The Mayfield Clinic and Spine Health

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1 MayfieldStandard The Summer 2010 A seasonal publication for friends of the Mayfield Clinic & Spine Institute As joints & arteries age, tamer rides could be in order In terms of relative risk posed by warmweather pastimes, riding a roller coaster does not rank at or even near the top. The number of adults and children who are injured riding bicycles, playing baseball or soccer, or riding in vehicles is higher by an order of magnitude. Nevertheless, roller coasters are associated with occasional injuries, and these injuries have been treated by specialists at the Mayfield Clinic. An injury can occur to the brain or neck because of the speeds at which some modern roller coasters operate. Those injuries include: carotid or vertebral artery dissection, which can cause a stroke a ruptured aneurysm caused by blood pressure changes while on the roller coaster injury to the spinal cord in the neck in people with an underlying cervical stenosis (a narrowing of the spinal canal and nerve root in the neck) whiplash and neck pain the development of bleeding on the surface of the brain With any of these conditions, it is hard to place direct blame on the roller coaster, says Lori Shutter, M.D., a neurointensivist with the Mayfield Clinic. An individual can have a neurological weakness that is already present, and that weakness can reach a tipping point when subjected to the twists, turns, and speeds of a roller coaster. Charles Kuntz IV, M.D., advises that patients who have serious spinal conditions should not subject themselves to anything that rocks or shoots you around, including a roller coaster or bungee jumping. Todd Abruzzo, M.D., an interventional neuroradiologist with the Mayfield Clinic, points to a study published in the January 2000 issue of Neurology, the scientific journal of the Academy of Neurology, about a 24-year-old Japanese woman who developed a brain injury after riding one of world s highest and fastest roller coasters. This is admittedly a rare phenomenon, Dr. Abruzzo says. But the accelerationdeceleration forces can cause the brain to shake inside the skull. If the brain has enough momentum, it moves abruptly away from the inner surface of the skull, putting tension on bridging vessels. This can cause them to tear. The resulting hemorrhage can cause significant brain injury. Mayfield physicians recommend that certain individuals avoid very high and fast roller coasters, including those who have been 1) treated for neck injuries, arthritis in the neck, strokes, connective tissue disorders, and even migraines; 2) diagnosed with a brain aneurysm or brain blood vessel malformation; or 3) advised that they are at risk for a brain aneurysm. Solid to the core The muscles in your abdomen and back which we call the core are central to your everyday spine health. They are at the heart of any fitness regimen designed to strengthen a healthy or ailing back. Just as you protect your heart through cardiovascular exercises, you will benefit from strengthening your back through core exercises. To read more and view a sampling of exercises you can do at home, see page 3.

2 Outcomes... Mayfield s Focus on Quality As one of the leading neurosurgery practices in the United States, the Mayfield Clinic has a long and rich history of striving to continuously improve the quality of care that our patients receive. We accomplish this quality assurance by measuring the results, or outcomes, of all of our patients experiences. By analyzing these outcomes, we can develop ways to make treatments and our patients experience at Mayfield even better. Many organizations around the country are developing tools to measure quality. Some of these tools are effective and credible, while others provide very little useful information. A few years ago, Mayfield made a commitment to develop an Outcomes Measurement Process to effectively measure the quality of our patient care and treatment. Led by Philip Theodosopoulos, M.D., a Mayfield neurosurgeon, the process was piloted and eventually introduced to all Mayfield physician practices. Since that time, more than 15,000 patients have been treated and included in the process. The data is being analyzed and audited now and eventually will be made public. This has been a fascinating process, Dr. Theodosopoulos says. While we have always looked at our patient experiences very carefully through quality assurance initiatives, we have never looked at the data through such a powerful microscope. I don t believe anyone has. I am proud of our organization for taking on this initiative and for doing everything we can to continually improve the care our patients