Clinical Neuroscience News

A Publication of the Cushing Neuroscience Institute, Member of North Shore-LIJ Health System
Clinical
NeuroscienceNews
A YEAR
IN
REVIEW

Clinical
NeuroscienceNews
The Vulnerable Lower Back 4
December 2012
Emergency Neurosurgery for the Brain 8
March 2013
Advanced Treatment for
Craniocervical Instability 12
June 2013
Adolescent and Adult Scoliosis 16
September 2013
Taking on Brain Tumors 20
December 2013
A YEAR IN REVIEW
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Onward Publishing, Inc.
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NORTH SHORE-LIJ HEALTH SYSTEM 3
Dear Readers,
Welcome to New York Neurosurgery, a symposium coordinated
by the Cushing Neuroscience Institute of the North Shore-LIJ
Health System. This program focuses on the state-of-the-art
treatment and management of brain tumors, cerebrovascular
disorders and head trauma.
We would like to share with you this collection of recent articles
from our newsletter Clinical Neuroscience News describing
facets of the neurosurgical work being done at the Cushing
Neuroscience Institute.
The first report focuses on the vulnerability of the lower back
and the second on our multidisciplinary response to traumatic
brain injury. The third report looks at cutting edge surgical
approaches to remodeling the complex of bony structures that
make up the cranio-cervical junction in patients suffering from
congenital or accident-related cranio-cervical instability (CCI).
Also included here are articles on the newest neurosurgical
treatments for scoliosis and brain tumors. The highly variable,
three-dimensional spinal deformity known as scoliosis typically
develops in adolescence but occasionally develops de novo in
adulthood, requiring individualized solutions and a suite of
advanced intraoperative imaging tools. As set forth in our brain
tumor article, our team of neurosurgeons, neuro-oncologists,
radiation and medical oncologists, neuroradiologists and others
provide the latest state-of-the-art diagnostic and multi-modality
treatment options for this potentially life-threatening disease.
We thank you for your attendance at the symposium and hope
you find interest in this publication as well.
Raj K. Narayan, MD, FACS
Chair, Department of Neurosurgery
North Shore University Hospital
and Long Island Jewish Medical Center
Senior Vice President and Executive Director,
Neuroscience Service Line
Chair and Professor, Neurosurgery
Hofstra North Shore-LIJ School of Medicine
A Letter from
Raj Narayan,MD,FACS

4 CUSHING NEUROSCIENCE INSTITUTE
The lower back carries most of the torso’s weight. Constantly
strained by lifts and twists, the lumbar region is exceptionally
vulnerable to a variety of acute and degenerative injuries.
Each incident tends to be more severe and debilitating
than the last, until neither simple analgesics nor steroid
injections provide relief. At that point, surgical intervention
is considered.
Many lower back injuries start with an acute injury, but far
more cases of lower back pain are the result of cumulative
damage brought on by poor posture, sedentary habits, excess
body weight, osteoarthritis, sports injuries or the constant
biomechanical stresses of flexing, bending, twisting and lifting.
Over time, the discs that separate and cushion the vertebral
joints lose fluid and become less flexible, herniate or tear, or
the foramen within the spinal canal become narrower due to
osteophytes, commonly known as bone spurs. What remains
are entrapped nerves and bony surfaces grinding against bony
surfaces that produce excruciating pain signals, numbness,
tingling and reduced mobility. These symptoms set off a
vicious cycle of more physical inactivity, further loss of
back muscle strength, and progressive misalignment of the
vertebral column as the back adjusts to protect the
weakened structure.
At the Cushing Neuroscience Institute at North Shore-LIJ,
medical treatment and pain management options through
drugs, epidural injections and physical therapy are exhausted
before any kind of surgery is considered. Until recently,
surgery involving disorders of the spinal column required
major open surgery, entailing general anesthesia, deep
incisions, substantial blood loss and partial immobilization of
the patient during lengthy rehabilitation. While the outcomes
from open surgery can be excellent; it is rarely suitable for
elderly patients, and younger patients are understandably
reluctant to devote the time it takes to recover from the
effects of deep tissue injury that accompanies open surgery.
For these and other reasons, more patients and their referring
physicians are turning to neurosurgeons and advanced
medical centers that offer minimally invasive surgery (MIS)
as a better alternative for most lower back pathology. The
advantages of MIS are many, starting with decreased tissue
trauma. Muscles can be gently separated instead of cut
through to access the spine, and the one or possibly two
incisions needed average one inch. Less blood loss, less pain
and scarring, shorter time in the OR, fewer complications
and the possibility of same-day recovery and discharge are
other persuasive considerations. Even patients in their 80s
and 90s can tolerate MIS back surgery in the hands of an
experienced MIS specialist.
Minimally invasive surgery is carried out by neurosurgeons
with advanced subspecialty training. Our neurosurgeons
are not only recognized pioneers in the development of MIS
back surgery and its supportive technology, but they are
consistently among some the most active practitioners in
the region.
Our MIS surgical suites are also equipped with the newest
generation of technology. One of the essential new materials
used in MIS surgery are osteobiologics. These include
recombinant bone morphogenic protein (BMP), smaller
surgical instrumentation and a remarkable selection of
miniaturized stabilization hardware. Interbody spacers, made
especially for MIS procedures, insert tidily between vertebrae
as part of reconstruction.
We also have the newest 3D image-guided visualization
systems, including intraoperative microscopes and the C-arm
fluoroscope, the latter a mobile x-ray machine that provides
our neurosurgeons a 360-degree view of the spine. Lastly, our
MIS specialists have the newest and most sensitive devices to
monitor nerve function in real time as they proceed.
Among the many advanced MIS procedures offered for
lumbar surgery at the Cushing Neuroscience Institute are:
• Microdiscectomy to treat a herniated lumbar disc with
radicular symptoms due to nerve compression.
• Arthrodesis or fusion for refractory pain traceable to
disc degeneration, fractures, spondylolisthesis and spinal
instability.
• Kyphoplasty/vertebroplasty, MIS approaches to treat and
stabilize vertebral compression fractures. Primarily
due to osteoporosis, VCFs occur six times more frequently
in women than men. Both procedures involve injection
of bone cement into the fracture to stabilize and seal
the break.
In a kyphoplasty, a balloon is first inserted through the needle into
the fractured bone to create a cavity or space into which the
biocompatible material is injected. The needle is removed and the
biomaterial is allowed to harden. The small opening is covered with a
bandage. This procedure can take from 1-2 hours, about a half-hour
for each treated vertebra.
TheVulnerable
Lower
Back

Peter Hollis, MD, FACS
A 56-year-old woman was first seen in January 2011,
complaining of difficulty walking due to progressive back
pain, leg pain radiating down both legs and imbalance.
An MRI revealed significant cervical spondylitic
myelopathy and she subsequently underwent an anterior
discectomy and fusion at C4-C5 and C5-C6 at North
Shore-LIJ. Though the surgery was successful in relieving
her cervical pain, she continued to experience intensifying
lower back and leg pains, which were initially treated
elsewhere with physical therapy, epidural steroids and
chiropractic. Additional scans taken at North Shore-LIJ
showed L4-L5 spondylolisthesis and stenosis and after
discussing her options, we determined that an L4-L5
posterior interbody fusion and reduction of her
spondylolisthesis via MIS would give the greatest relief.
Placed under general anesthesia, wired with
neuromonitoring equipment, and under C-arm 3-D image
guidance, the patient received two 1.5-inch incisions on
either side of the spinal midline over the L4-L5
complexes. Following removal of a small portion of both
sides of the lamina (laminotomy) and partial
decompression of the corresponding nerve root
(facetectomy), we prepared the disc space for insertion of
an interbody prosthesis filled with a mixture of BMP and
autologous bone material. Once the prosthesis was well-
seated and the collapsed interior space distracted, we
performed a bilateral discectomy. The space was
expanded using the screw extenders of the PEEK
interbody fusion system until neuromonitoring signals
indicated that nerve compression was resolved. The
surgical area was given a final irrigation, surgical tools
removed and the anatomical layers of soft tissue closed.
Within six weeks, the patient reported that her
claudication symptoms were gone, that her wounds had
healed without incident, that her rehabilitation exercises
were restoring muscle tone and that she was looking
forward to returning to work shortly.
Case Study
MIS Interbody Fusion and Bilateral Discectomy
Preoperative imaging showing L4-L5
spondylolisthesis.
Preoperative imaging showing spinal
stenosis and spinal cord compression.
Postoperative imaging showing
plateless cervical fusion.
Postoperative imaging showing reduction of spondylolisthesis and stenosis
and the screw rod fixation.

