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Winthrop University Hospital

Areas of Expertise

Aneurysm Clipping & Coiling

Jonathan Brisman, MD, Director, Cerebrovascular & Endovascular Neurosurgery 516.255.9031
John Pile-Spellman, MD, Endovascular Neuroradiologist 516.255.9031
The surgical approaches to patients with brain aneurysms include clipping and coiling. Clipping involves a craniotomy (removing a section of the skull) and placing a tiny metal clip across the neck to stop blood flow into the aneurysm. After clipping, the bone is secured in its original place, and the wound is closed. Coiling is a form of endovascular therapy, a minimally invasive procedure that accesses the treatment area from within the blood vessel. In the case of aneurysms, this treatment (coil embolization) does not require open surgery. Instead, surgeons use real-time fluoroscopic imaging, to visualize the patient's vascular system and treat the disease from inside the blood vessel.

Endovascular treatment of brain aneurysms involves inserting a catheter (small plastic tube) into the femoral artery in the patient's leg and navigating it through the vascular system, into the head and into the aneurysm. Tiny platinum coils are threaded through the catheter and placed within the aneurysm, blocking blood flow and preventing rupture. The coils are made of platinum so that they can be visible via X-ray and flexible enough to conform to the aneurysm’s shape.

Artificial Disc Replacement

The disc is a cushioning structure located between the individual bones of the spine (vertebrae). Composed of an outer part and inner core, discs are flexible enough to allow the spine to bend. Traditionally, the treatment for disc pain, including that caused by disc degeneration, has been spinal fusion, a surgical procedure in which diseased disc tissue is removed and bone is placed between the vertebral bodies. The goal is to fuse the vertebra around the disc causing pain. By removing disc tissue and eliminating movement, the pain may be significantly reduced. An artificial disc is a device placed into the worn-out disc space instead of a bone graft. The purpose and advantage of artificial disc replacement is to replace the disc, while preserving motion. This potentially treats the underlying back pain and protects patients from developing problems at an adjacent level of the spine. Several artificial disc replacements for both the neck (cervical) and back (lumbar) spine are currently available to appropriate candidates at select American hospitals, such as Winthrop.

Brain Tumor Treatment

Michael Brisman, MD, Chief, Division of Neurosurgery 516.255.9031
Jeffrey Brown, MD, Neurosurgeon 516.255.9031
Lee Tessler, MD, Neurosurgeon 516.255.9031
Paul Duic, MD, Neuro-Oncologist 516.255.9031
Jay Grewal, MD, Neuro-Oncologist 516.255.9031
Over the past decade, diagnostic advances, new treatments and innovative research have significantly increased survival rates, providing hope for many brain tumor patients, who once would have been hopeless.

Winthrop-University Hospital’s Brain Tumor Program — a collaboration between the specialists in the Institute for Neurosciences and the Institute for Cancer Care — provides the most progressive multidisciplinary treatment by world-class clinicians with outstanding, advanced training in a wide range of specialties, including neurology, neuro-oncology, neurosurgery, medical oncology, radiation oncology, neuropathology and neuroradiology. From the initial evaluation and diagnosis, they work as a cohesive team to optimize each patient’s treatment plan.

The Program focuses on treating patients with primary and metastatic brain tumors, as well as central nervous system lymphoma, neoplastic and lymphomatous meningitis and paraneoplastic syndromes.

Winthrop’s Brain Tumor Program utilizes the finest and most sophisticated minimally invasive, image-based diagnostic technologies. In addition to two new state-of-the-art, 64-slice computed tomography (CT) scanners, modern magnetic resonance imaging (MRI) equipment and positron emission tomography (PET) scanning technology, the Program’s neuroradiologists use dmagnetic resonance perfusion, which illuminates cerebral blood volume and identifies vascular abnormalities and altered blood flow dynamics that often signal a tumor’s existence.

To obtain a definitive diagnosis, neurosurgeons may perform a biopsy to remove a small sample of the tumor tissue, or the entire tumor, for examination. When a tumor lies deep in the brain, or in a critical area, they use stereotactic needle biopsy, which employs a computer and three-dimensional scanning to pinpoint the exact tumor site. For ventricular lesions, they visualize the brain’s fluid chambers with neuroendoscopy, a minimally invasive, safe and effective modality that involves a small fiber optic camera attached to an endoscope — a thin, tube-like instrument inserted through a small opening in the skull.

Winthrop’s neuropathologists, use the latest immunohistochemical staining procedures to identify the proteins and pinpoint the tumor type. They also employ advanced molecular pathology techniques on certain tumors to try to predict how they will respond to chemotherapy.

Treatment is dictated by the type and stage of the tumor, as well as its location in the brain and a host of other variables. The Program’s team often uses multiple treatment strategies, including surgery, radiation therapy and chemotherapy — alone or in combination. The following state-of-the-art therapies are among a wide range of treatments available at Winthrop for many types of brain tumors, including gliomas, astrocytomas, acoustic neuromas, meningiomas, pituitary adenomas and metastatic brain tumors.
  • Image-guided stereotactic surgery marries MRI technology with a stereotactic frameless and frame-based computer system that creates a virtual roadmap of the surgical field. The technology guides neurosurgeons through the innermost depths of the brain, enabling them to expand the parameters of what is operable, visualize tumors and identify abnormal growths or lesions in three-dimensional space.
  • CyberKnife® stereotactic radiosurgery, the gold standard for non-invasive, frameless radiosurgery, is an alternative to conventional brain surgery in certain cases. Winthrop is the only hospital in the metropolitan area currently offering this breakthrough treatment, which uses cruise-missile-guidance technology and ultra flexible, computer-controlled robotics to deliver precisely targeted radiation to deeply imbedded, complex tumors once considered inoperable.
  • Intensity-modulated radiation therapy (IMRT) is one of the most advanced radiation therapy techniques. Using sophisticated computer technology, it can sculpt radiation beams of varying intensity to match specific tumor angles and shapes so that the mass is targeted as uniformly and precisely as possible, minimizing radiation exposure of surrounding normal tissue and reducing potential side effects.
  • Chemotherapy has traditionally been used with brain tumor patients following surgery and radiation therapy. In recent years, neuro-oncologists have succeeded in developing drugs helpful in slowing brain tumor growth. Winthrop neuro-oncologists, with extensive experience with clinical research, have established a clinical trials program to deliver novel, cutting-edge treatments. Additionally, they are utilizing a protocol employing hyperbaric oxygen therapy for patients with newly diagnosed glioblastomas to be administered in Winthrop’s new, state-of-the-art hyperbaric units. They are also developing other studies, including vaccine therapies, genome slicing and delivery of drugs directly into the brain.

