What is a cavernoma?

Mr Christos Tolias explains to us about cavernomas.

A cavernoma is a gathering of abnormal blood vessels usually located in the brain and spinal cord. Cavernomas can also be known as cavernous angioma, cavernous haemangioma or cavernous malformation (CCM). Cavernomas look like raspberries and usually measure from around 2 millimetres to several centimetres in diameter.

Symptoms of cavernoma

Cavernomas may not cause a person to have any symptoms but they are often diagnosed after a person has experience symptoms and is being investigated.

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  • Seizures

  • Haemorrhage

  • Headache

  • Weakness, numbness, memory issues and trouble when concentrating

  • Other neurological problems such as slurred speech, double or blurred vision, balance problems, tremor or dizziness.

Cavernomas are different from patient to patient, it all depends on severity, location and duration. A person can experience problems with cavernomas when they are putting pressure or bleeding in certain areas of the brain. Severe cases of haemorrhage can potentially be life threatening and have long-term effects on the individual but more commonly the bleed is small and may not be symptomatic.

 What causes a cavernoma?

 Cavernomas do occur without clear cause and there is no obvious reason, but there are genetic links to cavernomas but most cases are completely random. Genetic testing can be carried out on cavernomas.

Diagnosing cavernoma

Scanning is the best way of quickly diagnosing a person for many different conditions. An MRI scan may be used which will be able to show a detailed image of the brain and spine and will show the cavernoma.  Other imaging and testing is available, such as CT or angiography but MRI is preferable.

Treating the cavernoma

Treatment for a cavernoma does very from person to person. As mentioned before, it is all about severity, symptoms and location and effective treatment will vary depending on the cavernoma.

Watch and wait – If a person is not experiencing symptoms or very little and the cavernoma is not causing any type of risk to the brain then the option of watching and waiting may be more beneficial. A patient will be asked to come in for regular check-ups and have MRI scans to check for any changes.

Medication – Medication will not resolve or change a cavernoma but it will help manage the symptoms it is causing such as seizures.

Neurosurgery – Neurosurgery can be carried out to remove the cavernoma. There are risks involved but usually the benefits of surgery outweigh the risks.

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Other avenues of treatment can be stereotactic radiosurgery such as GammaKnife or CyberKnife which is non-invasive. This is used when it is too much of a risk to perform surgery on the patient which usually occurs when the cavernoma is in a compromising position. 

A patient who has a cavernoma or has undergone treatment for this will need regular check-ups and scans such as MRI. Your doctor will be able to see if the cavernoma is changing in size if it has not been removed or see if it is growing back if it was surgically removed.

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition. 


London headache and Facial Pain Symposium

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London Neurosurgery Partnership works closely with London Neuroscience Academy to provide some of the best academic courses for continued professional development. We are excited to share LNA’s recent Headache and Facial Pain Symposium short video with you to give an in-sight of what happens on an LNA course.

We had our own Mr Sinan Barazi and colleague Dr Giorgio Lambru host and speak at the event along with special guest speakers such as Mr Ranj Bhangoo, Dr S Chong, Professor T Renton, Dr P Surda, Professor L Bendtsen, Dr s Palmisani and Dr A Al-Kaisy. Together they provided a comprehensive approach to facial pain and extensive teaching of diagnosis, pathogenesis and the treatment and options for headaches and facial pain.

Take a look at our video and if you are interested LNAs website for more upcoming courses!

Why we use CyberKnife Radiosurgery at London Neurosurgery Partnership.

Professor Ashkan explains why we use CyberKnife at LNP.

CyberKnife is a non-invasive form of radiotherapy treating benign and cancerous tumours. It is specifically used to treat inoperable tumours located throughout the body in places such as the brain, spine, head, neck, lungs and liver. The robotic system delivers targeted mapping throughout the body to locate the tumour and with sub-millimetre precision it delivers radiation to the affected area.

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We use CyberKnife treatment because it is a pivotal part of treatment for inoperable tumours and it absolutely lifesaving. The technology it uses is extremely precise and advanced in locating and treating tumours. It is also very patient friendly, unlike some other technologies like GammaKnife, there is no bolting of the skull or frame and the patient is completely awake. It is pain free and non-invasive and does not require an overnight stay in hospital.

Here are some clinical studies CyberKnife Accuray have performed:

In a clinical study of 133 patients treated for tumor metastases to the brain presenting with clinical symptoms such as headaches and seizures, 90 percent of patients either stabilized or improved performance status following treatment with the CyberKnife System. 1

In a clinical study of 333 patients using the CyberKnife System to treat tumor metastases to the brain, more than 85 percent of evaluable patients achieved local tumor control at two years post treatment.1 That is, the tumor either decreased in size or stopped growing.

A clinical study of 199 patients whose lesions were unsuitable for treatment with surgery and/or a portion of the lesion remained after surgery found that more than 92 percent of patients either experienced stabilization or a significant improvement of their symptoms following treatment with the CyberKnife System. 2

If you would like to discuss the option of CyberKnife radiosurgery in more detail then please do not hesitate to contact us for an appointment.

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition. 

Flat Head Syndrome

Mr Sanj Bassi explains what is plagiocephaly and brachycephaly:

As a paediatric consultant I frequently see babies who have been born or even developed plagiocephaly. Today I am going to be explaining what it exactly is and why you should not be worried.

There is often a slight misconception when it comes to babies having plagiocephaly and brachycephaly, the words in itself are complicated enough to make even the most resilient parents fear for the worst - but do not demise I am here to explain.

As mentioned above, there are two types of flat head syndrome 

Plagiocephaly – Is the flattening on one side of the baby’s head. This can be caused due to continued pressure on one side of the head and causes it to look asymmetrical. The ear can be more forward than the other and there can be an unbalanced or bulging look to the face.

Brachycephaly – Is the flattening of the back of the head, resulting in a wider and shorter head. This can be caused when the baby is laying down on their back for a long period of time.

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Babies have soft skulls when they are born, this makes them vulnerable to conditions like this. It is also very common, affecting 1 in every 5 babies. 

The causes of these conditions do vary. Here are some of the reasons as to why babies can be born with or develop plagiocephaly or brachycephaly:

Problems in the womb – Due to increased pressure in the womb or a decrease in amniotic fluid, the baby may be a bit squashed with not much room to move around, which causes the skull to flatten.

Premature babies – They can be vulnerable to flat head syndrome because their skulls are underdeveloped.

Sleeping position – Sometimes due to babies constantly sleeping on their back, it can cause the head to become flat at the back because of the constant pressure when the baby is sleeping.

