Complex Spinal Surgery / Instrumentation
Epilepsy represents the second most common cause of mental health disability, particularly among young adults, and accounts for a world wide burden of illness similar to that of breast cancer in women and lung cancer in men. In this country, it has a prevalence of 5-10 per 1,000 population.
Seizures in temporal lobe epilepsy occur both as simple partial seizures with preserved awareness and surroundings (also known as auras) and as disabling complex partial seizures in which consciousness is lost. Generalized convulsions also occur in a significant number of patients.
In the past, many clinicians who care for patients with epilepsy have been uncertain about the overall benefit and safety of costly surgical procedures and have therefore viewed surgery as a last resort for patients with intractable seizures. However, recent advances in neuro-imaging and surgical techniques have improved the surgical treatment of epilepsy to such an extent that It now appears to be a better early option that waiting years until multiple anti-seizure drug regimens have failed.
This was recently borne out in a landmark study published in the New England Journal of Medicine in which the results of a randomized, controlled trial of surgery for temporal lobe epilepsy was reported. More interestingly the lead authors of the study speculated further about the epidemiologic impact of their results and determined that there will likely be an additional 200,000 patients per year needing seizure surgery.
Meeting this new demand we offer the full array of surgical techniques required for the treatment of seizure disorders. We are versed in the use of cortical surface electrodes for assistance in diagnosis and further characterization of a seizure disorder. In addition, we utilize state-of-the-art functional imaging data in tandem with image-guided neuronavigation and intra-operative localization for achieving precise resection of epileptigenic cortex. Sometimes, such resections also warrant the use of “awake craniotomy” particularly when eloquent areas of the brain are involved. Finally we have an experience with the implantation of vagal nerve stimulators for treatment of non- localized seizure disorders.
Hydrocephalus remains a surgically treated condition, which is due to either inadequate cerebral spinal fluid (CSF) reabsorption, or rarely CSF over production. The underlying etiology of this condition is either a congenital or an acquired disorder.
Although, we in the past participated in a limited role at Children’s Hospital in the treatment of congenital hydrocephalus, the bulk of our experience encompasses the adult population. Typically, adult hydrocephalus occurs in the aftermath of head trauma or intracranial bleeding episodes due to aneurysm, AVMs, or stroke. Alternatively, certain types of tumor can obstruct CSF outflow from the brain.
Increasing excitement has more recently been directed toward the detection and treatment of normal pressure hydrocephalus (NPH). In particular, the increasingly aged American population has become more exposed to the travails of dementia. In many cases senile dementia has a devastating progression that ultimately robs a person of their identity. However, NPH represents a subset of patients with dementia, whose symptoms can be reversed by surgical intervention. Indeed, we have had particular success in using the new programmable ventriculoperitoneal shunts for treatment of NPH. This technique allows tension within the ventricles of the brain to be dissipated by diversion of CSF from the brain to the abdomen. Any slight adjustments in the performance of the shunt can then easily be made via a transcutaneous telemetry device obviating the need for any revision surgery.
Coming to the realization that you or a loved one has cancer can be terrifying and overwhelming. It is reassuring to know that more than half of patient diagnosed with cancer will be cured, but importantly, the choices made right at the start can be critical to the patient’s outcome. Indeed the initial set of tests as well as the first treatment (which is often surgery) may determine whether the cancer therapy is ultimately successful. In most cases, decisions do not need to be made within a day or two of diagnosis and the outcome will not be affected by taking time to determine the best course of action.
You should therefore select a Neurosurgeon that has expertise, and board certifications are some indicators of the expertise. In addition, a Neurosurgeon who has supplemental formal training in Neuro-oncology will be particularly knowledgeable about all your options for care, not just the operation.
At LJNA, we possess such supplemental qualifications. Not only has Dr. Coufal participated in NIH sponsored Neuro-oncologic research fellowship training both at The Brain Tumor research Center (UCSF) and the Ludwig Institute for Cancer Center (La Jolla); he has also gained unique technical expertise in tumor surgery. In particular, complex spinal fellowship training allows the surgeon to tackle the most complex tumors of the spinal cord and spinal column. Other unique capacities include the use of functional mapping and image guided neuronavigation for treatment of tumors in eloquent areas of the brain. Finally Dr. Coufal is specifically certified and has extensive experience using the gamma knife and cyberknife for treatment of selected brain and spinal tumors.
