Daily Archives: November 4, 2015

Spine Surgery Program

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In the world of medicine, the words “minimally invasive” and “spine surgery” don’t usually go together. But for the past decade, the University of Michigan Spine Surgery Program has moved many spine surgeries into the minimally invasive realm—with great success. In fact, U-M is the first program in the state completely dedicated to the advancement of minimally invasive spine surgery.

“A lot of the minimally invasive spine procedures started with ‘basic’ spine procedures such as discectomies, laminectomies and level-one lumbar fusions of the spine,” says Paul Park, M.D., associate professor of neurosurgery and of orthopaedic surgery. The program soon realized success in outcomes as good as or better than the traditional surgery. The surgeries also had the added benefits of smaller incisions, less tissue injury and blood loss during surgery, less postoperative pain and reduced hospital length of stay.

SPINE_SURGERYNow, discectomies and laminectomies are outpatient procedures, and the hospital length of stay for fusion surgery is much shorter.

“It’s a constantly evolving field because once we saw success for these more basic spinal surgeries, we started applying them to more complex situations such as tumor resections and deformity.” Although not all complex cases are amenable to minimally invasive surgery, each patient is evaluated for a less invasive approach with the ultimate goal of achieving best possible outcomes.

WHO WE TREAT
Today, the U-M Spine Surgery Program provides state-of-the-art services to individuals whose spinal disorders affect their health and productivity, and whose disorders require surgical intervention. Patients referred to the spine surgery program may suffer from pain and/or neurological deficits due to degenerative spinal disease, scoliosis, spinal tumors, spine cancer, spine infections or traumatic injury.

“We offer treatment options for the whole spectrum of spinal pathologies,” Park says.

NEW TECHNOLOGIES
Minimally invasive spine surgery is an area in which new technologies matter greatly. Along with the latest state-of-the-art computer-assisted image guidance and operating microscopes, U-M has technologies and resources that few other hospitals have. For example, the University of Michigan was the first hospital in the state to use the O-ARM Multidimensional Imaging System.

Neurosurgeons have the option to use the O-ARM to view patient anatomy in the operative position, monitor the status of the surgery and verify surgical changes with real-time 3-D volumetric images, all before the patient leaves the surgical suite.

“We’re always investing in or trialing new technologies such as the O-ARM for increased patient safety and better outcomes,” Park says. “We also use new technologies in conjunction with newer techniques for improved outcomes as well, such as using the O-ARM for image guidance for lateral interbody fusion, which is an alternative minimally invasive approach for fusion of the thoracic and lumbar spine.”

For Referring Physicians
Dr. Park suggests that it is appropriate to refer patients who have failed nonoperative management, for example, if they have had physical therapy and injections and are still having issues (the most common of which are back pain or leg pain). In patients with neurological deficits such as weakness, referral should be done urgently.

“If you have a patient with a weak foot, for example, I wouldn’t try nonoperative measures; they need more of an urgent surgical evaluation first,” Park says. “But if it’s typically a pain issue, a trial of nonoperative management is typically recommended.”

Clinical Trials
Multiple clinical trials are ongoing or planned at the University of Michigan Spine Program involving treatments for a variety of spinal pathologies including degenerative disease, infection, trauma and deformity.

One example is our participation in a Phase 2 multicenter clinical trial to study stem cell transplantation in cervical spinal cord injury,
sponsored by StemCells, Inc.

For more information: contact Clinical Trial Coordinator Karen Frisch, 734-936-7469. kfrisch@med.umich.edu.

 

Fall prevention research for Parkinson’s Disease

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Every year, up to 70% of people with Parkinson’s Disease (PD) will fall, often leading to serious medical and social issues. The National Institute of Neurological Diseases and Stroke has awarded the Michigan Department of Neurology a five-year, $11.5 million grant to establish the Morris K. Udall Center of Excellence for Parkinson’s Disease Research focused on developing a treatment to prevent falls.

Clinical Trial Opportunities
Importantly, much of the Center’s work is clinical research on patients with earlier stages of Parkinson’s before falls emerge, but it is hoped that the novel therapeutic approach will ultimately help decrease falls in those experiencing them. Involvement of adequate numbers of patients is critical for success.

fall_preventThose interested in participating can register to be contacted at www.clinicalstudies.org (search for “Parkinson’s disease” and click on study titled “Cholinergic Mechanisms of Gait Dysfunction in Parkinson’s Disease”).

The Center conducts experimental, computational and human research to further investigate the possibility that the degeneration of cholinergic neurons is an important cause of gait dysfunction in Parkinson’s Disease. The Center is both testing this possibility—based  upon considerable earlier findings—and working to develop a novel treatment strategy targeted at cholinergic neurotransmission.

With this grant, Michigan becomes one of only nine Morris K. Udall Centers of Excellence in Parkinson’s Disease in the United States.

For more information, visit udallpd.umich.edu.

