Editor’s Message Concussion Brain Tumor Story TFAS Study Upcoming Events

Physiatrists Brian Couri, MD Daniel Hurley, MD Min Kyung Kim, MD Howard Robinson, MD Christine Villoch, MD Surgeons Thomas Brown, MD Kenneth Heiferman, MD Dean Karahalios, MD Martin Luken, III, MD Edward Mkrdichian, MD Gail Rosseau, III, MD Noam Stadlan, MD

CINN has specialists available to evaluate job requirements and susceptibility to back injuries. If you are interested in this service, please contact Lisa Dombro at ldombro@cinn.org

Editor’s Message In this issue of the Discussant, CINN’s electronic newsletter focused on the worker injury community, we highlight the importance of understanding the incidence and seriousness of concussion.  While concussion does take place in the work place, the issue is even more pronounced in youth sports.  Because of increasing youth participation in collision and contact sports, we thought highlighting the issue of concussion was important — and appropriate — for a professional community newsletter.  Recently, the local newspapers and television media reports have been deluged with information on concussion. Unfortunately, these articles and TV segments tend to be brief.  We hope the article in the Discussant, along with the information on our website, provides valuable information for you in discussing the issue with your children.  I also personally invite you to check out my blog at www.neuro-ortho.org/blog/.  Weekly I share new insights on a multitude of professional and personal topics.  A sample of a recent post is included below. Sign-up to receive future posts and to join into the discussion.  Finally, the third article included in this issue of the Discussant provides an overview of new technology we are investigating to treat patients suffering from back pain attributable to the facet joints.  Dr. Noam Stadlan, Director of the Spine Surgery Program at CINN, is participating in a national clinical trial to test the use of artificial joints to address pain but maintain mobility in the spine. On behalf of my colleagues, I wish you a safe and enjoyable summer.  Leonard Cerullo, MD Guest Editor

Leonard Cerullo, MD Neurosurgeon Leonard J. Cerullo, MD, is the founder and medical director of the Chicago Institute of Neurosurgery and Neuroresearch (CINN), Chicago, Illinois. A board-certified neurosurgeon with over 30 years of experience, Dr. Cerullo is widely recognized as one of the nation’s leaders in the field of neurosurgery. He is highly regarded for his skill in the diagnosis and treatment of brain tumors and spine disorders.

Concussion

Barely a week passes without mention of new statistics on concussion. Most recently, concussion related to youth sports injuries has received front page billing. Historically the widely accepted incidence of sports related concussion in the United States was 300,000 each year. Estimates have recently been updated to reflect 1.6-3.8 million concussions in the United States on an annual basis. The disparity between the old and new estimates is clearly striking and what becomes apparent is the frequently underreported and/or undiagnosed scenario of this serious condition. As all of you know, concussion is a brain injury and the result of not recognizing that a person has sustained a concussion can be devastating. Under the leadership of Dr. Dean Karahalios, neurosurgeon, CINN is developing a concussion program to provide athletes and others access to technology and professional resources focused on the identification and treatment of concussions.

In December 2007 an article appeared in the Journal of Athletic Training that detailed the incidence of concussion in various youth sports. The adjacent graph provides these statistics.

Based upon data presented on the Illinois High School Association website, there are just over 200,000 high school athletes in Illinois participating in the most at-risk sports. At this level of participation and looking at all of these sports together, concussion is estimated to occur 45 times during each contest or practice session statewide. As would be expected, football is plagued with the highest incidence of concussion, and over 200 concussions are suspected among Illinois high school players each year. Perhaps less understood, female soccer and basketball carry relatively high incidence rates, and it is estimated that there are over 100 concussions in female soccer and basketball in Illinois each season.

Clearly these statistics are alarming, and education can significantly reduce both the incidence and repercussions of concussion. CINN physicians are routinely involved in providing education sessions for sports camps and coach clinics. A complementary coach’s clipboard sticker is also available outlining the symptoms, management recommendations and return to play guidelines. Requests should be submitted through the CINN website (www.cinn.org).

In addition to athletes, CINN professionals frequently see laborers and car-accident victims suffering from the headaches, confusion and other mental status deficits associated with concussion. Through the clinical psychology program at CINN, education and coping mechanisms can be introduced to concussion sufferers to assist in their rehabilitation. Please call 1-800-446-1234 if you would like to speak with Von Shade-Zeldow, Ph.D., Director of the Concussion Program at CINN.

Brain Tumor Story

On a weekly basis Dr. Cerullo shares his candid thoughts through the Neurologic & Orthopedic Hospital of Chicago Physician Insights blog. Following is a recent excerpt. We invite you to sign up to receive future blogs from Dr. Cerullo by clicking here:

Complicated Treament Decisions

May 8, 2008 - Speaking of decisions. I saw a young lady today, about 30 years old. She was diagnosed with a pituitary tumor about five years ago during an evaluation for lactating breasts and irregular menstrual periods. Luckily, the tumor was small and of the type which could be treated with oral medications. She began taking the pills, which she tolerated well. Her periods became regular, and she stopped the treatments. She had no desire to become pregnant at the time. Her symptoms (irregular menses and galactorrhea) recurred, so she resumed the medication. Now, four years later, she remains free from symptoms on treatment but desires pregnancy. She has the option of continuing the medication while becoming pregnant or undergoing surgery. She was told there are small risks to the fetus if she becomes pregnant while taking the medicine for her tumor. On the other hand, there are risks of surgery, including the loss of pituitary gland function, which would require her to take other medicines (with their own risks) to conceive.

