.

Dr. Michael Brisman and Dr. Jeffrey Brown are among a small, select group of neurosurgeons in the region with the expertise and experience to perform this delicate surgery. They treat hundreds of TN patients each year, and their widespread reputation for success has made Winthrop’s Institute for Neurosciences a center of excellence for the treatment of this condition in the tri-state region.

During MVD, which takes about two-to-three hours and requires general anesthesia, a quarter-sized hole is made behind the ear on the side of the face that is painful. The surgeon enters the skull through the small opening, and with the aid of an operative binocular microscope to magnify the field, the brain is carefully retracted to expose the trigeminal nerve. If an artery is found in contact with the nerve root, it is directed away, and a tiny Teflon cushion-like pad is placed between the nerve and the vessel. The pad isolates the nerve from the pulsating effect and pressure of the artery. If a vein is compressing the nerve, the vessel is removed.

Pain relief is usually instant, and after a brief hospitalization with the first night spent being closely monitored in Winthrop’s Neuroscience Intensive Care Unit, patients are discharged, requiring no further medications. “I was back on my computer the day I got home,” said Mr. Kent, “and six months later, I’m still pain-free without drugs. I can’t believe I waited so long to do this.”

“MVD is remarkable,” said Dr. Brisman. “The nerve and the vessel are so tiny and intertwined, yet simply separating them by just 1 mm fixes the problem.” That is exactly what happened to Ms. Worth: “When I woke up after the surgery, I immediately touched my face,” she reported. “I didn’t feel any discomfort or pain. I was elated. That was more than two years ago. It’s such a good feeling not to be scared. I feel like Dr. Brisman saved my life.”

Reprinted from Progressive Neuroscience with permission from Winthrop-University Hospital’s Institute for Neurosciences.

www.nspc.com



viewmedia.com ©2007 Swarm Interactive


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e Medical ServicesPediatric Neurosurgery

Endoscopic Third Ventriculostomy Effective Alternative to ShuntingShock, disbelief and a sense of helplessness overwhelm most parents when they hear their child has hydrocephalus — the most common reason for brain surgery in children. Their feelings are understandable, but advances in technology and treatment protocols are bringing hope to these families, helping more and more youngsters with an excessive amount of cerebrospinal fluid (CSF) lead full, active lives.

At Winthrop-University Hospital, pediatric neurosurgeon Elizabeth Trinidad, MD, an expert in endoscopic brain surgery, uses the latest sophisticated, minimally invasive techniques to treat patients with hydrocephalus, as well as a variety of other conditions, including craniosynostosis, tumors, congenital malformations, epilepsy, trauma and degenerative disease.

“Although hydrocephalus is not a household word, it is not uncommon,” said Dr. Trinidad. “We see the condition in about one or two out of every 1,000 live births. The abnormal accumulation of CSF within the brain can occur for many reasons, but it usually results from an obstruction located in the ventricles. While there’s no cure, it’s treatable.”

Hydrocephalus can be congenital or acquired, with aqueductal stenosis, brain hemorrhaging and in-utero infection the most common causes of the former. The acquired condition is associated

with the interaction of environmental and genetic factors, including birth injury, cysts, tumors, blood clots, head trauma or infection.

“Regardless of the cause, the fluid build up that elevates intracranial pressure (ICP) can lead to seizures, motor and behavioral problems, learning disabilities, coma and even death,” explained Dr. Trinidad. “While severity differs considerably among individuals, the key to effective care is early detection and treatment.

Specific symptoms depend on the cause of the blockage, the patient’s age and how much brain tissue has been damaged. Hydrocephalus is detectable in utero via ultrasound. After birth, symptomatic patients are diagnosed through computed tomography (CT) and magnetic resonance imaging (MRI) scans.

The goal of treatment is to decrease and prevent brain damage by draining the collected CSF to reduce the ICP. While specific treatment depends on the child’s gestational age, overall health and medical history, as well as the cause, type and extent of the condition, surgery is usually the treatment of choice. If possible, the obstruction is removed, and the hydrocephalus is resolved. Frequently, however, a direct method is not available to open obstructed CSF pathways, and a bypass must be created to allow for the fluid’s normal flow.

To achieve this, a shunt — the traditional approach to treating hydrocephalus — may be placed in the brain to drain and redirect the extra fluid from the ventricles to another part of the body, such as the abdomen. However, since a shunt is a foreign body, potential complications include infection, bleeding and malfunction, as well as over- or under-draining.