A major source of lower back pain is degeneration of
cartilage within the intervertebral discs (IVDs) of the
spine. While years of wear and tear, acute injuries and aging
are variously cited as the triggers of degeneration
and attendant pain, it has also been posited that
inflammatory mechanisms may play a destructive role,
independent of injury.
To test this hypothesis, neurosurgeon Mitchell Levine, MD
and investigator Nadeen Chahine, PhD, at The Feinstein
Institute for Medical Research Biomechanics and
Bioengineering Lab, set out to track the expression
and responses of the Toll-Like Receptor TLR4. Though
previously implicated in the disease mechanisms of
cartilaginous breakdown, no detailed study had ever
tested the premise in the context of IVD degeneration.
Classed as a “pattern recognition receptor,” TLR4 is a
protein associated with the innate immune system,
providing host defense against microbial infections. Further,
TLR4 is activated by stimulation with the TLR4 ligand
lipopolysaccharide, resulting in upregulation of
proinflammatory cytokines; it also downregulates the
synthesis of extracellular matrix which slows tissue repair.
Dr. Chahine’s study, which involved stimulating IVD cells
by injecting the TLR4 ligand (LPS) in the intervertebral
discs of animal subjects and measuring inflammatory
cytokine levels, showed moderate degenerative changes.
Drs. Levine and Chahine conclude that this study provides
the first solid evidence that inflammation can exert a direct
role in cartilage degeneration of the IVD.
The next step, Dr. Chahine reports, will be to examine
human responses to TLR4 activation and inflammation.
They plan to enroll 100 patient volunteers undergoing
spinal surgery, using damaged tissue removed during their
procedures for laboratory investigation. The New York
State Department of Health is providing a grant to
bring on board a research fellow for one year to further
their work.
Inflammatory Mechanisms
in Cartilage Degeneration
TLR4

A 52-year-old woman was referred to us for a
neurosurgical evaluation in May 2012. She described
having experienced a “pop” in her lower back two weeks
earlier. The pop had rapidly developed into severe sciatica
of the left leg, accompanied by numbness, tingling and
occasional buckling. She was placed on oral steroids and
analgesics, and the pain, initially 10/10, subsided
significantly to 4/10. The weakness and numbness
continued and further MRI analysis found L3-L4 lateral
disc herniation. During the examination, straight leg
raising was found to be positive on the left side, left knee
reflex was absent, and there was decreased sensation on
the left thigh.
The patient’s surgeon recommended a microdiscectomy,
which was performed one week later.
The patient was prepped in the usual manner, receiving
general anesthesia, lower extremity EMG monitoring, and
C-arm visualization. A small incision was made and the
fascia beneath opened. A quadrant retractor was placed
over the L3-L4 facet and lamina revealing the L3 and L4
transverse processes. A high-speed burr was used to carry
out a left hemilaminectomy. Upon further penetration of
the ligamentum flavum, a severe compression of the left
L3 nerve root was also revealed and a complete
facetectomy performed to achieve decompression.
Finally, a discectomy was carried out and the disc space
prepared for an appropriately sized interbody prosthesis.
A combination of BMP and autologous bone was tamped
into place within the prosthesis and the entire unit
inserted under C-arm guidance. The pedicles were then
threaded, titanium screws inserted, and a rod inserted on
the left at L3-L4 to lock the fixation. The wound was
closed, a sterile dressing applied, and the patient was sent
to recovery.
She was instructed to do light exercising and stretching at
home, and returned for post-status check-ups at one and
four weeks. She reported greatly reduced radicular
symptoms as well as improvement in strength and
function. X-rays showed solid construct and alignment of
the spine at the surgical site.
Case Study
Microdiscectomy
Preoperative MRI showing L3-L4 disc herniation.
Postoperative MRI showing stabilization
after discectomy and fusion.
Postoperative MRI showing stabilization
after discectomy and fusion.

Traumatic brain injury (TBI) affects up to two percent of the
population per year. These incidents take a higher toll among
the young, who are more likely to be involved in high-impact
sports, dangerous lines of work, car accidents and assaults.
Close behind are the elderly, who are prone to serious falls,
and whose injuries are often complicated by being on blood-
thinning medications.
The degree of permanent damage due to a TBI may depend
less on the primary injury than it does on the cascade of
secondary complications that can set in hours or even days
after the primary injury. The ability to identify problems
before they worsen and to respond aggressively is critical to
the ultimate outcome.
For these reasons, TBIs require a range of highly specialized
neurosurgical services and post-surgical monitoring that is
only available at certain specialized hospitals. Our dedicated
team is on call 24/7 to evaluate patients in the emergency
room, identify those who may require surgical intervention
and carefully monitor the others as appropriate.
The first critical task in the ER is to evaluate the degree of
injury. This determination is usually made based on a
physical examination combined with information from the
attending paramedics or witnesses to the injury. Most
patients also are given a CT scan of the head.
Generally, 80 percent of TBIs are classified as mild with a
Glasgow Coma Score (GCS) of 13 to 15. These patients are
awake and are able to speak and follow commands. They
may be confused and lethargic, but should be easily
arousable. The other 20 percent are evenly divided between
moderate (GCS of 9-12) and severe (GCS of 3-8). The
moderate TBI patients have an altered sensorium, but are still
able to follow commands. The severe TBI patients are
comatose and are unable to follow even simple commands.
For these patients the outcome is less certain.
Closed head injuries are typically the result of blunt trauma
or a fall in which the head takes a significant hit. The impact
results in stresses as the brain sloshes repeatedly from side to
side within the skull before coming to rest. This motion can
stretch and tear neural cells, causing diffuse disruptions in the
brain’s communication network. Closed TBI may also result
in a brain contusion or bruising. This is usually managed
without surgery, unless the associated brain swelling
becomes severe.
Mild TBI: Most patients with a mild TBI do not require
surgical intervention, and ultimately make a good recovery
after a period of observation, medications and time.
However, a small proportion of these patients can suffer from
post-concussion syndrome, with symptoms that can include
memory loss, headaches, dizziness and loss of smell.
Moderate and severe TBI: The likelihood of needing
surgical intervention rises in patients with moderate or severe
TBI, and is usually determined by an initial CT scan followed
by a CT scan a few hours after admission to check for a
growing hematoma. This is especially true if the initial CT
scan shows any bleeding or if the patient is on blood-thinning
medications. Intracranial pressure (ICP) monitors are often
surgically placed on comatose patients.
Hematomas: There may be a large hematoma outside the
dura (epidural hematoma), or within the dura (subdural
hematoma). If these hematomas are causing significant
pressure on the brain, they need to be surgically removed
with a craniotomy, which involves cutting a hole in the skull
to temporarily remove a bone flap in order to access the
brain. Sometimes, in a procedure known as decompressive
craniectomy, the skull bone is not replaced or may be
removed a few days after the injury, in order to allow
the brain to swell without the ICP going to dangerously
high levels.
Penetrating or open head injuries: Most penetrating
injuries are caused by firearms, and vary in the damage
caused by the velocity and rotational impact of the type
of bullet. The management of these injuries is very specific
to the type of injury, its location and the patient’s
overall condition.
Post-operative care: After surgery, the patient is transferred
to the ICU and continuous monitoring begins. During this
time, staff watches for the subtle signs of secondary injuries.
These include excessive ICP, low blood pressure, fever,
high glucose levels, low serum sodium levels and seizures.
All of these factors can interfere with normal recovery.
Unfortunately, they are very common and occur in almost
all patients. Using an array of state-of-the-art tools, our
specialized teams are prepared to counter with aggressive,
rapid action when indicated. Delayed intracranial hematomas
or brain swelling can also require urgent surgery.
Monitoring devices: Intracranial pressure monitoring and
routine CT scans form the mainstay of monitoring TBI
patients. Electroencephalography (EEG) is being increasingly
used as we recognize the frequency of silent seizure activity in
the injured brain. Brain oxygen monitoring is also valuable in
some cases. Advanced transcranial Doppler (TCD)
ultrasonography is sometimes used to assess dynamic change
in the brain’s blood flow velocity and perfusion. When the
patient is more stable, MRI diffusion tensor imaging (DTI) is
performed to give us higher resolution imaging of white
matter, not only in the acute phase but also during the
recovery phase.
Emergency
Neurosurgery
for the Brain

