Neurosurgery | Clinical Briefings | Penn Medicine

Surgical Management of Drug-Resistant Epilepsy

noreply@blogger.com (Anonymous) — Thu, 16 Apr 2015 08:17:00 -0400

Penn Epilepsy Center

Epileptologists from the departments of Neurosurgery and Neurology at Penn Medicine have recently introduced a collection of innovative technologies to better treat patients with drug-resistant epilepsy (defined as having seizures refractory to two or more seizure medications).

Medications can control seizures in about two-thirds of persons with epilepsy. The approximate one-third of patients with drug-resistant epilepsy experience a significant impact on quality of life, elevated risk of injury and increased risk of sudden unexpected death.

For patients with drug-resistant epilepsy, the options available at Penn Medicine include resective surgery and vagus nerve stimulation (VNS), as well as newer approaches. Surgery has the potential to cure or decrease seizure frequency when an epileptogenic focus can be identified. Intracranial EEG evaluations are often performed to identify seizure foci prior to resection. Vagus nerve stimulation is an option for patients who are not resective surgical candidates. VNS reduces the frequency and intensity of seizures, but is not curative.

The new technologies available to treat patients with refractory epilepsy at Penn Medicine include Visualase® MRI-Guided Laser Ablation and the NeuroPace RNS® System. Penn neurosurgeons and neurologists have collaborated to introduce these advanced modalities, which can better identify the source of seizures and treat or prevent seizures in patients with drug-resistant epilepsy.

Visualase MRI-Guided Laser Ablation Technology

Visualase laser ablation is a technology that combines a saline-cooled 15 watt, 980-diode laser probe (less than 2 mm diameter) with real-time MRI-guidance to induce interstitial thermal ablation of targeted lesions in the brain (Fig. 1).

Pre-treatment images are acquired for target planning and an intraoperative temperature map is used to minimize damage to healthy tissue. Open surgery is not required. Patients may be awake during therapy and are usually discharged the next day.

NeuroPace RNS System

The NeuroPace RNS System is a programmable responsive neurostimulation system designed to detect and treat abnormal electrical activity in the brain. The System employs brief bursts of electrostimulation from an RNS neurostimulator implanted in the cranium to abort pre-seizure EEG patterns programmed by physicians.

Intracranial EEG (iEEG)
Structural MRI, fdg-PET and ictal scalp EEG recordings cannot identify the epileptic network in many refractory epilepsy patients having pre-surgical evaluation. For these patients, intracranial EEG (iEEG) hybrid depth and subdural grid and strip electrodes (Fig. 3) are required for long-term, high-resolution monitoring and mapping of the cortical surface. iEEG allows Penn clinicians to map the epileptic network and cortical function, making safe resective surgery with a goal of cure possible for many drug-resistant epilepsy patients.

Visualase®; 2015 Medtronic, Inc. Minneapolis, Minnesota.
NeuroPace RNS® System; 2015 NeuroPace, Inc. Mountain View, CA.

Faculty Team

The Penn Epilepsy Center (PEC) is comprised of an interdisciplinary team of clinicians dedicated to advancing the fields of invasive neurophysiology, neuroimaging and neurosurgery for patients with epilepsy in all of its forms. The PEC offers state-of-the-art diagnostic techniques, medical treatments, surgery and support to patients
with epilepsy.

Treating Epilepsy at Penn Medicine

Brian Litt, MD
Director, Penn Epilepsy Center
Professor of Neurology, Bioengineering and Neurosurgery

Gordon H. Baltuch, MD, PhD
Director, Center for Functional and Restorative Neurosurgery
Professor of Neurosurgery

Kathryn Davis, MD, MTR
Medical Director, Epilepsy Monitoring Unit
Assistant Professor of Neurology

Timothy H. Lucas II, MD, PhD
Director, Translational Neuromodulation Laboratory
Assistant Professor of Neurosurgery

John R. Pollard, MD
Associate Professor of Clinical Neurology

Sarah Schmitt, MD
Director, EEG Laboratory
Assistant Professor of Clinical Neurology

Danielle Becker, MD, MSc
Assistant Professor of Clinical Neurology

Doug Maus, MD, PhD
Assistant Professor of Clinical Neurology

The Penn Epilepsy Center

The Penn Epilepsy Center offers a comprehensive, individualized evaluation and a wide variety of surgical treatments for patients whose epilepsy is difficult to manage. As a Level 4 epilepsy center, we have the expertise and facilities to provide the highest-level of medical and surgical evaluation and treatment for patients with epilepsy.

The Center offers comprehensive evaluation for people who have experienced:

Long-standing seizures that are not adequately controlled
One or more seizures
Unacceptable side effects from epilepsy treatments
Unusual events that a physician believes may have been seizures

Epilepsy Monitoring Unit

The Epilepsy Monitoring Unit features a modern eight-bed unit with video EEG for the evaluation of individuals who are candidates for surgery and for differential diagnosis of “spells.” Epilepsy patients are admitted for long-term monitoring (anywhere from 3 to 7 days) and are typically weaned from medications to determine the cause and origin of seizures. Some patients undergoing this treatment require intracranial electrode monitoring. A number of other diagnostic tools may also be used to locate the origin of the seizures, including MRI, MEG, EEG, SPECT and PET.

Access

Penn Neuroscience Center
Perelman Center for Advanced Medicine
South Pavilion, 2nd Floor
3400 Civic Center Boulevard
Philadelphia, PA 19104

Pennsylvania Hospital
330 South 9th Street
Philadelphia, PA 19107

Penn Medicine Bucks County
777 Township Line Road
Yardley, PA 19067

Comprehensive Management of Acoustic Neuromas

noreply@blogger.com (Anonymous) — Wed, 6 Nov 2013 08:18:00 -0500

Specialists at the Center for Cranial Base Surgery at Penn Medicine are treating acoustic neuromas (vestibular schwannomas) with the most advanced modalities, including: 1) sophisticated microsurgery with and without endoscope assistance and 2) precision stereotactic radiosurgery (Gamma Knife® Perfexion[TM] and CyberKnife). The Center is comprised of cranial base neurosurgeons, otorhinolaryngologists and radiation oncologists who together develop comprehensive treatment plans for these complex tumors.