Image copyright ©2010- www.upstate.edu


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ETV: Popular Alternative“Generally, over 50 percent of shunts need to be revised within the first year of being inserted,” reported Dr. Trinidad, who uses endoscopic third ventriculostomy (ETV) as an alternative to shunting in order to treat obstructive, tumor-related hydrocephalus; remove colloid cysts that can block the foramen of Monroe; and fenestrate loculations, where possible, to help cysts communicate with the ventricles. “With the significant advances in endoscopes, fiberoptic imaging and other specialized instruments, ETV has become a popular, safe and effective alternative to ventricular shunt placement. We aim to treat patients without using shunts, or to simplify the shunt process as much as possible by fenestration of loculated fluid spaces.”

ETV, an internal bypass procedure, involves passing a slim-tubed endoscope with a tiny camera at the tip through a tiny burr hole in the skull. The microcamera is connected to a TV monitor that clearly displays the brain as the endoscope is navigated from the top of the skull through the brain to the base of the third ventricle. A small hole in the thin membrane of the ventricle floor allows the accumulated fluid to bypass the obstruction and flow into the subarachnoid space. This establishes normal CSF circulation within the brain and spinal cord.

“The success of ETV depends on patient selection and what caused the hydrocephalus in the first place,” explained Dr. Trinidad. “If the patient is chosen carefully, our success rate can be as high as 85 percent. When the cause is an infection or a bleed in the brain, success is about 50 percent.”

Once a third ventriculostomy functions and the hydrocephalus is relieved, there’s usually no need for further surgery. This compares favorably to the use of shunts, since about 70 percent fail with a 10-year period, with a hydrocephalic child potentially needing five-to-six shunts inserted before reaching adulthood. What’s more, the risk of ETV is low, with few potential side effects. There is no over drainage, no blockage, very little risk of infection, and most important, no implanted foreign material to cause future problems.

Symptoms of Hydrocephalus

Infants • Full or bulging fontanel• Accelerated and

disproportionate growth of the head

• Sun-set eyes• High-pitched cry• Lethargy• Difficulty feeding• Vomiting • Developmental delays

Babies able to communicate • Excessively irritable• Headaches• Vision changes• Uncontrolled eye movements• Loss of coordination

Elizabeth Trinidad, M.D., is a fellowship trained pediatric neurosurgeon who specializes in the treatment of children and adults afflicted with complex disorders of the brain and spine. Dr. Trinidad is expert in neuroendoscopy and uses minimally invasive techniques when treating diseases of the brain and spine such as tumors, congenital malformations (craniosynostosis, spina bifida and Chiari), hydrocephalus, epilepsy and spasticity, trauma and degenerative disease.


Reprinted from Progressive Neuroscience with permission from Winthrop-University Hospital’s Institute for Neurosciences.


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e Case StudiesNeurovascular

Figure 1 - Aneurysm

Copyright ©2006 Massachusetts Medical Society, All rights reserved.

Endovascular Coiling Treats Cerebral AneurysmEndovascular coiling of cerebral aneurysms (Figure 1) is now an accepted alternative modality to craniotomy and clipping and is the preferred treatment for aneurysms that are deemed to be surgically high-risk. The case presented is that of a 53 year old woman whose sister had suffered from a hemorrhage from a brain aneurysm. After complaining to her doctor of headaches, an MRI and an MRA were performed, which disclosed a brain aneurysm that was ultimately demonstrated using conventional diagnostic cerebral angiography (Figure 2).

The aneurysm was considered to be a paraclinoid region aneurysm, situated partially in the anterior skull base, partially blocked by the anterior clinoid. This makes surgery quite difficult and the patient was offered endovascular coiling as a less invasive alternative. The aneurysm also had a wide neck, relative to its dome, making it difficult for the coils to sit properly inside the aneurysm without falling out and obstructing the carotid artery, potentially causing a stroke.

An advanced technique, known as “stent-assisted coiling” was used in which a stent was deployed across the aneurysm neck, followed by coil deployment inside the aneurysm (Figure 3). This was performed successfully (Figure 4) and the patient was discharged home neurologically intact three days after the procedure.

Jonathan Brisman, M.D., is a neurosurgeon who specializes in cerebrovascular and endovascular surgery. He is one of an estimated 80 neurosurgeons nationally trained in both microneurosurgery and endovascular techniques and the first dual-trained endovascular neurosurgeon on Long Island.

John Pile-Spellman, M.D., is recognized as an international leader in Interventional Neuroradiology. He specializes in the diagnosis, management and treatment of cerebral aneurysms, strokes, tumors, vascular malformations and development of innovative image-based services.

Figure 2 - microcatheter/coil in place

Figure 3 - stent-assisted coiling Figure 4 - before and after treatment

Jonathan L. Brisman, M.D. John Pile-Spellman, M.D.


