CONDITIONS OF THE BRAIN
Tumours of the brain that arise from the lining membrane of the skull and skull base called the dura. They can also occur in the spine. These tumours are usually benign and slow growing. They can also arise from the membrane between the two halves of the brain which is a fold of the dura called the falx or from the tentorium which separates the hemispheres from the cerebellum and brain stem. Rarely meningiomas can also be found within the ventricles.
Many meningiomas are often found by accident when having a CT or MRI scan of the head. Small incidental meningiomas not causing any symptoms may be monitored with repeat CT or MRI scans and treated if there is a change in symptoms or size of the tumour.
Larger meningiomas may present with symptoms such as headache, nausea or vomiting or more often may present with seizures. It is also possible, depending on the location of the tumour to present with other focal neurological deficits or cognitive dysfunction.
A meningioma can been seen on CT scans preferably with contrast or better visualised on an MRI scan with contrast.
The majority of these tumours are benign and it is rare for them to be malignant.
Treatment of meningiomas is best achieved by surgical resection including the dural base and attachments where possible. Usually a craniotomy is performed for this. Complete surgical resection is usually curative although patients have ongoing monitoring with imaging for recurrence. If the tumour is malignant then radiotherapy may also be necessary. Radiotherapy or radiosurgery can also be used for inoperable tumours which have been as deemed necessary.
Gliomas are the most common type of primary brain tumour. They can occur anywhere in the cerebellar hemispheres or, rarely, in the cerebellum or spinal cord or brain stem. There are tumours that arise from the glial or supporting cells for the neurons. There are a variety of types, depending on the cell type. The most common type of these tumours is called a glioblastoma multiforme (GBM). This is a rapidly growing tumour that infiltrates the brain. It is the most common type of primary brain tumour. These tumours are malignant. They are graded as a grade 4 glioma.
The grading of a glioma reflects how aggressive it is. Grade 1 tumours are usually seen in childhood and are benign (pilocytic astrocytoma). Grade 2, or low-grade, gliomas can be seen in younger people. These tumours may progress to more aggressive forms. Grade 3 is an anaplastic or glioma. Grade 4 is a malignant glioma. Both grade 3 and grade 4 tumours are considered malignant and warrant other adjuvant therapy.
These tumours may present with a neurological deficit or, sometimes, present with symptoms such as seizures. Other symptoms include headache, nausea, vomiting, or change in personality or neurological function.
These tumours can be imaged with CT and MRI with contrast.
Treatment options include surgery to debulk the tumour, adjuvant radiotherapy and chemotherapy (temozolomide). There can be a number of factors influencing the best treatment options, and these can be discussed with your surgeon and oncologist.
Metastatic tumours to the brain or secondary tumours are one of the most common forms of brain cancer. Any malignant tumour may metastasise to the brain, however, the most common types are from melanoma, lung, breast, bowel and kidney cancer. These tumours may be discovered incidentally in people having staging workup for known metastatic disease.
Most common symptoms for cerebral metastasis, such as headaches, nausea, vomiting, seizures or other neurological symptoms.
Metastasis to the brain can be identified by CT scan, MRI scan or PET. There may be a single metastasis to the brain or even multiple metastases.
There are multiple treatment options for cerebral metastasis including no treatment, surgery, radiotherapy, stereotactic radiosurgery (focused radiotherapy), chemotherapy and immunotherapy. Often many of these treatment options are combined. There are many factors in considering which is the best treatment option and these need to be discussed with your surgeon or oncologist.
Pituitary tumour is an abnormal cellular growth in the pituitary gland located in the brain. Pituitary gland releases hormones that act directly on the body tissues and also regulates the production of hormones from other glands such as thyroid and adrenal gland. Thus pituitary tumours lead to overproduction of one or more hormones causing conditions such as hyperthyroidism, gigantism, Cushing’s syndrome and abnormal discharge from the nipples of the breasts. As they grow they may put pressure on the optic nerve affecting vision. Their diagnosis is thus made on the basis of endocrine function test for cortisol, follicle stimulating hormone, insulin growth factor-1, luteinizing hormone, serum prolactin, testosterone and thyroid hormone levels. The diagnosis is further confirmed by MRI of the head.
