Craig Hospital - Rehabilitative Neurosurgery - Scott P Falci M.D.
Rehabilitative Neurosurgery
Rehabilitative neurosurgery is a subspecialty that involves specialized
surgeries on patients with traumatic spinal cord injury. These
surgeries offer treatment for syringomyelia, post-traumatic tethered
spinal cord, pain and spasticity. Craig Hospital initiated its
rehabilitative neurosurgery program in the late 1970s, and is
an international referral center for the neurosurgical treatment
of posttraumatic syringomyelia and tethered spinal cords. Over
1,000 cases of posttraumatic syringomyelia and posttraumatic tethered
cords have been treated neurosurgically at Craig Hospital.
 Scott P. Falci M.D. is the Chief Neurosurgical Consultant for Craig Hospital. Dr. Falci is a graduate of Georgetown University Hospital of Medicine in Washington, D.C. and completed his neurosurgical residency at Georgetown University Hospital in 1992. He received his undergraduate training at Princeton University, Princeton, NJ. Dr. Falci initiated and designed the First Transplantation of Embryonic Nerve Cells for Spinal Cord Injury Project at Craig Center for Spinal Cord Research in collaboration with the Spinalis SCI Research Unit, Karolinska Institute, Huddinge University Hospital, Stockholm, and the department of Neurosurgery, University of Uppsala in Sweden. (J. of Neurotrauma, Vol. 14, No. 11, November, 1997)
If you would like to make a referral to Dr. Falci, want further
information, or have questions, please call Charlotte Indeck, RN at
Dr. Falci’s office at 303-761-5281 or e-mail cindeck@craighospital.org.
Because of the high volume of requests and our busy surgery schedule,
please allow several days to hear back. If your request requires a
quicker response, please indicate that when you call. If you are
having a medical emergency, call 911.
Post-traumatic Syringomyelia and Post-traumatic Tethered Spinal
Cord
Post-traumatic syringomyelia and post-traumatic tethered spinal
cord are conditions that can occur following spinal cord injury
and can result in progressive deterioration of the spinal cord.
Posttraumatic syringomyelia involves development of a cyst or
fluid-filled cavity within the spinal cord following an injury
to the spinal cord. Posttraumatic tethered spinal cord is a condition
which occurs following injury to the spinal cord where scar tissue
forms and tethers or holds the spinal cord to the soft tissue
covering which surrounds it called the dura. This scar tissue
prevents the normal flow of spinal fluid around the spinal cord
and impedes the normal motion of the spinal cord. Myelomalacic
(softening or increased water content) changes may then occur
in the spinal cord. Tethering of the spinal cord has been suggested
as a pathophysiological cause for the formation of cysts in the
spinal cord. A posttraumatic tethered cord can occur without evidence
of syringomyelia; however, in our experience, post-traumatic cystic
formation will not occur without some degree of tethering of the
spinal cord. Posttraumatic tethered cords and syringomyelia are
treated surgically when a complex of clinical symptoms occurs.
The clinical symptoms for syringomyelia and tethered spinal cord
are the same. The symptoms may include: progressive loss of sensation
or strength, hyperhidrosis (profuse sweating), spasticity, pain,
autonomic dysreflexia (labile blood pressure), and/or Horner's
syndrome (dilated pupil). Deterioration of the spinal cord related
to these myelopathies can occur above and/or below the level of
injury.
Sensory and motor symptoms are a result of changes occurring in
the spinal cord, and are directly related to the specific location
of these changes in the spinal cord. In other words, if changes
occur above the level of injury preserved function is affected.
Patients may experience a slow and progressive loss of the ability
to feel hot or cold water on their skin or develop hypersensitivity,
so that touching the skin causes pain. This change in sensation
occurs in areas where the patient previously had normal or impaired
sensation. Loss of strength can be described by patients as the
inability to use certain muscles that were previously present
and/or the development of fatiguing muscle groups which interferes
with function. For instance, patients often say they have difficulty
wheeling their chair the same distances or performing repetitive
motions for the same amount of time.
Hyperhidrosis or profuse sweating can occur anywhere on the body
and occurs without a specific cause.
Patients can develop the new onset of spasticity, or spasticity
can worsen, unrelated to other issues such as a plugged catheter,
skin breakdown, or bowel program.
