BRAIN TUMORS

What are brain tumors?
Brain tumors can be primary or secondary. They can grow from the cells of the brain, blood vessels in the brain, nerves that emerge from the brain or the membranes covering the brain. Benign (non-cancerous) brain tumours are generally slow - growing tumours. Malignant (cancerous) brain tumours are rapid growing and they spread into the surrounding brain. Secondary or metastatic brain tumours grow from cancer cells that originate from a primary cancer located in another organ (eg. lung, breast or colon).

What are the causes?
A few genetically inherited diseases have been identified that can increase the risk of the development of brain tumours.

What are the symptoms?
The symptoms may be generalized or localised.

Generalised symptoms are due to increased pressure exerted on the brain and include:

• A recurring headache that may worse in the morning.
• Nausea and vomiting
• Seizures
• Increased drowsiness

Localised symptoms depend on the location of the tumour and include:

• Progressive weakness or numbness in the arms or legs
• Progressive difficulty with speech, hearing, concentration or vision, including double-vision
• Memory loss or a change in memory
• A significant change in personality or behaviour

How brain tumors diagnosed?
Specialised imaging tests such as Computed Tomography (CT scan), Magnetic Resonance Imaging (MRI) will usually be performed.

What are the treatment options?
Exact treatment is planned depending upon the tumor grade. Grade one and two tumors have good survival rate where as grade three and four tumors have poor survival rate.

Stereotactic brain surgery for small lesions can be done through a small hole.

Surgery(Craniotomy)
In most cases, surgery using microsurgical techniques is required to remove as much tumour with minimal injury to the brain.

Radiosurgery
For selected small tumours, Gamma Knife Surgery using very strong focused gamma rays can be given over a few hours to arrest tumour growth without the need for surgery.

Radiation Therapy
For cancerous brain tumours that cannot be completely removed, surgery may be followed by external beam radiation delivered by a linear accelerator over 4-6 weeks to destroy the remaining tumour cells.

Chemotherapy
Drugs that destroy or slow down the growth of tumour cells can be administered either orally or by intravenous injection. Hair loss, nausea and susceptibility to infection are potential side effects of chemotherapy.

Case illustration - 44 years female presented to us with history of headache and vomiting of 1month duration. Scan done revealed brain tumor. She underwent surgery. Her biopsy report came as grade III astrocytoma. She received radiation and chemotherapy.
 

CERVICAL SPONDYLOSIS

What is cervical spondylosis?
With growing age , the bones and the discs will degenerate. Bone spurs (osteophytes) may form and spinal canal may narrow (stenosis). These changes are known as cervical spondylosis.

What are the symptoms?

SYMPTOMS

• Neck pain
• Constant deep ache that radiates over the shoulder and down to the arms, hands and fingers.
• Numbness or weakness of the arms, hands, fingers or legs
• Muscles spasm, neck stiffness
• Headache
• Difficulty in walking
• Dropping objects and difficulty in buttoning shirts.

What investigation do I need?
X-rays and Magnetic Resonance Imaging (MRI) studies are helpful. EMG and NCV is some times required

What are the treatment options?

Rest
In the acute phase, you may need to wear a cervical collar to limit neck movement and relieve the nerve irritation.

Medication
(NSAIDs) or other pain relievers TENS can also help.

Surgery
Anterior or posterior surgery may be required if there is cord compression.
 
PREVENTION
There is no specific way to prevent this condition. However, some lifestyle modifications may slow the process of the degeneration.
Lifestyle Modifications include:

• Regular strengthening and flexibility exercises for neck and back muscles
• Regular aerobic exercises e.g. running, swimming, cycling
• Postural awareness to maintain good posture
• Workplace modifications to reduce stress to the back and neck
• Quit smoking
• Maintain healthy weight range

CERVICAL DISC REPLACEMENT AS A TREATMENT OPTION
32 year old male with neck pain. In young adult aim of surgery is to preserve motion. Underwent cervical disc replacement.

Anterior cervical discectomy and fusion as a treatment option.
 

HYDROCEPHALUS AND SHUNT SURGERY.

What is hydrocephalus and what is the prognosis?
Hydrocephalus is excessive accumulation of CSF in the brain.

