Clınıcal Neurosciences

Clınıcal NeurosciencesMinimally InvasiveSpinal SurgeryVolume 2 Number 1Winter 2008

I S S U E S I N

A Q u a r t e r l y P u b l i c a t i o n o f t h e N e u r o s c i e n c e s I n s t i t u t e s a t R o o s e v e l t H o s p i t a l

Leading the wayto the future...

I S S U E S I NClınıcal NeurosciencesTM

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Minimally Invasive Spinal Surgery


Issues in Clinical NeurosciencesTM

WelcomeIt gives me great pleasure to

present to you this issue dedicated to spinal disorders and the proce-dures performed at the Center for Minimally Invasive Spine Surgery.

Minimally invasive spinal surgery is an area that is undergoing remarkable innovations, an area of specialized surgical science that is building on revolutionary tech-niques and exciting technologies. Dr. Noel Perin leads our minimally

invasive center and, along with several other department members, treats a large number of patients.

In the past, many of the spinal problems that were treated with large, open operations can now be performed using minimally invasive techniques. These techniques allow shorter hospital stays, faster recovery times, and a quicker return to work.

Drs. Perin and Elowitz have been intensely involved with these innovations. Dr. Perin has been involved in teaching courses nationally and internationally.

In this issue, Drs. Perin and Elowitz will guide you through some of the successful and innovative techniques and procedures employed at Roosevelt Hospital. I believe that we provide the very fi nest spinal care available anywhere. Our staff of neurosurgeons is known throughout the world for its excellent work and dedication to outstanding patient care.

Sincerely yours,

Chandranath Sen, MD

Chandranath Sen, MDChairman, Department of Neurosurgery, Co-Director, Center for Cranial Base Surgery

Journal Contents

3 CHAIRMAN’S NOTE

Dr. Chandranath Sen welcomes you to this issue dedicated to minimally invasive spinal surgery..

4-5 INTRODUCTION

Dr. Noel Perin and Dr. Eric Elowitz explain the innovative proce-dures being performed in the Center for Minimally Invasive Spine Surgery and its integrated role in the practice of neurosurgery.

6 XLIF® PROCEDURE

Spinal fusion using the extreme lateral interbody fusion procedure (XLIF) has been very successful at Roosevelt Hospital.

6-7 CASE PRESENTATION #1

A 60 year-old female with pain resulting from severe spinal stenosis was successfully treated using the XLIF fusion technique.

7 LUMBAR MICRODISKECTOMY

This minimally invasive procedure is used routinely to repair herniated lumbar disks that are often accompanied by painful radiculopathy.

8-10 CASE PRESENTATION #2

A two-stage procedure to correct a T6-7 thoracic disk herniation with associated spinal cord herniation was performed on a 59-year-old female patient.

11-12 CASE PRESENTATION # 3

A 52 year-old female was operated on successfully for removal of an isolated schwannoma at T2-3 with encroachment on the foramen.

12-13 HH SYMPATHECTOMY

Roosevelt Hospital is one of the few institutions where sympathec-tomy for hyperhidrosis (HH), or excessive sweating, is successfully performed on a routine basis.

14-15 NEUROSURGICAL STAFF

Neurosurgeons, affi liated departmental professionals, and neuro-surgery residents represent the members of our team approach to minimally invasive spinal surgery.

15 EDITORIAL

Dr. Charles Ippolito, Editorial Director, discusses advances in spinal surgery that represent state-of-the-art procedures whose successes have been achieved with advanced technologies from the neurosciences, neurosurgery, optics, computer-assisted instrument positioning, and neuroradiologic imaging.

Chandranath Sen, MD

© 2008. Issues in Clinical NeurosciencesTM A Quarterly Publication of the Department of Neurosurgery at Roosevelt Hospital

www.roosevelt-neurosurgery.com1000 Tenth Avenue, Suite 5G-80

New York, NY 10019.All rights reserved.

