Transcription:
Neurosurgery at TCH

Melanie Cole (Host): From strokes to brain tumors, to degenerative disk disease, and more, neurosurgery at the Christ Hospital Health Network offers patients a broad range of expert neurological care. My guest today, is Dr. Mark Magner who is a Neurosurgeon with the Christ Hospital Health Network. Welcome to the show, Dr. Magner. Tell us a little bit about your area of expertise and give us a general update in the world of neurosurgery today.

Dr. Mark Magner (Guest): Sure, well thank you, very much, for having me. I do all of the neurosurgery here, at Christ Hospital. I would say that I do a fair amount of cranial surgery – a lot of times for brain tumors -- also, sometimes and certainly, emergent management of hemorrhages, such as intracerebral hemorrhages, and then sometimes, other more common cranial abnormalities, such as Chiari Syndrome, and facial pain. And then certainly, I also do spinal work like any neurosurgeon, so a lot of people with neck pain, back pain, and et cetera, so I kind of do it all.

Melanie: Then let’s talk about some of the newer treatment modalities available.

Dr. Magner: Yeah, there’s a lot of really pretty neat updates in neurosurgery in general, and Christ has the leading edge and has them all. One of the biggest aspects, I would say, of cranial or brain tumor surgery recently, is the combined use of formal surgery – brain surgery – with radiosurgery. It used to be we would do the surgery, and someone could have whole brain radiation if they fail. As we started to develop radiosurgery, which is pinpoint precision of radiation right to a brain tumor, a lot of oncologists, radiation oncologists, and patients were looking towards that. However, we’ve got a good mix – good teamwork where we can often do surgery, and then follow it by radiosurgery just to the remnant or outer region to where a brain tumor was, and patients typically do pretty well.

It used to be, in the past, we had very large incisions; had a -- surgery was a very, very darn near gruesome sort of experience and patients were in the hospital for many days. We have basically, stereotaxis in surgery now, where we can use computer imaging to bring up someone’s MRI directly into the operating room, and I can literally point to a portion of their brain, and it can show me exactly where I am on the MRI. This allows smaller incisions, shaving only minimal parts of hair, removing only small portions of the skull, so people do really well with these surgeries, often only needing to be one night or two nights in the hospital and generally feeling well. And then, quickly thereafter, within two weeks, we can actually start radiotherapy – again, high beam, precision radiation, to that region where someone had a tumor.

The outcomes are excellent. It affords very, very quick relief of symptoms of a brain tumor from a surgery standpoint, but then all of the excellent benefits you get with radiation of zapping any sort of microscopic tumor cells that may be left behind. It’s really been sort of a game changer in neurosurgery, and certainly, we have that here at Christ, and I think our patients are benefitting very well.

Melanie: If intracerebral hemorrhage accounts for about 15% of all strokes, but it’s one of the more disabling forms of stroke, focus a little for us, on the minimally-invasive cranial treatments for ICH.

Dr. Magner: Yeah, so intracerebral hemorrhage has been a devastating diagnosis really from the beginning of time. Fifty years ago, we started trying to do surgery and count on big surgeries in the brain to try to evacuate or remove these blood clots. We’d have to remove so much normal brain to get there, and so patients did not do well. As we started developing stereotaxis and getting pinpoint accuracy for finding hemorrhages though, we’ve been able to tailor making smaller and smaller incisions, and now we have a couple of neat options. One is still technically in the research stage, but it’s very promising where we put a tiny catheter directly into a hemorrhage and actually inject tPA, which is the clot-busting agent that’s been used in ischemic stroke for thirty years, we can put that tPA directly into the hemorrhage to try to break down the hemorrhage and allow it to drain out the catheter through a tiny tube. You remove the hemorrhage – decrease mass effect – but you don’t actually invade normal brain tissue. It’s pretty special.

We can also do the same when people have hemorrhage that’s into the ventricles or the fluid sacs of the brain. That can cause a swelling of the brain and ultimately, death if not treated effectively. We can put catheters directly into those fluid sacs and do the same, inject this tPA – this clot-busting agent to break it down.

