February 21, 2020

 Sports Medicine & Orthopaedic Center

…surgical and non-surgical solutions for complex conditions of the spine

It has long been a hallmark of Sports Medicine & Orthopaedic Center that the practice has continued to grow with the communities it serves – both in terms of expanding availability to patients and mastery of the latest technologies and treatment options for the most complex orthopaedic conditions.

That is especially true in the case of SMOC’s two Spine Centers. In two locations throughout Southeast Hampton Roads, two spine surgeons, a non-surgical spine specialist and two interventional pain medicine specialists – all Board certified – provide state-of-the-art care for patients suffering the acute and chronic pain associated with spine conditions of every etiology.

Fellowship-trained spine surgeon David G. Goss, MD treats all aspects of spinal disorders and injuries, including degenerative and traumatic disorders of the cervical, thoracic, and lumbar spine, scoliosis, infection, and spinal deformity.

(L-R, back row): Richard D. Guinand, DO; Michael Ingraham, MD
(L-R, front row): Bryan A. Fox, MD; David G. Goss, MD; Victor W. Tseng, DO

Fellowship-trained spine surgeon Bryan A. Fox, MD is an expert in minimally invasive spine surgery techniques, having performed thousands of spinal surgeries and taught several types of highly effective and innovative spine surgery procedures.

Non-surgical spine specialist Richard Guinand, DO offers diagnosis and treatment of general orthopaedic injuries, acute and chronic back pain, workman’s compensation injuries, and non-surgical management of spinal pathology.

Victor W. Tseng, DO, Board certified in Physical Medicine, Rehabilitation and Pain Management, treats patients with a holistic approach, utilizing injections, interventional procedures and therapies.

Michael J. Ingraham, MD, a Board certified Physical Medicine & Rehabilitation Specialist, uses his knowledge to diagnose the cause of his patient’s pain or functional limitations, and helps alleviate pain and restore vitality.

These highly trained physicians are supported by Timothy Winkler, PA-C, Deniz Goss, PA-C, Scott Clingan, PA-C, Michael Mitchell, PA-C, and Eileen Scott, PA-C, all of whom have been certified by the National Commission on Certification of Physician Assistants. In addition, physical and occupational therapists are available to assist patients who need them.

Working as a cohesive team, these SMOC professionals have the knowledge, training and experience to offer real solutions for their spine patients. Both Spine Center locations feature sophisticated surgical equipment and technology, including fluoroscopy units and digital radiography.

And they are constantly alert to advances in both surgical and non-surgical treatment of spine patients, and in some cases, at the forefront. Dr. Goss recently participated in an international cervical disc replacement trial. “The purpose of the trial was to design and implant disc replacements in the cervical spine in an effort to determine whether or not short term and long term cervical disc replacement was as good as, if not better than, the gold standard treatment for cervical disc herniation, which had been a cervical fusion,” Dr. Goss says. “The Spine Center At Chesapeake was one of the US research centers. The trial went well; the patients were by and large happy with cervical disc replacement as a treatment option for cervical disc herniations, and as time has gone by, more and more insurers have recognized that that is a good long term surgical treatment for cervical disc herniations and cervical radiculopathy.”

Among the biggest points of pride for this team of spine specialists is their ability to serve more patients, more quickly – and to offer the latest medical and technological advances – in efficient, welcoming offices. As Dr. Goss says, “We’re increasingly better able to field referrals from emergency departments, family doctors and even patients themselves, in a time frame that makes our patients happy.”

“We’re increasingly better able to field referrals from emergency departments, family doctors and even patients themselves, in a time frame that makes our patients happy.”


Spine Center of Chesapeake | 501 Discovery Drive • Spine Center of Suffolk | 150 Burnett’s Way

Spine Center of North Suffolk | 3920A Bridge Rd • 757-547-5145 | smoc-pt.com

SMOC-HRPhysicians-Article-062717.indd 1 6/27/17 8:41 AM

How to Insure Your Real Estate Closing Happens on Time

By J. Mansisidor

With all the new regulations in today’s mortgage industry, closing on time has become more challenging than ever and more costly to the consumer.  Consider some of the examples below and how they can affect you and your wallet.

· Lost work or vacation time.  Taking additional days off to attend a rescheduled closing can cause financial and professional headaches.

· Increased moving expense. The moving truck may be all packed up and ready to unload – but if the closing is delayed, you may have to pay additional days of storage on that truck.

· Storage expenses. If you’re moving over a holiday weekend, you may not be able to keep your household items on the same truck. You may have to rent a temporary storage unit and/or find another company to complete the move on the new schedule.

· Increased temporary lodging expense. Imagine you’ve just sold your house and moved out, but your closing is delayed.  You may find yourself with an unexpected hotel bill.

· Frustration.  Rescheduling child care, furniture or appliance deliveries, contractor services (flooring, painting, etc.) and utility activation are but a few examples of the hassles that delayed closings cause.

The above scenarios may seem extreme, but they happen all the time.  So how do you avoid these situations?  It starts with having a knowledgeable, experienced, ethical and diligent Loan Officer.  When you begin shopping lenders and interviewing loan officers, ask how they will ensure that your loan closes on time.

Lenders aren’t permitted to require supporting documentation from an applicant during the pre-qualification stage.  However, providing your supporting documentation will allow the Loan Officer to reference that vital information on your Pre-Qual Letter.  The following are standard requirements:

· Most recent (two years) tax returns (personal and business, if applicable)

·  Most recent (two years) W2’s, 1099’s, K1s  (if applicable)

· Most recent two months paystubs (or employment contract, if applicable)

· Most recent (two months) checking/savings/retirement/ investments statements (all pages)

·  Photo ID

If you’re a Non-Permanent Resident Alien, be sure to ask if your qualification is still valid.  And if you’re a first time home buyer, don’t forget to ask about any programs available to you.

The more questions you ask or the Loan Officer brings up at the beginning of the process, the more likely you will close on time – and the more likely you’ll avoid any of those unpleasant scenarios!

