Procedures

Discectomy

Discectomy is one of the more common surgical procedures used to remove pressure on a
nerve root or the spinal cord from a bulging, herniated disc or bone spur. During the
procedure the surgeon takes out a small piece of the lamina (the arched bony roof of the
spinal canal) to remove the obstruction below. It can also be called open discectomy.
These procedures are usually performed in a hospital using general anesthesia, but may
be performed in an outpatient surgical center in some cases.
 


Anterior Cervical Disectomy

Dr. Berti may use an anterior cervical discectomy to treat damaged cervical discs, which may put pressure on nerve roots or the spinal cord. It is called anterior because the cervical spine is reached through a small incision in the front of the neck (anterior means front).

Posterior Microdiscectomy

A posterior microdiscectomy is a minimally-invasive procedure used to relieve pressure on a nerve caused by a herniated disc. Dr. Berti will use a magnifying instrument to view the disc and nerves, allowing him to remove the disc matter through a smaller incision, reducing the damage to the surrounding tissue. It is called posterior due to the approach
through the back of the patient's body. A microdiscectomy is usually performed on an outpatient basis.

Corpectomy

Many diseases and lifestyle habits cause compression of the spinal cord. A corpectomy is an invasive surgical procedure that removes a portion of the vertebra and adjacent intervertebral discs in order to decompress the cervical spinal cord and nerves. A bone graft with or without a metal plate and screws is used to reconstruct the spine and provide stability. It is often performed in association with some form of disectomy.

Anterior Cervical Corpectomy

In instances of severe cervical disease, such as when it encompasses more than just the
disc space, Dr. Berti may recommend an anterior cervical corpectomy. This procedure
involves removing the whole vertebral body as well as the disc spaces at either end to
completely decompress the cervical canal. This procedure is often performed for multi-level cervical stenosis with spinal cord compression caused by bone spur (also known as osteophytes) growth. This is called anterior because the cervical spine is reached through the front of the neck. The approach is similar to a discectomy (anterior approach), although a larger and more vertical incision in the neck will often be used to allow more extensive exposure.

Laminotomy/Laminectomy

Laminectomy and laminotomy are open surgeries performed to relieve pressure on the spinal cord and/or spinal nerve roots by removing all or part of the lamina. The lamina is the thin part of the bones that make up the spine (vertebrae ), which forms a protective arch over the spinal cord. A laminotomy removes a part of the lamina to make a larger opening to relieve pressure; a laminectomy removes all of the lamina on select vertebrae and may also remove thickened ligament tissue. They are typically performed under general anesthesia. Different terms are used to describe the laminectomy or laminotomy depending on where in the body they are performed. For example, in the neck, the term used is cervical laminectomy or laminotomy.  The choice of procedure depends on the location and severity of the spinal problem that
requires treatment. Reducing pressure on the nerve roots often can relieve leg or arm pain and allow resumption of normal daily activities. Laminectomies and laminotomies are often performed in the course of a number of operations on the spinal canal, such as removal of a ruptured disc.

Lumbar Laminectomy

A lumbar laminectomy is used to relieve pressure on the lumbar spinal cord or spinal nerve by widening the spinal canal. A small section of the bony roof of the spine, the lamina, is removed to create more space for the nerves. A surgeon may perform a lumbar laminectomy with or without fusing vertebrae or removing part of a disc. It is also known as open decompression.

Posterior Cervical Laminectomy
This surgical procedure is used to remove the pressure on the spinal cord by opening the spinal canal from the back of the cervical spine to make the spinal canal larger.

Medial Facetectomy

Facetectomy is an invasive surgical procedure that is performed to relieve pressure on spinal nerves. The procedure involves exposing the affected vertebra and removing one or both of the articulating facet joints that are rubbing against the nerve. Sometimes a laminotomy is performed in conjunction with a facetectomy. Most patients are given a general anesthetic for the procedure.

