When a Chattanooga man in his early 40s experienced numbness in his arms and hands recently, his primary care physician provided a referral to the Neurosurgical Group of Chattanooga. The patient’s immediate reaction was to question his doctor’s decision.
“There was nothing wrong with my brain,” he recalled, “and I didn’t understand exactly what a neurosurgeon could do to help me. Several days after my visit, I had surgery to relieve the pressure a herniated disc had put on my spinal cord. I felt better immediately and have made a full recovery. In the process I also learned something about what a neurosurgeon does.”
This patient’s experience was not uncommon. It is, in fact, a popular misconception that the field of neurosurgery is exclusively related to the brain. Actually, neurosurgery embraces a wide range of diseases and or injuries affecting the central nervous system (the brain and spinal cord), and the peripheral nervous system (the nerves as they emerge from the spinal cord and emanate throughout the body).
Now in its 60th year, the Neurosurgical Group of Chattanooga was founded in 1947 by Dr. Walter Boehm, Sr., and Dr. Augustus McCravey, who were the first neurosurgeons in the city. Today, the practice includes seven physicians and more than 20 employees. Hundreds of patients receive care on an annual basis, many of them learning firsthand about the broader scope of the neurosurgical field.
“Neurosurgery is more than brain surgery,” explained practice administrator Lee Wood, who has been with the group for 17 years. “When most people think about neurosurgeons they immediately think of something involving the head and brain. Most of our patients actually have problems related to the spine, and looking at what our group does, approximately 60 percent of the practice is related to the cervical, thoracic, and lumbar spine, and about 40 percent to cranial problems.”
In addition to cranial maladies, such as primary and metastatic brain tumors, pituitary tumors, acoustic neuromas, aneurysms, cerebral hemorrhages, and carotid stenosis (narrowing); spinal problems such as herniated discs, degenerative spine syndromes related to arthritis, tumors of the spinal cord, and trauma cases are seen regularly. Pediatric issues, such as spina bifida and hydrocephalus, are also treated. Some treatments overlap with other specialties and procedures related to the peripheral nervous system, such as carpal tunnel syndrome.
“It is amazing how often people, even physicians, say that they didn’t know about all of the things neurosurgeons do,” related Dr. Philip Megison, who has been with the practice 17 years following medical school at Louisiana State University and residency at Parkland Hospital in Dallas, Texas. “The ‘neuro’ part of neurosurgery connotes the brain, and that is part of it, but we want to break down that wall of misconception.”
Given the prevalence of health issues related to the spine, it is logical that the majority of the Neurosurgical Group’s patients are seeking relief from pain and discomfort resulting from stenosis or some other cause.
“Just because we as humans stand up straight, we put more pressure on our lower spine,” explained Dr. Megison. “That causes degenerative changes, which create back pain. I think it has been said that about 80 percent of people will have some bout of back pain at some point in their lives. Whether all of those will need medical care is hard to say, and that is one reason why the imaging we do with MRI and CAT scans are so important in showing us what the problem really is so we can tailor the treatment to that.”
Only about half of patients with back problems, referred to neurosurgeons, actually undergo surgery. After the evaluation of the patient’s condition, the case is managed without surgery as often as possible. Alternatives to surgery include physical therapy, pain management, bracing, or steroid injections.
“Most of our patients have already gone through some conservative treatment before they see us, but only about 50 to 60 percent of the spine patients we see actually receive surgery,” said Megison. “For people who do need surgery, it is important to understand that surgery is a lot different today than even 10 years ago as far as what we are able to do and how we are able to do it. Surgery is much less invasive, and there is much less tissue damage now.”
According to Megison, the primary improvement achieved in spinal surgery during the last decade involves the method. The standard of success in dealing with a herniated disc, for example, remains the same -- removal of the disc that is out of place and causing the pain and discomfort. State-of-the-art instruments, however, now allow the surgeon to make a much smaller incision. Powerful microscopes provide strong magnification and better light in the wound. Also, rather than stripping neighboring muscle tissue away from bone during the surgery itself, the muscle is actually spread apart in order to reach the problem area.
