GENERAL KNOWLEDGE

DIAGNOSIS AND MANAGEMENT OF DISC AND DEGENERATIVE SPINAL DISORDERS

Introduction

Diagnosis and management of disc and degenerative spinal disorders are essential for providing appropriate treatment and improving patients’ quality of life. Here’s an overview of the process:

Diagnosis:

  1. Medical History: The first step is to take a detailed medical history, including the patient’s symptoms, duration, and any past medical conditions or injuries related to the spine.
  2. Physical Examination: A thorough physical examination helps the physician assess the patient’s range of motion, muscle strength, reflexes, and any signs of nerve compression or spinal instability.
  3. Imaging Studies: Imaging techniques like X-rays, CT scans, and MRI provide detailed pictures of the spinal structures and can help identify herniated discs, spinal stenosis, and other degenerative changes.
  4. Electrodiagnostic Tests: Nerve conduction studies (NCS) and electromyography (EMG) may be conducted to evaluate nerve function and identify any nerve compression or damage.
  5. Diagnostic Injections: In some cases, diagnostic injections (e.g., epidural steroid injections) may be used to confirm the source of pain and the level of involvement.

Management: The management of disc and degenerative spinal disorders often involves a combination of conservative (non-surgical) and surgical approaches:

1. Conservative Management:

  • Pain Management: Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and pain relievers may be prescribed to alleviate pain and inflammation.
  • Physical Therapy: Specific exercises and therapies can strengthen the core muscles, improve flexibility, and relieve pressure on the affected structures.
  • Rest and Activity Modification: Avoiding activities that worsen the symptoms and adopting proper body mechanics can aid recovery.
  • Epidural Steroid Injections: These injections can help reduce inflammation and pain around affected nerves.

2. Surgical Management: Surgery is considered if conservative treatments fail or in cases of severe nerve compression, progressive weakness, or loss of bladder or bowel function. The type of surgery depends on the specific condition and may include:

  • Discectomy: Removal of a herniated disc that is pressing on spinal nerves or the spinal cord.
  • Spinal Fusion: Fusing two or more vertebrae together to stabilize the spine and alleviate pain.
  • Artificial Disc Replacement: Replacing a damaged disc with an artificial one to preserve motion in the affected segment.
  • Laminectomy: Removing part of the vertebra (lamina) to relieve pressure on the spinal cord or nerves in cases of spinal stenosis.

3. Lifestyle Modifications: Encouraging patients to maintain a healthy lifestyle, including regular exercise, weight management, and avoiding smoking, can also play a role in managing these conditions.

It’s important to note that the approach to diagnosis and management can vary based on the individual patient and the severity of their condition. A thorough evaluation by a spine specialist is necessary to determine the most appropriate treatment plan for each person.

 

Whiplash Management Principles

Whiplash and soft tissue injuries commonly result from sudden acceleration-deceleration forces, often occurring in car accidents or sports-related incidents. These injuries primarily affect the neck region and can lead to various symptoms and complications. Here’s an overview of their natural history, diagnosis, and management principles:

Natural History of Whiplash and Soft Tissue Injury: The natural history of whiplash and soft tissue injuries involves several phases:

  1. Acute Phase: Occurs immediately after the injury and can last for several weeks. Symptoms during this phase include neck pain, stiffness, headaches, and sometimes dizziness or cognitive difficulties.
  2. Subacute Phase: Lasting from weeks to months, this phase involves the gradual improvement of symptoms. However, some patients may experience ongoing pain and disability.
  3. Chronic Phase: If symptoms persist beyond three months, the condition is considered chronic. Chronic whiplash and soft tissue injuries can lead to long-term pain, reduced neck mobility, and psychological distress.

Diagnosis: Diagnosing whiplash and soft tissue injuries involves a comprehensive evaluation, which may include:

  1. Patient History: Understanding the mechanism of injury and the patient’s symptoms.
  2. Physical Examination: Assessing the range of motion, tenderness, and muscle strength in the neck and surrounding areas.
  3. Imaging: X-rays, CT scans, or MRI may be used to rule out fractures, identify soft tissue damage, and assess the severity of the injury.
  4. Other Tests: In some cases, electromyography (EMG) or nerve conduction studies may be performed to assess nerve function.