receive. Anti-seizure Medications levetiracetam for seizures What we found: The anti-seizure medication levetiracetam, marketed as Keppra, is as effective at preventing seizures as the traditional medication, phenytoin, marketed as Dilantin, while producing fewer negative side effects. Patients treated with Keppra also had improved long-term outcomes. Where it was published: Neurocritical Care Who led Mayfield s research efforts: Lori Shutter, M.D., Associate Professor of Neurosurgery and Neurology and a neurointensivist with the Mayfield Clinic Why the finding is important: Seizures are common following severe brain injury, and minimizing or eliminating them is a primary objective of neurocritical care, Dr. Shutter says. We continue to make incremental, meaningful strides in the care of patients who are hospitalized in the NSICU following a bleeding stroke or traumatic brain injury. Stroke Prevention What we found: Two medical procedures designed to prevent future strokes are safe and effective overall. Researchers from 117 centers in the United States and Canada, including the Mayfield Clinic, compared two treatments for carotid stenosis, the buildup of plaque inside the carotid arteries, which are a major source of blood flow to the brain. The treatments were a) carotid endarterectomy, a surgical procedure that clears blocked blood flow and is considered the gold standard in preventative treatment; and b) carotid artery stenting, a newer and less invasive procedure that involves threading a stent and expanding a small protective device in the artery to widen the blocked area and capture any dislodged plaque. carotid stenosis Where it was announced: International Stroke Conference in San Antonio Who led Mayfield s efforts: Andrew Ringer, M.D., Mayfield neurosurgeon and Director of Endovascular Neurosurgery at the University of Cincinnati, and Mario Zuccarello, M.D., Mayfield neurosurgeon and Interim Chairman of the Department of Neurosurgery and Director of Cerebrovascular Surgery at UC. Why the finding is important: The study demonstrates that physicians have two good options for treating people who are at high risk of stroke, Dr. Zuccarello says. There were slight differences. Patients under 70 had better results with stents, while those over 70 had better results with surgery. Also, we saw slightly more heart attacks in patients undergoing surgery and slightly more strokes in patients who had stenting. These serious complications occurred infrequently, however, and we are pleased to have two excellent treatments for carotid stenosis, which is itself a potentially life-threatening condition. 2

3 Core curriculum: Spine-smart exercises for everyday health By Paul Cohen, MD Just as the stays support the mast and the cables support the bridge, your core muscles support your spine. The muscles in your abdomen and back which we call the core are central to your everyday spine health. They are at the heart of any fitness regimen designed to strengthen a healthy or ailing back. Just as you protect your heart through cardiovascular exercises, you will benefit from strengthening your back through core exercises. For those who are experiencing difficulties with their back, a gentle, step-by-step strengthening program is an important aspect of recovery and prevention. For those with a healthy back, maintaining or increasing strength in the core muscles is also advisable. Strong core muscles work by taking the stress off the discs and joints. Picture for a moment your bony spine, a long, curving structure consisting of 33 vertebrae from the base of your head to your tailbone. Strong muscles can take some of the stress off that backbone. This is especially important as we age because, as we know, deterioration of the joints is another unfortunate consequence of the aging process. Crunches Lie on your back (top left photo) Bend your knees and hips at a 90-degree angle and lift your legs into the air Cross your arms across your chest Lift your head and shoulders off the floor and hold for 5 to 10 seconds. Variation 1 (middle left photo): place your hands behind your head, with fingers interlocked, and raise your head and shoulders off the floor; hold for 5 to 10 seconds. Variation 2 (bicycle crunches, bottom left photo): With your hands behind your head, raise your left leg, knee bent, and point your right elbow toward that leg; alternate. Medicine ball rotation (top right photo) Sit on the floor. Lift your legs slightly off the floor and cross your feet Hold a medicine ball, small weight, or food can with both hands and move it from one hip to the other. Start with a small number of rotations, then build up as you gain strength. Plank (bottom right photo) Get down on your hands and knees. Bend