What’s New In Neurosurgery

By Dr. Jon F. Graham
Interviewed by Melissa Moniz
Wednesday - March 11, 2009
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Dr. Jon F. Graham
Neurosurgeon, The Queen’s Medical Center

Interviewed by Melissa Moniz

Where did you receive your schooling and training?

I went to undergrad at Michigan State University, then I went to medical school at Wayne State University in Detroit. Then, after that, I got into the Army and did my internship and residency in neurosurgery at Walter Reed Army Medical Center. My first tour was out at Tripler Army Medical Center when I finished my residency in 1984.

What is a neurosurgeon?

The basic thing with a neuro-surgeon is that we take care of patients with surgical diseases of the nervous system. We do non-surgical treatments, but our specialty is mostly in surgical treatment. We do surgery on the brain, such as brain tumors, blood vessel problems, and other aspects on the brain like drainage problems. And then there’s various kinds of tumors we would treat in the brain and the covering of the brain. We also treat tumors of the skull, and tumors with the spinal columns, spinal cord and those sorts of things. A bulk of our work involves the spine, so we treat spinal cord disease and degenerate problems with the spine itself. We also treat the nerves that come out of the spinal column.


You mentioned degenerative-type problems. Do you also see congenital conditions?

Most of what we see are degenerative conditions, kind of wear and tear. I would say the bulk of our patients are in the older segment of the population.

Of the conditions you see and treat, which are the most difficult to correct?

In the brain, probably the most difficult thing to treat is what we call skull-based tumors, because they are hard to approach and it requires extra training. Also, a lot of the large brain tumors are difficult to treat. In the spine, probably the most difficult problem to treat is a condition called OPLL, where it’s a ligament that turns into calcium in the spinal cord and it compresses the spinal cord. The treatment is high-risk, and it’s very difficult and stressful to treat surgically.

(from left) Anna Crisostomo, Arlene Lewis, Dr. Jon Graham, Elena Watson and Cristina Watarida

Queen’s now offers a new minimally invasive spine procedure called XLIF (Extreme Lateral Interbody Fusion). Can you discuss this new procedure?

I’ve been interested in the minimally invasive spine procedures since about 1998. To make a long story short, one of the guys who helped develop this minimally invasive technique where you perform an operation on the lower spine is Dr. Kevin Foley. He is a good friend of mine, and he came here when I was at Tripler and taught me the technique. Since then I’ve become more and more interested in minimally invasive surgery. The reason for that is the patients recover faster. Some of the procedures may be more difficult for the surgeon, but the patients reap the benefits.

This XLIF procedure is a relatively new minimally invasive procedure that approaches the spine. You can use it on the chest or in the lower back, and it involves just a small incision, maybe 3 centimeters in length, that allows you to approach the spine from the side. Traditionally we would approach the spine from the back, and we would make an incision that would be sometimes 5 or 6 inches long, just to get one or two areas of the spine. With an XLIF, you can approach the spine from the side through a smaller incision. You bypass having to go through all the spine muscles in the back, and you go through smaller muscles on the side of the spine. So the patient recovers faster and there isn’t as much pain. It’s an indirect decompression and you don’t have to expose the nerves, so it’s a little bit safer. It’s used for people who have a lot of back pain and can’t walk very far, or even a person who has a pinched nerve in the spine.


Can you go into detail with numbers, as far as the comparison of time in the operating room with the XLIF procedure versus the traditional approach, as well as the recovery time?

Minimally invasive surgery itself, when we first started, took longer for the surgeons. Dr. Morris Mitsunaga, an orthopedic surgeon who specializes in spine, and I do all these minimally invasive procedures together. There are basically four minimally invasive procedures that we do on the spine - the XLIF is the newest one. There’s one procedure called the TLIF, and that procedure used to take five hours, but we got that time down to three hours now. And for the XLIF, we got that time down to an hour. So there’s less anesthesia time, and the recovery time is much faster. Here, if a patient has an XLIF, they usually go home in a day. If we do the other minimally invasive procedures, of which the most common is the TLIF, the patients usually stay about four days. Overall the results are about the same, but the recovery time is faster.

How many cases have been done using this new procedure?

I would say about 20.

What has the feedback been from patients who received the XLIF?

Amazingly, a lot of the patients we do XLIFs on are patients who have failed conventional open surgery. Those patients who have had a laminectomy before and now had an XLIF are really happy. Another common group of patients on whom we would do an XLIF is if they had a fusion in the past, because really, an XLIF is really just a minimally invasive fusion. Other people who have had previously conventional fusions take three to six months to heal, and what will sometimes happen is the area above where it’s been fused wears out and needs another fusion. We don’t want to go back through all that scar and mess and try to do another fusion, so we just go in from the side, and those patients are extremely happy. In fact, we just had a guy who had a previous fusion and he said it took him about six months to recover. We did an XLIF and he wanted to go home the next day.

How has neurosurgery evolved since you first started?

When I finished my residency, we were doing laminectomies to treat disk disease. That’s about a 3-inch incision in the lower back to take out a ruptured disk that’s pushing on a nerve. For the neck, we had an approach from the front, which is a fusion. For the brain, we had various approaches - and in all three areas the microscope was new. When I started, I was in one of the first groups to be trained entirely on what we call microneurosurgery, which is neurosurgery with a microscope. As I continued to practice, the next important thing was they started using image guidance, which is almost like a GPS system for the body. So what those did is allow you to do surgery in the brain in a much safer manner. For spine, they started coming out with ways of stabilizing the spine and instrumentation. So those are probably the biggest breakthroughs. And then, of course, over the last five years, we’ve seen a tremendous growth in minimally invasive surgery. Not only spine, but brain as well. And there’s a higher reliance on image guidance.

 

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