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What is the difference between a neurologist and a neurosurgeon?

A neurologist and a neurosurgeon are similar to a cardiologist and a cardiac surgeon: The neurosurgeon employs neurosurgical means to treat neurological disorders while the neurologist uses medical (pharmacological) means to treat them.

What is neurosurgery

Neurosurgery is the surgical treatment of the nervous system and its coverings. That is, neurosurgeons operate on the brain, spinal cord, the skull and scalp, and the spine itself (bony vertebral column). This specialty treats many different kinds of disorders, including epilepsy, brain and spine tumors, movement disorders, vascular disorders, degenerative conditions of the spine and more. Dr. Fineman’s neurosurgical specialties include functional and stereotactic neurosurgery, stereotactic radiosurgery, craniotomies for brain tumors and other brain lesions, andcervical, thoracic and lumbar spine surgeries of all types.

What is functional neurosurgery

Functional neurosurgery is the surgical treatment of certain neurological disorders, notably movement disorders such as Parkinson’s disease, essential tremor and dystonia. Some neurosurgeriesare both “functional” and “stereotactic,” like deep brain stimulation, which is currently the neurosurgery of choice in the treatment of movement disorders.

What is stereotactic neurosurgery

Stereotactic neurosurgery uses imaging studies (MRI and/or CT) to identify discrete target locations and guide the approach to the target, typically through a very small opening in the skull,called a burr hole.

Deep Brain Stimulation

How is deep brain stimulation (DBS) surgery performed?

This surgery is performed through a small skull opening (burr hole) with the patient awake, using only local anesthetic and light intravenous sedation. Surgery is guided by stereotaxis, a method used for approaching deep brain targets through a small incision and skull opening. With stereotaxis, a rigid frame is attached to the patient’s head just before surgery, and a brain imaging study (usually an MRI) is obtained with the frame in place. The images of the brain and frame are used to calculate the position of the desired brain target and guide instruments to that target with minimal trauma.
To maximize the precision of the surgery, most surgeons use the electrical activity of the brain to guide the procedure. The surgeon records brain cell activity to check neurological response to electrical stimulation in order to confirm the correct location before implanting the electrode. The neurological status of the patient (such as vision, strength, reduction of tremor and/or appropriate relaxation of muscles) is monitored frequently during the operation. For implanting a single brain electrode, two to three hours of awake surgery is required. While pain can be eliminated, the discomfort of having an awake procedure with one’s head immobilized may be significant for some patients.
When the electrode has been implanted, a thin wire is “tunneled” under the skin (under full sedation) of the neck to the collarbone, where a battery called a “neurostimulator” is implanted to control the electrical impulses sent to the electrode in the brain. Dystonia and Parkinson’s patients whose symptoms are significant on both sides of the body, will usually require electrode placement on both sides of the brain. Dr. Fineman normally performs the two implants in two separate surgical procedures, spaced one to two months apart.

What are the risks of deep brain stimulation (DBS)?

The most serious risk of DBS is bleeding in the brain, potentially — but not always — resulting in a stroke. This risk varies from patient to patient, depending on other medical factors, but generally ranges from 1-3%. If stroke occurs, it usually occurs during or within a few hours after surgery. Another risk is infection, typically at the burr hole or at the site of the neurostimulator implant. Infection occurs in 4-5% of patients and is very rarely life threatening, although infection can require removal of all or part of the DBS system.

What are the benefits of deep brain stimulation (DBS)?

DBS surgery does not cure disease in Parkinson’s, essential tremor or dystonia, though it can significantly reduce symptoms in some patients. When the stimulator is turned off, or if it malfunctions, symptoms return. DBS can decrease abnormal movements, rigidity, tremor, abnormal postures (e.g. dystonia) and other symptoms, but usually does not totally eliminate them. The degree of benefit varies — in dystonia — with the type of disease, duration of symptoms and age of the patient. Adolescents and young adults with inherited forms of dystonia appear to get very significant benefit, while patients with dystonia due to stroke or head trauma may improve only slightly. Adults who have had dystonia for many years generally improve less than those with recent symptom onset. People with essential tremor are generally strongly benefited by DBS while, in Parkinson’s and dystonia patients, a number of factors interact to determine degree of benefit. Any patient considering DBS should have a frank and comprehensive discussion with their neurosurgeon to determine possible benefits and risks based on their unique history.