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www.nspc.comMedical ServicesNeurovascular

Compression fractures, back pain, spinal stenosis and herniated disc. These are just a few of the many painful conditions the physicians at Neurological Surgery, P.C., treat with the latest exciting techniques. Techniques such as Kyphoplasty, Spinal Stimulation, X-STOP® and Microdiscectomy cure these spinal problems efficiently and effectively.

KyphoplastyKyphoplasty is a new technique for repairing spinal compression fractures in patients with intractable pain. A special needle is inserted into the fractured vertebral body under fluoroscopy, a balloon is inflated, which restores vertebral body height, and cement is injected into the space left by the balloon. Patients go home the next day, and pain relief usually occurs within 48 hours. Drs William Sonstein, Benjamin Cohen, Artem Vaynman, Ramin Rak, and Donald Krieff perform the kyphoplasty.

Spinal StimulationSpinal stimulation, also known as dorsal column stimulation, offers relief for patients with low back and leg pain. The stimulator, a flexible tiny wire, is placed just under the spinous lamina in the epidural space, and sends signals up to the brain which can cancel out sensations of pain. The newest version of this device (“octad”) has a lead with eight stimulation electrodes for faster, easier delivery of relief. It also has a rechargeable pulse generator which looks like a small pacemaker battery that powers the stimulator lead. Since this new device can now be recharged externally, it will last for nearly a decade. Drs Michael Brisman, Jeffrey Brown, Ramin Rak, Alan Mechanic, Donald Krieff, and Brian Snyder implant this “octad” spinal stimulator.

X-STOP™ X-STOP is a titanium implant that can provide relief from the pain of spinal stenosis without a traditional laminectomy. Patients with lumbar spinal stenosis (LSS) suffer from pain in the low back and legs as a result of compression of the nerves in the spinal canal. This pain is classically worse when walking, and better when flexing forward. This flexion tends to open up the spinal canal. The X-STOP places a small metal implant between the affected levels in the spine (usually L3/4 or L4/5) and effectively produces a permanent slight flexion. This then provides symptom relief. Drs Stephen Burstein, William Sonstein, Benjamin Cohen, Artem Vaynman, Ramin Rak, Alan Mechanic, and Donald Krieff offer this new procedure. According to Dr. Sonstein, “This X-STOP is really wonderful! My patients keep calling to thank me for how much better they feel.”

Microdiscectomy In a microdiscectomy a surgeon makes a small incision to remove a portion of the disc material to provide more room for the nerve to heal and relieve symptoms of neural impingement. The surgeon uses a specialized microscope or magnifying instrument to view the disc and nerves, making it possible for the surgeon to remove herniated disc material through smaller incisions than possible with a regular discectomy, therefore it causes much less tissue damage. Microdiscectomies can decrease the pain caused by a herniated disk and allow for more normal movement and function with a faster recovery time than ever possible before. Drs Stephen Burstein, William Sonstein, Benjamin Cohen, Artem Vaynman, Ramin Rak, Alan Mechanic, and Donald Krieff perform the microdiscectomy.

Experts at Minimally Invasive Treatments for Spine Conditions

Spine Surgery


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Cervical spinal stenosis is defined as narrowing of the space for the spinal cord in the neck. The spinal cord carries nerve fibers from the brain to the arms and legs, and also carries sensory information back from the arms and legs to the brain. Naturally, such important nerve tissue needs protection, and is therefore surrounded by bone (and joints) in all direction, hence creating a “canal.” The spinal canal is normally composed of the vertebral body in front of the spinal cord, and the pedicle and lamina bone and facet joints in the back of the spinal cord. Under normal conditions, there is plenty of space in this canal, allowing for a gap of fluid that cushions the spinal cord from these bones. However, various conditions can cause a narrowing of this spinal canal, thereby causing pressure on the spinal cord. This narrowing of the canal in the neck is called “cervical spinal stenosis.”

A number of different conditions can result in cervical spinal stenosis, namely degenerative, trauma, certain congenital conditions, and even certain tumors or infections. However, the most common cause is the so-called degenerative process, where age, time, and gravity, gradually result in settling of the bones and joints of the cervical spine.

Symptoms of cervical spinal stenosis can vary depending on the severity or degree of stenosis, as well as how quickly the condition came on. Mild stenosis can cause neck pain or stiffness, or can sometimes be asymptomatic (no symptoms whatsoever). Moderate stenosis can show up as subtle numbness of the hands, or weakness and difficulty with fine skilled movements of the hands. Finally, severe stenosis can result in weakness of part of the arms or shoulders, weakness of the hands, weakness of the legs, imbalance, difficulty walking, and even incontinence.

