This is for you – my patients and their families.
Please scroll down to the surgery or procedure we talked about. I look forward to more conversations about what option is best for you. If in doubt, just reach out and ask.
Aneurysm coiling or clipping defuses a brain aneurysm by stuffing it from the inside (coiling) or by pinching it off from the outside (clipping). A stent may be placed to buttress the coils, or to cover the opening of the aneurysm for flow diversion. It sounds complex but we now have good treatment options compared with even a few years ago.
Anterior cervical discectomy and fusion (ACDF) creates access to the spinal cord and nerves from the front of the neck. The damaged disc is replaced with a strut graft implant, secured by a metal plate. This is a workhorse operation for cervical disc herniation, cervical radiculopathy and cervical spinal canal stenosis. The approach makes this a practically painless surgery – a true bonus.
Artificial Disc Replacement (ADR) is an alternative to fusion surgery. The damaged intervertebral disc is removed and replaced with a mobile titanium or polyethylene implant in an operation also called Total Disc Replacement (TDR). This method preserves spinal mobility but is only effective if the spinal facet joints are still healthy (I will check on that for you).
Burr holes are drilled into the skull using power drills or hand held twist drills. Like tiny manholes for the neurosurgeon, we use them to place drains to remove blood clots or fluid, to insert epilepsy monitoring strips or electrodes for deep brain stimulation (DBS), to take biopsies of brain tumors, or to navigate instruments deep into the brain for endoscopic brain surgery like the one where I removed the infamous pork tapeworm.
Carpal tunnel release takes pressure off the median nerve in the hand and wrist through a small incision along the palmar crease. Small sutures are placed to close the skin. This is a 10 minute same-day outpatient surgery. You will be awake and anesthesia will have you listen to some music during this operation. You may bring your own music devices of course.
Cervical dorsal foraminotomy takes pressure off pinched spinal nerve roots. This is accomplished by navigating a small tubular access retractor (about the size of a cigarillo) through the muscle in the back of the neck right onto target under Xray guidance, then drilling out the bone spurs and resecting the thickened ligaments around your pinched nerve.
Cervical laminectomy removes the bones in the back of the neck behind the spinal cord to relieve nerve pressure or to get access to a spinal tumor or infection. It’s a pretty deep spot buried under thick layers of muscle, so removing the bone will not be noticeable to anyone around you including yourself. The muscles and nerves in the back of the neck are quite sensitive, so you will experience occasional pain and discomfort until it’s completely healed up some weeks later.
Cervical laminoplasty is surgery through the back of the neck to treat cervical spinal stenosis. Different from cervical laminectomy, the bones behind the spinal cord are not removed but out-fractured and hinged away from the nerves, then secured in position using metal plates. Bone material is used in the joints and around the metal plates to allow for stable fusion. Laminectomy versus laminoplasty is a discussion we will have. The CliffsNotes are – if you are young and spine still forming, or the spine is weak, you get a laminoplasty. If you are in your second half and the spine is otherwise strong, you get a laminectomy.
Chiari decompression or suboccipital decompression surgery removes portions of the occipital bone and the posterior ring of C1. The underlying thickened tissue planes are opened to create more space for the cerebellum, medulla oblongata and upper spinal cord. Sometimes large cerebellar tonsils are encountered and gentle cauterization is necessary for tissue reduction. A patch graft is carefully sewn into the brain coverings under operating microscope magnification to expand the suboccipital space and avoid future crowding of brain, brainstem and spinal cord.
Cranioplasty is repair of a skull defect using either the patient’s own skull bone preserved in a deep freezer after previous skull removal (craniectomy), or a biosynthetic skull bone replacement that can be 3D printed based on reconstruction CT scans of the patient’s head. Bone cement, customized sheets of metal mesh, or titanium plates may be used to recreate the head shape.
Craniotomy removes a segment of skull bone to access the brain. After brain surgery is complete, the bone flap is put back and secured to the skull with thin metal plates. Craniotomy is used to remove tumors, infections, hemorrhages or damaged brain tissue, to repair brain aneurysms and vascular malformations, or to place monitoring equipment onto the brain surface.
Decompressive craniectomy removes a large portion of skull to reduce brain pressure in severe traumatic brain injury or stroke. This is a life saving operation but it will not reverse the brain damage. The removed skull bone is kept sterilely in a deep freezer, and should the patient survive, the bone will be put back in a cranioplasty surgery some months later.