Carotid Endarterectomy & Stenting

Jonathan Brisman, MD, Director, Cerebrovascular & Endovascular Neurosurgery 516.255.9031
John Pile-Spellman, MD, Endovascular Neuroradiologist 516.255.9031
Carotid endarterectomy, a surgical procedure, removes plaque from the carotid artery and restores blood flow to the brain. It is used to prevent stroke by correcting stenosis. Plaque that builds up on the inner surface of the artery, can narrow or constrict the vessel, reducing blood flow to the brain. What’s more, pieces of the plaque can break off and travel up the internal carotid artery to the brain, where it blocks circulation and can cause a stroke. In endarterectomy, the surgeon makes an incision in the affected artery and removes the plaque contained in the artery's inner lining. This procedure opens the vessel and restores blood flow. Carotid artery stenting is a non-surgical, catheter-based procedure. The surgeon threads a catheter up from the groin into the carotid artery. The catheter uses a balloon to expand the artery, and a stent is then inserted. The stent, a tiny mesh device, holds the artery open by holding back the flattened plaque like scaffolding in a mineshaft.

Cerebrovascular & Endovascular Surgery

Jonathan Brisman, MD, Director, Cerebrovascular & Endovascular Neurosurgery 516.255.9031
John Pile-Spellman, MD, Endovascular Neuroradiologist 516.255.9031
Cerebrovascular surgery is a distinct specialty practiced by neurosurgeons uniquely trained to provide medical and surgical vascular treatment of the brain, including newer, less invasive endovascular techniques used for peripheral and cerebrovascular conditions such as brain aneurysms. Winthrop’s Director of Cerebrovascular and Endovascular Surgery is one of fewer than 100 neurosurgeons nationwide — and the first on Long island — with dual training in endovascular and microneurosurgery techniques, including aneurysm clipping and endovascular coiling, as well as advanced procedures to treat arteriovenous malformations (AVM), carotid stenosis and acute stroke. Dr. John Pile-Spellman is a world-renowned expert in endovascular management of cerebrovascular disorders.

Cyberknife® Radiosurgery

Jeffrey Brown, MD, Director, CyberKnife® Neurosurgery 516.255.9031
Michael Brisman, MD, Chief, Division of Neurosurgery 516.255.9031
Lee Tessler, MD, Neurosurgeon 516.255.9031
The CyberKnife® facility at Winthrop (the first such hospital-based program in the NY Metropolitan area) offers patients with otherwise untreatable or inaccessible tumors – both benign and malignant – new hope. It uses a noninvasive and scientific approach to stereotactic radiosurgery, taking the treatment of central nervous system tumors and tumors of other sites in the body to new levels.

Winthrop’s CyberKnife® program has been spearheaded by the Divisions of Neurosurgery and Radiation Oncology. The equipment employs groundbreaking cruise-missile guidance technology to target and track tumors and lesions anywhere in the body with computerized image-guided precision. These views are provided by several X-ray cameras configured with powerful computer software, which continuously update the target's position during treatment. They feed the images to a computer-controlled robotic arm carrying an advanced linear accelerator (radiation source) that delivers hundreds of radiation beams to the designated site.

With the data received from the X-rays, the robot is in constant motion. Computers monitor the anatomy, check and recheck the patient's position and compensate for the slightest movements by instantly repositioning the linear accelerator so it can deliver the radiation beams quickly and accurately. On its own, each beam is relatively weak. However, when the beams converge on the target, their power is precise — so precise that physicians can destroy even deeply imbedded tumors and lesions with complex shapes without harming adjacent healthy tissue.

Achieving surgical-like outcomes, CyberKnife® can be an alternative to open surgery. Treatments are performed on outpatients, anesthesia is unnecessary, there is no blood loss and the complication risk is lowered.

Deep Brain Stimulation (DBS)

Brian Snyder, MD, Neurosurgeon 516.255.9031
Nora L. Chan, Director of the Movement Disorders Program 516.663.4525
Today’s leading functional neurosurgery procedure, deep brain stimulation (DBS), is based on the premise that electronic stimulation of particular regions of the brain can improve the major symptoms of some movement disorders, and may enable neurologists to reduce the amount of medication needed to manage symptoms more effectively.

Approved by the FDA, DBS is performed in two separate operations. They involve the implantation of a multi-contact electrode lead into the crucial part of the brain considered responsible for — or at least involved in — the pathology of a given disorder and connecting the lead to a pulse generator or “pacemaker” implanted under the skin in the chest. The pulse generator produces a high-frequency pulsed electrical current, which interferes with pathologic brain signals that produce disabling motor symptoms, such as tremor, rigidity and dyskinesias.

In patients with Parkinson’s, essential tremor and dystonia, the electrode is inserted into the part of the brain deemed responsible for symptom generation or propagation. Without destroying brain tissue, DBS permits modulation of the neurocircuitry of the brain. In many instances, remarkable improvement is achieved. Many Parkinson’s patients can return to leading independent lives, feeding and dressing themselves. Those with essential tremor may have a 60-90% reduction in their tremor, and dystonia patients may improve 90%.