Graphic Design: State of the Art. Cover Illustration: Bryan Christie DesignOnline version: www.roosevelt-neurosurgery.com/publications/

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INTRODUCTIONEndoscopic surgery began with the development of the

cystoscope. In 1806, while practicing urology in Frankfurt-am-Main, Dr. Philip Bozzini (1773-1809) developed the first cystoscopic instru-ment powered by candle light, which he called the “Lichtleiter,” or light conductor. About a hundred years later, Dr. H.C. Jabcobaeus, a Swedish pulmonologist, improved on Bozzini’s idea by using an electric light bulb; he performed the first thorascopic procedure at the Royal Seraphim Hospital in Stockholm in 1910 and is now considered to be the father of modern thoracoscopy.

The modern era of video-assisted thoracoscopic surgery (VATS) started in the 1990s with instruments developed by thoracic surgeons. By 1993, spinal applications of thoracoscopy procedures became routine as a result of rapid technological advances in high-resolution cameras and video equipment.

Recent years have witnessed even greater technological and surgical advances in minimally invasive spinal surgery. The advantages of these minimally invasive techniques to patients have been significant. Not only are the incisions smaller, but there is also far less postoperative pain and quicker recovery times. Spinal fusions that would have required many days in the hospital and often months of recovery can now be performed quickly with patients’ returning back to work in just a few weeks.

Not only do the advantages include a shortened length of hospital stay, but minimal blood loss is also achieved. One of the driving forces for this type of surgery is clearly centered around patient interests, including successful outcomes, reduction of pain, and improved overall quality of life.

Many people find out about the advantages of minimally invasive spinal surgery through the media and the internet, searching out those physicians who specialize in this advanced technology.

Minimally Invasive Spinal SurgeryDrs. Noel Perin and Eric Elowitz have created the Center for

Minimally Invasive Spine Surgery at Roosevelt Hospital in order to offer patients the best state-of-the-art, minimal access spinal surgery in a high-quality environment. We focus on new approaches and innovative surgical techniques to treat many types of spinal patholo-gies such as: ● Disk herniation● Lumbar stenosis● Lumbar spondylolisthesis● Cervical foraminal stenosis● Thoracoscopy for disk herniation, tumors, and hyperhidrosis

State-of-the-Art in the Comprehensive Treatment of Spinal Disorders

We have dedicated neurosurgery operating rooms with neurosurgery-trained nurses and neuro-anesthesiologists. The neurosurgery intensive care units are operated by neuro-intensivists covering the ICU 24 hours-a-day, with dedicated neuro-nurses on duty around-the-clock.

Complex Spinal Procedures

Complex occipito-cervical, cervical, thoracic, lumbar as well as sacral procedures are routinely performed in the Department of Neurosurgery at Roosevelt Hospital.

In this issue, we describe some of the minimally invasive spinal procedures we encounter on a routine basis. Case presentations will familiarize the reader with the practical aspects of our work here at Roosevelt Hospital.

Dedicated Contact Number

The contact number for the Center for Minimally Invasive Spine Surgery is 212-523-BACK (212-523-2225). Referring physicians and patients can contact us to schedule appointments at the Center. Patients may also call for information regarding our physicians and our minimally invasive spine surgery programs.

Recent staff publications

Shin H, Barrenechea IJ, Lesser JB, Sen C, Perin NI. Occipitocervical fusion in craniocervical junction tumors: Indications, technical chal-lenges, and results. J Neurosurgery-Spine. 2006; 4(2):137-144.

Barrenechea IJ, Lesser JB, Gidekel AL, Turjanski L, Perin NI. Diagnosis and treatment of spinal cord herniation: A combined experience. J Neurosurgery-Spine. 2006; 5(4):294-302.

Barrenechea IJ, Perin NI, Triana A, Lesser JB, Costantino P, Sen C. Surgical management of chordomas of the cervical spine. J Neurosurgery-Spine. 2007; 6(5):398-406.