Acoustic neuromas are benign tumors that generally arise inside the internal auditory canal, a bony passage shared by the seventh (facial) and eight (auditory) cranial nerves. Expanding in a confined region of the skull, these indolent tumors can cause pressure on both nerves, resulting in unilateral hearing loss, vertigo, tinnitus, headaches and balance problems.

The objectives for neuroma treatment are maintenance of quality of life, complete removal or stabilization of tumor growth, preservation of hearing and preservation of facial nerve function (a normal smile). Factors influencing the decision for desired procedure include patient age, size of tumor, health status, risk tolerance and desired outcome.

Small to medium-sized tumors (p< 2.5cm) can be treated with either surgical resection or Gamma Knife Perfexion radiosurgery with excellent results. Surgical resection has the advantage of complete removal of the tumor with little likelihood of recurrence, and remains the gold standard for benign tumors. However, surgery has higher risks of complications than Gamma Knife radiosurgery.

By contrast, Gamma Knife controls (rather than removes) brain tumors, halting their growth with close to 200 beams of targeted gamma ray energy. The benefits of Gamma Knife include a low side effect profile and high quality of life after the procedure. Unfortunately, a small percentage of tumors can continue to grow after radiosurgery.

For larger tumors (>2.5cm), microsurgical resection is the best option. At Penn Medicine, the cranial base team uses three microsurgical approaches. The retrosigmoid approach is the most versatile, as it allows both small and large tumors to be removed and provides the ability to preserve hearing. The translabyrinthine approach does not require significant brain retraction and is also quite versatile, but is only for patients in whom hearing cannot be preserved. The middle fossa approach is used only for small tumors confined to the internal acoustic canal.

In addition to conventional surgical approaches, John Y. K. Lee, MD, of Penn Neurosurgery, has pioneered the use of the endoscope in the cerebellopontine angle to provide angled views and minimally invasive options.

Case Study 1

Mr. M, a 38-year-old man, was referred to Penn Neurosurgery with right-sided hearing loss, tinnitus and progressive gait ataxia. An MRI revealed a large acoustic neuroma measuring 3.4 cm anteroposteriorly, and 3.0 cm superoinferiorly with significant brainstem compression (Figure 1). Because of the tumor’s large size, Mr. M underwent retrosigmoid craniotomy. Both microscopy and endoscopy were used to obtain an optimal result. The tumor was completely resected; the facial nerve was anatomically preserved, and his gait improved. By his three-month visit, Mr. M had normal facial function and had returned to work without any restrictions. He has remained well at several years follow-up.

Case Study 2

Mrs. G, a 67-year-old woman, was referred to the Center for Cranial Base Surgery at Penn Medicine after her personal physician confirmed a moderate loss of hearing in her right ear. An MRI at Penn showed a tumor at the right auditory canal consistent with an acoustic neuroma (Figure 2, left) with a total volume of 3 cc. Mrs. G chose the less invasive option of Gamma Knife surgery for her therapy. Her Gamma Knife treatment involved a single outpatient session, during which she received a 12 Gy prescription to the 50% isodose line. Her recovery was unremarkable and she has since enjoyed an improved quality of life without side effects. Five years after her treatment (Figure 2, right), Mrs. G retains moderate hearing in her right ear and normal facial function.

Faculty Team

The Center for Cranial Base Surgery at Penn Medicine specializes in the evaluation and treatment of tumors of the head, neck and face. Currently, the Center treats ~100 patients/year for acoustic neuroma, employing an individualized algorithm for treatment approach.

Treating Acoustic Neuromas at Penn Medicine
Neurosurgery

John Y. K. Lee, MD
Medical Director, Gamma Knife Center
Assistant Professor of Neurosurgery

M. Sean Grady, MD
Charles Harrison Frazier Professor and Chairman
Department of Neurosurgery
Co-Director, Cranial Base Center
Otorhinolaryngology–Head and Neck Surgery

Bert O’Malley, Jr., MD
Co-Director of the Cranial Base Center
Gabriel Tucker Professor of Otorhinolaryngology

Douglas Bigelow, MD
Director, Division of Otology/Neurotology
Associate Professor of Otorhinolaryngology–

Head and Neck Surgery

Michael J. Ruckenstein, MD
Vice Chairman, Department of Otolaryngology
Professor of Otorhinolaryngology–Head and Neck Surgery

Radiation Oncology

Michelle Alonso-Basanta, MD, PhD
Assistant Professor of Radiation Oncology

James Kolker, MD
Clinical Assistant Professor of Radiation Oncology

Suneel Nagda, MD
Assistant Professor of Clinical Radiation Oncology

Geoffrey A. Geiger, MD
Assistant Professor of Clinical Radiation Oncology

Access
Penn Neurosurgery
Hospital of the University of Pennsylvania
3400 Spruce Street
3rd Floor, Silverstein Building
Philadelphia, PA 19104

Pennsylvania Hospital Washington Square West Building
235 South 8th Street
Philadelphia, PA 19106

Department of Otorhinolaryngology — Head and Neck Surgery
Hospital of the University of Pennsylvania
3400 Spruce Street
5th Floor, Silverstein Building
Philadelphia, PA 19104

Pennsylvania Hospital
811 Spruce Street
Philadelphia, PA 19107

Comprehensive Surgical Options for Trigeminal Neuralgia

noreply@blogger.com (Anonymous) — Fri, 25 Jan 2013 11:53:00 -0500

Neurosurgeons at Penn Medicine continue to pioneer and advance a comprehensive treatment program to address trigeminal neuralgia. The Penn Trigeminal Neuralgia program encompasses the spectrum of current and innovative treatment options, including endoscopic microvascular decompression surgery, Gamma Knife® radiosurgery and neuromodulation.

Vascular compression of the fifth cranial nerve as it enters the brainstem is among the most common causes of trigeminal neuralgia. Compression of the nerve results in intense unilateral facial pain affecting the forehead, cheek, jaw and teeth.

A leading surgical option, microvascular decompression (MVD) addresses the source of the neuralgia directly by inserting a barrier between the nerve and blood vessel. The barrier (a Teflon sponge) isolates the nerve from the dilation and pressure of the blood vessel, thereby relieving the symptoms of neuralgia.