Discography

Discography is a diagnostic procedure that helps determine the source of pain in the neck, mid-back, low back and/or arms, chest wall, abdomen and legs. Degenerative disc disease, which destroys the discs that cushion the vertebrae, is a common cause of such pain. However, other structures in the spine may also cause similar pain. Discography can confirm the disc(s) as a pain source.

It is a relatively simple procedure that uses a small needle to inject contrast dye into the disc. The physician numbs a small area of skin, and uses X-ray guidance to direct a small needle into the center of the suspected disc and possibly at several adjoining disc levels. After the needles are in their proper locations, a small amount of contrast dye is injected into each disc. If a disc is the source of pain, the injection will temporarily reproduce discomfort. If a disc is not involved, the injection will not produce discomfort.

Embolization of Arteriovenous Malformations (AVM)

Jonathan Brisman, MD, Director, Cerebrovascular & Endovascular Neurosurgery 516.255.9031
John Pile-Spellman, MD, Endovascular Neuroradiologist 516.255.9031
A congenital disorder, an AVM is an abnormal, tangle of vessels with arteries directly connected to the veins. Since the capillary bed is missing, high-pressure blood flows directly from the arteries into the veins. Over time, the center of the AVM can become fragile and prone to bleeding due to the constant pounding circulation. AVMs can occur anywhere in the body; the majority are asymptomatic until they rupture or leak. When located in the brain, a bleeding AVM can produce seizures, headaches, hemorrhage, stroke, or severe neurological disability — depending upon both its location and the amount of bleeding — and can even lead to death.

Modern treatment comprises the following interventions alone or in combination: surgery, stereotactic radiosurgery and embolization.

Over the last 10-to-15 years, endovascular surgery has progressed to the point where the AVM’s arterial feeders can be blocked with embolic glue, which then allows the neurosurgeon to excise the AVM with lowered risk to patients and improved outcomes.

Aided by fluoroscopy, the neurosurgeon carefully threads a microcatheter via the femoral artery into the center of the AVM. Once the microcatheter tip is in the desired position, the embolic glue — in liquid form — is slowly injected through the catheter to the targeted malformation. When the liquid comes into contact with the blood, it changes into solid material, sealing off the blood vessels, shutting down the blood flow and reducing the risk of rupture during resection.

Preoperative embolization gives the brain time to quiet down after spending years shunting high-powered blood to the AVM. In appropriately selected patients, it can reduce the size and vasculature of the AVM, eliminate surgically inaccessible vessels and dramatically decrease intraoperative blood loss. Basically, it facilitates easier and safer surgical resection.

Until recently, many rapidly acting embolic glues hardened too quickly and did not always penetrate smaller diameter vessels. At Winthrop, a newer agent called ONYX® is used, representing an important, relatively new intracranial AVM treatment option with its ability to facilitate a slower, more deliberate and controlled procedure. ONYX® takes longer to harden, allowing for more precise management of its delivery.

Endoscopic Pituitary Surgery

Michael Brisman, MD, Chief, Division of Neurosurgery 516.255.9031
The most common pituitary growths — adenomas — are divided into secretory lesions, which give rise to hormonal disturbances caused by hypersecretion, and non-secretory growths, which do not usually present until reaching a size sufficient enough to cause pituitary dysfunction or compress surrounding neural structures — mainly the optic nerves. When this happens, symptoms can include compromised vision and headaches.

The main indications for surgery are either uncontrolled symptoms of endocrinologically active tumors, such as those causing acromegaly or Cushing’s Disease, or symptoms associated with compression of surrounding anatomy. The goal is to reduce pressure on nearby structures and/or normalize hormone levels.

Optimal pituitary tumor removal has progressed from traditional craniotomy to the transsphenoidal approach using less invasive endoscopic endonasal surgery. Employing an endoscope with the latest image-guidance neuronavigation technology is a safe and effective way to remove even very large tumors.

The small fiberoptic-like endoscope used in the innovative procedure is only 4 mm in diameter with angled lenses and a camera on its tip, which brings the viewing lens close to the work area and provides unparalleled illumination, magnification and high optical resolution of the surgical field. The image is projected onto a video monitor, and the extraordinary visualization even allows for treatment of tumors sometimes considered inoperable by traditional surgery.

At Winthrop, endoscopic pituitary surgery is a dual-surgeon procedure involving a neurosurgeon and otolaryngologist, who begins the operation by carefully threading the endoscope into the sphenoid sinus to the roof of the sphenoid, which is also the floor of the pituitary. After the endoscope is placed in front of the mass, the vivid panoramic view of the area enables the neurosurgeon to access, dissect and remove the tumor using special microsurgical instruments.

This minimally invasive procedure is well tolerated by patients and has several benefits. Since the point of entry is through the natural pathway of the nostril, there is no need for sublabial incisions. Therefore, there is less swelling and discomfort after surgery. Risk and patient morbidity are reduced, bleeding and post-operative pain are minimized, length of hospital stay is shortened and recovery is easier.

Endoscopic Third Ventriculostomy

Elizabeth Trinidad, MD, Pediatric Neurosurgeon 516.255.9031
Advances in technology and treatment protocols are bringing hope to families with children who have hydrocephalus, helping more and more youngsters with an excessive amount of cerebrospinal fluid (CSF) lead full, active lives.

At Winthrop the latest sophisticated, minimally invasive techniques are used to treat patients with hydrocephalus, as well as a variety of other conditions, including craniosynostosis, tumors, congenital malformations such as Chiari Malformation, epilepsy, trauma and degenerative disease.

The goal of treatment in hydrocephalic patients is to decrease and prevent brain damage by draining the collected CSF to reduce the intracranial pressure. While specific treatment depends on the child’s 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 — or diversion — 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.

