Procedures

NEUROLOGY/SLEEP CONSULTATION

Dr. Rosenfeld sees patients with all Neurologic and Sleep conditions. Please arrive at Rosenfeld Neurology and Sleep prior to your appointment time to make sure all the appropriate paperwork have been filled out, to confirm insurance will cover your visit, and to fill out any medical questionnaires Dr. Rosenfeld may need for your specific issue.

After checking in, Dr. Rosenfeld's medical staff will bring you back to an exam room and take your medical history and make sure everything is available in the Electronic Medical Record system. They will also check your vital signs such as your blood pressure, temperature, and other essential basics.

Following your intake above, Dr. Rosenfeld will go over your pertinent medical history and perform a physical exam. This will be followed by a discussion of the diagnoses, recommendations for treatments, testing, time for questions, and a plan for follow up if needed.

A new patient consultation can last from 15 min to over an hour depending on the complexity of the problem or problems.

OFFICE VISIT

An Office Visit will typically last anywhere from 10 to 30 minutes, but if the situation is very complex a longer amount of time may be needed.

Dr. Rosenfeld will typically review the results of diagnostic testing during the visit, such as a MRI or CT scan, Laboratory results, EEG, or EMG/Nerve Conduction testing, or a Sleep Study, which may help to confirm a Neurologic or Sleep condition.

Medications which were prescribed will be evaluated as to their benefits, side effects, and any questions regarding their administration will be answered.

Lastly, a plan for follow up will be scheduled, or if there are no further ongoing issues, you may be referred back to your referring physician or primary care doctor, with an order to return should your condition worsen, change or progress in any way.

TELEMEDICINE VISIT

For patients that live more than an hour away, or for those for whom travel is not possible, Dr Rosenfeld can consider using Telemedicine to conduct follow up visits. Telemedicine is not advised for initial consultation due to need for Physical Examination, as well as possible lab work or diagnostic testing which has to be performed in person. Insurance companies may cover Telemedicine visits.

ELECTROMYOGRAM AND NERVE CONDUCTION STUDIES (EMG/NCON)

An electromyogram (EMG) measures the electrical activity of muscles at rest and during contraction. Nerve conduction studies measure how well and how fast the nerves can send electrical signals. Nerves control the muscles in the body by electrical signals (impulses), and these impulses make the muscles react in specific ways. Nerve and muscle disorders cause the muscles to react in abnormal ways. Measuring the electrical activity in muscles and nerves can help find diseases that damage muscle tissue (such as muscular dystrophy) or nerves (such as amyotrophic lateral sclerosis or peripheral neuropathies). EMG and nerve conduction studies are often done together to give more complete information. The test takes about 1 hour.

An electromyogram (EMG) is done to: Find diseases that damage muscle tissue, nerves, or the junctions between nerve and muscle (neuromuscular junctions). These disorders may include a herniated disc, amyotrophic lateral sclerosis (ALS), or myasthenia gravis (MG).

Nerve conduction studies are done to: Find damage to the peripheral nervous system, which includes all the nerves that lead away from the brain and spinal cord and the smaller nerves that branch out from those nerves. Nerve conduction studies are often used to help find nerve disorders, such as peripheral neuropathy, carpal tunnel syndrome or Guillain-Barré syndrome.

Tell your doctor:

• If you are taking muscle relaxants or anticholinergics (certain kind of antidepressant) which can change the electromyogram (EMG) results.
• If you have had bleeding problems or take blood thinners, such as warfarin (Coumadin) or heparin. If you take blood thinners, your doctor will tell you when to stop taking them before the test.
• If you have a pacemaker.

Wear loose-fitting clothing so your muscles and nerves can be tested. You may be given a hospital gown to wear.

Do not wear use any lotions or creams the day of your nerve conduction study as this can interfere with the electrical conduction of the test.