Rick Madhok, MD
A 60-year-old woman was found
unresponsive at home, presumed to
have sustained a severe closed TBI
due to a fall. Rushed to the ER by
ambulance, her GCS was a critically
low 6. A CT scan showed a large
subdural hematoma with resulting
cerebral swelling and herniation,
though much of the blood collection
within appeared to be old, as though
the primary injury had occurred
several days earlier. The resulting
compression had caused the brain to
undergo a large midline shift, and an
emergency craniotomy was
performed. Re-expansion of the brain
was nearly complete 24 hours later.
Postoperatively, the patient showed
some improvement in pupil reactivity
as well as in facial motor responses,
but issues of functional connectivity,
visible on a series of fMRIs,
continued to indicate underlying
structural damage to white matter
associated with diffuse axonal injury
and cognitive impairment.
The patient was eventually moved to
a sub-acute facility where she initially
showed little improvement beyond
withdrawal motor responses. By
month five, however, when it was
time for her to be readmitted to the
hospital for a cranioplasty, she was
able to move about in a wheelchair
and to walk short distances
unsupported.
The patient’s skull was closed using a
titanium plate.
After the procedure, her condition
steadily improved, and she regained
the ability to speak and could move
about more easily. Her recovery
exceeded the expectations
of her doctors and family, and she has
continued to gain strength and
cognitive function since then.
At The Feinstein Institute for
Medical Research, neurosurgeon Raj
Narayan, MD and electrical engineer
Chunyan Li, PhD, have been
collaborating with scientists at the
University of Cincinnati since 2008
on the development of what they
anticipate will be the next generation
of brain monitoring devices. Their
“lab-on-a-tube” is a catheter system
packed with multiple miniaturized
sensors that allow for real-time
continuous in vivo monitoring of
critical parameters such as brain
tissue oxygen, blood flow,
intracranial pressure, temperature,
EEG and brain chemistry.
Using microelectromechanical
(MEMS) technology, their smart
catheter is compact, simple to use
and highly accurate.
It includes sensors both inside the
tube and outside, so in addition to
measures taken from the
cerebrospinal fluid (CSF) by its
interior sensors, the outer sensors
can transmit data about the
condition of the injured brain
tissue immediately surrounding
the catheter.
Progress toward a clinically-ready
device took a great step forward in
2010 when the US Department of
Defense provided $5 million towards
the research, in recognition of the
smart catheter’s potential to improve
outcomes for soldiers suffering TBI
in combat. The grant is shared by
Dr. Narayan and Dr. Li at North
Shore-LIJ and their colleagues at the
University of Cincinnati.
Lab-on-a-Tube
Case Study
Subdural Hematoma with Diffuse Axonal Injury

Rick Madhok, MD
A 59-year-old woman was struck by an automobile after
running into the road after her dogs. The impact resulted
in a severe closed head wound. On arrival in the ER, her
GCS was 9 and an initial CT scan showed diffuse
hemorrhaging and a small frontotemporal hematoma.
After stabilization, she was moved to the ICU and placed
on an intracranial pressure monitor. Over the next few
days, the intracranial injury evolved, generating an
increase in intracranial pressure. When the patient
proved unresponsive to medical therapy, a bifrontal
craniotomy was performed and a shunt was inserted into
her right ventricle to provide drainage. The patient
remained in the hospital for six weeks and was then
discharged to a subacute rehabilitation facility.
A month later, she was readmitted to the hospital for
acute secondary hydrocephalus, which required insertion
of another right external ventricular drain. The patient
remained in hospital for another six weeks, undergoing a
bifrontal cranioplasty when the swelling subsided.
Within two months she was making substantial progress,
able to track moving objects and to speak haltingly.
Within four months she had regained spontaneous
movement of all four extremities as well as her ability to
read and process written words. She continues to make
progress through rehabilitation.
Case Study
Acute Closed TBI and
Secondary Sequelae
CT scan without contrast demonstrating diffuse injury.
CT scan without contrast showing evolution of intracranial
injury with increase of intracranial pressure. Patient is
unresponsive to medical therapy.
CT scan without contrast demonstrating decompressive craniectomy.
CT scan without contrast demonstrating cranial reconstruction
and shunt placement.

Rick Madhok, MD
A 45-year-old woman sustained multiple skull, facial
and skeletal fractures as a result of being hit by a motor
vehicle while out walking on New Year’s Day.
Paramedics called to the scene found her bleeding
profusely from the head, but responsive to verbal
stimuli, her functional capacities intact, and her eyes
swollen and closed bilaterally.
She was taken into surgery for an emergent craniotomy
to relieve an epidural hematoma and for repair of
multiple skull base fractures. An oromaxillofacial
surgeon fixed her broken jaw and a plastic surgeon
attended to a 10 cm facial laceration and other
contusions caused by her contact with the pavement.
After several days in the ICU, she had her fractured left
elbow surgically repaired. Since that time, she has made
a remarkable recovery through rehabilitation and home
rest. She is now back at work.
Case Study
Multiple Trauma Case
CT scan without contrast demonstrating initial
small hematoma.
CT scan without contrast showing expansion of hematoma.
CT scan without contrast showing decompression of epidural hematoma.
Glasgow
Coma Scale
EYE OPENING
RESPONSE
SPONTANEOUS 4 POINTS
OPENS TO VERBAL COMMAND 3 POINTS
OPENS TO PAIN 2 POINTS
NONE 1 POINT
VERBAL RESPONSE
ORIENTED 5 POINTS
CONFUSED 4 POINTS
INAPPROPRIATE 3 POINTS
INCOMPREHENSIBLE 2 POINTS
NONE 1 POINT
MOTOR RESPONSE
OBEYS COMMANDS 6 POINTS
PURPOSEFUL 5 POINTS
WITHDRAWS FROM PAIN 4 POINTS
ABNORMAL FLEXION/DECORTICATE POSTURE 3 POINTS
EXTENSOR RESPONSE/DECEREBRATE 2 POINTS
NONE 1 POINT
The Glasgow Coma Scale is a tool for
measuring level of consciousness,
especially after a head injury.
Highest Score .........15
Coma ......................8 or less
Lowest Score ..........3