Tightened neck muscles – Some babies can have tight neck muscles which can prevent them from turning their head, this can cause the head to flatten due to increased pressure on one side.

Here are some suggestions to help your baby take pressure off the flattened part of the head and also strengthen neck muscles.

Tummy time – Tummy time is an important part of a baby’s development, it encourages them to strengthen their neck muscles and improve their co-ordination. As they get older they will be able to lift their head and push up.

When sleeping – The Safest way for your baby to sleep is on their back, this is to prevent SIDS (sudden infant death syndrome) but if your baby constantly lays on a preferred side or the flattened side then you can move their head the other way.

Feeding or holding – When feeding or holding your baby you can change the position so they are not always on one side. Moving from left arm to right arm can do this.

The thing is, the more you change your baby’s position the less chance they have of getting a flattened head. This does not mean to constantly move them in fear that this will happen, but just to be aware and if you notice your baby favours one side then you can take the steps to encourage them to move to another side.

 If your baby does have a misshaped head and you are wondering if your baby’s head will ever round out then I am here to tell you that by the time your baby is 1 or 2 years old then any flattening should have improved by then and will hardly if not at all noticeable, especially as their hair grows.

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition. 

A private consultation with a London Neurosurgery Partnership surgeon – what actually happens.

How do I book an appointment with a surgeon?

It’s extremely simple to book an appointment with one of our surgeons, either call or email our team on 02070348709 or info@londonneurosurgerypartnership.co.uk.

You can also check us out on various certified medical booking websites, like Doctify, Topdoctors and HCA Healthcare.

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How can I be referred to an LNP surgeon through my private healthcare insurance?

If you have health insurance then your likely to have been referred to us by another healthcare professional - like your GP.

Some insurance companies require a referral letter or confirmation your referring doctor to cover your initial consultation with us, so it’s always important to check your level of cover before you book your appointment.

But rest assured, we’re recognised by all the big insurance companies like Bupa, Aviva, Alliance, AXA PPP and WPA along with many others.

Do you accept patients without insurance?

Of course, if you choose to self-fund, we will take a card pre-authorisation to secure the appointment. The payment won’t leave your account until after the appointment has taken place or if the appointment has been cancelled in line with our 24 hour policy.

How do I know my appointment has definitely been booked?

All appointments are confirmed by a confirmation letter sent via secure email or post, depending on how you’ve told us you’d like to be contacted.  

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What happens during my appointment?

Each appointment is tailored specifically to each individual patient and therefore it’s hard to specify what will happen in your consultation. However, generally most initial appointments will cover your medical history, symptoms and potential treatment options.

We understand that you may feel anxious during your appointment, but rest assured, our internationally-recognised surgeons offer an unparalleled level of care and will take the time to explain everything to you, including any possible examinations and treatments.

Should I bring anything with me to my appointment?

It’s extremely beneficial to bring along any medical history documents or scans relating to the appointment, or if you’re feeling organised, you can post or e-mail your paperwork to our office prior to your appointment.

What happens if my consultation discovers something worrying?

 If your case is urgent, then we ensure scans are performed on the same day, with a written report and findings available within hours of your consultation. 

Our priority is always you, our patient, and our teams are well equipped to give you the best and safest treatment.

It goes without saying that should we need to expedite your treatment, we are prepared to admit patients immediately after a consultation with priority surgery appointments usually offered within the week.

We are partnered with major private hospitals like The Harley Street Clinic, London Bridge Hospital and King’s College Hospital meaning we are well resourced to offer you the best possible treatment and care.

It is our duty to make sure you feel important, listened too, cared for, safe and understood.

If you would like further information then we would love to hear from you.

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition. 

 

What is syringomyelia?

Mr Sanj Bassi explains what is syringomyelia:

Syringomyelia is a fluid filled cyst (syrinx) that has developed within the spinal cord. The syrinx will get larger over time and will start to compress and damage the spinal cord. 

The formation of the syrinx is when the cerebrospinal fluid that circulates and protects the brain, turns back on itself, towards the spine and collects tissue from the spinal cord which then causes a small cyst. Over time, the cerebrospinal fluid will gradually fill the cyst which causes the compression and damage to the spinal cord.

The causes of syringomyelia do include, damage and injury to the spinal cord, tumours and most commonly Chiari malformation.

Patients who have syringomyelia may experience symptoms like those listed below:

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  • Headache

  • Weakness, numbness and stiffness in the back, legs, arms and shoulders

  • Intense pain in the neck and shoulders and face

  • Difficulty walking

  • Muscle weakness and signs of wasting

  • Reduced sensitivity (unable to feel hot or cold)

  • Loss of pain sensation

  • Bladder and bowel dysfunction

  • Scoliosis (spinal curvature)

Although symptoms do vary from patient to patient so it is important to watch out for signs. Usually patients experience early symptoms of weakness in their back, neck, arms and legs and loss of reflexes first.

How is syringomyelia diagnosed?  

If a patient is presenting with the above symptoms associated with syringomyelia then their doctor talk through their medical history and perform a physical examination to look for signs of the condition. It will then be necessary to refer the patient for an MRI or CT scan of the spine. This scan will be able to produce detailed imaging of the patient’s spine and pick up any syrinx on the spinal cord.

What are the different causes of syringomyelia?  

Chiari 1 malformation is the main cause for syringomyelia. Chiari is a malformation where the bottom part of the brain protrudes the spinal canal. If you would like to read more about Chiari from our previous blogs then click here

Other causes may be injury to the spinal cord, spinal tumour, meningitis and a tethered cord which is a condition present at birth

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How is syringomyelia treated?

There are a few different ways to treat syringomyelia and it all depends on the severity and whether it is affecting the patient’s day to day life.

Watch and wait – this option would be for patients with a less disruptive syringomyelia and it may have been caught early on where the cyst is still very small. As this condition can be slow growing, it may not be necessary to go ahead with treatments just yet, especially if the patient is not presenting with any symptoms.

Medication – although syringomyelia cannot be treated through medication, it can help some of relieve some of the symptoms that it is causing.

Draining the syrinx (shunt) – this is a surgical procedure in which the consultant inserts a tube which drains the fluid in to another area of the body such as the abdomen and prevents backflow.

 Other surgical options can be removing the tumour or a growth which may be obstructing the spinal cord. If the patient has Chiari malformation then the surgeon will aim to free up and expand the base of the cerebellum and improve the flow of cerebrospinal fluid.

The patient will need consistent follow up care just in case the syrinx comes back. Your doctor will perform regular scans and follow up appointments to check whether there is any changes. 

The patient must be aware that a syrinx can cause permanent spinal damage even after surgery so it is important that the patient understands the risks with and without surgery.