What are the symptoms ?

• Drowsiness, enlargement of head.
• Headache
• Irritability and/or tiredness
• Loss of coordination or balance
• Nausea and/or vomiting
• Personality changes
• Vision problems
• Seizures
• Swelling or redness along the shunt track

If any of the above symptoms occur, please seek medical attention immediately.

Who is affected?
Hydrocephalus can occur at any age, but is most common in infants and adults age 60 and older. It can affect adult males and females after an injury or illness, as well as people of different races equally.

Symptoms of hydrocephalus?
Acute hydrocephalus

• Drowsiness and altered consciousness
• Headache
• Nausea and vomiting
• Unsteadiness

Subacute or low-pressure hydrocephalus

• As above symptoms, but slower in onset and more insidious

Normal pressure hydrocephalus (NPH)

• Gait disturbances (Difficulty walking)
• Dementia or forgetfulness
• Bladder control problems

DIAGNOSIS
Radiologically, hydrocephalus usually presents with dilated or big ventricles as seen in CT scan or MRI.

TREATMENT
Permanent shunt or third ventriculostomy
 
FOLLOW-UP : Regular followup will be required as shunts tend to get obstructed.
 

LOW BACK PAIN

Know about your Back pain
Back pain is a common problem with an incidence of 50% in life time requiring attention. The source of back pain can be muscles of the back,facet joints, degenerated disc or sacroiliac joint. The treatment of each of them differs so it is very important to establish the cause and source  of back  pain. If the source of your back pain is muscle the you need analgesics, TENS therapy, gentle back extension exercises and some times trigger point injections. If the source of your pain is facet joint then you need facet block and facet rhizotomy with a radiofrequency generator. If disc is the source of the pain then you may need discography followed by total disc replacement. Some times discprolapse can cause back pain with leg pain. This usually requires microsurgical discectomy. Your back pain can also be due to movement of bones which is known as listhesis. This needs lumbar fixation with pedicle screws and rods. If your source of pain is sacroiliac joint then you need SI joint block and rhizotomy.

How to identify the source of your pain?
You can identify  the source of your pain yourself. If it gets aggravated on extension the it is probably comming   from facets. If the pain is more on flexion and sitting  then probably disc is the source of your pain. If you have multiple joint pain then get your uric acid level checked. If your HLAB27 is positive then sacroiliac joint can be your source of pain. Be carefull of osteoporosis. Get your vitamin D level checked on a regular basis.

How to prevent back pain?
Correct posture while sitting, standing  and sleeping is important. Regular back strengthening exercise should be done. Do brisk walking and swimming. Yoga also helps. Correct your Vit D level if it is low. Never let your back pain become chronic as that leads to muscle spasm aggravating your back pain.

What are the common causes of low back pain?

• Mechanical injury
• Herniated disc (slipped disc) may cause irritation to the nerves and cause sciatica, a condition where pain travels down the buttocks or legs.
• Degenerative disease affecting the spine.
• Rare conditions may include spinal tumour, infection and fracture.

 

What are the investigations for low back pain?
1. Clinical examination by the doctor
2. Blood test
3. Radiological investigations e.g. x-ray, CT scan, MRI
4. EMG and NCV
5. Discography

What are the treatment options?
1. Rest 
2. Medications

• Pain killers

3. Physical Therapy

• Perform the flexibility and strengthening exercise

4. Facet blocks, epidural steroids injections
5. Surgical Management

What should I do to prevent low back pain?
Low back pain can be prevented through lifestyle modifications:

• Maintain good body postures at all times.
• Maintain healthy weight range.
• Use proper body mechanics/ lifting techniques. Avoid bending at waist level.
• Modify workplace/space (workplace ergonomics) to reduce back strain.
• Exercise regularly. Proper exercise can help to strengthen and increase flexibility of back muscles and help to increase bone density. Swimming, brisk walking and cycling are good examples of exercises for back pain sufferers.
• Stop smoking.
• Avoid staying in the same position for a prolonged period of time.
• Sleep on a firm mattress.

