SCHOONMAN, PAUL M.
Comprehensive Spine Program
The surgeons of the Divisions of Neurosurgery and Orthopaedic Spine Surgery work in close collaboration to evaluate, diagnose, and treat a variety of conditions relating to the spine.
Back and Neck Pain
Painful symptoms of the neck and back are very common and may become debilitating. The majority of these symptoms will improve with physical therapy and pain management. Surgery is indicated if there is compression of the spinal cord or nerve roots that results in persistent pain, weakness, or numbness. The multi-disciplinary approach at NENA is invaluable in the evaluation of all possible causes of pain. MRI, CT, PET scans, myelography, and discography are available to facilitate the diagnosis. We work very closely with our neurologists, physiatrists (specialists in physical medicine and rehabilitation), rheumatologist, and pain medicine specialists to treat not only degenerative disc diseases, but also vascular, neoplastic and congenital diseases of the spine as well.
Cervical, Thoracic, and Lumbar Disc Herniation
We are very experienced with the treatment of herniated discs that cause weakness, numbness or pain that is not relieved with pain management and physical therapy. The spine surgery commonly involves removal of areas of the bone (laminotomy) and parts of the disc that compress the nerves (discectomy). Patients who undergo discectomies often have very short hospital stays, and surgical incisions usually heal after a week. Many patients can be discharged on the day of their surgery.
Complex Spine Surgery
We perform instrumented fusions using screws, rods, plates, or cages to treat conditions that require stabilization, such as rheumatoid arthritis, odontoid fractures, burst fractures, spondylolisthesis, and tumors that cause instability. The surgery is guided by fluoroscopy or frameless stereotactic technique. Patients generally require a few days of hospital stay following these complex surgeries. We also perform recently developed, less invasive techniques that use smaller incisions and minimal muscle dissection. These usually reduce post-operative pain and allow patients to return home sooner.
We treat all kinds of spine fractures. Stable fractures may be treated with kyphoplasty for pain control. Unstable fractures require implantation of screws, rods, plates, or cages.
Compression fractures in elderly patients with osteoporosis can be quite painful and debilitating even with pain medications. We have been performing kyphoplasty since 2005. In our experience, a majority of the patients undergoing kyphoplasty have significant pain relief and improvement in their quality of life. This procedure involves the insertion of balloon-tipped catheters into the fractured bone through small tubes inserted through the skin under fluoroscopic guidance. As the balloons are inflated, they create a cavity within the bone. After they are deflated and removed, bone cement is injected into the fractured bone to fill the cavity and stabilize the fracture.
Minimally Invasive Spine Surgery
We always perform microdiscectomies using microscopes or loupes. The added magnification improves the quality of surgery. We also perform minimally invasive lumbar fusions that use smaller incisions and result in less post-operative pain, shorter hospital stay, and earlier return to normal activities for many patients. These techniques include anterior lumbar interbody fusion (ALIF), transforaminal lumbar interbody fusion (TLIF) and direct lateral interbody fusion (DLIF).
Outpatient, “Same-Day” Disc Surgery.
The length of stay in the hospital following a surgical procedure is determined primarily by the patient's need for nursing care and pain management. With this in mind, NENA has developed a protocol to minimize post-operative pain and to assure a smooth post-operative course and the possibility of early discharge from the hospital. Utilizing this approach, the majority of laminectomy patients are able to leave the hospital on the day of their operation. Our model incorporates several aspects of patient care: (1) patient education about pain during the pre-operative visit with the neurosurgeon; (2) preemptive pain control with the use of long-acting anesthetic and anti-inflammatory medications during the operation; (3) nursing protocols that provide detailed plans for the patients' post-operative course on an hourly basis; (4) follow-up by the nurse treating the patient on the morning after discharge and by the surgeon when needed. There has been no increase in the complications associated with “same-day” disc surgery. In fact, early mobilization and pain control have allowed many patients to return to work and full activity sooner.
The narrowing of the spinal canal caused by a combination of joint enlargement, thickening of the ligaments and bone, and disc degeneration may worsen with age and compress the spinal cord or nerves in the spinal canal. Surgery is done to relieve this compression. We perform laminectomies, laminoplasties, or vertebrectomies to decompress the spinal cord and nerve roots.
Spondylolisthesis, Scoliosis, and Kyphosis
Patients with misalignment of the spine and instability may benefit from spinal fusion. Some of these patients have long-standing spondylolisthesis, a situation in which one vertebra slips onto the next, which results in progressive nerve root compression. If symptoms do not improve with pain management or physical therapy, complex spine surgery with implantation of screws and rods may be considered. Our experience has shown significant improvement of pain and return to normal activities in a majority of patients. Hospital stays of a few days are needed to control post-operative pain. NENA specialists also treat spinal deformities such as scoliosis (abnormal spine curvature when looking from the front), and kyphosis (abnormal spine curvature when looking from the side).
Spinal cord tethering is a congenital condition that may present in adults. Patients may complain of back pain, leg pain or weakness, balance problems, progressive scoliosis, and bladder or bowel incontinence. MRI of the lumbar spine will show the spinal cord in an unusually low position. We treat this condition with lumbar laminectomy and cutting of the structure that is pulling down the spinal cord.
Peripheral Nerve Surgery
We perform surgeries that relieve the symptoms caused by the compression of the nerves in the wrist (carpal tunnel syndrome) or elbow (ulnar neuropathy). Patients usually present with pain, numbness, weakness or muscle atrophy. NENA neurologists confirm the diagnosis with EMG. These surgeries are done under local anesthesia with light sedation. Patients are discharged on the same day. We also remove tumors of the nerves such as neurofibromas and schwannomas.
Surgery for Pain and Spasticity
We understand how pain can adversely affect the quality of life of many patients. We perform many surgeries to alleviate pain arising from a variety of causes. In addition to the spine surgeries, we also perform procedures that help control the pain in cancer patients and those with neuropathic pain. We coordinate with the oncologists and pain specialists to offer the best treatment options for these patients who have intractable pain.
Cingulotomy involves the lesioning of the cingulate gyrus of the brain to diminish the unpleasant experience of pain. This is done with stereotactic guidance similar to DBS electrode placement. This procedure may benefit some cancer patients with severe pain that is not relieved by medications.
For patients with complex regional pain syndrome or neuropathic pain that is not responsive to medications, spinal cord stimulation may provide sufficient pain relief to allow them to return to normal activities. We work with NENA pain specialists who evaluate potential patients and insert a trial electrode into the epidural space of the spinal canal. The electrode is connected to a generator that sends electrical impulses to stimulate the spinal cord. In patients who obtain good pain relief during the trial, we insert a permanent lead and generator. Patients usually go home on the same day. The stimulator is programmed two weeks after implantation.
We work with the neurologists and physiatrists to care for patients who present with severe spasticity of the arms or legs caused by spinal cord injury or stroke. The spasticity may become quite painful or may hinder rehabilitation. Baclofen injected into the spinal canal may result in better control of the spasticity than oral medications. In patients who respond well to the intrathecal baclofen injection, we insert a catheter into the spinal canal and connect it to a programmable pump that is implanted under the skin. The procedure is done under general anesthesia. Patients are usually discharged on the same day.
Botox injections are also available in the treatment of various forms of spasticity and rigidity, and dystonias.