If you have any of the above symptoms and/or are suffering from syringomyelia and would like diagnosis and treatment then please do not hesitate to contact us.

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.

What is microdiscectomy?

Mr Nicholas Thomas explains the procedure for a microdiscectomy.

A microdiscectomy is a minimally invasive surgical procedure used to treat patients who are suffering with a herniated lumbar disc. The aim of the surgery is to remove parts of the herniated disc from the lower back and alleviate their pain. It is a type of keyhole surgery and thanks to pioneering medical equipment and technologies we are able to perform such a procedure this way.

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What is a herniated disc?

A herniated disc is when the soft tissue that sits between the individual bones of the spine pushes out through the spinal canal through a tear or rupture in the annulus.

What symptoms require a microdiscectomy for a herniated disc?

  • Worsening sciatic pain

  • No improvement using treatments

  • Worsening muscle weakness and numbness

  • If a patient got a herniated disc after a serious accident

Depending on the patient’s symptoms and how serious the herniated disc is will decipher on whether the patient does need to go ahead with surgery. Other simpler and less invasive treatments can be recommended before surgery is decided as many do work and mostly surgery is not necessary. Remember – surgery is always a last resort.

What risks of having a microdiscectomy are involved?

As with every procedure, risks are involved but with microdiscectomies complications are rare.

  • Bleeding

  • Nerve root damage

  • Infection

  • Recurrent disc herniation

  • Bladder/bowel incontinence

  • Blood clot

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The surgery

A microdiscectomy is performed using general anaesthesia which means the patient will be fully unconscious during the operation. As stated above, the aim of the surgery is to improve the patient’s pain by removing the disc material that is putting pressure on the spinal cord.

A patient would have had MRI scans to discover and keep track of the herniated disc. Before surgery has taken place and new scan will be necessary to identify the area needed to operated and check for any changes.

The patient is positioned prone on the operating table. A microscope is used to enhance visualisation and see the affected area through a small tube clearly. X-ray is performed to locate the herniated disc and an incision is made to the skin. Retractors placed and fixated. X-ray and microscope used to visualise the spine. A burr is used to enter the spine and utilising microsurgical instruments, part of the ligamentum flavum is removed. The nerve root is gently mobilised using a ball tip probe and the nerve root is freed up and mobilised and retracted out of the way. Rongeurs are used to remove the herniated disc fragment. Retractors are removed and incision is closed with sutures.

Usually the patient will stay in hospital overnight and be discharged the following day. It takes a patient about 6 weeks to recover and during this time they will need to keep mobile without doing any heavy lifting or strenuous tasks. A follow up and scan with the surgeon will be necessary during a post-operative follow up to check all is ok.

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.

Managing your headache

Mr Sinan Barazi explains how to self-manage headaches

There are many options when it comes to managing headaches, it can almost seem quite daunting. But do not despair, we are here to help things make sense!

Headaches come in lots of different forms, from the most common tension, sinus and menstrual headache to the more severe being a cluster headache and migraine. The way you will manage your headache will depend on the type. Today I am going to be discussing tension, sinus and cluster headaches.

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Tension headache

Tension headaches usually last from several minutes to a couple hours but for most people, it should not stop them from carrying on their day. The symptoms for a tension headache can range from a constant ache on both sides of the head, you may feel your neck muscles tighten and even have a straining type feeling behind the eyes.

 Here are some self-management treatments to help your pain: Firstly, start with the simple ways of easing a headache like drinking plenty of water, getting lots of rest especially if you have a cold or the flu. It can help if you try some exercise if you feel up to it and also taking paracetamol or Ibuprofen and even aspirin usually makes the headache symptom subside.

The management for tension headaches can be quite simple because they do not tend to be too painful or serious and are very common. Following the instructions above should make your headache disappear.

Sinus headache

A Sinus headache is related to Sinusitis and it is one of its symptoms but it is quite an uncommon headache and many people who assume they have a sinus headache actually have a migraine or tension-type headache.

The cause for a sinus headache is when the upper airways and lining of the nose becomes infected. This causes the sinuses to swell and leads to a build-up of pressure due to it being blocked.

Some symptoms can include throbbing around the cheeks, forehead and eyes typically on one side, worsening of headache when your head is strained, leaning forward for example. Also your face may feel quite tender to touch, almost like its swollen.

Ways in which you can manage this headache can consist of taking over the counter painkillers such as, ibuprofen and paracetamol along with having lots of rest and keeping yourself hydrated. Purchasing a decongestant to clear the sinuses and help with the tension it is causing, it also may help holding a warm flannel to your nose to help with the congestion. You can also try medications in which can help reduce the swelling in the nose like decongesting and saline nasal sprays.

Cluster headache

Cluster headaches can be excruciating, start quickly and most times without any indication. They can be described as a piercing sensation at the side of the head along with burning or a sharp pain which radiates towards the eye temple. These types of headaches occur in a pattern and typically occur every day lasting up to several weeks or months each time before they disappear. There can be periods where you can go weeks, months or even years without this type of headache before it returns. They occur around the same time each day and at similar times of the year.

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There are ways in which you can manage and treat a cluster headache. The usual pain management like paracetamol and ibuprofen is likely not to help as they are not fast acting enough.

Here are the treatments you will want when suffering from a cluster headache:

Sumatriptan injections – you can give yourself up to twice a day

Sumatriptan or Zolmitriptan nasal spay

Oxygen therapy – where you breathe pure oxygen using a face mask

The above treatments can relieve the pain within 30 minutes.

It is important to see your GP or consultant if you are suffering with cluster headaches as they may give you medication and treatments specifically to treat this. 

if you would like to read more on cluster headache then this organisation is all about supporting and raising awareness for people suffering with cluster headaches. Ouchuk.org

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.

Awake Brain Surgery (Craniotomy) – Answering the questions you need to know.

Professor Ashkan explains what’s what with awake brain surgery. An awake craniotomy is a type of surgical procedure performed on the brain whilst the patient is awake. Surgery like this is necessary because the patient may have a tumour near the speech/motor parts of the brain.  

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Why does the patient need to be awake?

It is important the patient is awake because it allows us to continually check the patients function throughout the procedure. We may need to talk to the patient and ask them questions to monitor the activity in their brain before anything is incised or removed.

What are the risks?

Craniotomies do carry risks, but so does all surgeries. Here are some general risks when performing this surgery, although it does differ from patient to patient and some risks will be greater than others depending on the patients’ health.

  • Seizures

  • Speech and learning difficulty

  • Impaired coordination and balance

  • Visual changes

  • Swelling to the brain

  • Infection

  • CSF leak

  • Memory loss

  • Meningitis

 

What happens during surgery?

