After four years of confinement to a wheelchair, Rick Constantine, 58, is now walking again after undergoing an unconventional surgery at University of California, San Diego Heath System to restore the use of his leg. Neurosurgeon Justin Brown, MD, performed the novel 3-hour procedure.
“Following a car crash, Mr. Constantine had a brain stem stroke that caused paralysis on the right side of his body. His leg muscles became so severely spastic that he could not walk,” said Brown, director of the Neurosurgery Peripheral Nerve Program at UC San Diego Health System. “Our team performed a delicate surgery to reduce input from the nerves that were causing the muscles to over contract to the point of disability.”
“After my injury, I was told I would never walk again. All I could to was move from my wheelchair to my bed or a chair,” said Constantine, a former NASCAR crew member. “After surgery with Dr. Brown, I could put my foot flat on the ground to walk. With physical therapy, everything just gets better and better. I’m a firm believer in never giving up.”
Prior to surgery, Constantine underwent botox treatments and physical therapy in an attempt to restore the use of his leg. The results were positive but minimal. An additional nerve conduction study, called an electromyogram (EMG), identified the muscles causing the dysfunction.
“When all other options did not produce satisfying results, we opted for surgery,” said Brown. “With the EMG, we identified the over-excited nerves that needed to be downgraded. Mr. Constantine had surgery on a Friday and within days was in physical rehabilitation. Two weeks later he was walking without a walker and has even completed a 1-mile race without assistance.”
The surgery, called a selective peripheral neurotomy, is a procedure performed under a microscope. Brown makes an incision behind the knee to reach the tibial nerve. He then selectively trims back the troublesome nerve branches by up to 80 percent. Cutting the nerve reduces the “noise” being relayed back to the spinal cord which causes the spasticity.
Alternative Hip Replacement Technique Results in Faster Recovery
Only 15 Percent of Joint Replacement Specialists in Nation Capable of Muscle-Sparing Approach
University of California, San Diego Health System is one of only a few hospitals in the nation to offer computer-assisted navigation technology with the direct anterior hip replacement technique, potentially resulting in less pain, faster recovery and fewer dislocations for patients with osteoarthritis and other forms of degenerative joint disease.
Only 15 percent of the top joint centers in the United States have the expertise and technological capability to perform an anterior hip replacement, where the incision is made in the front (anterior) of the hip as opposed to the side (lateral) or back (posterior). The anterior approach allows the surgeon to work in between a natural muscle plane without detaching muscles or tendons from the hip or thigh bone, avoiding undue trauma to the muscle and surrounding tissue.
“With traditional hip replacements, we have to cut muscle to do the surgery, which affects the recovery process and may limit immediate hip movement in the early post-operative period,” said Francis Gonzales, MD, orthopedic surgeon specializing in adult joint reconstruction at UC San Diego Health System. “The muscle-sparing approach is performed in between muscle groups, gently pushing the muscle aside during the hip replacement instead of cutting through it.”
UC San Diego Health System performs a high volume of anterior hip replacements annually, making it a leader in the region on the technique.
Carpal tunnel syndrome: a Q & A with Reid Abrams, chief of hand and microvascular surgery
Carpal tunnel syndrome (CTS) is not a modern affliction. It has plagued workers since at least the Industrial Revolution and the dramatic rise in jobs requiring repetitive, physically stressing movements, from assembly-line workers to meat-cutters and machine operators.
There may be fewer of those jobs these days, but plenty of other ways to develop CTS, from dental hygienists and supermarket cashiers to bank tellers and baseball pitchers.
Women are three times more likely to develop CTS than men, according to the National Institutes of Health, though the reasons are unclear. Evidence suggests 3 percent of women and 2 percent of men will be diagnosed with CTS during their lifetime. Age is major risk factor. Peak prevalence for CTS occurs in women older than 55.
Researchers have been studying CTS and other repetitive stress injuries for years, with clinical trials focusing on preventative measures and behaviors. We asked Reid Abrams, MD, professor of clinical orthopedic surgery at UC San Diego and chief of hand and microvascular surgery at the UC San Diego Medical Center, to talk about what’s known about CTS and how best to treat it.
Q: What is carpel tunnel?
A: The carpal tunnel is an oval-shaped canal at the base of the palm, about 1 ½ inches long and an inch wide. The tunnel is surrounded on three sides by bone and on the palm side by a thick ligament. All of the flexor tendons that control the fingers and thumb run through the tunnel, plus the median nerve. This is the nerve responsible for sensation in the thumb, index, middle and half of the ring finger, plus motor function for most of the muscles at the base of the thumb. CTS is what happens when the median nerve becomes compressed.
Q: How do you know you have CTS?
A: The condition produces a constellation of symptoms, including intermittent or constant numbness or tingling in the thumb, index, long and ring fingers. There can be hand numbness, tingling or burning at night, which awakens patients; swelling or stiffness in the hand; grip weakness; a tendency to drop things.