With the significant advances in endoscopes, fiberoptic imaging and other specialized instruments, Endoscopic third ventriculostomy (ETV) has become a popular, safe and effective alternative to ventricular shunt placement. Neuroendoscopy can be used 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.

ETV is an internal bypass procedure that 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 is then made in the thin membrane of the ventricle floor, which allows the accumulated fluid to bypass the obstruction and flow into the subarachroid space. This establishes normal CSF circulation within the brain and spinal cord.

The success of ETV depends on patient selection and the cause of the hydrocephalic condition. If the patient is chosen carefully, the success rate can be as high as 85%. When the cause is an infection or a bleed in the brain, success is about 50%. 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.

Endovascular Mechanical Embolectomy for Stroke

Jonathan Brisman, MD, Director, Cerebrovascular & Endovascular Neurosurgery 516.255.9031 John Pile-Spellman, MD, Endovascular Neuroradiologist 516.255.9031
Treatment innovations — including improved imaging technology, modern pharmacology and advanced clot-retrieval techniques — have brought new hope to stroke patients.

Winthrop is a designated New York State Stroke Center with highly regarded neuroscience specialists and a multidisciplinary Stroke Team that can be mobilized within minutes, 24/7. Since prompt treatment is vital to stroke survival and the degree of recovery, immediate intervention by the Team is crucial to successful outcomes.

With the majority of strokes caused by blood clots, the most effective treatment involves early perfusion to save brain tissue, reduce the size of the clot and increase oxygen delivery to the cells in the affected area in order to limit cell death. If a stroke is diagnosed, and can be treated within three hours of symptom onset — and if the patient is medically suitable — the first line of attack is intravenous administration of tpA [tissue plasminogen activator]. But, this clot-busting drug is not always successful. Sometimes the burden of clot is just too large.

Endovascular mechanical embolectomy can achieve revascularization in acute ischemic stroke patients when used within eight hours after symptoms appear — particularly in those with late treatment start, IV tpA failure or contraindications for tpA use. Experience at Winthrop underscores the literature and shows that mechanical therapies can extend the window of treatment time. They are designed to extract stroke-causing blockages that do not respond to medication. To improve outcomes, in many cases, specialists perform percutaneous endovascular mechanical therapy immediately after administering tpA.

Approximately 20% of emergency stroke patients with an otherwise hopeless prognosis benefit from endovascular mechanical embolectomy when applied in the prescribed timeframe. What’s more, the procedure obviates the need for an additional intra-arterial dose of tpA, thereby reducing the risk of hemorrhage. Depending upon each patient’s unique situation and physiology, Winthrop specialists utilize either the Merci® or — the newer — Penumbra™ System. Both employ standard catheterization techniques to revascularize large vessels.

Inserted through a tiny incision in the femoral artery, each system’s catheters can be carefully guided via standard angiography to the site of the clot. The Merci® Retriever System deploys a thin, soft coiled wire that acts like a corkscrew to engage, ensnare and remove the obstruction lodged in the blocked brain artery, while the Penumbra™ System employs suction to gently grab and aspirate the clot out of the intracranial vessels.

Epilepsy Surgery

Brian Snyder, MD, Neurosurgeon 516.255.9031 Elizabeth Trinidad, MD, Pediatric Neurosurgeon 516.255.9031 Alan Ettinger, Epilepsy Neurologist 516.255.9031 Shicong Ye, Epilspsy Neurologist 516.663.4525
When antiepileptic medications fail to eliminate or control seizures, surgery may be considered to remove seizure-producing areas of the brain. Indications for surgery include: documented epileptic seizures withfailure of standard medical treatment, seizures that always start in just one part of the brain, and seizures in a part of the brain that can be removed without damaging important functions such as speech, memory or eyesight.

Pre-surgical evaluation may include baseline electroencephalogram (EEG), video EEG, MRI or CT of the head, positron emission tomography (PET), functional MRI and single-photon emission computerized tomography (SPECT).

Epilepsy surgery is usually performed under general anesthesia. The procedure involves making a small opening in the skull to access the brain. Sometimes the surgeon may wake up the patient during part of the operation to help determine which parts of the brain control language and movement.

The type of epilepsy surgery used depends on the types of seizures and where they occur in the brain. Surgical procedures include:
  • Temporal Lobe Resection. Removing a portion of the brain that's causing the seizures. It is very successful for seizures that start in the temporal lobe.
  • Multiple Subpial Transection. Making incisions to seal off part of the brain, if the portion of the brain causing the seizures is too vital to remove. In this case, surgeons may make a series of cuts to help isolate that section of the brain, preventing the seizures from moving into other parts of the brain.
  • Corpus Callosotomy. Separating the connection between the brain’s hemispheres. The surgery severs the network of neural connections between the right and left halves of the brain. This surgery is used primarily in children who have severe seizures that start in one hemisphere and spread to the other side.
  • Hemispherectomy. Removing the outer layer of half the brain. This is the most radical type of epilepsy surgery. The procedure is used in children who have seizures because of damage to just one half of the brain — which occurs in rare congenital conditions.
Most patients see a significant reduction in the number of seizures; many actually stop having seizures entirely. For patients who do not qualify for conventional neurosurgery, vagus nerve stimulation (VNS) has been shown to reduce the brain’s potential to generate abnormal seizure activity.

Facet Joint Injections

Facet joints are small joints at each segment of the spine that provide stability and help guide motion. They can become painful due to arthritis of the spine, a back injury or mechanical stress to the back. Facet joint injections help diagnose the cause and location of pain and also provide relief. By placing the numbing medication into the joint, the amount of immediate pain relief helps confirm or deny the joint as a source of pain. Article continues below

Along with the numbing medication, a facet joint injection also includes injecting time-release cortisone into the facet joints to reduce inflammation, which often provides long term pain relief. The procedure may also be called a facet block, as its purpose is to block the pain.