In addition, her tumor may be growing in spite of the medicine, which must now be given at a higher dose to control the tumor. What is the answer? If the higher dose of drug controls the tumor, she will be back to square one. If not, she must consider radiation therapy or surgery to protect her normal gland as well as her optic (visual) nerves which are very close to the pituitary gland and tumor. Either of these treatments runs a small risk of loss of pituitary function with the need for replacement hormone medications in addition to the general risks of surgery. What would be your choice? Note: There are no right or wrong answers

TFAS Study Tests Non-Fusion Solution to Spinal Stenosis

Laminectomy and decompression is widely accepted as the standard intervention for moderate to severe lumbar spinal stenosis. In many cases, due to the instability of the spine, instrumentation is used to augment this procedure. While successful in reducing pain, spinal fusion restricts motion and adds stress and degeneration to other joints, increasing the risk of needing additional surgeries. In addition, this intervention may require the patient to undergo a painful bone graft harvest. CINN is participating in the Total Facet Arthroplasty System® (TFAS®) clinical study to evaluate an approach that can eliminate the need for a bone graft harvest, maintain a patient’s range of motion after surgery, and relieve stress on the joints, potentially reducing the need for further intervention.

Spinal Stenosis and Current Treatment

Most often affecting people over the age of 50, spinal stenosis describes a condition where the spine’s joints or facets enlarge and produce bony spurs due to arthritic degeneration. This enlargement narrows the spinal canal and is often coupled with an age-related reduction in the height of the discs between the vertebrae. Spinal stenosis results in the compression and irritation of the nerve roots, spinal cord, or both.

Leg pain, numbness or a tingling sensation are frequent symptoms of lumbar spinal stenosis. These systems can worsen as the condition progresses, resulting in severe leg weakness. This condition, aggravated by standing and walking and relieved by sitting, can have a negative impact on an individual’s ability to perform everyday activities.

Laminectomy and decompression is the current standard of surgical intervention for patients with moderate to severe stenosis who do not respond to non-surgical treatments such as physical therapy and pain medications. During this procedure, the surgeon removes the laminae, parts of the facet joints and other spinal structures to provide decompression of the affected nerve roots. Frequently, either the spine is unstable to begin with, or removal of bone adds to the potential instability and, therefore, the surgeon often places instrumentation to fuse the patient’s vertebrae and stabilize the spine.

This intervention has been successful in reducing back and leg pain. However, posterior instrumented spinal fusion may require a painful bone graft harvest.

The Total Facet Arthroplasty System® (TFAS®)

By participating in the Total Facet Arthroplasty System (TFAS) clinical trial, CINN is the only center in the Chicago area and one of about 20 nationwide evaluating the effectiveness of a non-fusion surgical approach to moderate to severe spinal stenosis. TFAS is a new spinal implant currently limited by United States law to investigational use.

Neurosurgeon Dr. Noam Stadlan, CINN’s primary investigator for the study, says the clinical trial will examine the safety and effectiveness of the TFAS approach in giving patients a greater range of motion after the surgery. “We believe TFAS can restore stability and sagittal balance to the spine,” Dr Stadlan says. “More importantly, TFAS may greatly reduce the need for future interventions by relieving the stress and degeneration fusion surgery places on other joints.” Dr. Dean Karahalios and other CINN neurosurgeons also are participating as investigators on the study.

Using the TFAS technique, the surgeon removes the diseased facet joints in the lumbar region of the spine (lower back), specifically either at L3-L4 or L4-L5. The removed joints are replaced with the TFAS motion-preserving implant, which stabilizes these joints without rigidly fusing them. Study participants hope that by restoring natural motion to the joints, TFAS will enable patients to resume daily activities and enjoy long-term results without the need for the additional surgeries.

Study Criteria

Patients with symptomatic lumbar stenosis and spinal instability who are unresponsive to non-surgical pain management treatments such as physical therapy and pain medications can be evaluated to be TFAS study participants and placed into one of two groups. Two-thirds of the study participants will receive treatment with TFAS, and one-third will receive treatment with posterior instrumented spinal fusion.

Inclusion criteria include:

• Degenerative spinal stenosis, central or lateral, at spinal levels L3-L4 or L4-L5;
• Skeletally mature male or female between the ages of 50 and 85 years of age inclusive;
• Persistent leg symptoms – including pain, numbness, burning or tingling – for a minimum duration of six months;
• No more than three levels of degenerative lumbar spinal stenosis requiring decompression;
• Failure to respond to non-operative treatment modalities for a minimum duration of six months; and
• No greater than grade I degenerative spondylolisthesis at the index level with objective evidence of neurologic impairment.