TN Brain and Spine

Traditional spine surgery is performed through larger incisions ranging from two to six inches with extensive muscle dissection and spinal exposure, but evolving minimally invasive techniques have made it possible to perform many spine and neck surgeries through one or more small incisions that are only one-half to one inch long.

Minimally invasive spine surgery o­ffers patients many advantages, including less post-operative pain, reduced risk of surgical complications, and a faster recovery.

We treat the following spine conditions with minimally invasive surgery:

• Compression or trauma to the sciatic nerve
• Herniated or ruptured discs
• Degenerative disc disease
• Spondylolysis – a crack or stress fracture of the spinal vertebrae
• Spondylolisthesis – instability of the spinal vertebrae
• Stenosis – narrowing of the passageways between vertebrae
• Small spinal canal tumors

• Anterior Cervical Discectomy and Fusion
• Anterior Lumbar Interbody Fusion for Degenerative Disc Disease
• Minimally Invasive Lumbar Discectomy
• Minimally Invasive Lumbar Fusion for Spondylolisthesis
• Minimally Invasive Posterior Cervical Discectomy (Foraminectomy)
• Minimally Invasive Thoracic Discectomy
• Minimally Invasive Laminectomy for Spinal Stenosis
• Surgery for Spinal Tumors

Some procedures can be performed as an outpatient procedure, including disc herniations or spinal stenosis, and patients are typically discharged home within two to three hours after surgery. The average hospital stay is less than two days, and most patients can return to activities of daily living and work within one to four weeks.

Return to work varies from 1 to 3 months depending on the type of surgery and the physical demands of your employment.

Postoperative pain is easily managed in most patients with oral medication.

Spinal instability refers to excessive movement between two vertebrae resulting in a misalignment of the vertebrae. This misalignment is called spondylolisthesis and may cause spinal stenosis and pinched nerves.

It refers to the use of titanium screws and rods to surgically stabilize an unstable segment of the spine and promote fusion of the affected vertebrae. The rods and screws are used in conjunction with techniques to fuse the unstable vertebrae together.

If you break an arm or leg you must wear a cast to keep the broken bones aligned while they grow together. Screws and rods in the spine serve the same purpose as a cast on a broken arm or leg. They maintain constant contact between the vertebrae and the bone grafts to promote the fusing together of the vertebrae.

The four screws and two rods are approximately one-fourth inches in diameter and two to three inches under the back muscles. Only an extremely slender patient with small back muscles might be able to feel the heads of the screws. We have seen this occur one time in over 800 cases. In that patient, the screws were removed after the fusion matured.

No. As long as solid fusion occurs after surgery, the rods and screws will remain in place. This is true for patients undergoing short segment fusions and may not apply to patients undergoing more extensive fusions for problems such as scoliosis.

There is no evidence in the surgical journals to justify the use of lasers in spine surgery. The term “laser” is frequently used as a marketing ploy to attract patients with spine disease who may need surgery. We do not use a laser for spine surgery because there is no advantage for the patient over current minimally invasive techniques and instruments. The laser is simply a cutting tool.

When a surgeon removes a herniated disc the surgeon must work under, between, and around nerves to remove herniated disc fragments in the spinal canal. Laser light energy cannot be bent. It won’t work around a corner or reach under or around nerves. It requires skilled hands and specialized minimally invasive instruments to perform this type of surgery through small incisions. Attempting to do this with a laser would, in our opinion, greatly increase the risk of nerve damage.

Also, performing a laminectomy requires removal of bone. Lasers will not cut or evaporate bone and cannot be used for this procedure.

In summary, spine surgeries such as lumbar discectomy, laminectomy, or spinal fusion cannot be performed with a laser as a primary surgical instrument. A surgeon could conceivably make part of the incision with a laser but there would not be any additional benefit to the patient.

A tumor is an abnormal mass of tissue that grows on or inside the body. It is known as primary if located where its growth first started, or secondary if it began growing elsewhere in the body and metastasized, or spread, to its present location. Most primary brain tumors do not metastasize outside the brain.

Inside the skull, tumors can grow almost anywhere: within brain tissue, from the meninges, or inside the ventricular system. They can be encapsulated (self-contained) or interwoven with blood vessels, nerves, or other brain structures from which they cannot be removed without devastating consequences. Metastatic tumors are usually well localized, may occur alone or in clusters, and may spread throughout much of the brain.

