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Endoscopy illustration by Sam Newman, Creative Media Services

Big relief through a hole the size of a dime

June 2014

by Will Sansom

Nanette Hathaway well remembers when the pain began. It was Christmas 2009, and she had flown down from Seattle, Wash., to visit her daughter in San Antonio.

"I was in bed when a sharp pain hit my vocal cords and never went away," she said. "The pain was so strong that I couldn’t talk for the whole vacation. I thought it was a flu or something. I went to a pain management place and they guessed it was neuralgia. I kept yelling, help me, help me get rid of this pain."

Doctors put her on hydromorphone, a narcotic analgesic, but the medicine only masked the pain.

"It was like I drank acid through my mouth," she said. "It was the worst pain in the whole world, and eventually it made me want to commit suicide. I lived through it for my children because I always asked myself, what would happen if I did commit suicide? They would have to live with it."

She coped with the pain for four years. Neurosurgeons and ear, nose and throat doctors sent her away with medications and referrals. Then in September 2013, two months after she permanently moved to San Antonio, Hathaway broke her neck in a traffic accident. She was taken to University Hospital where she met David F. Jimenez, M.D., FACS, professor and chairman of the Department of Neurosurgery in the School of Medicine at the UT Health Science Center San Antonio.

He repaired her neck, but her vocal cord pain continued. After more rounds of medications and referrals, she returned to Dr. Jimenez for help.

"He looked at an MRI of the brain and showed me where it was abnormal," she said. "He kept me there for at least an hour, showing me all the pictures. He explained it all to me."

A large blood vessel had shifted over her brain stem and was touching a nerve with every pulse of blood. It was fixable, Dr. Jimenez said, and surgery would be minimally invasive.

On March 3, through a hole the size of a dime and with instruments the size of a pencil lead, Dr. Jimenez finally relieved her pain.

A new generation
From the brain to the hands, neurosurgical procedures are going the way of the endoscope, and Department of Neurosurgery faculty members are routinely performing these surgeries at St. Luke’s Baptist Hospital and University Hospital.

Dr. Jimenez is an internationally recognized expert at the neurosurgical use of endoscopy, which offers an internal view of the body using a flexible tube with a small camera attached at the tip. He also is editor of Intracranial Endoscopic Neurosurgery, a textbook published by the American Association of Neurosurgical Surgeons. He wrote three chapters of the book, including one with his wife, Constance M. Barone, M.D., FACS, on endoscopy-assisted surgeries for the management of craniosynostosis.

"Endoscopy is an important and interesting area in neurosurgery today," Dr. Jimenez said. "Instead of performing a full craniotomy with a large bone flap and scar from ear to ear, we can access an area of interest through a hole the size of a dime. We are able to do things inside the brain and spinal cord to alleviate suffering and improve lives. The hole is repaired with a tiny titanium plate that is as thin as a piece of paper but is not vulnerable. The patient can live worry free."

Dr. Jimenez and Dr. Barone, who joined the Health Science Center in 2004 from the University of Missouri, pioneered endoscopic surgery for craniosynostosis, the premature closing of one or more sutures on a baby’s skull. The brain triples in size from birth to 3 years of age and grows tremendously fast in the first six months. To accommodate this expansion, the skull has five elastic sutures, or seams. If even one of the sutures is closed in the womb or at birth, headaches, eye problems and permanent disfigurement can result. The disfigurement occurs because the brain presses on other parts of the skull, resulting in elongation of the head, a bulging forehead and other deformities.

Before endoscopy-assisted craniectomies for craniosynostosis, babies went untreated or their skulls were opened from ear to ear. Dr. Jimenez said the technique remains largely the same, but a new set of endoscopic instrumentation is making it even better. The operation, which once took two hours, is shorter, easier and safer. To date, Dr. Jimenez, Dr. Barone and their surgical teams have treated more than 600 children.

These less-invasive endoscopic approaches help another high-risk population—the elderly.

Dr. Jimenez operated on a 96-year-old woman who could no longer walk to her mailbox because of pain in her back that radiated down to her legs. She had spinal stenosis, a narrowing of the open spaces within the spine that puts pressure on the nerves of the spinal cord. This results in pain, numbness and muscle weakness.

After a short surgery, her pain was eliminated almost instantly, Dr. Jimenez said. Within a month, she was back to bowling and dancing with her boyfriend.

"Traditional surgery is associated with higher risks for elderly patients," Dr. Jimenez said. "Minimally invasive surgery provides an excellent option for this population of patients who otherwise would not be treated and would have to suffer in pain, as was the case with my patient until she had the surgery."

People with carpal tunnel syndrome are experiencing relief through endoscopy, too. In patients suffering from carpel tunnel, the carpal ligament that connects the hand bones becomes thickened and hard through repetitive use such as typing, and this compresses the median nerve, which runs from the spinal cord down to the fingers. This pressure results in severe pain, tingling, numbness and weakness in the palm and ring finger, sometimes extending into the arm, Dr. Jimenez said.

Historically, carpal tunnel release was accomplished with an incision several inches long. Because the hand is very highly sensitive and nerve-rich, patients faced a six- to eight-week recovery with considerable pain. But Dr. Jimenez can free the carpal tunnel through two tiny incisions, inserting a special endoscope. The pain is greatly reduced, and patients recover in one to two weeks.

"I’ve worked on administrators who had endoscopic surgery on a Thursday and went back to work the following Monday," said Dr. Jimenez, who has performed endoscopic carpel tunnel releases for 20 years.

Patients who have had both procedures—open surgery on one hand and endoscopic surgery on the other—said the endoscopic procedure is overwhelmingly better.

"I’ve had a lot of patients who suffered for years, who then had the endoscopy and kicked themselves for waiting," Dr. Jimenez said.

The Department of Neurosurgery is training a new generation of neurosurgeons, and action in 2014 by the Accreditation Council for Graduate Medical Education approved the expansion of the department’s residency program to 17 residents, one of the largest neurosurgery residency programs in the country. Endoscopies are part of their training.

"Every resident who leaves here is capable of doing these surgeries," Dr. Jimenez said, noting that he is establishing the Center for Neurosurgical Endoscopy by July to further education, research and patient care using the minimally invasive approaches.

For patients, this training will be invaluable, he said.

"If you were given the option of having a very invasive and long surgery," Dr. Jimenez asked, "versus one that involves making a hole the size of a dime, what would you rather have?"

A new life
Months removed from her endoscopic surgery, Nanette Hathaway’s outlook is remarkably changed. For the first time in years, the acid feeling in her mouth is gone. She said she is starting to date for the first time in eight years.

Sheknows exactly how long she suffered from the pain: four years and three months. It took years to diagnose her ailment, just two hours to fix it.

While she continues to recover from the dime-size hole and intrusion of endoscopic instruments into her skull, the vocal cord pain is a thing of the past.

"I’m pain-free, it’s gone," she said. "It disappeared immediately after surgery. I was sedated and when I woke up, Dr. Jimenez was right there. He kept asking me, ‘Does your mouth hurt? Is it gone? Is it gone?'"

Hathaway hopes her story will be an encouragement to others who suffer from the same condition, who look normal yet endure pain so unrelenting and severe that it causes suicidal thoughts.

"God gave me the strength, from the love of my children, to stay alive until I found Dr. Jimenez," she said. "Now I’m going to make a difference. I want to start saving lives of people with this disorder."




Learn more about minimally invasive endoscopic surgery.


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Updated 7/30/14