Baylor Scott & White - Texas Brain and Spine Institute

Brain tumor evaluation and treatment

There are several steps involved in diagnosing and treating brain and spine tumors. Obtaining the diagnosis is the first step. Imaging studies such as CT or MRI usually provide the first view of the brain tumor. These studies give the exact location of the tumor and some general information about the brain tumor type.

There are many different types of tumors. Thus, the diagnosis must be specific and certain to ensure the best treatment plan. After a diagnosis is made, a brain tumor treatment plan can be formulated. Treatment options may include surgical removal (sometimes combined with a biopsy procedure), radiation therapy and chemotherapy. Response to brain tumor treatment is monitored closely, and the plan is modified as needed.

Cerebrovascular disease evaluation and treatment

We treat all vascular problems in the brain and spine, most commonly including aneurysms, arteriovenous malformations and cavernomas.

We work closely with interventional neuroradiologists and radiation oncologists to deliver the best possible care for these issues, whether that includes surgery, endovascular treatment (minimally invasive treatment that avoids an open surgery) or radiation therapy.

Neck and lower back pain treatment

Because every patient is unique, we formulate neck and lower back treatments based on a thorough evaluation, which we perform using the latest technological advancements.

We believe in evaluating patients promptly and educating them on their diagnosis so they can play an active role in the decision-making and treatment process to reduce their lower back and neck pain.

Our clinical experience has shown us that patients who participate in their own healthcare decisions are far more likely to achieve optimal healing and recovery.

Skull base surgery

Skull-based tumors present a unique set of challenges due to their deep location.

We offer our patients the very latest in minimally invasive techniques for skull base surgery, including endoscopic surgery through the nose, when appropriate, to treat these tumors.

We believe skull base pathology requires a team approach to deliver the best care possible. As an integral arm of the Baylor Neuroscience Center Skull Base Center, we work in partnership with sub-specialized endocrinologists, otolaryngologists, radiation oncologists, neuro-oncologists and others to ensure our patients receive expert care for all facets of their skull base tumor treatment.

Stroke care

A stroke is a medical emergency that occurs when a blood vessel in the brain becomes blocked (ischemic stroke) or breaks (hemorrhagic stroke). During a stroke, nearly two million brain cells die every minute, which makes getting the proper care fast critical to limiting long-term disability or even saving lives.

Radiosurgery

Radiosurgery, defined as treatment using powerful beams of precisely focused radiation, is a crucial tool in the fight against difficult tumors.

We work in conjunction with radiation oncologists to develop precise plans to deliver radiation to the tumor while sparing the important structures nearby as part of our radiosurgery treatment.

Cervical disc herniation

A disc herniation is the same in the cervical region as in the remainder of the spine, but surgical treatment is very different. Initially, treatment starts with medications—usually anti-inflammatories and muscle relaxants—and physical therapy. The next tier of treatment is advanced imaging—usually an MRI—and pain management injections. Finally, the last level of treatment is surgery, which is generally an anterior cervical discectomy and fusion (ACDF). This differs from a lumbar disc herniation in two significant ways. In the lumbar spine, the incision is made in the back, but in the cervical region, it is created in the front. Secondly, there are no implants with a lumbar disc herniation surgery, but in the cervical region, there are. The implants for the cervical disc herniation occur because the herniation is removed from the front, requiring the disc to be completely removed. The implants fill this space created by removing the entire disc. The whole disc must be removed to reach the herniation in the back, and it is extremely risky to remove the herniation from the back because to do so, you would push the spinal out of the way, and that can cause a spinal cord injury and paralysis. The ACDF technique has been performed for decades, and research shows it is one of the most successful surgeries.

Cervical stenosis

Stenosis, or pinching or compression of the spinal nerves and spinal cord in the neck region of the spine, is called cervical stenosis. It is the same stenosis we see in the lumbar and thoracic spine, but the neck or cervical region of the spine is shaped quite differently than the other regions. Due to the different shapes and locations of other organs, the techniques for addressing stenosis in the cervical spine are usually different. For example, someone with lumbar stenosis would likely undergo surgery from the back to decompress the nerves; however, in the cervical region, that surgery would be done from the front of the neck.

Disc herniation

The disc is a combination of soft tissue and cartilage that acts as a shock absorber between the spine's vertebral bones. The outer annulus holds in the inner nucleus like a bag; the inner nucleus acts as the shock-absorbing substance. When a disc herniates, the inner nucleus squirts out from the annulus that contains it; the part that has squirted out can pinch on nerves and cause stenosis and symptoms.

Most disc herniations will not require surgery, but in some severe cases, surgery is necessary. Treatment with surgery involves removing the part of the disc that has been damaged and is pressing on nerves. The technical name for this is discectomy or micro lumbar discectomy in the lower back region. Before surgery, medications, physical therapy, and injections can be beneficial.