J. Mansisidor is a Senior Loan Officer with Fulton Mortgage Company, a division of Fulton Bank, NA.  www.fultonmortgagecompany.com

News from the AMA

CHICAGO – With increasing evidence that physicians and physicians-in-training are facing increased burnout, depression and suicide, the AMA adopted policy today aimed at improving physician and medical student access to mental health care. The new policy would help reduce stigma associated with mental health illness that could unfairly impact a physician’s ability to obtain a medical license and impede physicians and medical students from receiving care.

“We are concerned that many physicians and physicians-in-training are dealing with burnout, depression and even suicidal thoughts, and we find it especially concerning that physicians have a higher rate of suicide than the general population. In fact, in March the AMA partnered with leading CEOs in the health care industry and declared that physician burnout is becoming a public health crisis that needs to be addressed,” said AMA Board Member and resident Omar Z. Maniya, M.D. “Today’s policy builds on the AMA’s current efforts to prevent physician burnout and improve wellness. We are committed to supporting physicians throughout their career journey to ensure they have more meaningful and rewarding professional experiences and provide the best possible care to their patients.”

The policy calls on state medical boards to evaluate a physician’s mental and physical health similarly, ensuring that a previously diagnosed mental health illness is not automatically considered as a current impairment to practice. Additional policy calls for researching and identifying the risk factors for and rates of depression, burnout and suicide among medical students, including encouraging medical schools to confidentially gather and release this information from its students who authorize consent.

Through the AMA’s Professional Satisfaction and Practice Sustainability initiative launched in 2013, the AMA is partnering with physicians, leaders, and policymakers to reduce the complexity and costs of practicing medicine so physicians can continue to put patients first. As part of this work, the AMA’s Steps Forward program offers a series of practice transformation modules designed to improve the health and well-being of patients by improving the health and well-being of physicians and their practices.

The AMA has also adopted numerous policies over the past several years to reduce physician burnout and create the medical school of the future to ensure a healthier practice environment for physicians and close the gaps that exist in medical education to improve the health of the nation.

Responding to Physician Burnout, AMA Adopts Policy to Improve Physician and Medical Student Access to Mental Health Care

Maintaining Vision for Geriatric Patients

By Kapil G. Kapoor, MD

Maintaining vision for geriatric patients is a component of their very basic health.  As a retinal provider, I admit to ample bias in suggesting that visual health is truly integral; in spite of my confessed partiality, the data does in fact support this!  Aging patients with severe vision loss have significantly increased risk of falls and fractures, increasing the likelihood of hospital or nursing home admissions and/or disability.  Basic activities critical to daily health can become challenging with even moderate visual impairment, including identifying medications, bathing, dressing, or safely navigating familiar areas like the home or the grocery store.  It’s easy to see why there is significant increase in depression associated with visual impairment with aging.

Of the vision problems that beset older patients, age-related macular degeneration (AMD) is by far the most prevalent, and the greatest threat to these patients. AMD affects more than 10 million people in the US, and as our population ages, that number is expected to increase significantly. Establishing a basic familiarity with this condition will enable all of us to protect our patients.

AMD deteriorates the macula, which is responsible for central vision and focusing on fine detail.  Visual decline corresponds to the stages of dry AMD that often progress slowly, but can convert unpredictably to the potentially more devastating wet AMD.

In early dry AMD, characterized by small drusen (small yellow deposits made of lipids), patients may experience slight blurry vision centrally, or metamorphopsia (noticing small wavy lines when trying to focus on a straight line.)  In intermediate dry AMD, these symptoms become more pronounced, with many patients experiencing fatigue when reading, often closing one eye due to a slight asymmetry of disease.  In advanced AMD, patients develop atrophy, typically where drusen developed. Histologically, this corresponds to cell death, and functionally translates to gaps in vision. In the earliest stages of atrophy, patients experience loss of contrast, increased glare, and often describe skipping letters when reading. In the most advanced stage, atrophy becomes confluent throughout the central macula and patients can become legally blind.

The typical progression through the stages of dry AMD is slow, occurring over several years to decades. However, approximately 10-15 percent of patients with dry AMD can convert to the wet form of AMD, where a new vessel forms right in the center of vision, potentially leading to severe vision loss over weeks or even overnight.  Our best understanding supports that chronic oxidative stress in this aging macula creates a feedback demand for more oxygen, which engenders this harmful vessel to recruit more oxygen. Rather than actually recruiting any oxygen, this new vessel just bleeds and starts making a blind spot in the central visual field. Fortunately, we have developed treatments in the form of intravitrael injections of anti-VEGF for the wet form of macular degeneration. These treatments play superb defense – with over 95 percent of patients avoiding further severe vision loss after timely treatment.  These treatments also play better and better offense, with approximately half of patients enjoying a significant improvement in vision after converting to the wet form of AMD.

Kapil G. Kapoor, MD  is a Board certified ophthalmologist specializing in vitreoretinal surgery.   wagnerretina.com


Advance Directives

A Safe Haven when Making Medical Decisions
By William Charters and  Jeffrey Kiser

Advance Medical Directives are the most prevalent guidance documents seen by hospitals and medical professionals nationwide.  In 1990, Congress passed the Patient Self-Determination Act, requiring healthcare providers to inform patients of their right to make predetermined decisions regarding their medical care.  Since then, advance directives have consistently increased in popularity and are accepted in all fifty states.  Between 2000 and 2010, patients 60 years or older who died with an Advance Directive rose from 47 to 72 percent.

Often, healthcare professionals are tasked with interpreting and implementing a course of action based on incomplete or misunderstood parameters contained in a “legal document”.  Unfortunately, many of these directives were drafted by individuals without a thorough understanding of the medical, or legal, implications of the verbiage they have chosen – resulting in documents that are subject to misinterpretation or simply ineffective.

Among the first hurdles healthcare professionals face are conflicting laws between states, since not each follows the same processes or mandates the same requirements for a directive.  It is important, therefore, for healthcare providers to be cognizant of their own state’s laws regarding acceptance and enforcement of foreign directives. While the predominant standard is to honor a validly executed directive from another state, not all states follow this protocol.  Equally as impactful is the difference as to the powers that may be granted to the Healthcare Proxy.  Virginia, for example, does not recognize the Death with Dignity Act (or any other physician-assisted end of life program), but nearby Washington DC does.