Stereotactic Radiosurgery

What is Stereotactic Radiosurgery (SRS)?

Stereotactic radiosurgery is a minimally invasive approach for treatment of benign and malignant brain tumors and other brain disorders, such as arteriovenous malformations, pituitary tumors, trigeminal neuralgia and some cases of tremor and severe pain. SRS involves computer-guided, extremely precise delivery of high doses of radiation to the targeted area of the brain. By avoiding open craniotomy in appropriate patients, radiosurgery decreases risks as well as recovery time. SRS is typically an outpatient procedure allowing patients to resume normal activities immediately. Currently the most widely used systems for SRS are the Linear Accelerators, CyberKnife and Gamma Knife. CyberKnife may also be used for radiosurgical treatment of tumors of the spine and other organs, such as lungs and prostate.


What is a craniotomy?

A craniotomy is a surgical procedure in which a “bone flap” (a small part of the skull) is removed to allow the neurosurgeon access to the brain. It is the most common procedure employed for the removal of brain tumors, but it is also used for removing blood clots, controlling hemorrhage and epilepsy surgery, among other indications. Typically performed under general anesthetic and guided by a preliminary MRI scan, the amount of skull to be removed and the duration of the procedure will depend on the type of surgery to be performed

Brain and Spine Tumors

How are brain and spine tumors diagnosed?

Pre-surgical MRI studies and the appearance of a tumor during surgery can be vital in suggesting the specific diagnosis. However, the diagnosis can only be confirmed by examination of the tissue within the tumor under a microscope. This system relies heavily on the ability of the pathologist to recognize cellular patterns and has remained essentially unchanged since the 1950s. An exciting new field in the study of oncology is isolating the genes that are active in these tumors, allowing classification of tumors based on more sophisticated tests.

Are all brain and spine tumors malignant?

No. There are many different types of tumors that occur in either the spine or brain.
Benign brain tumors do not contain cancer cells. When they are removed, they usually do not grow back. The border or edge of a benign brain tumor can be clearly seen and cells from benign brain tumors do not invade surrounding tissues or spread to other parts of the body, though if they grow large enough, they can sometimes become life threatening.
Malignant brain tumors contain cancer cells and are generally more serious and often life threatening. They are likely to grow rapidly and to invade surrounding healthy brain tissue. Very rarely, cancer cells may break away from a malignant brain tumor and spread to other parts of the brain, spinal cord or even to other parts of the body. When this happens it is called metastasis.
There are many different types of spinal tumors as well. One category is related to tumors that involve the spinal bones and a second broad category involves tumors of the spinal cord and its coverings. Many are not aggressive in their growth potential, but still cause problems because of their mass and location. Many spinal tumors are easily treated with surgical resection alone and require no additional therapy. A metastatic tumor that has spread to the spine is often a sign of cancer and can be difficult to remove surgically. Metastatic tumors nearly always require radiation therapy in addition to surgical removal.

Brain and Lesions and Disorders

What are some of the other brain “lesions” and “disorders”?

The terms brain “lesions” and “disorders” can refer to a number of different diagnoses,
including brain tumors, in addition to (among others):

  • Arteriovenous malformations (AVMs), which are complex tangles of arteries and veins
    which result from abnormal development. They are congenital (present at birth) but
    enlarge during a person’s lifetime. AVMs divert arterial blood, which is under high
    pressure, directly to the venous system without intervening capillaries. This may have several effects, including hemorrhage and seizures.
  • Pituitary cysts or tumors, located on or around the pituitary gland at the base of the brain,
    are most often benign but can nonetheless cause pain and other symptoms and, if not
    monitored, impact other areas of the brain. These include Rathkes Cleft cysts,
    craniopharyngiomas, arachnoid cysts and pituitary adenomas.
  • Trigeminal neuralgia, also called tic douloureux, is a chronic pain condition that causes
    extreme, sporadic, sudden burning or shock-like face pain lasting, typically, from a few
    seconds to two minutes. Emanating from the trigeminal nerve, this severe pain can be
    both physically and emotionally debilitating.

All of the above, as well as other “lesions” and “disorders” can be treated by the appropriate radiosurgery or neurosurgery, as determined by your neurosurgeon.