Deep brain stimulation (DBS) introduces electrodes into nerve cell clusters deep in the brain, such as the subthalamic nucleus (STN) globus pallidus (GPi), or thalamic nuclei (VIM) to control symptoms of Parkinson’s disease (PD), non-PD tremors, or other movement disorders such as dystonia. After placing the electrodes through burr holes, they get attached to cables that are tunnelled under the scalp and skin to a pacemaker that is implanted in the chest onto the pectoral muscle just below the collarbone, like a pacemaker for the heart. Testing will be done with the patient awake during surgery to find the perfect location for stimulation. Once the electrodes are in a good spot, the surgery is finished under general anesthesia, including pacemaker placement. Programming and fine-tuning is done as an outpatient a few weeks after surgery. DBS does not treat the disease but just its symptoms such as tremors. DBS may change your needs for certain medications, but cannot replace any treatments by your movement disorder specialist.
Endoscopic thoracic sympathectomy (ETS) is the most effective treatment for primary palmar hyperhidrosis, a disabling condition characterized by excessive sweating of the hands. Surgery is done together with a thoracic surgeon, incisions are small and discrete. It’s a genetically encoded condition mostly affecting Asians. I learned the operation properly from neurosurgeons in Singapore and China. It is a life changing operation that restores confidence, careers and relationships.
Frameless stereotactic navigation surgery enhances precision and accuracy during cranial and spinal surgery. Originally developed by BrainLab in Germany more than 30 years ago and perfected many generations later, this technology allows neurosurgeons to navigate the brain and spine in 3D space using reference probes and on-screen tools resembling an ultra high definition Global Positioning System (GPS).
LASER spine surgery, also called percutaneous LASER disc decompression (PLDD) was developed in Europe in the 1980s as an alternative to open surgery. It involved placing a needle into the disc space and cooking the disc, claiming that the thermal injury resulted in shrinking of the disc and pain relief. The reported results were ultimately not better than no treatment, because most disc herniations heal up without any intervention. The advertised “miracle cures” could not be reproduced, and superior technologies such as microdiscectomy came along and became the gold standard. LASER spine surgery was until recently still used in “bait and switch” schemes where LASER was marketed to gullible patients who ultimately received standard spine surgeries at exorbitant out-of-pocket costs. We only list it here for historical reasons because some patients remember the false advertising about “minimally invasive LASER spine surgery” so we still get asked about it on occasion.
Lateral mass screw fixation adds stability to the cervical spine after traumatic injury or as an adjunct in deformity correction or cancer surgery. Similar to pedicle screw fixation, specialized screws are inserted into the back of the spine and connected to rods. To add strength, bone substance is placed around the screws, bone and joints to enable a stable fusion. Lateral mass screw fixation is only used in the neck, because these delicate devices are insufficient to bolt down the larger bones in the lower spine.
Lumbar laminectomy removes bones in the back to treat lumbar spinal canal stenosis, large disc herniations, spinal tumors, intradural nerve sheath tumors, infections including epidural abscess and cauda equina syndrome. It is the workhorse surgery for most types of nerve and spine issues in the lower back.
Microdiscectomy alleviates nerve compression caused by a disc herniation. A small tubular retractor is inserted next to the disc space and the disc fragment is removed. As a bonus, the nerve and surrounding tissues can be inspected for any additional problems such as stenosis or bone spurs that can be addressed in real time.
Microvascular decompression (MVD) is the only non-destructive treatment option for trigeminal neuralgia. A craniotomy the size of a silver dollar is drilled behind the ear, the cerebellum is gently retracted to allow for inspection of the brainstem where a small pulsating artery is often found irritating the nerve. A tiny pad of surgical mesh will then be inserted to separate the artery and nerve, fixing the problem.
Minimally invasive surgery (“MIS”) is marketing jargon for making smaller incisions than what was done in the Used To Be. Historically, large open incisions allowed surgeons to operate in dim light situations such as candlelight. Neurosurgeons pioneered the use of microscopes, robotics, endoscopes and novel access instruments, allowing for smaller and smaller incisions. We routinely perform brain and spine surgery through keyhole incisions and small operating corridors, if it is safe and appropriate for the situation. The exact size of the incision depends on what needs to be fixed and on patient size. Incisions less than a half inch are plenty for disc or nerve surgery. The same tiny incision would not allow for major surgery such as cancer removal and spinal reconstruction because the surgeon would be flying blind.