Validly executed Advance Directives can not only provide evidence of a patient’s intent, but also lessen the degree of family/physician uncertainty when difficult decisions need to be made.  Proactively making end of life decisions can relieve family members of guilt and prevent intrafamilial conflict.  The provisions of a valid Advance Directive are virtually unassailable by family or physician and provide a safe haven for the decision-making process.

While these rules and the rest of the Health Care Decisions Act offer aid and guidance, they are most effective when implemented proactively. The time to inquire about the status of a patient’s Advance Directive or to provide resources for such a discussion with friends and family is early in the process, even as soon as the initial intake. The time to educate yourself and your practice on the many facets of Advance Directives and establish a protocol for how you will determine if an Advance Directive exists for a given patient and how to insure it is valid and enforceable, is now.

Next time:  What if you, as a treating physician, believe that the treatment demanded by patient or decision maker is inappropriate?

William Charters

Jeffrey Kiser

William Charters, a member of Goodman Allen Donnelly, focuses his practice on providing advice, risk and litigation support to healthcare.  Jeffrey Kiser, an Associate with GAD, provides detailed and targeted guidance to individuals and groups for their end of life and asset protection plans.  goodmanallen.com

Geriatrics and Palliative Medicine

Two Sides of the Same Coin


When our Physician Advisory Board suggested topics for our 2017 publication year, an update on geriatrics/palliative medicine was among the most frequently requested.  At first, it seemed there was enough difference between the two specialties to warrant a separate article for each – but as we got into the research, and began interviewing experts, the more it became apparent that as distinct as they are, they are also inextricably linked.

Marissa Galicia-Castillo, MD

As it turns out, one of the most striking connections between geriatrics and palliative medicine is the local and indeed national shortage of physicians trained in these disciplines.  In 2011, the Baby Boomers began turning 65, and that trend isn’t anticipated to abate for some time.  “By 2030, it’ll reach maximum impact,” says Marissa Galicia-Castillo, MD, Professor of Geriatrics and Section Head of Palliative Medicine at EVMS. “The number of geriatricians is nowhere near the number needed to take care of all those patients.”  An article in the January 25, 2016 edition of The New York Times supports that assertion: “According to projections based on census data, by the year 2030, roughly 31 million Americans will be older than 75, the largest such population in American history. There are about 7,000 geriatricians in practice today in the United States. The American Geriatrics Society estimates that to meet the demand, medical schools would have to train at least 6,250 additional geriatricians between now and 2030, or about 450 more a year than the current rate.”

Laura Cunnington, MD

The same holds true in palliative medicine, says Laura Cunnington, MD, a hospice and palliative medicine specialist with Riverside Health System:  “There are simply not enough of us to do all the palliative care that needs – and will need – to be done.”  An August 20, 2015 article in The New England Journal of Medicine, sets out the numbers:  “…the number of palliative care specialists falls far short of what is necessary to serve the population in need. A 2010 study estimated that 6000 to 18,000 additional physicians are needed to meet the current demand in the inpatient setting alone.”

Unfortunately, these statistics are unlikely to improve.  It’s understandable:  both geriatrics and palliative medicine are among the lowest-paying specialties in medicine.  And since geriatric patients are covered for the most part by Medicare, that program’s low (and slow) reimbursement rates make sustaining a practice difficult.

Daniel Dickinson, MD

Thus, many of the practitioners in these fields consider the rewards of long-term, rich relationships with patients an incentive.  And in fact, many physicians come to geriatrics and/or palliative care medicine after practicing in other areas for many years and experiencing these long term relationships, explains Steven Griswold, MD, a geriatrician and palliative medicine physician with Bon Secours.  “We’re trained in medical school basically to think that all problems are fixable with the right medications and treatment,” he says, “but the longer we’re in practice, the more we learn that that’s not the case, so that’s one of the reasons people with more experience tend to gravitate to these fields.”

And, he adds, “It may not be that there’s so much a lack of interest as a lack of training spots to train people to meet the demand.” At Eastern Virginia Medical School, Dr. Castillo says, “We’re teaching geriatric concepts to everyone.  We’re still trying to grow geriatricians, but the big focus now is to train other physicians to care for older patients. There is now a required geriatrics rotation students go through in their third year, and there are geriatrics electives in the fourth year.”  In addition, internal medicine residents do a month with Dr. Castillo and her colleagues, and EVMS welcomes residents from the Naval Medical Center at Portsmouth to participate as well.

Nakeisha R. Rodgers, MD

For students at EVMS, Dr. Castillo says, there are six sessions offered throughout the third year, one two-hour session every eight weeks, on a variety of topics.  Her next session will concentrate on how physicians deal with patient loss.  “It’s not in the textbooks,” she says, “but it’s something these students are going to have to deal with.”

“Who You Calling Old?”

There’s not always an easy way to suggest to patients that they have become geriatric, or indeed, even an agreed upon age in which someone becomes a geriatric patient.  “Everyone would probably say 65,” says Daniel Dickinson, MD, Medical Director of Clinical Integration with Sentara Medical Group, “but there are plenty of 65-year olds who are healthy, and there are some younger than 65 who have functional or cognitive challenges.  So age is less a criterion than behavioral or functional capability.”

Nakeisha R. Rodgers, MD, is an internal medicine physician with JenCare Senior Medical Center in Norfolk.  She sees her 400+ patients on a regular basis, far more often than the two-or-three times a year typical of many practices.  “Caring for geriatric patients isn’t a one-size-fits-all situation,” Dr. Rodgers says.  “You can’t approach all seniors with the same mindset.  I have 80-year old patients who can run circles around some of my 65-year olds.”

Steven Griswold, MD

There are key elements to aging, however, to which Dr. Rodgers is keenly attuned.  “Dementia, falls, incontinence, these are more common in geriatric patients,” she says.  While dementia gets a lot of attention, she feels one of the biggest problems of all for this age group is polypharmacy:  “Some of these patients are taking so many medications, it’s like their own little pharmacy in their medicine cabinets.  The prescriptions may be years old, or may have been borrowed from a friend – often they don’t know why they’re taking the pills.”  Dr. Castillo agrees: “Some of these patients are taking as many as 40 different prescriptions.  Their entire day is nothing but taking medicine.”  An example of a seemingly innocuous medication – “safe, because it’s over the counter” – is Benadryl.  “Most people don’t realize it can cause delirium, confusion, urinary retention and other side effects.”