Foraminotomy

Foraminotomy is an operation that widens or enlarges the opening or foramen where a nerve root exits the spinal canal.
Bulging, herniated discs or joints thickened with age can cause narrowing of the space through which the spinal nerve exits and can press on the nerve, resulting in pain, numbness, and weakness in an arm or leg. Small pieces of bone over the nerve are removed through a small slit, allowing the surgeon to cut away the blockage and relieve the pressure on the nerve. This may performed on any level of the spine, and most patients undergo the procedure with general anesthesia.

Spine fusion

Spinal fusion is an invasive surgical procedure used to strengthen the spine, treat spinal instability, and prevent painful movements. Spinal fusion is usually performed at the end of other surgical procedures for the spine, such as discectomy, laminectomy, and foraminectomy.

The spinal discs between two or more vertebrae are removed and the adjacent vertebrae are “fused” together by bone grafts and/or metal devices secured by screws. The patient's bones will grow over the graft. Spinal fusion may result in some loss of flexibility in the spine and requires a long recovery period to allow the bone grafts to grow and fuse the vertebrae together.

Spinal disc replacement

Spinal disc replacement surgery is also called as “total disc replacement, inter vertebral disc arthroplasty or, artificial disc replacement”. In this procedure, intervertebral degenerated discs in the spine are replaced with artificial (plastic or metal) discs in the upper or lower spine. This procedure is used to treat severe, chronic lumbar pain and cervical pain that resulted from degenerative disc disorder. It allows more motion in the spine than some spine fusion surgeries, and may prevent the breaking down of premature adjacent spine levels. Not everyone is eligible for this procedure.

Minimally Invasive Spine Surgery

Dr. Berti is one of few neurosurgeons who specializes in minimally-invasive spine surgery (MIS). Minimally-invasive procedures take place through one or more short incisions, as opposed to conventional, open surgery's deeper and longer cuts. These smaller incisions lead to less post-operative pain, quicker recovery, less blood loss, and shorter hospital stays.
Typically, in MIS, Dr. Berti inserts an endoscope through a small incision into the area to be worked on. An endoscope is a long, thin tube with a lighted camera on its tip. Dr. Berti can then monitor the surgical site on a high-definition monitor. MIS requires specially designed instruments, which are placed through the small incisions made earlier. Not every patient is eligible for this procedure.

Pain management (Epidural steroid injections, Facet Blocks)
Dr. Berti explores all possible conservative, non-surgical procedures to treat back pain before recommending surgery. His goal is to provide safe pain relief for his patients. He offers epidural steroid injections and facet blocks among others. These injections are used in conjunction with a thorough physical therapy plan. These injections are temporary solutions, effective from one week up to one year, that help the patient with acute episodes of pain or with progressing in their rehabilitation program.
Steroid injections are used in the cervical (neck), thoracic (mid-spine), and lumbar (lower back) regions, and can also treat radicular pain such as sciatica. The steroidal injection delivers medication directly or very near to the source of pain, while also avoiding the side effects caused by oral steroids. Injecting these steroids directly can noticeably decrease the inflammation associated with spinal stenosis, hernias, and degenerative disc disease, and is thought to also flush out inflammatory proteins. The most commonly performed injection is an epidural steroid injection.

Facet joints are two hinge-like joints of the spine that link vertebrae together. They are located on the back of the spine. A facet block or facet joint injection is a surgical procedure that involves injecting a time-release steroid medication into the facet joint to reduce inflammation, under imaging guidance. The facet block is designed to relieve pain so that a patient can tolerate physical therapy, and to diagnose the cause and location of the back pain.

Vertebroplasty and Kyphoplasty:

Vertebroplasty is one of the minimally-invasive procedures Dr. Berti uses to strengthen and stabilize a spinal fracture, and relieve pain caused by that fracture. The procedure is performed with the patient sedated (either under general anesthesia or a local anesthetic with intravenous sedation). The doctor will inject a specially formulated acrylic bone cement into the diseased vertebra under x-ray guidance. Vertebroplasty generally takes about one hour to perform per vertebra.
Kyphoplasty is a newer, minimally-invasive procedure performed on patients with compression fractures of the spine. The procedure is similar to vertebroplasty, but adds one step before the cement is injected into the vertebra. The patient is anesthetized, the bone is drilled, and one balloon (called a bone tamp) is inserted into each side of the vertebra. The two balloons are inflated with a contrast medium and expanded until the desired height is reached, and then removed. The spaces created by the balloons are filled with cement. This procedure can restore height to the spine and can reverse deformity of the spine. It works best on recent compression fractures.

