Health & Fitness

Brain and Spine Treatment Options are Expanding

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Aneurysms, tumors, memory loss and spine disorders are among the complex health problems treated by neurology professionals in the greater Rockford region. Fortunately, recent advancements in this field are providing them with an ever-widening array of treatment methods.

Dr. Bratislav Velimirovic, Rockford Health System, Rockford, uses a relatively new, minimally-invasive technique to prevent aneurysms from bursting.

Inlike the body’s other major systems, which tend to be connective and more self-contained, the central nervous system impacts every function and cell. And even though the brain and spinal column are encased in protective skeletal armor, they are vulnerable to trauma and disease.

Brain aneurysms are among the most dreaded of neurological events. Excruciating pain, described by patients as the worst headache they have ever experienced, may be the only symptom. For many, blood vessels rupture without warning, causing instantaneous death. About 30 percent of patients with ruptured intracranial aneurysms don’t even make it to a hospital. Of those who do, only half experience a meaningful recovery.

But for the lucky ones whose bulging aneurysms are detected in time, a bold and relatively new technique is being used to save lives and enhance quality of life. Cerebral embolization with coiling is a minimally-invasive procedure that prevents aneurysms from rupturing, which means reduced pain and blood loss, and a faster recovery.

“The technology has a modest history,” says Dr. Bratislav Velimirovic, PhD., a neurosurgeon at Rockford Health System’s Brain and Spine Center, 2350 N. Rockton Ave. “European neurosurgeons began using it about 40 years ago. The procedure was introduced in the United States roughly 20 years ago, but has only enjoyed wide recognition for the past 10 years. It took a lot of followers.”

Brain aneurysms were once routinely treated with surgery, but today cerebral embolization with coiling is chosen in about 70 percent of cases.Velimirovic explains how it works. A micro catheter is threaded through the femoral artery in the patient’s leg, all the way into the aneurysm, with the help of x-ray guidance. Once there, thin platinum wires housed in the catheter are pushed into the aneurysm, where they coil into a mesh ball. Blood then clots naturally around the coils and reduces the chance of the aneurysm bursting. The coil remains in place. Clotting agents are not used, because they increase the risk of strokes.

“During the procedure, the risk of rupture remains,” Velimirovic says. “We avoid touching the wall of the aneurysm, which is fragile at this point. This is a very elegant procedure that demands precision and expertise, because even the slightest trauma to the wall can cause rupturing.” As the only neurosurgeon in the region providing this highly technical procedure, Velimirovic knows it’s not appropriate for every patient. Some are not good candidates because of pre-existing conditions. The decision to go ahead with the treatment also depends upon the size and shape of the aneurysm, as well as its location within the brain.

“Once the cerebral embolization with coiling procedure is completed, we follow up with patients every six months to a year,” Velimirovic says. “Sometimes, the aneurysm can continue to grow, or the coils can weaken. The major downside to this procedure is that we may need to re-treat the patient. Still, this technology is now more commonly used than traditional craniotomies.” (A craniotomy is any surgical incision into the skull.)

This same technology also can be used to treat patients with first-time strokes.

“Within a reasonable window of time, we can use the same minimally-invasive access procedure to find and remove brain clots and open blood vessels,” Velimirovic explains.

While there is no correlative age bracket for brain aneurysms, Velimirovic says that patients who smoke or have high blood pressure appear to be at greater risk.

Dr. Christopher Sturm, Mercy Health System, Janesville, uses highly technical scans to map a patient’s brain before any operation.

Brain tumors are another cause for deep concern. Dr. Christopher Sturm, a neurosurgeon with Mercy Health System’s Regional Neurological Center, 1000 Mineral Point Ave., Janesville, Wis., says there are many kinds of brain tumors that produce many different symptoms – or none at all.

“Patients are often referred to me after being seen in the emergency department or by their primary care provider,” Sturm says. “Signs and symptoms of brain tumors can vary widely, depending on a multitude of factors, including location, size and type of tumor. Some will irritate the brain more than others, while some grow slowly and quietly, creating few or no symptoms.”

A brain tumor may be indicated by headaches that build to a crescendo; nausea; vomiting; vision changes; and weakness or loss of sensation on one side of the body. Seizures in patients who have not previously experienced them may reveal a brain tumor. Patients may present with changes in pituitary function or hormonal levels, or experience unexplainable lactation or growth in the feet and other extremities.