The highest incidence of polypharmacy is found in nursing homes, according to the National Institutes of Health, which also found that “the burden of taking multiple medications has been associated with greater health care costs and an increased risk of adverse drug events, drug-interactions, medication non-adherence, reduced functional capacity and multiple geriatric syndromes.”

David Murray, Executive Director of the coalition

Yet one of the most difficult conversations a physician can have with geriatric patients is trying to convince them to relinquish these unnecessary and sometimes harmful drugs.

In these instances, and many others in dealing with aging patients, Dr. Rodgers tries to enlist the help of a caregiver.  “When you’re talking to an 80-year old patient, giving her a list of things to do and when to do them, you can’t always be sure she’s comprehending, or will remember it well enough to tell it back to you, let alone a family member,” she says.  “So I’ll often call the caregiver and relay the information at the same time.”  When the patient has no such support system, Dr. Rodgers relies on the social worker JenCare retains on staff, or to Social Services.  “There are many resources available to these patients, and to the physicians who care for them, but they aren’t always well known,” she says.  “Social Services is one of these vital resources.”

Dr. Dickinson agrees wholeheartedly.  “One of my wishes is that over time, we have stronger systems in place to communicate and collaborate across our medical neighborhoods for geriatric patients, so we not only have PCPs and geriatricians co-managing our patients’ needs, but also connecting them with other services and professionals—medical and non-medical—within the community,” he says, adding, “Our Clinically Integrated Network, Sentara Quality Care Network, is one such vehicle for that type of collaboration, as it connects independent/private practice and employed physicians and a hospital or health system to improve the quality and delivery of health care services for patients.”

Talking to patients about palliative care.

One of the biggest misconceptions about palliative care is that it’s the same as hospice, Dr. Griswold says, and it’s important to assure patients that this isn’t the case.  “Palliative care is broader, in that we can apply the same principles of improving symptoms, maximizing comfort and quality of life to patients at any stage of a serious illness.”

Some physicians and other health care providers, and most patients, still don’t fully understand all the elements of palliative medicine, Dr. Cunnington believes.  “We’re still the newest medical specialty,” she says, with Board certification only since 2008.  “But there are significant differences between palliative care, comfort care and hospice.”  Hospice, Dr. Cunnington says, is fairly well understood by both physicians and laypeople: system-based care for patients within the last six months of their lives.  It’s quality-of-life, not curative, treatment.

She explains: “Comfort care is like hospice, but patients don’t have to be on hospice to receive comfort care.  We can provide comfort care to patients who decide they don’t want any more active treatment.  Palliative care is broader – it can be provided at any point in the disease process.  From the time of the diagnosis of the illness, the patient can have palliative care, even if that patient is going to get better. And when the illness is over, and the majority of the patient’s symptoms have abated, there are residual symptoms that can be helped with palliative care.”

Palliative care can be rendered in the hospital, in a nursing facility, at home or in an outpatient center like the Outpatient Palliative Care Clinic, which opened in December 2016 at Bon Secours Mary Immaculate Hospital in Newport News.  “Outpatient care is probably the area of palliative medicine that’s expanding most rapidly,” Dr. Griswold says, “in attempt to serve those patients who aren’t at the end of their lives, but who are living with chronic illness or being actively treated for a life-limiting disease, who can benefit from better care coordination and symptom management while they’re receiving these other services in the outpatient setting.”

When Dr. Cunnington joined the staff of Riverside Health System, palliative care was offered to inpatients in the main hospital.  Today, that care is available at Riverside hospital locations, as well as its nursing homes and complex care centers throughout the middle and upper peninsula.

Still, these doctors all agree, primary care physicians and specialists alike aren’t aware of what palliative medicine can bring to patient care.  “In the hospital, doctors who’ve seen the value of what we do, like to send patients home with home-based palliative care,” says Dr. Cunnington, “but out in the community, it’s been slower to catch on, mostly because these other doctors don’t have that level of experience with palliative care.”

And because there aren’t enough palliative medicine specialists to provide all the care that’s needed, “our focus is on education, to ensure that all of our students have a basic understanding,” Dr. Castillo says.  “That’s why every EVMS student is exposed to both geriatrics and palliative care before they graduate.”

“One of the goals for our specialty is to serve as a resource to train people to do primary palliative care in terms of better symptom management, better ability to conduct goals-for-care discussions,” Dr. Griswold says.  And that, he emphasizes,

is the most basic level of primary palliative care: a candid, thoughtful discussion with patients about their goals for care.  The question is, when should that discussion begin?

“No doctor has a crystal ball,” Dr. Rodgers says.  “We don’t always know how long our patients will live.  Thus, initiating that discussion before they are in crisis is far superior to waiting until there’s an admission to the emergency room or the hospital.”

And, she says, there are resources to help physicians with the discussion, which many find challenging or uncomfortable.

As You Wish – a unique community resource for physicians, caregivers and patients alike.

Students aren’t trained to have these discussions in medical school, so it’s no wonder they can seem difficult or even uncomfortable to physicians. In a typical 15-minute visit, when there are multiple medical issues to be dealt with (more with aging patients), introducing a sensitive topic like a patient’s wishes and goals for treatment when illness or infirmity strike down the road is impractical, even impossible.  And until January of 2016, these conversations weren’t reimbursed by Medicare.

In 2011, the four major hospital systems in Hampton Roads – Bon Secours, Chesapeake Regional Healthcare, Riverside Health System and Sentara – recognized that the majority of advance care discussions occurred when the patients were in crisis.  In a remarkably visionary step, these four competing systems came together to look for a community partner to engage the public in a variety of platforms to introduce the importance, steps and benefits of advance care planning.  After years of strategic planning, the Advance Care Planning Coalition of Eastern Virginia was established in 2014.  The Coalition launched the As You Wish Advance Care Planning program as the unified community education brand later that year.