What is Hydrocephalus?

Hydrocephalus is a central nervous system disorder that can cause increased pressure in the brain, resulting in brain damage and neurological deficits. Hydrocephalus is caused by inadequate drainage or obstruction of drainage of cerebral spinal fluid (CSF) in the brain. Normally, CSF flows through the central nervous system much like oil flows through your car’s engine. A membrane in the brain produces CSF, which travels down the spinal cord and back again to the brain, where the brain reabsorbs it. Under normal circumstances, this flow pattern keeps just enough CSF in the brain for the brain and nervous system to be healthy. If the brain does not properly reabsorb the CSF, or something in the brain blocks the normal CSF flow, hydrocephalus occurs.
Normal pressure hydrocephalus occurs in the elderly and results in enlargement of CSF spaces in the brain, leading to memory problems, difficulty walking and incontinence of urine.

How does a surgeon treat Hydrocephalus?

A surgeon will operate to provide a way for the excess CSF to leave the brain safely. Typically, a surgeon will place a ventriculo-peritoneal (VP) shunt into the brain. This is a tube hidden inside the body that connects ventricles (the CSF reservoir in the brain) to the peritoneal cavity (the space in the abdomen that contains the stomach and other organs). Because the head sits higher than the peritoneal cavity, the excess CSF flows down into the peritoneal cavity, where the cavity lining absorbs it. This restores the normal balance of CSF and normal functioning to the brain.


What is a seizure?

A seizure, or convulsion, can be a sudden, violent, uncontrollable contraction of a group of muscles caused by abnormal electrical activity in the brain. A seizure can also be more subtle, consisting of only a brief “loss of contact” in which the patient seems to be daydreaming, or even a repetitive, uncontrollable body movement. Seizures can be treated with anticonvulsant medications or surgery.

What causes seizures?

The most frequent causes of seizures include epilepsy, injury or trauma to the head, infection, the presence of a brain tumor (30-40% of patients with a brain tumor will experience a seizure), high fever, heatstroke or, when blood sugar is too low, diabetes. There may be other causes of seizures as well, including other diseases and medications. Furthermore, the cause may vary based on age and gender of the affected person, as well as on the specific characteristics of the symptom such as quality, time course, aggravating factors, relieving factors and associated complaints. It is important to see a doctor for a thorough evaluation to determine a seizure’s cause and, thus, appropriate treatment.

The Spine

What is the purpose of the spine?

The spine protects the spinal cord, nerve roots and internal organs while it provides flexibility in movement and structural support and balance for upright posture.

What are vertebrae and how many kinds are there?

In a nutshell, vertebrae are protective, bony structures that encase the spinal cord. The top seven vertebrae of the neck are called cervical vertebrae. The upper back has twelve thoracic vertebrae and the lower back has five lumbar vertebrae.

Back and Neck Pain

What causes back pain?

Back pain — which is often accompanied by pain in one or both legs — can have numerous causes, including muscle trauma, inflammatory disease, spinal tumors or simply the natural wear and tear of aging, which creates degenerative disease impacting the structure of the spine: the bones, the intervertebrael discs, etc. Degenerative disease causing back pain (and sometimes leg pain) will generally be located in the thoracic or lumbar sections of the spine. It is important to work closely with your doctor to determine the cause and, thus, the appropriate treatment of back pain. Your doctor may order diagnostic tests after he/she completes a physical exam. These tests may include MRI and CT scans.

What causes neck pain?

Neck pain, like back pain, can result from a number of causes, including trauma, infections or inflammatory disease and age-related degenerative disease in the cervical spine. Symptoms can include pain, tingling and numbness in your neck, shoulders, arms and/or hands. As with all disease, it is important to provide your doctor all the information he/she will need to determine the cause and appropriate treatment. Helpful tests, in addition to a physical exam, can include MRI and CT scans.

How is back or neck pain treated?

Your doctor will determine your treatment path after a thorough exam and any tests or scans necessary. Treatment can sometimes be as minimal as appropriate physical therapy. More severe problems in the back or neck often require surgery.
The most common surgeries, aside from tumor removal, for correcting problems in the cervical spine are discectomy and fusion and laminectomy. For the lumbar and thoracic