Oblique lumbar (lateral) interbody fusion (OLIF) uses natural tissue planes for access to the ventrolateral lumbosacral spine for interbody work and fusions. Compared with anterior lumbar interbody fusion (ALIF), there is less risk to belly contents and large vessels. Compared with a posterior or transforaminal lumbar interbody fusion (PLIF/TLIF) there is less muscle dissection and less pain. Compared with extreme lateral interbody fusion (XLIF) there is no need to dissect the psoas muscle, that means less pain and less risk of injury to spinal nerves and lumbar plexus.
Odontoid screw fixation is used for unstable type 2 odontoid fractures. These fractures occur in the very elderly after taking an unprotected fall and often do not heal properly without stabilization. A lag screw is inserted from the front of the spine behind the pharynx through the fracture line into the off-fractured odontoid process. If bone quality is decent, the fracture fragment will be cinched down allowing for adequate bone healing.
Open reduction and internal fixation (ORIF) is often necessary to fix traumatic fracture-dislocations or deformities of the spine. Surgery may require decompression of the nerves or spinal cord and re-alignment of the displaced vertebrae. Some serious hardware including bone struts, metal cages, bolts and rods may be implanted in the front, back or side of the spinal column to achieve complete stabilization.
Pedicle screw fixation (PSF) creates instant stability at a spinal segment during surgery for a fracture, deformity, infection, nerve compression or cancer. Solid screws are inserted into the pedicles which are the strong peg-like connections between the front and back parts of the spine. The screws are then interconnected using metal rods.
Radiosurgery uses focused radiation beams to obliterate pathological tissues. This is done by a team of radiation specialist, physicist and neurosurgeon to treat small deep seated brain tumors, brain metastases, arteriovenous malformations (AVMs) or trigeminal neuralgia.
Robotic spine surgery allows the surgeon to place more screws quicker without much extra work. Patient benefits remain to be demonstrated because there rarely is a valid indication for extensive spinal screw placements. Much research is going on currently to extend the utility of robotics beyond the access and screw driver assist functions.
Spinal deformity correction surgery optimizes the 3D load relationships of head, shoulders, spinal column, pelvic girdle, hips and lower extremity joints through strategic realignment and corrections of the vertebral column. Overall goals are to restore normal coronal and sagittal balance, to control and manage pain, while preserving neurological and musculoskeletal function, mobility and strength.
Spinal fusion locks vertebral segments into place to provide instant stability. This is done by inserting metal hardware and bone graft materials to treat unstable spine fractures or to restore strength following bone removal for deformity correction, nerve decompression, infections and cancer. Spinal mobility is permanently lost at the fused segments.
Third ventriculostomy creates a bypass for cerebrospinal fluid (CSF) for obstructive hydrocephalus. It involves navigating a rigid endoscope into the center of the brain through a burr hole, to create an opening in the floor of the third ventricle.
Transsphenoidal hypophysectomy is a procedure to remove pituitary tumors in the sella, a bony outpouching at the base of the skull, behind the eye sockets. Most tumors can be removed using an endoscope through the nose. Sometimes, an incision in the upper gum is used to enter the sphenoid sinus, an air filled cavity below the sella, to create a larger opening for better visualization using the 3D operating microscope. For most tumors, 2D images obtained through endoscopes suffice to successfully remove the tumor. Despite the name (introduced by Harvey Cushing, the pioneer of this type of surgery), removal of the pituitary gland (hypophysectomy) is not the goal of the operation. The gland can usually be spared, avoiding the need for life-long hormone replacement therapy.
Vagus nerve stimulator (VNS) placement is surgery for epilepsy. The electrodes will be gently wrapped around the vagus nerve in the deep left anterior neck, under full operating microscope magnification for safety. The battery pack implant will be placed on the pectoralis muscle, the incision just below the collarbone. Cosmetic sutures will be used to avoid visible scars.
Ventriculo-peritoneal shunting (VPS) treats hydrocephalus by diverting cerebrospinal fluid (CSF) from the brain into the abdominal cavity. The brain drain is inserted into the ventricles through a burr hole and connected to a pressure valve that is placed between skull and scalp. A second drain is connected at the valve and then passed under the skin from the head to the belly area where it is inserted into the peritoneal cavity. Cerebrospinal fluid that the brain cannot handle will pass through the shunt system into the abdominal cavity to get absorbed.
Ventriculostomy places a tube into the ventricles of the brain through a burr hole. This allows for drainage of cerebrospinal fluid (CSF) to reduce intracranial pressure (ICP) in hydrocephalus, head injury or brain hemorrhage. Ventriculostomy is also called external ventricular drainage (EVD).