 

MEET Elizabeth Scheffler

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Elizabeth

Retired teacher Elizabeth Scheffler had been dealing with some form of essential tremor (ET) for 10 to 15 years. Finally, she says, “It had become increasingly worse, to the extent that I had very little, if any, fine motor control and progressively compromised gross motor skills.”

The tremor was bilateral, and she also had a head and voice tremor. “It was not possible to carry a cup of coffee without spilling, eat a sandwich without shaking it apart or feed my then-infant grandson,” Scheffler remembers. She tried three or four medications, which made little or no impact on the tremors. “One neurologist in Colorado was even treating me for Parkinson’s, which it turns out I do not have.”

One day, Scheffler saw a television program about a man with essential tremor who underwent deep brain stimulation (DBS), a pacemaker-like procedure for the brain. The results were remarkable.

After Internet research, she met with Dr. Kelvin Chou, co-director of the University of Michigan Movement Disorders Clinic, who confirmed that she was a good candidate for DBS.

Like all DBS candidates, Scheffler underwent speech and neuropsychological testing before being accepted for surgery. “Dr. Parag Patil, the DBS neurosurgeon, also met with me, to explain the surgery,” she says. “Although initially it was a difficult decision and I was apprehensive, the staff was very reassuring and gave me success rates, number of operations completed, etc.  They allayed my anxiety by answering all my questions in such a caring way that I wasn’t even really nervous before the surgery.”

DBS is a two-part surgery. During the first part, in which the stimulator is placed in the brain, she says, “The neurosurgical staff told me exactly what to do, explained each step of the surgery and the result to expect. They also conducted speech evaluations throughout the surgery to

Scheffler received consultation from Laura Zeitlin, MSW, to understand how to control the batteries implanted in her chest that generate electrical pulses to her brain.

Scheffler received consultation
from Laura Zeitlin, MSW, to
understand how to control the
batteries implanted in her chest
that generate electrical pulses to
her brain.

ensure speech centers would not be affected.”

The second surgery (two weeks later) implanted the battery pack into her chest. “Although the first surgery made for a long day, I experienced no pain and required none of the prescribed drugs. The second surgery was a breeze.

“I now have full control in my dominant hand and my head tremor is gone,” Scheffler says. “Now I fully enjoy my retirement, volunteering as treasurer of a non-profit agency, playing bridge, doing floral arranging, yoga and golf. I can even do some photography and enjoy my electronic devices.

“I heartily encourage anyone with this condition to further explore whether they are a good candidate for DBS. It has changed my life in such positive ways.”

Essential Tremor: A New Life Through Deep Brain Stimulation

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Approximately 10 million people in the United States have essential tremor (ET), which eventually can interfere with daily activities such as eating, drinking and writing. Yet, most people with ET are never offered a therapy that was FDA approved in 1997.

At the University of Michigan, a program called STIM—Surgical Therapies Improving Movement—is changing the lives of people with ET using this very treatment, called deep brain stimulation (DBS).

Surgical Therapies Improving Movement— changing the lives of people with ET using deep brain stimulation

Surgical Therapies
Improving Movement—
changing the lives of
people with ET using
deep brain stimulation

“I think most people know DBS is a really good and effective therapy for Parkinson’s because two-thirds of our referrals are for Parkinson’s. But fewer people know how good it is for essential tremor. And ET is a much more common disease than Parkinson’s,” says Kelvin Chou, M.D., co-director of STIM and co-director of the Movement Disorders Clinic.

Approximately 10 million people have ET compared with approximately 1 million who have Parkinson’s.

“There’s an incredible unmet clinical need for this therapy. The major barrier to patients getting this quality-of-life-improving therapy is essentially a lack of awareness. That’s why we’re very interested in helping to educate providers and patients about the risks and benefits of DBS for ET,” says Parag Patil, M.D., Ph.D., an assistant professor in U-M’s departments of Neurosurgery, Neurology, Biomedical Engineering and Anesthesiology.

The STIM program treats essential tremor and Parkinson’s primarily, but DBS is also effective for patients with dystonia and a few other neurological disorders.

DBS Device
A DBS device is similar to a pacemaker for the heart, but instead of having electrodes (or electrical wires) implanted in the heart, the electrodes are placed into the thalamus portion of brain. The electrodes carry electrical signals to specific brain locations. These electrical signals cause the brain cells around the DBS electrode to change their activity. By changing the activity of brain cells, DBS can reduce the symptoms of many neurological disorders, depending on where the electrodes are placed.

DBS is not a cure for the disease but a way to manage it more effectively. It can offer many benefits, including the need to take less medication and therefore experience fewer medication side effects.

Patient Evaluation
Before patients are considered for DBS surgery, they are evaluated by the multidisciplinary STIM team, which has extensive training in DBS. The team includes a neurosurgeon, neurologist, clinical neuropsychologist, speech pathologist, social worker and other team members who ensure that the patient and their family understand the procedure and discuss expectations and concerns.