Most of these tumours are non-cancerous and do not spread to other areas of the body. The treatment involves radiation, medications and surgery as monotherapy or combination therapy. The surgery is essential when the tumour is pressing the optic nerve and may cause blindness. Most of these tumours are removed through nose and sinus without external incision using endoscopic transnasal transsphenoidal approach. However in case the tumour is big it is removed through the incision in the skull (transcranial approach).
Details to come.
Details to come.
Details to come.
CONDITIONS OF THE SPINE
Cervical Disc Herniation
Injury to the disc in the neck is not uncommon and can occur with relatively minor trauma or major trauma. If the disc herniation compresses the exiting cervical nerve root then a cervical radiculopathy can occur. If the cervical disc herniation compresses the spinal cord then a cervical myelopathy may occur. Over time and with age bony spurs called cervical osteophytes may also form where the nerves exit the spine and the foramen leading to nerve compression and symptoms also are also cervical radiculopathy.
Cervical radiculopathy is similar to sciatica in the leg. The nerve compression can lead to pain, numbness and weakness in the arm or hand. Depending on which nerve is affected, there can be a variety of symptoms in the arm. Certain nerve supply, certain muscles as well as the feeling to the arm and hand. A careful neurological examination is needed to work out which nerve roots are compressed. Unfortunately, as we all age, degeneration will occur in the spine and these degenerative changes may lead to nerve compression which is not necessarily symptomatic. Neck pain is not usually due to nerve root compression. It is usually due to damage to the disc or other structures in the neck.
Investigations used to help identify the cause of the problems in the neck include CT cervical spine, MRI cervical spine, plain x-rays and cervical bone scan and SPECT. Each of these imaging modalities give different information as to the cause of the symptoms and helpful on deciding on which treatment options are best suited to you.
The majority of people with cervical radiculopathy will get better with time and often do not need any treatment apart from analgesia. Physiotherapy may be helpful. Chiropractor treatment should be avoided as this may make the cervical disc herniation worse. If your symptoms are not settling with conservative treatment then there are a number of other options to help you. A cervical nerve root block or CT guided foraminal steroid injection can be useful to inject the compressed area with cortisone. This can have an anti-inflammatory affect and lead to improvement in pain. It is often not particularly successful for improving weakness or numbness. For symptoms failing to settle with these treatments, then surgery may be considered. The approaches for surgery are either from an anterior (front of neck) or posterior (back of neck) approach. Anterior cervical approaches require either a fusion procedure or disc replacement. Posterior cervical procedures may simply require a decompression, although fusion is often performed as well. The surgeon will discuss with you what they think is the best approach for your particular nerve compression.
Treatment is usually quite successful and if surgery is required it is relatively straight forward. The majority people having a cervical disc herniation causing radiculopathy, over time these symptoms usually improve.
Thoracic Disc Herniation
Investigations that are useful in assessing thoracic disc herniations are plain x-rays, CT scan or MRI scan. In some instances one or more of these are required to confirm your diagnosis.
Lumbar Disc Herniation
Lumbar disc herniations are common and can be associated with a lifting and twisting type of injury although sometimes can occur with minimal trauma. Anyone can be affected by a lumbar disc injury, but they are probably more common in the 40 to 60-year-old age group. Many lumbar disc herniations are asymptomatic and do not cause any problems whatsoever. If there is significant compression of one of the spinal nerves, then this can lead to symptoms such as sciatica (leg pain), numbness and weakness down the leg.
Depending on which nerve is being compressed depends on where you experience your symptoms. Lumbar disc herniation can also cause back pain, but this is often associated with damage to the disc. The most important thing to remember is that removal of a herniated disc does not necessarily improve back pain and can occasionally worsen lumbar back pain.
Lumbar disc herniation can be diagnosed on CT, although MRI scan gives better visualisation.
The majority of people with a lumbar disc herniation do not require surgery. Most times the sciatica can settle within three to four months. If the symptoms are failing to settle or you are experiencing significant sciatica, then early treatment options are a nerve root block or epidural steroid injection. These are varieties of cortisone injection aimed to produce an anti-inflammatory effect around the herniated disc and nerve root. Even large lumbar disc herniations can resolve over time, and it is often difficult to predict who is going to get better and who will not.