Induced Hypothermia

Elzbieta Wirkowski, MD, Co-Director, Neuroscience Intensive Care Unit (NeuroICU) 516.663.4525
In Winthrop’s NeuroICU, patients critically ill with traumatic brain injury, stroke, cardiac arrest and other severe and potentially ruinous conditions affecting the central nervous system are cared for by neurointensivists and neurosurgeons, who use the latest therapies to rescue, protect and treat the brain. One of their innovative approaches is induced hypothermia, which reduces swelling and prevents secondary brain cell damage. Because of this, many patients with grim prognoses due to severe brain damage are experiencing once-inconceivable recoveries.

While neuroscientists do not yet fully understand exactly how hypothermia protects the brain, it is clear that oxygen deprivation, alone, does not precipitate cell death; the massive biochemical, structural and functional insults result from a cascade of reactions triggered by the oxygen deficiency. Since many of these processes are temperature-sensitive, hypothermia can reduce their impact and protect the brain.

To be eligible for hypothermia, a patient must be available within 12 hours of the start of the cerebral insult. To achieve maximum efficiency, cooling must be initiated within six hours of the patient’s arrival in the ER. The goal is to lower the body’s temperature to 32-34o C as quickly as possible — within three-to-four hours — and keep patients cool for a few days.

To avoid overshooting the targeted temperature, the experts in the NeuroICU adhere to strict protocols and monitor each patient carefully and constantly. They employ medications to minimize the natural shivering response, and remain watchful of potential side effects, such as arrhythmia, decreased clotting ability, increased risk of infection, hypotension and electrolyte imbalance.

There are several ways to induce hypothermia, including intravascular cooling and water blankets. The former, an invasive procedure, involves a central venous catheter, which carries cold saline and is threaded through the femoral vein. The device serves as a heat-exchange element, which helps cool the circulating blood. However, while it reduces body temperature rapidly and precisely, this invasive technique has been associated with serious risks, including bleeding, infection, vascular puncture and deep vein thrombosis.

Used more often to lower core body temperature, non-invasive water blankets present much less of a risk. But, this technique is susceptible to leaking, takes longer to achieve the goal temperature and does not include sophisticated temperature management.

Winthrop’s NeuroICU utilizes the latest surface therapeutic temperature technique — Arctic Sun®, which is an advanced, computer-controlled temperature management system that combines the best of the more conventional approaches. Coupling the non-invasive benefit of water blankets with the precision and speed of intravascular catheters, the system consists of a main temperature control module connected to thin hydro-gel pads that conform to any body shape. Conventional water blankets trap air between the cooling source and the skin, rendering them far less efficient than the Arctic Sun® Energy Transfer Pads, which are applied directly to the patient’s skin and provide direct thermal conduction through the skin. It is one of the most effective and efficient ways to quickly lower core body temperature.

The rewarming phase is critical, and the literature recommends rewarming slowly, increasing the temperature by 0.5-1.0o C per hour. Arctic Sun® offers great control over the process, which usually takes about eight hours.

Kyphoplasty

William Sonstein, MD 516.255.9031
Benjamin Cohen, MD 516.255.9031
Artem Vaynman, MD 516.255.9031
Kyphoplasty is a newer treatment for patients immobilized by the painful spine compression fractures associated with osteoporosis. A minimally invasive procedure, kyphoplasty can alleviate the fracture-related pain. In addition, the procedure can also stabilize the fracture, restore height and reduce deformity. Kyphoplasty is performed under local or general anesthesia. Using X-ray guidance, two small incisions are made, and a probe is placed into the vertebral space where the fracture is located. The bone is drilled and a balloon is inserted on each side. These balloons are inflated with dye so they can be seen on the X-rays until they expand to the desired height. They are then removed and the spaces they created are then filled with special orthopaedic cement, binding the fracture. The cement hardens quickly, providing strength and stability to the vertebra, restoring height and relieving pain. Patients usually go home within 24 hours, and pain relief usually occurs within the first few days.

Lumbar Epidural Steroid Injection

Richard Fuss, MD (Anesthesiologist) 516.255.9031
Edward Rubin, MD (Anesthesiologist) 516.492.3100
Lumbar epidural steroid injections (ESIs) are an integral part of the non-surgical management of sciatica and low back pain. The injections deliver medication directly (or very near) to the source of pain, compared to oral steroids and painkillers, which have a dispersed, less-focused impact and may have unacceptable side effects. Additionally, an epidural steroid injection can help control local inflammation. While the effects of the injection tend to be temporary, an epidural injection can be very beneficial for a patient during an acute episode of back and/or leg pain.

Lumbar Sympathetic Block

Lumbar sympathetic block is an injection of a local anesthetic (lidocaine or bupivacaine), adrenaline (epinephrine) and/or steroids into the nerves that are a part of the sympathetic nervous system; the nerves are located in the back, on either side of spine. The anesthetic, which blocks the sympathetic nerves, may reduce pain and swelling in the lower extremity and may improve mobility. The procedure involves inserting a needle through skin and deeper tissues. The skin and deeper tissues are numbed with a local anesthetic using a very thin needle before inserting the actual block needle. The local anesthetic wears off in a few hours. However, the blockade of sympathetic nerves may last for many more hours, days or weeks. Usually, relief time gets longer after each injection. If the patient responds to the first injection, repeat injections are recommended. Usually, a series of injections is needed to treat the problem. Some patients may need only two to four and some may need more than 10. Response varies from patient to patient.