“In our program, a third of patients who are referred for DBS just need to have their medication adjusted. Another third go through the evaluation process, are offered the surgery and choose to defer. They’re not quite ready. So, that leaves one-third who actually have the surgery. And that’s fine, because for us, the emphasis is education, not just operating on people,” Patil says.

 

Endoscopic Skull Base and Pituitary Programs: Pioneering Minimally Invasive Surgeries For Faster Recovery

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The University of Michigan’s Cranial Base and Pituitary programs diagnose and treat benign and malignant tumors involving the cranial base and pituitary regions, cerebrospinal fluid leaks, encephaloceles and traumatic injuries to the face and skull. Endoscopic skull base surgery is an increasingly used technique that does not require facial incisions.

pituitary1

Resection of suprasellar craniopharyngioma

“Minimally invasive endoscopic approaches to the skull base have largely replaced the more invasive transcranial and transfacial approaches that were the mainstay of treatment for decades,” says Stephen E. Sullivan, M.D. Sullivan is director of the minimally invasive skull base program based in the departments of otolaryngology and neurosurgery and the minimally invasive pituitary program.

“We’re able to access most skull base brain tumors endoscopically, just through the nostrils. We actually get better visualization than we could previously in an open operation,” he says. Computer image guidance like a GPS is often used.

This approach causes patient lengths of stays to come down significantly. For the patient, it means no incisions, less pain and quicker recoveries.

“We evaluate patients in a multidisciplinary manner with all of the necessary consultants.  One

Resection of pre-pontine craniopharyngioma

Resection of pre-pontine craniopharyngioma

stop shopping, so to speak,” says Sullivan.

High Volumes and Types of Care
Sullivan’s programs perform about 225 skull base surgeries a year, approximately 120 of which are pituitary surgery. The remaining types of tumors are meningiomas, chordomas, craniopharyngiomas, esthesioneuroblastomas and sinonasal malignancies that involve the skull base.

Sullivan’s clinic takes a multidisciplinary approach in assessing patients by including all the specialists involved, including neurosurgery; ear, nose and throat; neuro-ophthamology and radiology. “Together, we come to joint decisions about care,” Sullivan says.

“We are one of the highest volumes centers in the country, certainly in the Midwest.”

For the Referring Physician
His area also has ongoing research looking at, for example, chordoma treatments and cells lines, and the genetic profile of chordoma cells. “It’s important for patients to participate in clinical trials.

“I want referring physicians to know that, while these are complicated tumors, the treatment paradigms are changing very rapidly right now. What wasn’t possible even a year ago is indeed possible now,” Sullivan says. “We’re happy to field any and all calls.”

Skull Base Program
  • Patients needing surgery can be seen in clinic within 1 or 2 weeks
  • 225 skull base surgeries a year, 120 of which are pituitary surgeries

 Find more information at UofMhealth.org/CranialBase or call M-LINE at 1-800-962-3555.

Concussion: Not an End Game

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The variability of concussion injuries makes experience a critical component to providing quality care.   Michigan NeuroSport sees 2,400-2,500 sport concussion cases every year, in addition to cases of peripheral nerve injury, spinal cord injury, stingers and other neurological injuries. It’s one of the few programs in the country dedicated to the neurological concerns of athletes of all ages.

“We provide a comprehensive neurological approach because we know that not every injury produces the same clinical syndrome or appears at the same time,” says Jeffrey S. Kutcher, M.D., director, Michigan NeuroSport, and associate professor of neurology. “A detailed yet focused history and examination allow us to put a lot of things in perspective like migraine, ADHD and depression. We’re able to sort through those and provide an accurate diagnosis.”end_game

NeuroSport physicians are team physicians for the University of Michigan, Eastern Michigan University and USA Ski-Snowboard, director of NBA concussion program, and consultants for the NFLPA and NHLPA. “Working with the teams, we’re taking care of athletes in real time, understanding the brain in real situations,” Kutcher says.

Customized Treatment
Just as each athlete is unique, so is every concussion. NeuroSport uses a customized, gradual, step-by-step process for safe return to play. This approach is based on elements such as the patient’s history and the nature of their sport.

“From diagnosing and treating thousands of patients and conducting research, we firmly believe that concussions are not a death sentence for athletes. Most of those who are concussed recover fully and can return to playing their sport safely, if they receive the appropriate medical care,” Kutcher says.

“What sets us apart is that we offer athletes neurological care and concussion treatment that is focused in neurology.” He notes that concussion clinics are popping up all over the United States. “They tend to only scratch the surface of the complex care these patients need.”

For Referring Physicians
Kutcher says that NeuroSport physicians can be helpful across the entire spectrum of athlete brain health management—anytime a referring physician feels uncomfortable evaluating a patient or making management decisions, whether it’s concussion, post-concussion syndrome, long-term concerns or other neurological issues.

Michigan NeuroSport Clinic: 734-930-7400