Ventriculoperitoneal shunt:

A ventriculoperitoneal shunt is a surgery performed to relieve increased inctracranial pressure caused by hydrocephalus. A shunt system consists of the shunt, a catheter, and a valve. One end of the catheter is placed within a ventricle inside the brain, or in the CSF outside the spinal cord. The other end is usually placed within the peritoneal cavity, or wherever the physician decides to place it for CSF reabsorption. A shunt is a flexible and sturdy plastic tube.The valve is located along the catheter and should regulate and maintain a one-way CSF flow. This procedure is performed in an operating room under general anesthesia.

Craniotomy:

A craniotomy is a cut that opens the skull (cranium). This surgical procedure is used by neurosurgeons for a variety of neurological conditions and diseases, including brain tumors, arteriovenous malformations, swelling of the brain, and skull fractures, and is often a first step in other complex procedures. A craniotomy is performed under general anesthesia.

Stereotactic biopsy:

Stereotactic biopsy is a minimally-invasive procedure used to remove a small amount of tissue from a tumor site. The tissue will be examined by a pathologist under a microscope to diagnose the tumor. A stereotactic biopsy is performed for deeper tumors in critical locations with the use of a titanium stereotactic headframe and a computer, which are used to create a reference for all imaging and scants to a coordinate system, allowing for a precise approach. The procedure generally takes around 1 1/2 hours.

Microsurgery:

In microsurgery, surgeons view the minute structures within the body they operate on through a compound operating microscope. Neurosurgeons can operate on delicate nerves, treat vascular abnormalities, and tumors precisely with miniaturized instruments.

Stereotactic Radiosurgery (Gamma Knife, Cyberknife, LINAC)

Stereotactic radiosurgery (SRS) is an alternative to open-skull brain surgery, spine surgery or microsurgery, offering significantly fewer complications and lower risk than open surgery. It is an advanced form of radiation therapy, focusing high-powered x-rays or gamma rays onto a small area in contrast to traditional radiation therapy's approach.
Stereotactic radiosurgery uses sophisticated 3-D computerized imaging to precisely target and deliver narrow, highly concentrated doses of radiation to the affected tissue. It is most commonly used in the treatment of brain or spinal tumors and brain metastases from other cancer types, and is generally restricted treating only small tumors with well-defined edges. It is not considered a surgical procedure because there is no incision involved, and no general anesthesia is required.
Radiation therapy requires a multi-disciplinary approach. The team of treatment specialists may include a radiation oncologist, a neurosurgeon, a medical radiation physicist, a dosimetrist, a radiation therapist or radiation therapy nurse, and a neuro-oncologist, among others. As your neurosurgeon, Dr. Berti will oversee the treatment process and interpret the results of the procedure with the radiation oncologist.
There are many types of radiation therapy. Dr. Berti specializes in Gamma Knife and CyberKnife.

Gamma Knife:

Gamma Knife is a stereotactic radiosurgical treatment that safely delivers a single, large dose of gamma radiation to the targeted brain tumor or affected tissues in the brain with precision. The radiation kills the cancer cells at a molecular level by disrupting its DNA, thus interfering with the tumor's ability to survive.
Gamma Knife requires the use of a stereotactic, 3-D reference frame which is attached to the patient's head. This frame provides a reference which can be seen on the imaging equipment, which can provide exact coordinates for the target. This frame keeps the patient's skull perfectly still for further accuracy.
Approximately 201 sources of Cobalt-60are available in the Gamma Knife treatment unit. Thousands of radiation beams can be generated from the sources with a level of accuracy of more than 0.5 mm, or the thickness of one strand of hair. An individual radiation beam is too weak to damage tissue on its path to the target. The accurate intersecting of all the beams on the target results in radiation sufficient to treat the targeted area. A full dose of radiation can be delivered during a single session. Lesions from 5 to 40 mm can be treated. This is an outpatient procedure that takes roughly 30 minutes.