Cervical spinal stenosis can be diagnosed by your doctor through a combination of careful history documentation, neurological examination, and diagnostic imaging tests such as an MRI scan (magnetic resonance imaging) or sometimes CT scan (computed tomography). Mild or moderate stenosis can sometimes be observed and treated with anti-inflammatory medications and physical therapy. However, severe spinal stenosis can be dangerous, and some of the symptoms can become permanent. It is important to catch cervical spinal stenosis before the symptoms become permanent, since symptoms can be reversed with surgery if caught early enough. Surgery for severe cervical spinal stenosis can involve an anterior neck approach, a posterior neck approach, or both. Anterior neck approaches include cervical discectomy, where one or more joints are removed and replaced with bone graft, or cervical corpectomy, where an entire vertebral body (or more) is removed and replaced with bone graft. Posterior neck approaches include cervical laminectomy, where one or more laminae (bony covering of the spine) is removed; cervical laminoplasty, where a small portion of the laminae on one side of the spine is opened; and cervical laminectomy plus fusion, where one or more laminae are removed followed by welding together several segments of the spine using bone graft and titanium screws.

A case which dramatically illustrates the importance of diagnosing cervical spinal stenosis early (and treating early) is that of Cooper Manning. The older brother of both Peyton and Eli Manning, Cooper was once a promising wide receiver at Isadore Newman High School in New Orleans. As a junior, Cooper didn’t drop a single pass. However, in his senior year he started noticing numbness in his hands, and uncharacteristically dropped several passes (because of lack of sensation in his hands). He was eventually diagnosed with cervical spinal stenosis, requiring surgery.1 Please see your doctor for an evaluation if you have any of the aforementioned symptoms.

1. Scheiber, David. The Other Manning. St. Petersburg Times. November 7, 2004. Available at: http://www.sptimes.com/2004/11/07/Sports/The_other_Manning.shtml

Spinal DisorderMedical Services

Cervical Spinal Stenosis


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Update

C2 Fracture from Fibrous DysplasiaCase Study:This 38 year old man was wrestling with his nephew when he felt a pop and had sudden pain in his neck.

He was neurologically intact, but admission CT scan showed a C2 fracture and “ground glass” appearance of the entire C2 segment, including vertebral body, pedicle, lamina, facet and spinous process. This was consistent with fibrous dysplasia, a bone disorder in which soft fibrous tissue develops in place of normal bone. The etiology is a mutation in the GNAS1 gene (a cell-signaling protein) which causes osteoblast cells (which normally manufacture bone) to secrete the soft connective tissue.

Given the pathology of the fibrous dysplasia, an odontoid screw was precluded. An attempt was made to place him in a halo vest; however, serial CT scans showed persistent non-union after two months. Since an odontoid screw was precluded, the only option was posterior fusion/fixation. He was taken to surgery for C1 pars/pedicle screws-C3 lateral mass fixation. In addition, this construct was supplemented with sublaminar wires and an iliac crest bone graft from C1 to C3.

Long term post-op films showed solid arthrodesis (not shown). The patient will require longer term serial follow up CT scans because of the low risk of degeneration of the fibrous dysplastic bone into osteosarcoma (a bone cancer).

Case Studies www.nspc.com

Pre-op CT showing type II odontoid fracture

X-rays of neck in extension, neutral and flexion positions showing no instability.

Post-op CT scan showing

C1 pars/pedicle screw

Admission scan showing fibrous dysplasia

Severe Neck Pain Case Study:This was a 71 year old man who was a retired engineer. He was working on his boat at the dock, lifting some poles (with great effort). His grip loosened, causing him to slip backwards. He fell, striking the back of his head. He had sudden onset of neck pain.

On admission he was found to be neurologically intact but he had severe neck pain. Admission CT scans showed a type 2 odontoid fracture.

This was initially treated nonsurgically, with an external halo rigid fixation (a very uncomfortable device where screws are placed in the skull and fixated with rods to a stiff plastic body vest), however after four months in a halo, follow up CT scans showed non-union.

It was decided an odontoid screw should be used to to facilitate fusion.

The operation lasted about one hour, and he was discharged one day after surgery, the halo being replaced by a neck brace.

One month after surgery, follow up CT scan showed bridging bone across the fracture. Two months after surgery, his neck brace was removed and he was allowed to return to normal activities. Longer term X-rays (one year) showed solid healing of his neck fracture.

CT of neck. Middle image shows odontoid screw in good position.


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e Medical ServicesEpilepsy

Epilepsy is a medical condition that produces seizures affecting a variety of mental and physical functions. It’s also called a seizure disorder. When a person has two or more seizures, they are considered to have epilepsy.

A seizure happens when a brief, strong surge of electrical activity affects part or all of the brain. One in 10 adults will have a seizure sometime during their life.