A benign tumor usually is encapsulated, does not spread to other areas of the body, grows slowly, and often causes problems by compressing brain tissue. A malignant tumor grows uncontrollably, spreads throughout the brain, and destroys brain tissue.

Symptoms

A brain tumor may at first cause the vague feeling of being “unwell”. This may be followed by other, more specific symptoms: dull, persistent headache; nausea or vomiting; generalized weakness; vision problems. Because the left side of the brain governs the right side of the body, and vice versa, a tumor will cause specific weakness or loss of movement on the opposite side of the body. Some symptoms may be caused by the increased pressure inside the skull from brain swelling, which can temporarily be treated with a steroid medication.

Because brain tissue is irritated by the tumor, the brain can temporarily “short-circuit” as its normal electrical activity is interrupted. These periods of uncontrolled brain activity can cause seizures, which may be generalized and cause contractions of all parts of the body, loss of consciousness or bladder and bowel function. The seizures may instead be of a focal nature, affecting only one arm, a leg, or part of the face. Seizures usually can be controlled with anticonvulsant medications.

Evaluation

A detailed history-taking of the patient’s symptoms and a physical examination are done first, followed by any of several tests, such as x-ray studies, Computerized Tomography (CT) scans, Magnetic Resonance Imaging (MRI), and angiograms. All findings are used to evaluate the patient’s symptoms, determine the tumor’s exact location, and provide the physician with a tentative diagnosis of the tumor type.

During surgery, ultrasound imaging may be used to pinpoint the tumor’s precise location and help the surgeon plan his approach for its removal.

If an emergency craniotomy is required, an extensive workup may not be possible.

Primary brain tumors include those arising from the various cell types within the brain tissue:

• Gliomas
• Astrocytomas are tumors that arise from the glial cells and are typically classified as grade 1 through grade 4 dependent on their rate of growth and vascularity as well as other factors.
• Oligodendrogliomae are tumors that arise from the oligodendrocytes in the brain and typically are slow growing tumors and will have a more favorable outcome.
• Ependymomas are tumors arising from the cells lining ventricular cavities of the brain. These tumors also tend to have a more benign course and a more favorable outcome.

Types

Metastatic Brain Tumors

Metastatic tumors are those tumors arising outside the nervous system, in areas such as the lung or other organs, and will often spread to the brain through the blood stream, forming a growth within the substance of the brain or within the skull base. These tumors may be treated surgically in combination with radiation therapy, or with radiation therapy alone, which may consist of either whole brain radiation or gamma knife radiosurgery.

Intraventricular Tumors and Cysts

Tumors such as epidermoid tumors, ependymoma, meningioma, and cysts of various types may arise within the ventricular system. Tumors within the ventricles often represent a unique challenge from a neurosurgical standpoint but can be managed successfully.

Pineal Region Tumors

Although uncommon, pineal region tumors also represent a particular challenge from a neurosurgical standpoint due to the location near the center of the brain. Tumors in this area consist of a variety of cell types and occur at all ages.

Pituitary Tumors

Tumors of the pituitary gland are relatively common in neurosurgical practice. They are divided into two types: functional or non-functional, depending on whether the tumor is secreting excess hormone. Tumors that produce an excess of pituitary hormone are described as functional, and the non-secreting tumors are considered non-functional. A tumor can produce a specific hormone, such as human growth hormone, which will produce a disease called acromegaly, in which the bones of the face, hands, and feet enlarge in an adult. It is also associated with enlargement of various organs and can produce a variety of medical conditions. These tumors can be managed successfully with both surgery and radiosurgery, depending on the circumstances. Other hormones produced by these tumors can include prolactin, thyroid stimulating hormone (TSH) and adrenal stimulating hormone (ACTH). Excess amounts of any of these hormones can cause specific symptoms related to the hormone’s basic function.

Tumors of the Skull Base and Meninges

These tumors are often referred to as extra axial tumors, since they arise outside the substance of the brain.

