Neurosurgery

Specialties

Brain abscess

Brain abscess is an infection within the substance of the brain. This can occur in conjunction with chronic infections of the paranasal sinuses or with blood borne infections. Brain abscesses may occur at any age, but they seem to be more common in people who have a depressed immune system. They are best diagnosed with either CT or MRI scanning. Brain abscesses can often be drained with minimally invasive stereotactic techniques. Occasionally they will require open operation for removal.



Chiari malformation

Chiari malformation is a condition where portions of the hindbrain, the cerebellar tonsils, are positioned too low. Crowding of the opening at the base of the skull where the spinal cord connects to the brain stem results. This may cause headaches, problems with eye movements, and syringomyelia, a condition where a cyst forms within the spinal cord. Syringomyelia may present in many ways: pain in the extremities, numbness, and weakness. It often can be confused with other neurologic disorders. MRI scanning best evaluates Chiari malformations and syringomyelia. When a Chiari malformation causes these symptoms or syringomyelia, it should be treated with a decompressive operation. In this surgery more room is created for the cerebellar tonsils and the brain stem. This procedure will usually arrest the progression of the neurologic symptoms.



Hydrocephalus

Hydrocephalus is excess cerebrospinal fluid (CSF) in the head. This often begins at birth with blockage of one of the CSF drainage pathways, such as in aqueductal stenosis. It may also occur through impairment of absorption of the CSF following bleeding into the brain either in infancy or after a ruptured aneurysm. Often the fluid back up will cause symptoms such as headache, lethargy or vomiting. In the infant it may cause excessive enlargement of the head. In the elderly, hydrocephalus may cause difficulties with memory, bladder control or gait. The treatment often includes placement of a ventriculoperitoneal shunt to drain the fluid from the ventricles to the peritoneal cavity where it can be reabsorbed into the blood stream. Shunts may develop problems such as blockage or infection and thus they may need further surgery for repair. In some situations the ventriculoscope may be used to open a new pathway to bypass the block and thus treat the hydrocephalus without a shunt.



Syringomyelia

Syringomyelia is the presence of a syrinx, an acquired cavity, within the spinal cord. Syringomyelia is often associated with trauma, arachnoidiits, or congenital defects of the nervous system (Chiari malformation). Syrinxes often affect the lower cervical region but can extend along the length of the entire spinal cord. The symptoms are classically a dissociated sensory loss where pain and temperature sensation is lost around the upper torso and arms while light touch sensation is preserved. This leads to painless burns on the arms. An MRI is most useful in defining the anatomy. In children, treating concurrent abnormalities such as a Chiari malformation can alleviate this condition. In adults, a post-traumatic syrinx can appear years after the original insult. Operative intervention is indicted for progression of symptoms. Small cavities are observed, while larger ones may respond to drainage directly or via a catheter.



Disc disease

Disc disease refers to degenerative conditions of the spine, which cause pain in the neck or low back or pain in the arms or legs due to pressure on nerves exiting the spine. Common names also associated with this entity include herniated or ruptured disc or degenerative disc disease. These conditions are usually treated conservatively with rest, physical therapy, non-steroidal anti-inflammatory agents, or, perhaps, steroids. If a patient does not respond to conservative measures or if there is significant or progressive weakness due to the nerve compression, patients will usually be advised to have surgery to relieve the pressure on the nerves. Occasionally the disc may cause spinal cord compression in the neck or thoracic spine. If there is evidence of spinal cord dysfunction then surgery is often indicated to take the pressure off the spinal cord.



Lumbar disc disease

As one ages, the discs between the spinal vertebrae weaken and can herniate, or bulge, into the spinal canal compressing the nerves which travel down to the legs. This usually occurs to one side, causing either left- or right-sided symptoms but can affect both legs. A congenitally narrowed spinal canal increases the susceptibility to nerve root compression. Back injuries from falling or lifting often precede the symptoms as well. 95% of lesions affect the nerves supplying the back of the leg and foot. Coughing and sneezing aggravates the leg pain. Raising the leg causes pain down the back of the leg. Advanced lesions cause bilateral leg pain, leg numbness, and loss of bladder and bowel control. An MRI is the study of choice to evaluate this condition. Conservative treatment, including analgesia, avoidance of heavy lifting and bending, and spinal support, resolves many simple bouts of leg pain. However, continuing pain that affects quality of life and progressive neurological change merit surgical intervention, which can ameliorate the majority of symptoms. A variety of surgical methods have been developed for treatment including the traditional method, the microscopic removal of the disc, and the state-of-the-art endoscopic and laser techniques available at Stanford.



Thoracic disc disease

Thoracic Disc Disease is rare, as the thoracic spine is very stiff and not subject to the twisting and bending that our necks and lower backs are. Only 0.2% of all disk lesions, occur in the thoracic area. However, trauma can cause disk problems that result in root pain or progressive or fluctuating leg weakness. Thoracic disc herniations can be treated conservatively but often require surgery. Unlike neck and back surgery, thoracic spine operations are approached through the front of the chest or through the side of the back. The posterior approach carries an unacceptable risk of leg paralysis.

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