Here is a common example of a craniotomy: Firstly the patient will be given some drugs to make them feel relaxed and numb around the area of incision. A small part of the hair will be shaved and the incision will be marked out using high quality neuronavigation equipment. The patients head will be in a fixed position to ensure accuracy but they are still able to move their arms and legs during the procedure. Drapes will be placed around the patient but they will still be able to see and speak to the surgical team.

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During the first part of the procedure, the anaesthetist will make sedate the patient whilst we drill and open the skull. Once opened, the sedation will stop being administered so the patient is awake during the craniotomy.

Using pioneering brain mapping which sends tiny electrical probes to the brain surface. We will map out the important areas of the brain by stimulating the motor, sensory and speech regions so we can avoid and preserve them during surgery. We will continually test these regions while we remove the tumour from the brain.

Once the tumour has been removed and bleeding stopped then sutures will be applied to close the dura and the scalp will be closed. Staples to close the skin together and a wound dressing applied. 

How long will my hospital stay be and what is the recovery process?

Depending on how straight forward the surgery went, the patient may only need to stay in hospital for a couple of days if not less. The first night will be in ITU so they can be closely monitored. The patient will be able to mobilise as soon as possible and eat and drink as normal. A post-operative scan is likely to take place before discharge to check the operation site.

The recovery does take a couple of weeks and patients are advised to take some time of work. Upon discharge you will be given some medication as some pain may occur, like a headache for example. A lot of rest is needed as the patient will feel more tired than usual.

The patient will have another postoperative scan and follow up to check the progress and operation site.

 This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.

 

Spelling out Spondylolisthesis

Many of our patients are diagnosed with spondylolisthesis, but they have no idea what it is. Today Mr David Bell, one of the London Neurosurgery Partnership’s Complex Spine surgeons, is going to help explain what spondylolisthesis really means, the symptoms it causes and how we can treat it.

Spondylolisthesis is simply when a bone in the spine (vertebra) slips out of place, usually forwards relative the one below it. There is often a misconception that spondylolisthesis relates to or is a slipped disc, this is not true. A slipped disc is a rupture of the spinal disc between the vertebrae.

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There are five major types of spondylolisthesis which are:

  1. Dysplastic spondylolisthesis – a congenital defect where part of the vertebra called the facet causes it to slip forward.

  2. Isthmic spondylolisthesis – a defect in the vertebra which can cause it to slip

  3. Degenerative spondylolisthesis – due to ageing and arthritic changes in the joints

  4. Traumatic spondylolisthesis – a sudden injury or trauma such as fracture to the spine

  5. Pathologic spondylolisthesis – a weakness in the spine, possibly caused by a tumour or disease

So, what are the typical causes of spondylolisthesis?

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Well, the causes do vary, some people are born with a defective vertebra and if no symptoms, it may not be identified until later in life. Other causes are more identifiable such as:

  • Sports injury such as gymnastics

  • Degeneration (ageing or overuse)

  • Tumour or illness

  • Sudden injury or trauma

  • Birth defect

  • Surgery

Spondylolisthesis can carry quite common symptoms and which is why many people do not realise they have this condition.

Although some people do not have any symptoms, here are the symptoms you may notice:

  • Lower back pain

  • Pain and/or weakness in one or both legs or thighs

  • A tingling sensation that radiates from lower back down to the legs.

  • Tenderness or stiffness in the back

  • Tight hamstring and buttock muscles

  • Excessive curving of the spine known as lordosis

  • Difficulty walking or running 

Treatments and surgical options

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There are many ways to treat spondylolisthesis. Initial treatment could be simply avoiding back straining activities such as lifting, bending or sports, this can give your back a chance to get back to normal. If that does not work or show much progress when an introduction of anti-inflammatory painkillers such as Ibuprofen or stronger may be required to help reduce the pain and inflammation.

If the above is of no use or not proactive enough then your doctor may recommend some physiotherapy, stretching out those hamstring and the lower back may really help strengthen and increase the motion in the back.

Another non-surgical method is corticosteroid injections. This will be used for patients who are suffering from symptoms of numbness, pain and tingling. The injection will be placed around the compressed nerve and into the spinal canal.

Surgery is the last resort. If the above non-surgical treatments are ineffective and the patient is still suffering with symptoms or the spondylolisthesis is severe and persistent, then your doctor may take you down this route. Another reason for surgical intervention would be because of a trauma like spinal damage.

Depending on what type of spondylolisthesis the patient has will decipher which surgical procedure is needed. Usually a decompression (laminectomy) and a spinal fusion with pedicle screw instrumentation is needed. This can be discussed in detail with your doctor as the surgery will be tailored to you.

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.

 

The pros and cons of minimally invasive spine surgery

Mr Irfan Malik talks about his knowledge and experiences of the pros and cons of minimally invasive spine surgery.

As a neurosurgeon, I am always looking for ways to improve the surgical procedures and outcomes for my patients. I have spent much of my career as a neurosurgeon working to improve understanding and the scope of many minimally invasive and complex spinal surgeries as well as pioneering procedures such as endoscopic and keyhole spinal surgery.

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Firstly, let me lightly explain what minimally invasive spine surgery (MISS) is.

It is advanced technology that uses innovative techniques to treat neck and back pain. We use specialised instruments along with excellent imaging to access the spine. Rather than traditional open spine surgery where we would make a 5-6 inch incision, minimally invasive uses an incision as little as 1 inch to access the intended location of injury.

Let’s talk about some the pros and cons of minimally invasive surgery.

Pros of Endoscopic Spine Surgery

  • Reduced risk of infection when compared to open back surgery

  • There is minimal loss of blood due to the tiny incision

  • Less scarring

  • Less soft tissue and muscle damage

  • Minimal pain involved during and post operatively

  • Rapid recovery time (post patients will be able to go home the same day as the procedure)

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Cons of Endoscopic Spine Surgery

  • Unfortunately, only a handful of surgeons have the expertise to perform these procedures

  • Not all patients meet the criteria for this type of surgery. More challenging spinal injuries sometimes have to be operated on by open back surgery because of difficulty visualising the surgical field.

  • Minimally invasive is more technical and can sometimes prove difficult for your surgeon to perform for multiple level procedures.

As with any type of surgery, minimally invasive spine surgery does carry risks such as; bleeding, stroke, infection and need for additional surgeries. Even though the risks are small, they are still there and it is worth weighing up the options.

After having minimally invasive surgery it is common for patients to have some type of post-operative instructions to follow. These usually include light physiotherapy and to mobilise within the first couple of days. You will need post-operative follow ups and possibly more scans to make sure the operation is a success but after that patients usually have an easy recovery.