The Center for Minimally Invasive Spine Surgery at Roosevelt Hospital is a collaborative effort using the latest innovative techniques and expert surgical talents from various departments, including thoracic and vascular surgery. Our goal is to ensure the best possible outcomes for our patients.


Noel I. Perin, MD, FRCS (Edin.), FACS

Director, Spine Surgery, and Co-Director, Center for Minimally Invasive and Endoscopic Spine Surgery

Eric H. Elowitz, MD

Spine Surgery, Neurosurgery, Co-Director, Center for Minimally Invasive and Endoscopic Spine Surgery

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Smaller Incisions With Minimally Invasive Approaches

The XLIF procedure employs a unique approach to the spine. A 2-3 cm incision is made in the lateral fl ank region. Dissection is performed down through the retroperitoneum, and a tubular retractor is placed just above the disk space (Fig. 1). With recent advances in neurologic monitoring capabilities, surgeons are able to navigate safely around the lumbar nerves.

The disk material is then removed. A spacer made of PEEK is then inserted into the disk space (Fig. 2). Surgeons monitor the posi-tion and correct placement of the spacer using real-time fl uoroscopy in addition to the dynamic EMG monitoring. Following the placement of the XLIF spacer, some patients may have a lateral plate placed through the same incision, or the surgeon may choose to place posterior pedicle screws via minimally invasive techniques.

CASE PRESENTATION #1XLIF® Fusion Technique Chief Complaint, History of Present Illness, and Presentation

Our patient was a 60-year-old woman who had been very active and maintained a full-time work schedule. Over approximately a six-month period, she developed increasing pain extending into her left leg. Her activities became very limited, and even walking one or two blocks was challenging. An MRI scan and radiograph were performed, which revealed an L4-5 spinal stenosis with disk degeneration and col-lapse (Fig. 1.1). The patient received conservative treatment including physical therapy and antiinfl ammatory medications without any relief. The patient felt that her quality of life was greatly diminished, and she sought surgical intervention.

Evaluation, Impression, Intervention

Dr. Elowitz evaluated the patient. Based on her high level of pain, MRI fi ndings, and previously active lifestyle, he recommended an XLIF fusion. Dr. Elowitz was able to restore disk height with the

XLIF graft (Fig. 1.2). Within the same surgery, the stenosis was addressed using unilateral small tubes for a minimally invasive lami-nectomy. Titanium screws were then placed using x-ray guidance.

Postoperative Response

The patient awakened from anesthesia and immediately noticed that her leg pain was gone. She was discharged from the hospital the next day and started walking more than an hour every day, just a few days later. One week after her fusion, she returned to work full-time.

Results and Conclusion

At the Center for Minimally Invasive Spine Surgery at Roosevelt Hospital, we have found the XLIF procedure to be a safe and reproducible technique.

The advantages of this procedure have been demonstrated numerous times, resulting in an increased quality of life. In com-parison to a traditional spinal fusion, where patients would generally be in the hospital for many days and convalescing at home often for months, most patients are back to full activities including work within just a few weeks.

Figure 1.1. Lateral radiograph revealing disk space degeneration (L4-5) with loss of disk height.

Figure 1.2. Intra-operative radiograph following placement of L4-5 XLIF and restoration of disk height.

Extreme Lateral Interbody Fusion (XLIF® ) ProcedureDegenerative spinal disease is a common problem treated

by spinal surgeons. Patients can present with multiple symptoms, including back pain and radiculopathy. MRI fi ndings may include herniated disks, disk degeneration with loss of height, spinal stenosis, and scoliosis. While many of these types of degenerative spinal disorders can be treated effectively with nonoperative measures, many patients do require spinal surgery to alleviate symptoms and to decompress nerves.

Spinal Fusion in Degenerative Disease

Spinal fusion has been a successful method of treating many types of degenerative spinal problems. Conventional spinal surgery is often associated with long hospital stays, high blood loss at surgery, and prolonged periods of rehabilitation.