Craniocervical instability (CCI) is a condition where the
cervical spine is unable to maintain adequate alignment and
support of the cranium during certain movements, allowing
the head to “wobble.” The underlying cause of CCI is
structural: one or more bony and/or ligamentous anomalies
involved in the craniocervical junction prevent normal range
of movement of the head and neck. In many instances, the
instability reduces the cervical spaces through which the
brainstem and spinal cord pass, causing pressure on the
delicate soft tissue, with neurologic and vascular
consequences as well. Cushing Neuroscience Institute’s Chiari
Institute is one of the leading centers for the evaluation and
treatment of CCI in the country. While some patients with
CCI will improve sufficiently with conservative non-surgical
treatment, the remainder require complex surgical correction
and realignment. The sooner such interventions are begun
the better the outcome; CCI tends to worsen over time,
eventually causing irreversible damage to spinal nerves
and muscles and loss of physical strength and mobility.
Adding to the challenge for primary physicians and
pediatricians, identifying CCI in a patient can be difficult.
The first symptoms tend to be subtle, ambiguous and
intermittent; younger patients in particular may have
difficulty describing the various sensations they experience.
Since 50 percent of diagnosed CCI cases are associated with
certain congenital disorders — Down syndrome, congenital
scoliosis, cerebral palsy, ankylosing spondylitis, osteogenesis
imperfecta, neurofibromatosis and connective tissue disorders
such as Ehler’s-Danlos — special attention should be paid to
any member of this cohort exhibiting one or more symptoms.
The most common precursor of accidental CCI is whiplash
— the dynamic extensions and flexions of head and neck
associated with automobile crashes and contact sports. In
rare instances, the cause is iatrogenic — the result of bone
removal during a prior surgery to cut away a tumor or treat
Chiari syndrome. Ironically, the squeezing of the parts of the
brain through the hole at the base of the skull, referred to as
the Arnold Chiari or Chiari I malformation, is sometimes
taken to be the cause of signs and symptoms when actually
the squeezing results from craniocervical instability.
Common CCI symptoms to look for in patients with
otherwise undiagnosed cervical complaints include headaches
in the occipital space at the back of the neck and skull,
painful neck, torticollis, tingling and numbness in the upper
extremities, muscle weakness, difficulty walking, difficulty
swallowing, sleep apnea, snoring, drooling, progressive
hearing loss and recurring fatigue. Drop attacks, provoked
by specific movements of the head and neck that cause
temporary ischemia, are another. In the pediatric and
adolescent populations where physical growth can play a
part in the timing of CCI onset, an indicator may be as
simple as an increasing reluctance to participate in play.
Primary care physicians who suspect CCI in a patient should
initially order an MRI of the area to visualize the anatomy
and rule out other causes. At the Chiari Institute, experienced
neurologists and neurosurgeons can determine which
patients are likely to improve with conservative intervention;
these patients are prescribed physical therapy, strengthening
routines, relaxation training and medications. Patients with
acute or multiple CCI symptoms that will not respond to
therapy alone are considered for surgical stabilization
and/or fixation.
At the Chiari Institute, all CCI surgery is performed by a
team of neurosurgeons. Each patient’s anatomy is unique, so
each surgery requires extensive, pre-planned imaging and
bioengineering analysis to determine the patient’s operative
stabilization and fixation. Days before the surgery, the patient
goes through several hours of advanced dynamic MRI. This
pinpoints the location of millimeter-thin compressions that
are causing brain and spinal cord symptoms. We also
measure several critical craniocervical angles against norms;
these provide a basis for intraoperative surgical stabilization
and fixation.
The surgery itself is very delicate, typically taking 5-6 hours.
After the patient undergoes general anesthesia, the surgical
team makes one opening, approximately 10-15 inches in
length from the top of the head to the back of the neck. As
the surgical field is highly trafficked with vertebral arteries
and veins, the brainstem and critical cranial nerves, each step
in the realignment of bones, the remodeling of angles and in
the relief of compression points requires exquisite surgical
precision. A unique feature of our approach is the use of
intraoperative ultrasound during surgery, in addition to
continuous brainstem and spinal cord monitoring. This
guides precise adjustments during our realigning and
stabilization of the cranium on the cervical spine. Post-
operative recovery in the hospital takes 4-5 days, followed
by rehabilitation and a gradual return to normal activities.
AdvancedTreatment for
Craniocervical
Instability

Harold L. Rekate, MD, FACS, FAAP and
Salvatore Insinga, DO
An eight-year-old girl with multiple
birth defects related to monosomy of
chromosome 18p, was brought to us
from her home in another state for a
neurosurgery consult. She is of extremely
short stature, has hypothyroidism and
asthma, and is moderately
developmentally delayed with little
indication of language facility; her medical
history includes previous surgeries to
address various physical limitations. We
evaluated her to examine the causes of her
extreme difficulty in swallowing; she was
taking all her nourishment through a
gastrostomy tube. She also had frequent
bouts of uncontrolled coughing.
Our MRI scans showed a severe Chiari I
malformation together with bony
abnormalities of the anterior skull base,
resulting in occipitocervical instability,
anterior compression of the brainstem
from a retroflexed odontoid and basilar
invagination. We advised and performed a
decompressive surgery, realignment of the
occipital cervical region and fixation to
reduce instability, as these are key to the
patient’s swallowing issues and possibly
other problems. Intraoperatively, we found
her spinal cord sensory signals to be
normal, but her motor signals extremely
attenuated. Using ultrasound guidance,
our team first performed a surgical
reduction of her occipitocervical
instability. Next, under microscopic
visualization, we did an extensive
dissection of the scaring over the cerebellar
tonsils and an autologous tissue graft
was sewn in place to expand that area.
Subsequently the patient’s head was gently
repositioned in extension and distraction,
followed by insertion of permanent
fixation. This reduced pressure on the
anterior brainstem, thus improving motor
spinal cord signals dramatically.
By the fifth day, postoperatively she was
ambulating under oral pain medication.
By the eighth day, the patient showed a
marked improvement in her ability to
swallow and to eat ordinary solid food
comfortably. She was also speaking more
clearly, walking well and was in minimal
pain. She returned home where she
continues to improve.
Look for these symptoms of CCI in
patients with otherwise undiagnosed
cervical complaints:
• Headaches in the occipital space at the
back of the neck and skull
• Painful neck
• Torticollis
• Tingling and numbness in the upper
extremities
• Muscle weakness
• Difficulty walking
• Difficulty swallowing
• Sleep apnea
• Snoring
• Drooling
• Progressive hearing loss
• Recurring fatigue
Common Symptoms of
Craniocervical Instability
Case Study
Chiari Malformation
Preoperative sagittal cervical MRI showing
basilar invagination.
Postoperative MRI of the cervical spine showing
reduction of the odontoid (C2) process.

A 13-year-old female with Ehlers-Danlos syndrome, an
inherited disorder of connective tissue, came to us for
evaluation after undergoing two failed operations for
Chiari I malformation with syringomyelia at an out-of-
state institution. The child presented with incapacitating
headache, neck pain and loss of balance that confined
her to a wheelchair. Through advanced imaging and
other diagnostic tests, we identified a pseudomeningocele
and an anterior compression of the brainstem due to
severe instability of the cervical spine in the regions of
C1, C2 and C3.
Our team used a combined procedure to correct the
existing defects. In the first stage, the anesthetized
patient was put in a Mayfield head holder under mild
flexion while she underwent a posterior fossa
decompression revision. Several holes in the dural patch
attributed to the earlier craniectomies were found to be
leaking spinal fluid and were closed. At this point
intraoperative ultrasound was brought in, revealing that
the anterior brainstem was being distorted by the
odontoid process, significantly reducing ventral CSF
flow. We then performed an occipitocervical fusion.
Adjusting the head holder, the patient’s neck was put in
significant extension. When we determined that
sufficient space was opened between the brainstem and
the odontoid process to achieve decompression, the
fusion was completed.
The patient’s recovery was uneventful and on the fifth
day, postoperatively she was discharged home. Beginning
physical therapy six weeks later, she subsequently
improved to the point that she was able to return to
school and resume normal activities.
Case Study
Chiari 1 Malformation with
Syringomyelia
Preoperative sagittal cervical MRI
showing basilar invagination.
X-ray of the cervical spine showing the instruments used
to fix the position of the skull and spine to prevent
damage to the front of the brain.

