Physician
Profile
Special Features
Clinical Studies
Advances/Research
SPINAL SURGERY
St. Luke's-Roosevelt Hospital Center offers a comprehensive clinical program for the diagnosis and treatment of disorders of the spine and spinal cord. Complex problems involving the occipito-cervical junction through the sacrum and coccyx are investigated extensively and recommendations for treatment are made.
 |
|
| Treatment is available in the following areas: | |
|
|
| • | Spinal cord injury management |
|
|
| • | Traumatic spinal fractures |
|
|
| • | Spinal tumors (primary and metastatic) |
|
|
| • | Spinal cord tumors (astrocytoma, ependymoma, hemangioma, etc.) |
|
|
| • | Occipito-cervical anomalies (fracture instability, tumors, rheumatoid arthritis, congenital anomalies, etc.) |
|
|
| • | Cervical (disc herniations, stenosis, spondylosis, OPLL, fracture instability) |
|
|
| • | Thoracic (disc herniation, tumors, scoliosis, deformity, syringomyelia, arachnoid cyst) |
|
|
| • | Lumbar (disc herniations, stenosis, instability, spondylolysis, spondylolisthesis, tumors, synovial cysts |
|
|
| • | Tethered cord, meningeal cysts (tarlov) |
|
|
| • | Sacrum (tumors, meningomyelocele, lipoma) |
|
|
| • | Endoscopic spinal surgery (see Indications for Endoscopic Surgery) |
Endoscopy is the most exciting new development in the surgical treatment of disorders of the spine. Minimally invasive surgery, and laparoscopic surgery in particular, have become the standard of care for many disorders requiring surgery.
At St. Luke's-Roosevelt Hospital Center, a thoracoscopic approach is adopted for the treatment of many thoracic spinal problems that previously required an open thoracotomy.
Thoracoscopic spinal surgery is a minimally invasive surgery in the thoracic spine. Minimally invasive techniques reduce tissue trauma, resulting in less post-operative pain and reduced shoulder girdle disability (associated with the open thoracotomy). Since there is a shorter hospital stay and post-operative recuperation, patients return to work and other activities sooner.
|
|
| Indications
for Endoscopic Surgery Thoracoscopic spinal surgery |
|
|
|
| • | Sympathectomy for hyperhidrosis, reflex sympathetic dystrophy (RSD) |
|
|
| • | Thoracic disc herniations |
|
|
| • | Thoracic tumors (extra-dural, metastatic) |
|
|
| • | Infections (discitis, osteomyelitis) |
|
|
| • | Fractures |
|
|
| • | Scoliosis (anterior release) |
|
|
| Laparoscopic spinal surgery | |
|
|
| • | Anterior lumbar inter-body fusion, for segmental instability and discogenic pain |
CONSULTATION
Dr. Perin specializes in spinal thoracoscopy, laparoscopy and all other
spine and spinal cord problems, including spinal instrumentation. To
arrange a patient consultation, contact:
Office:
425 W. 59th St. Suite 4E
New York, NY 10019
Phone: (212) 523-6720
Fax: (212) 523-6115
E-mail: nperin@slrhc.org
CASE
PRESENTATION
Procedures commonly performed for hyperhidrosis:
Palmar hyperhidrosis is a disabling condition interfering with
a patient's personal, social, professional and recreational activities.
In severe cases, sweat visibly drips from a patient's hands.
Severe axillary hyperhidrosis and bromhidrosis (axillary malodor) can
be associated with palmar hyperhidrosis and can be treated effectively
with endoscopic sympathectomy. This condition is thought to be due to
overactivity of the sympathetic nervous system.
Various treatments are available, including the use of topical agents,
such as Xerac™ and Drysol™, and also use of iontophoresis,
but these usually only provide temporary relief.
More recently, Botox™ injections (botulinum toxin) have held promise
for relief, however, this also is only temporary and the injections
have to be repeated every few months. Further, some patients develop
antibodies to the drug and this limits long-term use.
In the past, surgical treatments were difficult, with high complication
rates and significant postoperative pain. Thoracoscopic sympathectomy
has revolutionized the treatment of hyperhydrosis, and over 90 percent
of patients experience permanent relief of sweating in the axillae and
hands following bilateral thoracoscopic sympathectomy.
Surgical Technique
The operation is performed under general anesthesia with a double-lumen
endotracheal tube. The patient is placed in a lateral position and each
side is performed sequentially. The arm is flexed and abducted 90 degrees
and the patient's chest is prepared and draped. Two incisions are made
in the axilla (2 and 1.5 centimeters respectively) in the mid and anterior
axillary lines.
Ventillation to the lung on the side of the operation is stopped and
the first incision is made in the fourth or fifth intercostal space
and carried into the pleural cavity. The first port is inserted and
the endoscope is placed inside the chest cavity. A general inspection
of the entire chest is made.
The second incision is smaller (1 to 1.5 centimeters) for the working
instruments and suction. The ribs are counted down from the top and
a clip is placed on the pleura over the head of the second rib.
Fluoroscopy is utilized to count the ribs and identify the location
of the clip in relation to the underlying rib. The second and third
ribs are identified and marked. The harmonic scalpel (ultrasonic instrument)
is utilized to open the parietal pleura over the second and third ribs.
The sympathetic chain is identified, and electrical stimulation with
blood flow monitors over the skin of the forearm on the ipsilateral
side and leads to a fall in the flow, at the same time the hand temperature
monitors also record a fall in temperature.
The sympathetic chain is divided with scissors just above the head of
the second rib and just below the head of the third, after dividing
all branches from the ganglia. The temperature in the hand rises immediately
three to five degrees. The sympathetic chain is sent for pathology.
After hemostasis is achieved, a 28-French chest tube is placed through
the inferior port and the wounds are closed. The tube is connected to
suction through a water seal. The patient is repositioned, prepared
and draped for the opposite side as described above.
At the end of the second side, a chest x-ray is obtained, and, if well
expanded, the first tube is removed. The second tube is left on suction
and the patient proceeds to the recovery room, where the second tube
is removed. The patient leaves hospital the next day.
The success rate for the relief of palmar hyperhidrosis is 95-100 percent.
Axillary hyperhidrosis and bromhidrosis is relieved in over 80 percent
of patients. Several patients also obtain relief from plantar hyperhidrosis,
the reason for this, however, is unknown.
Complications include compensatory hyperhidrosis, where there is increased
sweating in the head, chest, abdomen, back and legs. The incidence,
though reported to be as high as 40 percent worldwide, has been much
lower among patients in the US. In most patients, this complication
is mild, but it can be severe among five to 10 percent of patients.
This has not been a problem with any of Dr. Perin's patients. Horner's
syndrome (drooping of the eye lid) and gustatory sweating (facial sweating
brought on by the smell and taste of food) have been reported after
sympathectomy in one to two percent of cases.