If you have persisting sciatica symptoms, then you could be considered for a microdiscectomy. Urgent surgery is indicated if you have cauda equina syndrome. In this condition, you experience perianal numbness and loss of control of your bowel or bladder function. It is associated with large disc herniations compressing the nerve roots that control the bowel and bladder function. Urgent surgical decompression is indicated. It is important that you discuss with your surgeon if you are experiencing any difficulty with your bowel or bladder function.
Surgery for lumbar disc herniation is quite successful.
Sciatica refers to pain that radiates down the leg. It is due to compression of a nerve root. There are a number of nerve roots in the lower back (lumbar spine) that form to make the sciatic nerve which starts in your buttock. Nerve branches travel down your leg to move the various muscles and supply sensation.
Compression of the nerve root causes referred pain down the leg, commonly referred to as sciatica. Depending on which nerves are involved depends on whether the pain may go down the back, front or side of your leg depends on which nerves are involved. You may have associated weakness of muscles as well as numbness or pins and needles.
Most patients with sciatica will settle down over time. If your symptoms are failing to settle, then you could be considered for a nerve root block or surgery.
Spondylolisthesis is a condition commonly seen in the lumbar spine. This is where the higher vertebra slips forward compared to the lower vertebra and the spine is out of alignment (in a sagittal plane). There are a number of causes of spondylolisthesis. In a younger age group, the spondylolisthesis is a result of a stress fracture usually from a hyperextension injury. This damages part of the vertebra called the pars and means that the ring is incomplete. This allows the vertebra to shift forward. This is most commonly seen at the L5/S1 level. This usually results in compression of the exiting nerves in the foramen rather than compression in the spinal canal. It can typically lead to sciatica. Sometimes the acute pars injury can be associated with significant back pain.
Spondylolisthesis may also be the result of degeneration. The facet joints can become degenerate over time and lead to slippage forward of one vertebra compared to the other one. This commonly occurs at L4/5 or L5/S1 and is more associated with central canal stenosis. You can present with sciatica or other symptoms such as paraesthesia or symptoms worse when you walk (spinal claudication).
The degree of slippage forward of one vertebra over the other can be graded into four levels (<25%, 25-50%, 50-75% or >75%. The degree of nerve compression can be exaggerated if there is a degree of instability on movement, i.e. one vertebra slips forward on flexion or extension).
Investigations that are useful in assessing this are plain x-rays, CT scan or MRI scan.
Most people with a spondylolisthesis require no treatment whatsoever. If sciatica is an ongoing issue, then consideration can be given to a nerve root block. If back pain is an issue then this may be treated with facet block or block into the pars defect. For patients not improving with conservative management and with significant sciatica-type symptoms, then consideration can be given to surgery. The issue to consider is whether the spine needs to be stabilised with pedicle screw fixation. This surgery often involves removing the disc and fusing the spine with pedicle screw fixation. This fusion-type of procedure can be done from a posterior approach, although it is also possible from an anterior approach. The pros and cons of the best approach can be discussed with you.
Spinal stenosis is most commonly seen in the older population due to facet joints of the vertebra becoming enlarged, thickening of the facet joint tissue due to inflammation, bone spurs or osteophytes forming on the vertebra, reduction in space between vertebra resulting in smaller space for spinal nerves to pass through, calcification of ligaments of the spine, herniated discs or slipping of one vertebra over another. Along with aged related degeneration, it can sometimes occur after trauma to the lumbar spine.
Sometimes other conditions such as a spinal tumour, scoliosis or rheumatoid arthritis of the spine can also cause spinal stenosis.
The most common symptom of spinal stenosis is claudication. This is cramping discomfort and/or weakness in either both or one calf, thigh and buttock. Prolonged walking or standing often aggravate it and rest usually will relieve your symptoms. If the spinal nerves are compressed, sciatica is the most common symptom. Persistent discomfort or pain in both or one leg, dull to severe aching in the lower back or buttock and numbness and tingling in both or one leg are all common symptoms.
Investigations that are useful in assessing this are plain x-rays, CT scan or MRI scan. In some instances one or more of these are required to confirm your diagnosis.
A majority of people with spinal stenosis will have symptoms however they will subside over time, several weeks or months and do not require surgery. Medications such as various analgesia or non-steroidal anti-inflammatory drugs often will help reduce the pain. In other circumstances anticonvulsant medications such as Lyrica will be used to relieve the nerve pain you are experiencing.
