Conditions We Treat
Acoustic neuromas, (vestibular schwannomas), one of the most common types of brain tumors, are slow growing and benign. They develop adjacent to the brain on a portion of a nerve that runs from the brain to the inner ear. Symptoms include hearing loss, ringing (tinnitus) in the affected ear, dizziness, loss of balance, facial numbness and weakness. Treatment options include observation, surgery and stereotactic radiosurgery. Large tumors usually require surgery. Small or medium sized tumors are usually treated with radiosurgery.
Astrocytomas are primary brain tumors. In almost 50% of cases, the first symptom is a seizure. Between 60-75% of patients have recurrent seizures. Headache, vomiting and signs of increased intracranial pressure usually occur late in the disease course. Children with astrocytomas can have some combination of vision deterioration uncorrectable by glasses; gait instability; headache; vomiting; and decreased memory, attention and motor abilities. A computed tomography (CT) or magnetic resonance imaging (MRI) scan is necessary to determine size, location and consistency of the tumor. Surgery generally allows for functional survival for many years for lower-grade tumors.
Arteriovenous Malformations - AVM
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, and the majority are asymptomatic until they rupture or leak. When located in the brain, a bleeding AVM can produce seizures, headaches, intracranial hemorrhage, stroke, severe neurological disability — depending upon both its location and the amount of bleeding — and even death. Treatment options include conservative management and monitoring,surgery, stereotactic radiosurgery and embolization, alone or in combination.
Back pain may originate from muscles, nerves, bones, joints or other structures in the spine. The pain may be acute and sudden or it can be chronic, felt constantly or intermittently, and can be localized or radiate to other areas. It may be occur in the neck (and might radiate to the arm and hand), in the upper back or in the low back, (and might radiate to the leg or foot). The feeling may be a dull, sharp, piercing or burning sensation. Accompanying symptoms may include weakness, numbness or tingling. Most back pain syndromes are due to inflammation, especially in the acute phase. Generally, back pain does not require immediate medical intervention. The vast majority of episodes of back pain are self-limiting and non-progressive. A wide range of treatment is available, depending on the cause and duration.
A brain aneurysm is an abnormal bulging outward of a cerebral artery. Often discovered when they rupture, brain aneurysms cause intracranial bleeding or bleeping into the space closely surrounding the brain (subarachnoid space). A ruptured brain aneurysm can lead to a hemorrhagic stroke, brain damage and death. Before an aneurysm ruptures, patients are usually asymptomatic. Some patients with unruptured aneurysms have symptoms, including peripheral vision deficits, thinking or processing problems, speech complications, perceptual problems, sudden changes in behavior, loss of balance and coordination, decreased concentration, short-term memory difficulty and fatigue. Ruptured aneurysm symptoms include severe headache, nausea and vomiting, stiff neck or neck pain, vision problems, sensitivity to light, loss of sensation and altered level of consciousness. Once an aneurysm has ruptured, the major goal is to prevent rebleeding. Treatment options include surgery or minimally invasive endovascular techniques.
Brain & Spinal Traumas
Traumatic brain injury (TBI) can result from a closed or penetrating head injury. Brain damage can be confined to one area (focal) or involve more than one area (diffuse). Localized injuries may be associated with neurobehavioral changes or other neurological deficits linked to specific areas of the brain. Diffuse trauma is frequently associated with concussion, diffuse nerve fiber injury or coma. Symptoms can be mild, moderate or severe, depending on the extent of the brain damage. TBI can cause different physical, cognitive, emotional and social problems. Outcome ranges from complete recovery to permanent disability or death. Traumatic spinal cord injury damages the white matter that carries sensation and motor signals to and from the brain. Treatment involves stabilizing the patient immediately after the injury, rehabilitating and returning the patient to the community and continuing rehabilitation to treat long-term impairments.
A brain tumor is created by abnormal and uncontrolled cell division. It can occur in the brain itself, the cranial nerves, brain envelopes, skull or pituitary and pineal glands; or it can spread from cancers located in other organs (metastatic tumors). Although there is no specific clinical symptom or sign for brain tumors, slowly progressive neurologic signs, phantom odors and tastes and indications of elevated intracranial pressure are warning signs. A sudden onset of symptoms, such as an epileptic seizure in a patient with no prior history of epilepsy; sudden intracranial hypertension, which may be due to bleeding within the tumor; brain swelling; or obstruction of cerebrospinal fluid's passage are also red flags. While computed tomography (CT) and magnetic resonance imaging (MRI) are important to diagnosing brain tumors, a definitive diagnosis can be confirmed only by examining tumor tissue samples obtained by brain biopsy or open surgery. The tissue cell examination is often needed for determining appropriate treatment, which includes surgery, radiotherapy and chemotherapy.
