Degenerative disease of the spine is very common and affects almost
everybody to some degree from mid thirties onwards. It is caused by
wear and tear of the bones, ligaments and discs that make up the
spine. It can occur anywhere between the base of the skull and the
coccyx (tail bone). The most common sites are the areas which
experience the most movement (and therefore wear and tear), these are
the neck and lower back. Below are some common questions patients ask
about degenerative spine disease.
Some questions patients had:
Do I have "sciatica" ?
"Sciatica" is a term used to describe severe pain which starts in the low back and shoots into the buttock and down the leg. It is usually associated with tingling or numbness in the foot and may be associated with weakness at the ankle. It is usually caused by a disc in the lower spine pressing on a nerve root as it leaves the spinal canal to go to the leg.
Do I need an operation?
Many episodes of "sciatica" improve spontaneously with rest and pain relief. Patients with severe, progressive or unrelenting "sciatica" may require an operation. Those who have more worrying features such as ankle weakness or sciatica on both sides or symptoms relating to bowel and bladder function often need surgery as a matter of urgency.
What does a lumbar microdiscectomy involve?
This is an operation through a small incision in the lower back to remove the part of the disc which is compressing the nerve. A microscope is used and some bone and ligament are removed for access. The nerve root is identified and gently moved to one side to allow access to the bulging disc which is removed.
How will I feel afterwards?
You should experience immediate relief of leg pain. Back pain may improve but doesn't always. Leg weakness generally needs a lot of help from a physiotherapist to improve. Numbness can take up to a year to get better and doesn't always improve completely.
I have numb clumsy hands and my legs give way when I walk. My doctor says I have compression of my spinal cord but can't have surgery because of my heart/lung problems. Is there anything that can be done?
This is a common problem called "cervical myelopathy" which can arise as one gets older. In general, the aim of surgery is to prevent progression of the problem, not necessarily to reverse any problems you are already experiencing. If untreated this problem can leave a patient wheelchair-bound.
The reason you cannot have an operation is because the general anaesthetic poses too much risk to your health. It is however, possible to perform a cervical laminectomy as an "awake" procedure under local anaesthetic in selected cases.
Treatments for Peripheral Nerve Conditions
PERIPHERAL NERVE ENTRAPMENT
The spinal cord acts as a conduit for nerves travelling from the brain; branching from the spine nerves are peripheral nerves. Symptoms such as discomfort, pain, weakness and tingling or numbness in hands, arms and legs can be caused by a peripheral nerve being trapped or squashed. This usually occurs at a mobile joint, for example carpal tunnel syndrome is entrapment of the median nerve at the wrist that affects the hand. The ulnar nerve can be trapped at the elbow and the lateral cutaneous nerve of the thigh can be trapped in the groin. Surgery can be a good option for treatment, immediately releasing pressure from the nerve.
Questions that patients had:
I think I might have carpal tunnel syndrome, how can I be sure?
CTS is pain and numbness in the palm affecting the thumb, index and middle fingers. It may also cause weakness and if severe muscle wasting. Symptoms are generally worse at night. When your doctor examines you there are a number of tests which can be done which will point towards the diagnosis. To be absolutely certain you will require nerve conduction studies, which involves putting a small needle into the muscles to watch their reaction when the nerve is stimulated.
I have carpal tunnel syndrome. What are my options?
Carpal tunnel syndrome can occur as a result of another condition such as pregnancy, rheumatoid arthritis or hypothyroidism among others. In cases like these treatment of the underlying condition often improves symptoms (eg carpal tunnel in pregnancy usually resolves spontaneously after birth).
Some patients benefit from weight loss, injections into the carpal tunnel or splinting at night. The only definitive treatment is an operation to relieve the pressure on the nerve, which is usually done under local anaesthetic.
Operations on the brain are performed to treat conditions including hydrocephalus, haemorrhage, tumour, head injury, vascular abnormalities and Arnold-Chiari malformation. Any operation on the brain carries significant risk and needs to be performed by a surgeon specifically trained for the procedure in a specialised theatre. Modern operating theatres are equipped with up-to-date computers, microscopes and facilities which make surgery as precise and safe as possible.
Some questions patients had:
I have an aneurysm in my brain do I need treatment?
If the aneurysm has burst, resulting in a brain haemorrhage treatment is recommended because their is a substantial risk of it bursting again. Every time an aneurysm bursts there is a chance of death, stroke and seizure. If an aneurysm is discovered during tests for something unrelated and it has not produced any symptoms the situation is less clear-cut as many aneurysms never rupture, but those that do may produce serious problems. In this situation, a decision is best reached by discussion with your neurosurgeon.
Is there anything I can do to reduce the risks posed to me by my aneurysm?
If your blood pressure is raised, having it treated and making sure it stays at reasonably normal levels reduces the risk to you. If you smoke, stopping smoking also reduces risk. Although exercise is fine anything involving explosive changes in blood pressure like lifting heavy weights should be avoided.
Are aneurysms inherited?
In general no. However, in a small number of cases there can be a hereditary aspect to brain aneurysms.
Some members of my family have had aneurysms which have bled. Should I have screening?