Seizures can last from a few seconds to a few minutes. They can have many symptoms, from convulsions and loss of consciousness to some that are not always recognized as seizures by the person experiencing them or by health care professionals: blank staring, lip smacking, or jerking movements of arms and legs.

There are many different types of seizures. The kind of seizure a person has depends on which part and how much of the brain is affected by the electrical disturbance that produces seizures.

Treatment for seizures involves either medical therapy or surgery. Anticonvulsant (anti-seizure) medications are typically used to treat this disorder.

Surgical options for epilepsy include procedures to map and more effectively identify the regions of the brain responsible for seizures, resections of the area of the brain responsible for seizures, and vagus nerve stimulation. Temporal lobectomy has been proven to be superior to prolonged medical therapy in patients with temporal lobe epilepsy. Surgery is effective in reducing seizures in other regions as well. Vagus nerve stimulation may be used as an aid in reducing seizure frequency in patients with partial onset epilepsy.

Alan B. Ettinger, M.D. and his team of specialists are proud to introduce four new cutting edge epilepsy programs to Long Island:

1. The Center for Treatment of Uncontrolled Seizures.

2. The Epilepsy Surgery and Brain Mapping Program, designed to provide state-of-the-art approaches to controlling severe seizure disorders.

3. The Anti-epileptic Drug Management Program, designed to find the safest and most effective anti-epileptic medical treatments available.

4. The Quality of Life in Epilepsy Program, designed to compassionately address the overall well-being and psychological needs of adults and adolescents with epilepsy.

What is Epilepsy?





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Update


Glioblastoma Multiforme Case StudyGlioblastoma multiforme, also known as grade 4 astrocytoma, is the most common and aggressive type of primary brain tumor, accounting for 52% of all primary brain tumor cases and 20% of all intracranial tumors.

Case Study:This is a 58 year-old gentleman with a glioblastoma of the left basal ganglia and midbrain. He experienced significant right arm and right leg weakness and required a wheelchair. He received standard-of-care treatment with radiation and temozolomide with no significant change in the tumor on MRI, and no change in his weakness.

His chemotherapy regimen was then switched to a different regimen created by NSPC physicians, resulting in the dramatic improvement seen on MRI, as well as improvement of his right-sided weakness. The improvement was seen after approximately 2 months of the new therapy. The patient’s quality of life has also improved, and no significant side effects were reported from the treatment.

Before After

Before After

Neuro-Oncology

Paul Duic, M.D.

Jai Grewal, M.D.

NSPC Neuro-OncologistsPaul Duic, M.D., is a Neuro-Oncologist. He specializes in the medical management of brain tumors and spine tumors, including central nervous system (CNS) tumors, gliomas, metastatic tumors, and CNS lymphoma. Dr. Duic completed his fellowship in Neuro-Oncology at the Neuro-Oncology Branch of the National Cancer Institute, National Institutes of Health (NIH).

Jai Grewal, M.D., is a Neuro-Oncologist. His clinical practice includes management of patients with primary and metastatic tumors of the brain and spine. These include glioblastoma, astrocytoma, meningioma, lymphoma, as well as other diagnoses. Dr. Grewal completed his Neuro-Oncology fellowship at the MD Anderson Cancer Center, in Houston, Texas.


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Scott Uretsky, M.D.

Eye Exam Detects Pituitary Tumor

Neuro-Ophthalmology

Case Study:Pituitary tumors cause progressive visual loss through compression of the optic nerves or optic chiasm. Occasionally they can be difficult to diagnose and may even be asymptomatic to the patient. Jane Doe is an example of such a case. Jane Doe went to her optometrist for a new pair of glasses. Jane was asymptomatic and did not notice any difficulties with her vision. Astutely her optometrist noted that Jane’s vision could no longer be corrected better then 20/40, where it had always been perfect in the past. The optometrist referred her to our office.

The neuro-ophthalmologic exam was consistent with bilateral optic nerve dysfunction, worse on left. Testing included visual fields which were abnormal bilaterally and optical coherence tomography, which was consistent with loss of nerve fibers in the optic nerve. This was despite the fact Jane Doe was asymptomatic of her condition.

We proceeded with an MRI to evaluate Jane. This revealed a large pituitary tumor. I referred Jane, to my colleague, Dr. Michael Brisman, who specializes in surgical removal of such masses. This is just one of the many examples of Neurological Surgery P.C.’s ability to coordinate and provide comprehensive care for patients with complex nervous system disease.