Carotid stenosis refers to the blockage and narrowing of the carotid artery, which is located in the neck and supplies blood to the brain. The blockage is caused by fatty buildup, which accumulates in the inner lining of blood vessels and results in narrowing or “stenosis” of the artery. This may result in the formation of blood clots, which can break loose and flow up to the brain. Symptoms depend on the area of the brain affected. Although many patients are asymptomatic, they may experience a mini stroke (transient ischemic attack -TIA) that can cause momentary loss of vision in one eye, weakness/numbness of one side of the body, slurred speech or an inability to speak. Some diagnostic tests include Doppler ultrasound, which uses noninvasive sound waves to reconstruct an image of the carotid arteries and the blood flow; magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA), which use magnetic fields to generate an image or neuroangiography, which involves injecting a blood vessel with dye and producing images to monitor the flow within the vessel. The goal of treatment is to reduce the risk of stroke with anti-clotting medications, carotid endarterectomy — a microsurgical procedure that removes plaque from the narrowed vessel — or carotid stenting, which involves opening the narrowed artery and leaving a tiny structure in place to keep it opened.
Cerebrovascular & Endovascular Diseases
Cerebrovascular disease is caused when blood vessels in the brain are damaged. They can burst and bleed or become clogged with fatty deposits, which interrupt blood flow and can result in a stroke. Endovascular disease most commonly affects carotid arteries, the main artery from the heart to the rest of the body (aorta), pathways for blood flow to the lower extremities, pathways for blood flow to the kidneys, bowel and leg veins. Endovascular disease is a slow process and symptoms may not appear until there is a significant blockage that can lead to serious consequences.
Chiari malformation is a rare congenital brain deformity. It most often involves displacement of the back of the brain through the opening in the back of the skull, which results in part of the brain extending into the spinal canal and interfering with the flow of cerebral spinal fluid (CSF) to and from the brain. In infants, the most common symptoms are high-pitched breathing sounds and swallowing difficulties. In older children, limb weakness and breathing difficulties may occur. Patients may experience no symptoms or remain asymptomatic until early adulthood, when they often experience severe headaches and neck pain. Other symptoms include fatigue, dizziness, vertigo, visual disturbances, difficulty swallowing, ringing in the ears, sleep apnea, impaired fine motor skills, muscle weakness and palpitations. The most frequent treatment is decompression surgery, in which a neurosurgeon opens the base of the skull and restores normal CSF flow.
Very different and more complex than acute pain, chronic pain has no time limit and may have no apparent cause. It can generate many psychological problems leading to debilitating feelings of helplessness and hopelessness. Most common causes include low-back problems, headache, recurrent facial tenderness, cancer and arthritis. Chronic pain requires careful investigation of symptoms and specialized care. It is rare to achieve absolute and sustained relief of pain. Thus, the clinical goal is pain management, which often involves multidisciplinary care.
In craniosynostosis, some or all of the spaces between the plates of bone making up the skull close too early. This can lead to very misshapen heads as a child grows older. The treatment is surgical correction within the first one or two years of life. The condition can cause problems with normal brain and skull growth. Also, intracranial pressure can be increased. Surgery is typically used to separate the fused sutures and reshape the skull.
Degenerative Disc Disease
Degenerative disc disease occurs when a damaged spinal disc causes pain. The discs act like shock absorbers between the bones of the spine and are designed to help the back stay flexible. A disc may be painful when it bulges, herniates, tears or degenerates and may cause neck pain, as well as pain in the mid-back, low back and/or arms, chest wall, abdomen and legs. Each disc has two parts: A firm, tough outer layer and a soft, jelly-like core. In degenerative disc disease, the inner jelly material can bulge out and stimulate the pain receptors causing back pain to occur. Common symptoms include pain that is worse when sitting, bending, lifting or twisting; feeling better while walking or running than while sitting or standing for long periods; feeling better when lying down; severe pain that comes and goes; pain affecting the low back, buttocks, thighs or neck, depending on the location of the disc; pain radiating to arms and hands; numbness and tingling in the extremities; leg muscle weakness or foot drop. Discs can degenerate with aging, as well as with daily activities and participation in sports. Diagnosis is based on a medical history and physical examination, as well as the symptoms and the circumstances that first caused the pain. A magnetic resonance imaging (MRI) scan can show disc damage. Treatment options include artificial disc replacement, surgery and non-operative symptom treatment.
Scoliosis is a congenital condition in which a person's spine is abnormally curved. The spine of an individual with typical scoliosis may look more like an "S" or a "C" rather than a straight line. The cause is unknown or it can be a secondary symptom of another condition, such as cerebral palsy. Surgery is usually indicated for curves that have a high likelihood of progression, cause a significant amount of pain and are cosmetically unacceptable as an adult. Curves in patients with spina bifida and cerebral palsy that interfere with sitting and care, and curves that affect physiological functions, such as breathing also benefit from surgery. While very good corrections can be achieved with surgery, it is usually impossible to completely straighten a scoliotic spine.
Dystonia is a chronic movement disorder causing muscles to contract and spasm involuntarily. The contractions force the body into repetitive and often twisting movements, as well as awkward, irregular postures. There are several forms of dystonia, and many conditions include dystonia as a major symptom. Dystonia may affect a single body area or be generalized throughout multiple muscle groups, causing varying degrees of disability and pain. The majority of dystonias do not affect cognition, intelligence or life span. There is no cure, but multiple treatment options include medication and surgical therapy, which includes deep brain stimulation (DBS). DBS involves a surgically implanted pacemaker-like device that delivers electrical stimulation to very specific areas in the brain; it has reduced the symptoms of dystonia in some patients.
