Functional Neurosurgery

Diseases of our nervous system can be difficult to understand and challenging to live with. The body’s nervous system is made up of the brain, spinal cord, and peripheral nerves. Neurosurgeons provide care for a range of disorders of these organs. To our good fortune, we have seen dramatic growth in our understanding of the nervous system and its diseases, as well as science fiction-like technological advancements available to the specialists who treat nervous system problems. This may be most true in the subspecialty of functional neurosurgery.

What is “functional” neurosurgery? Just as it sounds, functional neurosurgery is a super-specialized field which treats degenerative and idiopathic (i.e. without known cause) nervous system diseases which compromise an individual’s everyday function. This generally includes movement disorders, pain syndromes, and epilepsy. As a group, functional disorders have been traditionally challenging to treat. Those who suffer with them are usually under the care of a neurologist who is familiar with the patient, the history of their illness, and their treatments. A neurosurgeon with modern functional expertise can play an important role in helping make neurologists’ treatments more efficient and effective.

Deep brain stimulation (DBS) gets the most attention of any current technique in functional neurosurgery. This therapy, where deep brain structures are electrically stimulated, has made significant impact particularly on the treatment of movement disorders. Movement disorders are neurological diseases which are characterized by the presence of abnormal movement or muscle tone, absence of normal movement, or combination of the two. The most well-known movement disorder is Parkinson’s Disease, but other noteworthy disorders include essential tremor, dystonia, spasticity, and chorea. Those with Parkinson’s Disease suffer from rigidity of their limbs, tremor, and a difficulty and slowness with normal movements. Contemporary medications can dramatically reduce these symptoms, but over time these drugs begin to lose efficacy and come with side effects. DBS is now proven as an effective procedure for reducing symptoms of Parkinson’s Disease and essential tremor, and potentially lowering the amount of medication needed to treat both disorders. DBS is a minimally-invasive surgery usually performed with the patient awake under light sedation. The surgeon uses a computerized guidance system and high-resolution MRI to implant small electrodes into the deep brain target with sub-millimeter accuracy. The patient recovers from surgery quickly and usually goes home from the hospital the day after the procedure.

The functional neurosurgeon also treats pain syndromes, including trigeminal neuralgia, cancer pain, and chronic low back and leg pain. Various functional procedures may be helpful for these patients. For example, trigeminal neuralgia is a facial pain syndrome caused by abnormal activity of the trigeminal nerve (the nerve that transmits sensation from the face). This can be a disabling problem, which in its most severe form can make even eating and talking very painful. Neurologists offer medications that may significantly reduce the frequency and severity of pain attacks. When pain continues despite medicines, a neurosurgeon with functional expertise may suggest surgical microvascular decompression of the nerve, stereotactic radiosurgery to the nerve, or targeted injections of substances designed to quiet nerve activity. Stereotactic radiosurgery is a non-invasive procedure in which the neurosurgeon uses computer guidance to deliver highly focused beams of radiation. The decision as to which treatment is best for trigeminal neuralgia is complicated and done on an individual basis. This decision should be undertaken with a neurosurgeon experienced with the disease and all forms of therapy.

Current functional neurosurgery makes a significant impact on the lives of those who suffer with these chronic, debilitating conditions. Research is rapidly improving our knowledge of brain function, our understanding of these and other complicated neurological diseases, and advancing avenues of treatment, such as: gene and molecular therapy. With that in mind, the future of functional neurosurgery is extraordinarily bright.

Understanding Insurance Plans

Health Insurance plans and options are more complicated than ever.  On the positive side many newer plans do further to empower the consumer to make healthcare choices that can assure them excellent care and at the same time save them money.  In addition a thorough knowledge of all of the benefits of your particular plan allows you to take maximum advantage of classes, support groups or discounts due to participation in wellness programs, etc.