Newer methods of minimally invasive spinal surgery have brought tremendous advances. One of these procedures is the Extreme Lateral Interbody Fusion, or XLIF procedure. With the XLIF, surgeons can approach the spine in a minimally invasive way with very little disruption of surrounding tissues. One of the great advantages of the XLIF procedure is the ability to restore disk and foraminal height in a far less invasive manner than the traditional fusion. Also, spinal stenosis can be decompressed in an indirect fashion by restoring alignment and height to the spinal canal.

Reduced Blood Loss

Generally, with this procedure there is negligible blood loss. Typically, patients are ambulatory within a few hours and are then discharged the next day. Patients are often back to work within two to three weeks.

Figure 2. A PEEK spacer is inserted to restore lost height as a result of spinal degeneration.

Figure 1. This minimally invasive surgical technique enables our neurosurgeons to gain maximum lateral access to spinal patholo-gies.

Minimally Invasive Lumbar MicrodiskectomyHerniated lumbar disks can cause a variety of symptoms,

including back pain, sciatica, and leg weakness. Symptoms are gener-ally caused by the herniated disk pressing on a nerve root. In the majority of patients with herniated lumbar disks, we strongly favor ini-tially conservative treatment. This usually includes anti-infl ammatory medications, muscle relaxants, and physical therapy. In selected cases, epidural steroid injections may be advised. Only a small percentage of patients with herniated lumbar disks will require surgery.

Surgery Advised in Prolonged Pain

Minimally invasive lumbar microdiskectomy is reserved for patients who have failed conservative treatment and suffer continued pain. Patients who have weakness or other neurologic defi cits may be considered for surgery earlier. Minimally invasive lumbar microdis-kectomy is usually performed in less than one hour. In comparison to prior techniques for diskectomy, the incision and muscle retraction required in the minimally invasive approach are considerably less, thereby limiting postoperative discomfort.

Surgical Procedure

The goal of minimally invasive microdiskectomy is to remove the herniated portion of the disk and to relieve pressure on the affected nerve. A one-centimeter incision is made. Using x-ray guidance, a circular retractor tube is inserted down to the level of the herniated disk. The operative microscope is then used to carefully remove the herniation and free the nerve. The retractor is then removed and the wound closed using plastic-surgery techniques.

Patients are also able to return to normal activities on an earlier basis. In our experience, 95% of patients will have relief of their pain following this procedure.

X-ray guidance is used to insert a circular retractor at the level of the herniated disk. The herniation is removed, and pressure on the nerve is relieved.

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The vertebral bodies on either side of the disk were drilled to create a trough in front of the disk space (Fig. 2.6). this allowed the herniated disk to be pulled away from the spinal cord into the trough without manipulation (Figs. 2.7 & 2.8).

If surgically indicated, the piece of the 7th rib is removed to expose the pedicle of T7 and is used as a rib graft between T6-7.

CASE PRESENTATION #2Two-Stage Procedure: T6-7 Thoracic Disk Herniation with an Associated Spinal Cord Herniation Chief Complaint, History of Present Illness,and Presentation

Our patient was a 59 year-old female who presented with a nine-month history of walking with a limp that was noticed by her friends. She sought medical attention, when she experienced weakness in her left leg. Subsequently, she began to experience a numbness girdling around the left fl ank into her lower chest and anterior abdominal wall. She did not complain of pain, but had urgency of micturition for 2 years, which was treated by her urologist with Detrol.

On neurologic evaluation, she walked with a slight limp that favored the left leg. There was weakness of hip fl exion on the left 3+/5 and left ankle dorsifl exion 4/5. She had a sensory dulling to pin prick in the right leg, with a sensory level at T8-9 (Brown-Séquard syndrome). In addition, she also had hyperesthesia over the left T6 to 9 dermatomes. Lower extremity refl exes were brisk (3), with an up-going plantar refl ex on the right.