Epilepsy is a seizure disorder caused by uncontrolled electrical activity in the brain, which may produce physical convulsions, minor physical signs, thought disturbances or a combination of symptoms. Seizures can be caused by head injuries, brain tumors, lead poisoning, brain developmental problems, genetic and infectious diseases and fevers. In 50% of the patients with seizures, no cause can be found. Symptoms, ranging from mild to severe, differ with each patient. At least two unprovoked seizures are required for an epilepsy diagnosis. Even mild seizures require treatment, which includes anti-seizure medication or surgery. Surgery can involve procedures to map and identify regions of the brain responsible for seizures; removal of the area of the brain responsible for seizures; and vagus nerve stimulation (VNS), which 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.
Essential tremor (ET), a genetic condition, usually affects the hands, but it may also affect the head and neck, face, jaw, tongue, voice and trunk. It is not caused by another neurological condition, by injury or as a side effect of a medication. The tremor may be a rhythmic movement produced by involuntary muscle contractions. Severity can vary greatly from hour to hour and day to day. Some people experience tremor only when the body or a part of the body is held in certain positions (postural tremor). Tremor that worsens during a particular action such as writing or eating is kinetic or action-specific tremor. Most people with ET have both postural and kinetic tremor. ET may begin at any age from childhood through late adulthood. However, it is rarely seen in children; the incidence increases with advancing age, with the mean age of onset at about 45. Overall, the symptoms and the possibility of related functional disability tend to progress with increasing age. As the disease progresses, tremor amplitude may increase, leading to decreased ability to manage fine, discrete motor tasks. Treatment involves medications as well as surgery, which can include deep brain stimulation (DBS). DBS involves a surgically implanted pacemaker-like device that delivers electrical stimulation to very specific areas in the brain. Surgical thalamotomy involves using a small electrode to burn a small region of cells in the brain considered responsible for tremor.
Trigeminal neuralgia (TN) is a disorder of the trigeminal nerve that causes episodes of intense pain in the eyes, lips, nose, scalp, forehead and/or jaw. TN usually occurs when a small blood vessel comes into contact with the fifth cranial nerve, applying pressure at the point where the nerve joins the brain stem. TN can also be caused by multiple sclerosis or small tumors pressing on the trigeminal nerve. The pain is sudden and described as feeling like stabbing electric shocks or unrelenting shooting pain. Although TN is not fatal, successive recurrences may be incapacitating, and the fear of provoking an attack may make sufferers reluctant to engage in normal activities. There is no cure, but most people find relief from medication. Surgery may be recommended, either to relieve the pressure on the nerve or to selectively damage it in such a way as to disrupt pain signals from getting through to the brain. Of the several surgical options, microvascular decompression (MVD) is the only one aimed at fixing the presumed cause of the pain. In this procedure, the surgeon enters the skull through a small hole behind the ear, exploring for an offending blood vessel. When one is found, the vessel and nerve are separated with a small pad. When successful, MVD procedures can give permanent pain relief with little to no facial numbness.
Glioblastoma multiforme (GBM), also known as grade 4 astrocytoma, is the most common and aggressive type of primary malignant brain tumor. Treatment can involve chemotherapy, radiotherapy and surgery, which are palliative measures, not cures. Even with complete removal of the tumor via surgery plus the best available treatment, management of glioblastoma remains challenging.
Headaches can be isolated or recurrent and localized to one or more areas of the head and face. Primary headaches include tension headaches (muscular contraction), vascular headaches (migraine) and cluster headaches. Secondary headaches result from other medical conditions. Treatment depends on accurate categorization of the headache.
The bones of the spine are cushioned by small discs that act as shock absorbers. When damaged by injury, normal wear and tear or disease, they may bulge or rupture, forming a herniated disc. Pain or numbness occur when pressure from the herniated disc is put on the nerve roots or spinal cord. Herniated discs can occur anywhere in the spine, but most occur in the lower back. Symptoms in addition to pain vary greatly, depending on the location of the herniated disc. They may include tingling or numbness, weakness in certain muscles, severe deep muscle pain and spasms. Medical treatment is usually tried first, including bed rest, pain and anti-inflammatory medications and exercises. Surgical options include laminectomy, discectomy and fusion, such as minimally invasive spinal fusion. Surgery is indicated if a patient has a significant neurological deficit, or if non-surgical therapy fails. A primary focus of surgery is to remove “pressure” or reduce mechanical compression on either the spinal cord or a nerve root.