Minimally invasive surgery does not mean that it is any more efficient or better than traditional open back surgery, it is simply different technique and being able to offer this to patients means that they get best care for their injury and also what they are most comfortable with.

If you are suffering with a back injury or pain then it is always worth getting it checked, and if surgery is the route for you then your surgeon will be able to tell you the risks, benefits, complications and limitations to all the approaches of surgery that they could take. My advice is to make sure you always voice your concerns and make sure you completely understand what is going to happen before any type of surgery or treatment has taken place.

What is meningioma?

Chris Chandler explains to us what Meningiomas are and what the treatment options are.

Meningioma is a brain tumour which develops within the meninges of the brain. Meninges are layers of body tissue that cover and protect the brain and spinal cord. Meningiomas are graded from 1-3, while most meningiomas are slow-growing with a low potential to spread (grade 1), some can be faster spreading and more likely to return after treatment, these are called atypical (grade 2). Lastly (grade 3) meningiomas are most uncommon and are malignant, they are fast growing and have a high chance of returning.  

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What are the symptoms?

While some meningiomas do not present with any obvious symptoms and can be stumbled upon during tests for other conditions, others do show symptoms of the brain being affected and some of the most common symptoms can be:

  • Headaches

  • Seizures

  • Memory loss and confusion

  • Weakness in arms of legs

  • Changes in vision

  • Vomiting

If a patient presents with these types of symptoms then it is common to undergo tests like MRI and CT scans to effectively detect and diagnose a meningioma. Once diagnosed and assessed then treatment can be undertaken.

Treatment for meningioma

There are a number of different treatments that can be undertaken for a meningioma and there are many different factors to consider when doing so. Firstly, the decision has to be right for the patient and it is something that should be discussed in length with the treating doctor. Depending on the grading of the meningioma, either management, treatment or surgery can be considered.

The factors include:

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  • Your general health

  • Symptoms

  • Location of tumour

  • Size of tumour

  • Grade of tumour

Watch and wait

As meningiomas are often slow-growing and only increasing in size by 1-2mm per year, there may be no need for any immediate treatment but just simply watching and waiting. By this we mean that a patient will have a scan every six months to a year along with a check-up to see if the meningioma has increased in size and if it has not then no further treatment will be needed.

Surgery

Surgery can be required if the tumour is affecting the patients’ day to day abilities and poses a risk to life. The treating doctor will run through all the risks, possible complications and benefits of the operations with the patient. Meningioma surgery is usually relatively straight forward but there can be complications and it is important for the patient to be aware of this prior to the operation.

Depending on the size, accessibility and grade of the meningioma the surgeon will do what is necessary to remove the tumour without causing any further risk to quality of life. The type of process this could be is:

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  • Confirm diagnosis by obtaining scans and tissue and classify grade.

  • Check to see if tumour is invading any arteries, large veins or on the underside of the brain.

  • Remove sufficient or if safe all the tumour to restore normal pressure of the normal brain tissue and to make sure the tumour will not grow back.

  • Preserve or improve neurological function

Once surgery has taken place the patient will need to stay in hospital to recover for a couple of days and thereafter may need physiotherapy to restore function and gain strength.

Radiotherapy

Radiotherapy is another option to treat a meningiomas but it is less common, this is because it is only used for inaccessible or irremovable meningiomas. This type of treatment uses high-energy rays to destroy the tumour cells and stop them from coming back. There are many ways to treat a meningioma with radiotherapy and the treating doctor will tailor this specific to the patient’s tumour. Gamma Knife and Cyber Knife treatment can also be used.

As with most types of treatment, radiotherapy does carry side effects and it is important that the patient understands this as it can sometimes take months or years for the side effects to happen.

Chemotherapy

Lastly, Chemotherapy is rarely used to treat meningiomas but is used in some circumstances to treat high grade meningiomas reoccurring after surgery and radiotherapy.

Regular post-operative follow ups and MRI scans with your surgeons will be necessary to keep an eye on the remaining tumour or simply to check if it is returned.

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.

Carpal tunnel syndrome

Mr Bassi tells us all about what happens if you suffer from carpal tunnel syndrome.

Carpal tunnel syndrome is a condition whereby compression of the median nerve at the wrist causes pain, numbness and tingling in the thumb, middle finger and thumb side of the ring finger.

The carpal tunnel itself is a narrow space covered by a fibrous strip of tissue on the palm side of the wrist bone. The median nerve as well as the tendons which bend the fingers run through this space. As the space is limited, if there is any swelling in the area the nerve often gets squashed which means that it doesn’t work as well. This is then known as carpal tunnel syndrome.

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Symptoms of carpal tunnel syndrome include:

  • Pins and needles and numbness in the thumb, middle finger and half of the ring finger nearest the thumb

  • Pain and aching in the hand and thumb, middle finger and half of the ring finger nearest the thumb. This pain can on occasion travel up the arm

  • A weakened grip

Why does carpal tunnel syndrome occur?

In many cases there is no clear reason why carpal tunnel syndrome starts but it is clear that it is associated with pressure on the median nerve. This can be associated with:

  • Pregnancy – the fluid retention associated with pregnancy can cause swelling around the carpal tunnel, compressing the median nerve.

  • Wrist dislocations and fractures can put pressure on the median nerve.

  • Bone or arthritic conditions of the wrist such a rheumatoid arthritis – these conditions can be associated with thickening of the ligament at the carpal tunnel, narrowing the space.

  • Side effects of some medicines for example the combined oral contraceptive pill can disrupt the hormonal balance enough the cause carpal tunnel syndrome.

  • Other conditions including obesity, diabetes or menopause can increase water retention resulting in compression on the median nerve.

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When would surgery be needed?

If symptoms persist and are not relieved by medication or exercises then surgery may be an option.

Surgery involves either local anaesthetic to numb the wrist area during surgery or general anaesthetic. During the surgery, the surgeon will cut the ligament over the front of the wrist with the aim of relieving pressure on the median nerve.

After surgery, in most cases, patients can return home on the same day as the procedure. To help prevent swelling in the fingers raise the arm can stay on pillow when resting, wiggling the fingers and make a fist regularly. Most individuals (depending on their job of course) return to work and most daily activities in approximately 2 weeks. 

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.

Baclofen: Applications and how it works

Mr Sanj Bassi explains to us all about Baclofen pumps and what they can be used to treat.

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As neurosurgeons we see a wide variety of patients with differing symptoms and diagnoses. In my practice I often see individuals with conditions such a cerebral palsy and increased spasticity. Spasticity can be quite disabling and have a significant impact on quality of life.