“It is easier to get over both neck and back surgery,” said the doctor. “Recovery time is significantly better, and return to work time is better, particularly for the neck part of it. A good percentage of the patients are not even staying in the hospital, and many more go home the next day. Two things we hear very often are the words ‘minimally invasive’ and ‘laser.’ Minimally invasive surgery is what we are talking about. The surgical scar is much smaller, and the way we get to things has become significantly better. On the other hand, we don’t do anything with lasers, nor can we do anything with lasers. Invariably, we will be asked if we are going to use a laser.”
Kyphoplasty, a highly effective procedure for the treatment of osteoporosis fractures and some trauma related fractures, has developed in recent years. “It is a fantastic tool, which is mainly used in the elderly who are experiencing back pain from the collapse of their vertebrae,” explained Dr. Megison. “Essentially, we blow up a balloon inside the bone and put cement in the balloon so that it supports the bone. It has really worked well. In many cases, the patient’s pain is gone immediately, and it also restores some height which has been lost from compressed vertebrae. This technology has been out for three or four years, and we started doing it about three years ago.”
Patients with cranial issues are benefiting from advancements in treatment as well. For example, an aneurysm is a bulge, which may occur in the wall of a weakened blood vessel, increasing the risk of a hemorrhage. Some aneurysm patients are treated in a cooperative effort between the neurosurgeon and the interventional radiologist with the insertion of a titanium or platinum coil, which fills the aneurysm and allows it to occlude.
In some cases, lesions of the brain are being successfully treated with advanced stereotactic radiosurgery. “This type of surgery has been done for about 70 years,” commented Dr. Megison, “but over the last 20 years it has been married to the computer so that the point that gets radiation can be so refined that only the tumor is involved. The rest of the brain doesn’t get exposed to the radiation. This is the surgery without a knife thing that some people have seen.”
Stereotactic radiosurgery patients receive treatment at the hospital on an outpatient basis, and there is no damage to surrounding tissue. “Really, the only limiting factor is the tumor’s size,” the doctor noted. “We can do it anywhere in the brain, but not on a tumor larger than four centimeters because it is simply too big of a target. There are a lot of tumors that we can’t operate on because of where they are, which we would use this for. Surgery is still the best way to treat many tumors because it makes chemotherapy and other treatments more effective, but in the ones we can’t operate on most can be treated with radiosurgery, depending on their size. Removing the bulk of a tumor and following surgery with a course of treatment is preferred to radiosurgery alone.”
Advances in computer technology have enhanced surgical outcomes in recent years as well. “The way we treat brain tumors has significantly changed in the last five to ten years,” Megison added. “Now, we can take MRI scans and actually plug these into a computer that marries with the microscope. We can actually see the tumor in virtual reality, so we know exactly where it is even before we make an incision in the skin. It is similar to the navigational system in your car, except we are using it in the brain. The technology is totally amazing, and in the past, if a tumor was underneath the surface of the brain you really had no clue about exactly where to go because you have to make an incision through the brain to get to it. You sort of had to use your best guess. Now, we know exactly where the tumor is and can be much more precise and safe about taking it out.”
With the addition of stereotactic radiosurgery, there are rarely any tumors of the brain which are completely “inoperable.” Radiosurgery is more effective on metastatic rather than primary brain tumors because tumors which originate in the brain are generally less responsive to radiation than those which have developed secondarily to malignancy somewhere else in the body. Overall, treatment is much more effective than it was even 15 years ago. However, the survival rate for some tumors has remained fairly constant due to their natural history. Progress in the field of gene therapy, identifying markers on genes which predispose people to such tumors, may indeed have a positive impact on life expectancy.
“Specifically, research is being completed today that involves taking a biopsy of a tumor, its cells then grown in the lab, and then something similar to antibodies to that tumor being injected into the patient to directly affect just that tumor and not the rest of the body. It is almost here,” related Dr. Megison. “Also, on the horizon with radiosurgery is the ability to treat tumors in other parts of the body, not just the head. We can use it with the head now because we can immobilize the head, keep it still, and achieve submillimeter accuracy with radiation. With the rest of the body, you have movement when you breathe and when your heart beats. The next generation of radiosurgery will involve a computer that sort of erases that movement so that lesions of the spine, lung, liver, prostate or other areas can be treated.”
Dr. Megison’s colleagues in the Neurosurgical Group’s Chattanooga office include Drs. Peter E. Boehm, Timothy A. Strait, Michael R. Gallagher, R. Lee Kern, Jr., and Daniel B. Kueter. Dr. Michel Paré resides in Dalton and practices there.