MVD is performed through a small suboccipital opening on the affected side of the skull, and has the advantage of providing long-term relief of pain and preservation of facial sensation. Recently, the endoscope has been used during surgery to provide improved visualization of the offending pathology. This has resulted in greater surgical confidence and patient success.

Gamma Knife radiosurgery is an effective, minimally invasive approach to trigeminal neuralgia, and is used in patients for whom more invasive approaches are unsuitable. Gamma Knife concentrates approximately 200 individual beams of radiation on a single point to create a focused, surgical lesion within the nerve to block the transmission of pain signals. The procedure results in minimal damage to normal tissues.

Neuromodulation is an ideal approach for patients with atypical facial pain. Electrodes are placed through small (less than 1 cm) incisions in the skin to tunnel electrodes over the supraorbital (V1) and infraorbital (V2) branches of the trigeminal nerve. The procedure is first performed as a trial. If the stimulation provides pain relief, the electrodes are attached to a pulse generator placed subcutaneously in the infraclavicular space. Studies suggest that neuromodulation offers substantial relief for the majority of patients.

Case 1
Mrs. T, a 40-year-old woman, visited a neurologist for treatment of trigeminal neuralgia radiating into the right side of her face. Over a period of several years she was prescribed Tegretol (carbamazepine), Neurontin (gabapentin) and baclofen. These drugs helped initially. Over time, however, Mrs. T experienced breakthrough pain. She was then referred to Penn Neurosurgery, where she estimated her pain to be 10/10 during breakthrough episodes. After a discussion of her options, Mrs. T
agreed to microvascular decompression procedure.

The procedure: Following general anesthesia, a one-inch incision was made behind Mrs. T’s right ear and a 1 cm keyhole incision made in the dura mater (see “Minimally Invasive Endoscopic MVD Surgery,” back page). Endoscopic microsurgical exploration revealed that the superior cerebellar artery was compressing the nerve at the dorsal root of the right trigeminal nerve (Fig. 1). The artery was dissected away from the nerve and a Teflon sponge placed between the vessel and nerve to act as a barrier. The endoscope and instruments were then retracted and the small wound closed.

Results: Mrs. T went home on the second postoperative day. She was able to discontinue her medications within two weeks of surgery, and at her six-month follow-up reported a significant reduction in discomfort.

Case 2
Mr. Z, an 80-year-old man with a history of left-sided V2 trigeminal neuralgia, came to Penn Neurosurgery to explore options for treatment following an increasing intolerance to the side effects of medication, which included carbamazepine, neurontin, and trileptal. Because of his age, it was recommended that Mr. Z have Gamma Knife radiosurgery rather than an open procedure.

The procedure: Mr. Z was fitted with a frame to stabilize his head during the procedure. A series of imaging scans was then performed to accurately pinpoint the root of the trigeminal nerve and develop dose planning (Fig. 2). During the procedure, approximately 200 beams converged at the target to deliver a single dose of gamma knife radiation (80 Gy). Mr. Z. was discharged home the same day.

Results: Mr. Z’s pain improved over the course of several weeks, during which time he noticed a gradual diminishment in the number and severity of triggers for his neuralgia. At his six-month follow-up visit, he reported that he was able to satisfactorily control his pain with occasional NSAID use.

Gamma Knife® is a registered trademark of Elekta AB (publ) or it’s subsidiaries.

Case 3
Mrs. L, a 55-year-old woman, had a twelve-month history of burning pain radiating from her forehead. This pain was precipitated by a chickenpox outbreak. The skin vesicles had disappeared, but the pain had increased over time in both intensity and duration, and was constant when she was referred to Penn by an outside neurologist. Her treatments for pain included the antiepileptic drugs carbamazepine and gabapentin, both of which had provided transient relief, but to which her pain was now refractory.

The procedure: After a discussion of her options, Mrs. L chose to have a neuromodulation procedure. During her surgery, an electrode was implanted above her eyebrow and under the skin (Fig. 3).

Results: Mrs. L trialed the effects of the stimulation for several days before concluding that the “tingling” sensation was very soothing. She went on to permanent implantation with an implanted battery and was discharged on the same day as her surgical implant. At one year followup, she continued to have approximately 70% relief of the pain with use of the stimulator and was pleased with the results.

Faculty Team
Penn Neurosurgery is comprised of a skilled team of neurosurgeons, each of whom has a particular subspecialty focus. This permits the department to encompass the spectrum of surgically treated disorders of the nervous system. Given the enormous volume and intensity of exposure, patients benefit from that experience as well as the multidisciplinary approach to achieving the best possible outcomes.

Treating Trigeminal Neuralgia at Penn Medicine

John Y.K. Lee, MD
Director, Cranial Nerve Disorder Center
Medical Director, Penn Gamma Knife Center
Assistant Professor of Neurosurgery

Eric L. Zager, MD
Professor of Neurosurgery

Access
Penn Neurosurgery
Pennsylvania Hospital
Washington Square West Building
235 South 8th Street
Philadelphia, PA 19106

Hospital of the University of Pennsylvania
3 Silverstein
3400 Spruce Street
Philadelphia, PA 19104

Download a pdf of this Clinical Briefing.

Pipeline™ Embolization Device for Wide-Necked Intracranial Aneurysms

noreply@blogger.com (Anonymous) — Thu, 23 Feb 2012 11:41:00 -0500

Endovascular neurosurgeons at Penn Medicine are now offering the Pipeline^TMembolization device (PED, eV3, Inc., Plymouth, MN) as a treatment for adults with wide-necked intracranial aneurysms, a group of endovascular lesions for which effective treatment was, until recently, an unmet need. A tubular covered endoluminal stent composed of flexible bimetallic mesh, the PED is only available at select, specialized centers in the United States at this time.

The treatment of wide-necked aneurysms is complicated by the width of the orifice at the vessel wall, an anomaly that can preclude both clipping and coil embolization. Unlike these techniques, which block or fill the aneurysm, the PED excludes the aneurysm by providing a scaffold within the parent artery that recreates the vessel’s structure.