If symptoms are failing to settle or you are experiencing more pain, then early treatment options are a nerve root block or epidural steroid injection. These are varieties of cortisone injections aimed to produce an anti-inflammatory effect around the herniated disc and nerve root.
If you are still struggling with leg pain, surgical options can be discussed. This can usually be a laminectomy procedure however in some instances if you are struggling with back pain as well a spinal fusion may be indicated. The pros and cons of the best approach can be discussed with you.
Cervical Myelopathy / Spinal Cord Compression
Spinal Cord compression is caused by cervical disc herniations or bone spur formation that lead to narrowing of the spinal canal and can compress the spinal cord. Continuous compression of the spinal cord can result in damage and a condition called cervical myelopathy.
Cervical myelopathy symptoms are abnormal sensation and clumsiness of the hands, difficulty walking, altered leg sensation and loss of bowel and bladder control. Paralysis may occur in extreme cases. Pain is usually minimal in spinal cord compression, however cord compression often is associated with nerve compression that can result in pain.
Investigations that are useful in assessing spinal cord compression are plain x-rays, CT scan or MRI scan. In some instances one or more of these are required to confirm your diagnosis.
Surgery is often recommended for patients with cervical myelopathy as symptoms can often get worse. Prevention of further damage to the spinal cord is the aim.
Cauda Equina Syndrome
Cauda equina syndrome is condition where the nerves that control the bowel and bladder function (sacral S2-S4) are severely compressed. This results in problems with the bowel and bladder working. This can lead to incontinence of either the bladder or bowel, or difficulty emptying the bladder with incomplete emptying. The condition is a surgical emergency and if you have problems with your bowel or bladder function then this should be discussed with your doctor or you should present to the nearest emergency department. Usually there are associated symptoms such as severe sciatica usually in both legs as well as significant back pain.
The common cause is a large central disc herniation causing severe compression. This can occur at any level in the lumbar spine but is most common at L4/5 and L5/S1.
Patient's having cauda equina syndrome will usually have loss of sensation around their anus or in the perineum. There is reduced or absent anal tone. There could be other signs and symptoms in the lower limbs.
Spinal cord compression can also affect bowel and bladder function. Sometimes there are other causes that effect your bowel or bladder function such as severe pain or medications. If you are having difficulty your bowel or bladder function, please discuss this with your doctor urgently.
Investigations that are critical in assessing if a you have cauda equina syndrome is an MRI scan, as well as a physical examination in some cases.
Urgent surgery is recommended for patients with cauda equina syndrome
Details to come.
Investigations that are useful in assessing spinal trauma are plain x-rays, CT scan or MRI scan. In some instances one or more of these are required to confirm your diagnosis.
Lumbar Back Pain
Lower back pain can either be acute usually as a result of an injury, or chronic. This pain may be associated with traumatic or degenerative injuries to the lower back.
Acute lower back pain usually results from a lifting or twisting injury. The lumbar disc or facet joints may be injured or there may be a musculoligamentous strain. Acute lower back pain is a common problem experienced by many of us. It usually settles down with rest and analgesia. Sometimes physical therapy, such as physiotherapy are useful interventions.
There are a number of rare but more serious conditions that can be associated with lower back pain. Spinal infections present with back pain and fever. Malignant or benign tumours of the spine are uncommon but can present with pain in the back at night that often wakes you. They may also be associated with other neurological symptoms if there is nerve compression.
The majority of people with lower back pain do not require surgical intervention.
The treatment of lower back pain can be difficult. This is because working out where the pain is originating from is not always easy. There are number of structures in the back that may cause back pain. Damage to the disc or facet joints or degenerative changes here can be associated with pain. Muscle weakness or damage can also cause problems. Damage to the bone such as osteoporotic fractures may be associated with back pain as well.
In trying to manage your back pain one of the key concerns is to work out where your pain is coming from.
It is important to remember that although back pain may be coming from damage to a disc, a disc bulge compressing a nerve does not usually cause back pain and is more associated with referred pain to the leg (i.e. sciatica). This also means that some of the common surgeries performed to treat sciatica such as a microdiscectomy or laminectomy do not treat lower back pain and in some cases may worsen your lower back pain.