“Often in this clinical setting, an MRI of the brain, sometimes with contrast dye, is ordered for the patient,” Sturm says. “Contrast enhancement allows better visualization of the abnormal tissue. These results, along with knowing what the patient is physically experiencing, helps us to determine if the tumor is coming primarily from the brain tissue or if it may stem from other places in the body [metastases]. Family history is also important. We need to know if other family members have had similar symptoms or a diagnosis of brain tumor. A thorough assessment of the patient’s health status is conducted.”

Sturm explains that the appropriate procedure depends upon the location and appearance of the tumor. Not all tumors require surgical treatment. Surgeons may choose to observe a tumor over time.

“If the situation suggests that surgery is the appropriate next step, further imaging may be requested to map specific blood supply routes in the brain,” he explains. “The vessels supplying the tumor may need to be interrupted, which will help prevent bleeding during surgery. Bleeding into the brain can be very serious.”

Adhesive sensors are attached to the patient’s scalp and a frameless STEALTH imaging system through MRI or CT is used to create a melded, three-dimensional picture of the tumor.

“This allows us to know exactly where the tumor is, what shape and size it is, even at millimeters, before we make an incision,” Sturm says. “The result is that we can devise a pathway to remove as much of the tumor as possible, while avoiding collateral damage to important areas of the brain, such as speech and vision. Also, tumors can be oddly shaped, or even look like normal brain matter. We must navigate in a minimally-invasive manner. This three-dimensional imaging aids us in achieving our mission with significantly reduced risk to the patient.”

The surgery itself is fairly straightforward. After the skull is exposed, the surgeons remove part of the skull by drilling small holes and then connect them with more cuts. This exposes the brain covering, which is then incised to access the brain.

“Some tumors are close to the surface of the brain, while others can be deep within,” Sturm notes. “We work meticulously to avoid any trauma or unnecessary bleeding. Once the tumor is excised, we close each layer and secure the skull fragment with titanium brackets.”

Recovery time varies, but in general, patients can plan on spending one to two days in intensive care with postoperative MRI imaging. Typically, the patient is next transferred to the neurological floor for further rehabilitation and care, with the hospital stay averaging four to five days. The rehabilitation program, which may or may not be necessary, depends on the patient’s condition prior to surgery.

Lynette Gisel, Illinois Neurological Institute at OSF Saint Anthony, Rockford, works with patients to identify the causes of their memory loss.

While aneurysms and tumors are dramatic and traumatic brain problems, others are less obvious but just as insidious. Memory loss resulting from Alzheimer’s and Parkinson’s diseases and other conditions can have just as devastating an effect on patients’ lives. Lynette Gisel, a geriatric nurse practitioner in the Illinois Neurological Institute at OSF Saint Anthony Medical Center, 5666 E. State St., Rockford, explains that, contrary to popular belief, memory loss is not a normal part of aging.

“We see patients in different age groups,” says Gisel. “Younger patients with memory loss have most likely suffered it because of head injuries. Older patients may have developed Alzheimer’s Disease or are experiencing vascular dementia. I want to emphasize that memory loss is not a normal part of getting older. People assume it is, but in truth, older people are simply at higher risk for developing diseases that can cause it.”

Autopsies have taught physicians about another particularly harmful side effect of brain disease. Lewy bodies (abnormal clumps of protein) found in brain tissue can cause behavioral problems such as hallucinations and delusions that Gisel describes as “tricky to manage.” Lewy body dementia is a sad diagnosis, because families have such a struggle dealing with its effects.

“We’re not certain what causes Alzheimer’s,” Gisel says. “And we really can’t cure it. The best we can do is slow it down, giving patients six months to a year more of a better quality of life.”

Strokes can also cause memory loss, depending on what type of stroke and which parts of the brain it affected.

“Memory-loss patients are referred to the institute by primary physicians,” Gisel says. “We work in tandem with their doctors to do a total health history, over the past several months and even years, to pin down what is going on with the patient. We conduct memory tests and order CT scans and MRIs of the brain to search for tumors, evidence of a stroke or hydrocephalus [water on the brain]. We do blood workups for vitamin B-12 and folate levels, thyroid levels, kidney and liver function and electrolytes.”

Gisel describes the search for the cause as a “rule out, rule in” process. Once the cause is determined, medications are prescribed to counteract the problem. One class of drugs increases the level of chemical acetylcholine (a neurotransmitter). Another class reduces glutamate levels and improves cognition.

Clinical tests now underway indicate that b-secretase inhibitors may stop the formation of amyloid plaques in the brain and also may actually halt the progression of memory-related diseases such as Alzheimer’s.

Statins, normally prescribed for cholesterol control, also appear to have some beneficial influence for vascular-related problems.