Pre-Operative Imaging Studies

The referring neurosurgeon ordered an MRI myelogram and myelo-CT. These imaging studies showed a large central disk herniation at T6-7 with signifi cant spinal cord compression (Fig. 2.1). Additionally, the MRI scan of the thoracic spine showed “spinal cord herniation” at the level of the T6 vertebral body, with a dorsal arachnoid cyst (Fig. 2.2).

Spinal cord herniation is a rare entity that has been reported in association with a thoracic disk herniation. We have recently reported on a series of spinal cord herniations, presentations, and treatment recommendations [J Neurosurgery-Spine. 2006;5(4):294-302].

Management Plan

We had to decide which disorder to treat fi rst, as both the T6-7 disk herniation and the spinal cord herniation could be responsible for her lower extremity myelopathy and accompanying Brown-Séquard syndrome.

We elected to repair the thoracic disk first (Stage 1), using thoracoscopic techniques (Figs. 2.3 & 2.4), as the posterior reduction of the spinal cord hernia could lead to more manipulation of the cord, and could further compress it against the disk herniation.

The patient was placed in the lateral decubitus position, as in an open thoracotomy procedure. Thoracoscopic port placement was very specifi cally selected based on the location of the disk to be treated.

The working port was placed in line with the disk to be approached (Fig. 2.5). Other ports included one for suction/irrigation, one for retraction of the lung, and a third for the endoscope (Fig. 2.6)

Figure 2.2. Pre-operative sagittal MRI showing the disk herniation at T6-7, causing cord compression and the spinal cord herniation above it.

Figure 2.3. Minimally invasive thoracoscopy technique used to access the T6-7 disk herniation.

Figure 2.4. Typical thoracoscopic port placement for a mid-chest diskectomy.

Figure 2.1. Pre-operative myelographic CT scan showing a large central disk herniation at T6-7 with spinal cord compression

Figure 2.5. T6-7 localization of the disk.

Figure 2.6. Schematic of thoracoscopic diskectomy procedure.

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Figure 2.7. T6-7 vertebral bodies drilled straddling the disk anterior to the spinal canal.

Figure 2.9. Partial vertebrectomy anterior to the disk herniation and spinal canal, allowing the disk to be pulled into the defect without manipulating the cord.

Figure 2.8. Herniated disk removed at T6-7 with good decompres-sion of the spinal cord.

CASE PRESENTATION #3Thoracic Paravertebral Tumor Surgery Using Thoracoscopic Technique Chief Complaint, History of Present Illness,and Presentation

Our patient was a 52-year-old female who had a chest x-ray prior to elective pelvic surgery that revealed a mass in the thoracic spine at the level of T2-3. To further investigate this thoracic mass, she had a CT scan of the chest and an MRI of the thoracic spine (Figs. 3.1 & 3.2).

A tumor measuring 8x5x5 cm was noted. The tumor was thought to be an isolated schwannoma with encroachment into the foramen at T2-3. (Fig. 3.1 & 3.2) Because of the uncertainty regarding the actual tumor pathology and the tendency for schwannomas to grow over time, we recommended that this tumor be removed.

Paravertebral tumors in the thoracic spine under 8-10 cms can be removed endoscopically with minimal morbidity. The endoscopic procedure is performed in the lateral decubitus position, as if the patient were prepared for an open thoracotomy (Fig. 3.3). A hemi-laminectomy may be required when the tumor extends through the foramen into the spinal canal. The intraspinal component is dissected away from the neural elements with the operating microscope using continuous SSEP and MEP monitoring, thus moving the tumor into the foramen. The laminectomy wound is packed off, and the operating table is rotated back (Fig. 3.3).

Figure 3.2. Pre-operative axial MRI scan showing the schwannoma.

Figure 3.1. Pre-operative sagittal MRI showing the paravertebral tumor with pyramidal encroachment at T2-3.

Figure 3.3.Patient in lateral decubitus posaition with table rotated to allow laminectomy.