• Meningioma is a typical example of an extra axial tumor over the surface of the brain or along the base of the skull under the brain. These may also be referred to as skull base tumors, particularly when they invade the base of the skull.
• Acoustic neuroma is another skull base tumor that arises from the 8th cranial nerve (auditory or hearing), as it enters the skull base. These are typically benign tumors that can be managed surgically, with radiosurgery, or a combination of the two depending on the circumstances.
• Epidermoid tumors are benign, usually arising around the base of the brain. They can be managed surgically but are not responsive to radiation therapy.
• Craniopharyngiomas are tumors found more often in children than in adults. They arise in the pituitary gland or 3rd ventricle and can grow to a very large size before discovered. They interrupt the normal endocrine function of the brain and pituitary gland and can also potentially affect vision. Ideal management of these tumors is total excision by surgical intervention. If removal is incomplete, follow up treatment with radiation therapy (either standard or radiosurgery) is usually recommended.

The most common form of cerebral aneurysm is called a berry aneurysm, because its shape resembles a small berry. They develop at branching points of cerebral arteries where the arterial wall tends to be thin. The aneurysm wall can thin out and leak, especially at its dome. An aneurysm may never leak, but once it does, the risk of subsequent hemorrhage increases.

Patients with leaking cerebral aneurysms typically present with the sudden onset of severe headache, often followed by nausea, vomiting, and varying degrees of altered consciousness or neurological deficit. These symptoms are caused by sudden leakage of arterial blood from the aneurysm. The degree of leakage varies from mild to severe. After the initial hemorrhage, there is risk of recurrent hemorrhage – particularly in the first 24 hours.

The treatment goal is to stabilize the patient medically then take the steps necessary to exclude the aneurysm from the cerebrovascular circulation. There are several techniques to accomplish this including a direct surgical intervention or endovascular obliteration of the aneurysm. There may be delayed complications as a result of the hemorrhagic event, which must be managed medically while treating the aneurysm itself.

Types

Arteriovenous Malformations

Arteriovenous malformations consist of an abnormal network of arteries and veins that are usually present from birth and may enlarge over a period of years. These lesions may also produce hemorrhage, although the risk of death from a single hemorrhage is not as high as it is with cerebral aneurysms. Malformations may also cause progressive neurological deficit and seizures.

Arteriovenous malformations may be surgically excised, treated by endovascular techniques, or by a combination of endovascular and surgical management.

Arteriovenous Fistulae

Arteriovenous fistulae are lesions consisting of an abnormal communication between an artery and a vein, usually around the base of the skull where the arteries and veins are in close proximity. These lesions can be present from birth or can be acquired as a result of head trauma. They can often be managed by endovascular techniques.

Subarachnoid Hemorrhage

Hemorrhage is the medical term for bleeding. The rupture of one of the brain’s blood vessels can cause bleeding into the subarachnoid space; beneath the arachnoid membrane, on top of the pia mater; and into brain tissue. The bleeding usually stops, at least temporarily, when a clot forms over the ruptured area.

The most frequent cause of spontaneous subarachnoid hemorrhage (not due to injury) is the rupture of a small aneurysm, or bulging sac, on one of the blood vessels that supplies the brain. It is usually impossible to determine why the aneurysm forms and bursts, but the condition is common in adults and may be associated with aging, diabetes, pregnancy, hypertension (high blood pressure), heredity, or trauma.

Cerebral aneurysms are usually of three types: saccular with a narrow “neck” (called “berry” aneurysms because of their shape and their tendency to occur in clusters); saccular with a broad base; and fusiform, in which a short section of the artery bulges all the way around. Each shape determines the degree of difficulty a surgeon faces in attempting to treat the problem.

An aneurysm ruptures spontaneously, even during sleep, and therefore is not related to the strain of hard work, sexual intercourse, or other physical activity.

Although it is not always possible to discover the exact source of bleeding, other causes of spontaneous subarachnoid hemorrhage include: arteriovenous malformations, small angiomas, certain types of infections, and bleeding disorders.

Symptoms

A ruptured cerebral aneurysm at first causes severe headache, which can be followed by nausea, vomiting, double vision or sensitivity to light, neck pain or stiffness, weakness, memory loss, paralysis, coma, or death. How severe the symptoms are and how long they last will depend on the amount and location of the bleeding. Blood in and around the brain can cause pressure, swelling, and brain irritation, which can lead to drowsiness, confusion, weakness or paralysis, memory loss, speech problems, behavior changes, or coma (complete loss of consciousness).