Lumbar Transforaminal Epidural Steroid Injection

The transforaminal epidural steroid injection is a very selective injection around a specific nerve root. Foraminae are tiny openings between the vertebrae through which the nerve roots branch from the spinal canal and enter the body. Physicians can determine if a particular nerve root is causing low back or leg pain by injecting medication around a specific nerve root. Using fluoroscopy, a needle is guided into the opening where the nerve root is being compressed. A dye solution that can be seen on the X-ray monitor is injected to determine the extent to which the nerve is being compressed. Local anesthetic is then injected around the nerve root to relieve the pain. A steroid medication is also injected around the nerve root to decrease the inflammation and swelling of the nerve root.

Microdiscectomy

William Sonstein, MD, Neurosurgeon 516.255.9031
Benjamin Cohen, MD, Neurosurgeon 516.255.9031
Artem Vaynman, MD, Neurosurgeon 516.255.9031
Nancy Epstein, MD, Chief, Neurosurgical spine, Education & Development 516.354.3401
Stephen Burstein, MD, Neurosurgeon 516.255.9031
A discectomy is the surgical removal of herniated disc material that presses on a nerve root or the spinal cord. Microdiscectomy uses a special microscope or magnifying instrument to view the disc and nerves. The magnified view makes it possible for the surgeon to remove herniated disc material through a smaller incision, thus causing less damage to surrounding tissue. Microdiscectomies can decrease the pain caused by a herniated disc and allow for more normal movement and function with a faster recovery time.

Microvascular Decompression for Trigeminal Neuralgia

Michael Brisman, MD, Chief, Division of Neurosurgery 516.255.9031
Jeffrey Brown, MD, Neurosurgeon 516.255.9031
Trigeminal neuralgia (TN) — a neuropathic disorder of the trigeminal nerve — plagues victims with intermittent severe facial pain. Over time, it can lead to serious anticipatory anxiety, depression and life-threatening malnutrition. TN usually results when a small blood vessel compresses the fifth cranial nerve, applying pressure where the nerve joins the brain stem. In patients with multiple sclerosis, TN is caused by demylenation of the trigeminal pathways. In rare cases, TN can be caused by a mass, such as a tumor compressing the trigeminal nerve.

Most TN sufferers get temporary help from pain relievers or anticonvulsant medications, but, after a while, the pain attacks typically grow more frequent and severe, requiring higher dosage and more continuous usage of medication. If patients cannot tolerate medication because of side effects, or have pain despite medication, surgical intervention is indicated.

According 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 does not damage or destroy any part of the trigeminal nerve. About 95% effective, with a low risk of pain recurrence and minimal side effects, 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.

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, it is removed.

Pain relief is usually instant, and after a brief hospitalization patients are discharged requiring no further medications.

Minimally Invasive Spinal Fusion

Artem Vaynman, MD, Neurosurgeon 516.255.9031
Benjamin Cohen, MD, Neurosurgeon 516.255.9031
Sophisticated imaging, tiny cameras and computer-assisted navigational tools, as well as miniature, specially designed instruments, now allow spine surgeons to operate with great precision in smaller surgical fields, providing alternatives to conventional spinal fusion surgery. The advanced technologies and the development of bone morphogenetic proteins (BMP) to enhance the formation of bony fusion, enable minimally invasive surgery to achieve the same objectives — spinal stability, pain reduction and improved function — as open spine surgery, but with considerably less trauma.

One of the most advanced minimally invasive approaches — transforaminal lumbar interbody fusion (TLIF) — obviates the need for a large midline incision to access the spine. What’s more, the procedure greatly reduces the amount of dissected or retracted muscle and tissue. The system uses dilators to gently separate the muscles surrounding the spine rather than cutting them. This helps preserve surrounding muscular, neural and vascular function.

TLIF is ideal for patients with mechanical low-back and pain associated with degenerative disc disease, spinal stenosis that has not responded to conservative treatment, recurrent disc herniation, spine fractures and spinal instability due to spondylolisthesis. In addition to reduced intraoperative blood loss, minimal scarring, less damage to muscles and nerves and diminished post-operative pain, TLIF benefits include improved low back pain, improved radiating leg pains, reduced post-operative narcotic intake, shortened hospitalization and easier rehabilitation. TLIF’s results (overall fusion rates >90%) are comparable to the published results for traditional open spine surgery.

Motor Cortex Stimulation (MCS)

Jeffrey Brown, MD, Neurosurgeon 516.255.9031
Brian Snyder, MD, Neurosurgeon. 516.255.9031
Motor cortex stimulation (MCS) is used in patients with difficult-to- manage chronic pain, particularly in the face. The procedure is employed only after other treatments have failed. MCS uses a programmable device to send electric pulses to an electrode attached to the layer covering the brain. The procedure involves brain imaging in order to map the brain and identify the motor cortex — the part of the brain associated with movement of the face, arms and legs. Then, an electrode is surgically placed on the tough protective layer covering the motor cortex area of the brain and attached to the programmable device. Once the patient is awake after surgery, electronic pulses from the device are adjusted to reduce pain. After the pain is consistently reduced by at least 50%, a second surgery is performed to connect the electrode more permanently and to insert the programmable battery device under the skin, often near the collarbone. A connecting wire from the device goes up the back of the neck and under the scalp to the electrode.

Neurointensive Care

Michael Brisman, MD, Chief, Division of Neurosurgery, Co-Director, Neuroscience Intensive Care Unit (NeuroICU) 516.255.9031
Elzbieta Wirkowski, MD, Neurointensivist, Co-Director, Neuroscience Intensive Care Unit (NeuroICU) 516.663.4525
Mohammad Ibrahim, MD, Neurointensivist 516.663.4525
Jay Yasen, MD, Neurointensivist, Critical Care/Stroke Neurologist 516.663.4525
Typically, patients with serious neurological problems are treated in medical-surgical ICUs where the traditional orientation is toward the medical or surgical aspects of the patient’s condition. However, neurological diseases and episodes are often best treated by experienced specialists highly trained to manage such conditions, which can threaten both survival and brain function.