Hydrocephalus is sometimes known as "water in the brain". Normally, cerebrospinal fluid (CSF), which protects the brain’s soft tissue, circulates through the brain, its ventricles and the spinal cord, and is continuously drained away into the circulatory system. Each day, the same amount of CSF that is produced must be reabsorbed into the blood stream. With hydrocephalus, something blocks or slows the fluid’s path and it accumulates in the brain’s ventricles, which expand and press on the brain. In early childhood, the skull may become enlarged because of the great volume of fluid. The condition may result from an overproduction of the CSF fluid, from a congenital malformation blocking normal drainage of the fluid, or from complications of head injuries or infections. Symptoms depend on the cause of the blockage, the patient’s age and how much brain tissue has been damaged. Hydrocephalus is detectable in utero via ultrasound. After birth, symptomatic patients are diagnosed through computed tomography (CT), magnetic resonance imaging (MRI) scans or ultrasound in infants. Infants and young children with hydrocephalus typically have abnormally large heads, because the pressure of the fluid causes the individual skull bones — which have not yet knitted together — to bulge outward at their junctures. Hydrocephalus can cause seizures and mental disability. It was routinely fatal until surgical techniques for shunting the excess fluid out of the central nervous system and into the blood or abdomen were developed. Endoscopic third ventriculostomy (ETV), an alternative to shunting, is a minimally invasive bypass procedure that allows the accumulated fluid to bypass the obstruction and establishes normal CSF circulation.
Symptoms of Hydrocephalus
- Full or bulging fontanel
- Accelerated and disproportionate growth of the head
- Sun-set eyes
- High-pitched cry
- Difficulty feeding
- Developmental delays
Babies able to communicate
- Excessively irritable
- Vision changes
- Uncontrolled eye movements
- Loss of coordination
Intracranial Atherosclerotic Disease
Atherosclerosis, which affects arterial blood vessels, occurs when there is a fatty deposit buildup along the arterial wall. Intracranial atherosclerotic disease refers to atherosclerosis in the brain, which can lead to a stroke and potential irreversible loss of function. Treatment includes minimally invasive angioplasty to expand narrowed arteries or major invasive surgery to create additional blood supply connections that go around the more severely narrowed areas.
An intracranial hemorrhage (ICH) is bleeding within the skull that occurs when a blood vessel in the head is ruptured or leaks. It can result from physical trauma or non-traumatic causes, such as stroke or a ruptured aneurysm. An ICH is a serious medical emergency because the buildup of blood within the skull can lead to increased intracranial pressure, which can crush delicate brain tissue or limit its blood supply. Computed tomography (CT) is the definitive tool for accurate diagnosis of an intracranial hemorrhage. Treatment depends on the type of ICH; it may include both medication and surgery.
Kyphosis, a deformity characterized by an exaggerated forward rounding of the upper back, can occur as a result of developmental problems; degenerative diseases, such as arthritis of the spine; osteoporosis with compression fractures of the vertebrae; or trauma to the spine. Severe cases can affect the lungs, nerves and other tissues and organs, causing pain and other problems. Symptoms may include slouching posture or hunchback, mild back pain, spinal stiffness or tenderness and fatigue. Treatment depends on the cause of the curvature and its effects. Conservative treatment includes pain relievers, exercise and physical therapy. More serious cases require more aggressive treatment, including bracing and surgery, which is generally recommended if the patient does not respond to other treatment measures, the condition continues to worsen, debilitating pain is not reduced with medication, neurological problems occur, or the condition is related to a tumor or infection. The goal of surgery is to reduce the degree of curvature by fusing or joining the affected vertebrae.
Meningiomas, the most common benign tumors of the brain, can rarely also be malignant. Depending on the size and location, symptoms include seizures; progressive spastic weakness in legs; incontinence; motor, sensory and speech problems; and eventual rise in intracranial pressure. Meningiomas can usually be removed surgically, with permanent cure, if the tumor is superficial and easily accessible. Radiosurgery is also used in some cases.
Mesial Temporal Sclerosis
Mesial temporal sclerosis is a seizure disorder closely related to temporal lobe epilepsy. It involves scarring of the deepest portion of the temporal lobe, which can occur with brain damage due to traumatic injury, infection, a brain tumor, lack of oxygen or uncontrolled seizures. Symptoms include strange sensations, changes in behavior or emotions, muscle spasms or convulsions. Usually localized, the seizures may spread to involve the entire brain and may cause a sudden loss of awareness or consciousness. Treatment includes anti-convulsant medications and surgical therapy, which involves either temporal lobectomy or vagus nerve stimulation (VNS).
Metastasis is the spread of a disease from one organ to another. When tumor cells metastasize, the new tumor is called a secondary or metastatic tumor, and its cells are like those in the original (primary) tumor. This means that if breast cancer spreads (metastasizes) to the brain or spine, the secondary tumor is made up of abnormal breast cells, not abnormal brain or spine cells. The tumor in the brain or spine is then classified as “metastatic breast cancer,” not “brain or spine” cancer”. Metastatic cancer may be treated with radiosurgery, chemotherapy, radiation therapy, biological therapy, hormone therapy, surgery, laser-immunotherapy or a combination of these. Treatment generally depends on the type of primary cancer, the size and location of the metastasis, the patient's age and general health and previous treatments.