Conditions We Treat

Acute Vision Loss

Bell’s Palsy

Blepharitis and Dry Eye Syndrome

Blepharospasm and Hemifacial Spasm

Double Vision (Diplopia)

Drusen and Pseudopapilledema

Idiopathic Intracranial Hypertension (AKA Pseudotumor Cerebri) and Papilledema

Micro-vascular and Other Cranial Nerve Palsies

Migraine

Ocular & Systemic Myasthenia Gravis

Optic Neuritis

Pituitary Tumors

Pupillary Irregularities: Anisocoria, Horner’s Syndrome, Third Nerve Palsy & Adie’s Pupils

Thyroid Eye Disease

Trigeminal Neuralgia

Tumors of the Visual Pathways

Visual Field Disturbances

Dr. Scott Uretsky specializes in treatment of optic nerve disorders, visual disturbances and eye movement disorders of the nervous system. These include neurological, ophthalmic and systemic diseases that impact the visual system.

Tumors of the pituitary gland are common and usually benign in

nature. The close proximity of the pituitary gland to the visual

pathways, specifically the optic nerves and chiasm, causes visual

dysfunction to be one of the more common presenting symptoms

of such tumors. Visual symptoms can be non-specific and may

even be found incidentally on routine visual testing, without prior

knowledge by the patient. Classically, symptoms include decreased

peripheral vision to both sides. However, unilateral decreased

vision or an abnormal visual field is possible as well. Double

vision may also occur less commonly. Visual field testing, especially

automated visual fields, are of great importance. Visual prognosis

can now be made with optical coherence tomography, a painless,

noninvasive imaging test. Laboratory studies for hormonal levels

are part of the evaluation as well. Depending on the hormonal

status of the tumor and its size and impact on vision, treatment is

with medication, surgical intervention, or radiation.

Medical Services


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Update

Eye Exam Detects Pituitary Tumor Many people are unaware that Botox® injections are not only used to reduce wrinkles in the face, but also for easing spasms associated with pain in the neck and back region. Botox® is a purified form of Botulinum toxin type A that has long been used to relax and treat uncontrolled muscle contractions caused by a number of medical conditions.

Botox® is the brand name for the neurotoxic protein used in the injection which can temporarily inactivate nerves in the area of pain. For the treatment process, the Botox® drug is placed in the muscles to help improve the ache from chronic muscle spasm. Botox® injections are a simple procedure safe enough to be performed in the office without any image guidance such as fluoroscopy.

According to many studies, the complications associated with Botox® therapy as treatment for chronic pain are rare. However, as with any invasive procedure, the unwanted side effects need to be considered. Temporarily, side effects from the Botox® drug may include flu-like symptoms, increase in pain, weakness in the muscle injected, body ache, dry mouth, difficulty swallowing and hoarseness of voice.

Researchers are unsure why Botox® relieves head pain. For its other uses including alleviating facial wrinkles and treating other medical conditions, purified protein relaxes the overactive muscle by blocking nerve impulses that trigger contractions. Some researchers believe Botox® works by blocking the protein that carries the message of pain to the brain in migraine pain relief. Pain relief takes effect two to three weeks after injections. Injection can be repeated after three months. Botox® therapy is an excellent addition to physical therapy to relieve neck pain caused by chronically contracted muscles.

Relaxing the neck muscles before physical therapy maximizes the potential for rehabilitation and repair of damaged muscle tissue, strengthens weakened muscles caused by spasms, and relieves pain. Treating chronic neck pain with Botox® injections also has an advantage over oral pain medication because the effects of injection are local and do not cause the side effects associated with oral pain medication such as sedation, fatigue, dizziness and addiction.

Muhammad M. Khan, M.D., is a board certified Interventional Physiatrist who specializes in Pain Management and Physical Medicine and Rehabilitation. Dr. Khan practices interventional pain management, spine and musculoskeletal medicine, electrodiagnostic medicine and general physiatry.

Madan K. Raj, M.D., is a board certified Interventional Physiatrist who specializes in Pain Management and Physical Medicine and Rehabilitation. Dr. Raj practices interventional pain management, non-operative spine care, musculoskeletal medicine and general physiatry.

Pain ManagementBotox®: A New Weapon Against Chronic Pain


Madan K. Raj, M.D.



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Neuropsychology is a specialty within the field of psychology that focuses on the relationship between brain function and behavior. In addition to their training in psychology, neuropsychologists have additional training in neuroanatomy and cognitive neuroscience. They use this training to assess, diagnose, and treat a variety of medical, neurological, neurodevelopmental, and psychiatric conditions that can affect cognition. Cognition can refer to different areas of brain function such as language, memory, visuospatial function, and decision making.

Conditions AssessedEpi lepsy – A neuropsychological evaluation can be

critical to patients with epilepsy who very often experience difficulties with such functions as memory, language, and concentration. A thorough evaluation can pinpoint their cognitive deficits and direct the patient for the proper rehabilitative treatment. For patients who are possible epilepsy surgical candidates the evaluation serves as a critical aspect of the pre-surgical workup as it can assist in localizing the area of the brain where the seizures originate and help to determine any possible post-operative cognitive declines.