The As You Wish initiative also serves as an extension for area physicians who have neither the time nor the training to initiate these discussions, and may not have office staff certified to conduct them.  “As You Wish has the joint goal with practitioners of educating patients and easing the burden on the care providers,” says David Murray, Executive Director of the coalition.  “Unfortunately, many area practitioners aren’t yet aware of the resources the coalition can offer.”

The program is not a substitute for physician-patient discussions, but rather a complement to the need to have these discussions – early and often.  “Crisis isn’t the time to understand the planning steps leading to the fact that one day, we’re all going to die,” Murray says.  “Modern medicine is about curing, healing and fixing.  In 2011, it typically didn’t include discussions about that time when curing, healing and fixing weren’t possible.”

Murray is candid about the challenge: “People don’t want to talk about end-of-life issues.  Medicine today is about living longer and better.  We’ve taken death out of the picture.  People aren’t taking the time to consider their personal goals and wishes about the care they’ll receive.  “That’s the irony,” he says.  “As independent and control-oriented as we become as adults, we abdicate that independence at this time of life.”

So he takes the message about advance care planning to people where they are: at community centers, in their homes, in a comfortable setting like a restaurant, if necessary, in a hospital – wherever they’re receptive to learning.  He talks about the ways in which having an advance care directive can help them maintain their dignity, and ensure that they receive only the care they want.  He explains how it can protect fragile relationships.  And he notes that currently, fewer than three out of every 10 adults has an advance care directive.  In the first year of the coalition, the goal of a three percent increase was achieved – a goal As You Wish hopes to replicate.  In addition to having the directive, Murray stresses, it’s important that it’s in the patient’s chart where every physician, caregiver and hospital have access to it.

But, he emphasizes, “Our focus is always on the importance of starting – and finishing – the conversation before the all-important documentation becomes necessary.”

If there’s a common thread that ties geriatrics and palliative medicine together, it’s the need for honest, candid conversation between doctor and patient, and between patient and caregivers.  As Dr. Rodgers says, there are many resources available to anyone dealing with these issues.

For more information about the resources and services As You Wish provides, visit asyouwishvirginia.org.

Advanced Therapeutics for Overactive Bladder…third line therapy for men and women of all ages

By Jennifer Miles-Thomas, MD and Jessica DeLong, MD


The American Urological Association estimates that about 33 million Americans suffer from overactive bladder (OAB) – 30 percent of all men and 40 percent of women.  It’s one of the vexing conditions associated with aging, but OAB is prevalent in the general population as well.  A significant amount of OAB is never diagnosed or treated because many patients are embarrassed to reveal their symptoms to their family physician.

Symptoms of an overactive bladder can be caused by any number of conditions, including neurological disorders, diabetes, urinary tract infections, certain foods or drinks, or tumors.  In men, OAB can be caused by an enlarged prostate. No matter the etiology of the condition, OAB can have a tremendous negative impact on quality of life.

In the past, large surgeries like augmentation cystoplasty were performed to increase the capacity of the bladder when patients failed conventional treatments such as anticholinergic medications.  Today, however, advances in third line therapies are providing relief for patients of all ages, and those surgeries are less frequently performed.

OnabotulinumtoxinA (Botox) – The same substance that is used by cosmetic and plastic surgeons to smooth facial lines and wrinkles is injected directly into the bladder muscle, where it calms the nerves, helping block the signals that trigger overactive bladder.  Once relaxed, the bladder can hold more urine and is less overactive, eliminating the need for multiple trips to the bathroom.  Each Botox treatment lasts on average six months.

Percutaneous (or posterior) tibial nerve stimulation (PTNS) – Understood by patients as similar to acupuncture, PTNS is the least invasive form of neurostimulation.  The procedure targets the sacral plexus, which regulates bladder function, through an electrical pulse delivered via the tibial nerve.  The low electrical current calms down the bladder and allows it to retain more urine.  Initial PTNS generally consists of 12 quick, weekly treatments.  Patients then require less frequent maintenance treatments to maintain efficacy.

InterStim – After an in-office test of a temporary system to determine efficacy, this treatment involves the implantation of a neurostimulator next to the sacral nerves just above the tail bone.  The patient can adjust the stimulator as needed with a remote, applying personal programs, and can control the level of the stimulation by holding the programmer over the neurostimulator.

Studies have shown that these therapies are greater than 80 percent effective, and are offering new hope to patients with the sequelae of overactive bladder.  As the technology continues to improve, patients who were afraid to leave the proximity of their home bathrooms are increasingly able to enjoy a more normal lifestyle.

Jessica DeLong, MD

Jennifer Miles-Thomas, MD

Jessica DeLong, MD and Jennifer Miles-Thomas, MD are co-directors of the Center for Health and Wellness at Urology of Virginia.  www.urologyofva.net

The Evolving Use and Benefits of Cementless Total Knee Replacements

By Jon H. Swenson, M.D., F.A.A.O.S., Hampton Roads Orthopaedics & Sports Medicine


Cementless total knee replacements have gained popularity in the past five years, thanks to improved technology that allows for even more precise fit and enduring adhesion.

Using advanced 3D printing systems and lasers, we are able to shape titanium powder into rough, porous metal surfaces. The metal surface has a rough texture which helps it to “stick” to the bone when impacted. A patient’s natural bone then can grow into those microscopic, sponge-like holes on the prosthetic’s coating over time, creating a strong, long-term bond.

As is the case with cemented joints, surgeons also carefully shape natural bone so the prosthetic fits snugly. In addition, four pegs and a central stem anchor the implant in place during bone growth into its complexly patterned surface, which generally occurs over about six weeks.

The basic difference is this: cemented bonds, which affix with a fast-drying acrylic polymer, are strongest immediately after surgery, but they often break down and weaken after a decade or two. Non-cemented joints – also referred to as press-fit implants – are designed to gain strength over time and ultimately form a more permanent bond.