Complications

The blood vessels around the aneurysm are irritated by the blood from the hemorrhage and will at times go into a state of spasm, tightening and narrowing. This vasospasm (“vaso” meaning vessel) can occur any time after the rupture until the hemorrhaged blood has been absorbed by the body, and it can increase any or all symptoms. It is the body’s own attempt to prevent a second hemorrhage by restricting the flow of blood through the vessels around the aneurysm. Vasospasm thus reduces pressure on the delicate aneurysm but unfortunately also reduces the normal blood supply to parts of the brain.

Ongoing research is being done to discover a medicine that will control vasospasm; as yet, none has proven effective.

Other complications from subarachnoid hemorrhage, such as hydrocephalus, hematoma (blood clot), and brain swelling, involve the brain; but other body systems can also be affected because of the severe nature of the illness. Pulmonary embolus, heart abnormalities, and bleeding from an ulcer may cause further complications.

Diagnosis

Several tests are used to confirm the diagnosis of ruptured cerebral aneurysm. Some are explained in the latter portion of this section.

Because cerebrospinal fluid flows within the subarachnoid space, a sample of CSF taken during a spinal tap at the base of the spine will show blood from the hemorrhage. A CT scan will show blood inside the skull and indicate how much bleeding has occurred.

To find the source of the hemorrhage, an angiogram is performed, which may have to be repeated to try to pinpoint the aneurysm’s exact location.

Hospitalization

Activity

Because the aneurysm can rupture again, a quiet, restful atmosphere is important. The patient usually is placed in the Intensive Care Unit (ICU), a highly specialized area providing close observation with specialized nursing care. Complete bedrest without physical strain is essential while the patient’s condition stabilizes, usually in preparation for surgery.

Medications

Medications will be given when necessary to reduce pain, control blood pressure, relieve stress, and maintain fluid balance.

Breathing

If necessary, a respirator may be used to help the patient breathe and to control intracranial pressure. Most often, however, oxygen is merely administered to the patient through nasal prongs or a mask.

Monitoring devices

Various monitoring devices may be used to assess the patient’s condition during recuperation. Among the most common are: an EKG (heart) monitor, an ICP monitoring device, a Swan-Ganz catheter to assess the patient’s fluid balance, and an arterial line to continuously measure blood pressure and aid in drawing frequent blood samples for laboratory study.

Nutrition

Intravenous (I.V.) fluids may be given until liquids and food can be taken adequately by mouth. The amount of fluid given will be closely monitored until the dangers of brain swelling (edema) and vasospasm lessen.

Trigeminal Neuralgia (Tic Douloureux)

Trigeminal neuralgia is a general term referring to facial pain caused by a disturbance of the Trigeminal nerve (V cranial nerve). There are many causes of trigeminal neuralgia with variable patterns of facial pain. Tic Douloureux is a specific form of trigeminal neuralgia with a unique pattern of pain. The trigeminal nerve has three branches that go to the forehead, cheek, and jaw, and the painful condition can exist in one or all of these areas.

Symptoms

The pain consists of intermittent episodes of severe facial pain, lasting anywhere from a few seconds to a few minutes, with periods of no pain at all. The pain can be elicited by facial stimulation, chewing, or talking, or may occur spontaneously.

Causes

Several known causes exist, including small, benign tumors that compress the nerve adjacent to the brain stem; multiple sclerosis (usually in younger patients); or simply changes in the arterial positioning that are a natural part of aging. As our arteries become more elongated and meandering with age, the superior cerebral artery can begin to impinge on the 5th cranial nerve. In these cases, a procedure known as Microvascular Decompression (MVD) can be beneficial, with the advantage of preserving facial sensation. Other techniques include various methods by which the nerve is partially damaged to stop the painful transmissions. Radiosurgery is now an option for treatment of Tic Douloureux and has had excellent success.

Hemifacial Spasm

Hemifacial spasm is a disorder manifested by involuntary contractions of the facial muscles. It typically only involves one side of the face an may affect part or all of the facial muscles. Most patients have thythmic contractions of the muscles around the eye resulting in partial closure of the eyelid. The contractions may spread to the muscles of the cheek and mouth causing a drawing sensation in the face.

This problem occurs due to irritation of the VII cranial nerve near the brain stem. Rarely the irritation is due to a benign tumor at the base of the skull. More commonly it is caused by a loop of an artery wedged under the nerve. The rhythmic muscle contractions appear to be due to the rhythmic pulsations of the artery against the nerve.