Not all hand pain is caused by CTS. If the pain is not associated with hand tingling or numbness, it’s not CTS. Also, not all hand tingling or numbness is CTS. Other nerve problems originating in the hand, forearm, elbow, shoulder or neck can also cause these symptoms.
Q: What causes it?
A: CTS occurs when there is abnormally high pressure on the median nerve, so high that the nerve can’t function. That pressure can be the result of an injury that produces sudden swelling, like a wrist fracture, or something else in the canal crowding the nerve, like an engorged blood vessel or intruding muscle.
Most often, the cause is idiopathic or unknown. It’s often activity-related because the dimensions of the carpel tunnel change with different positions of the wrist and fingers. Activities such as driving, tightly holding a book or newspaper while reading, jobs that entail sustained periods of wrist flexion or extension while gripping or pinching, such as maneuvers performed by a dental hygienist, mechanic or construction worker, can bring on symptoms. Some summer activities can set off CTS, such as carrying a surfboard for long distances, cycling or racket sports.
It’s a myth that keyboard use causes CTS. It’s been shown that intense keyboard users have the same incidence of CTS as the general population. This is not to say that symptoms of CTS can’t be brought on by keyboard use. If keyboarding is performed in a non-ergonomic fashion, with the wrists in hyper-flexion or extension, CTS symptoms could arise. Keyboarding can also be responsible for painful problems other than CTS.
Q: How is CTS treated?
A: In the mildest forms, keeping the wrist straight or wearing a splint at night may completely relieve symptoms. Avoiding extreme wrist positioning and repetitive or sustained heavy pinching and gripping can help. Cortisone injections into the carpal canal can also provide temporary relief, though severe CTS usually requires surgery.
Carpal tunnel release surgery enlarges the carpal canal by cutting the transverse carpal ligament. We know the ligament heals with the canal 25 percent bigger. It’s highly successful with rare complications, failures or recurrences.
There are two basic techniques; both work. Endoscopic is done through one or two small incisions using a visualizing camera and a specialized small blade. It produces a modestly faster return to work, but has a three-fold higher incidence of transient median nerve injury. Open surgery through an incision in the palm has a slightly higher incidence of wound healing problems.
ABC News recently reported on 5 common medical tests that the American Board of Internal Medicine Foundation deem unnecessary. A team of researchers with the UC San Diego School of Medicine and the Urinary Incontinence Treatment Network have one more the add to the list: unnecessary invasive bladder tests before incontinence surgery.
Charles Nager, MD, director of Urogynecology and Reconstructive Pelvic Surgery at UC San Diego Health System and researchers found that post surgical outcomes for stress urinary incontinence (SUI) were just as successful for women who had an office check-up alone. More here
From Shattered Elbow to Ground Breaking Mountain Climbs
Mountaineer, Ben Horne, has accomplished athletic endeavors that most people never even attempt in a lifetime – he’s finished marathons, climbed Mt. Whitney, ran the Grand Canyon from rim to rim, and most recently, made the first winter ascent of the Evolution Traverse – an eight mile route that links nine peaks in the Sierra.
“Our team climbed 36 hours over four days, enduring temperatures as low as negative seven degrees Fahrenheit,” said Horne, an economics graduate student at UC San Diego.
But three years ago, Horne never thought he would step foot on a mountain again after shattering his elbow during a long distance bike ride.
“I thought this was it – my lifestyle is over,” said Horne.
His elbow was crushed in five pieces upon impact.
“Because he is young, and an athlete, the team wanted to preserve his natural bone. We also wanted to avoid a prosthetic replacement, which is commonly used but unpredictable in terms of longevity. As a cyclist, I understood the flexibility and stability that Ben would require for cycling, climbing and swimming well into the future,” said Reid Abrams, MD, chief of hand and microvascular surgery at UC San Diego Health System.
During a delicate two-hour surgery, Abrams’ team re-built Horne’s elbow with a series of strategically placed plates, screws and pins woven with wire. After four months of healing, a second surgery was performed to remove hardware and to reduce bone adhesions to improve range of motion.
Now, due to surgery, physical therapy and Ben’s tenacity, he can fully flex his elbow.
“For mountain climbing, you have to be able to pull yourself up under rigorous conditions,” said Horne. “Since my surgery with Dr. Abrams, I’ve been able to climb at even higher levels. I’m a stronger athlete now because I had to learn different sports from cross training during the recovery process.”
“As a surgeon, and someone who has recovered from his own hand injury after a biking mishap, I understand the need to get back to doing what you love,” said Abrams. “I encourage every athlete to continue to pursue their passion after an accident. With the right surgery and follow-up care, the results can be amazing. Ben proves it every day.”
Since the surgery, Horne has completed an ironman and climbed Mt. McKinley in Alaska, referred to as “Denali,” which stands 20,320 feet tall and is the highest mountain in the United States.
“These latest accomplishments are a big deal for me personally. As my rock climbing group says, ‘go big and don’t cut corners,’ and Dr. Abrams made it possible to do so – I am forever grateful.”