Lower back can present as a wide variety of symptoms. Most people will have only mild symptoms, however others can become severe and debilitating. Pain that is dull or achy in the lower part of the back. Muscle spasms and tightness can also occur in the lower back, pelvis and hips. Burning pain can often occur. Standing, walking, or standing to sitting can also be affected or aggravate it, however it ranges in severity between people.
It ranges in duration, from a sudden onset that only last a few days or weeks. Sometimes a more subacute presentation can occur that can be 6 to 12 weeks. Chronic back pain will last over 3 months.
There are a number of usual investigations to assess back pain. These only need to be performed if your symptoms are not settling down. A CT scan is good for looking at the bony anatomy and may show some detail regarding the disc. MRI scan is useful for looking at discs and other soft tissues. A nuclear medicine study called a lumbar bone scan and SPECT can help localise facet or sacroiliac joint inflammation. This investigation may be useful in targeting treatments and focusing on treating the pain generators.
Plain x-rays can be also useful in assessing the alignment and instability of the spine.
Most people with lower back pain do not require invasive treatments. Usually, acute lower back pain will settle down with rest and simple analgesics or anti-inflammatories. Physiotherapy can help with muscular problems and help in reducing muscle spasm and improving mobility.
If symptoms are persisting there are more invasive treatments such as facet blocks. These are cortisone injections given under radiological guidance into the facet joints. These can improve pain. How well they work, and how long they last can be very variable. They can be repeated if they are successful. Facet rhizolysis is a different type of procedure where the tiny nerve that supplies the sensation to the facet joint is burnt or cauterised. This is usually performed as a secondary procedure once it has been identified if there is pain due to the facet joints. This can provide longer lasting relief of chronic lower back pain. It is not something that is usually used in the acute lower back pain situation.
There are also new restorative therapies to improve the muscle strength. Reactiv8 is a spinal stimulator, that stimulates the nerves that control Multifidus, one of the key muscles providing stability and strength to the lower spine. This involves implantation of small electrodes near the nerves that are connected to a battery. Regular use of the stimulator strengthens the Multifidus muscle and, in some studies, has been associated with significant improvement in back pain and quality of life.
Surgery such as microdiscectomy and laminectomy do not often relieve back pain. Occasionally they can make your back pain worse. Spinal fusion procedures can also be performed for back pain. These are usually performed in a highly selected individuals after less invasive procedures have failed to provide a permanent fix for the problem. These procedures are quite invasive and will require an extensive recovery and rehabilitation. The majority people do not need these treatments.
PERIPHERAL NERVE CONDITIONS
Carpal Tunnel Syndrome
The carpal tunnel is a passage in the hand that the median nerve and tendons pass through. Carpal tunnel syndrome occurs when the nerve and tendons swell or the ligament of the tunnel thickens to compress the median nerve. Carpal Tunnel Syndrome is most common in women. Repetitive activities involving the hand and wrist will often aggravate symptoms.
The most common symptoms of carpal tunnel syndrome are tingling and numbness of the thumb, index, middle and ring finger, pain running up the arm to the shoulder, trouble with gripping as well as decrease in hand motor skills.
Nerve Conduction Studies completed by a Neurologist will confirm diagnosis of Carpal Tunnel Syndrome.
Hand splints can be used to relieve patient symptoms, however if symptoms persist surgical decompression of the median nerve to release the pressure is required.
The ulnar nerve can become compressed as it passes behind the elbow. This is the same nerve that you hit, when you hit your “funny” bone.
Compression of the ulnar nerve can cause pain in the ring and little finger as well as general weakness of the hand. In extreme cases, the forearm can become weakened.
Nerve Conduction Studies and EMG’s completed by a Neurologist will confirm diagnosis of Ulnar Neuropathy. Ultrasound is also required in some instances.
Surgical decompression of the ulnar nerve to release the compression is required.
Nerve Conduction Studies completed by a Neurologist will confirm diagnosis of Peripheral Neuropathy.
Details to come.
Common Peroneal Nerve Palsy with Foot Drop
Nerve Conduction Studies/ EMG’s completed by a Neurologist will confirm diagnosis of Common Peroneal Nerve Palsy.