A group of complex neurological/neurodegenerative diseases, movement disorders include ataxia (lack of coordination), dystonia Huntington's disease, multiple system atrophies, Parkinson's disease, restless leg syndrome (RSD) and periodic limb movement disorder (PLMD), tics (involuntary muscle contractions), Tourette syndrome, tremor (e.g., essential tremor or resting tremor) and Wilson disease. Once diagnosed, treatment depends on each patient’s unique condition and special needs. Many of these diseases are treated with combinations of medications, physical therapy, occupational therapy and sometimes surgery, including deep brain stimulation (DBS) for select patients.
Moyamoya disease is extremely rare except in Japan. It is characterized by progressive narrowing of a ring of arteries at the base of the brain, which restricts blood supply. Hemorrhagic events can also occur. The cause is unknown. The condition leads to irreversible blockage of the carotid arteries as they enter the skull. In children, Moyamoya disease tends to cause strokes or seizures. In adults it tends to cause bleeding or strokes. Once the blockage process (vascular occlusion) begins, it tends to continue despite medical management unless treated with surgery.
Normal Pressure Hydrocephalus (NPH)
Normal pressure hydrocephalus (NPH) is a chronic type of hydrocephalus that almost always afflicts people over 55. The disorder involves an accumulation of cerebrospinal fluid (CSF) in the brain’s ventricles. Patients can develop gait difficulties, urinary incontinence and mental decline. Due to the condition’s chronic nature and presenting problems, it is often misdiagnosed as dementia, Alzheimer’s disease, Parkinson's disease, or a spinal problem. The cause is unknown, but some patients have suffered severe head injury, stroke, infection or a brain tumor well in the past, which may have caused scarring that gradually interfered with drainage of spinal fluid. NPH may be relieved by surgically implanting a shunt to drain excess CSF to the abdomen where it is absorbed. Once the shunt is in place, the ventricles often diminish in size.
Occipital neuralgia is a headache characterized by piercing, throbbing or electric-shock-like chronic pain in the upper neck, back of the head and behind the ears. Some individuals also experience pain in the scalp, forehead and behind the eyes. The location of pain is related to the areas supplied by the greater and lesser occipital nerves. The pain, caused by irritation or injury to those nerves, can result from trauma to the back of the head, pinched nerves in overly tight neck muscles, compression of the nerve as it leaves the spine due to osteoarthritis or tumors and other types of lesions in the neck. In many cases, no cause can be found. Relief from pain after an anesthetic nerve block confirms the diagnosis. Treatment includes massage and rest; in some cases, antidepressants may be used. Other treatments may include local nerve blocks and steroid injections directly into the affected area. In some patients who do not improve with conservative management, surgery may be considered.
Acute pain, which often has a reversible cause, may require only correction of the underlying problem. Chronic pain often results from difficult-to-diagnose conditions that are hard to treat and may take a long time to reverse. Often, pain pathways continue to transmit the sensation of pain even though the underlying condition or injury has healed. In such situations, the pain itself is frequently managed separately from the underlying condition. Pain management generally involves a multidisciplinary approach that includes pharmacologic measures; interventional procedures, such as physical therapy and exercise; application of ice and/or heat; and psychological measures, such as biofeedback and cognitive therapy. Interventional procedures typically used for chronic back pain include epidural steroid injections, facet joint injections, neurolytic blocks, spinal cord stimulators and intrathecal drug delivery system implants. Trigger point injections and nerve blocks utilizing long acting anesthetics and small doses of steroids may also be used.
Parkinson's disease, the most common movement disorder, is a chronic, progressive condition that worsens over time. Parkinson's disease occurs when a group of cells in an area of the brain begin to malfunction and die. These cells produce a chemical called dopamine, which is a neurotransmitter (chemical messenger) that sends information to the parts of the brain that control movement and coordination. With Parkinson's, dopamine-producing cells begin to die and the amount of dopamine produced in the brain decreases. Messages from the brain telling the body how and when to move are delivered more slowly, rendering the individual incapable of initiating and controlling movements in a normal way. Symptoms vary with each person and can include tremor of the extremities, jaw and face; rigidity or stiffness of the limbs and trunk; slow movements; postural instability; or impaired balance and coordination. Treatment includes medications, as well as physical, speech and surgical therapies, including deep brain stimulation (DBS), which involves a surgically implanted medical device, much like a pacemaker, that delivers electrical stimulation to very specific areas in the brain and is proven to improve motor function in certain Parkinson’s disease patients.
Phantom Limb Pain
Phantom limb pain is discomfort felt in the area of an amputated limb. Although the limb is no longer there, nerve endings at the amputation site continue to send signals to the brain that make it think the limb is still there. The pain can range from mild to extreme and can be disabling. When phantom limb pain continues for more than six months, prognosis is poor. In addition to pain, some people experience tingling, cramping, heat and cold in the amputated phantom limb. Treatment depends on the amount of pain. Multiple treatments might be combined, including pain medications, heat application, biofeedback, relaxation techniques, massage, surgery to remove scar tissue entangling the nerve, and spinal cord stimulation or deep brain stimulation (DBS).