DIAGNOSTIC OVERNIGHT POLYSOMNOGRAM (PSG)

Polysomnography is used to diagnose, or rule out, many types of sleep disorders including Sleep Apnea, Periodic Limb Movements, REM Behavior Disorder, Parasomnias. PSG is often ordered for patients with complaints of daytime fatigue or sleepiness that may be caused by interrupted sleep. The test consists of a continuous recording from 6 to 8 hours and occurring during a patient's typical sleep hours. A polysomnogram typically records a minimum of eleven channels requiring a minimum of 22 wire attachments to the patient. Two channels are for the EEG, one or two measure airflow, one is for chin movements, one or more for leg movements, two for eye movements (EOG), one for heart rate and rhythm, one for oxygen saturation and one each for the belts which measure chest wall movement and upper abdominal wall movement. All the leads will be cleared after the procedure.

Do not use any creams or lotions, makeup or hair weaves that can interfere with lead placement.

CONTINUOUS POSITIVE AIRWAY PRESSURE TITRATION (CPAP TITRATION)

If a patient is diagnosed with Obstructive Sleep Apnea or Central Sleep Apnea a during a diagnostic polysomnogram then a CPAP titration may need to be performed. CPAP is initiated and the pressure is increased by the technician until your breathing and body oxygen is normalized and Obstructive Apnea has been eliminated, especially while supine and during REM sleep when sleep apnea tend to be at its most severe. Similar to an overnight PSG patients will spend the night in the lab. All the leads will be cleared after the procedure.

Do not use any creams or lotions, makeup or hair weaves that can interfere with lead placement.

MULTIPLE SLEEP LATENCY TEST (MSLT)

The MSLT is usually performed during the day following after your sleep study. The Multiple Sleep Latency Test (MSLT) can be used to test for Narcolepsy. It is used to measure the time it takes from the start of a daytime nap period to the first stage of sleep, called sleep latency. The test consists of 4 to 5 nap opportunities occurring every 2 hours lasting approximately 20-35 minutes following the PSG. You are asked to stay awake during the procedure. Please bring reading material or a laptop to keep yourself occupied between the nap tests. All the leads will be cleared after the procedure.

Do not use any creams or lotions, makeup or hair weaves that can interfere with lead placement.

HOME SLEEP APNEA TEST (HSAT)

Home Sleep Testing is only indicated in patients who have a high probability for having severe Obstructive Sleep Apnea and for whom formal in-lab Polysomnography cannot be accomplished. Patients are sent home with a portable monitoring device that is worn as a band around the head and a cannula in the nose that measures airflow, body position and oxygenation. This is worn at night for one or two nights then returned to the clinic. Usually a deposit is required which is then refunded upon return of the equipment the following day.

PROLONGED ELECTROENCEPHELOGRAM (EEG)

An EEG is used to analyze brain waves to look for seizures and epilepsy. 22 electrodes will be placed on the scalp which are cleared after the test. The setup process takes about 1 hour, and will be recorded for 1 hour. Please arrive early for your appointment so as to prepare for the procedure. Please do not wear any hair weaves or creams or lotions on your scalp which can interfere with lead placement. All the leads will be cleared after the procedure.

AMBULATORY EEG WITH VIDEO (aEEG)

You will be asked to come to the SouthCoast Medical Clinic for an ambulatory EEG "set-up" and then you are able to return to home or work during the testing process which typically takes 1-3 days depending on the physicians' order. During the setup, a technologist will educate you on the process and answer your questions about this safe and painless procedures. Sixteen to 24 electrodes will be placed on your head using a conductive paste and special adhesive to hold the electrodes in place, which will be cleared from your head at the end of the procedure.

The electrodes are small metal discs with thin wires that will be connected to a small head-mounted amplifier which records your brainwaves. Once the setup is complete, your head is wrapped with gauze to hold everything in place. The technologist will provide you with supplies and instructions for your use during the test. There is a small video camera that will record all the brain wave activity and video for the recording period, including at night. It is important to keep a log that tells us what you were doing or what events or spells happened at what time.