Winthrop’s Neuroscience Intensive Care Unit (NeuroICU) is reserved for patients recovering from complex neurosurgical procedures or those with acute neurological problems. These include: subarachnoid hemorrhage, ischemic stroke, status epilepticus, traumatic brain injury, serious neuromuscular disorders that can cause life-threatening paralysis and tumors or infections of the brain or spinal cord.

The first of its kind on Long Island, Winthrop’s NeuroICU includes 14 acute-care beds and an expert team of neurosurgeons, neuro-intensivists, neurologists, nurse practitioners, physician assistants and nurses with extensive training in neuro-critical care and the use of advanced monitoring technology. They work as a team to orchestrate the complex range of testing, constant monitoring and immediate interventions required to minimize immediate or delayed brain damage and maximize the chances for a full recovery. Their ability to make a differential diagnosis and exercise timely intervention distinguishes the NeuroICU from the standard medical-surgical intensive care unit.

With state-of-the-art technology to monitor intracranial pressure, cerebral perfusion pressure, brain oxygenation levels and core body temperature, the NeuroICU staff can manage the delicate balance of sophisticated techniques that promote healing of brain injuries. To assess situations such as brain aneurysms, cerebral hemorrhages and strokes, they use:
  • Continuous EEG Monitoring
  • Intracranial Pressure Monitoring
  • Licox (Brain Oxygenation) Monitoring
  • Single Photon Emission Computed Tomography (SPECT)
  • Invasive Hemodynamic Monitoring
Even when a patient is unresponsive and cannot communicate, advanced brain monitoring technology can detect brain functioning and problems can be addressed. The specialized procedures used for NeuroICU problems include: Ventricular Drainage Thrombolysis Plasmapharesis Hemicraniectomy Hypothermia Specific Pharmacotherapies Interventional Neurovascular Procedures Additionally, an array of sophisticated neuroradiology and interventional neuroradiology diagnostic tools are located in close proximity to the NeuroICU, allowing for quick access to testing that enables physicians to gain further insight into a patient’s condition. They include:
  • Computed Tomography Angiography (CTA)
  • Positive Emission Tomography (PET)
  • Magnetic Resonance Angiograpy (MRA)
  • 64-slice Computed Tomograghy Scanner (CT)
  • Biplane Digital Angiography system
  • CT Perfusion

Neurostimulation for Pain

Michael Brisman, MD, Chief, Division of Neurosurgery 516.255.9031
Jeffrey Brown, MD, Neurosurgeon 516.255.9031
Brian Snyder, MD, Neurosurgeon. 516.255.9031
Neurostimulation for pain is an advanced, effective treatment option for many chronic pain sufferers and includes deep brain stimulation, motor cortex stimulation, spinal cord stimulation and peripheral nerve stimulation. The process involves implanting a pacemaker-like battery-generated device that sends electrical signals through a lead to electrodes that stimulate the nervous system in the brain, spinal cord or nerves. The electrical impulses block the transmission of pain messages to the brain. Neurostimulation does not cure the cause of the pain. People with certain kinds of chronic pain may be candidates for neurostimulation, including those with chronic sciatica, failed back syndrome, neuropathy, reflex sympathetic dystrophy (complex regional pain syndrome) or vascular insufficiency. Many people consider neurostimulation successful if it reduces their current pain level by 50% or more.

Pain Management

Richard Fuss, MD (Anesthesiologist) 516.255.9031
Edward Rubin, MD (Anesthesiologist) 516.492.3100
Pain is a complex, challenging problem requiring careful investigation of symptoms and specialized care. For patients suffering from acute, chronic and cancer-related pain, Winthrop’s pain specialists offer a full range of evaluation and treatment techniques, as well as inpatient consultation services. Generally, pain management techniques are classified in terms of invasiveness.

Noninvasive, non-drug pain management techniques include exercise, physical therapy, superficial cooling and heating of the skin and electrotherapy (transcutaneous electrical nerve stimulation — TENS), which attempts to reduce pain via low-voltage surface electric stimulation. Pain relievers and related drugs are used at every stage of the medical treatment of pain. Invasive pain management techniques include injections that deliver steroids or anaesthetics to nerve, joint or epidural space and surgically implanted electrotherapy devices, such as implantable spinal cord stimulators (SCS) and peripheral nerve stimulators.

Pediatric Neurosurgery

Elizabeth Trinidad, MD, Neurosurgeon 516.255.9031
Mark Mitler, MD, Neurosurgeon 516.354.3401
Stephen Schneider, MD, Neurosurgeon 515.354.3401
Pediatric neurosurgery, a sub-specialty of neurosurgery, requires additional fellowship training after residency to specialize in the care of infants and children with disorders affecting the central and peripheral nervous system.

Care is provided by pediatric neurosurgeons, who specialize in the evaluation and treatment of children with a range of neurosurgical disorders, such as brain tumors, spasticity, movement disorders, epilepsy, hydrocephalus, craniosynostosis, head injuries, and spina bifida, as well as other cranial malformations and spinal deformities. Other conditions treated include: brain and spinal cord trauma, Chiari malformations, syringomyelia, moyamoya, brachial plexus and peripheral nerve injuries.

Comprehensive services include angiography, CT scanning, MRI, SPECT and PET; seizure surgery, including hemispherectomy; complex brain and spine surgery; and complex reconstruction for congenital facial and skull deformities, brachial plexus injuries and craniosynostosis; and endoscopic third ventriculostomy for hydrocephalus.

Prestige® Cervical Disc

The PRESTIGE® Cervical Disc System is a two-piece metal device that is attached to adjacent vertebrae with bone screws to replace a diseased cervical disc. The device — an artificial disc — consists of two main metal pieces that move with respect to one another by a ball and trough mechanism. The PRESTIGE® Cervical Disc System is intended to replace a cervical (neck) disc. Unlike in conventional spine fusion, the Prestige® System is designed to allow motion at the operated spinal level. Replacing a diseased disc with this device should include pain relief and improved function.