A pinched (compressed) nerve occurs when too much pressure is applied to a nerve by surrounding tissues — bones, cartilage, muscles or tendons. It can occur anywhere in the body. The pressure disrupts the nerve's function, causing pain, tingling, numbness or weakness. Some patients experience sharp or burning pain that may radiate outward. With rest and other conservative treatments, most people recover. Sometimes surgery is necessary.
Pituitary adenomas are benign, slow-growing tumors found in the pituitary gland. They remain confined to the gland or surrounding tissues, and are often undiagnosed until visual problems, headaches or excessive hormone secretion occur. If diagnosed early enough, prognosis is usually excellent. Treatment can include medication, surgery and radiotherapy. The choice depends upon the type and size of the tumor, and whether or not it has invaded or pressed on surrounding structures. In some cases, all three options are used. The goal is to reduce pressure on nearby structures and/or normalize hormone levels. Endoscopic pituitary surgery, a minimally invasive, safe and effective procedure uses an endoscope with the latest image-guidance neuronavigation technology to remove the tumor.
Post-herpetic neuralgia (PHN) is a painful condition caused by the shingles virus after the skin rash has crusted over and begun to heal. Treatment options include antidepressants, anticonvulsants and topical agents. Opioid analgesics may also be appropriate in many situations. There are some sporadically successful surgical treatments, such as rhizotomy (severing or damaging the affected nerve to relieve pain), and TENS (a type of electrical pulse therapy).
One of the worst consequences of a stroke is severe burning pain on the affected side of the body. Post-stroke pain occurs most frequently following strokes that affect the left side of the body. The cause is unknown, and common pain medications are not effective. Twenty percent of patients improve over a period of years. Treatment includes narcotics and other medications. Brain stimulation may help, including motor cortex stimulation (MCS), which involves the placement of electrodes on the surface of the brain and administering an electrical stimulus to that region and deep brain stimulation (DBS), which involves placing electrodes in deeper regions of the brain considered responsible for the generation or perpetuation of pain.
Sciatica is a set of symptoms, including pain, that may be caused by general compression and/or irritation of one of five nerve roots that give rise to the sciatic nerve, or by compression or irritation of the sciatic nerve itself. The pain is felt in the lower back, buttock, and/or various parts of the leg and foot. In addition to pain, which can be severe, there may be numbness, muscular weakness and difficulty in moving or controlling the leg. Typically, the symptoms are felt only on one side of the body. Treatment depends upon the underlying cause of the symptoms.
Seizure disorders are caused by uncontrolled electrical activity in the brain, which may produce involuntary changes in body movement or function, sensation, awareness or behavior. A seizure can last from a few seconds to status epilepticus (a continuous seizure that may not stop without intervention). Seizures are often associated with a sudden and involuntary contraction of a group of muscles. However, a seizure can also be subtle, including numbness of a part of the body, a brief loss of memory, visual sparkling or flashes or sensing an unpleasant odor. Seizures can be caused by head injuries, brain tumors, lead poisoning, brain developmental problems, genetic and infectious diseases and fevers. In 50% of the patients with seizures, no cause can be found. Symptoms experienced during a seizure depend on where in the brain the electrical disturbance occurs. Therefore, seizures are typically classified as motor, sensory, autonomic, emotional or cognitive. Even mild seizures require treatment, which involves medication and can include surgery, as well as vagus nerve stimulation (VNS). Epilepsy is a complex seizure disorder. Several types of seizures are easy to control, and many patients are well enough between seizures to lead normal lives.
Skull Base Tumors
Many tumor types originate from or extend into the base of the skull. Not all tumors in the skull base are malignant, but even benign tumors can cause symptoms. Skull base tumors produce few symptoms until they grow large enough, with symptoms varying greatly, depending on the specific location and growth rate of each tumor type. Symptoms may include facial pain or numbness, headache, recurrent sinusitis, nasal obstruction, shortness of breath, hoarseness, hearing loss and tinnitus (ringing in the ears). Treatment for tumors of the skull base may involve surgery, radiation therapy, chemotherapy or a combination of therapies. Recent advances in diagnostic and surgical techniques have made the area more accessible to surgery.
Spasticity is a disorder of the central nervous system (CNS) in which the nerves leading to certain muscles are unable to regulate themselves causing the muscles to continually tighten and contract. This interferes with gait, movement and, sometimes, speech. Spasticity is most common in forms of spastic cerebral palsy. It also is seen extensively in multiple sclerosis and to different degrees in most other neuromuscular diseases. Spasms can be triggered by cold weather and fatigue, as well as multitasking (e.g., walking, talking and eating). Treatment includes massage and stretching, as well as medications to diminish the spastic signals between the nerves and muscles.
