Treatments

What is botulinum toxin injection? Botulinum toxin injection is an effective treatment for a variety of movement disorders including myoclonus, hemifacial spasm, spasticity, tremor, blepharospasm, cervical dystonia, spasmodic torticollis and dystonia of the leg and foot. Excessive salvation or drooling resulting from a variety of neurological conditions may also respond to treatment. How long does it take for botulinum toxin injection treatment to work? Benefit is typically realized in 3-10 days after injection with a lasting response measured in months. What is involved in botulinum toxin injection treatment? The treatment involves the injection of a small dose of Clostridium botulinum-a...

Cortical Motor Mapping Electrophysiological brain mapping is performed as a necessary adjunct in surgery to clarify the relationship of brain tumors to functional regions of the brain. Mapping is most commonly performed during surgery to identify areas in the brain responsible for body movements (primary motor cortex, precentral gyrus or the Rolandic area) as well as language (Broca’s or Werneckie’s areas) (Figure 1). Although all areas of the brain are functionally active, some may be considered dormant or redundant in function with other anatomical areas. In these regions, manipulation of the brain incurred during surgery or brain injury resulting from...

What is the brainstem? The brainstem is a vital part of the nervous system that not only transmits motor and sensory fiber tracts but also houses centers or ‘nuclei’ which initiate and maintain a variety of automatic functions of the brain. Functions include maintenance of consciousness, breathing, salivating, maintenance of muscle tone of the arms and legs, swallowing and phonation. What is involved with brainstem surgery? Functional tissue is densely represented and therefore all areas may be considered eloquent and cannot be must be dissected with great delicacy and caution. When treating lesions within the brainstem, monitoring is crucial and...

What is a cerebral angiogram? Angiography is the most reliable and sensitive diagnostic test for the detection and clarification of the anatomy of brain aneurysms, AVM and other cranial or spinal vascular lesions. This procedure requires needle access to the main artery of the leg (femoral artery) and on rare occasions the arm (brachial artery) to guide a small diameter catheter to the blood vessels supplying the brain and spinal cord. From this access point, neuroendovascular surgeons inject a dye that is detectable by x-ray and is demonstrated by a device called a fluoroscope. A cerebral angiogram is more accurate...

In certain cases when the brain aneurysm cannot be safely clipped using standard techniques, and the aneurysm cannot be treated with coils, the patient may require a reconstruction of the arterial tree allowing for blood flow to “bypass” the aneurysm. Bypass procedures involve grafting a blood vessel from the neck or harvesting a vein or artery from the arm or leg and attaching it to the blood vessel of the brain feeding the aneurysm using microscopic sutures. The aneurysm is then treated by placing either surgical clips or endovascular coils in the blood vessel that supplies the aneurysm. Using this...

The division of neuro-oncology is actively involved in research to advance the treatment of gliomas and other brain tumors. Clinical trials are offered to carefully selected patients and serve as an adjunct to standard of care. These innovative treatments include novel preparations of chemotherapeutic drugs designed to bypass physiological barriers. Immunotherapy, harnessing the patient’s own immune system to fight cancer is another mechanism that has been developed to treat brain cancer and involves the administration of vaccines directed to brain tumors. Treatment paradigms based on the manipulation of the brain tumor genome-gene therapy is also offered to broaden the opportunity...

Computerized Tomography (CT) Despite the fact that MR has largely superseded CT in defining the anatomy, CT remains a necessary tool for the neurosurgeon in a variety of circumstances. CT is used routinely in emergency settings and in the immediate postoperative period due to its availability, short acquisition time and sensitivity in demonstrating potential bleeding complications. This study is also incredibly sensitive in assessing for hydrocephalus and ventricular anatomy. For tumors of the pituitary and skull base, CT provides a superior view of intricate and delicate bony anatomy of the paranasal sinuses and inner ear. CT also gives a detailed...