The PED is introduced through a catheter in the femoral artery. Once inside the brain, the device is deployed within the vessel across the neck of the aneurysm, disrupting blood flow into the dilated segment. Eventually the PED is incorporated into the vessel wall by neoendothelial growth, and ultimately achieves complete occlusion of the aneurysm. The parent artery and adjacent branch vessels are preserved.

The PED uses a proprietary delivery system requiring specialized training to achieve the unique techniques for catheter positioning and stent deployment. At Penn Medicine, the procedure expands the options for patients
with aneurysmal disease, a spectrum of treatments that also includes coil embolization, open surgery (clipping) and balloon remodeling.

Case Study

Mr. U, a 57-year-old patient, was referred to the Department of Neurosurgery by his ophthalmologist for evaluation after a two month period of progressively worsening headaches, retro-orbital pain
and diplopia.

At Penn, an MRI discovered a large mass posterior to the left orbit (Fig 1). A subsequent neuroradiological evaluation via three-dimensional cerebral angiography further defined the lesion as a large, wide-necked aneurysm of the cavernous internal carotid artery
(Fig 2).

After a discussion of his options, Mr. U opted to have a PED procedure. He was premedicated with aspirin and Plavix^®, and was admitted on the morning of his procedure.

Immediately before surgery, he underwent general anesthesia and a femoral artery sheath was placed. Neuromonitoring was performed by a neurologist.

After performing diagnostic angiography to determine exact vessel measurements for stent selection, two PEDs were deployed in the internal carotid artery across the neck of the aneurysm.

Post-procedure angiography confirmed good stent placement and immediate stagnation of contrast in the aneurysm, indicating initiation of occlusion (Fig 3). Mr. U was extubated and transferred to the neurology critical care unit in stable condition.

On post-op day one, he was transferred to the floor and discharged home on post op day two. He reported significant relief from his retro-orbital headache. He will undergo repeat angiography in six months to ensure complete occlusion of the aneurysm.

Faculty Team
At Penn Medicine, an expert multidisciplinary team of neurosurgeons, neurologists, diagnostic and interventional neuroradiologists, neurointensivists and neuroanesthesiologists provides highly specialized care for all aspects of cerebrovascular disease.

Performing Pipeline^TM Surgery at Penn Medicine for Wide-Necked
and Giant Intracranial Aneurysms

Michelle J. Smith, MD
Assistant Professor of Neurosurgery

Robert W. Hurst, MD
Professor of Radiology

Bryan A. Pukenas, MD
Assistant Professor of Radiology

Access
Penn Neurosurgery
Hospital of the University of Pennsylvania
3 Silverstein
3400 Spruce Street
Philadelphia, PA 19104

For neurological emergencies, please call 877.936.7366

For neurological non-emergencies, please call 800.789.7366

Download a pdf of this Clinical Briefing.

Treatment of Idiopathic and De Novo Scoliosis in Adults

noreply@blogger.com (Anonymous) — Fri, 20 Jan 2012 07:57:00 -0500

Surgeons from the departments of orthopaedic surgery and neurosurgery at Penn Medicine have developed a program to provide the full spectrum of treatments for adult patients with scoliosis of the spine.

Generally defined as a curvature of the spine in excess of 30°, scoliosis has two primary classifications in adults: idiopathic disease originating in adolescence, and de novo (or degenerative) scoliosis occurring in middle age and later life. Idiopathic scoliosis affects the thoracic/lumbar spine and has an unknown etiology.

De novo scoliosis affects the lumbar spine and is usually caused by progressive intervertebral disc degeneration. In adults, both types of scoliosis are associated with pain, disfigurement and varying degrees of disability.

Treatment for scoliosis at Penn begins with conservative (non-operative) approaches, with the objective of controlling pain and maintaining function. Typically, conservative therapy involves exercise and conditioning regimens combined with physical therapy and, when warranted, nonsteroidal anti-inflammatory drugs and/or epidural steroid injections.

Surgery has the objective of minimizing pain and ameliorating spinal curvature, and is indicated when pain is unremitting or significant coronal or sagittal decompensation occurs. Chief considerations include the likelihood of successful outcome and the potential for complications given the patient’s age, history and condition.

At Penn, surgery for adult scoliosis involves thorough preoperative evaluation and planning to tailor the procedure to the needs of the individual patient; the primary goal is to minimize complications. Surgeries include posterior and/or anterior spinal fusion and segmental instrumentation; vertebral column resection; pedicle subtraction osteotomy; and spinal reconstructive surgery.

Most patients are ambulatory within 24 to 48 hours of surgery. In many instances the scoliosis surgery will involve the expertise of both the orthopaedic surgeon and neurosurgeon.

Case Study

Mrs. A, a 62-year-old female presented with incapacitating back and leg pain and ambulatory impairment. She could walk only with the aid of a walker and her posture was significantly stooped. Mrs. A’s medical history included four surgeries (among them a lumbar fusion) and failed attempts at conservative treatment, including, physiotherapy, pain medications and epidural steroid injections.

X-rays demonstrated a severe sagittal imbalance and a degree of curvature exceeding 30° (Fig 1). Following a consultation, and after thoroughly understanding what her surgery involved, Mrs. A agreed to have a pedicle subtraction osteotomy and extension of her fusion down to the pelvis. The surgery, which involved the removal of vertebral bone and the placement of pedicle screws and rods, was performed in seven hours.

A year after her surgery, Mrs. A’s pain level has dramatically decreased. Her posture is now upright (Fig. 2) and she can walk without a walker.

Faculty Team

The Spine Service at Penn Medicine involves the expertise of a multidisciplinary team that, in addition to orthopaedic surgeons and neurosurgeons, includes neurologists, rheumatologists, oncologists, physical therapists, physiatrists, radiologists and pain management specialists. This extensive and collaborative team approach to spine care ensures a thorough consideration of both surgical and non-surgical treatment of pain and neurological symptoms.

Performing Scoliosis Surgery at Penn Medicine

Vincent Arlet, MD
Chief, Orthopaedic Spine Surgery

William C. Welch, MD, FAANS, FACS, FICS
Vice Chairman (Clinical), Neurosurgery

Access

Penn Neurosurgery
Pennsylvania Hospital
Washington Square West Building
235 South 8th Street
Philadelphia, PA 19106

Penn Orthopaedics
Penn Presbyterian Medical Center
1 Cupp Pavilion
51 N 39th Street
Philadelphia, PA 19104

Download this Clinical Briefing.