This 46-year-old female came to us with a long history of
health problems consistent with fibromyalgia and chronic
fatigue syndrome. She reportedly managed well enough
with exercise until 2007 when she hit her head on the edge
of a cabinet and suffered the first of her chronic severe
prolonged headaches. Since then, the headaches began to
interfere with her ability to work. She also reported
gastroesophageal reflux, irritable bowel syndrome,
lightheadedness, pervasive fatigue, burning pain in neck
and shoulders, tingling and numbness in extremities and
nystagmus. Her pain reportedly spiked with the Valsalva
maneuver and was relieved when lying down.
Consulting neurosurgeons near home, she was assured
that she did not have Chiari I. She then sought treatment
at a renowned, out-of-state headache institute, had
Botox® injections to reduce muscle tension, and took
various pain relief medications, none of which brought
relief. In 2010, coincident with a lumbar puncture test, she
experienced two weeks of low-pressure headaches
followed by a week of improvement, leading another
specialist to diagnose pseudotumor cerebri or idiopathic
intracranial hypertension. The patient was urged to try
therapeutic lumbar punctures every 4-6 weeks. She then
sought our expertise.
We supplemented MRIs from her previous physicians with
our own dynamic MRI and identified a severe degree of
tonsillar descent. Her images indicated an abnormally
acute retroflexed odontoid process causing distortion of
the upper end of the spine into the brainstem. We also
detected the absence of a cisterna magna between the
cerebellum and the medulla oblongata where CSF
normally drains.
Surgical intervention consisted of performing an
occipitocervical decompressive craniectomy to relieve the
area of neural compression. Subsequently, using
ultrasound guidance, traction and realignment proceeded
to establish CSF flow to a newly created cisterna magna
anterior to the brainstem. Intraoperative fluoroscopic 3D
imaging showed that the cervical spine was now in normal
alignment. The operation concluded with fixation and
fusion of the cranium to the cervical spine in this newly
formed angle. Postoperatively the patient was in an
improved state and returned home.
Case Study
Severe Headache Resulting
from Craniocervical Instability
Preoperative sagittal brain and cervical MRI
showing length of 9mm Grabb.
Postoperative MRI of the cervical spine showing that the
elements of the cervical spine in front the brainstem are no
longer pushing into the brain.

Scoliosis is a complex three-dimensional
deformity of the spine. The condition causes
lateral curves of the spine to the right or left,
decreased forward and/or lateral flexion, and
asymmetric shoulder and pelvic positioning. In
more pronounced cases of vertebral rotation, a
rib hump develops on the convex side of the
curve and a lesser protrusion on the chest. In
more recent years, an increased number of
patients have been seeing neurosurgeons to correct
their deformities. With fully half of a
neurosurgeon’s seven-year-long residency training
devoted to spinal disorders, and another year or
more of fellowship training specifically in treating
deformities, our team of neurosurgical specialists at
the Cushing Neuroscience Institute are particularly
well-suited to diagnosing and treating the
complexities of both adult and adolescent scoliosis.
Not all consultations at the Cushing Neuroscience
Institute lead to surgical intervention; our solutions
are highly individualized, depending on each
patient’s age, discomfort, coexisting conditions,
functional limitations, progress of the disease and
cosmetic appearance. We begin our evaluation
with a series of visual and radiographic tests.
A key indicator is the patient’s Cobb angle, a
measurement of the angle of curvature of the
spine at its apex. An adolescent with a Cobb
angle less than 40 degrees is usually treated
medically with physical therapy and
temporary orthotic bracing, on the premise
that the developing bone and musculature
are still malleable enough to respond to
noninvasive correction. Watchful waiting
that includes yearly serial radiographic
evaluations is the prescribed follow-up,
with the understanding that surgery may
be needed later.
By contrast, we regard any teenager
presenting with a Cobb angle between 40-50
degrees to be in a “gray zone” concerning
surgical intervention. Not only is the curve —
in being more pronounced — less amenable to
easy correction with bracing, but the
youngster’s own self-image and level of activity
are probably suffering too. We also look at
prior history to get any clues as to how fast the
curve has progressed and whether there is a
family history of scoliosis.
Lastly, when we see an adolescent patient with a
Cobb angle of 50 degrees or more we start
thinking about an operation, the sooner the
better, as this degree of deformity is usually a
sign that it will continue to grow if unopposed.
A different set of considerations guides our
treatment of adult scoliosis. The condition
most commonly develops de novo at an older
age, though a small percentage of cases
actually trace to mild childhood scoliosis that
has gone previously undetected. As the spine
goes through wear and tear, compensatory
ligamentous and muscular stabilizers can no
longer maintain alignment, as the natural
regional curves of the spine weaken,
significant sagittal plane imbalance (upper
body pitched forward) may develop. In yet
another version — degenerative scoliosis —
the condition may arise in later life,
particularly as the result of arthritic changes.
The disc spaces and facet joints collapse
asymmetrically, causing coronal plane (side-to-
side) imbalances, with frequent nerve
impingement a result.
The most common clinical complaint of adult
scoliosis is chronic back pain and radiculopathy
(leg pain). The pain may be caused by the
unequal tension placed on back muscles and
ligaments, or asymmetrical loading, when
individual facet joints compress nerve roots as
they are pulled out of alignment. Radicular pain
and claudication, neurological symptoms
including numbness in the extremities, are other
common sources of discomfort.
Neurosurgeons tailor surgical treatment options
to the patients in order to get the maximum
result with the minimum amount of surgery. If
conservative treatments have failed and
surgery is an option, minimally invasive
surgery is considered foremost. However, if
open surgery is elected due to the patient's
needs, physicians will customize the surgery
to the individual patient. Thanks to the
practice of using intraoperative imaging
(C-arm fluoroscopy), and when needed,
stereotactic guidance to place pedicle
screws, we are able to achieve positive
results in the treatment of adolescent
and adult scoliosis patients.
Adolescent and
Adult Scoliosis

Ahmad Latefi, DO
A 16-year-old young woman was referred
to us complaining of significant back pain
mostly at the thoracolumbar junction.
Her postural presentation revealed three
abnormally exaggerated coronal curves,
at least one of them presumed to be
structural and the other(s) compensatory.
She reports having been examined for
scoliosis eight years earlier at which time
mild idiopathic scoliosis was detected and
a conservative treatment approach
recommended. A review of those earlier
films showed a clear progression of the
curvatures, with the apex of the deformity
at the T12-L1 site estimated at over 60
degrees. Physical examination showed that
her sensory responses and reflexes were
normal, her muscle strength 5/5, her
general state of health good.
Before a treatment plan could be
discussed, the patient was sent for a
number of full-length x-rays, an MRI to
visualize the spinal cord, and a CT scan of
the cervical, thoracic and lumbar spine to
assess the integrity of bony structures and
the size of pedicles. Seeing clearly that the
thoracolumbar curve was the site of the
deformity and of the dynamic rotation,
we recommended surgical correction,
including insertion of instrumentation
from T8 to L4 vertebral levels, followed
by osteotomy and fusion.
During summer vacation in July, she
underwent the proposed procedure, using
intraoperative sensory and motor EPs to
monitor integrity and CT scans to assess
and plan for the correct placement of the
multiple fixation screws that would
anchor the instrumentation.
Fourteen days postoperatively, the patient
reported restored balance and receding
pain. She is able to stand straight, head
positioned normally over the midline of
her pelvis. Long-cassette x-rays show her
Cobb angle was now corrected to an
acceptable 25 degrees. At her three-month
follow-up, she had healed nicely, felt good,
was back in school and very happy with
her results.
Case Study
Exaggerated Coronal Curves Fixed
Ahmad Latefi, DO
A 28-year-old female native of a foreign
country, currently studying in America,
was referred to us in June 2012. She
reported that she had been diagnosed with
adolescent idiopathic scoliosis, but that
she deferred treatment until coming to this
country. She also stated that the curve had
progressed over time and that it was
physically and cosmetically painful. Her
general appearance revealed a pronounced
dextroscoliosis that was concentrated in
the proximal thoracic. Her right shoulder
was mildly elevated compared to the left.
The x-rays she brought with her
confirmed the dextroscoliosis, but in order
to get a more complete description of her
deformity, long-cassette films were
ordered which included standing lateral
and side-bending anteroposterior views.
A CAT scan and an MRI of the cervical,
thoracic and lumbar spine regions were
also ordered.
Upon receipt of these new images, the
patient was found to have thoracic
scoliosis with a Cobb angle of 90 degrees.
We recommended surgical correction
consisting of T1 to T12 instrumentation,
and T6 vertebral column resection; the
two-phase operation was scheduled for
two days in early September. Surgical
intervention was carried out while
sensory and motor responses were
monitored; they remained at the
patient’s preoperative baseline.
The patient returned for her post-op
examination in late September, reporting
some residual pain but otherwise very
pleased. The visible hump in her thoracic
spine was entirely gone. Her shoulders are
now symmetrical and leveled and her head
is in midline position, indicating that she is
coronally balanced. Her Cobb angle has
been reduced by half and is now at 40
degrees, the maximum possible without
additional surgery. A temporary
stabilization brace and external bone
stimulator device were provided to hasten
healing, but all the goals of the initial
deformity surgery have been met. She is
now standing and walking comfortably.
She is understandably happy with
the improvements.
Case Study
Two-Phase Scoliosis
Intervention
(Left) Preoperative and (right) postoperative
x-rays of adolescent idiopathic scoliosis.
Anteroposterior (AP)
and lateral
preoperative x-ray
showing
thoracolumbar
scoliosis in an
adolescent patient
and AP and lateral
postoperative x-rays.
Preoperative Postoperative