your elbows and rest your forearms on the floor. With your toes on the floor, lift up your knees. With your weight balanced on your forearms and toes, count to 10 and then rest. Extend the time and number of repetitions as you gain strength. My patients who have been most successful in maintaining their spine health are those who have incorporated a spine exercise program into their daily routine, right along with bathing, brushing, and flossing. If you are already performing core exercises regularly, keep it up! If you are not, consult with your primary care physician, a physical therapist, or a trainer at a fitness facility before you begin. The good news about core exercises is that they can be easily done in the comfort of your home without extra equipment or expense. I encourage you to make an effort to develop these new habits, as a strong core will reward you with long-term benefits. (Photos by Cindy Starr.) 3 Crunches Medicine ball (above), Plank (below)

4 International Conference to be held here in 2011 n the realm of neurological care, it is a dreaded instance of I adding insult to injury. Known as vasospasm a sudden spasm of a blood vessel the phenomenon occurs all too often following a ruptured aneurysm. When blood flows from the aneurysm into the subarachnoid space, a narrow, protective membrane around the brain, the resulting irritation can cause a nearby artery to go into spasm and constrict. The closing down of the artery can be likened to an open palm clenching into a fist. An artery that has shut down can no longer carry oxygenated blood to the brain, and cells in the oxygen-starved area can die, triggering a deadly or disabling stroke. Though temporary, a vasospasm can cause permanent brain damage or death. Vasospasm, which occurs in a significant percentage of patients who suffer an aneurysm rupture, remains mysterious and perplexing to doctors. But every two or three years, the world s most respected cerebrovascular specialists gather to share what they have learned in their ongoing effort to better understand and treat this dangerous complication. The Mayfield Clinic, University of Cincinnati Neuroscience Institute, and UC Department of Neurosurgery are honored to have been named host of the 11th International Vasospasm Conference, to be held July 21-23, Specialists from approximately 15 nations are expected to attend. Mario Zuccarello, M.D., Interim Chairman of the UC Department of Neurosurgery and a Mayfield Clinic neurosurgeon, is the Organizing Committee Chairman of the event. Joe Clark, Ph.D., UC Professor of Neurology, is Co-Chairman. What to do after a minor stroke? Researchers compare two treatments minor stroke or TIA is not something A to take lightly. It is a warning that a larger, more serious stroke could occur. But for years doctors have fretted about what to do next, and they have often felt that nothing could be done. Researchers nationwide are now trying to determine the best way to prevent a more serious stroke in people who have suffered a minor stroke because of a narrowed artery in the brain. The narrowing of a brain artery, called intracranial artery stenosis, is caused by a buildup of plaque (atherosclerosis) inside the artery wall. If the artery becomes completely blocked, blood flow to the brain is interrupted, and brain damage or death can occur. The five-year research study, which is sponsored by the National Institutes of Health, is known as SAMMPRIS: Stenting vs. Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis. Patients are eligible for this research study if they have suffered a minor stroke or TIA within the last 30 days, says Andrew Ringer, M.D., a Mayfield neurosurgeon and Director of Endovascular Neurosurgery at the University of Cincinnati. Patients who qualify are randomly assigned to receive one of two treatments: intensive medical therapy alone or intensive medical therapy with angioplasty and stenting. The treatments are not new, and patients have been successfully treated with both methods. Placing a stent, a minimally invasive procedure, carries a small risk of stroke, which varies with each patient. 4 Patients will receive intensive medical therapy no matter which arm of the research study they are assigned to. All patients will be followed carefully, and preventive medications will be provided as part of the research study. The research study also will help cover costs that insurance might not pay. In addition, participants will have access, at no charge, to a comprehensive education and counseling program known as Interxvent USA, which will help them with tobacco cessation strategies and nutrition. For more information about SAMMPRIS, please contact Carolyn Koenig at or carolyn.koenig@uc.edu.