SMALL NERVE BIOPSY (Bx)

A Small Nerve Biopsy is performed to identify small fiber neuropathy which cannot be identified on a Nerve Conduction Study and EMG which looks for large fiber neuropathies. This can be frequently seen in diabetes or B12 deficiency, which are common causes of small fiber neuropathy.

A piece of skin will be biopsied from the thigh and leg, This is with a small 3 mm biopsy tool. The skin will first be cleaned and lidocaine will be used to numb the area. This procedure takes about 20 minutes.

LUMBAR PUNCTURE (LP)

A lumbar puncture (also called a spinal tap) is a procedure to collect and look at the fluid (cerebrospinal fluid, or CSF) surrounding the brain and spinal cord.

During a lumbar puncture, a needle is carefully inserted into the spinal canal low in the back (lumbar area). Samples of CSF are collected. The samples are studied for color, blood cell counts, protein, glucose, and other substances. Some of the sample may be put into a special culture cup to see if any infection, such as bacteria or fungi, grows. The pressure of the CSF also is measured during the procedure.

A lumbar puncture is done to:

• Find a cause for symptoms possibly caused by an infection (such as meningitis), inflammation, cancer, or bleeding in the area around the brain or spinal cord (such as subarachnoid hemorrhage).
• Diagnose certain diseases of the brain and spinal cord, such as multiple sclerosis or Guillain-Barré syndrome.
• Measure the pressure of cerebrospinal fluid (CSF) in the space surrounding the spinal cord. If the pressure is high, it may be causing certain symptoms.
• In rare cases, a lumbar puncture may be used to lower the pressure in the brain caused by too much CSF.

How To Prepare
Before you have a lumbar puncture, tell your doctor if you:

• Are allergic to any medicines, such as those used to numb the skin (anesthetics).
• Have had bleeding problems or take blood-thinners, such as aspirin or warfarin (Coumadin).
• Are or might be pregnant.
• Take any herbal remedies. Some of these remedies may thin the blood.
• You should try to empty your bladder before the procedure.

For a lumbar puncture, you will be asked to sign a consent form. Talk to your doctor about any concerns you have regarding the need for the procedure, its risks, how it will be done, or what the results will mean.

A post spinal tap headache can occur in approximately one third of patients after a lumbar puncture. Women are more susceptible to getting them. The chance of it occurring may be lessened by using a smaller gauge needle. Typically doctors will have patients lie flat after the procedure for 20 to 30 minutes.

Post spinal headaches are diagnosed if a patient has a headache that is present when standing up but goes away as soon as they lie down. Usually this headache will go away in about 24 hours. Bed rest, analgesics, hydration and caffeine can help. If the headache persists, your doctor may want you to have a blood patch, which is a procedure done typically by an anesthesiologist where some of your blood is drawn and injected back into the epidural space forming a seal over the site of the lumbar puncture which usually is very effective at improving a spinal headache.

VESTIBULAR AUTOROTATION TEST (VAT)

A VAT study is test used to look for causes of vertigo and dizziness by studying eye and head movement. Older technologies such as Vestibular Nystatograms (VNG)t are very expensive and require injecting water into patients' ears and moving them around and will frequently cause vertigo and vomiting. The VAT test is a simple procedure where electrodes are placed above the eyes and your are asked to follow a spot in the distance while being monitored by a computer, while sitting. The test takes about 20 min to prepare and 20 min to perform.

NEUROCOGNITIVE TESTING (NCOG)

A Neurocognitive Test is used to assess for issues like Attention Deficit Disorders, Memory Loss, and effects of Head Injury on cognition. This test takes about 1 hour, and you are asked to sit in front of a computer screen and perform simple tasks. You do not need to be computer savvy to be able to perform this test. This is a screening test that can provide useful information about all aspects of cognition. In more complex cases, a referral to a Neuropsychiatrist for formal testing may be required.