LOW BACK PAIN WITH LEG PAIN

What is lumbar canal stenosis?
Lumbar canal stenosis most commonly affects the middle-aged and elderly population. It is caused by entrapment of the cauda equina roots by hypertrophy of the osseous and soft tissue structures surrounding the lumbar spinal canal is often associated with incapacitating pain in the back and lower extremities, difficulty ambulating, leg paresthesias.

Why does it happen?
It is caused by narrowing of the lumbar canal due to bony and soft tissue hypertrophy. Some times it is seen in acquired conditions like fluorosis, hyperparathyroidism, Paget's disease, ankylosing spondylitis, Cushing's disease and acromegaly.

What is the clinical presentation?
It is associated with pain and numbness in both lower limb aggravated by walking and standing.

What do I do if I have lumbar canal stenosis?
Seek advice of a spine surgeon.

Imaging/Diagnostic Studies
Plain films of the spine and MRI of spine is diagnostic. Electromyograms with nerve conduction velocity studies may assist in confirming the multiradicular involvement of cauda equina compression.

Treatment is surgery - Laminotomy and not laminectomy is advocated.

Risks and Complications of Decompressive Surgery
The risks of surgery are minimal and patient can walk a day after his surgery.
 

PITUITARY TUMOR

What is the cause of pituitary tumor?
The cause of pituitary tumours, like that of other brain tumours, is unknown.

What are the symptoms of pituitary tumor?
Headache, vison loss,fatigue

What are the treatment options?
Endoscopic pituitary adenoma removal with or without radiation.

Drug Therapy:
1) Bromocryptine is given when the tumour produces large amounts of prolactin, and in addition to suppressing prolactin production may cause a dramatic shrinkage of the tumour. Somatostatin injections may be used for growth hormone producing tumours.

What are the chances of recurrence?
Incomplete removal results in recurrence so radiation to residual tumor should be given.
 

HEAD INJURY
Head injury, is a broad term that describes a variety of injuries and damages to the scalp, skull, brain and underlying tissue and blood vessels in the head.

 
What are the common causes?
In India, head injury occurs most commonly after motor vehicle accidents, falls height or at work, acts of violence, sports and recreational injuries.

Concussion – when there is loss of consciousness.

What are the signs & symptoms?
Varying degrees of symptoms including temporary or permanent loss of consciousness, nausea, vomiting, headache, giddiness, and loss of memory may appear associated with the severity of the head injury. The signs and symptoms of a head injury may occur immediately or develop slowly over several hours to days.

Even if no serious injury is found, careful watching with a responsible adult either at home or hospital must occur in the first 24-48 hours after the injury.

For the 1st 24 hour after a head injury, the person SHOULD NOT:

• Be left alone
• Drive a vehicle or operate machinery
• Take alcohol or any medications that can cause drowsiness

 

Call for help or go to the emergency department if:

• Any symptoms is getting worse e.g. sleepiness, headache, vomiting, dizziness
• Changes in behaviour e.g. irritability, confusion
• Weakness or numbness in the arms or legs
• Trouble walking or talking
• Fits or seizures

 

Investigations
CT scan of the brain may be ordered if the doctor thinks that there is risks of acute bleeding that can cause life-threatening problem.

What is the treatment?
Treatment is individualised, depending on the degree and extent of injuries. It ranges observation for signs of worsening such as drowsiness, increasing headache or giddiness (minor head injury) to removal of the blood clot in the brain to relieve the pressure in the brain (cause by the blood clot) or insertion of a brain pressure monitor (severe head injury).

Treatments for most minor head injuries include symptom relief and adequate rest.

What is the outcomes ?
This depends in the type, location and degrees of injury. People with a minor head injury may have concussion syndromes such as slight headache, giddiness, easily tired, decreased concentration etc that may persist for a while, but most recover with no permanent problems. After a severe head injury, one-third make good recovery, one-third is left with varying degrees of disability, and the rest do not survive.

Also consult your doctor – if you have running nose after head injury. It can be brain fluid.

TRAUMATIC BRAIN AND SKULL INJURY REQUIRING SURGERY.

Depressed skull fractures.

Air in the skull

Brain contusion

Extradural hematoma

Subdural hematoma

Lefort fracture with CSF leak