Revision Spine Surgery

William Sonstein, MD, Neurosurgeon 516.255.9031
Benjamin Cohen, MD, Neurosurgeon 516.255.9031
Artem Vaynman, MD, Neurosurgeon 516.255.9031
Nancy Epstein, MD, Chief, Neurosurgical Spine, Education & Development 516.354.3401
Revision spine surgery is used to correct failed back syndrome or mend a newly diseased area in a once-repaired — yet still dynamic — spine. At Winthrop, such complex and arduous surgery is often performed by a team consisting of a neurosurgeon and orthopaedic surgeon.

Under the best of circumstances, first-time spine surgery is complicated and challenging. Revision spine surgery can be even more involved, with the possibility of scarring significantly increasing the difficulty and risks, especially in the lumbar region. It necessitates the use of more intricate techniques than primary surgery because the normal spine anatomy is often altered by the original surgery, making it more difficult to free nerve structures. Additionally, revision spine surgery can require rebalancing the spine, which is especially challenging when portions of it have already been fused and are no longer flexible.

In addition to performing spinal fusion to deal with herniated discs and degenerative disc disease, Winthrop offers primary revision spine surgery to patients with a wide range of serious spinal deformities and diseases, including kyphosis, spondylolisthesis, scoliosis, herniated discs and lumbar spinal stenosis.

Skull Base Surgery

Michael Brisman, MD, Chief, Division of Neurosurgery 516.255.9031
Jeffrey Brown, MD, Neurosurgeon 516.255.9031
Lee Tessler, MD, Neurosurgeon 516.255.9031
Ramin Rak, MD, Neurosurgeon 516.255.9031
The skull base provides the base on which the brain rests. It contains the eye orbits, ear canals, two carotid arteries, two vertebral arteries, 12 cranial nerves and the blood drainage system of the brain. With so many intricate structures, the skull base is one of the most complex areas on which to operate. In the past, many tumors at the base of the skull were inoperable. But advances in diagnostic imaging, surgical techniques and instruments, and a better understanding of the skull-base anatomy have allowed surgeons to remove previously inoperable lesions with far fewer risks to the patient. Through magnetic resonance imaging (MRI), lesions can be detected earlier, allowing surgeons to operate sooner and prevent many complications. Many skull base tumors are now also treated with minimally invasive stereotactic radiosurgery treatment, such as CyberKnife®.

Spinal Cord Stimulation

Michael Brisman, MD, Chief, Division of Neurosurgery 516.255.9031
Jeffrey Brown, MD, Neurosurgeon 516.255.9031
Brian Snyder, MD, Neurosurgeon. 516.255.9031
Spinal cord stimulation, also known as dorsal column stimulation, is a minimally invasive technique that can offer pain relief for patients with intractable pain in the spine or extremities — especially pain in the low back and legs. The stimulator, which is a flexible tiny wire, is usually placed through a small puncture in the skin, and sends signals up to the brain which can cancel out sensations of pain.

Spinal cord stimulation may be considered when conservative treatments have failed, surgery is not an option, the patient does not have a pacemaker and the patient has had a successful spinal cord stimulator trial.

The trial period is important to determine if the therapy provides satisfactory pain relief. If the system works, and the patient is comfortable with the sensation (most often described as “tingling”), a permanent stimulation system can be implanted.

Vagus Nerve Stimulation

Brian Snyder, MD, Neurosurgeon 516.255.9031
Elizabeth Trinidad, MD Pediatric Neurosurgeon 516.255.9031
For adults and children over 12 with partial onset seizures — who do not quality for conventional epilepsy surgery or do not respond to anti-epileptic medications — vagus nerve stimulation (VNS) has been shown to reduce the brain’s potential to generate abnormal seizure activity. An advanced treatment option offered by specialized epilepsy programs such as Winthrop’s, VNS is FDA-approved as an adjunctive therapy to reduce seizure intensity and frequency; it does not involve brain surgery, is mechanically and electrically safe and has been used in more than 50,000 patients worldwide.

VNS inhibits seizures by delivering mild, intermittent electrical pulsed signals to the brain via the vagus nerve. The energy stems from a compact, pacemaker-like disc surgically implanted in the left chest, with electrodes tunneled under the skin and wrapped around the vagus nerve. Once implanted by a neurosurgeon, each patient’s device is programmed by a neurologist using non-invasive computer software to deliver a selected “dose” of stimulation automatically, based on patient tolerance and seizure response. Should a patient or caregiver sense the start of a seizure, they can activate extra, on-demand stimulation by passing a hand-held magnet over the implanted generator.

While VNS patients rarely become seizure-free, a significant number experience fewer seizures. In clinical trials, the treatment resulted in median reductions in seizures of 31.3%, 40.7% and 40.4% at one, two and three years respectively. Alertness, daytime sleepiness, mood and memory have shown improvement in VNS therapy patients. While it is almost always necessary to continue anti-epileptic medication, the number of medications and the dosages can usually be reduced.

X-Stop® for Spinal Stenosis

Stephen Burstein, MD 516.255.9031
William Sonstein, MD 516.255.9031
Benjamin Cohen, MD 516.255.9031
Artem Vaynman, MD 516.255.9031
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) can suffer from pain in the low back and legs as a result of compression of the nerves in the spinal canal. The pain is classically worse when patients walk, and better when they stop walking and flex forward. This is because flexion tends to open up the spinal canal. The X-Stop places a small titanium implant between the affected levels of the spine (usually L3/4 or L4/5), and effectively produces a permanent slight flexion, which in turn can provide symptom relief.
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