We provide cortisone injections in various joints such as the shoulder, elbow wrist, hip and knee. Cortisone is a powerful anti-inflammatory that can achieve significant temporary relief of conditions such as bursitis, tendinitis and arthritis. However they cannot be performed frequently.

Accuracy and conformity of targeting in cranial neurosurgery is achieved through the use of stereotaxis. With this technique, imaging studies are used to create a three dimensional map of the skull and brain or other anatomical structures. This map is co-registered with the patient at the time of treatment and a plan is created allowing for the precise convergence of radiation to exclusively capture the complex 3-dimensional geometry of tumors and AVMs. The synchronization of a virtual map to the patient may be achieved by either ‘frame based’ or ‘frameless’ systems. In the former, a metal frame is secured to...

Craniofacial Resection procedures require the coordinated efforts of a team of surgeons generally comprised of a skull-base neurosurgeon, an otolaryngologist and a plastic and reconstructive surgeon. Together these specialists work to resect tumors that typically originate in the paranasal sinuses and extend through the skull-base and into the cranial vault. Circumferential visualization of the mass is achieved by trans nasal and simultaneous transcranial exposure. After tumor removal, reconstruction of a watertight barrier is paramount to prevent complications.

Review some of the most commonly asked questions about Craniotomy: What is Craniotomy? Which Conditions Can Benefit From Craniotomy? What is the Recovery After Craniotomy? What is Craniotomy? Craniotomy is a surgical procedure that involves the removal of a portion of the skull to access the brain. Which Conditions Can Benefit From Craniotomy? A craniotomy is commonly performed to treat conditions such as brain tumors, traumatic brain injury, brain aneurysm, arteriovenous malformations and epilepsy. The procedure is most often performed under general anesthesia and involves making an incision in the scalp, usually behind the hairline. A piece of the skull...

What is microsurgical clipping? Anatomical factors at times compel the surgeon to recommend microsurgical clipping of an aneurysm rather than endovascular coil embolization. Craniotomy and clipping requires the placement of an incision behind the hairline or at the eyebrow with a small cranial opening to allow the surgeon access to the blood vessels at the base of the brain. Learn More: Craniotomy vs Craniectomy With the use of an operating microscope, the surgeon exposes the aneurysm as well as the surrounding vascular tree and places a small metallic clip across the opening or “neck” of the aneurysm without compromising normal...

Craniotomy vs Craniectomy vs Cranioplasty The three procedures of craniotomy, craniectomy, and cranioplasty are all related in that a surgeon performs a procedure to access the cranial cavity. The differences between a craniotomy vs craniectomy occur primarily in the second stage of the procedure. What is a craniotomy? Craniotomy defines a procedure whereby surgeons gains access to the cranial cavity to perform a variety of procedures including tumor resection, hematoma evacuation or clipping of a brain aneurysm. After incising the skin and with elevation of the scalp, the bone of the skull is exposed. A bur hole is then placed...

What is Deep Brain Stimulation Deep brain stimulation (DBS) for Parkinson’s disease, essential tremor and dystonia relies on the application of small but meaningful electrical pulses to well defined targets (nuclei) in the brain rather than creating a lesion as in pallidotomy or thalamotomy. These pulses alter the electrical rhythm of the motor nuclei resulting in a ‘restoration’ of more normal ease and fluidity of movement. The precise implantation of surgical wires or ‘leads’ is facilitated by stereotactic techniques. The underlying cause of Parkinson’s as mentioned above is a loss of a population of dopamine producing cells in the substantia...

This procedure is based on the hypothesis that the awareness and debilitating quality of back and leg pain may be lessened by modulating the electrical conductivity of the spinal cord. Modulation of electrical activity is achieved by the surgical placement of electrical leads (wires) in the lower thoracic spinal canal. Typically, the procedure requires a trial prior to definitive implantation. The leads are placed in the epidural space of the spinal canal-outside of the sac that contains the spinal cord. Small electrical impulses are imparted by a ‘pulse generator’ that is implanted in the subcutaneous fat just above the buttock....