Postoperative Clinical Status and Follow-Up

Postoperatively, the patient had a chest tube inserted for 24 hours and was mobilized thereafter and discharged to home on day 3. Recovery of her leg weakness was incomplete after the diskectomy, although there was no deterioration

She was brought back two months later and underwent a laminectomy at T5-6 with reduction of the herniated cord and repair of the ventral dural defect (Stage 2). She also underwent stabilization and fusion posteriorly following the decompression (Fig. 2.9). She went on to recover well after the latter procedure, with improvement in her gait and proximal leg weakness.

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Thoracoscopic Removal of Intrathoracic Tumor

Three-to-four operative ports are created in the flank on the appropriate side to access the tumor thoracoscopically (endoscopic port, a suction port, and a working port). Occasionally, an additional port may be necessary for retraction of the lung (Figs. 3.4 & 3.5).

A harmonic scalpel is used to take down the parietal pleura at the edges of the tumor, eventually isolating and dividing the nerve of origin. The tumor is placed in an Endocath bag and removed through one of the ports. If the tumor is firm, it may need to be crushed within the bag for removal through one of the ports, or the port may be enlarged to accommodate removal. An intracapsular removal is appro-priate in hard-to-reach tumors. Postoperatively, patients have a chest tube inserted and generally stay in the hospital for 24-48 hours

Postoperative Clinical Status and Follow-Up

The patient recovered from the surgery without any other problems. She experienced thoracic intercostal pain for a few weeks. The pathology was a benign schwannoma. Repeat MRI scans were negative for tumor. She will be followed yearly with MRI studies.

Figure 3.5. Intra-operative isolation of the schwannoma using thoracoscopic technique. Retraction of the lung is accomplished through an additional operative port (lower right).

Figure 3.4. Longitudinal illustration of the 8x5x5 cm schwannoma with encroachment into the foramen at T2-3.

Sympathectomy for Hyperhidrosis Using Thoracoscopic Visualization HH Can Lead to Serious QOL Problems

Primary hyperhidrosis (HH) is a condition where excessive sweating occurs in areas of the body unrelated to normal physi-ologic thermoregulation. Hyperhidrosis commonly affects the hands, armpits, feet, and less often the face, with or without facial blushing. The degree of sweating can vary in the different parts of the body. Occasionally, axillary HH is associated with odor (bromhidrosis). The excessive sweating can cause social embarrassment, leading to psychological problems and depression.

The severe sweating interferes with the patient’s quality of life (QOL) interfering with social functioning, often causing psychologi-cal problems, school absences, and occupational difficulties.

Hyperhidrosis starts primarily in adolescence, and its cause is unknown. Persons with palmar hyperhidrosis (Fig. 1) often seek treatment because the condition almost always causes great distress. Individuals who suffer from hyperhidrosis deal with everything from minor issues, such as smudged writing paper, to major issues, such as difficulty holding pens, tools, buttons, and social isolation.

HH Can Hinder Social Activities

Perhaps the most distressing result of palmar hyperhidrosis is the discomfort and embarrassment caused by the simple act of shaking hands. In fact, many patients with palmar hyperhidrosis will avoid social situations or pick a profession that requires little interaction with others.

Patients with axillary hyperhidrosis (severe armpit sweating) have to change clothing several times a day to stay dry; they can only wear certain types of clothes and only dark colors.

Figure 1. Palmar hyperhidrosis can be a serious impediment to quality of life in both personal and employment situations.

HH Successfully Treated at Roosevelt Hospital Using ETS

We have established a niche practice for the treatment of patients with hyperhidrosis at the Roosevelt Hospital center. Thoracic sympathectomy operations are often performed as a collaborative procedure along with Dr. Cliff Connery from the thoracic surgery service.

With the endoscopic thoracic sympathectomy (ETS), our patients have a 98% success rate, allowing them to enjoy lasting relief from excessive sweating.