Spina bifida, a serious birth defect, occurs when the tissue surrounding the developing spinal cord of a fetus does not close properly. The condition is part of a group of birth defects called neural tube defects. The neural tube is the embryonic structure that eventually develops into the baby's brain and spinal cord and the tissues that enclose them. In babies with spina bifida, a portion of the neural tube fails to develop or close properly, causing defects in the spinal cord and in the bones of the backbone. Spina bifida occurs in three forms, each varying in severity: Spina bifida occulta (mildest); Meningocele (rare); and Myelomeningocele, (most severe). In the last case, the spinal canal remains open along several vertebrae in the lower or middle back causing the membranes and the spinal cord to protrude at birth and forming a sac on the baby's back. In some cases, skin covers the sac. Usually, however, tissues and nerves are exposed, making the baby prone to life-threatening infections, neurological impairment and other medical complications. Surgery is the treatment of choice.
Spinal Cord Injury
Many spinal cord injuries cause permanent disability or paralysis below the site of the injury. Symptoms depend on the location and severity of the injury and can include pain; an intense stinging sensation; loss of movement, sensation, bowel or bladder control; and difficulty breathing, coughing or clearing secretions from the lungs. Severity depends upon how much of the spinal cord is damaged. Partial spinal cord injuries enable patients to retain some sensation and possible function below the affected area. A complete spinal cord injury is characterized by total loss of motor function and sensation below the area of injury. Many people with partial spinal cord injuries are able to experience significant recovery, while those with complete injuries are not.
Spinal stenosis occurs when the spinal canal narrows and puts pressure on the spinal cord and nerves that branch out from the compressed areas. This usually arises from the natural spinal degeneration that comes with aging. It can also sometimes be caused by spinal disc herniation, osteoporosis or a tumor. Depending on the location of the stenosis, symptoms can include cramping; pain or numbness in the legs, back, neck, shoulders or arms; a loss of sensation in extremities; and sometimes bladder or bowel function problems. Mild symptoms are often helped by pain relievers, physical therapy or a brace. For more serious cases, surgery is an option, including decompression and fusion procedures. Recent surgical developments include several new implants that preserve as much normal motion in the spine as possible. The only FDA-approved non-fusion implant is the X-Stop™, which works via indirect decompression.
Minor spine fractures may never require treatment, but major fractures can result in serious long-term problems unless treated promptly and properly. The more severe can cause pain and spinal cord injury. Because the spinal cord and nerve roots are contained within the spine, the cord or nerve roots may be injured, resulting in a loss of sensation and paralysis. Indications of nerve injury include pain radiating into the leg, weakness of the leg muscles, and incontinence. Spine surgery is a highly specialized procedure, determined on a case-by-case basis. For compression fractures, spine surgeons can perform kyphoplasty to re-expand the vertebrae and strengthen them with an injection of bone cement. Sometimes bone cement can be injected without re-expanding the fracture (vertebroplasty).
In rare cases, the cause of back pain is a benign or malignant spine tumor. Spine tumors can be dangerous and even life-threatening, if they grow and compress the spinal canal, which can lead to paralysis or other neurologic problems. Spine tumors can occur between the membranes and the bones of the spine, within the spinal cord or within the membranes covering the spinal cord, or they may extend from other locations. Back pain is often the primary symptom. The pain of spine tumors may or may not be related to activity and can occur when moving or at rest. Other symptoms may include fever, numbness, sciatica, weakness or partial paralysis in the limbs or spinal deformity (such as kyphosis or scoliosis). Recent treatment advances include various types of surgery and radiosurgery.
Spondylolisthesis is a forward slip of one vertebra relative to another. It usually occurs in the lower area of the spine and is often seen in people who are very physically active. It can be congenital or acquired through injury or repetitive actions that may weaken the spine. Many people have no symptoms, and become aware of the problem only after it is revealed in an X-ray prescribed for a different problem. In other cases, several symptoms may accompany spondylolisthesis, including low back pain, especially after exercise; swayback; pain and weakness in thighs and legs; reduced ability to control bowel and bladder functions; and tight hamstring musculature. Treatment includes bed rest, medications and bracing. Surgery may be recommended if other treatments fail.
Strokes can be caused by a disruption in the blood supply to part of the brain due to a blood clot or plaque-narrowed blood vessels or when blood vessels in the brain leak or rupture. Most strokes damage the brain within minutes. Common symptoms include loss of sensation; weakness or paralysis in an arm, leg or one side of the body; partial loss of vision or hearing; double vision; dizziness; slurred speech; severe headache; cognitive problems; imbalance and falling. For strokes caused by clots, rapid action with clot-busting drugs or mechanical clot removal may reduce the damage or prevent more damage. Strokes require urgent evaluation to detect and treat. If a person is suspected of having a stroke, the National Stroke Association recommends conducting the FAST test:
Face: Ask the person to smile. Does one side of the face droop?
Arms: Ask the person to raise both arms. Does one arm drift downward?
Speech: Ask the person to repeat a simple sentence. Are the words slurred? Can he/she repeat the sentence correctly?
Time: If the person shows any of these symptoms, time is important. Call 911 or get to a hospital fast.