 

Anything that causes damage to part of the brain can increase spasticity such as cerebral palsy, stroke, head injury and multiple sclerosis. Increased spasticity causes the muscles to go into spasm which can be extremely painful and quite distressing for the individual. Left untreated the increased muscle spasms can have a considerable impact on daily activities including walking and using arms and legs.

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 In the treatment of these individuals there may be the option of implanting an intra-thecal Baclofen pump which delivers a drug directly to the fluid around the brain and spine. This drug is known as Baclofen. Baclofen is a relative of Diazepam and works as a muscle relaxant. In fact, it is known as a Gaba (neurotransmitter) agonist which provides negative (inhibitory) impulses to the muscles thus relaxing them.

Baclofen can be taken by mouth however only a small amount of the drug will go into the brain and spine and therefore oral Baclofen has quite limited benefits. If the dose of Baclofen is increased enough to improve the spasticity significantly, patients unfortunately suffer many side effects of the drug such as sleepiness and drowsiness.

Since 1998 it has been possible to deliver Baclofen directly into the brain and spine at a dose that is 1000 times less than that taken by mouth. This tiny dose of Baclofen is very effective in relieving spasticity and has none of the side effects of the oral version of the drug.

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 The drug is delivered through a small pump which is the size of an iPhone 5. This pump is implanted in the fat of the tummy and a small tube (about the thickness of a pencil lead) is run from the pump into the spine. The operation to implant these is quite straightforward. The pump is then programmed by Bluetooth to deliver the drug continuously to the brain and spine thus improving the spasticity. The dosage can be changed and increased using the Bluetooth device.

The pump usually holds enough drug for about 4 months of treatment and then has to be refilled with the drug using a small needle. The refilling of the pump is probably very similar to having blood taken. These pumps have a limited battery life and usually need to be changed every 8 years.

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.

What is a pars defect?

Mr Nick Thomas explains about pars defects for us.

A pars defect is a condition affecting the lumbar (lower) spine. It affects an area of bone called the pars interarticularis. The pars interarticularis is a small segment of bone which joins the facet joints at the back of the spine. A pars defect means that the lower and upper portion of the vertebrae (spine bones) can become separated during repeated stress and strain. This can happen on one side (unilateral) or both sides (bilateral) of the spine. Although often asymptomatic it is the most common cause of lower back pain in adolescents (with the majority of cases being in 10 -15 year olds). The most common area of the spine this affects is the lower or lumbar spine specifically L5-S1 and L4-5.

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A pars defect is present it can lead to development of other conditions such as stress fractures or spondylolisthesis. Sometimes the upper vertebra slips forward relative to the lower one – this is referred to as spondylolisthesis. Neurological deficits are relatively rare with the most common symptoms being back pain and leg pain which limits the activity level of the patients.

 

Causes of a pars defect:

The break in the bone occurs due to undue pressure on the pars interarticularis which can be linked to activities which cause repeated stress and strain. These may include (but not limited to):

  • Gymnastics, athletics, diving due to hyperextension and/or extreme twisting.

  • Weight lifting, wrestling, tennis, dancing due to repetitive, forceful movements.

  • Pars defects can also be linked to degenerative changes in the spinal discs and facet joints, which occurs with age.

 

Treatments for pars defects:

If the pars defect is present without spondylolisthesis and neurological symptoms then rest, immobilisation of the area and time can heal the defect. Rest and proper healing are vital prior to returning to sport and other activities. Physical therapies can help with speeding up the recovery and can include back strengthening exercises and gradual return to sport.

If there is a spondylolisthesis, neurological symptoms and pain with the pars defect the treatment plan can be a little different. Whilst pain medications and physical therapies as well as exercises to gradually return to sport can help some may not heal or could have resulting neurological problems. These cases may require surgical intervention which include a decompression (to release and free up the nerves being compressed by the slippage) and spinal fusion (to stabilise the spine whilst the bone heals).

 

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.

What are vertebral compression fractures?

Mr David Bell explains all about vertebral compression fractures, who gets them and how to go about treating them.

Vertebral compression fractures occur when the weight bearing, block-like part of the vertebra (spine bone) becomes compressed or squashed. These occur most commonly in the lumbar (lower spine) but can happen anywhere in the spine.

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How do we get vertebral compression fractures?

There are three possible causes of a vertebral compression fracture:

·      Osteoporotic: Osteoporosis is a disease of the bone causing reduced bone density. This may increase the chance of sustaining a vertebral compression fracture without trauma. The risk of osteoporosis and therefore vertebral compression fractures increases in women post-menopause.

·      Trauma: Usually the force needed to cause a vertebral compression fracture is fairly high. These often occur as a result of a fall from a height, landing feet first or road traffic accidents.

·      Pathological: Fractures occur as a result of pre-existing disease such as metastatic cancer but also other conditions such as osteomyelitis (infection of the bone) or Paget’s disease.

 

How do you know if you have a vertebral compression fracture?

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There are a few possible symptoms of vertebral compression fractures which can include:

  • Pain – especially in the lower back.

  • Numbness, tingling and weakness – this can occur if the bony fragments from the fracture cause compression of the nerves at the fracture level.

  • Incontinence or urinary retention – this can occur if fracture fragments press on the spinal cord.

Vertebral compression fractures are diagnosed through imaging of the spine to look at the bones which may include and x-ray, CT scan or MRI scan.

 

How are vertebral compression fractures treated?

There are several treatment options for vertebral compression fractures:

  • Back brace

  • Rest and ice

  • Pain relief – including non-steroidal anti-inflammatories, muscle relaxants

  • Exercise – when signed off by the doctor to prevent further osteoporosis and strengthen the muscles in the back.

If the conservative treatments do not have the desired effect or the fracture is causing neural problems there are surgical options.

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  • Kyphoplasty: A kyphoplasty is a minimally invasive procedure which aims to reduce or stop the pain caused by micro-movement in vertebrae often linked to a fracture. During a kyphoplasty the spine is accessed from the back via a small keyhole incision through with the surgeon passes a narrow tube. Positioning of the tube is confirmed and guided by x-ray images. The tube creates a pathway from the skin to the damaged vertebral body via the pedicle (part of the vertebra linking the front to the back). The surgeon inserts a special balloon through the tube into the vertebra and gently inflates it. As the balloon inflates it compacts the soft bone to create a void inside the vertebra. It may also partially restore the height of the vertebral body. The surgeon removes the balloon and injects a cement-like material into the void via the tube. The cement-like material (polymethylmethacrylate) hardens quickly once injected to stabilise the bone.