The ETS Procedure

The patient is given a general anesthetic, and two 1- centimeter incisions are made under each axilla creating an endoscopic and an operating port (Fig. 2). A 5 mm, 0º angled endoscope is placed in one port, and an ultrasonic instrument is placed down the working port. X-rays are taken to define the rib level, thereby isolating the relevent sympathetic ganglion.

Once the overactive nerves are located, they are severed (Fig. 4). This procedure is repeated on the opposite side, and a few sutures are placed to close the ports, but these stitches are not visible on the skin surface. The entire procedure takes about an hour to perform. Patients generally stay in the hospital overnight and are able to return to work and to engage in their regular daily routine in about a week. The ETS procedure is considered safe with a very low incidence of side effects.

Some Reported ETS Side Effects

All patients have some degree of increased sweating with exercise and hot weather after sympathectomy. In 5% of these cases is the compensatory sweating bothersome, and this problem may decrease within 6 to 9 months following surgery.

In very rare cases, patients may experience a drooping of the eyelids (Horner’s syndrome). This is much less of a problem now, that we are going lower in the sympathetic chain to treat palmar hyperhidrosis and performing a T3 ganglion isolation, as opposed to the older T2 ganglion procedure.

Figure 2. Typical working ports for HH sympathectomy.

Overall Excellent Results with ETS

● Over 98% of patients experience complete relief from excessive hand sweating

● Over 80% of patients experience relief from excessive underarm sweating and underarm odor

● About 67% of patients experience relief from excessive foot sweating

We have performed over 600 endoscopic thoracic sympathec-tomy operations for hyperhidrosis in the last few years, and we are one of the few centers in the North East performing these procedures. Drs. Noel Perin and Cliff Connery are in the organizing committee preparing to host the “8th International Symposium on Sympathetic Surgery” to be held in New York City in the year 2009.

Figure 3. Using endoscopic techniques, the sympathetic nerves responsible for controlling hidrosis are isolated.

Figure 4. Schematic of the sympathetic chain with the parietal pleura opened. The inset shows the chain divided at the head of the rib.

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Affiliated Departmental ProfessionalsNEUROSURGERY

CHANDRANATH SEN, MDChairman, Department of Neurosurgery, Co-Director, Center for Cranial Base Surgery

1000 Tenth Avenue, Suite 5G-80 New York, NY 10019 212-523-6720 [email protected] www.CranialBaseCenter.org

GEORGE V. DIGIACINTO, MDGeneral Neurosurgery & spine surgery

425 W. 59th Street, Suite 4E New York, NY 10019 212-523-8500 [email protected]

DOUGLAS S. COHEN, MDGeneral Neurosurgery,

425 W. 59th Street, Suite 4E New York, NY 212-523-8502 [email protected]

DAVID J. LANGER, MDCerebrovascular & general neurosurgery.

1000 Tenth Avenue, Suite 5G-49 New York, NY 10019 212-636-3204 [email protected]

ERIC H. ELOWITZ, MDSpine surgery

1000 Tenth Avenue, Suite 5G-44 New York, NY 10019 212-636-3660 [email protected] www.nycneurosurgery.com

NOEL I. PERIN, MDDirector, Spine surgery/minimally invasive and endoscopic spine surgery.


RAJ K. SHRIVASTAVA, MDGeneral neurosurgery.


ARTHUR WILLIAMS, MDGeneral neurosurgery


VEDRAN DELETIS, MD, PHDMonitoring Neurophysiologist Associate Professor, Albert Einstein College of Medicine

212-870-9686 [email protected]

CRANIAL BASE SURGERY & ENT

PETER COSTANTINO, MDVice-Chairman, Department of Otolaryngology, & Co-Director, Center for Cranial Base Surgery


ENDOVASCULAR SURGERY

ALEJANDRO BERENSTEIN, MDChief, interventional neuro-radiology

1000 Tenth Avenue, Suite 10G New York, NY 10019 212-636-3400 [email protected]

YASUNARI NIIMI, MDEndovascular surgery


JOON SONG, MDEndovascular surgery


NEURO-OPHTHALMOLOGY

MARK KUPERSMITH, MDDirector, Neuro-ophthalmology


Staff

Minimally Invasive Advances Improve Patient Outcomes

Recent advances in the basic neurosciences, computer science, molecular biology, fiber optics, bone biochemistry and metabolism, neuro-imaging techniques, computer-assisted instrument positioning, operating microscopes, video monitoring, and endoscopy have all contributed to produce remarkable changes in the overall practice of spinal surgery.