Subarachnoid hemorrhage (SAH) is bleeding into the space surrounding the brain. It may be spontaneous or caused by trauma. The classic symptom is for spontaneous SAH is thunderclap headache. Other symptoms include vomiting, seizures, sensitivity to bright light, confusion, decreased consciousness or coma. Risk factors include smoking, high blood pressure and alcohol abuse. Spontaneous SAH is a medical emergency that can lead to death or severe disability even if recognized and treated early. Stabilizing the patient is the first priority. Once the diagnosis is confirmed, admission to a neuroscience intensive care unit is preferable, especially since 15% of patients may have further bleeding soon after admission. After stabilizing the patient, rebleeding is prevented by obliterating the bleeding source.
A subdural hematoma (SDH) is a form of traumatic brain injury (TBI) in which blood gathers between the dura (outer protective covering of the brain) and the arachnoid (middle layer of the membrane that envelopes the brain and spinal cord). Subdural bleeding may cause an increase in intracranial pressure (ICP), which can compress and damage brain tissue. SDHs are most often caused by head injury. It is important that a patient receive medical assessment, including a complete neurological examination, after any head trauma. Computed tomography (CT) or magnetic resonance imaging (MRI) scans can usually detect significant SDHs. Treatment depends on the hematoma’s size and rate of growth. Small ones can be managed by careful monitoring until the body heals itself. Large ones require the surgical opening of the skull to remove the blood clot with suction or irrigation, identify the bleeding sites and control them.
Syringomyelia is the development of a fluid-filled cyst (syrinx) within the spinal cord. Causes can include Chiari malformation, spinal cord tumors, spinal cord injuries and damage caused by inflammation around the spinal cord. Over time, the cyst may grow, damaging the spinal cord and causing pain, weakness and stiffness in the back, shoulders, arms or legs. Other symptoms may include headaches and a loss of the ability to feel extremes of hot or cold, especially in the hands. Each patient experiences a different combination of symptoms, depending on the extent and location of the syrinx within the spinal cord. Signs of the disorder tend to develop slowly, although sudden onset may occur with coughing, straining, or spinal cord damage or disease. Surgery is the only viable treatment, but not all patients advance to the stage where surgery is needed.
Traumatic Brain Injury (TBI)
Traumatic brain injury (TBI) occurs by direct impact to the brain, scalp or skull. TBI can be classified based on severity, how it occurred or other features, e.g., location. Causes include falls, vehicle accidents and violence. In addition to the damage caused at the moment of injury, brain trauma causes secondary injury — a variety of events that may occur in the minutes and days following the initial injury. These processes, which include alterations in cerebral blood flow and intracranial pressure, contribute substantially to the damage from the primary injury. TBI can lead to physical, cognitive, emotional and behavioral problems; outcome can range from complete recovery to permanent disability or death.
Tremor is an unintentional, somewhat rhythmic, muscle movement involving one or more parts of the body. The condition is generally caused by problems in parts of the brain that control muscles throughout the body or in particular areas, such as the hands. Some forms of tremor are hereditary, while others have no known cause. The most common of all involuntary movements, tremor can also affect the arms, head, face, vocal cords, trunk and legs. It can occur in otherwise healthy people; in some people, tremor is a symptom of another neurological disorder. Although tremor is not life-threatening, it can be embarrassing and make it harder to perform daily tasks. Neurological disorders or conditions that can produce tremor include multiple sclerosis, stroke, traumatic brain injury and neurodegenerative diseases that damage or destroy parts of the brainstem or the cerebellum. Other causes include the use of some drugs, alcohol abuse or withdrawal, mercury poisoning, an overactive thyroid or liver failure. Some forms of tremor are better managed with medical or surgical therapies than others.
Trigeminal neuralgia (TN) is a neuropathic disorder of the trigeminal nerve that causes episodes of intense pain in the eyes, lips, nose, scalp, forehead and/or jaw. TN usually results from a small blood vessel that compresses the fifth cranial nerve, applying pressure where the nerve joins the brain stem. TN can also be caused by multiple sclerosis or by masses that involve the trigeminal nerve. The condition is diagnosed after taking a detailed history, performing a neurological examination, analyzing magnetic resonance imaging (MRI) scans and ruling out other possible causes of facial pain, including dental problems, migraine headaches and tumors. Pain episodes occur suddenly. TN can be triggered by light touching, tooth brushing, breezes, wintry weather or even a kiss. The attacks, which feel like stabbing electric shocks, usually affect one side of the face at a time, last several seconds or longer, and can occur many times throughout the day. Attacks typically worsen in frequency or severity over time. There is no cure, but most people find relief from anti-seizure medication or from one of five surgical options. Surgery may be recommended either to relieve the pressure on the nerve or selectively damage it in order to keep pain signals from getting through to the brain. Of the five surgical options, microvascular decompression is the only one aimed at fixing the presumed cause of the pain. In this procedure, the surgeon enters the skull through a tiny hole behind the ear. The nerve is then explored for an offending blood vessel, and when one is found, the vessel and nerve are separated or "decompressed" with a small pad. Alternatively, TN can be treated by minimally invasive “nerve injuring” procedures, such as percutaneous trigeminal rhizotomy or stereotactic radiosurgery.