As an additional indicator of our dedication to treating central nervous systems tumors, it should be emphasized that LJNA has a dedicated staff member coordinating our active participation in cutting edge research trials; we also maintain an active collaboration with the National Brain Tumor Foundation and have participated in their local fundraising efforts.
Tumors of the brain we treat include glioblastoma, lower grade astrocytoma and oligodendroglioma, meningioma, metastatic tumor, pituitary tumor, skull base tumors of a variety of subtypes, and intraventicular tumors.
Tumors of the spinal cord/column that we treat include metastatic tumor chordoma, sarcoma, multiple myeloma, neurofibroma, ependymoma, astrocytoma, and hemangioblastoma.
In addition to performing extensive 360- degree decompression and fusion operations of the cervical, thoracic, and lumbar spine, Dr. Coufal as developed and refined skills encompassing the developing field of minimally invasive spinal surgery (MISS). Simply stated, this new field strives to compensate for a structural - anatomic spinal problem with minimal soft tissue injury and thereby allow more rapid recovery. In particular MISS techniques are suited for the treatment of chronic pain syndromes so often encountered in the workmen’s compensation population.
Below is a listing of the MISS procedures being performed by LJNA physicians and their corresponding target patient groups:
- Endoscopic Spinal Decompression and Pedide Fixation.
“For selected low back pain patients with single level degenerative disc disease with or without accompanying radiculopathy”
- Cervical artificial disc
“For eliminating the need for hip grafting in the treatment of neck and radicular arm pain.”
- Balloon Kyphoplasty
“For traumatic osteoporotic, neoplastic compression fractures of the thoracolumbar spine.”
- Endoscopic thoracic sympathectomy
" For post-traumatic RSD pain and hyperhidrosis”
- Spinal stimulator insertion
“For chronic refractory lower extremity pain syndromes”
- Intrathecal Pump (morphine/baclofen) insertion
“For failed back syndrome, painful spasticity”
- C2 dorsal root ganglionectomy
“For cervicogenic (whiplash pattern) headache/chronic neck pain”
- Intradiscal Electro Thermal Therapy (IDET Procedure)
“For chronic low back pain”
- Coblation Nucleoplasty
“For chronic low back pain”
- Spinal Epiduroscopy
“For direct visualization of nerve root condition and precision delivery of steroid in the previously operated lumbar spine”
The Endoscope represents a technical advance in neurosurgery by virtue of its provision for minimally invasive approaches to the brain, spine, and peripheral nerves; Endoscopic procedures which we are certified to perform, and offer to our patients, include:
- Third Ventriculostomy
“For selected types of hydrocephalus”
- Intraventricular Biopsy
“For selected deep tumors of the brain”
- Endoscopic Thoracic Sympathectomy
“For post-traumatic RSD pain and hyperhidrosis”
- Endoscopic Thoracic Spinal Biopsy
“For diagnosis of infections and tumors of the spine”
- Endoscopic Pedicle Fixation of The Lumbar Spine
“For selected low back pain patients with single level degenerative disc disease with or with out radiculopathy”
- Endoscopic Carpal Tunnel Release
“For carpal tunnel syndrome”
The sheer volume of work injuries that occur in Southern California place considerable demands on all healthcare delivery services. When one considers that the majority of such injuries entail back or neck pain the paramount importance of qualified spine specialists is clear. As a neurosurgeon who has completed additional advanced training in complex spinal surgery, Dr. Coufal considers the more challenging spinal cases encountered in “work comp” to be an integral part of his practice. In this regard, he has participated as a tertiary referral spine surgical specialist for a network of clinics in greater Los Angeles, Orange County and San Diego since 2001. During this period of time Dr. Coufal has also served as a QME and AME and enjoys the medicolegal evaluation of the more complex work comp cases. Now‚ in 2008, Dr. Coufal´s referral network incorporates clinics as far north as Fresno. For each clinic site within this network Dr. Coufal works collaboratively with chiropractor and primary treating physicians as well as pain management and orthopaedic specialists.
The end goal for each treated patient is that they be afforded timely and state-of-the art spinal surgical treatment. More recently, artificial disc technology has been adopted as part of the surgeon´s panoply of state-of-the art techniques for treating work comp spinal injuries. In this regard, Dr. Coufal has established a dialogue with work comp case managers and work comp insurance companies so that authorization can be obtained when appropriate.
Under the auspices of work comp‚ Dr. Coufal also evaluates and treats peripheral nerve injuries (whether acute or secondary to continuous occupational exposure) as well as selected cases of traumatic brain injury.