In general the recommendation is if you have 2 or more first degree relatives affected then you are a candidate for screening. Other co-existent medical conditions are also an indication for screening such as adult polycystic kidney disease (APKD) where we know the incidence of aneurysms is high.
I have an arteriovenous malformation (AVM) do I need to worry?
AVMs are abnormal tangles of blood vessels in the brain. They are believed to be present from birth. Many of them cause no problems throughout life. Others do produce symptoms. The 2 most common symptoms are epilepsy (or seizures) and bleeding (rupture). If your AVM has never produced symptoms (and has been discovered incidentally) the chances are very high that you will not need any treatment. If it has produced symptoms, treatment may be advisable.
What forms of treatment are available for AVMs?
For AVMs which require treatment there are 3 options:
- Endovascular treatment ( also know as "gluing")
- Radiosurgery (in the form of gamma knife or cyberknife)
A decision as to the best form of management in any particular case can only be reached after detailed discussion with your neurosurgeon
I have a cavernoma, what should I do?
Management of a cavernoma depends most importantly on 2 factors:
- Whether it has produced symptoms
- Where it is located
If a cavernoma has produced symptoms (ex. seizures, severe headache, stroke) treatment will usually be discussed provided it is in a suitable (accessible) location. The exception to this is cavernomas in very sensitive locations (eg brainstem) where evidence of 2 bleeds is generally required before embarking on any form of treatment. If a cavernoma has produced no symptoms usually a "watch and wait" policy will be adopted.
Do cavernomas run in families?
Usually not but a small subgroup of patients with multiple cavernomas do have a hereditary component. These are more prevalent in Hispanic families.
What is a meningioma?
A meningioma is a tumour of the dura (which is the lining around the brain). These tumours are generally benign but occasionally malignant.
What is the treatment for a meningioma?
The traditional treatment has always been, and still is surgery for tumours in accessible sites. For inaccessible tumours stereotactic radiosurgery (gamma knife or cyberknife) is often used now.
I have a glioblastoma, what is the prognosis?
Glioblastomas are the most aggressive of brain tumours. Traditionally neurosurgeons and oncologists were very nihilistic about these tumours with typical survival of up to 6 months. Recently however, there have been many advances in all aspects of managing these tumours and survival is now much better.
I have a brain tumour, do I need an "awake" operation?
Tumours that benefit from being removed with an "awake" patient are tumours of the brain itself (not metastases that have spread from elsewhere) which are located in or directly adjacent to eloquent brain. Eloquent brain has an important function and damage to an eloquent area of brain will produce a serious problem such as inability to speak or understand or a stroke, with inability to move one side of the body.
Cyberknife is targeted x-ray therapy delivered by a precise robotic arm programmed by a neurosurgeon or oncologist. It can be used to treat several tumours which previously required surgery, such as malignant tumours, benign tumours, meningiomas and acoustic neuromas/schwannomas. Cyberknife is also very useful for treating non-tumour conditions such as arteriovenous malformations and trigeminal neuralgia. It does not involve an incision and does not require an anaesthetic. The treatment is comfortable and generally doesn't last longer than an hour (sometimes treatment is repeated on successive days).
Some questions patients had:
What is Cyberknife?
Cyberknife is robotic radiosurgery
Who can benefit from Cyberknife?
Cyberknife benefits patients with any of the following conditions:
- brain and spine tumours
- pituitary gland tumours
- arteriovenous malformations (avms)
- trigeminal neuralgia
The Accuray Cyberknife and the London Clinic
webpages give detailed information about apparatus, techniques, and cyberknife
What are the benefits of Cyberknife over Gamma knife treatments?
Benefits of Cyberknife are:
- No frame is screwed into the skull
- Tumours greater than 3cm in diameter can be treated
- Treatment contours the shape of the target
- Damage to nearby structures is avoided
How does radiation treat tumours?
It interferes with the DNA in cells which are multiplying and makes it impossible for them to replicate. It also damages many normal cells, but to a lesser extent as they replicate less often.
I have been told my tumour is inoperable/ untreatable. Can Cyberknife help?
In many cases like yours cyberknife can be worthwhile. However, it is not the answer for every case. Suitability depends on many factors including previous treatment and tumour location.
If you need (or think you need) a neurosurgical operation it is worth
considering treatment as a private patient. Treatment as a private patient allows you to chose your surgeon and the timeframe for investigation and treatment. For the medically insured, private treatment is always an option and particularly if
investigation and treatment are slower than desirable in the NHS. For
those who are uninsured, self-paying is a way of ensuring high
quality and prompt treatment.
Who is private neurosurgery a good option for?
Private neurosurgery is a good option for those who are insured or can afford to self-pay and wish to be seen and treated quickly.
How quickly will I be seen?
Usually within a week.
Is private neurosurgery safer?
In general neurosurgical care on the NHS is very good. The difficulty is often in accessing this quickly, which is easy for potentially life-threatening conditions like brain haemorrhage or brain tumours, but it is more difficult for more chronic, less dangerous conditions like back pain, sciatica or carpal tunnel syndrome. In the latter group private neurosurgery can be a better option.
I am travelling from outside London for my consultation/treatment. Who can give me information about transport, accommodation, etc?
My secretary Tracey Coppen will be happy to help on
Tel 0747 870 6351 or firstname.lastname@example.org