While data is still emerging, research to date has shown success rates at least equal to – and possibly greater than – cemented prostheses. A 2012 study, for example, found 96 percent survivorship after 18 years, longer than the 10- to 15-year rate generally quoted to our knee replacement patients. That can be particularly beneficial for younger or more active patients.

Cementless prostheses often reduce time in the operating room by 15 or 20 minutes, as surgeons don’t need to wait for bone cement to set. That can potentially trim costs and reduce uncommon complications such as blood loss and infection.

The non-cemented approach also tends to involve less bone loss should a patient ever require revision surgery, as any cement debris in surrounding tissues must be removed to prevent irritation and inflammation.

All that said, cemented joint replacements have been used successfully for many years, and they do remain the best choice for about 10 percent of my patients. Most of those have bones weakened by osteopenia, osteoporosis, vitamin D deficiency, rheumatoid arthritis or some other form of connective tissue disease.

In these cases, which frequently involve more elderly patients, natural bone likely would not effectively affix to, or grow into, the artificial joint. Bone cement, on the other hand, can immediately anchor deficient bones to the prosthesis.

In my experience, post-operative pain levels and recovery time are similar for patients who receive both types of replacement joints. Surgeons also are developing hybrid solutions that use both cementless and cemented components in different parts of the knee joint.

I expect the use of cementless knee replacements to continue to expand as improved fixation methods. The same is true of hip, shoulder and possibly other types of total joint surgeries.  Over time, we also will gain better insights into long-term results, along with more specific indications and contraindications, for these promising technologies.

Dr. Swenson has practiced orthopaedic surgery on the Peninsula since 1991. He completed orthopaedic surgery training at the world-renowned Campbell Clinic in Memphis, Tenn., and specializes in sports medicine and minimally invasive joint replacement of the knee, hip and shoulder. www.hrosm.com.

For Back Pain, Physical Therapy Plays Key Role in Prevention and Rehabilitation

By Brian Hoy, PT, CMP, FMS-C


The goal of any physical therapist is straightforward: to help patients gain or regain the highest degree of quality of life.

Meeting this goal involves both prevention and rehabilitation.  And while our human body is both fragile and resilient, one area that’s frequently a source of discomfort is the back.  In addition to discomfort and frustration, back pain also brings high financial cost and is a significant cause of missed work.

A University of North Carolina study found that “that more than 80 percent of Americans will experience an episode of low back pain at some time in their lives and that total costs of the condition are estimated at greater than $100 billion annually, with two-thirds of that due to decreased wages and productivity.”

Further, according to the American Physical Therapy Association (APTA):

• 61% of Americans experience low back pain.

• In a survey, 69% of respondents indicated that low back pain affects their daily lives. Most affected: exercise, sleep, and work.

• Three out of four women take over-the-counter or prescription medication to treat the symptoms.

• 31% of men and 20% of women report that low back pain affects their ability to work.

So what role can physical therapy play in helping address this global epidemic? 

The first is cost: the APTA states, “Early physical therapy can be cost-effective treatment for low back pain,” adding that “a recent study suggests there’s no reason to delay physical therapy that might relieve pain.”

Another benefit of physical therapy is the avoidance of medication and opioids. 

A study published in JAMA Internal Medicine (“Worsening Trends in the Management and Treatment of Back Pain”) indicates that “physicians often over-treat back pain, with increases in use of imaging, narcotics, and referrals to other physicians. The over-treatment leads to unnecessary expenses,” according to the APTA.

Of course, sometimes back and spine problems persist and a doctor may advise that surgery is required. Even these individuals, though, can benefit from physical therapy – before the surgery occurs.

A study published in the journal Spine (Preoperative pain neuroscience education for lumbar radiculopathy), followed a group of individuals who were undergoing surgery of the lumbar spine.  “Prior to surgery, half of the participants received typical pre-surgical care.  The other half received specialized education from a physical therapist on the neuroscience of pain.  The researchers followed up with the participants one year after surgery and found the group who received a single, educational session from a physical therapist viewed their surgical experience much more favorably, and utilized 45% less health care expenditure following surgery.”

Of course, physical therapy cannot solve all back pain issues. However, given the number of people this problem afflicts – and given associated costs, missed work, and frustration – inquiring about the role PT can play in both prevention and rehabilitation can pay significant dividends.

Brian Hoy, PT, CMP, FMS-C serves as Vice President of Clinical Services and Director of the Clinical Excellence Team at Pivot Physical Therapy.

Riverside Neurological & Spine Institute

(L-R) Jackson B. Salvant, Jr, MD; William McAllister, IV, MD; Dean Kostov, MD; Javier Amadeo, MD and Brian Farrell, MD, PhD

A multidisciplinary program focusing on complex conditions of the brain and spine.


The relationship between the brain and spine is undeniably one of the most delicate and complex in the human body.  The smallest misalignment in the spine or misfire in the brain – unless identified and treated by the most well trained and highly skilled neurosurgeon – can cause excruciating pain, debilitating loss of function and even death.

The surgeons of Riverside’s Neurological and Spine Institute have the knowledge, training and skill to treat these potentially devastating conditions with exquisite precision.   Their combined years of surgical experience and mastery of 21st century technologies prove once again that Riverside Health System is providing the highest level of health care to the people of the Virginia Peninsula and beyond.

Despite their surgical expertise, these five neurosurgeons agree that surgery should always be the last resort.  “Our job is to try to keep patients out of the operating room,” says Dr. Dean B. Kostov, “so that by the time the patient and I decide together to proceed with surgery, we know there’s nothing else that could have been done, and we know that the benefits will outweigh the risks.”

No surgery is without risk, but when conservative treatment fails or is inappropriate, or when patients no longer respond to medical therapies, surgery can be the correct choice.  With the aid of the latest three-dimensional image guided, computer assisted navigation , these surgeons are able to perform complex and delicate, minimally invasive procedures for the most complicated cases, with results equivalent to those found in major university medical centers.

Unprecedented precision when micro-measurements count.
The use of a bi-plane digital x-ray in treating brain aneurysms is one example. Because in their earliest stages, aneurysms are asymptomatic, often the first sign of trouble is when they rupture.  Between 30 and 50 percent of patients with a ruptured aneurysm die, or are left with significant disability; but when patients receive timely treatment, they can survive and even thrive.