We have the capability to perform in office EMG nerve testing. This involves testing the electrical response of muscles and nerves and can help diagnose conditions such as sciatica, pinched nerves, and carpal tunnel syndrome.

Endoscopic techniques are useful in treating a variety of intra-ventricular conditions including hydrocephalus and for tumor biopsy. Ventricles are the fluid filled spaces in the center of the brain; cerebrospinal fluid (CSF) is synthesized in the ventricular system and circulates from the inside to the outside of the brain through the ventricular network. Endoscopy allows for access to the ventricular system with minimal brain disruption. Biopsy of tumors localized within the ventricular system is facilitated by ventriculoscopy. A meaningful treatment plan may developed from this established tissue diagnosis.

This minimally invasive procedure is performed under general anesthesia and is similar to a cardiac catheterization. As reviewed in the cerebral angiography section above, a small plastic tube (catheter) is placed into an artery of the leg and advanced under x-ray guidance into the artery that supplies blood to the aneurysm. A smaller tube called a microcatheter is then advanced under x-ray guidance into the aneurysm. Special metallic platinum coils are carefully advanced into the aneurysm until it is completely filled. The coils within the aneurysm cause blood to stop flowing within the aneurysm. This prevents leakage of blood and...

A major factor in the duration of and complications related to the resection of brain and spinal tumors is tumor vascularity-the density and richness of blood supply. In selected cases, the surgeon may request that an endovascular embolization is performed in an attempt to interrupt the blood supply of the tumor prior to surgery. The blood vessels feeding the tumor are accessed using angiographic techniques; a catheter is navigated to the origin of feeding vessels and imaging is obtained to assure that blood flows only to the tumor and is not shared with critical structures i.e. viable brain tissue or...

This adjunct to the surgical resection of brain tumors aids in distinguishing the infiltrative edge of tumors from normal brain tissue thereby increasing the possibility of a more complete resection (figure 1). Pre-operative administration of fluorescing medications accumulates in tumor tissue preferentially and is detectable with light filtered to specified wavelengths. Although these technologies are in evolution and available only in select brain tumor centers, there is compelling supporting its use. Axial (A) and coronal (B) T1 weighted MR fMRI localizing hand function with relation more laterally placed hypo-intense neoplastic process (white arrows) with more medially situated descending motor fibers...

Petrosal sinus sampling Endovascular treatment of ischemic stroke: Intra-arterial thrombolysis MERCI clot retrieval Stenting of vascular stenosis and dissection Direct surgical repair of aneurysms Intra-cerebral arterial angioplasty: Pharmacologic Mechanical–balloon Ventriculostomy (EVD) Cerebrospinal fluid shunts Ventriculo-peritoneal shunt Ventriculo-atrial shunt Ventriculo-pleural shunt Lumbo-peritoneal shunt

What is Gamma Knife Radiosurgery? This technique was developed in the 1960’s and allows for the focusing of high and therapeutic doses of radiation with great accuracy thereby limiting damage to surrounding structures. The effect of ionizing radiation to control pain from trigeminal neuralgia was first noted in the early 20th century but due to limitations in technique could not be administered without causing injury to normal tissues. This initial experience, likely, informed the developer of the Gamma Knife, Dr. Lars Leksell in his consideration for using this device for facial pain. Together with the advances in MR imaging to...

Some circumstances require that a biopsy of a tumor is recommended rather than performing significant removal or debulking. Stereotactic biopsy is recommended in this case and is performed using a computer system as noted in the paragraph above to guide placement of a 2.5 mm blunt tipped biopsy needle. The aperture created in the skull is either called a bur hole or twist drill hole depending on its dimension but is usually no greater than the diameter of a dime or nickel. Biopsy is typically indicated for patients in whom the tumor is located in a functional or eloquent portion...