The cost to not understanding your exact health plan can be significant.  Far too often a denial for coverage can be due to a consumer not following required procedures or failing to understand limits of coverage.  Here are some commons problems:

• A patient with an HMO visits a specialist. The health plan denies payment of the visit as the patient needed a referral from his primary care.
• A PPO participant sees a doctor who is not in the PPO network.   The plan might cover 80% of the care if you saw an in –network physician and far less or maybe nothing if you go out of network.
• A patient schedules surgery however the procedure is not authorized by their insurance plan as the criteria for that particular plan has very specific limits.
• A patient receives a denial for a procedure and does not follow the specific appeal process in the timeframe outlined by that plan and automatically loses the appeal.
• A patient has a procedure at one location and has no out of pocket expense.  They then have the same procedure at another facility and end up with a large deductible they must pay out of pocket.

In order to avoid these costly mistakes here is what you can do.

•  Be aware of what kind of plan you have ( HMO, PPO, etc).   Find out in advance who is in network and who is not and if a referral is needed.  Ask your provider if they have the referral on file prior to your visit.  If not, call your PCP and get one in advance.  Many plans will not authorize a retro-active referral.
•  Determine if any procedures require prior authorization and whether your provider’s office will do this on your behalf.   A medical provider’s office can assist you with obtaining the authorization however that is not a guarantee of payment and often only the member can find out how much it will cost them out of pocket and if there are any limitations to that coverage.
• Find out if your plan excludes certain services and if there are any service limits during the calendar year. 
• Many plans now have a “Site of Service” differential meaning some facilities will provide a service at a significantly lower cost.  For example, a spinal injection at your doctor’s office may only result in an office copay ( for example 10.00- 50.00) versus having it done at a hospital or out-patient center might be subject to a deductible and co-insurance.  ( 250.00 to 1,000.00 or more)

Finally, you will receive optimal service and coverage if you do your research in advance.  Advise your doctor's office of any changes in your personal information and be sure to provide them with a copy of your health insurance card.  Since the contractual agreement for your Insurance coverage is between you and that Insurance company there is some information only available to you.   Therefore in some cases only you can determine exactly how your benefits will work and what your out of pocket costs might be.  We will gladly provide you with any information needs ( such as procedure codes,etc) so that you can obtain this information. 

Just as is necessary in optimizing your medical care, we must work as a team to assure you the best medical care and obtaining the most benefit from your health insurance plan.  These concepts are not easy to understand and can be even more challenging when you or a loved one is ill.  At NHNSI we Care about the quality of your life and strive to assist you in anyway we can.  If there is something we can assist with, please do not hesitate to ask. 

Fall Fitness Tips

With summer gone and the crisp cool air setting we are getting ready for winter, the holidays, shorter days and less physical activity.  Take advantage of the time you still have left and spend it outside.  It’s the perfect time of year for outdoor activities.  You no longer have to battle the bugs, the humidity and the heat and you get to enjoy the fall colors. 

Get outside and go for a walk.  Even a twenty minute walk can be refreshing and exerting.  Be sure to do some warm up stretching even for a short walk and wear appropriate footwear.

Rake the leaves.  You have to do it anyway so think of it as a workout.  Put on your favorite tunes, some old clothes and really get into it.  Warm up stretching is very important.  It is likely that raking will affect muscles that you don’t realize aren’t getting used.  Here are some proper body mechanics:

• When raking, stay close to the work area
• Keep you back straight and stable.
• Use your arm movements to do the work
•  Move your feet so you do not have to reach, bend, or twist.

Take a trip to the apple orchard.  This is a great way to get some exercising in and to do something with the family.  Search for the perfect apple - use this as a way to extend walking.  Not to mention having a healthy snack on the way.

Visit the mountains.  The colors are wonderful this time of year and living in New England gives us the advantage of being surrounded by mountains.  Even a short easy hike can be invigorating and offer a spectacular view at the top.  Be sure to wear appropriate footwear, such as hiking boots.  Having ankle support is imperative when there is an incline or decline.  Make a point to warm up with stretching and follow these proper body mechanics:

                 

•  On upward slopes be sure to watch your posture.  It is easy (especially when carrying a pack) to be slouched.
•   Going down, use shorter strides and go slowly.  This will reduce the impact to your knees.
•  Use a heel to toe motion.  This will reduce the impact on your foot and ankle, also taking additional stress of your knees and spine.