Mo vement Disorders – Patients with movement disorders such as Parkinson’s and Huntington’s disease often complain of various cognitive difficulties even early on in the course of the disease. A neuropsychological evaluation can serve as a baseline measure of cognitive performance and

can track disease progression and help guide treatment. Patients undergoing deep brain stimulation surgery for Parkinson’s disease should receive pre-operative evaluations to rule out any cognitive factors (e.g. early onset dementia) that may be predictive of increased post-surgical cognitive and psychiatric side effects.

Brain Tumors – Tumors can lead to cognitive difficulties for a number of reasons. The tumor itself may be in or affecting an area of the brain that is important for functions such as language or decision making. Pre and post-surgical neuropsychological evaluations can help to clarify these deficits and help to inform and prepare the patient for what they can expect post-operatively. Non-surgical treatments such as chemotherapy can also impact cognitive function. Evaluation during and after treatment is useful for elucidating the specific difficulties that an individual patient is experiencing and planning rehabilitative treatment or dictating specialized accommodations for both school and work environments.

Neuropsychology

How Brain Function Affects Behavior


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www.nspc.com

Dementia – People often experience various changes in cognitive function as they age, however these perceived changes can occur for different reasons. A neuropsychological evaluation can assist in determining whether these changes are the result of the normal aging process, psychiatric factors such as depression, or if they represent an abnormal neurodegenerative condition such as dementia. A full evaluation can be critical not only for the patient, but also for the caregivers and extended family who often do not fully understand the changes they are witnessing and are not sure how to care for their loved one or plan for the future.

Other Conditions – Many other neurological and medical conditions lead to cognitive, behavioral, or psychiatric changes and a neuropsychological consultation can help to clarify these changes and possibly improve treatment options. An evaluation can also be critical for those with developmental disorders such as ADHD or learning disabilities to help guide medical or behavioral treatments, and to help make recommendations for school or work accommodations when warranted.

Gad E. Klein, Ph.D.

Gad E. Klein, Ph.D., specializes in the cognitive aspects of various neurological disorders including epilepsy, movement disorders such as Parkinson’s disease, as well as brain tumors and dementia. Dr. Klein is also an expert in advanced neuro-imaging techniques such as functional MRI, as well as the intracarotid amobarbital test (Wada test) and electrocortical stimulation mapping. These procedures enable accurate brain localization of motor and sensory function, as well as higher-order cognitive functions such as language and memory in order to minimize post-surgical functional deficits in patients undergoing brain surgery.


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Intraoperative neurophysiologic monitoring (IONM) is a technique that is directly aimed at reducing the risk of neurological deficits after operations that involve the nervous system. IONM is based on recordings of electrical potentials from the nervous system (brain, spinal cord and peripheral nerves) and muscles during surgical operations.

Why Do We Offer IONM?IONM is a technique that has evolved during the last two decades. The use of IONM allows us to asses the functional integrity of sensory and motor systems of the human body that are often at risk during complicated spine or brain surgeries and thus provides the surgical team with valuable real time information about the status of the patient. The goal of such monitoring is to identify changes in brain, spinal cord, and peripheral nerve function prior to irreversible damage. Intraoperative monitoring also has been effective in localizing anatomical structures, including peripheral nerves and sensorimotor cortex, which helps guide the surgeon during dissection. Introduction of IONM has reduced the risk of debilitating deficits such as muscle weakness, paralysis, hearing loss, and other loss of normal body functions

Main TechniquesThere are several core techniques that are employed by IONM. Somatosensory and motor evoked potentials are used for evaluation of the sensory and motor function during the surgical procedures. Brainstem auditory evoked potentials allow monitoring of the function of the entire auditory pathway including acoustic nerve, brain stem, and cerebral cortex. Electroencephalography is used to monitor cerebral function and to determine resection margins for epilepsy surgery, and to monitor for seizures during electrical stimulation of the brain carried out while mapping cortical function. Electromyography is applied to monitor the activity of peripheral nerves.

IONM TeamIONM is normally performed by a technologist supervised by a neurophysiologist, or a neurologist. Together they interpret the recorded data and pass the information to the surgeon and anesthesiologist. Nowadays the IONM professionals are a significant part the surgical team. The major goal of IONM team is the help the surgeon and the anesthesiologist and thus to ensure the safe outcome of the surgical procedure.

Neurophysiology

What is Intraoperative Neurophysiological Monitoring?




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www.nspc.comMedical Services

Stephen D. Burstein, M.D.