All these technological achievements have allowed difficult surgical approaches to become routine procedures. They have also allowed for direct visualization of serious pathologies, provided access to difficult anatomical regions, and facilitated manipulation of delicate spinal structures through small port holes placed in the thorax and abdomen.

Working with techniques already in use by thoracic and abdominal surgeons, neurosurgeons quickly adapted video-assisted endoscopy and stereoscopic microscopy to treat many spinal disorders previously repaired using open-surgery approaches. These advanced optical and operative techniques have allowed for reductions in the size of incisions and have produced a better view of the operative field.

Our outstanding successes in minimally invasive spinal surgery, as a subset of neurosurgery, are largely a combined result of departmental surgical skills coupled with advanced technologies. These new techniques have allowed neurosurgeons to treat complex spinal problems with shorter hospital stays and swifter recovery times for our patients.

Minimally invasive spinal surgery has also encouraged the development of specialized surgical instrumentation. These innovative spinal instruments have made it possible to perform many intricate procedures, such as vertebral interbody fusions, with smaller incisions and less tissue disruption.

Spinal surgeons at Roosevelt Hospital are considered foremost experts in the field of minimally invasive techniques. Their skills have resulted in successful outcomes for a long list of patients with complex spinal pathologies. In the practice of minimally invasive spinal surgery, we are leading the way to the future.

Sincerely,

Charles J. Ippolito, MD

CHARLES J. IPPOLITO, MDEditorial Director Department of Neurosurgery1000 Tenth Avenue, Suite 5G-41A New York, NY 10019 1-212-523-6097 [email protected]

Charles J. Ippolito, MD

Affiliates, Residency Program & Editorial

Louis Noce, MD Chief: PGY-7

Juan Alzate, MD Chief: PG-7

Markus Chwajol, MD PGY-6

Sid Chandela, MD PGY-6

Adesh Tandon,. MD PGY-5

Gaurav Jain, MD PGY-4

Chris Lenart, MD PGY-4

Lawrence Daniels, MD PGY-3

David Altschul, MD PGY-2

Alex Scheer, MD PGY-2

Neurosurgery Residents

NEUROLOGY

Susan Bressman, MD 212-844-8379

Carolyn Brockington, MD 212-636-3236

Ed Chai, MD 212-265-8070

Joel Delfiner, MD 212-523-6521

Virginia Moreno, MD 212-523-6521

NEURO-ANESTHESIA

Jonathan Lesser, MD Director 212-523-7521

CRANIAL BASE SURGERY & ENT

Joseph Krespi, MD Chairman 212-523-7791

Peter Costantino, MD Vice Chairman 212-523-6756

DIAGNOSTIC NEURORADIOLOGY

Richard Pinto, MD Director 212-870-8421

HEAD AND NECK RADIOLOGY

Deborah Shatzkes. MD 212-523-7043

REHABILITATION

Malcolm Reid, MD 212-523-6595 Director

Salvatore Girardi, MD 212-523-6598

NEURO-INTENSIVE CARE

Rup Swarup, MD

Graciano Riveira, MD

Vala Berjis, MD

Armando Aloran, MD

© 2008. Department of Neurosurgery. Roosevelt Hospital, Suite 5G-40, 1000 Tenth Avenue, New York, NY 10019

www.roosevelt-neurosurgery.com/publication/

Code Number: 08-001 Printed: 02-29-2008


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