There are many ways to get out and enjoy the weather.  Just keep in mind that safety and injury prevention are extremely important.  Be sure to research items, such as good body mechanics and proper attire, when trying something new!

Top 7 Back Pain Treatments for Summer Vacation Car Rides

Well, it’s that wonderful time of year when school is out, the weather is getting beautiful and the days are much longer and brighter. For most people, the summer is an ideal time to get away from the grind of the 9-to-5 and take a vacation with family.

With money tighter and the economy what it is, more families vacationing this summer may decide to travel by car, which may not present the most ideal situation for people dealing with a history of lower back pain.

Still, lower back pain doesn’t have to throw a wrench in your summer travels. In fact, if you keep the following tips in mind, you may very well make your trip a comfortable one.  


In the first installment of Spine-health’s summer series of tips for limiting back pain on vacation, we examine how you can “have the back” of your back during that long car ride to the destination of your dreams. More...

What can you plan to gain from the NHNSI Golf Enhancement Program?

NHNSI has created a golf program designed to increase an individual's fitness level, assess body mechanics and help to strengthen golfers’ overall performance. Our goal is help increase your distance and power, minimize the chance of injury and improve accuracy. The program helps focus on five cores areas: flexibility/mobility, balance, strength, stabilization, and endurance.

NHNSI's very own Titleist Performance Institute (TPI) certified Physical Therapist, Matthew Harrison, will work with you on an individual basis and determine what you can do to increase your execution on the golf course. Working with a team of musculoskeletal experts allows Matthew to utilize the knowledge of our providers along with his knowledge as a Physical Therapist to give you the best golf performance recovery experience.  

For more information or to sign up today, click here or call 603-472-8888.

Advances in the Treatment of Spinal Compression Fractures

A spinal fracture occurs when one of the bones in the spinal column breaks. This type of fracture is also known as a vertebral compression fracture because the bone that breaks (the vertebral body) often cracks and collapses, becoming compressed.

 

The bones in your spinal column are different than the bones elsewhere in your skeleton. For example, the long bones in your legs are more rigid and dense than the square bones in your spine.

Strong, dense bone enables your legs to withstand rigorous movement. The vertebral bodies, however, are less dense and more “spongy,” to accommodate movements like bending and twisting. Because your vertebral bodies aren’t as strong as the bones in your legs, they can become more vulnerable to fracture.

Certain diseases, such as osteoporosis or cancer, are known to cause loss of bone mass and changes in bone structure, making them brittle and weak. Genetic factors and certain lifestyles, such as a low calcium diet, can also damage bone. Over time, the vertebral bodies can become so weak that normal activities such as bending over or lifting a bag of groceries, can cause a spinal fracture. You can’t feel the changes in your bones while they are happening; in fact, many people are unaware that there is anything wrong until a fracture occurs.

When more than one spinal fracture occurs, loss of height or spinal deformities such as a dowager’s hump may result. Even though most osteoporotic spinal fractures are typically a stable injury, in many cases they cause debilitating pain and reduce the quality of life for those who suffer from them. In recent years, the treatment of osteoporotic fractures has advanced considerably with the development of the surgical procedure known as Balloon Kyphoplasty. With Balloon Kyphoplasty, an orthopedic balloon is used to elevate the bone fragments of the fractured vertebra and return them to the correct position. The incision site is approximately 1 cm in length. A hollow instrument is used to guide the balloon into the vertebra. The balloon is then inflated so that the collapsed vertebra is returned to its normal position. Once the vertebra is in the correct position, the balloon is deflated, leaving a space for bone cement. The cement stabilizes the fracture and holds the vertebra in place. The Kyphoplasty is minimally invasive. It is typically done in an outpatient setting at a hospital or surgery center. As with any procedure, there are potential risks and the procedure is not for everyone.

The New Hamshire NeuroSpine Institute is unique in our approach to compression fractures as we have a team of experts to work together in addressing our patients’ problems. Our team of professionals may look at the underlying cause of the problem (through our Osteoporosis Clinic), utilize therapies such as PT and Bracing in cooperation with our Physical Therapists and if indicated, a surgical consultation might be arranged with one of our physicians trained in Balloon Kyphoplasty.

