Jaime Lewis (Host): Meaningful Medicine is a Novant Health Podcast bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future. Today, I'm sitting down with Dr. Elizabeth Kuhn, a Neurosurgeon at Novant Health to discuss a condition called normal pressure hydrocephalus or NPH, which affects nearly 700,000 people, but is properly diagnosed in less than 20% of cases.

Welcome, Dr. Kuhn. Glad to have you here.

Dr. Elizabeth Kuhn: Thank you for having me. Happy to be here.

Host: Let's start with the very basics. What is NPH and why is it so often misdiagnosed?

Dr. Elizabeth Kuhn: So NPH, like you said, normal pressure hydrocephalus is a condition where spinal fluid accumulates in the brain. It typically happens in people that are older, and doesn't have any known causes. It's often misdiagnosed because the symptoms that it causes, which are gait or balance difficulties, unsteadiness with walking, cognitive or memory problems, and sometimes urinary incontinence or difficulty controlling the bladder; those are things that happen or can happen for a variety of different reasons, especially in folks who are getting older. So many times those symptoms may be brushed off as normal parts of aging, or attributed to other types of dementia or other conditions. And even though it affects a lot of people, NPH is something that is still not as well recognized, both by the lay public and by medical experts. You know, as things like Parkinson's or Alzheimer's, so sometimes it can just take a little extra work, and thoughtfulness to get to the diagnosis of NPH.

Host: You mentioned that it's unclear what causes NPH, but I wonder does it develop quickly or slowly. What would people look for?

Dr. Elizabeth Kuhn: So it can develop either fairly quickly, but typically more often, it develops slowly over time. And the things that you would look for are those classic symptoms. In medical school, they teach you wet, wobbly, and wacky, meaning the urinary incontinence, wobbly, having trouble with your balance or walking, and then wacky, which is just an alliterative way to allude to the dementia.

And so those are the things that you would want to pay attention to. Many times it's noticed by other family members more so than the patient themself. And if you do have those symptoms, the best place to start is by talking to your primary care doctor. Because like I said earlier, there are a lot of other conditions that can cause similar symptoms. And so we want to rule some of those out, before doing any imaging or invasive testing.

Host: It does sound difficult to parse those symptoms though given age related. There's so many other things that it could be. So what can be done in terms of treatment?

Dr. Elizabeth Kuhn: As far as treatment goes, we are able to pretty effectively treat this with a surgical procedure called a shunt. That's a procedure where a small drainage tube is put into the ventricles or the spinal fluid spaces inside brain, and that allows drainage of that excess built up spinal fluid, and pretty much immediately people see improvement in their symptoms after shunt placement.

One of the challenges with NPH is since there's no single lab test or imaging test that can a hundred percent diagnose NPH, figuring out who we should operate on, can be a challenge. And so how we do that is essentially through a test, through a lumbar puncture. As an outpatient in the office, a patient, would have a spinal tap or a lumbar puncture to drain out some spinal fluid. And then we have them work with our physical therapists who are trained to identify and monitor any changes before and after that spinal tap. What we know is that if people have notable improvement in their symptoms after that spinal tap, they're very likely to see similar benefit with a permanent shunt surgery.

Host: Well, relatively speaking, I mean, we are talking about spinal surgery, brain surgery. is this considered a complex process or a simple one?

Dr. Elizabeth Kuhn: Shunts are one of the most common things that as neurosurgeons we're trained to do. And during all of our training, we put in hundreds of shunts, for a variety of different types of hydrocephalus. So the treatment, while it's relatively straightforward, like you said, it's still major surgery, it's still brain surgery, but typically, it only involves, one night stay in the hospital and people are able to get home and get back to regular activities pretty quickly.

Host: Well, that's incredible. And can you, as the surgeon, can you make adjustments after the procedure if the patient feels like the symptoms have somehow returned.

Dr. Elizabeth Kuhn: Yes, absolutely. So the shunt that we put in, the one that I put in, always has an adjustable valve. So that valve can control how much spinal fluid is being drained. And so depending on the patient and their individual symptoms and response to surgery, if we need to adjust that shunt, to drain more or less spinal fluid, we can do that.

And that's a non-invasive procedure just where we put a magnet on their head and it changes the shunt setting.

Host: Wow. Okay. Well let's say I am noticing one of my senior parents maybe acting differently or you know, making comments about some of those symptoms that you mentioned, and I suspect it could be NPH. What kind of advice would you give me if I am their caregiver?

Dr. Elizabeth Kuhn: So I think the best advice that I could give a caregiver is if you see symptoms, don't write them off as normal aging, and talk to your doctor about them. Because just like NPH, many of these conditions are very treatable. So we want to try and get to the right diagnosis so that if treatment is appropriate, it can be started.

So, encouraging your parent or loved one to talk to their primary care doctor about it. And if you're worried about NPH, say that specifically. Because sometimes it takes naming it to light that spark and, in a physician or nurse practitioner to know to kind of go down that route as well.

Host: This is such an interesting niche in medicine that you occupy it makes me curious if I can ask you a question about your background. What made you decide to go into neurosurgery?

Dr. Elizabeth Kuhn: So I have wanted to be a neurosurgeon since elementary school. The family story goes, we were visiting my dad's parents and they live up in Montreal. So we had arrived there late at night, but I couldn't sleep. And so I was watching something on TV. It was some equivalent of the Discovery Health Channel and they were doing brain surgery on TV.

And I woke up the next day and I was like, that's the coolest thing I've ever seen. Mom, dad, I'm going to be a brain surgeon. And I joke that after that I was just too stubborn to ever change my mind. But I also, I also never found anything else that cool, you know, that made me excited to go to work.

And, it's such a privilege to be able to take care of patients struggling with these challenges and, you know, making a meaningful difference, really is so rewarding for me.

Host: That is very cool. Thank you so much Dr. Kuhn, for sharing all your expertise and insight with us today.

Dr. Elizabeth Kuhn: You are welcome.

Host: Once again, that was Dr. Elizabeth Kuhn, Neurosurgeon at Novant Health. To find a physician, visit novanthealth.org. And for more health and wellness information from our experts, visit healthyheadlines.org. And thank you again for joining us.