  • Vertebroplasty: A vertebroplasty is a minimally invasive procedure which aims to reduce or stop the pain caused by micro-movement in vertebrae often linked to a fracture. During a vertebroplasty the spine is accessed from the back via a small keyhole incision through with the surgeon passes a narrow tube. Positioning of the tube is confirmed and guided by x-ray images. The tube creates a pathway from the skin to the damaged vertebral body via the pedicle (part of the vertebra linking the front to the back). The surgeon removes the balloon and injects a cement-like material into the void via the tube. The cement-like material (polymethylmethacrylate) hardens quickly once injected to stabilise the bone.

  • Decompression to relieve pressure on the spinal cord by removing some bone from the back of the spine.

How to prevent vertebral compression fractures?

Many vertebral compression fractures are a result of osteoporosis therefore if the osteoporosis is prevented the risk of fracture is also reduced. So, how do we go about this?

  • Balanced diet with plenty of Calcium and vitamin D

  • Exercise particularly weight bearing exercise to help keep bone strength high

  • Quit smoking

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.

 

Deciphering the alphabet soup that is spinal fusion surgery!

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One of our complex spine experts, Mr Irfan Malik, explains to us all about spinal fusion surgery and what all the acronyms mean.

What is a PLIF, what is a TLIF, what is an ALIF? What are all of these different spinal fusion options that are out there for patients? You can read about one then another but they all sort of sound and look the same, so what do they mean?

Spinal fusion is an operation to make two of the segments of the spine become one, to fuse the segments. The spine is made up of:

  • Bones which provide support

  • Discs which act as shock absorbers between the bones

  • Ligaments which hold it all together

  • Muscles which provide movement.

As we age, or sometimes through trauma, the discs become degenerative and start to cause a problem in the spine. This can result in back pain although this is usually accompanied by pain down the legs like sciatic pain and if this progresses it can result in a lack of or reduction in function in the lower limbs, so this could be a foot drop or could just be weakness in the legs but whichever one of these it is, it will need to be treated.

So how do we go about doing that?

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In the simplest way it could be a decompression which is just removing part of the bones at the back of the spine to free up the spinal cord and the nerves which is being affected. When a nerve becomes trapped or compressed, it can result in leg pain, weakness or numbness. If this progresses further sometimes more bone needs to be removed than a simple decompression which can cause the spine to become unstable. If this is the case the surgeon may have to add extra instrumentation into the spine to hold it in place whilst the bones grow and it becomes stable again. So this is where the PLIF, TLIF and ALIF comes in to play.

What is a PLIF, TLIF and ALIF?

A PLIF is a Posterior Lumbar Interbody Fusion. The easiest way to understand this is to break it down by each word and what happens in the procedure. The surgeon will approach the lower spine (lumbar) from the back (posterior), remove the disc (that is the interbody part – i.e. between the vertebral bodies) and replace it with a cage or a spacer to restore the disc height and allow space for the nerves to move again and be free. The fusion aspect comes from putting a screw in the level above and below the affected disc and holding them together in order to keep everything stable until the bones have grown around the edge and formed one spinal segment rather than two - the fusion part of the operation.  This can be encouraged by putting bone graft down in the lateral gutters or edges of the spine bones to encourage bone to grow more quickly whilst the screws are holding it steady.

A TLIF is just a different approach to the same operation. Instead of being called a posterior lumbar interbody fusion it is called a transforaminal lumbar interbody fusion. This means that the disc is usually accessed via one side (usually about 2 or 3 centimetres from the midline of the back rather than directly from the back) and is often accompanied with minimally invasive techniques meaning the operation is carried out through small stab incisions like keyhole surgery.

An ALIF on the other hand is an anterior lumbar interbody fusion where the disc spaces are approached through the anterior aspect (stomach) and a larger spacer is placed in to the disc space once the disc is removed. This is often accompanied with minimally invasive posterior fixation, from the back of the patient, as well.

The final option is an XLIF which is an extreme lateral lumbar interbody fusion. This is where the patient is placed on their side and the disc space is accessed directly from the side of the patient, past the iliac crest and on to the spine from the side. Again, this is often accompanied by screws in the back to hold everything in place until the fusion takes place.

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Recovery times vary from fusion to fusion and from patient to patient. It is hard to say exactly when a patient will fully recover but we usually expect patients to be going home within a couple days of surgery and to be getting back to normal activities within six weeks, but again this varies from patient to patient.

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.

 

 

ACDF? What is it and what does it mean?

We asked Mr Bell all about what happens when you get pain, tingling and weakness in your arms and hands, what it means and how to treat it.

What does ACDF mean?

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ACDF stands for Anterior Cervical Discectomy and Fusion. To break it down - anterior refers to the front, cervical being the neck region of the spine, discectomy means cutting out the disc and fusion, joining two bones together. This is fusion surgery after removing the disc from the front of the neck (ACDF).

 

Why do people have ACDF surgery?

ACDF is usually in relation to radicular pain which is radiating from the neck, down the arms and in to the fingers. It is when one or more nerves in the neck are affected by a bulging or herniated disc and the disc is compressing the nerves to cause pain, weakness, tingling or numbness down the arms in to the fingers.

 

During surgery what actually happens?

An incision will be made in the front of the neck and the muscles, trachea (wind pipe), oesophagus (food pipe) and any other tissues in front of the spine will be moved to one side so the surgeon can see the spine bones and the discs. The offending level is then identified using X-ray guidance and the disc at that level is removed – this is the discectomy part of the operation. In place of the disc, a spacer or cage is put in which is filled with bone graft to encourage bone to grow from the level above to the level below, forming one motion segment – that is the fusion part of the operation.

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In terms of recovery, patients tend to go home within a couple of days of the operation and recovery time is usually in the region of four weeks. There may be some stiffness immediately following the operation but this should ease up through keeping mobile and doing some exercises prescribed by the physio.

Postoperatively, patients will wake up in the recovery area and will be taken to the ward to be looked after for a couple of days before they return home. Sometimes hoarseness and sore throat or difficulty swallowing may occur in some patients but these symptoms should not continue for long.

Within a few days the patient should be able to return to daily activities without any strenuous activity and walking is encouraged with short distances building up. Using proper lifting techniques, good posture and an appropriate exercise programme whilst maintaining a healthy weight will all help with a speedy and successful recovery.

As with all surgery, this does carry risks and these should be discussed at length with your consultant prior to any decision.

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.

What is Trigeminal Neuralgia and why do you get it?