“Unfortunately, we can diagnose for memory loss, but we can’t offer a good prognosis,” Gisel says. “We manage the patient on the ABCs of the problem – activities of daily living, behavior and cognition. Right now, the verdict is out on how long we can help them maintain a reasonably good quality of lifestyle. Staying active physically, along with mental stimulation such as word puzzles, helps.”

Learning to play a musical instrument or speak a foreign language also can help patients to stimulate their brains.

“I have a patient who has started piano lessons,” Gisel says. “Other factors including weight control, healthy eating, exercise and monitoring other health conditions, such as diabetes, hypertension and cholesterol.”

The second major component of the body’s central nervous system, the spine, sometimes presents its own mysterious challenges to specialists. A fellowship-trained spinal surgeon, Dr. Fred Sweet is one of three spine surgeons practicing at Rockford Spine Center, 2902 McFarland Road, Ste. 300. Patients come to him with such painful, complex conditions as curvature of the spine, herniated discs and stenosis, the narrowing of a vessel within the spinal column. Sometimes come to his office after a previous surgery has failed.

Fortunately, for 90 percent of patients, surgery isn’t required. Sweet may prescribe pain management, exercise, physical therapy, orthopedic options or other techniques to relieve pain.

“Chiropractic can be a good place to start for patients with back and neck pain,” says Sweet. “We have a number of excellent doctors of chiropractic in the Rockford area.”

But sometimes, surgery is necessary. Sweet’s surgical patients range from children with scoliosis to seniors in their nineties.

“For patients who do need surgery, things have come a long way,” Sweet explains. “Minimally-invasive techniques, along with sophisticated spinal implant systems, have rapidly changed the way in which spinal problems are treated.”

Twenty years ago, spinal surgery patients typically remained in the hospital for a week to 10 days. Now the hospital stay is more likely to be two to three days. Simple procedures are done on an outpatient basis in Rockford Spine Center’s surgical suite. They might take 20 to 30 minutes, after which patients often return to work in a week or two.

“Even severe traumatic injuries to the spine are stabilized with the newer techniques,” says Sweet. “In the past, spinal injuries were treated with prolonged bed rest, casts and braces. Now we can treat spinal fractures with an internal frame of screws and rods, and then get the patient up the next day with less pain and fewer risks. Recovery times are notably quicker.”

An up-and-coming technology which may soon play an important role in spinal surgeries is an adaptation of da Vinci robotics.
“Da Vinci is a juggernaut for abdominal and pelvic surgeries because it preserves the most delicate nerves,” Sweet says. “About five to 10 years down the road, we may be able to adapt this technology for spinal surgeries.”

Dr. Fred Sweet, Rockford Spine Center, offers a variety of spinal procedures, both simple and complex.

Asked about stem cell treatment to repair spinal cord injuries, Sweet says this research has a long way to go.

“Injecting stem cells into damaged spinal cords is like pouring super glue onto broken glass,” he says. “At this point, it’s far from a miracle cure. So far, the FDA has approved it only for a few specific extreme cases, only a handful a year.” Because it’s used on such a limited basis, on the most severe cases with the least chance of success, it’s difficult to measure its usefulness.

“I look to see stem cell technology develop in maybe the next 10 to 20 years,” Sweet says. “There are always emerging technologies in medicine. Patients frequently ask about the latest development or procedure, as they want the latest, and hopefully greatest, solution to their particular problems.”

Many new treatments are still in the development stage.

“After a period of time, we sometimes discover that a new procedure doesn’t produce good long-term results or may even harm patients,” Sweet says. “Disc replacements were thought to be a great idea, but in practice help only a limited number of people. Frequently, insurance companies will not pay for the emerging or unproven technologies.”

Sweet recommends that patients ask their surgeons a few important questions before agreeing to a surgical procedure.

“You want to know if your surgeon has the best training, which is a Spinal Surgery Fellowship. While most surgeons are board-certified in their areas of surgery, many do not have fellowship training in spinal surgery,” Sweet explains. “Patients should ask their surgeons what the risks of surgery are, how long the recovery time will be, and what the documented long-term [more than two years] outcomes are.”

In particular, patients should ask how many of this same procedure their surgeon performs every year. The answer should definitely be more than 25; more than 100 is very reassuring, says Sweet. “Surgeons should also be able to get the prospective surgical candidate in contact with other patients who have had the same procedure, which can really reassure patients about their surgeon and the procedure.”

Finally, doing a name search on the Internet may inform patients about a surgeon’s credentials and alert them to potential issues.
While disease and injury to the brain and spine are among the most serious of health conditions, local professionals are continually increasing their understanding of them, and are utilizing an ever-widening array of treatment options. ❚

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