Anterior Cervical Discectomy and Interbody Fusion with Posterior Stabilization for Severe Spondylolisthesis of the Cervical Spine

noreply@blogger.com (Anonymous) — Mon, 1 Nov 2010 13:25:00 -0400

Surgeons at Penn are performing anterior cervical discectomy and interbody fusion (ACDF) surgery to treat patients with severe spondylolisthesis of the cervical spine with concomitant neurological impairment. Spondylolisthesis occurs when one vertebra slips forward in relation to an adjacent vertebra resulting in central stenosis of the spinal cord or foraminal stenosis of the nerve roots. The condition may be caused by arthritis or age-related degeneration of the vertebrae and cartilage. Symptoms of cervical spondylolisthesis can include pain and paresthesias (numbness and tingling) in the arms and legs. Patients with advanced spondylolisthesis may experience neurological impairment resulting in gait and balance problems, loss of bowel and bladder function, and paralysis. For patients with severe cervical spondylolisthesis refractory to medical therapy, surgery to decompress the spinal cord and stabilize the vertebrae is the primary treatment. Offered at Penn within both the Departments of Orthopaedic Surgery and Neurosurgery, these procedures typically involve combining surgical techniques (including cervical discectomy, decompression and fixation) with spinal instrumentation and fusion employing allograft or autologous bone. The surgery is done to stabilize the spine both from the front and the back. The vertebral bodies are realigned, the spinal cord is decompressed either directly or indirectly, and a fusion is performed, often with a plate and screws anteriorly. Then screws and rods or wires are used to stabilize the spine posteriorly.

Case Study
Mrs. L, a 60-year-old female, was referred to the Department of Orthopaedic Surgery at Penn Medicine with a history of progressive neurological deficits that included a rapid and advanced deterioration in ambulation and bilateral upper extremity weakness, numbness, and tingling. At her presentation, Mrs. L reported that she had progressed from independent walking to a walker in a span of four weeks, and soon thereafter to a wheelchair. Upon physical examination, she demonstrated significant weakness in her bilateral upper and lower extremity motor function. She had weakness supporting herself with both of her arms and was unable to stand up from a seated position. In addition, she had multiple upper motor neuron signs, an indication of spinal cord compression. This was evidenced by hyperreflexial in both arms and legs, drifting reflexes, and a positive Hoffman’s signs in both hands. A cervical spine MRI performed at Penn revealed a grade 4 spondylolisthesis at the C4/C5 (Figure 1) manifesting as severe abnormal alignment of the vertebrae and advanced stenosis. After discussing the risks, benefits, and alternatives of the available options for treatment, and at the recommendation of her surgeon, Mrs. L decided to have a cervical decompression and fusion procedure. During the procedure, surgeons removed the damaged disk at C4/C5 and replaced it with a polyetheretherketone (PEEK) spacer filled with cancellous allograft and secured by plate and screw fixation anteriorly (Figure 2). The posterior stabilization was also performed and consisted of posterior cervical sublaminar wiring with autograft and allograft bone. After an unremarkable recovery, Mrs. L was discharged to home on post-operative day four. Six months after her surgery, she is ambulating independently with occasional use of a cane. Her paresthesia and numbness have resolved and she is able to perform all activities of daily living independently.

Team of Faculty
A national leader in the surgical treatment of the musculoskeletal system, Penn Medicine offers surgery for disorders of the spine within the Departments of Orthopaedic Surgery and Neurosurgery. The spectrum of care provided by Penn orthopaedic surgeons embraces hand, shoulder, elbow and spine surgery, and trauma and reconstructive surgery. In addition, the department offers advanced therapies for destructive lesions and diseases affecting the skeletal system, and is at the forefront of pioneering clinical research to develop new orthopaedic treatments and therapies. The department administers a renowned orthopaedic training program that attracts residents and fellows from the nation’s leading medical schools. At the Penn Neurosurgical Spine Center, neurosurgeons provide comprehensive medical and surgical care for the most complex disorders of the brain, spinal cord and peripheral nervous system. Here, a multidisciplinary team of clinician specialists bring the latest advances in techniques and technology and apply basic science and clinical research to the improvement of patient care.

Performing Cervical Discectomy and Interbody Fusion at Penn Orthopaedic Surgery

Neurosurgery
William C. Welch, MD, FACS, FICS Vice Chair, Neurosurgery Chief of Service at Pennsylvania Hospital Professor of Neurosurgery
James M. Schuster, MD, PhD Associate Professor of Neurosurgery
Paul J. Marcotte, MD Associate Professor of Neurosurgery
Neil R. Malhotra, MD Assistant Professor of Neurosurgery
Stephen J. Dante, MD Assistant Professor of Neurosurgery

Access

Penn Orthopaedics Penn Presbyterian Medical Center
1 Cupp Pavilion
North 38th Street
Philadelphia, PA 19104

Penn Neurosurgery Pennsylvania Hospital
Washington Square West Building
235 South 8th Street
Philadelphia, PA 19106

To refer a patient and/or consult with a physician: Call 800-789-PENN (7366) or visit: PennMedicine.org/referral

Download a pdf of this Clinical Briefing. (pdf will print at full resolution)

Neurosurgical Advances at Penn: Awake Craniotomy for Resection of Oligodendroglioma

noreply@blogger.com (Anonymous) — Mon, 11 Oct 2010 14:39:00 -0400

Surgeons at Penn Medicine’s Department of Neurosurgery are performing awake craniotomy, which uses functional MR imaging intraoperatively to delineate the relationship between infiltrative glial tumors and speech and motor pathways in the brain. The techniques of awake craniotomy surgery permit Penn neurosurgeons to preserve functional tissue within the motor and speech cortex with greater reliability and better tumor resection than other forms of brain surgery.

During awake craniotomy surgery, the patient is sedated while electrical stimuli are induced on the brain surface by the operating neurosurgeon. The patient is then wakened and his or her conscious reaction to this stimulation is used to tailor a motor and/or speech map of the brain. This map permits surgeons to maximize tumor removal while preserving functional tissue during surgery with minimal neurologic risk to the patient.