Hydrocephalus

Hydrocephalus, sometimes called “water on the brain,” is a condition where the circulation of spinal fluid within the ventricular system is obstructed or interrupted in some fashion. There are many causes for hydrocephalus. In most cases, hydrocephalus is treated by a procedure known as a ventriculo-peritoneal shunt.

Communicating Hydrocephalus

The cerebrospinal fluid is produced within the ventricular system and is reabsorbed into the bloodstream through specialized veins between the brain and skull. Communicating hydrocephalus occurs when the fluid reabsorption system fails and the ventricles begin to enlarge.

Obstructive Hydrocephalus

Obstructive hydrocephalus occurs when one or more of the ventricles become blocked or trapped by obstructions such as a tumor, cyst, or scarring from infection.

Normal Pressure Hydrocephalus (NPH)

Normal pressure hydrocephalus is a condition seen in elderly patients who develop a triad of symptoms consisting of dementia, gate disturbance known as ataxia, and bladder incontinence. These symptoms typically occur over a relatively short period of time (a few months) and can be successfully treated by a shunting procedure.

Herniated or Ruptured Discs

A herniated, slipped or ruptured disc in your back can cause each of these pain patterns. The ways in which a slipped disc causes different pain patterns and problems with your back is related to the location of the slipped disc along your spine and also to the anatomy of your spinal column.

The spinal column, or backbone, consists of 33 bones (vertebrae) and can be divided into five segments, called the cervical, thoracic, lumbar, sacral, and coccygeal sections of the spine. Each of these sections corresponds to a particular part of your body. The cervical spine is that part of the spine in your neck, the thoracic spine supports your trunk, the lumbar spine supports your lower back and abdomen, the sacrum supports your pelvis, and the coccyx is your tailbone.

Degenerative Disc Disease

Degenerative disc disease affects the spinal discs between the vertebrae. This condition often results in the loss of cushioning, fragmentation and herniation. Some patients don’t notice any symptoms, but  others suffer pain or weakness in their backs due to bone spurs that pinch a nerve root.

Sciatica

Sciatica is the descriptive term for when pain runs from your back or buttocks down your leg and into your foot.

It is a condition caused by either compression or trauma of the sciatic nerve. Sciatica is made worse when you cough or if someone lifts your leg up while you are laying down. Symptoms may begin abruptly or gradually, are usually irritated by movement, and often grow worse at night. Sciatica implies that there is an irritation of your nerve root in the lower part of your spine. In some instances, this could be due to a ruptured or herniated disc in your lower back.

Spondylolysis

Spondylolysis is a defect in the lamina of the vertebrae in the pars interarticularis, usually the fourth or the fifth lumbar vertebrae in the lower (lumbar) spine. Spondylolysis may occur as a congenital defect or be the result of repetitive trauma. Some physicians believe spondylolysis may be caused by genetics and that someone could be born with thin vertebral bones causing them to be vulnerable to the condition. Spondylolysis is common in teenage gymnasts and football players and presents with lower back pain that is worse with strenuous exercise or activity. Radiographic findings are subtle, but bone scans or CT scans will usually detect the lesion. Activity modification, bracing, or surgical treatment may be indicated for persistent symptoms.

Spondylolisthesis

Spondylolisthesis occurs when spondylolysis weakens one of the vertebrae so much that the bone slips out of place.

The condition can also be caused by degenerative disc disease. If the vertebrae slip too much and begin to press on nerves, surgery may become necessary. Spondylolisthesis may also be caused by degenerative conditions that affect the vertebral joints.

Early treatment usually involves rest and medication. Progressive spondylolisthesis usually requires surgical treatment.

Sprains and Strains

Sprains and Strains are the most acute pain in the back and results from sustaining a mild strain in the back or back musculature. Sprains and strains in your lower back usually happen during a sudden and stressful injury, causing stretching or tearing of the muscles, tendons, or ligaments in your lower back. When you strain or sprain your lower back, it causes a lot of stress on your spine, irritating it. If you have this condition, you may also suffer from painful muscle spasms which can occur during your daily activities or at night while you’re sleeping. The pain is usually limited to five or ten days.

Stenosis

Stenosis, a narrowing passage way of the spine, causes pressure on the spinal cord or nerves that often produces a dull, aching pain in the lower back when standing or walking. People with stenosis may or may not have back pain – but if they do, the pain usually radiates down into the buttocks and thighs. The pain usually gets worse over time and eventually causes a slow decrease in the ability to walk short distances.