Complex Spine, General Neurosurgery, Peripheral Nerve Surgery


Trigeminal Neuralgia, Pituitary Tumors, Acoustic Neuroma

William J. Sonstein, M.D.

Complex Spine


Trigeminal Neuralgia, Brain Tumors, Pain Surgery

Benjamin R. Cohen, M.D.

Complex Spine

Artem Y. Vaynman, M.D.

Complex Spine

Sub-Specialties at a Glance


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Lee Eric Tessler, M.D.

Brain Tumors, Stereotactic Surgery

Jonathan L. Brisman, M.D.

Brain Aneurysms, Brain AVM’s, Carotid Stenosis

Ramin Rak, M.D.

Complex Spine, Brain Tumors

Alan Mechanic, M.D.

Complex Spine, Brain Tumors, Trigeminal Neuralgia

Donald S. Krieff, D.O.

Complex Spine, Pediatric Neurosurgery, Neurotrauma


Parkinson’s Surgery, Epilepsy Surgery, Pain Surgery

Sub-Specialties at a Glance


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Pediatric Neurosurgery, Epilepsy Surgery

Mihai D. Dimancescu, M.D.

Neurosurgical Consultation

John Pile-Spellman, M.D.

Stroke, Aneurysm, AVMs, Congenital Vascular

Paul Duic, M.D.

Neuro-Oncology

Jai Grewal, M.D.

Neuro-Oncology

Scott Uretsky, M.D.

Neuro-Ophthalmology

www.nspc.comMedical ServicesSub-Specialties at a Glance


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Epliepsy Neurology


Pain Management, Interventional Spine

Madan K. Raj, M.D.

Pain Management, Interventional Spine


Neurophysiology


Neurophysiology

Gad E. Klein, Ph.D.

Neuropsychology

Medical ServicesSub-Specialties at a Glance


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Update

Commack353 Veterans Memorial Hwy.

Suite 303Commack, NY 11725

(631) 864-3900

West Islip500 Montauk Hwy.

Suite KWest Islip, NY 11795

(631) 983-8400

Queens112-03 Queens Blvd.

Suite 200Forest Hills, NY 11375

(718) 263-1414

Lake Success1991 Marcus Avenue.

Suite 108Lake Success, NY 11042

(516) 442-2250

Patchogue 55 Medford Avenue / Route 112

Patchogue, NY 11801 (631) 569-8325

Port Jefferson Station1500-8A Route 112

Port Jefferson Station, NY 11776 (631) 828-3001

Locations www.nspc.com

Great Neck600 Northern Boulevard

Suite 118Great Neck, NY 11021

(516) 478-0008

Rockville Centre100 Merrick Road

Suite 128WRockville Centre, NY 11570

(516) 255-9031


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Good Samaritan Hospital Medical Center 1000 Montauk HighwayWest Islip(631) 376-4444

Huntington Hospital 270 Park AvenueHuntington(631) 351-2000

John T. Mather Memorial Hospital 75 North Country RoadPort Jefferson(631) 473-1320

Southside Hospital-LIJ 301 East Main StreetBay Shore(631) 968-3000

St. Catherine of Siena Medical Center 50 Route 25ASmithtown(631) 862-3000 St. Charles Hospital 200 Belle Terre RoadPort Jefferson(631) 474-6797

Franklin Hospital900 Franklin AvenueValley Stream(516) 256-6000

Glen Cove Hospital101 St. Andrews LaneGlen Cove(516) 674-7300

Long Beach Medical Center455 East Bay DriveLong Beach(516) 897-1000

Long Island Jewish Medical Center 269-05 76th AvenueNew Hyde Park(516) 470-7000

Mercy Medical Center1000 North Village AveRockville Centre(516) 705-2525

Nassau University Medical Center2201 Hempstead TurnpikeEast Meadow(516) 572-0123

New Island Hospital4295 Hempstead TurnpikeBethpage(516) 579-6000

North Shore University Hospital300 Community DriveManhasset(516) 562-0100

Plainview Hospital888 Old Country RoadPlainview (516) 719-3000

South Nassau Communities HospitalOne Healthy WayOceanside(516) 632-3000

St. Francis Hospital100 Port Washington Blvd.Roslyn(516) 562-6000

Syosset Hospital221 Jericho TurnpikeSyosset(516) 496-6400

Winthrop-University Hospital 259 First StreetMineola(516) 739-6444

Nassau County

Suffolk County

Hospital Affiliations

Update100 Merrick RoadSuite 128WRockville CentreNew York 11570

Presorted StandardU.S. Postage

PAIDPermit #385

Hicksville, NY

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NSPC 2010 Newsletter Volume 3

Documents

Transcript of NSPC 2010 Newsletter Volume 3