Management Principles: The management of whiplash and soft tissue injuries usually involves a combination of conservative treatments to alleviate pain and promote healing. Here are some key management principles:

  1. Rest and Activity Modification: Initially, rest may be necessary to avoid exacerbating the injury. Gradual return to normal activities, including exercises to improve neck strength and flexibility, is often recommended.
  2. Pain Relief: Over-the-counter pain relievers, such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), can help manage pain and inflammation.
  3. Physical Therapy: Physical therapy can be beneficial to improve neck function, strengthen muscles, and reduce pain.
  4. Heat and Ice Therapy: Applying heat or ice to the affected area may help alleviate pain and reduce inflammation.
  5. Cervical Collars: The use of cervical collars is generally limited to the acute phase, as prolonged use can lead to muscle weakness and stiffness.
  6. Injections: In some cases, corticosteroid injections may be used to reduce inflammation and pain.
  7. Psychological Support: Chronic whiplash injuries can lead to psychological distress. Supportive counseling or cognitive-behavioral therapy may be beneficial.
  8. Medications: In some cases, muscle relaxants or neuropathic pain medications may be prescribed for severe or chronic pain.
  9. Education and Self-Management: Providing patients with information about their condition, self-management strategies, and the expected natural history of the injury can empower them to cope better.

It is essential for individuals with whiplash and soft tissue injuries to follow their healthcare provider’s recommendations, actively participate in their treatment plan, and report any new or worsening symptoms to ensure appropriate management and recovery. In severe cases or those with persistent symptoms, referral to specialists, such as pain management or orthopedic experts, may be necessary for further evaluation and intervention.

 

Spinal Pain & Radiculopathy

Spinal pain and radiculopathy are related conditions that can cause discomfort and dysfunction in the spine and surrounding areas. Here are the broad categories for both:

  1. Spinal Pain: Spinal pain refers to any discomfort or pain that originates from the structures in the spine. It can be caused by various factors, including mechanical issues, inflammation, injury, or degenerative conditions. The broad categories of spinal pain include:

a. Non-specific Back Pain: This is the most common type of spinal pain, and the exact cause may not be identifiable. It is often related to muscle strain, ligament sprain, or minor injuries in the back.

b. Mechanical Back Pain: This type of pain is caused by abnormalities in the spine’s structure, such as herniated discs, spinal stenosis (narrowing of the spinal canal), facet joint dysfunction, or degenerative disc disease.

c. Inflammatory Back Pain: Inflammatory conditions like ankylosing spondylitis, rheumatoid arthritis, or other autoimmune disorders can lead to pain and inflammation in the spine.

d. Traumatic Back Pain: Pain resulting from acute injuries such as fractures, dislocations, or soft tissue injuries caused by accidents or falls.

e. Postural Back Pain: Discomfort or pain caused by poor posture or prolonged sitting or standing in improper positions.

  1. Radiculopathy: Radiculopathy is a condition that occurs when there is compression or irritation of a nerve root in the spine. It can lead to pain, weakness, numbness, or tingling sensations that radiate along the path of the affected nerve. The broad categories of radiculopathy include:

a. Cervical Radiculopathy: Occurs when nerve roots in the cervical spine (neck) are affected, leading to pain and other symptoms in the neck, shoulder, arm, or hand.

b. Thoracic Radiculopathy: This is less common than cervical or lumbar radiculopathy and involves compression of nerve roots in the thoracic spine (upper back). It can cause pain, numbness, or weakness in the chest or abdomen.

c. Lumbar Radiculopathy (Sciatica): Lumbar radiculopathy, commonly known as sciatica, results from compression of nerve roots in the lower back. It can cause pain, tingling, or numbness that radiates down the buttocks, legs, and feet.

It’s essential to identify the specific cause of spinal pain and radiculopathy accurately to develop an appropriate treatment plan, which may include physical therapy, medication, injections, or, in severe cases, surgery. Proper diagnosis and management by healthcare professionals are crucial to address these conditions effectively.