The benefits of multidisciplinary care at Penn are especially evident in awake craniotomy surgery, which requires a seamless coordination between surgeon and anesthesiologist to achieve the interaction of surgeon and patient and the balance of states of waking and sedation.

Other team members include a neuroradiologist, who provides functional MRI scans during the procedure, neurologists/ neurophysiologists to assess functional speech and brain electrical recordings, and nurse practitioners and trained operating room nurses, who facilitate the use of surgical technologies required in these brain tumor cases.

Case Study
After experiencing several seizures, Mr. S, a 61-year-old male, underwent resection of an oligodendroglial brain tumor of the left temporal lobe in 1992, followed by standard radiation therapy. Following his surgery, he was highly functional with only rare seizures and returned to work as a practicing nurse anesthetist.

In July 2008, however, he noted an increase in his seizure frequency and underwent a repeat MRI that showed increased infiltrative left temporal tumor with close proximity to the language cortex.
He underwent a functional MRI that allowed mapping of his speech center in a non-invasive manner. This MRI scan was performed at the same time as an image-guided MRI, allowing for precise intraoperative localization of the tumor with an accuracy of less than 1mm.

The cumulative data indicated that Mr. S would be ideal for awake surgery with intraoperative speech mapping, and after counseling, he agreed to this approach. In the operating room, direct cortical stimulation was performed by the surgical team and the data were analyzed by anesthesiologists and neurophysiologists. The surgical team was able to maximize tumor resection while at the same time minimizing manipulation of critical language cortex.

Post-operatively, Mr. S was without a speech deficit and the post-resection MRI scan indicated a near complete tumor removal in a highly infiltrative recurrent oligodendroglial brain tumor. The resected tumor tissue was then subjected to cytogenetic and molecular analysis to allow for a more rational treatment selection.

Faculty Team
The Department of Neurosurgery at Penn is recognized internationally for excellence in patient care, resident education and scientific research. The faculty includes highly experienced neurosurgeons, each of whom has a subspecialty focus in addition to neurosurgery. Our surgical neuro-oncology specialists include:

Hospital of the University of Pennsylvania

Donald M. O’Rourke, MD
Associate Professorof Neurosurgery

James M. Schuster, MD, PhD
Assistant Professor of Neurosurgery Pennsylvania Hospital

John Y. K. Lee, MD
Assistant Professor of Neurosurgery

Access

Patient appointments are available at:

Department of Neurosurgery
Hospital of the University of Pennsylvania
3 Silverstein
3400 Spruce Street
Philadelphia, PA 19104

Department of Neurosurgery

Pennsylvania Hospital
4th Floor
330 South 9th Street
Philadelphia, PA 19107

Neurosurgery Research at Penn: The Human Brain Tumor Tissue Bank

Under the direction of Donald M. O’Rourke, MD, the Human Brain Tumor Tissue Bank at Penn is among the largest repositories of brain tumor tissue in the United States, and as such, represents an invaluable foundation for research into the genetic origins of gliomas and other human cancers. Gliomas, the most common of the primary brain tumors, are the object of intense research efforts at Penn. Thus, the objectives of the Brain Tumor Tissue Bank include the development of drug-based treatments for gliomas and other human cancers.

In addition, Penn researchers are refining methods of genetic testing for gliomas and oligodendrogliomas; new treatments for gliomas based on genetic alterations detected in these tumors; and an exploration of the relationship between an epidermal growth factor receptor mutation present in many primary glioblastomas and glioma cell growth, angiogenesis and survival.

One of only a few such dedicated brain tumor banks in the United States, the Brain Tumor Tissue Bank is operated by the research faculty of the Penn Department of Neurosurgery, who play a critical role in advancing clinical research in neurosurgery as investigators in the full gamut of research modalities.

To refer a patient and/or consult with a doctor: Call 800-789-PENN (7366) or visit: pennmedicine.org/referral

Gracilis Functional Free Muscle Transfer following Brachial Plexus Injury to Restore Upper Extremity Function

noreply@blogger.com (Anonymous) — Fri, 24 Sep 2010 14:55:00 -0400

At Penn Medicine, a multidisciplinary team of surgeons from the Departments of Neurosurgery and Orthopaedic Surgery and the Division of Plastic Surgery are performing gracilis functional free muscle transfers (FFMT) to restore upper extremity movement to patients with brachial plexus injuries (such as avulsion, laceration or contusion).

Brachial plexus injuries are typically traumatic in origin and are marked by paralysis and other functional upper extremity deficits. If initiated within six to nine months of injury, nerve grafting and nerve transfers (also known as neurotization) can restore function to patients with brachial plexus injuries. For patients with brachial plexus denervation exceeding this timespan, gracilis FFMT has the potential to restore movement to the shoulder and elbow.

Located on the medial aspect of the thigh, the gracilis muscle has the advantages of a rich blood supply and reliable motor innervation. Gracilis FFMT surgery involves minimal donor site morbidity and little to no impairment of leg function. Once transferred to the upper arm, the gracilis has the capacity to mimic the function of the biceps and brachialis muscles. Neurotization and vascular anastomosis of the muscle at the recipient site are achieved through microsurgery. The reported success rate for gracilis FFMT in patients with brachial plexus avulsion is approximately 70%.

Case Study
RL, a 28-year-old man, was referred to the Department of Neurosurgery at Penn Medicine for restoration of movement in his paralyzed right arm. Two years prior, RL had a motorcycle accident resulting in spinal injury and complete right brachial plexus avulsion. Following the injury, he had rehabilitative therapy, including range of motion exercises, which maintained flexibility but did not restore function in the right arm.

Since direct nerve repair was no longer an option, a functioning gracilis muscle in his left leg and donor nerves that could serve to reinnervate the muscle transfer were selected. At Penn, gracilis FFMT surgery proceeds in phases and involves coordinated teams of surgeons from Neurosurgery, Orthopaedics and Plastic Surgery. At the start of surgery, neurosurgeons first explored the brachial plexus to identify viable donor nerve sites.