This modality is used to assess the integrity of nerves by measuring the excitability and activity of their target muscles during surgery. The resection of tumors intimately attached to nerves is facilitated by monitoring activity of muscle fibers during dissection. The surgical team is able to detect excessive electrical activity and muscle activation in circumstances when nerve fiber manipulation is nearing tolerance. Furthermore, the nerve and surrounding tumor tissue may be activated with an electrical stimulus to differentiate between the functional substance of the nervous system and non-functional tumor tissue. This technique of stimulation is commonly used as an adjunct...

Limitations of MR and CT guided navigation are based on the fact that imaging is obtained prior to surgery and does not reflect subtle real time changes in the position of the brain occurring during surgery. This intra-operative distortion of the brain is termed ‘brain shift’ and varies according to the location of the tumor and other factors. Intraoperative ultrasound offers a solution to this problem by providing immediate updated information on the position and location of residual tumor (Figure 1). Ultrasound, however, is not without its limitations in that the quality of the images obtained can be obscured by...

This procedure involves the implantation of a small catheter into the spinal canal of the lower thoracic and upper lumbar spine. This allows for the regulated administration of medication directly into the thecal sac-the fluid filled sac that bathes and encloses the brain, spinal cord and nerves. Typically, when infusion of baclofen is considered, the patient undergoes a spinal tap to administer a small test dose thereby gauging the potential benefit of the medication. If a beneficial response is observed, the catheter is implanted. The rate of infusion is regulated by a pump that is implanted in the subcutaneous fat...

This non-radiation based diagnostic study was developed in the 1970’s and was widely distributed in the 1990’s and offers a precise view of brain and spinal anatomy. MR is an indispensable study to all neurosurgical disciplines including spinal surgery, neuro-oncology and neurovascular. Patient’s at times develop a level of anxiety during the study. This sense of confinement may be treated with medications to relieve anxiety; newer magnets furthermore offer more space for patient comfort without sacrificing image quality. Functional MR imaging (fMRI) This MR modality allows anatomical localization of centers of language and motor function and is useful as an...

What is Microvascular Decompression? Microvascular decompression is a surgical procedure that was developed based on a hypothesis that pain or other aberrant nerve function was the result of repetitive trauma incurred by the pulsations of a normal contiguous cerebral vessel. The microvascular decompression procedure involves the physical separation of the nerve from the offending vessel and is achieved through a craniotomy/craniectomy allowing for direct visualization of the artery/nerve interface. Microvascular decompression surgery, developed in the 1970’s, has been enormously efficacious in alleviating the symptoms of trigeminal neuralgia, hemi-facial spasm and glossopharyngeal neuralgia. Overall, when compared to other procedures used to...

This novel technique has recently been shown to be effective in the management of selected brain tumors and as a method for the management of intractable epilepsy. The procedure involves the placement of a 1.65 mm diameter laser catheter through a small opening in the skull (bur hole). The laser catheter is then placed in a precise location in within the brain (target) utilizing frameless stereotactic techniques or with live intra-operative MR localization. Activation of the laser causes intra-tumoral temperatures to rise resulting an in a time-dependent thermal injury to tumor or epileptogenic tissue. The treatment is delivered in an...

Select patients with Parkinson’s are at times unable to participate in traditional DBS. The necessity of stopping Parkinson’s medication preoperatively is often greatly debilitating and the anxiety associated with participation in surgery is prohibitive of a meaningful patient-surgeon interaction. MRI guided DBS is a surgical procedure that allows for placement of stimulating electrodes while the patient is fully anesthetized. The ClearPoint surgical navigation system is used in conjunction with live MRI guidance at the time of surgery. This method assures accurate lead placement and obviates the need for microelectrode recording or real-time patient feedback. The movement disorder program at New...

This procedure involves an incision in the spinal cord and is often necessary when removing spinal cord tumors. Alternatively, myelotomy may be a procedure unto itself when considering treatment of lower extremity or pelvic pain secondary to cancer. Although this surgery has largely been superseded by morphine pump implantation, it remains a useful consideration in some patients. A myelotomy is performed through a thoracic laminectomy. A precise incision is made with the intent of interrupting the specific fiber tracts that mediate pain.