 

Cauda Equina Symptoms

Cauda equina syndrome is a severe condition that occurs when the nerve roots at the base of the spinal cord, known as the cauda equina, become compressed. This compression can lead to a range of neurological symptoms due to impaired nerve function. It is considered a medical emergency, and immediate medical attention is crucial to prevent permanent damage. The signs and symptoms of cauda equina syndrome include:

  1. Severe low back pain: Patients may experience intense pain in the lower back, often extending down to the buttocks and legs.
  2. Leg pain or weakness: Pain, numbness, or weakness may affect one or both legs. The pain may be sharp, shooting, or burning in nature.
  3. Saddle anesthesia: There may be a loss of sensation in the buttocks, inner thighs, and genital area, resembling the sensation of sitting on a saddle.
  4. Bladder dysfunction: Patients might experience difficulty in emptying the bladder fully or having urinary incontinence (loss of control over bladder function).
  5. Bowel dysfunction: Difficulty in controlling bowel movements, leading to constipation or incontinence, can also be present.
  6. Sexual dysfunction: Cauda equina syndrome may lead to a loss of sexual function, including erectile dysfunction in men.
  7. Weakness or numbness: In addition to affecting the legs, the condition can cause weakness or numbness in the feet and toes.
  8. Loss of reflexes: Reflexes in the lower limbs, such as the ankle reflex or knee reflex, may be diminished or absent.

It’s important to remember that cauda equina syndrome can vary in severity, and not all individuals will experience all of the symptoms listed above. If you or someone you know is experiencing symptoms suggestive of cauda equina syndrome, seek immediate medical attention, as prompt diagnosis and treatment can significantly improve the outcome and prevent permanent neurological damage. This condition is typically managed with surgical decompression to relieve the pressure on the affected nerves.

 

Spine Conditions and Management

Here are common causes, their diagnosis, and management for cervical and lumbar disc herniation, osteoarthritic disease, and spondylolisthesis:

  1. Cervical and Lumbar Disc Herniation:

Cause: Disc herniation occurs when the soft gel-like center (nucleus pulposus) of an intervertebral disc bulges or ruptures through the tough outer layer (annulus fibrosus), causing compression of nearby nerves.

Diagnosis:

  • Physical examination: The doctor will assess your symptoms, reflexes, muscle strength, and pain distribution.
  • Imaging tests: X-rays, MRI, or CT scans can visualize the herniated disc and its effect on surrounding structures.

Management:

  • Conservative treatment: Rest, physical therapy, anti-inflammatory medications, and pain relievers can often help manage mild to moderate cases.
  • Epidural steroid injections: Corticosteroids are injected near the affected nerve to reduce inflammation and alleviate pain.
  • Surgical intervention: If conservative methods fail to provide relief or if there is significant nerve compression, surgical procedures like discectomy or microdiscectomy may be considered to remove the herniated part of the disc.
  1. Osteoarthritic Disease (Osteoarthritis):

Cause: Osteoarthritis is a degenerative joint disease that occurs when the cartilage that cushions the ends of bones in joints gradually wears away over time, leading to pain and stiffness.

Diagnosis:

  • Physical examination: The doctor will check for joint tenderness, swelling, and range of motion.
  • Imaging tests: X-rays can show joint space narrowing, bone spurs, and changes in the bone.

Management:

  • Pain relief: Analgesics or nonsteroidal anti-inflammatory drugs (NSAIDs) can help manage pain and inflammation.
  • Physical therapy: Strengthening and range-of-motion exercises can improve joint function.
  • Lifestyle changes: Weight management and low-impact exercises can reduce joint stress.
  • Assistive devices: Devices like canes or braces can help support affected joints.
  • In severe cases, joint replacement surgery may be considered.
  1. Spondylolisthesis:

Cause: Spondylolisthesis occurs when one vertebra slips forward over the one below it. This can be caused by degenerative changes, stress fractures (isthmic spondylolisthesis), or congenital conditions.

Diagnosis:

  • Physical examination: The doctor will check for spine alignment and neurological symptoms.
  • Imaging tests: X-rays, MRI, or CT scans can show the degree of slippage and its impact on the spinal canal and nerves.

Management:

  • Conservative treatment: Rest, physical therapy, and anti-inflammatory medications may help alleviate symptoms.
  • Bracing: Wearing a back brace can provide support and stabilize the spine.
  • Epidural steroid injections: These can be used to manage inflammation and pain.
  • Surgery: In severe cases with significant nerve compression or spinal instability, spinal fusion surgery may be recommended to stabilize the affected vertebrae.