Lumbar stenosis is a natural product of aging and the wear and tear on the spine throughout our lives. As our bodies grow older, the ligaments and bones that make up the spine grow thicker and become stiffer. The spinal canal gradually narrows, and the spinal cord and/or spinal nerves are slowly compressed. The compression of the spinal cord or spinal nerves causes symptoms of pain, weakness, numbness, and bowel and bladder dysfunction.

Diagnosing and Treating Stenosis

A first visit to TN Brain and Spine includes a review of symptoms and history of previous treatment methods. Spinal stenosis may develop or become symptomatic at any age, but is most frequently diagnosed in older patients – often people who are ready to enjoy retirement and want to remain active.

Our neurosurgeons work with patients to find alternatives to surgery if possible. If surgery is required, patients typically will undergo a lumbar laminectomy.

The surgical approach for a spinal tumor depends on the location and size of the tumor. Tumors within the spinal canal may be exposed by a posterior incision similar to the incision used for a lumbar microdiscectomy (small tumor) or a lumbar laminectomy for stenosis (larger tumor).

Tumors within the vertebral body or anterior position of the vertebra must often be exposed by an anterior approach through the abdomen, chest, or neck, depending on the location of the tumor.

In some cases, endoscopic techniques can be used for abdominal and chest approaches, reducing the size of the incision. A fusion may also be performed during the operation, if removal of the tumor and associated bone produces spinal instability.

Hemifacial spasm is a disorder manifested by involuntary contractions of the facial muscles. It typically only involves one side of the face an may affect part or all of the facial muscles. Most patients have thythmic contractions of the muscles around the eye resulting in partial closure of the eyelid. The contractions may spread to the muscles of the cheek and mouth causing a drawing sensation in the face.

This problem occurs due to irritation of the VII cranial nerve near the brain stem. Rarely the irritation is due to a benign tumor at the base of the skull. More commonly it is caused by a loop of an artery wedged under the nerve. The rhythmic muscle contractions appear to be due to the rhythmic pulsations of the artery against the nerve.

Trigeminal neuralgia, or chronic facial pain, may be the result of a condition affecting the trigeminal nerve, which carries sensation from the face to the brain. Symptoms of trigeminal neuralgia include mild to severe pain, tingling, or burning in the face and mouth, which is often triggered by chewing, speaking, or brushing your teeth. Some people also experience muscle spasms.

Anterior Lumbar interbody fusion is a procedure where a portion of the disc material is removed, then the adjoining vertebrae are fused to provide stability. The procedure is indicated for the treatment of lower lumbar degenerative disc disease causing low back pain and sciatica. The procedure may be combined with pedicle screw fixation (Sextant 5.0) if there is spinal instability associated with degenerative disc disease.

The spine is accessed through an incision in the abdomen, and the disc material removed. The vertebrae are then fused with an implant, usually an INFUSE® Bone Graft and LT-CAGE® Lumbar Tapered Fusion Device. The INFUSE® Bone Graft is recombinant human bone morphogenetic protein – a substitute for the patient’s own bone material, which would otherwise be taken from the hip.

Although recovery time is very much dependent upon individual health and circumstances, patients are generally up and walking in the hospital by the end of the first day after surgery, with a typical inpatient stay of 1-2 days.

Condition
Pituitary adenomas are benign tumors that grow from the pituitary gland. These tumors can cause hormone and vision problems if left untreated. Tumor removal often restores vision and normal hormone balance.

Procedure
A transnasal (nose) approach to tumor removal uses an endoscope placed through the natural passage from the nostrils to the base of the sphenoid sinus, and to the pituitary area. No incision is required. Endoscopes provide improved visualization, allowing the surgeon to see all areas and around corners. This helps facilitate complete removal of abnormal tissue while preserving the gland.

Patients achieve a better cosmetic result and experience less post-operative pain. Most patients are discharged within 24-48 hours.

In the surgical treatment of lumbar spondylolisthesis, there are two basic goals. The first goal is to eliminate the compression of the nerve roots by excision of compressive bone, ligaments, and disc material surrounding the nerve roots. The second goal is to stabilize the two vertebrae by placement of bone grafts, screws, and rods to stabilize the vertebrae and fuse them together.