When tPA was first developed thirty years ago, people were really afraid that it would cause hemorrhages of the brain, and it’s really very neat that we’ve come full circle. Not only are we no longer as afraid of tPA as we once were, but we’re also actually using it for these brain hemorrhages. The preliminary data that’s been coming out over the past couple of years is very impressive, and what used to be a 60% chance of death with an intraventricular hemorrhage – a hemorrhage into the fluid sacs of the brain – 50% of those people now are walking on their own within six months. We’ve made tremendous progress, and it’s extremely exciting.

Melanie: Wow, absolutely fascinating, Dr. Magner. Now, speak about artificial disk replacement and cervical spine because people hear that and what used to be done is certainly different than what you’re doing now, today -- speak about the differences.

Dr. Magner: Yeah, absolutely. Cervical disk disease – having a herniated disk or collapse of a disk and catching a nerve – has been a common problem. It’s been treated many different ways over the past sixty years, and really, what we’ve found is once you remove the disk and whatever’s pinching a nerve, you’ve really cured that nerve, but if you don’t put anything where that space used to be where the disk was, it will often collapse down. That can cause basically malalignment of the neck and increased neck pain.

We started fifty years ago basically putting pieces of the patients’ hip right there where that disk used to be to keep the disk space propped open and allow those bones to fuse as one. That was a fantastic procedure – an anterior cervical diskectomy and fusion. As our technology has improved over the last fifty years – we’ve gotten donated bones, sometimes synthetic gauges that can go in that space. But actually, by 2007, the FDA approved in the United States artificial disks for this, and then, over the past two or three years, we actually have more devices that are FDA approved. The idea is that you can put a spacer now in to keep the disk space propped open. You no longer have to fuse the bone above or below as one, solid piece of bone, so you maintain normal mobility of the neck, which is very, very helpful in terms of recovery, but also helps limit the degeneration or the changes in the alignment of the spine through the future.

The other thing is when you’re trying to get bones to fuse as one, we typically try to limit the NSAIDs --medications such as ibuprofen or naproxen, and since you’re not trying to fuse the bones as one, you can actually use those medications quite liberally. Therefore, people can have better pain control, limit narcotics, and so get back to driving, get back to work much faster. For a procedure – this is a procedure that typically, we’re doing as an outpatient now, and people are doing really well with limited narcotics. It’s very exciting, actually.

Melanie: Wow, and did you say that it’s been shown to have at least equivalent results to the anterior cervical disk?

Dr. Magner: So, we don’t have a tremendous amount of data compared to the fifty, sixty years with the fusion, but it’s been used in Europe before that. Even the data that we have here in the United States over the past ten years, we have at least two, large metanalyses – research papers that kind of pooled all of the research studies together. They showed basically, equivalence in terms of ability to decompress the nerve or get the neck pain better, and so it’s just as safe as a fusion. However, then you’re bypassing some of the potential negative aspects of the fusion --

Melanie: And grafting?

Dr. Magner: Like I said, such as not being able to use the NSAIDs or changing the neck mobility in the future.

Melanie: So, Doctor, what are some valuable prognostic tools to aid in diagnosis for neuro, and how important is the early diagnosis as being crucial to improving outcome prediction for some of these types of conditions?

Dr. Magner: Yeah, I’ll tell you -- certainly, the mainstays of treatment in any hospital would be CT scan and MRI, which are of course, extremely helpful. One of the really neat cutting-edge modalities that are going to separate Christ Hospital really from the other hospitals in the region – save for major academic centers is continuous EEG capabilities. If someone is having a seizure, most of us think of what used to be called the grand mal seizures – the tonic-clonic seizures with somebody shaking on the ground. That can be quite obvious, but there are much more subtle seizures when you’re dealing with brain tumors, hemorrhages, stroke, et cetera, that where someone may not be shaking all over and yet, they’re comatose and it’s because they’re actually seizing If you just do an EEG – an electroencephalogram, where you check the brain waves – if you just do that once in a while, someone may not be seizing at that moment, but if you were to continually do it for a period of let’s say 24 hours, you might catch very small seizures here or there. The game-changer aspect is those are typically so well-treated – if we can increase or changes someone’s anti-seizure medications -- take someone who looks very, very – who looks like they’re perhaps drifting into a coma – this could potentially save their life. For that reason, it’s become very important in research centers to try to get continuous EEG where we can monitor the brain waves for – well, for as long as we like – certainly 24 hours, but often even up to 72 hours. At regional hospitals, it’s just so expensive that it usually hasn’t been done. Either doc – if someone were comatose – would either have to choose to do a spot EEG once in a while or to transfer these patients.