It’s important to note that the management of these conditions may vary depending on the severity of symptoms, the patient’s overall health, and individual factors. Always consult a healthcare professional for proper evaluation and treatment recommendations.

 

Spinal Tumor Management

Differential Diagnosis and Management of Spinal Tumors:

Spinal tumors can be categorized into two main types: primary spinal tumors (originating in the spine) and metastatic spinal tumors (secondary tumors that spread to the spine from other parts of the body). The approach to diagnosis and management varies depending on the type of tumor.

I. Primary Spinal Tumors:

  1. Benign Tumors:
    • Osteoid osteoma
    • Osteoblastoma
    • Hemangioma
    • Schwannoma
    • Meningioma
    • Neurofibroma
  2. Malignant Tumors:
    • Osteosarcoma
    • Chondrosarcoma
    • Ewing’s sarcoma
    • Multiple myeloma
    • Primary malignant lymphoma
    • Chordoma

Diagnosis:

  • Medical history and physical examination: Assessing symptoms, neurological deficits, and risk factors.
  • Imaging studies: X-rays, MRI, and CT scans to visualize the tumor’s location, size, and involvement of nearby structures.
  • Biopsy: A tissue sample is taken and analyzed to determine the tumor type.

Management:

  • Surgery: Depending on the tumor type, location, and extent, surgical removal might be the primary treatment to alleviate pressure on the spinal cord or nerves.
  • Radiation therapy: Used to treat certain tumors that cannot be completely removed or as an adjuvant treatment.
  • Chemotherapy: Mainly used for aggressive tumors and as an adjuvant treatment.
  • Embolization: Before surgery, for tumors with significant blood supply, embolization may be performed to reduce bleeding during surgery.

II. Metastatic Spinal Tumors:

Metastatic tumors in the spine typically originate from cancers in the breast, lung, prostate, kidney, or other organs.

Diagnosis:

  • Medical history and physical examination: Identifying primary cancer and evaluating its stage and severity.
  • Imaging studies: MRI, CT scans, or PET-CT scans to locate the metastases and assess their extent.

Management:

  • Treatment of primary cancer: The management primarily focuses on treating the primary cancer with surgery, radiation therapy, and/or chemotherapy.
  • Pain management: Addressing pain with medications, nerve blocks, or other interventional pain management techniques.
  • Spinal stabilization: In cases of spinal instability due to metastases, spinal instrumentation or stabilization might be necessary.
  • Palliative care: Providing support and symptom relief to improve the patient’s quality of life.

The specific treatment approach will depend on factors like the patient’s overall health, tumor type, location, extent of metastases, and the presence of neurological deficits. A multidisciplinary team, including oncologists, neurosurgeons, radiation oncologists, and palliative care specialists, is essential to create a tailored treatment plan for each patient. Regular follow-ups and monitoring are crucial to assess treatment response and address any new developments.

 

Myelopathy Categories Overview

Myelopathy refers to any disorder or condition that affects the spinal cord, resulting in neurological symptoms and deficits. Broadly, myelopathy can be categorized into the following types based on their underlying causes:

  1. Compressive myelopathy: This type of myelopathy occurs when there is pressure on the spinal cord, usually due to a herniated disc, spinal stenosis (narrowing of the spinal canal), tumors, or other structural abnormalities in the spine. The compression leads to disruption of nerve signals, causing neurological symptoms.
  2. Non-compressive myelopathy: In this category, the spinal cord is affected by non-mechanical factors, such as inflammation, infection, vascular disorders, or metabolic disturbances. Some examples include transverse myelitis (inflammation of the spinal cord), vascular malformations, and vitamin B12 deficiency-related myelopathy.
  3. Traumatic myelopathy: This type of myelopathy is a result of spinal cord injury due to accidents, falls, or other physical trauma. The severity and extent of neurological deficits depend on the level and severity of the injury.
  4. Radiation-induced myelopathy: This occurs as a complication of radiation therapy used to treat cancer. High doses of radiation can damage the spinal cord, leading to neurological symptoms over time.
  5. Degenerative cervical myelopathy (DCM): DCM is a specific type of myelopathy that arises from degenerative changes in the cervical spine (neck region). It is commonly caused by degenerative disc disease, spondylosis, and osteophyte formation, which can compress the spinal cord.
  6. Cervical spondylotic myelopathy (CSM): Similar to DCM, CSM refers to myelopathy resulting from degenerative changes in the cervical spine.