5 Great Miami River near Vandalia, Ohio Clean water alert: dispose of unwanted meds properly Years ago, consumers were advised to flush unneeded or outdated medications down the toilet. No more. Unused, unneeded, or expired prescription drugs should be destroyed in an industrial incinerator, if possible, or discarded with the trash and entombed in a landfill, according to Bruce Whitteberry, Treatment Supervisor for Greater Cincinnati Water Works (GCWW). In a perfect world we would dispose of our medications in ways that would allow them to be either completely destroyed or recycled, Mr. Whitteberry says. But recycling isn t possible, and not all communities have a formal drug collection and incineration program. Although these emerging contaminants are being found at very low levels in parts per trillion we don t know their long-term effects. Science knows what the benefits of these drugs are to those who need them, but we don t know the long-term effects to populations that were never intended to ingest those compounds over long periods of time. The main water source for GCWW is the Ohio River. To protect customers from source water contaminants, like pharmaceuticals, GCWW draws water upstream of Cincinnati, where it is cleaner, and uses Granular Activated Carbon (GAC) as part of its treatment process. GAC is one of the most effective treatment methods available for removing impurities from water. Although landfilling old medicines is not ideal, the landfill does provide containment, while flushing medications down the toilet sends them to our rivers and streams. Sewage plants are not capable of removing the majority of chemicals from the water, Mr. Whitteberry says. We as a nation are now starting to pick up trace levels of antibiotics, anti-depressants, birth control medications, and other compounds in our rivers and streams. Although these compounds have likely been in the water for years, new analytical tools are enabling us to confirm their presence. Other tips: Always finish your prescriptions in accordance with your doctor s orders. When purchasing over-the-counter medications, buy only what you can consume before the expiration date. Practice preventive medicine to reduce your need for medications. Before placing unused medications in the trash, remove them from their original containers, mix them with coffee grounds or kitty litter, and put them in an empty can or sealable bag. For more information, please visit or Philip Theodosopoulos, M.D., walks in a Martin Luther King Day march with his two young daughters last January in downtown Cincinnati. Dr. Theodosopoulos and his wife sought to teach their children about the Civil Rights Movement and its historical significance. Photo by Gary L. Lewis. 5 Welcome Brad Curt, M.D. he Mayfield Clinic is pleased to welcome T Brad Curt, M.D., to its neurosurgical team. Dr. Curt graduated from the residency program at the University of Cincinnati College of Medicine and is now completing fellowship training in spine surgery under the guidance of Mayfield s Charles Brad Curt, M.D. Kuntz, IV, M.D. After his fellowship concludes in June, Dr. Curt will provide neurosurgery services at West Chester (Ohio) Medical Center at University Pointe, Mercy Fairfield, and Atrium Medical Center in Middletown, Ohio. His practice will be based primarily at University Pointe. Dr. Curt received his bachelor s degree from Brown University and graduated with honors from the Emory University School of Medicine.

6 MayfieldStandard The A seasonal publication for friends of the Mayfield Clinic & Spine Institute 506 Oak Street Cincinnati, OH PRESORTED STANDARD US POSTAGE PAID CINCINNATI OH PERMIT 6657 MayfieldStandard The Did you know? Mayfield Clinic neurosurgeons make presentations in 40 cities, 21 states and 6 countries in a typical year. This spring, William Tobler, M.D., traveled to Ljubljana, Slovenia, to report about Mayfield s experience with 300 minimally invasive cases of Axial Lumbar Interbody Fusion, also known as AxiaLIF. Dr. Tobler was the only American who presented. You can download printer-friendly, one-page public service announcements at Topics include the F-A-S-T Response to Stroke, Texting and Driving, Epilepsy and Driving, Aneurysm Screening, and Preventing Falls. These educational PSA s are suitable for posting at your office, school, or church. Upcoming events 2010 Midwest Regional Brain Tumor Conference A free educational event for patients and families Saturday, June 26, :00 am - 4:00 pm UC Tangeman Center, University of Cincinnati Call or events@ucneuroscience.com Sunflower Revolution VII Parkinson s Disease Symposium & Expo A free educational event for patients and families Saturday, September 11, 2010 The Oasis Conference Center, Loveland, Ohio Call or events@ucneuroscience.com Brain aneurysm: Who should be screened? Produced by the Communications Department, Mayfield Clinic. Cindy Starr, Editor Mayfield Clinic.