Timely treatment used to mean craniotomy.  Today, utilizing the bi-plane digital xray for guidance, Riverside surgeons insert a flexible catheter into the femoral artery, and thread it up through the neck into the brain; they can then insert a smaller catheter into the aneurysm through which progressively smaller platinum coils can be introduced until the aneurysm is tightly packed, thus depriving the aneurysm of its blood supply.  The patient, headache and symptom free, goes home the next day.

The extraordinary high-resolution visualization of the brain’s vascular network made possible by the imaging technology is assisting surgeons in managing stroke cases as well.

Stereotactic radiosurgery – still the gold standard for brain tumors and abnormalities.
The concept of stereotactic radiosurgery, introduced in 1951 by Dr. Lars Leksell, has an impressive track record in treating brain tumors and other abnormalities.  No other non-invasive treatment method in the field has greater clinical acceptance anywhere in the world.  Riverside’s Neurological and Spine Institute employs two modalities that deliver stereotactic radiosurgery, both of which focus very high beams of radiation on a small part of the body.

Gamma Knife Perfexion – treatment for tumors in the brain

Gamma Knife – from the 4C to the Perfexion™
In 2015, after successfully utilizing the 4C model for nearly a decade, Riverside’s joint venture with University of Virginia and Chesapeake Regional acquired the latest iteration of the Gamma Knife: the Perfexion, then one of only 300 in the world.

The Gamma Knife delivers a single, finely focused, high dose of radiation to its target within the brain, causing little or no damage to surrounding tissue. The 4C allowed the surgeons to treat abnormalities measuring less than three centimeters, or one inch in diameter.  The Perfexion system expands the treatable volume through an automated, multi-source collimator, and dramatically streamlines workflow.  System benefits include faster set-up and treatment delivery to one or more tumors in a single session.

The Perfexion’s unique collimator is a permanent device divided into moveable sectors, ensuring superior conformity, accuracy and dosimetry while reducing residual dose to unintended areas. Integrated and intuitive treatment planning software facilitates creation of even the most complex plans (e.g., a donut-shaped dose distribution) by configuring composite shots that avoid overexposure to critical structures. Perfexion offers 98 percent reliability and unrivalled accuracy, guaranteed to 0.50mm.

“When the Gamma knife was invented, it was really meant to treat the center of the head, deep in the brain,” says Dr. William H. McAllister.  “As it’s evolved, it’s become more of a primary modality for dealing with metastatic brain tumors. The problem with the design of the original unit was a lot of metastatic brain tumors occur right out on the periphery of the head, so if you had a tumor on the left and another on the right, with the old unit you could have a hard time getting to both of them: moving the head, you would actually bump into the actual machine and there would be an actual direct physical limitation as to how far you could move the patient to one side or the other in order to treat these tumors in multiple locations.  The Perfexion was designed with that in mind.”

With years of experience behind them, Riverside surgeons are always finding ways to fine tune these procedures, making them more patient friendly.  They have recently developed a new technique that allows them to preplan the treatment, using the patient’s diagnostic MRI.  “We’re now able to do all the planning before the patient even comes to the Gamma Knife unit,” Dr. McAllister says.  “where we used to have to put the head frame on the patient and sit at the computer for a half hour to plan, that’s no longer the case.  The time the patient has to wait to begin the procedure is reduced, which in turn reduces anxiety.”

Further, with the Perfexion, the risks associated with open surgery are eliminated; because no incisions are required, the procedure can be performed using only local anesthesia.  Treatment can be planned and programmed within a matter of an hour or two, requiring fewer MRI sequences.  Treatment time is significantly less than conventional radiation and other delivery systems – often just one or two sessions – and because it’s most often done on an out-patient basis, most patients return to normal activity within 24-hours.

Synergy S

From Synergy-S to Varian – improved radiotherapy delivery.
For cancers of the spine (as well as neck, chest, lung, prostate, pancreas and liver) and for tumors in the brain not accessible to the Gamma Knife, Riverside neurosurgeons have had remarkable success with the Synergy-S delivery system, which combined a linear accelerator with an on-board CT scanner to visualize internal structures, including boney and soft tissues, in three dimensions prior to treatment.

Bi-plane technology – 3D imaging of the brain used to treat aneurysms

However, advances in administering radiotherapy to these areas have enabled improvements in technologies, and Riverside has kept up, always seeking a safer, faster, more efficient delivery.  The Neurological and Spine Institute is in the process of upgrading the Synergy-S to an entirely new and different system: as this is being written, the vault is being built to house the Varian EdgeTM system.  The new Edge system has a real-time system architecture that enables a high level of synchronization between treatment planning, imaging, patient positioning, motion management, beam shaping, and dose delivery.  The Edge will allow for tighter radiation dose gradients, resulting in better targeting and dose conformity of tumors with less radiation dose to normal tissues.  Patient imaging and tumor tracking are also improved. The new upgraded Varian Edge system will continue to improve the success the neurosurgeons have seen over the past decade for intracranial and spine tumors.

Safer and more effective modalities to treat an aching back.
Among the reasons back surgery has such a negative reputation are the traditional methods of performing it.  As open procedures, such operations required a long incision in the back that would allow the surgeon to cut down to the fascia and then peel away the muscles of the spine on both sides to expose the area needing surgical intervention.  The unfortunate sequelae of open surgery were muscular damage and reduced circulation.  Patient recovery was lengthy and exhausting.

“The challenge with any spine surgery is you’re trying to achieve two seemingly contradictory goals,” says Dr. Brian T. Farrell, the newest member of Riverside’s Neurological team.  “You’re trying to decompress, and get the tissue out of the way of nerves that are pinched or disc material.  And you have to do that in a way that preserves stability – so we’re always working on techniques that try to accomplish both.”  He adds,  “As a matter of our standard training, neurosurgeons spend a minimum of seven years learning and performing spine surgeries – including surgeries of the lumbar, cervical and thoracic spine.”