When considering neck surgery there are a number of questions you may have: Do I Need Neck Surgery? What is the Difference Between a Discectomy and a Spinal Fusion Surgery? What Should I Look for in a Spine Surgeon for Neck Surgery? How Long Does It Take to Recover from Neck Surgery? Is Physical Therapy Required After Neck Surgery? What are Some Things I can Do Before Neck Surgery for a Faster Recovery? What Should I Do if I Think I Might Need Neck or Spine Surgery? I Have Been Told I Need Surgery on My Spine. Should I Get...

This technology has been present for over 15 years and links patient anatomy in the operating room to an imaging study obtained expressly for surgical planning immediately prior to operation. This device occasionally requires the placement of ‘fiducials‘ (Figure 1) or markers that are affixed to the patient with a gentle adhesive prior to obtaining the planning MR; these markers are identifiable on a computer monitor in surgery and allow for correlation of the patient’s head to its representation on imaging. Alternatively, the unique facial contours of a patient are defined by ‘tracing’ the face with a laser or probe...

In contradistinction to intra-operative mapping, neurophysiological monitoring does not serve to identify the location of critical regions but rather provides real-time information about the integrity of the connections of motor, sensory and auditory systems. As with mapping techniques, monitoring works by initiating an electrical impulse the response of which is interpreted and measured by a trained neurophysiologist. Stimuli and responses are delivered and measured by electrodes placed in the immediate pre-operative period after induction of anesthesia. Motor evoked potentials (MEP) require a stimulus delivered by needle electrodes placed in the scalp or with an electrode strip placed directly on the...

What is a Percutaneous Trigeminal Rhizotomy? These operations involve the radiographically guided placement of a needle through the skin of the cheek to the foramen ovale – the canal transmitting the trigeminal nerve and the location of the gasserian ganglion at the base of the skull (Figure 1). The technique was advanced in the early twentieth century and serves as a conduit allowing for targeted, partial injury of the nerve thereby deadening the transmission of pain. This conduit allows for either a chemical (glycerol rhizotomy), mechanical (balloon rhizotomy) or thermal (radiofrequency rhizotomy) injury depending on the preference of the operating...

Physical therapy at New Jersey Brain and Spine Our in-house physical therapist has particular expertise in spinal conditions such as herniated discs, pinched nerves and spinal stenosis as well as treating shoulder, hip and knee conditions and Parkinson’s Disease. We stress an exercise approach with the patient being an active participant in there rehabilitation program.

Skull-base tumors are by definition located underneath the brain in difficult-to-reach areas and are intimately associated with vital and delicate neurovascular structures. Surgical resection is often necessary to alleviate mass effect and brain swelling associated with larger tumors. Radiosurgery, however, is a viable and comparatively safe alternative that has been shown to arrest tumor growth and in a minority of cases to induce tumor contraction. Meningioma and vestibular schwannoma are but some of the tumors that benefit from this modality with literature demonstrating lasting control over years of follow up. Although the procedural risk associated with radiosurgery is exceedingly low,...

This procedure is offered to select patients with spasticity resulting primarily from cerebral palsy who may not be ideal candidates for other types of surgical intervention. The surgery is performed through a lumbar laminectomy which allows for exposure of the collection of nerve roots (cauda equina) emanating from the tip of the spinal cord (conus medullaris). These motor and sensory nerve roots innervate the lower extremities as well as allowing for continence of bowel and bladder. Neurophysiological monitoring and intra-operative EMG differentiate sensory from motor nerve roots. The surgeon then selectively cuts a proportion of the sensory nerve roots thereby...