Methods for treating neurosurgical conditions of the brain and spine do not always require open surgery. Beginning in the 1950s a pioneering neurosurgeon by the name of Lar Leksell at the Karolinska Institute began to develop what was to become known as stereotactic radiosurgery. Simply put, he was able to create a system for delivering very precise beams of radiation to specific target lesions in the brain. In so doing he was able to dramatically reduce radiation injury to normal adjacent areas of the brain, in turn reducing the morbidity typically seen with radiation therapy.
Over the last decade the field of stereotactic radiosurgery has exploded as the Gamma Knife has accumulated a successful record in treating certain types of brain tumors as well as AVMs and trigeminal neuralgia. In addition the field has expanded to treat cancer of the spinal column. Whereas the Gamma Knife was restricted to treating only intracranial lesions, the new Cyberknife device can now treat extracranially as well as intracranially. Patient comfort is an additional dividend offered by the new Cyberknife. By virtue of itís robotic technology and computer software the Cyberknife can successfully treat a lesion without having a patient’s head fixated in a stereotactic head frame.
In collaboration with radiation oncologists at two Cyberknife sites in San Diego (Encinitas and Clairemont) Dr. Coufal actively treats selected tumors of the spinal column and brain as well as AVMs of the brain and refractory cases of trigeminal neuralgia.
Aneurysms and AVMs of the brain frequently present with abrupt onset of symptoms which warrant emergent evaluation in the hospital. The consequences of bleeding in the brain caused by these two types of vascular problems can in turn be devastating. It is therefore critical that management of such conditions be undertaken promptly and expeditiously by a multidisciplinary team with the necessary experience. In Dr. Coufal’s practice aneurysms and AVMs are treated exclusively at Scripps Memorial Hospital where such a team is in place. Together with neurointerventional radiologists, neuroanesthesiologists, and Critical Care Specialists the patient is carefully marshaled through the critical peri-operative period and beyond. Depending on the anatomic nuances of the particular lesion in question treatment may consist of embolization or coiling by the interventional radiologist, stereotactic radiosurgery (using the Gamma knife or Cyber knife), open surgery, or a combination of the above. Subsequent care following discharge from the acute hospital then takes place over an extended period of time in collaboration with rehabilitation specialists and neuropsychologists with the ultimate goal of return to maximally functional activity.
More advanced degenerative conditions of the spine as well as distinctive spinal cancers, trauma, and certain congenital anomalies mandate more complex surgical strategies. In such cases, the removal of the offending structural problem (whether compression on the spinal cord and nerve roots by tumor or degenerative overgrowth) must be combined with a method of reconstructing the spinal cord column. This is because the safest way to physically remove the site of compression ends up destabilizing the natural elements that had already been in place to provide stability. To compensate for this loss, a variety of state of the art spinal implants are utilized for reconstruction. These can range from titanium screws, rods, and cages to “plastic- like” novel polymeric structural conduits. As with building construction, the framework of the design ultimately requires that an applicable “concrete” harden to achieve maximal strength. The biologic equivalent of concrete for surgical purposes may be either the patient’s own bone, bone derived from a tissue bank, or one of the newer genetically engineered bone substitutes.
When a certain threshold of disruption to the spinal column has been crossed, such spinal implants are used to “fuse” the involved spinal segment. However, when that threshold has not been crossed we can consider utilizing the new notion preservation implants-specifically, the cervical and lumbar artificial disc prostheses.
Since September of 2004 Dr. Coufal has served as Medical Director of Neurotrauma and Neurosurgical Emergency Services at Scripps Memorial Hospital La Jolla. In this capacity he has and continues to oversee quality assurance for a panel of four neurosurgeons exclusively contracted by the hospital to respond to “any and all” types of neurosurgical emergencies. Working in close collaboration with a dedicated team of trauma surgeons as well as emergency department physicians, Dr. Coufal’s team has sought to raise the bar regarding outcomes in these dire cases. A key component for success in their endeavor is the rapid integration of new technology and active research insights with existing treatment algorithms. With respect to new technology, Dr. Coufal’s team has pioneered the use of brain tissue oxygen (LICOX) monitors in managing traumatic brain injury (TBI). Of equal importance will be the experience derived from participation in the upcoming multinational RESCUE ICP study to determine the appropriate use of radical decompressive craniectomy for TBI.
The management of traumatic brain and spinal cord injuries also demands a strategic long term plan. Working in collaboration with skilled rehabilitation physicians, neurologists, and pain management specialists we ultimately seek the restitution of wellbeing.