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Trigeminal neuralgia is a condition where the patient suffers excruciating pain in one side of the face.  The pain has been compared to electricity, or being stabbed in the face with a hot poker or a knife. Patients invariably say it is the worst pain they have ever experienced.  It is usually triggered by eating, soft touch, brushing teeth, shaving and cold wind blowing on the face.  It affects women slightly more frequently than men and usually starts between the ages of 40 and 70.  Patients often think the cause of their pain is dental and may sometimes have teeth extracted or treated without improving their symptoms.

Trigeminal neuralgia is mostly managed well with medication such as carbamazepine or oxcarbazepine, or indeed several others. However, these medications can have side effects including sleepiness, difficulty concentrating, forgetfulness or feeling off balance.

A significant group of patients will, however, find that their dose will need to be increased as time progresses.  When the medication becomes ineffective, or the side effects are so pronounced that the patient is unable to perform daily tasks then the patient may wish to consider other treatments such as surgery or radiotherapy. The aim of these further treatments is to try and keep the patient pain-free for as long a period as possible.

The surgical procedure is called a microvascular decompression.  This involves making a small hole in the skull behind the ear and lifting an artery off the trigeminal nerve. This has traditionally been performed using a microscope, but at London Neurosurgery Partnership we use an endoscope. An endoscope is a long thin cord with a light and camera on the end. This allows for a much smaller incision to be used and the procedure to be minimally invasive. Surgery is performed under general anaesthetic and usually lasts about 2 hours. Patients are generally in hospital for 2 to 5 days after surgery. The risks of surgery are potentially serious but fortunately rare. Seventy percent of people with a correct diagnosis of trigeminal neuralgia who undergo a microvascular decompression are pain-free 10 years after surgery.

Alternative methods of treatment include one of the percutaneous techniques; glycerol injection, radiofrequency rhizotomy or balloon compression. These involve passing a needle into the cheek and though a small hole in the base of the skull onto the trigeminal nerve. X-rays are used to guide the needle and are performed under sedation or general anaesthetic. These procedures work on the premise of deliberately damaging the trigeminal nerve to disrupt the pain signals.

  • Glycerol injections: Glycerol (performed at LNP) is then injected around the nerve. More than ninety percent of patients with trigeminal neuralgia will experience relief of their pain with a few days of the procedure. Most patients will wake up with numbness in the face but this gradually improves. 
  • Radiofrequency rhizotomy: The needle is used to apply heat to the trigeminal nerve.
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There is, however, a recurrence of pain in about 50% of patients over three years and for this reason the procedure is recommended in patients who are frail or may otherwise not tolerate the microvascular decompression. The injection can be repeated but is less likely to be effective and complications are slightly more common. The risks of the injection include persistent facial numbness, weakness of the jaw, infection/meningitis, injury to an artery resulting in a bleed or stroke, reactivation of herpes infection, anaesthesia dolorosa (a very painful and numb face which is very difficult to treat).

Finally, there is the option of radiotherapy to the nerve, called gamma knife. Like the percutaneous techniques, this is also a destructive procedure. Performed as a day case, a frame is fitted to the patient’s head and a very focused beam of radiation is targeted at the trigeminal nerve. This does not, therefore, involve any incisions or surgery to the head. There is a 30-40% recurrence rate of 3 to 4 years after the procedure. This is a useful treatment for patients with serious medical problems who might not be suitable for a microvascular decompression.

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.

 

Chiari Malformations: What are they and why do they occur?

We asked Mr Sanj Bassi, London Neurosurgery Partnership’s Chiari expert, to explain a bit about Chiari malformations, the different types as well as how and why they happen.

Chiari malformation refers to a condition in which some of the brain tissue (namely the cerebellar tonsils, cerebellum, brain stem and/or part of the fourth ventricle) extends into the spinal canal. This can happen when the skull is unusually small or misshapen so the brain tissue is pushed downwards into the spinal canal.

The concern is that the abnormal positioning of the brain can lead to a blockage of signals from the brain to the body or a build-up of cerebrospinal fluid in the brain or spinal cord. There may also be pressure of the brain on the spinal cord and brain stem leading to neurological problems. That said, many people with a Chiari malformation have no signs or symptoms so the condition goes unnoticed without need of treatment. The increased use of imaging tests has led to more frequent diagnosis, even without symptoms. However, symptoms can occur depending on type and severity of the Chiari malformation.

The Chiari malformation can be divided into three types, with Chiari I and II being the most common, although some doctors will include a fourth type within the classification:

Chiari I:

  • Although often asymptomatic, if these become apparent it is usually in late childhood/early adulthood.
  • Symptoms include an impulse headache (associated with increased brain pressure especially after coughing or sneezing), balance and vision problems, and if associated with a spinal cyst (syringomyelia) can cause poor hand coordination, difficulty walking and difficulty swallowing (syringobulbia).
  • These occur when a part of the back of the skull is too small or is deformed causing the brain to become cramped. Therefore, the lower part of the brain (cerebellar tonsils) are pushed into the upper part of the spinal canal.

Chiari II: 

  • This type often presents at birth and is always related to an open myelomeningocele/spina bifida (the backbone and spinal canal do not close properly prior to birth). A greater proportion of the brain extends into the spinal canal than in a Chiari I.
  • Symptoms can include changes in breathing, feeding/swallowing problems, quick downward eye movements and arm weakness.

Chiari III:

  • This is one of the more severe but also rare forms of Chiari where a portion of the back part of the brain protrudes through an opening in the skull called an encephalocele. Chiari III can be associated with neurological problems and is usually diagnosed at birth or in pregnancy.

How do you treat a Chiari malformation?

The treatment of Chiari malformation varies depending on the type and symptoms.

Asymptomatic Chiaris will likely be treated with nothing other than monitoring with regular examinations, follow ups and MRI scans.

Symptomatic Chiaris will usually be treated surgically. The aim of surgery is to stop the progression of symptoms and anatomical changes whilst hopefully having some positive impact on symptoms.

With a symptomatic Chiari I it is important to always treat the hydrocephalus first (often with a shunt – see hydrocephalus post). Following this a posterior fossa decompression may be done to remove a small amount of bone from the back of the skull to give the brain more space. In some cases, the surgeon may also remove a small section of bone from the top of the spine to give the spinal cord more room. Sometimes the covering of the brain and spinal cord (dura) may be thinned to allow the brain and spinal cord more space. These options would all be discussed but the aim of these procedures is to free the brain and spinal cord of compression.

It is important to note that there are risks and complications as with all surgery and it is imperative to discuss these with your consultant when deciding if surgery is the best option.

This article is intended to inform and give insight but not treat, diagnose or replace the advice of a doctor. Always seek medical advice with any questions regarding a medical condition.