Loose or broken spinal implants

Loose or broken spinal implants are a sign that the spine did not fusion after a fusion surgery. This is called a spinal nonunion. The metal screws and rods and plates used in spine fusion surgery are placed to hold the spine in the correct position and prevent movement. Stopping spinal motion after fusion is necessary to allow that body to grow new and turn the individual bones into one large bone. The body cannot grow bone if the individual bones are moving, so casts are placed on broken bones. The spinal implants and casts also hold the bones in the correct alignment. Spinal implants take the place of casts. Once the body has grown the fusion bone and all the bones are together, the patient’s living bone holds the spine in alignment and the metal does not undergo any stress. However, if the spine does not fuse, the metal spinal implants will continue to experience anxiety and fatigue and will eventually break or loosen. Once that occurs, the spine will have abnormal motion and perhaps painful instability. The treatment of choice is to restore alignment and stability to the spine; this can almost always be done surgically.

Myelopathy

Myelopathy is the technical term for symptomatic compression of the spinal cord in either the cervical or thoracic region. The symptoms are generally more different than the compression of the spinal nerves. Pain, numbness, tingling and weakness can come from compression of the spinal nerves and spinal cord, but compression of the spinal cord can also balance difficulty and loss of fine motor control from a lack of proprioception. Proprioception is the ability to sense the position and location of your arms and legs without looking at them. This helps you walk in a straight line, touch your finger to your nose with your eyes closed and many activities we do not even consider. Myelopathy also could represent permanent damage to the spinal cord. The longer there is compression of the spinal cord, the more permanent damage could accumulate, and the symptoms and loss of function are permanent and not reversible. To prevent possible worsening of spinal cord damage, treatment for myelopathy is surgical to remove the pressure. The timing of surgery is also done expeditiously to decrease the time when more spinal cord damage can occur.

Revision spinal surgery

The need for revision spine surgery generally has three causes: a previous spine surgery that did not heal correctly, new or worsening problems at a site of prior surgery, and problems above or below an old spine surgery. For surgeries that did not heal correctly, there could be a lack of fusion, loose or broken screws and rods, or the spine could be fused in a bad position. Worsening or new problems at a site of previous surgery could be instability or spondylolisthesis that has developed after a decompression-type surgery. In the case of pinched nerves, often, decompressing the nerves surgically without fusing can lead to a good result. However, further degeneration of the disk and facet joints can lead to recurrent stenosis and instability over time. Lastly, most problems that require spine surgery in adults have a significant, if not sole, etiology from degeneration. When surgery is done and that spine level is addressed, the degenerative processes still occur at the other spine levels. If those other levels progress to needing surgery, it is expected that the new and old surgery levels will need to be joined together during surgery.

Treatments for revision spine surgery are varied and must be tailored to the problem and the person. Revision cases are more challenging than operating on a spine without surgery; it takes experience and skill. Most importantly, it takes willingness, not just from the surgeon but also from the patient. Patients facing revision spine surgery are often looking at a more extensive surgery than they had previously. They have experienced recovery once before, and sometimes, that may have been a trying experience. Ultimately, the patient must have courage and realize that revision spine surgery can significantly improve symptoms and quality of life.

Spinal instability

The technical term for spinal instability caused by degeneration is spondylolisthesis, and the different types are discussed in the spondylolisthesis section. There can be spinal instability from trauma that causes injury to the spinal ligaments, discs and soft tissues or fractures of the spinal bones. In general, it takes a significant amount of force to cause trauma that would destabilize the spine; almost all of these patients are first evaluated in the Emergency Department.

Spondylolisthesis

Spondylolisthesis is a term used to describe instability and malalignment between two vertebral bodies and the disc in between them, usually in the lumbar or lower back region. These three parts, the disc and the spine bone above and below it, are often referred to as a motion segment and are named by the bone above and below, for example, L4-5. L4-5 is the most common level for degenerative spondylolisthesis. It means there is enough degeneration or arthritis at the L4-5 level that the L4 bone on top of the L5 bone is sliding off L5. Commonly, it will slide forward, called anterolisthesis, but it can slide to the side (laterally) or the back (retro). With degenerative spondylolisthesis, there is usually significant pinching or stenosis of the nerves at that level. With the instability from the sliding out of place of the bone and the nerve pinching, spondylolisthesis usually causes significant back pain, leg pain, and numbness. Isthmic spondylolisthesis usually occurs at L5-S1, the bottom disc in the spine. This happens when there is a stress fracture in part of the spine bone called the pars. The fracture commonly occurs in childhood and adolescence but can be years or decades before spondylolisthesis occurs. Once it happens, the symptoms are very similar to degenerative spondylolisthesis with components of back pain and leg symptoms.

Several symptoms drive the treatment of spondylolisthesis. Still, ultimately, definitive treatment involves stabilizing the bones so they do not continue to slide out of place and unpinching the nerves. This surgery is called a decompression and fusion, where laminectomy and foraminotomies are performed, and implants hold the two bones together, allowing the bone to grow between them, fusing them into one bone. Before symptoms are severe enough for surgery, physical therapy, medications and epidural steroid injections can be helpful to lessen the symptoms.