What is an athlete's most important part of the body? The brain, of course!

New Hampshire NeuroSpine Institute is educating athletes, athletic directors, and coaches throughout the state of NH by sending them ImPACT informational posters.  NHNSI is dedicated to concussion prevention and recovery with the ImPACT program.  NHNSI’s Dr. Adam Cugalj is a certified ImPACT consultant and will oversee concussion testing, diagnosis, and recovery for your team or individual athlete. Doctors at NHNSI see the importance of concussion prevention every day and take preventative measures and immediate action for all head injuries.

ImPACT is a 20 minute neurocognitive test that has been scientifically validated to measure the effects of a sports-related concussion.  The baseline testing that takes place at the beginning of a season helps to better detect a concussion in the event of contact. After being hit, the athlete will take the same test and the results are compared. 

Dr. Jenkins Announced "Top Doc" For Tenth Year In A Row

New Hampshire Magazine has announced their 2012 "Top Doc" awards, and once again, N. Ross Jenkins, MD, FACS is a winner.  Dr. Jenkins has now been honored in the specialty of Neurosurgery for the 10th year in a row! In addition to his commitment to his patients, he also serves as the Chief of Surgery at Concord Hospital and is Chairperson for the Northeast quadrant of the Council of State Neurosurgical Societies. Dr. Jenkins is board certified by the American Board of Neurological Surgeons and provides comprehensive and compassionate care for patients with brain and spine disorders. Dr. Jenkins works closely with the nationally recognized members of the NH NeuroSpine Institute, and this multidisciplinary facility offers the most comprehensive NeuroSpine care in NH.

New Hampshire Magazine distributed surveys to every physician licensed to practice in New Hampshire, and they nominated specialists in 45 different categories whom they would recommend. The survey’s top vote-getters have been named "Top Doc" in their respective specialties.

OLIF - The Oblique Lumbar Interbody Fusion

It is well established that the best surgical treatment for chronic intractable low back pain is a spine fusion.  The challenge comes from the fact that the spine is in the center of the body and to get there, the surgeon has to go through some other part of the body.  That traditionally means incising the muscle and then removing boney elements of the spine.  The exposure alone can result in as much as 40% loss of back strength.  

It is for these reasons that a movement has been gaining momentum in spine surgery known as “Minimally Invasive Surgery” or “MIS”.  The concept of MIS is to access the spine without cutting the muscles, thus preserving the body’s full strength potential. 

One of the most exciting new MIS techniques is the DLIF or “Direct Lateral Interbody Fusion”.  This technique requires a small 1” incision along the side of the abdomen allowing a bloodless approach to all levels of the lumbar spine except the lowest level L5-S1.  Through this single incision it is often possible to correct complex multilevel deformity such as scoliosis. 

L5-S1 is blocked from this direct lateral approach by the pelvis and since it is often involved in the pathology requiring a spinal fusion, a small innovative group of surgeons from around the country (including Dr. Thomas J. Kleeman from the New Hampshire Neurospine Institute) have been working together to solve this dilemma to allow L5-S1 to be accessed in a manner similar to the DLIF.  This novel technique has been called the OLIF or “oblique lumbar interbody fusion”.  The OLIF is done “obliquely” (in front of the iliac crest) which gives direct access to L5-S1 while avoiding the back muscles (posterior fusion) and abdominal structures (anterior fusion).  This approach allows us to use a single larger implant providing a larger fusion area and greater stability.  Thus far, most of the patients were allowed to leave the hospital within 24 hours of their surgery.  As with all procedures performed at NHNSI, we continually review the benefits and indications of this approach.  We strive to provide the most effective and least invasive approaches to spine surgery.  Our varied specialists provide us with a vast knowledge of techniques so we can bring you, the patient, the best solutions for your condition.

Direct Lateral Interbody Fusion

Watch as our own Dr. Kleeman narrates this animation of a Direct Lateral Interbody Fusion