DEEP BRAIN STIMULATION (DBS)

DBS is used in the treatment of Tremor and Parkinson and is under investigation in other conditions as well. Deep brain stimulation (DBS) is a surgical procedure that involves implanting electrodes in the brain, which deliver electrical impulses that block or change the abnormal activity that cause symptoms.

The deep brain stimulation system consists of four parts:

• Leads (thin insulated wires) that end in electrodes that are implanted in the brain
• A small pacemaker-like device, called a pulse generator, that creates the electrical pulses
• Extension leads that carry electrical pulses from the device and are attached to the leads implanted in the brain
• Hand-held programmer device that adjusts the device's signals and can turn the device off and on.

In deep brain stimulation, electrodes are placed in the targeted areas of the brain. The electrodes are connected by wires to a type of pacemaker device (called an implantable pulse generator) placed under the skin of the chest below the collarbone.

Once activated, the pulse generator sends continuous electrical pulses to the target areas in the brain, modifying the brain circuits in that area of the brain. The deep brain stimulation system operates much the same way as a pacemaker for the heart. In fact, deep brain stimulation is referred to as "the pacemaker for the brain."

How is deep brain stimulation (DBS) used to treat Parkinson's disease?

Deep brain stimulation (DBS) delivers electrical impulses to a targeted area of the brain that is responsible for the movement symptoms (also called motor symptoms) caused by Parkinson's disease. The electrical impulses disrupt the abnormal activity that occurs in the brain's circuitry, which is causing thHow do I know if I'm a candidate for deep brain stimulation (DBS)?

Before being considered a candidate for deep brain stimulation (DBS), patients with Parkinson's disease must undergo an extensive evaluation process. Ideally, a multidisciplinary team of specialists in the area of movement disorders will assess the patient. This clinical team typically includes a neurologist, neurosurgeon, neuropsychologist and psychiatrist.

If patients are well managed on medications, DBS is not considered. Candidates for DBS are patients who meet one or more of the following criteria:

• Symptoms are not well controlled despite receiving the appropriate dose of levodopa and other medications.
• Symptoms are significantly reducing patients' quality of life.
• Abnormal or uncontrolled involuntary movements (dyskinesia) or motor fluctuations are not improving despite adjustments in medications.
• Four or more doses of levodopa are required a day.
• Tremors that have not been able to be controlled by medications.e symptoms.

Programming of the DBS device and monitioring its function and battery life is a painless procedure that we do during a routine office visit.

HYPOGLOSSSAL NERVE STIMULATION (HGNS)

HGNS is a relatively new treatment. It's also known as upper airway stimulation or a "pace maker for the tongue." The treatment works by stimulating the hypoglossal nerve to restore the tone to (or stiffen) the key tongue muscles that when relaxed, can block the airway causing an obstruction that reduces or stops breathing during the night (this is classic obstructive sleep apnea). The stimulating device (and battery) and breathing sensor are implanted in the chest and connected to a stimulation lead that touches the hypoglossal nerve. It's turned on when you go to sleep and off when you wake up by a small hand-held remote.

Inspire developed the world's first fully implanted neurostimulation device approved by the FDA for the treatment of OSA (shown below). The Inspire system uses neurostimulation technologies and incorporates a proprietary algorithm that stimulates key airway muscles based on a patient's unique breathing patterns.

There are a couple of different manufacturers of devices. While both require surgical implantation, unlike other surgical options for sleep apnea, HGNS devices do not require removing or permanently altering the patient's facial or airway anatomy. The implantation can usually be done as an outpatient procedure. After implantation during an appointment we find the ideal setting and will check that during an overnight sleep study.

VAGAL NERVE STIMULATION (VNS)

VNS Therapy® (also called vagus nerve stimulation) has been approved by the U.S. Food and Drug Administration (FDA) as an add-on theray for adults and children 4 years and older. It is approved to treat focal or partial seizures that do not respond to seizure medications. This is called drug-resistant epilepsy or refractory epilepsy.