Although the majority of tumors of the skull-base are not cancerous but rather slowly growing, they have the capacity to cause harm due to their proximity to critical structures underneath the brain. These tumors commonly present with symptoms of visual or hearing loss or difficulty with coordination and are in close proximity to the brainstem and nerves that sub serve vital functions such as vision, hearing and swallowing. Although a proportion of patients may be managed expectantly or with radiosurgery, surgical management is often necessary and requires careful consideration and planning. On occasion, treatment may require adjunctive radiation therapy or...

Radiosurgical principles may also be used for the treatment of selected spinal tumors as an adjunct to spinal surgery. This technology allows for the administration of a therapeutic dose of radiation to the tumor with minimal exposure of the nearby spinal cord.

The cingulum is a region of the brain associated with the “limbic” system; this circuitry regulates the perception of emotion and its relationship with pain. Stereotactic cingulotomies have been performed for treatment of refractory depression and for severe pain that is unresponsive to other modes of treatment.

Pallidotomy is an ablative procedure that involves the creation of a small lesion in the globus pallidus or pallidum, a sub-region in the chain of nuclei called the basal ganglia necessary for the control of movement. Historically, pallidotomy offered relief to Parkinson’s patients but had been associated with physical and cognitive side effects. The use of pallidotomy has largely been replaced by DBS although may be recommended in selected cases where DBS is contraindicated.

What is a Stereotactic Thalamotomy? A stereotactic thalamotomy procedure may be used to treat patients with essential tremor or Parkinsonism with tremor as the primary debilitating symptom. During a stereotactic thalamotomy procedure, precise lesions may be created with either a radiofrequency generator which causes a thermal injury and more recently Gamma Knife radiosurgery. Generally, the target is a region (nucleus) in the center of the brain called the thalamus. Successful targeting usually results in cessation or improvement of the tremor.

This non-invasive bedside test measures the velocity of blood flow from cerebral vessels at risk for the development of vasospasm. An increase in blood flow velocity when compared to baseline measurements offers a reliable indication of vasospasm; this test may be considered an early warning system allowing the neurovascular team to act more aggressively before irreversible symptoms develop. Learn more about transcranial doppler (TCD) tests here.

Endoscopic endonasal skull-base surgery is performed routinely allowing for maximal resection of selected tumors of the pituitary gland and surrounding structures. The transsphenoidal surgery takes advantage of the space afforded by the nose and paranasal sinuses allowing for expansive exposures while working entirely within the confines of the nose and nasal cavity, see videos below. The surgical team involves dedicated neurosurgeons and otolaryngologists who work closely before, during and after the transsphenoidal surgery to assure excellent outcomes. Pituitary adenoma-endoscopic transsphenoidal surgery resection Craniopharyngioma–endoscopic endonasal transsphenoidal transtubecular resection

We perform trigger point injections which are soft tissue injections usually of a local anesthetic and a small amount of cortisone. Trigger points are areas of painful soft tissue and muscle, usually at the base of the neck, shoulder blade, or low back.

Our office has musculoskeletal ultrasound, allowing us to help diagnose soft tissue, ligament, tendon and nerve conditions. Our ultrasound units also permit us to perform ultrasound guided injections as needed for increased accuracy of musculoskeletal injections.

For knee arthritis not requiring surgery we provide viscosupplementation injection of hyaluronic acid, a natural substance. These injections commonly referred to as “gel” injections can temporarily decrease pain, have an anti-inflammatory effect and potentially protect the cartilage from further deterioration.

The hippocampus is a region of the temporal lobe that forms the anatomical center of memory. Although language centers consistently localize to the left side of the brain (in the right handed), localization memory is more variable. Often, when temporal lobe surgery is contemplated for epilepsy or brain tumors, the surgeon requests a Wada test to help establish the laterality and localization of language and short-term memory. This test may serve as an adjunct to fMRI, another diagnostic test that clarifies the relationship between function and anatomy Wada testing involves angiographic access to both the left and right carotid artery-vessels...

Our office has a state of the art digital x-ray suite allowing us to perform in office x-rays with images immediately available to the physician and patient to review.