The spinal accessory nerve was selected as a functional donor nerve, maintaining several branches to the trapezius muscle to avoid loss of upper shoulder function. The orthopaedic and plastic surgery teams prepared the recipient site at the upper arm; the gracilis muscle, obturator nerve, blood vessels and a skin paddle were harvested from RL’s left leg. This tissue was then positioned within the recipient site and the gracilis secured via the clavicle and biceps tendons.

With the completion of microvascular repair to the arteries and veins, microdoppler probes were applied to ensure vessel patency and to measure blood flow. The neurosurgical team then returned to attach the obturator nerve of the gracilis muscle to the donor spinal accessory nerve. After five days in the hospital for observation, RL was discharged home and had an unremarkable recovery. He is currently participating in daily range of motion rehabilitative therapy.

Team of Faculty
Penn Medicine is involved in the management of the entire spectrum of surgically treated disorders and injuries of the nervous system. These conditions include brain tumors and aneurysms, spinal column lesions and peripheral nerve disorders, as well as traumatic injuries to the brain, spinal column and peripheral nervous system. Patients are often managed by a collaborative effort involving neurosurgeons, orthopaedic surgeons, plastic surgeons, otorhinolaryngology- head and neck surgeons and other specialists in a multi-disciplinary and multi-modality approach.

Performing Gracilis Free Functional Muscle Transfer Surgery at Penn Medicine Neurosurgery
Eric L. Zager, MD, FACS
Professor of Neurosurgery

Orthopaedic Surgery
L. Scott Levin, MD, FACS
Chair, Department of Orthopaedic Surgery
Paul B. Magnuson Professor of Bone and Joint Surgery;
Professor of Surgery, Division of Plastic Surgery

Plastic Surgery
Stephen J. Kovach III , MD
Assistant Professor of Surgery

Access

Hospital of the University of Pennsylvania
Department of Neurosurgery
3 Silverstein
3400 Spruce Street
Philadelphia, PA 19104

Division of Plastic Surgery
Perelman Center for Advanced Medicine
East Pavilion 1st Floor
3400 Civic Center Boulevard
Philadelphia, PA 19104

Department of Orthopaedics
Hospital of the University of Pennsylvania
2 Silverstein
3400 Spruce Street
Philadelphia, PA 19104

To refer a patient and/or consult with a physician: Call 800-789-PENN (7366) or visit: PennMedicine.org/referral

Nerve Repair Research at Penn
At Penn Medicine, nerve repair and regeneration research occurs within the Center for Brain Injury and Repair. One of five research divisions within the Department of Neurosurgery, the Center has been in existence for more than 30 years and is among the most respected centers for head injury in the United States. The Center is currently engaged in the following investigations:

Engineering Nerve Constructs for Clinical Application – A distinct approach to engineering an effective man-made nerve construct for nerve repair, this construct consists of numerous bundles of axons, which are embedded in a collagen gel and packaged in a biocompatible conduit. Sized to the length of the damaged nerve, axon bundles can be directly transplanted to provide a living and functional connection.
Peripheral Nerve Transplant – A new concept in which living dorsal root ganglion neurons and mechanically stretch-grown axons are transplanted into a 12mm sciatic nerve gap in the rat for repair of significant lesions within the peripheral nervous system.

Download a pdf of this Clinical Briefing. (pdf will print at full resolution)

Focus: Penn’s Neuro-Ophthalmology Service

noreply@blogger.com (Penn Medicine) — Mon, 21 Jun 2010 14:50:00 -0400

The Penn Neuro-Ophthalmology Service bridges the fields of ophthalmology and neurology to provide diagnosis and treatment for patients with neurological and systemic diseases that affect vision and eye movements.

A part of the renowned Scheie Eye and Penn Neurological Institutes, the Penn Neuro-Ophthalmology Service is the largest of its kind in the nation.

Penn’s fellowship-trained neuro-ophthalmologists work in concert with specialists in ophthalmology, neurology, neurosurgery, otorhinolaryngology and neuro-radiology to achieve a comprehensive approach to disease evaluation, diagnosis, and treatment.

The team has extensive experience with all forms of neuro-ophthalmic disease, including double vision, optic neuropathy, pupillary abnormalities, visual field defects, nystagmus, and visual defects related to neoplastic disease.

Case Study

Mrs. V,, a 36-year-old woman, was evaluated for acute visual loss and abduction deficits. Between the ages of 20 and 24, she had eight lumboperitoneal shunt revisions for treatment of pseudotumor cerebri. Three months prior to presentation she experienced headaches, blurred vision, and nausea. One month prior to presentation her vision and optic nerve appearance was normal.

She then developed a constant severe headache and neck pain and vision loss that worsened over several days. Upon examination, she had no light perception vision in the right eye, 20/70 visual acuity and a large nasal visual field defect in the left eye.

In addition, bilateral sixth nerve palsies, and severe pallid papilledema with peripapillary hemorrhages and venous distension were evident. Magnetic resonance imaging (MRI) of the brain was normal. Lumbar puncture opening pressure was markedly elevated at 550 mm H20 (nl <250mm

A diagnosis of severe acute vision loss due to pseudotumor cerebri and lumboperitoneal shunt failure was made. Intravenous methylprednisolone and acetazolamide were administered immediately. Optic nerve sheath fenestration was then performed on the right optic nerve, and the lumboperitoneal shunt was externalized. A malfunctioning valve was discovered when the shunt was revised.

Postoperatively, the steroids and azetazolamide were discontinued. The patient’s vision improved rapidly. Two weeks later the papilledema had almost resolved, and visual acuity was 20/20 in both eyes with residual infranasal constriction of the visual fields of each eye.

Clinical Trials

Multiple Sclerosis – The Penn Division of NeuroOphthalmology is currently participating in a randomized clinical trial to determine whether combination interferon beta1a (IFN) and glatiramer acetate (GA) is a measurably better therapy than either agent alone in patients with relapsingremitting (RR) multiple sclerosis (MS).

Our Team of Faculty

The Scheie Eye Institute and Penn Neurological Institute offer complete diagnostic and treatment services in comprehensive and subspecialty ophthalmology and neurology. The breadth of expertise and experience in the Penn Division of NeuroOphthalmology provides a comprehensive network of care for patients with complex conditions that span both neurology and ophthalmology.