Here, at Christ, we’re actually complete in our ability to essentially partner with the Epileptologist at the University of Cincinnati where here, they’re going to read our EEGs remotely. The patients here at Christ Hospital will have the continuous EEGs performed, these Epileptologists will be able to confirm if someone is having a seizure or not and then we’ll be able to much more accurate diagnose a patient, but keep them right here at Christ Hospital where they want to be, surrounded by their other oncologists, radiation oncologists, et cetera. I think this is going to be really a huge win for any neurologic patient at Christ Hospital, and I certainly hope that we’ll be able to be a guide for other hospitals and how they can deliver great care where you can set up all the infrastructure of your hospital, but outsource with an academic center to have specialist Epileptologists looking at these sort of rare or very difficult cases. I think it’s a very special thing that we’ve worked very hard, here at Christ, to get over the last couple of years, so I’m excited that it’s going to get started here very shortly.

Melanie: What does current research indicate for future developments and treatments? Give us a little blueprint for future research.

Dr. Magner: Yeah, so I would say a lot of research from the neurosurgery standpoint is certainly going into our use of combined surgery and radiosurgery and as I mentioned, earlier in our conversation that we’ve got a good thing going with doing surgery followed by radiosurgery. Some other research that’s actually pretty interesting is looking at maybe even doing radiosurgery first, and then doing surgery within one or two days to even try to limit further radiation doses that a patient might experience. And so, I certainly look forward to some of that.

The other aspects are using the clot-busting agent, tPA. Some of that is, I would say, standard of care, at this point. But certainly, some of what I mentioned – especially putting catheters into large hemorrhages to drain the fluid – is still in the research phase and so it certainly can be done and should be done for life-saving measures, but we’re going to have to see how this plays out in large, randomized trials. One of those trials is nearly complete, and I expect that data to be out soon.

And then, of course, anything, when we’re talking about spine – if it’s fusion, if it’s artificial disk, or whatever comes in the future – we’re always trying to maximize someone’s mobility – limit pain, maximize mobility, and get people back to their normal life. If it’s work or walking, or whatever it is in between, trying to get them back as quickly as possible and as cost-efficiently as possible. I think as we continue to improve artificial disks, I think there’s a technological or engineering piece of research there, but will also be trying to evaluate cost-efficiency – make sure that we’re delivering a good product that helps patients, but also can be sustainable for the future, so I think there’s going to be a lot of financial research moving forward.

Melanie: In summary, Dr. Magner, please tell other physicians what you’d like them to know about neurosurgery at the Christ Hospital Health Network when to refer, and what they can expect from your team at the Christ Hospital Health Network as far as your team approach?

Dr. Magner: I would say first, for Christ Hospital Neurosurgery, I think we’ve laid a great foundation, and we’re growing very nicely. As I spoke about the continuous EEG coming on, getting the radiation oncologists, and the oncologists, and the neurosurgeons on board. We also have a new hire. Dr. Monir Tabbosha started mid-2017 as a neurosurgeon with a complex scoliotic deformity focus. I poached him from the University of Arkansas, and he’s been a great find, and we’re continuing to grow, as well. I think our program has gained a lot of traction and the administration appears to be very much on board with helping us grow to deliver fantastic results for our patients.

In terms of referral, I’ll tell you this – and I don’t mean to be facetious at all – but I would say as soon as a Doc is just ready for help, we’re ready. Some docs feel very comfortable with very diagnoses to work it up with imaging and consultations before calling a neurosurgeon right towards the end when they think surgery might be needed. I think that’s very fine, but there are a lot of difficult diagnoses or scary diagnoses, especially when you’re dealing with brain tumors or hemorrhages and stroke, and I freely give out my cell phone, as does my partner quite a bit. They can call any at any point, day or night, and we’re happy to look at imaging if it’s on the PACS system – the computer system – to help guide a sort of management. The bottom line is I would say a doc can reach out as soon as they want. It’s never too late, and it’s never too soon.

Melanie: Thank you so much, for being with us today. What a great segment and a great topic. You’re listening to Expert Insights, Physician Views, and News with the Christ Hospital Health Network. More information on Dr. Magner and all of the Christ Hospital physicians is available at TCHPConnect.org, that’s TCHPConnect.org. This is Melanie Cole. Thanks so much, for listening.