It is essential to recognize the broad categories of myelopathy because the treatment and management may vary depending on the underlying cause. Early diagnosis and intervention are crucial to prevent further neurological damage and improve outcomes for individuals with myelopathy. If you suspect you or someone else may have myelopathy, it is essential to seek medical evaluation and consultation with a neurologist or a spine specialist.

 

Spinal cord injury signs and symptoms

Spinal cord injury (SCI) refers to damage to the spinal cord, which can lead to a range of signs and symptoms depending on the severity and location of the injury. SCI can be classified into two main types: acute and chronic. Let’s compare the signs and symptoms of both.

Acute Spinal Cord Injury: An acute SCI occurs suddenly, often due to a traumatic event, such as a car accident, fall, or sports injury. The signs and symptoms of acute SCI can vary depending on the level of the spinal cord affected and the degree of injury. Common signs and symptoms include:

  1. Loss of Sensation: Reduced or complete loss of sensation below the level of injury. This may include the inability to feel touch, pain, or temperature changes.
  2. Muscle Weakness or Paralysis: Partial or complete loss of muscle function below the injury level. The extent of paralysis depends on the severity of the injury and the affected spinal cord segments.
  3. Loss of Reflexes: Absence or reduction of reflexes, such as the knee jerk reflex, below the level of injury.
  4. Respiratory Problems: Injuries above the cervical region (neck) can affect the muscles involved in breathing, potentially leading to breathing difficulties or the need for mechanical ventilation.
  5. Bowel and Bladder Dysfunction: SCI can interfere with the normal functioning of the bowel and bladder, leading to incontinence or difficulty with bowel movements and urination.
  6. Sexual Dysfunction: Depending on the level of injury, sexual function and fertility may be affected.
  7. Blood Pressure Instability: SCI can lead to problems regulating blood pressure, which can result in low blood pressure and dizziness upon standing (orthostatic hypotension).

Chronic Spinal Cord Injury: A chronic SCI occurs when the symptoms persist for an extended period, usually beyond six months after the initial injury. The signs and symptoms in chronic SCI can be similar to those of acute SCI, but there are some key differences:

  1. Spasticity: Muscle spasms and increased muscle tone are common in chronic SCI. These can be painful and interfere with daily activities.
  2. Pressure Sores: People with chronic SCI are at higher risk of developing pressure sores (bedsores) due to immobility and decreased sensation.
  3. Muscle Atrophy: Prolonged muscle disuse can lead to muscle wasting and decreased muscle mass.
  4. Autonomic Dysreflexia: A potentially life-threatening condition characterized by a sudden, severe increase in blood pressure in response to certain stimuli, such as a bladder infection or skin irritation.
  5. Chronic Pain: Many individuals with chronic SCI experience persistent pain, which can be neuropathic (nerve-related) or musculoskeletal in nature.

It’s important to note that each SCI case is unique, and the signs and symptoms can vary significantly from person to person. Proper medical evaluation, treatment, and rehabilitation are essential to manage the effects of spinal cord injury and improve the individual’s quality of life.

 

Management of Cervical, lumbar disc herniation and osteoarthritic disease

Cervical and lumbar disc herniation and osteoarthritic disease are common musculoskeletal conditions that can cause pain and discomfort. Here are their common causes, methods of diagnosis, and management options:

  1. Cervical Disc Herniation:
    • Causes: Cervical disc herniation occurs when the inner core of a spinal disc in the neck ruptures or protrudes, pressing on nearby nerves. This can be caused by aging, degenerative changes, injury, or repetitive stress on the neck.
    • Diagnosis: A physical examination, medical history review, and diagnostic imaging tests such as X-rays, MRI, or CT scans can help diagnose cervical disc herniation.
    • Management: Treatment options include:
      • Conservative approaches: Rest, physical therapy, pain medications, and muscle relaxants.
      • Epidural steroid injections: These can help reduce inflammation and relieve pain.
      • Surgical intervention: In severe cases or if conservative methods fail to alleviate symptoms, surgical procedures like discectomy or cervical fusion may be considered.
  2. Lumbar Disc Herniation:
    • Causes: Lumbar disc herniation occurs when the inner core of a spinal disc in the lower back ruptures or protrudes, irritating nearby nerves. Common causes include aging, degenerative changes, lifting heavy objects improperly, or sudden twisting motions.
    • Diagnosis: A physical examination, medical history review, and imaging tests such as X-rays, MRI, or CT scans are used for diagnosis.
    • Management: Management options include:
      • Conservative approaches: Rest, physical therapy, pain medications, and muscle relaxants.
      • Epidural steroid injections: These injections can help reduce inflammation and alleviate pain.
      • Surgical intervention: In cases where conservative methods fail or severe symptoms persist, surgical options like discectomy or spinal fusion may be considered.
  3. Osteoarthritic Disease:
    • Causes: Osteoarthritis is a degenerative joint disease characterized by the breakdown of cartilage, which leads to pain, stiffness, and reduced joint mobility. The exact cause is unknown, but risk factors include aging, obesity, joint injury, and genetics.
    • Diagnosis: Diagnosis involves a combination of medical history, physical examination, and imaging tests such as X-rays, MRI, or joint fluid analysis.
    • Management: Management options include:
      • Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics, and corticosteroid injections can help manage pain and reduce inflammation.
      • Physical therapy: Exercises, stretches, and strengthening activities can improve joint function and mobility.
      • Lifestyle modifications: Weight management, regular exercise, and using assistive devices can alleviate symptoms.
      • Surgical options: In severe cases, joint replacement surgery may be considered.

It’s important to note that the specific diagnosis and management plan may vary for each individual. It’s advisable to consult with a healthcare professional for an accurate diagnosis and personalized treatment plan.

 

Differential diagnosis and management of transverse myelopathy, metastatic disease and primary spinal tumors

Differential diagnosis and management of conditions such as transverse myelopathy, metastatic disease, and primary spinal tumors involve careful assessment, diagnostic testing, and targeted treatment approaches. Below is an overview of each condition and its management:

  1. Transverse Myelopathy: Transverse myelopathy is a neurological disorder characterized by inflammation or damage to the spinal cord that affects both sides of the cord at a certain level, causing sensory, motor, and autonomic dysfunction. It can be caused by various factors such as infections, autoimmune diseases, and spinal cord compression.

Management:

  • Initial management involves addressing the underlying cause, if known.
  • High-dose corticosteroids (e.g., methylprednisolone) are often used early in the disease course to reduce inflammation and prevent further damage.
  • Depending on the cause, specific treatments such as immunosuppressive therapy may be required for autoimmune-related myelopathies.
  • Physical therapy and rehabilitation play a crucial role in maximizing functional recovery.
  • Pain management, bowel and bladder management, and support for psychosocial aspects are also important components of care.
  1. Metastatic Disease to the Spine: Metastatic spinal tumors are cancers that have spread (metastasized) to the spine from primary cancers in other organs. The spine is a common site for metastases due to its rich blood supply and proximity to major organs.

Management:

  • The treatment approach depends on the primary cancer type, the extent of spinal involvement, and the overall health status of the patient.
  • Options may include surgery to stabilize the spine, relieve pressure on the spinal cord, or treat pathological fractures.
  • Radiation therapy is often used to control tumor growth and alleviate symptoms.
  • Systemic treatments such as chemotherapy or targeted therapy may be used if the primary cancer is responsive to these approaches.
  • Pain management and supportive care are essential for maintaining quality of life.
  1. Primary Spinal Tumors: Primary spinal tumors originate within the spinal cord, meninges, or surrounding structures.

Management:

  • Surgical resection is often the mainstay of treatment when feasible, especially for benign tumors or localized malignant tumors.
  • Radiation therapy may be used in cases where complete surgical removal is not possible or to treat residual tumor tissue after surgery.
  • Chemotherapy is sometimes utilized for certain types of primary spinal tumors, especially those that are highly aggressive or have a significant risk of recurrence.
  • Steroids may be used to reduce swelling and inflammation around the tumor, helping to relieve symptoms.
  • In some cases, targeted therapies and immunotherapies may be considered if specific molecular targets are present in the tumor.
  • Pain management and rehabilitation are crucial for maintaining function and quality of life.

It’s essential to consult with a team of healthcare professionals, including neurologists, neurosurgeons, oncologists, and other specialists, to determine the most appropriate and personalized treatment plan for each individual case.

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