18 CLINICAL NEUROSCIENCE NEWS
The patient is a generally healthy, alert
79-year-old female with a four-year
history of debilitating lower back pain
for which physical therapy has
provided no relief. In 2010 she
underwent a failed micro lumbar
discectomy at another hospital, after
which she developed progressively
worsening radiating pain in both legs.
An epidural steroid injection six
months after surgery also brought no
improvement. In October 2011 she
came to North Shore-LIJ’s Cushing
Neuroscience Institute for a surgical
consult, bringing a recent MRI of her
lumbosacral spine. We identified severe
spinal stenosis and spondylolisthesis
with degenerative scoliosis localized at
L3-4 and L4-5. After discussions with
the patient and family members we
recommended a multilevel bilateral
decompressive laminectomy, medial
facetectomy and foraminotomy in
conjunction with insertion of fixation
hardware and intertransverse
autologous bone graft to supplement
spinal fusion.
The surgery, performed in November
2011, began with the patient placed on
her side and under general anesthesia.
After being wired for lower extremity
EMG and somatosensory-evoked
potential monitoring, the first phase of
surgery began with discectomies in the
L3-4 and L4-5 disc spaces. Once the
damaged disks were removed they
were replaced with PEEK interbody
prostheses. Each prosthesis was
precisely sized according to the
interbody space available and filled
with Osteofil bone matrix to enhance
grafting. The prostheses were then
tamped into place under interoperative
AP and lateral C-arm (fluoroscopy)
guidance, with excellent reductions in
the patient’s degenerative scoliosis and
subluxation obtained. Throughout
continuous intraoperative EMG
stimulation using the Neurovision
retractor/dilator system provided safe
percutaneous passage through the
surrounding tissues of the spine and to
the spinal nerve roots.
During the next phase-the patient
was placed on her stomach and a
small posterior midline incision
made over L3 to L5 with the goal of
decompressing associated nerves and
preparing the way for a fixation device
to stabilize the spine at this location.
The spinous processes of L3 and L4
were removed after which a bilateral
decompressive laminectomy was
carried out. A high-speed drill was
then used to drill down through facet-
transverse processes bilaterally at L3,
L4 and L5. (On the right side, where
the patient’s primary pain symptoms
were found, the dura was found to be
eroded into a cellophane-thin layer in
several places due to chronic wear.
These were sutured closed.)
Lastly, the six holes previously drilled
were probed for stability and holding
capacity, titanium screws inserted, and
custom-bent titanium fixation rods
inserted to create a permanent internal
brace or cage. Bony material harvested
from the laminectomy were prepared
in a bone mill and used to complete an
autologous bone graft between the
transverse processes.
Case Study
Debilitating Lower Back Pain
(Left) Preoperative CT of severe left lateral
listhesis and (right) postoperative xray of
a minimally invasive XLIF with posterior
screw placement for stabilization in an
80-year-old male.
Ahmad Latefi, DO
A 59-year-old female was referred to us
in August 2012 because of worsening
intractable lower back pain with
radiation to her left lower extremity.
She stated that she had undergone back
surgery 30 years earlier for unidentified
issues and had subsequently received
all forms of conservative care including
chiropractic, physical therapy and
epidural steroid injections in search
of relief with minimal to no effect.
She also stated that she was diagnosed
with curvature of the spine when she
was younger.
On physical examination in the office,
she was found to have a forward
posture with a complete absence of
normal lumbar lordosis. Her motor,
sensory and cerebellar responses were
within the normal range and her
reflexes and gait were found to be
normal and symmetric. The patient’s
previous MRI studies were also
examined and revealed a sagittal
deformity as well as the previously
noted flat back. In order to determine
the cause of the back pain and develop
treatment, a scoliosis series of x-rays
were subsequently ordered. The
resulting preoperative diagnosis was
fixed sharp kyphotic deformity, sagittal
imbalance and
dextroscoliosis. Spinal
instrumentation and
fusion were deemed
the appropriate means
to achieve spinal
alignment and
eradicate pain due to
nerve impingement
and the corrective
surgeries were scheduled.
The patient, a teacher, was able to
return to the classroom after recovery.
She is able to stand straight and to look
straight ahead. Her pain is significantly
improved with the result that she no
longer needs narcotic pain medications.
Case Study
Intractable Lower Back Pain
(Left) Preoperative and (right)
postoperative correction of a
kyphotic deformity.

The patient, an 82-year-old male, came to us for a
neurosurgical evaluation after having noted a relatively
rapid deterioration in his ability to walk. Once a vigorous
hiker, he had been diagnosed by his primary physician
with peripheral neuropathy, balance issues, and neck
stiffness. He also has some claudication type symptoms
with significant back pain radiating into the lower
extremities when he walked or stood for even brief
periods. Earlier EMG and nerve conduction studies
showed findings compatible with peripheral neuropathy
and possible multilevel lumbar radiculopathy. Imaging
studies of the lumbar spine showed spondylolisthesis with
profound stenosis at L3-4 moderating somewhat above
and below. Degenerative spondylosis was identified as the
precipitating factor.
Upon examination at Cushing Neuroscience Institute we
noted a markedly reduced range of motion in the neck
specific to extension and right rotation. Patient’s reflexes
were depressed throughout and his plantar reflexes were
mute as well. We recommended an MRI of the cervical
spine to investigate possible cervical spondylitic
myelopathy as an additional pathology. When the MRI
report came back, it revealed severe cervical stenosis at
C4-5 and C5-6 with disc osteophytes causing spinal cord
compression. It was then determined through discussions
with surgeons and patient that surgery to correct this
condition should take precedence over the lumbar issues.
A week later the patient underwent surgery for spinal
cord compression in the cervical spine.
The patient was given general anesthesia and his motor
and sensory EPs set up for monitoring. He was positioned
with head, neck, and body all in a neutral position on a
doughnut pillow so that the anterior aspect of his neck
was accessible. Using C-arm intraoperative imaging
guidance, the surgeon made an incision just above the C5
vertebral body to permit exposure of the cervical spine
from the midline to the medial border of the
sternocleidomastoid muscle on the left side. The
associated muscles were retracted and the C4-5 disc was
completely removed giving access to a broad-based
osteophyte projecting from the inferior aspect of C4. This
bony projection was also drilled down to a thin residual
ledge and removed, along with a ligament across the back
of the disc space. With total neural decompression
achieved at this site, an appropriately sized ROI-C®
interbody prosthesis filled with demineralized bone
matrix was tamped into place and locking plates applied
to complete segmental fixation.
A similar discectomy, osteophyte/ligament removal and
decompression were then carried out at C5-6, with the
same corrective results. Throughout the procedure the
patient remained stable with no change in EP potentials
and minimal firing from the EMG.
At the patient’s request, the lumbar correction was
postponed for a year, at which time the patient returned
to have his L2-5 spinal stenosis with degenerative
scoliosis and nerve root impingement surgically relieved.
Given general anesthesia and with routine EP monitoring
devices in place, the patient was placed on his right side
and further positioned so that when viewed
intraoperatively on the C-arm the critical areas were
precisely visible and in symmetrical position. Small skin
incisions were made above the left iliac crest to access L3-
5 and L2-3, after which dilators were placed under
continuous EMG stimulation to open up and navigate
safe passage through the layers of muscle to the disc
spaces. Discectomies and insertion of appropriate PEEK
interbody prostheses filled with demineralized cell matrix
were sequentially performed at L4-5 and at L3-4. With
these interventions the patient’s lateral scoliosis and
spondylolisthesis were observed to be markedly
improved. The remodeling also permitted safe access to
the L2-3 level, allowing the surgical team to complete a
third diskectomy and interbody arthrodesis at L2-3.
The patient tolerated the procedure well and eight weeks
later the patient was pain-free and back at work.
Case Study
Reduced Range of Motion
Postoperative x-ray after a C4-5 and C5-6
anterior cervical discectomy and fusion
without anterior plating.