Stenosis

Stenosis is pinching, pressure or compression on the spinal cord or nerves. The cervical and thoracic regions of your spine, the neck and chest area, contain both your spinal cord and spinal nerves that branch off and spread to your body. The lumbar region, or low back, contains only spinal nerves. Stenosis of spinal nerves can cause pain, numbness and weakness in the arms and legs; the symptoms can be episodic or constant and can range in severity from mild to excruciating and debilitating.

Treatment for significant stenosis usually involves surgical decompression of the pinched nerves to relieve the pinching and provide the best environment for the nerves to heal. The technical name for these types of decompressive surgeries is laminectomy, foraminotomy, and discectomy. These surgical techniques can be done in addition to other methods used simultaneously. Milder forms of stenosis can be treated with non-surgical techniques, such as physical therapy, medications, and injections.

Anterior cervical discectomy and fusion (ACDF)

ACDF surgery removes a disk through an incision on the front of the neck. Depending on your condition, one disk or more may be removed. After removing a disk, your surgeon fills the open space with a bone graft. The graft serves as a bridge between the two vertebrae to create a spinal fusion and is often held together with metal plates and screws.

Posterior spinal fusion

Posterior spinal fusion is a technique used to treat spinal instability, degeneration and malalignment. In its simplest form, it is getting two bones to grow together for one bone, removing the motion between them and making them stable. To do this, a spine surgeon will remove the facet joints, at least partially if not completely, rough up parts of the spine bones, and place a bone graft between the two spine bones. This bone graft acts as a scaffolding for the body to grow new, living bone between the two spine bones, connecting and fusing them. Over time, the bone graft is replaced with the patient’s living bone that will hold those two spine bones together. Metal implants hold the spine still without motion to give the new bone growth the best chance to succeed. Stopping the motion with the spinal implants provides the best environment for the bone to grow; if there is too much motion, the bone will not grow, scar tissue will form, and there will be a nonunion.

Anterior cervical discectomy and fusion (ACDF)

ACDF, or Anterior cervical discectomy and fusion, is a common technique spine surgeons use on the neck region. It has been performed for decades and generally has excellent results. It starts with an incision on one side of the front of the neck. Then, the space is made between muscles to allow the trachea and esophagus, also known as the windpipe and the muscular tube connecting your mouth to your stomach, to be held to the side out of the way and protected. This allows the spinal surgeon to see the front of the spine. Then, the disc is removed, and a microscope is used to un-pinch the nerves and spinal cord by removing the disc herniation and any bone spurs. In the space left by removing the disc and cage, a structural graft is placed by the spine surgeon, followed by a small plate and screws, to hold everything stable and allow the spine to fuse following surgery.

Transforaminal lumbar interbody fusion (TLIF)

Transforaminal lumbar interbody fusion, referred to as TLIF, is a technique surgeons use to place a cage or structural graft to replace the disc from a posterior or back incision. First, a spinal surgeon makes a back incision to expose the spine. Then, the facet joint is removed and a decompression is done to un-pinch and visualize the nerves. The nerves are then slightly swept out of the way to protect them, exposing the disc. An incision is made into the disc, and the disc material is removed. Next, the spine surgeon roughs up the bones above and below the disc to help them fuse. Finally, bone graft and structural graft are placed where the disc used to be. The structural graft is hollow and packed with bone graft to hold that bone graft in a specific location. It is often referred to as a cage.

Posterior lumbar interbody fusion (PLIF)

This procedure achieves spinal fusion in the lower back by inserting a cage of allograft bone or synthetic material directly into the disk space. When the surgical approach for this type of procedure is from the back, it is called a posterior lumbar interbody fusion.

Laminectomy and foraminotomy

Surgical decompression of the spine is when a spine surgeon removes bone spurs, discs, and degeneration to un-pinch the nerves. An incision is made in the back, and the muscles are pushed off the spine. Then, the doctor removes part of the lamina, part of the spine bone, to see the nerves and gain access to the disc and bone spurs that need to be extracted. This is called a laminectomy. Once access to where the nerves are in the spine, called the spinal canal, has been achieved, the nerves in the spinal canal can be decompressed, and the stenosis will be treated. The spine surgeon can also decompress the nerve in the foramen, the left and right side tunnels at each level where the spinal nerves exit the spine and go to the rest of the body. This is called a foraminotomy. These two techniques are almost always done together because stenosis in the central canal is usually accompanied by stenosis in the foramen.

Micro lumbar discectomy (MLD)

Discectomy, which some people call shaving the disc, is the surgery spine doctors use for a lumbar disc herniation when there are no signs of instability. Since this technique is in the lumbar spine and involves a microscope, it is called micro lumbar discectomy (MLD). During this procedure, a doctor makes a small incision on the back over the level of the disc herniation. The muscle is swept aside, exposing the top of the spine bone called the lamina. A small hole is made in the lamina to visualize the nerves and disc herniation through a microscope. The back doctor removes the disc herniation and any damaged disc material left in the disc space.