The onset of new pains or the worsening of pains that were present
at the time of injury may occur. Secondary to these pains, patients
report various types of symptoms, including burning, stinging,
stabbing, sharp, shooting, electrical, crushing, squeezing, tight,
vise-like cramping pains. These pains generally occur in areas
where patients have lost sensation or where sensation sense is
not normal.
Autonomic dysreflexia is described as an over-activity of the
autonomic nervous system in response to stimuli. This can result
in rapid swings in blood pressure, blotchy skin or goose bumps
and sweating. These symptoms can be present unrelated to a stimulus
or begin occurring at times when they had not before (i.e., bowel
programs).
The Horner's syndrome usually presents as one pupil appearing
smaller than the other pupil, and can switch from side to side.
This symptom is not always present and can occur at the time of
a spinal cord injury.
- Surgical Interventions for Syringomyelia
and/or Posttraumatic Tethered Spinal Cord
Surgical intervention for syringomyelia or tethered spinal chord
is an option when patients are experiencing progressive loss of
sensory and/or motor function. If medical management of pain,
spasticity, dysreflexia, and sweating has been unsuccessful, surgical
intervention may be considered.
- Spinal Cord Untethering: This surgery involves releasing the scar tissue around the spinal
cord to restore spinal-fluid flow and the motion of the spinal
cord. In addition, an expansion graft is placed to enhance the
dural space and decrease the risk of re-scarring.
- Cyst Shunting: If a cyst is present, a tube is placed inside the cyst cavity to drain the fluid from the cyst. Spinal cord untethering with expansion of the dural space is done as well.
Pain and Surgical Interventions
Craig Hospital does not have a formal
pain management program for patients with low back pain or other sources of pain
that are not spinal cord injury related. We also do not admit inpatients or
outpatients with a primary diagnosis of pain, or need for primary pain management
services. However, central deafferent or neurogenic pain can occur following
spinal cord injury. These are pains
generated by the injured spinal cord itself. Following spinal
cord injury, patients can experience pain in areas of the body
where they do not have normal sensation. These pains can occur
anywhere at or below the level of injury. Patients classically
describe these pains as burning, stinging, stabbing, electrical,
sharp, shooting and/or squeezing, tight, pressure, and vise-like.
These pains may present at or very near the time of the injury
or may occur later (one to many years after the time of injury).
The first line of treatment for these kinds of pains is medication.
Typically antidepressants or antiseizure medications are used
to treat these pains. If medication is not successful, neurosurgical
intervention may be appropriate.
- Surgical Interventions for Pain
- Computer-Assisted Dorsal Root Entry Zone Microcoagulation (CA- DREZ): This surgery is performed on the paraplegic population for burning, sharp, electrical, stabbing, pins-and-needles, and "aching" pains which occur at or below the level of injury. It involves electrical recording inside the spinal cord at the time of surgery to identify regions of abnormally active pain-producing nerve cells. These abnormal nerve cells are then destroyed with radio frequency heat lesions.
- Spinal Cord Untethering and/or Cyst Shunting: In some patients, the presence of "tethering" or scarring of
the spinal cord, or the presence of a cyst or syrinx within the
spinal cord causes abnormal activity of pain-producing nerve cells
within the spinal cord. Surgical release of the scar tissue (spinal
cord untethering) alone or in addition to drainage of the cyst
(cyst shunting) may lead to pain relief.
Spasticity and Surgical Interventions
Spasticity or spasms are spontaneous, involuntary, uncoordinated
reflex movements of muscles, which can occur following spinal
cord injury. While some spasticity may be useful, spasms can become
a problem and interfere with wheelchair positioning, transfers,
and sleeping. When spasticity becomes a problem and cannot be
treated adequately with medical management, surgical intervention
may be appropriate.
- Surgical Interventions for Spasticity
- Percutaneous Thermal Rhizotomy (PTR): This is an outpatient procedure in which radio-frequency heat
lesions are delivered to selected peripheral nerves involved in
spasticity.
- Intrathecal Baclofen Pump: This is a surgical procedure involving the placement of a pump,
which delivers spasticity medication through a catheter into the
spinal fluid space around the spinal cord.
- Selective Sensory Microrootlet Section (SSMS): This is a surgical procedure which involves cutting selected
sensory nerve rootlets entering the spinal cord.
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