Our team is also leading the development of novel therapies for neuroophthalmic diseases through cuttingedge clinical and basic science research studies, teaching, and residency and fellowship training.

Dina Jacobs, MD
Assistant Professor of Neurology

Grant T. Liu, MD
Professor of Neurology and Ophthalmology

Kenneth S. Shindler, MD, PhD
Assistant Professor of Ophthalmology

Madhura A. Tamhankar, MD
Assistant Professor of Ophthalmology

Access

Patient appointments are available at:
Scheie Eye Institute at Penn Presbyterian Medical Center
39th and Market Streets
Philadelphia, PA 19104

Penn Eye Care at the
Hospital of the University of Pennsylvania
Department of Ophthalmology
2nd Floor, Gates Building
3400 Spruce St.
Philadelphia, PA 19104

Department of Neurology
Hospital of the University of Pennsylvania
2nd Floor, Ravdin Building
3400 Spruce St.
Philadelphia, PA 19104

Penn Eye Care at Radnor
250 King of Prussia Road
Radnor, PA 19007

To refer a patient and/or consult with a physician:
Call 800-789-PENN (7366) or visit:
PennMedicine.org/referral

Endovascular Coiling for the Treatment of Brain Aneurysms

noreply@blogger.com (Anonymous) — Tue, 8 Dec 2009 13:07:00 -0500

Physicians with the Cerebrovascular and Endovascular Neurosurgery Program at Penn Medicine are applying minimally invasive endovascular coiling technology to the treatment of patients with cerebral aneurysms.

A technique developed as a safer alternative to surgical clipping, endovascular coiling does not involve open cranial surgery, and is typically performed in less time with quicker recovery. The only evidence of the procedure afterward is a small scar in the leg. During the procedure, a small catheter is advanced from a blood vessel in the patient’s leg up into the blood vessels in the neck.

Once in the neck, the catheter is used to introduce a contrast dye that clearly delineates the aneurysm and arteries around it. A smaller catheter is then advanced into the aneurysm in the brain under the guidance of x-rays. At this point, thin flexible platinum coils, approximately twice the width of a human hair, are deposited into the aneurysm (bottom figure, right).

The platinum coils conform to the shape of the aneurysm to form a mesh that mimics the fibrous foundation of a thrombus. Blood cells are caught in the mesh, restricting blood flow into the aneurysm and substantially decreasing the risk of rupture.

At Penn, the care and treatment of patients with cerebral aneurysms involves a multidisciplinary team of specialists comprised of neurosurgeons, neuroradiologists, and neuro-critical care specialists. Diagnosis of cerebral aneurysms is achieved via cerebral angiography or computer tomographic angiography. The size and location of the aneurysm are determinants in the choice to pursue endovascular coiling. Aneurysms with large necks may be treated with a stent in addition to the coils.

Endovascular Coiling vs. Surgical Clipping
Endovascular coiling has been compared to surgical clipping with open craniotomy in a single large multi-center, prospective, randomized study, the International Subarachnoid Aneurysm Trial (ISAT).1 The ISAT investigators had intended to assess 2,500 patients, but stopped enrollment when the trial steering committee concluded that randomizing patients to neurosurgical clipping was no longer ethical. At this point, the relative risk of death or significant disability at one year for patients treated with coils had been found to be 22.6% lower than that of patients in the clipping group. Subsequently, a variety of retrospective analyses have also determined that endovascular coiling is associated with a lower risk of new symptoms or disability after treatment, shorter hospital stays and shorter recovery times compared with surgery. 1. Molyneux A, Kerr R, Stratton I, et al. Lancet. 2002:360:1267-1274.

Case Study
Mrs. C, a 65-year-old female, went to her local emergency room after experiencing a headache that she described as the worst of her life. A computer tomograph of her brain revealed that she had a bleed in her brain typical of that caused by a ruptured aneurysm. Mrs. C was emergently transported by a PennSTAR helicopter to the Hospital of the University of Pennsylvania, a national referral center for the treatment of brain aneurysms. A computer tomographic angiogram performed upon her arrival at the hospital (Fig. 1) revealed a large aneurysm on Mrs. C’s right internal carotid artery. ISAT data indicated that Mrs. C would have a better outcome if her aneurysm was treated with endovascular coiling. She thus underwent a cerebral angiogram and coiling of her aneurysm (Fig. 2) and remained in the intensive care unit to be closely monitored. Following an excellent recovery from her bleed, Mrs. C was ultimately discharged to home. Six months later, she is doing very well and has not needed any further treatment.

Team of Faculty
The Penn Medicine Neuroscience Center (PMNC) represents a model for integrated clinical care, research and education, encouraging interdisciplinary thinking and uniting a diverse group of clinicians, researchers, and educators through a unifying vision, strategic thinking, program development and shared resources. The PMNC encompasses several entities at Penn Medicine, including the Penn Neurovascular Center, home to the Comprehensive Cerebrovascular and Endovascular Neurosurgery Program. Made up of a multidisciplinary team of neurosurgeons, neurologists, diagnostic and interventional neuroradiologists, neurointensivists and neuro-anesthesiologists, the Penn Neurovascular Center provides highly specialized care for all aspects of neurovascular disease. The Comprehensive Cerebrovascular and Endovascular Neurosurgery Program focuses exclusively on the diagnosis, treatment and clinical investigation of vascular disorders of the nervous system. It is the only program of its kind in the Philadelphia region, and among a very few in the United States.

Neurosurgery
Peter D. LeRoux, MD, FACS
Associate Professor of Neurosurgery
Eric L. Zager, MD
Professor of Neurosurgery
Michelle J. Smith, MD
Assistant Professor of Neurosurgery

Radiology
Robert W. Hurst, MD
Professor of Radiology, Neurosurgery, and Neurology,
Director, Interventional Neuroradiology

Bryan A. Pukenas, MD
Assistant Professor of Radiology

John B. Weigele, MD, PhD
Assistant Professor of Radiology

Access
Department of Neurosurgery
Hospital of the University of Pennsylvania
3 Silverstein
3400 Spruce Street
Philadelphia, PA 19104

To refer a patient and/or consult with a doctor: Call: 800-789-PENN (7366) or visit: PennMedicine.org/referral