Brain tumors rank relatively low in overall cancer incidence in the US, but they
are among the most difficult malignancies to treat. Because tumor activity is
associated with a heterogeneous assortment of neurological, motor and
behavioral changes, getting the right diagnosis as early as possible can be
critical to the outcome. Referral to a high-volume specialized center staffed by
experts who can bring to each case years of experience and cutting-edge
interventions can save valuable time and, in many instances, brain tissue.
Since its establishment in 2007, our Brain Tumor Center has been staffed with
specialists in brain tumor science, many of them recognized internationally as
pathfinders in this burgeoning field.
Methodology
Surgical removal via craniotomy has long been the principal treatment for
masses located in parts of the brain that can be resected without damaging
critical neurological functions. Targeted radiation and chemotherapy are often
used as secondary treatments to further suppress the ability of any tumor cells
that may remain after resection to survive, but radiation and drugs also pose
risks to surrounding healthy brain tissue.
Research into even more effective treatments for brain tumors is beginning to
pay off in a new generation of more effective clinical treatments. Abnormal
masses that were once regarded as surgically inoperable are now yielding to
sophisticated new strategies that sometimes achieve 100 percent recision, with
minimal or no neurological impairment.
Multidisciplinary Approach
The center is organized around a multidisciplinary program with a variety of
specialists all playing roles in care. As an individualized treatment strategy is
developed, the patient’s progress is reviewed in detail at a weekly 20-member
CNS Tumor Board.
We also work closely with scientists at The Feinstein Institute for Medical
Research, where work is currently focused on expanding knowledge of such key
issues as the signaling mechanisms that stimulate brain tumor invasion and the
specific proteins that protect certain malignant cells from the therapeutic (i.e.
killing) effects of radiation. From this collaboration we gain first-hand exposure
to the best new thinking on more effective strategies to pursue.
Naming and Grading Tumors
A key part of brain tumor diagnosis is developing a full picture of the tumor, a
process of naming and grading. Benign tumors grow relatively slowly, have
distinct margins and can often be cured entirely through surgical recision.
Malignant tumors are typically aggressive in growth and always
potentially life-threatening.
Brain tumors are also classified according to whether they
begin in the brain (primary tumor) or arise as secondary
tumors — colonies from primary tumors that have
metastasized elsewhere in the body. Tumors are further
identified on the basis of their type. Gliomas develop
from the supportive, or glial tissue of the brain. They
include astrocytomas, ependymomas, and mixed
gliomas and represent 30 percent of all brain
tumors. Non-glial tumors include
medulloblastomas, meningiomas and
schwannomas. Lastly, the grade of a brain tumor
is also a significant determinant of treatment.
Grade I is the least advanced and most
contained; Grade IV is very advanced.
Three advanced modalities for which the Brain Tumor Center is particularly
known are intraoperative MRI (iMRI) and awake brain mapping; laser interstitial
thermal therapy (LITT); and stereotactic radiosurgery (SRS).
Intraoperative MRI (iMRI) provides real-time image guidance to the surgeon in
carrying out precise resections of brain tumors in critical locations. Before the
clinical introduction of intraoperative imaging it was often difficult to distinguish
the margins of a tumor from the healthy normal brain around it, despite having
excellent preoperative maps. Dr. Schulder was the first neurosurgeon in North
America to employ the PoleStar® intraoperative MRI for brain surgery and
remains the leading user of this technology in the United States.
Laser Interstitial Thermal Therapy (LITT): Our center was one of the primary
investigators of this new interventional treatment for tumors that have
metastasized and cannot be removed by surgical means. (See Case Study #1). A
thin fiber is inserted into the tumor via a minimally invasive surgical approach.
The laser beam destroys the tumor by heating it from the inside out, under real-
time MRI guidance.
Stereotactic Radiosurgery (SRS) is a form of minimally invasive neurosurgery
that targets brain tumors with extremely precise high-energy radiation beams,
biologically inactivating cancer cells and reducing the tumor, often in a single
dose. We have been working with SRS at the Cushing Institute since 2005. This
technology combines CT and MRI imaging, multi-directional photon beam
delivery, and analytical software to analyze the 3-D shape and volume of the
tumor and create a customized radiation program.
Gamma Knife® therapy uses doses of radiation to kill cancer cells but does so
by focusing many beams each of relatively low intensity to target a brain tumor,
typically up to 4 cms in size. We are pleased to announce the imminent opening
of the North Shore-LIJ Gamma Knife® Center, which will add significantly to our
radiosurgery capabilities. The Gamma Knife® was the first practical device for
SRS and remains a leading technological standard for this treatment method.
Sharing Our Experience: Upcoming Programs in
Spring 2014
Each spring Dr. Michael Schulder and Dr. Jonathan Knisely, co-directors of the
North Shore-LIJ Center for Stereotactic Radiosurgery, run a one-day continuing
medical education (CME) program, a combination of talks, case presentations
and panel discussions aimed at physicians, physician assistants, nurse
practitioners and allied health care professionals interested in learning more
about stereotactic radiosurgery and stereotactic body radiation and their
applications. Our fourth such CME meeting is scheduled for Monday, March 3,
2014 and will be held at The Feinstein Institute for Medical Research. For more
information or to enroll, call 516-562-3065.
We are also honored that Drs. Schulder and Knisely have been
selected as co-chairs for the 17th International Leksell
Gamma Knife® Society Meeting, which will be held in New
York City May 11-15, 2014. An important objective of the
Society is the development of best practices in
Gamma Knife® surgery, fostered by bringing
together internationally recognized speakers in
the fields of neurosurgery, radiation oncology
and medical physics, in addition to key
presenters in other areas of medicine and
society. The Society is named for the
visionary Swedish neurosurgeon Lars Leksell
(1907-1986), who developed the Gamma
Knife® and was also a principal in the
development of SRS.
TAKING ON
BrainTumors
20 CLINICAL NEUROSCIENCE NEWS

Michael Schulder, MD, FAANS
40-year-old woman had an eight-year history of
recurrent carcinomas of the left breast, which had in
recent months metastasized to a half-dozen or more
lesions in the brain. The patient was treated with whole
brain radiation therapy.
Two years later, the patient returned for a surveillance
MRI, at which time we found a new left posterior
frontal tumor measuring 6 mm. These tumors were
treated with stereotactic radiosurgery (SRS). Revisited
after seven months, another MRI showed that all the
previously treated tumors were under control but a
right high frontal tumor measuring 3.5 mm had arisen.
This tumor was also treated with SRS.
A year after this last treatment it was determined that
this same lesion continued to resist radiation treatment
— its diameter had grown to 18mm — and that the
best remaining option was to use laser interstitial
thermal therapy (LITT). The procedure was done under
local anesthesia with intravenous sedation. A flexible
optical fiber probe was inserted so as to penetrate the
center of the tumor, which was ablated successfully
using real-time MRI guidance. The patient was
discharged home the next day.
Case Study
Laser Interstitial Thermal Therapy
(LITT) for Metastatic Brain Tumor
Preoperative MRI showing metastatic brain tumor.
Live image showing temperature during LITT.
Tumor ablation with expected ring enhancement post LITT.

A 76-year-old woman presented with a four-
week history of subacute ataxia or gait. An
MRI revealed a pineal mass causing obstructive
hydrocephalus. Using intraoperative MRI, a
minimally invasive stereotactic biopsy was
done, revealing the tumor to be a benign
pineocytoma. At the same time, the patient’s
hydrocephalus was treated by placing a
ventricuoperitoneal shunt that drained the
blocked fluid from her brain. She returned to
her previous intact neurological state, and the
pineocytoma was successfully treated with SRS.
However, a year later the patient returned with
symptoms of significant visual field loss; MRI
showed a new suprasellar cyst. A catheter was
placed under intraoperative MRI guidance, and
the cyst was drained successfully. The patient’s
vision returned to normal.
Case Study
Intraoperative MRI and
Stereotactic Radiosurgery
for Pineocytoma
MRI showing pineal mass and obstructive hydrocephalus.
Stereotactic radiosurgery treatment plan for pineocytoma.
Cyst before and after catheter drainage with intraoperative MRI.