Traditionally, the process of decompression and fusion has been accomplished through a wide surgical exposure of the posterior aspect of the affected vertebrae. A laminectomy is performed to relieve pressure on the nerve roots. Bone graft is removed from the posterior hip bone (iliac crest) through a separate incision. The bone graft is layered on both sides of the exposed spine. Pedicle screws are placed into the vertebrae and connected by rods to immediately stabilize the unstable vertebrae. The bone grafts provide long-term stability once they have fused to the vertebrae (usually 3-6 months). This procedure can require a four- to six-inch incision over the spine, with stripping of the spinal muscles away from the spine, over three to four vertebrae, to gain adequate exposure. The incision on the hip for harvesting of the bone graft is usually three to four inches long. Both of these incisions remain painful for many weeks after surgery, prompting the quest for better methods.

The evolution of minimal access surgical techniques (MAST), new instrumentation (METRx, Sextant) , new techniques to achieve fusion (BMP), and surgical image guidance technology (Stealth, ISO-C3D C-arm ) have made it possible to achieve the goals of decompression, stabilization and fusion, through multiple small incisions, minimizing surgical exposure of the spine, decreasing blood loss, reducing post-operative pain, and shortening recovery time. The procedure can be done without harvesting bone graft from a separate incision. The fusion process takes place between the vertebrae within the disc space (interbody fusion), rather than around the sides of the vertebrae. An interbody fusion is believed to be a more stable fusion with a higher rate of success. The procedure performed to fuse the vertebrae through the level of the disc space is called a posterior lumbar interbody fusion or a transforaminal interbody fusion.

ISO C-3D images are combined with the Stealth surgical navigation system to guide instruments through small incisions to defined points on the spine. The guidance system is, in turn, combined with the Sextant pedicle screw and rod insertion system to precisely place pedicle screws through half-inch incisions for the treatment of spinal instability.

The discectomy and interbody fusion is performed through a one-inch incision using the METRx tubular retractor system.

Back pain alone typically isn’t a neurosurgical problem, but it may be a symptom of a serious spine condition if you’re experiencing back pain that:

• radiates down one or both of your legs
• is associated with weakness in one or both of your legs
• causes numbness or tingling in your legs or feet

The use of image-guided technology provides a more accurate identification of tumor margins during the surgical removal of a tumor. Many tumors, such as astrocytomas and oligodendrogliomae, cannot be easily differentiated from normal brain tissue with the naked eye. Image-guidance technology allows for comparison of the tumor with the MRI images during surgery, so that tumor margins on the MRI can be correlated with tumor margins in the patient’s brain. The advantage of image-guided surgery is particularly useful when removing tumors that are in close proximity to the speech, motor, and visual centers of the brain, to avoid damage to normal brain tissue.

If you’ve been diagnosed with a brain tumor, our neurosurgeons will work closely with your cancer fighting team to develop a personalized treatment plan.

Gamma Knife Radiosurgery

Conditions

• Single and multiple metastatic brain tumors
• Primary malignant brain tumors
• Benign brain tumors – meningiomas, acoustic neuromas, and pituitary adenomas
• Vascular diseases – arteriovenous malformations (AVMs)
• Functional diseases – trigeminal neuralgia (facial pain)

Procedure

Leksell Gamma Knife® Perfexion™ is a non-invasive radiation technique, also called  stereotactic radiosurgery, used to precisely target brain tumors and disorders with finely-focused radiation beams that minimize damage to healthy brain tissue. Gamma Knife offers patients an alternative to traditional surgeries that sometimes involve additional risks and complications from incision. Instead, Gamma Knife offers a non-invasive, two-to-four hour procedure that often allows patients to leave the same day.

Fort Sanders Regional Gamma Knife Center at Thompson Cancer Survival Center

Our neurosurgeons perform Gamma Knife radiosurgery at the Fort Sanders Regional Gamma Knife Center at Thompson Cancer Survival Center. This center houses the first advanced system in Tennessee and one of the newest tools to treat brain disease, including conditions previously considered inoperable.

Additional Resources

For more information about Gamma Knife radiosurgery or Fort Sanders Regional Gamma Knife Center at Thompson Cancer Survival Center, click here.

Schedule an Appointment

If you’ve been diagnosed with a brain tumor, call 865-331-2835 for an appointment or more information