No matter how complicated the procedure nor how well trained the surgeon, precision is absolutely critical to a safe and effective result when operating on the spine.  In today’s minimally invasive spine surgery, Riverside neurosurgeons localize the target area with intraoperative x-rays, allowing them to insert a dilator, a small tube that gently nudges the muscle fibers out of their way.  Riverside Neurological and Spine Institute remains the only facility on the Peninsula with the capability to use both fluoroscopic and CT-based images intraoperatively.  This capability, known as StealthStation, is a computer program that allows surgeons to build and visualize a 3-D model based on images obtained either from intraoperative x-rays obtained from a C-arm, or when indicated by the complexity of the pathology being treated, by intraoperative CT scans obtained from the O-arm. Because these 3-D images are more accurate than the traditional two-dimensional x-ray, the result is a quicker and more accurate operation.

“The O-arm and StealthStation work together; they’re intimately linked,” says Dr. Javier Amadeo.  “They allow us to navigate instruments, very precisely, particularly for placing screws and rods in the spine.”

Minimally invasive spinal fusions.
For example, Dr. Amadeo explains, this technology allows him to perform procedures like the midline interbody lumbar fusion – Midlif, for short – with greater ease and precision: “When we do these fusions, we use something called pedicle screws that very securely anchor one vertebra to another vertebra through an intervening rod,” he says.  “These screws have to be put in very precisely through the pedicle, a relatively narrow tubular structure that links the front part of the spine to the posterior.  When you can thread a robust screw through there and into the front part of the spine, it’s a good way of providing fixation.”

He continues: “Doing this the traditional way, where the screw head is further out laterally and the tip of the screw points inward, we had to make a long incision and dissect the tissues out quite a bit laterally, about three and a half centimeters.  In a Midlif, instead of using a lateral starting point, we start closer to the midline and angle the screw outward, thus we don’t have the same anatomical landmarks that we traditionally use that kind of give us a tactile feel for where the screw is going.  The way we can do that by StealthStation guidance linked to the O-arm: that is, we get an O-arm set of images that are downloaded to the Stealth computer and the Stealth gives us a virtual image of the spine and a virtual image of the screw, and the drill we use to create the pilot hole.  We know exactly where that screw is going, so it’s a novel technique for doing a standard traditional procedure in a less invasive way.”

Bi-plane being used on a patient to treat aneurysms

Deep brain stimulation and movement disorders.
Many of the conditions that affect the nervous system are relatively free of observable symptoms, while others produce unmistakable signs of the disease within.  Two such conditions are essential tremor and Parkinson’s disease.  And because the symptoms are so similar and so overtly recognizable, many people believe they’re the same condition.

But despite their seemingly similar manifestations, they are in fact very different, notes Dr. Jackson B. Salvant, a neurosurgeon who works with these patients.  No matter the etiology of the condition, patients with these conditions tend to suffer social anxiety, which especially in the case of essential tremor can exacerbate symptoms.  While there is no cure for either condition, there are treatment options and techniques that can greatly improve the qualify of life of these patients.

Riverside has the only facility on the Peninsula that offers a unique treatment option to patients with either condition, Dr. Salvant says: “Deep brain stimulation, a modality that has shown significant results in controlling tremors.  Prior to administering the stimulation, we give the patient  mild sedation, and then under local anesthesia, we fit the patient with a frame similar to the Leksell frame used in Gamma Knife procedures.  Once the frame is secure, the patient is awake, alert and responding to commands – so I’m able to test and measure the effects of the stimulation.”

Using MRI imaging and stereotactic techniques, the surgeon guides an electrical stimulation lead to a target deep within the brain in the area of the thalamus.  The target areas for Essential Tremor and Parkinson’s are in relatively close proximity within the brain, but they are decidedly different in their functions and in the effects of treatment.  Thus precision in reaching the appropriate target is critical.

Once a stimulating lead is precisely placed to obtain the ideal results, it is later connected to an implanted pulse generator similar to a pacemaker.  The device then transmits painless electrical pulses to interrupt signals from the thalamus that may cause the tremors.

Awake brain tumor surgery with brain mapping.
Dr. Salvant also offers a unique surgical intervention for patients who have difficult brain tumors in locations where, if those patients were under general anesthesia, there is  a higher potential for new neurological problems.  “By doing the surgery with the patient awake and mapping the surface of the brain during surgery,” he says, “we can choose the safest avenue to perform the procedure, while getting real time monitoring of the patient’s condition.  It allows us to avoid new neurological problems ensuing from the surgery.”

The awake procedure is highly effective, Dr. Salvant continues, but cautions: “We have to be very careful about who we offer that option to, because there are patients who are confused or disoriented, or who might have some underlying medical condition, like severe anxiety, for whom the procedure would not be appropriate.  Even a significant fear of needles, or a history of poor interactions with a member of the medical community, could preclude some patients.”

Patient selection.
Just as critical to outcomes is the art of patient selection.  Not every Neurological procedure is indicated for every patient with symptoms.  The Riverside neurosurgeons, working with their colleagues at Riverside Neurological & Spine Institute – neurologists, neurovascular experts and neuroradiologists – insist on reserving the specialized treatment options considered herein for only those patients who will benefit the most.  Each case is thoughtfully reviewed, and each procedure performed under the strictest criteria, done in coordination with other specialists.

Riverside Neurological and Spine Institute surgeons pride themselves on doing the right surgery at the right time for the right patient, says Dr. Farrell, and by carefully managing expectations.  “We maintain a high standard as far as knowing when, and for whom, to recommend surgery.”  As he counsels his patients, Dr. Kostov tells them, “We don’t operate on pictures; we operate on patients.”

What lies ahead.
“We’ve continued to evolve,” Dr. Kostov says.  “We’ve pushed the technology and used it to make procedures safer.  We’re utilizing robots more and more, and three-dimensional images acquired intraoperatively to tailor each procedure to each patient’s pathology.”

As for the future, he says, “Neurosurgery has always been on the cutting edge, because our imaging has always been improving, and we’re pushing it to be even better.  We’re able to see tumors and nerve fibers better and better.  What’s exciting about neurosurgery is that there’s always something new on the horizon that allows us to preserve neurological function while treating our patients for back and spine problems.”