No More Falls: Novel Two-stage Minimally Invasive Operation Proves Effective to Reach the Spine Through the Nose
It was truly a team effort in the Department of Neurological Surgery, and today patient Elizabeth Barry reports, "I am walking so much better. People who know me are amazed. I have had no more dizziness and no more falls." Her 11-year old daughter, Jennifer, adds, "Since my mom came home after this surgery, I can see she is much more independent."
It had not been a walk in the park for Elizabeth. At age 8 she sustained a bad fall while playing that caused a cervical spine injury. The result: pins and needles sensations, numbness, and a pigeon-toed gait that included walking on the toes of her right foot. She had surgery during her childhood to correct the situation and the numbness and pins and needles vanished. However, the pigeon-toed walk and problem with the right foot continued. "But I lived a full and happy life for many years," says Elizabeth. Then a few years ago, she began to feel dizzy at times. "I kept falling and often had to lean on someone." The falls came on unexpectedly and one even resulted in two black eyes.
When Elizabeth reached Cornell's Department of Neurosurgery, via an internet search, she was finally presented with a surgical plan that she felt comfortable with. Her family members, who have been especially supportive, were relieved to know she had found a "team of pros" who "obviously had the highest tech equipment available."
Dr. Roger Härtl, Director of the Spine Center, could see that the conventional surgical approach, known as "transoral," would require major surgery through the open mouth to reach the spinal column and decompress the spinal cord. Elizabeth's spine problem, to be exact, included an old non-healed spinal fracture called "os odontoideum" and posterior atlantoaxial subluxation. Simply put, her spinal cord was being compressed and the spinal column had become unstable.
Dr. Härtl explained that they had a window of time to correct the problem, because if the situation progressed she could develop paralysis that would ultimately bind her to a wheel chair. He called in colleague, Dr. Theodore H. Schwartz, an expert in the minimally invasive technique of endonasal surgery, which allows the surgeon to operate via the nose.
Elizabeth remembers a meeting being pulled together in "record time" where Drs. Härtl, Schwartz, and Dr. Schwartz's colleague, Dr. Vijay K. Anand, described the plan patiently, answering all of her questions. Elizabeth preferred their plan, versus the typical approach via the mouth. Operating via the mouth includes the risk of tongue and/or tracheal edema. Also, there is a possibility of needing an additional tube placed in the trachea or stomach for breathing and feeding, which requires an even longer operation and a much longer recovery. This new streamlined endonasal, endoscopic approach would shorten recovery time, reduce the risk of infection, and ultimately return a good dose of freedom to Elizabeth's life.
The first part of the operation would be performed by Dr. Härtl (a fusion procedure to relieve the pressure on the spine). Elizabeth would lie face down for this portion. Then she would be turned over and wakened up briefly to check that she was still moving her arms and legs. The second part of the procedure was performed by Dr. Schwartz using minimally invasive endonasal endoscopic surgery. Working as a team, Drs. Anand and Schwartz removed the part of Elizabeth's spine that was compressing her spinal cord by working through the nostrils of her nose. By avoiding any incisions and keeping the surgical corridor high up in her nose and not in her mouth, Elizabeth was able to recover much more quickly and avoid any postoperative complications. "Minimally invasive surgery is much easier on the patients," says Dr. Schwartz, "but often more difficult for the surgeons, which is why many surgeons prefer to use older methods."
Completely effective, the 2-in-1 operation reduced recovery time and there was no infection. She remembers "nothing more than two tiny cotton swabs being removed from my nose and no pain." Elizabeth was able to start eating the day after surgery, which would be unheard of after a more traditional transoral surgery. This novel approach, combining two procedures-- usually performed as two entirely separate operations-- is the first of its kind. The surgeons have written a scholarly journal article on Elizabeth's case (submitted for publication).
Elizabeth's gait has improved greatly. She increasingly gains strength in her upper extremities and hand grip. And she has gained weight; good news, as she had been a bit underweight. But best of all, no dizziness and no more falls. In summarizing her story Dr. Härtl states: "Elizabeth's case is a perfect example of how a multidisciplinary team approach can bring together everything we have learned on how to make surgery for complex spine and brain problems safer, less invasive and highly effective." Dr. Härtl believes that with continued physical therapy one day Elizabeth will completely eliminate her "right foot" problem and certainly no wheel chair needed.
Not long after the surgery, Elizabeth and her family enjoyed a boat cruise to the Caribbean. "I had absolutely no problems on the trip. This surgery was so easy from beginning to end. Smooth sailing all the way."
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