CyberKnife:


The CyberKnife Robotic Radiosurgery system is a safe, non-invasive treatment alternative to conventional surgery for both benign and malignant tumors throughout the whole body, including the spine and brain. There is no incision, no blood, and it, too, is an outpatient procedure. The treatment accurately delivers high doses of radiation to tumors. The radiation kills the cancer cells at a molecular level by disrupting its DNA, thus interfering with the tumor's ability to survive. The precisely targeted beams destroy tumors painlessly, without incisions, and spare the surrounding healthy tissue.
The CyberKnife uses a compact, lightweight linear accelarator (LINAC) mounted on a robotic arm to deliver as many as 1,400 highly pinpointed beams of radiation to control or destroy the tumor in conjunction with a sophisticated Synchrony Respiratory Tracking System to monitor the movement of the tumor and the patient's breathing pattern, helping the surgeon maintain tighter control in real time and sparing even more healthy tissue. This procedure should last from 30 to 90 minutes. The patient may need to come back if the treatment is being delivered in stages.


Microvascular decompression:

Microvascular decompression (MVD) is a surgical procedure Dr. Berti employs to relieve abnormal compressions of cranial nerves for some patients with trigeminal neuralgia when medication to provide relief to patients does not work or causes serious side effects. MVD is performed to relieve symptoms caused by the compression of a nerve by an artery or a vein. When performing an MVD, your doctor will perform a craniotomy, and insert a tiny surgical sponge between the compressing blood vessel and the nerve, isolating the trigeminal nerve from the pulsating effect and pressure of the blood vessel. It requires general anesthesia.

Percutaneous stereotactic rhizotomy:

Percutaneous steretotactic rhizotomy (PSR) is an alternative, minimally-invasive outpatient procedure performed to relieve the pain caused by trigeminal neuralgia, glossopharyngeal neuralgia, and cluster headaches. PSR involves the surgeon passing an electrode inducer (hollow needle), into the selected nerve at the base of the skull. A heating current passed through the electrode destroys a portion of the nerve fibers- not the entire nerve- alleviating the pain, but potentially resulting in facial numbness.

Percutaneous glycerol rhizotomy:

Percutaneous glycerol rhizotomy is a procedure performed under local anesthesia. The doctor will insert a needle through your cheek into a natural opening at the base of your skull (foramen ovale). The needle will be maneuvered to the space surrounding the trigeminal ganglion, where the trigeminal nerve divides into three branches, and part of its root. Images are taken to confirm the proper placement of the needle, and then the sterile chemical glycerol is injected. This injures the nerve mildly, with minimal risk of permanent damage or facial paralysis. This treatment will produce relief for a majority of patients, but some may have a recurrence of pain later on.

Percutaneous balloon compression:

Another option for pain control, the percutaneous balloon compression procedure is performed while the patient is under general anesthesia. A needle is inserted into a small opening at the base of the skull. This needle is threaded with a special small catheter with an inflatable balloon attached at the end. The balloon is inflated with enough pressure to compress and injure the trigeminal nerve root.

Balloon compression is a successful treatment for most people, and lasts for some time. Some patients experience facial numbness. Many patients develop weakness in the chewing muscles, at least temporarily.

Motor cortex stimulation:
 
Dr. Berti may suggest using motor cortex stimulation (MCS) to trigeminal neuralgia for a select group of patients. The patient selection process includes a number of factors, assessing cardiovascular risk, the patient's likelihood of positive outcomes with the surgery, previous treatments, and mental health, among others.
MCS requires implanting electrodes over the primary motor cortex. One or more electrodes are placed outside the dura (the outermost layer of the meninges surrounding the brain and the spinal cord) over the motor cortex via a small craniotomy or burr hole. These electrodes are connected to an implanted, battery-powered neurostimulator. The patient adjusts the electrical impulses with an external radio transmitter to alleviate pain.