Vagus nerve stimulation (VNS) may prevent or lessen seizures by sending regular, mild pulses of electrical energy to the brain via the vagus nerve.

The therapy consists of a device that is implanted under the skin in the left chest area. An electrode or wire is attached to the generator device and placed under the skin. The wire is attached or wound around the vagus nerve in the neck.

The device is programmed in the outpatient clinic to deliver pulses or stimulation at regular intervals. A person does not need to do anything for this device to work.

A person with a VNS device is usually not aware of the stimulation while it is working.

If a person is aware of when a seizure happens, they can swipe a magnet over the generator in the left chest area to send an extra burst of stimulation to the brain. For some people this may help stop seizures.

Vagus nerve stimulation (VNS) is a type of neuromodulation. It is designed to change how brain cells work by giving electrical stimulation to certain areas involved in seizures.

The vagus nerve is part of the autonomic nervous system, which controls functions of the body that are not under voluntary control (such as heart rate and breathing). The vagus nerve sends information from the brain to other areas of the body. It also carries information from the body to the brain.

In the newer VNS models (AspireSR® and SenTivaTM), a fast increase in heart rate can be picked up. This triggers an extra burst of stimulation to help stop these seizures.

These models may be especially helpful for people who are not aware of when seizures happen, if seizures are not witnessed, or if seizures occur at night.

This therapy does not cure epilepsy. It's designed to help control seizures by lessening the number and severity of seizures. VNS is used for people with refractory or drug-resistant epilepsy. This means seizures are not controlled after trying at least 2 appropriate seizure medications.

It's an add-on treatment, which means it is used in addition to seizure medicines. For some people, when VNS works well, the dose or use of a seizure medicine may be decreased.

VNS is usually used if a person is not able to have epilepsy surgery or if surgery does not work.

Sometimes a person may be offered VNS if other reasons make surgery not possible.

BOTOX

Botox® (onabotulinum toxin A) was licensed specifically for the treatment of chronic migraine in July 2010 by the Medicines and Healthcare products Regulatory Agency (MHRA).

Botulinum toxin and headache

In the mid-1990s a number of people reported improvement in headaches in patients receiving botulinum toxin for other reasons. Well-conducted clinical trials of botulinum toxin in various types of headache followed, but the results were disappointing, with no difference over placebo being found in tension-type headache, episodic migraine, and undifferentiated chronic headache. Detailed analysis of the results suggested, however, that there might be a subgroup of patients with chronic migraine who could benefit, and further trials were undertaken.

How does botulinum toxin work in chronic migraine?

The simple answer is that we don't know fully. A recent US study by Rami Burstein et al using animal models suggested that botulinum toxin inhibits pain in chronic migraine by reducing the expression of certain pain pathways involving nerve cells in the trigeminovascular system. The trigeminovascular system is a sensory pathway thought to play a key role in the headache phase of a migraine attack.

Unlike many of the other conditions in which it is used, it is not thought to work by relaxing overactive muscles. Botulinum toxin has been shown to reduce pain in a number of disease states, including cervical dystonia, neuropathic pain, lower back pain, spasticity, myofascial pain, and bladder pain.

More research into the mechanism of action of botulinum toxin will hopefully shed light into all the pathways that it acts upon.

Is Botox® right for me?

Only patients with chronic migraine are eligible for treatment with Botox®. Chronic migraine is defined as headaches occurring on 15 or more days each month, at least half of which have migrainous features. There are, however, other treatments available to patients with chronic migraine, and it is important that patients have an informed discussion of their headaches and the options for treatment with a practitioner experienced in the diagnosis and management of headaches before a decision to use Botox® is taken.

The procedure takes only a few mintues and involves a very strict protocol where thirty sites are injected. Though it sounds a bit scary it is a very well tolerated procedures. Patients return routinely at 3 month intervals.