Michael Schulder, MD, FAANS and
Jonathan P.S. Knisely, MD
A 64-year-old year old woman complained
of left-sided hearing loss. She had
longstanding hearing loss in the right ear as
well. MRI revealed a 1.1 cm vestibular
schwannoma on the left. Treatment options
— from observation alone to surgical
removal or stereotactic radiosurgery (SRS)
— were described and we recommended
SRS as offering the highest likelihood of
tumor control and the best chance of
hearing preservation.
A radiosurgical plan was created to treat the
patient over five days. The patient received a
total dosage of 25 Gy/5 (25 Gy ionizing
radiation delivered over five days or
fractions). The patient has since returned for
annual follow-up MRIs and examinations.
Two years later, the vestibular schwannoma
remains controlled and she has experienced
no further hearing loss in her left ear.
Case Study
Stereotactic Radiosurgery
for Vestibular
Schwannoma
MRI prior to SRS showing left vestibular schwannoma.
MRI three years after SRS.
Radiosurgery plan for treatment in 5 fractions. The red line surrounding the tumor
is the conformal prescription dose. The lower isodose lines show a steep dose
gradient so that very little brain tissue will be irradiated.

NEUROSURGEONS
Paolo Bolognese, MD
Phone: (516) 570-4400
E-mail: pbologne@nshs.edu
David J. Chalif, MD, FACS
Phone: (516) 562-3070
E-mail: dchalif@nshs.edu
Amir R. Dehdashti, MD, FACS
Phone: (516) 562-3026
E-mail: adehdashti@nshs.edu
Mark B. Eisenberg, MD
Phone: (516) 773-7737
E-mail: meisenberg@nshs.edu
Peter Hollis, MD
Phone: (516) 773-7737
E-mail: phollis@nshs.edu
Phone: (631) 591-7470
E-mail: sinsinga@nshs.edu
Robert G. Kerr, MD, PhD,
FRCPSC
Phone: (631) 351-4840
E-mail: rkerr1@nshs.edu
David J. Langer, MD
Phone: (212) 434-3900
E-mail: dlanger@nshs.edu
Ahmad Latefi, DO
Phone: (516) 773-7737
Email: alatefi@nshs.edu
Mitchell E. Levine, MD
Phone: (516) 773-7737
E-mail: mlevine@nshs.edu
Ashesh Mehta, MD, PhD
Phone: (516) 325-7061
E-mail: amehta@nshs.edu
Mark A. Mittler, MD, FACS, FAAP
Phone: (516) 354-3401
E-Mail: mmittler@nshs.edu
Raj K. Narayan, MD, FACS
Phone: (516) 562-3816
E-mail: rnarayan@nshs.edu
M. Chris Overby, MD
Phone: (516) 773-7737
E-mail: moverby@nshs.edu
Harold L. Rekate, MD,
FACS, FAAP
Phone: (516) 570-4400
E-mail: hrekate@nshs.edu
Steven J. Schneider, MD,
FACS, FAAP
Phone: (516) 354-3401
E-mail: sschneid@nshs.edu
Phone: (516) 562-3065
E-mail: mschulder@nshs.edu
Justin M. Thomas, MD
Phone: (631) 591-7470
E-mail: jthomas33@nshs.edu
NEUROLOGISTS
Rohan Arora, MD
Phone: (516) 562-3066
E-mail: rarora@nshs.edu
Karen Blitz, DO
Phone: (516) 674-7500
E-mail: kblitz@nshs.edu
Li-Fen Chen, MD
Phone: (516) 674-1647
E-mail: lchen6@nshs.edu
Alexis Demopoulos, MD
Phone: (516) 562-3065
Email: ademopou@nshs.edu
Robert A. Duarte, MD
Phone: (516) 325-7070
E-mail: rduarte@nshs.edu
David Eidelberg, MD
Phone: (516) 325-7050
E-mail: deidelbe@nshs.edu
Zianka Fallil, MD
Phone: (516) 352-7060
E-mail: zfallil@nshs.edu
Andrew Feigin, MD
Phone: (516) 325-7050
E-mail: afeigin@nshs.edu
Marc L. Gordon, MD, FAAN
Phone: (516) 325-7000
E-mail: mlgordon@nshs.edu
Cynthia L. Harden, MD
Phone: (516) 325-7060
E-mail: charden@nshs.edu
Sean T. Hwang, MD
Phone: (516) 325-7060
E-mail: shwang2@nshs.edu
Ronald Kanner, MD, FAAN, FACP
Phone: (516) 325-7000
E-mail: rkanner@nshs.edu
Jeffrey M. Katz, MD
Phone: (516) 562-3064
E-mail: jkatz2@nshs.edu
Roger W. Kula, MD, FAAN
Phone: (516) 570-4400
E-mail: rwkula@nshs.edu
Danijela Levacic, MD
Phone: (516) 562-3065
Email: dlevacic@nshs.edu
Richard Libman, MD, FRCP(C)
Phone: (516) 562-2013
E-mail: rlibman@nshs.edu
Aviva Lubin, MD
Phone: (212) 434-4070
E-mail: alubin@nshs.edu
Martin Niethammer, MD, PhD
Phone: (516) 325-7050
E-mail: mniethamme@nshs.edu
Rafael Alexander Ortiz, MD
Phone: (212) 434-4070
Email: rortiz3@nshs.edu
Shalini Patcha, MD
Phone: (631) 351-5757
E-mail: spatcha@nshs.edu
Chilvana Patel, MD
Phone: (516) 325-7000
E-mail: cpatel1@nshs.edu
Noah Rosen, MD
Phone: (516) 325-7070
E-mail: nrosen2@nshs.edu
Daniel B. Rubin, MD, PhD
Phone: (516) 325-7000
E-mail: drubin@nshs.edu
Lyubov Rubin, MD
Phone: (516) 674-7500
E-mail: lrubin@nshs.edu
Guy Schwartz, MD
Phone: (516) 325-7050
E-mail: gschwart@nshs.edu
Musarat Shareeff, MD
Phone: (631) 271-1206
E-mail: mshareeff@nshs.edu
Beth Silverstein, DO
Phone: (516) 674-1647
E-mail: bsilverstein@nshs.edu
Scott J. Stevens, MD
Phone: (516) 325-7060
E-mail: sstevens2@nshs.edu
Santo Primo Terranova, DO
Phone: (516) 325-7000
E-mail: sterrano@nshs.edu
Murthy Vishnubhakat, MD
Phone: (516) 325-7000
E-mail: svishnub@nshs.edu
INTERVENTIONAL
NEURORADIOLOGIST
Avi Setton, MD
Phone: (516) 562-3021
E-mail: asetton@nshs.edu
NEUROINTENSIVISTS
Gregory Kapinos, MD, MS
Phone: (516) 562-3590
Email: gkapinos@nshs.edu
David LeDoux, MD
Phone: (516) 562-3590
E-mail: dledoux@nshs.edu
Celine Rahman, MD
Phone: (516) 562-3590
E-mail: crahman@nshs.edu
PHYSIATRIST
Shaheda Quraishi, MD
Phone: (516) 325-7000
E-mail: squraish@nshs.edu
NEUROPSYCHOLOGISTS
Paul J. Mattis, PhD, ABPP-CN
Phone: (516) 325-7000
E-mail: pmattis@nshs.edu
Sarah Schaffer, PhD, ABPP-CN
Phone: (516) 325-7000
E-mail: sschaffer1@nshs.edu
PSYCHOLOGIST
Dennis Thornton, PhD
Phone: (516) 325-7070
E-mail: dthornto@nshs.edu
Cushing Neuroscience Institute
North Shore University Hospital
300 Community Drive, 9 Tower
Manhasset, NY 11030
neuro@nshs.edu
NEUROSCIENCE STAFF
To learn more about the Cushing
Neuroscience Institute visit
NeuroCNI.com or scan the QR code.

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