Neuro Sleuths

Putting together clues that resemble puzzle pieces, five specialists take the anxiety out of treatment for nervous-system disorders.

Princeton resident Ursula Stephens-Alston always considered herself a survivor. She beat salivary-gland cancer 15 years ago, persevering through painful radiation and devastating weight loss. A September 2009 car accident caused several serious injuries, but she had three surgeries—two for her neck, one on her rotator cuff—and bounced back to enjoy life as a newlywed. Yet the seemingly minor complication that arose following that third procedure nearly destroyed her. “I developed an involuntary muscle spasm in my right shoulder near the bicep, which caused my arm to constantly swing out as though I were trying to hit someone,” recalls the 50-year-old. “The rippling became so severe, you could see it through my clothes.”

Worst of all, the movement was continuous: 24 hours a day, seven days a week, without reprieve. Restful sleep became impossible, chronic pain the norm. Soon Stephens-Alston couldn’t function without potent ache-relieving drugs. Her career as a consultant suffered, and she was taken off important projects. Low spirits further plummeted, so antidepressants were added to the mix. Baffled as to what caused the palpitations, doctors couldn’t decide how best to alleviate them. “I told my husband that if I didn’t find relief, I’d either cut off my arm or sign myself into a mental institution,” Stephens-Alston recalls. “That’s how bad my reality became.”

At this darkest hour, hope finally arrived from Princeton and Rutgers Neurology (PRN ), a practice with offices in Somerset, Monroe Township and Princeton, where Stephens-Alston was referred. Jeffrey Greenberg, M.D., Managing Partner of PRN and Chief of Neurology at Saint Peter’s University Hospital, with which the practice is affiliated, correctly diagnosed her condition as spinal myoclonus, a rare movement disorder defined by the sudden, shocking contraction of a muscle cluster due to an event—such as surgery—within the central nervous system. To treat it, he injected 30 units of an agent called Incobotulinumtoxin A into the anterior (front) section of her right deltoid muscle, and 50 more into the lateral (middle) part of that shoulder.

When Stephens-Alston learned that that agent is a close relative of Botox, she was baffled. “I asked Dr. Greenberg if he wouldn’t rather shoot that stuff into my lips,” she remembers, laughing. But the expert knew what he was doing. In small doses, this family of drugs relaxes and smoothes out muscles, which is why they work on wrinkles.

“I cautioned her to wait a week before expecting results,” says Dr. Greenberg.

Yet one day later, Stephens-Alston phoned back, ecstatic. “For the first time in two years, my arm wasn’t convulsing,” she says. “Dr. Greenberg truly saved my life.”

With treatments that range from the mundane to the miraculous, the five PRN neurologists—Jeffrey Greenberg, M.D.; Roger Behar, M.D.; Devin Friedlander, M.D.; Joshua Hersh, M.D.; and Seema Dixit, D.O.—address a wide array of ailments. Multiple sclerosis (MS), nerve and muscle problems, strokes, neuromuscular pain, migraines and other headaches, Alzheimer’s disease and other memory disorders, Parkinson’s disease and other movement disorders, epilepsy, dizziness and balance issues—these are diagnosed and treated on a daily basis. Early diagnosis and treatment are key with many of these conditions. In addition, many patients are perfectly healthy but just need some reassurance and explanation of their everyday symptoms.

“Rare conditions also present themselves on occasion,” says Dr. Greenberg. “One example would be paraneoplastic syndrome, a neurological symptom that precedes a cancer diagnosis and can cause behavioral changes or problems with coordination or sensory perception.”

Rotating schedules ensure a daily presence at Saint Peter’s, where the PRN neurologist on duty may deal with issues such as strokes, seizures and cognitive changes. This duality of care is somewhat unusual. Many neurologists currently work strictly in a private-practice capacity without ever stepping foot in hospitals, or vice versa.

“We consider that model less than optimal because we like to see our own patients who may need hospitalization, to streamline their passage through that system and to provide continuity,” says Dr. Greenberg. Between inpatient services at Saint Peter’s and separate PRN appointments, hundreds of individuals are examined each week. Yet despite massive volume, the doctors take time to talk with each patient at length, explaining necessary testing and calming uneasy nerves.

Thorough communication is imperative, because neurological problems can be difficult to diagnose—and to explain. “When a doctor checks for pneumonia, the procedure is relatively straightforward: listening to the patient’s chest with a stethoscope and administering antibiotics,” says Roger Behar, M.D., general neurologist at PRN and Stroke Director at Saint Peter’s University Hospital. “But our field is largely investigative, which means numerous questions are required to piece together clues that form a diagnosis.”

The patient relays a narrative, guided at times by the physician, in order to provide additional detail via specific questions. It can take considerable time to obtain this full history. “We then perform a neurological examination, which involves a series of mental and physical activities that may seem like party tricks,” explains Dr. Greenberg. “For example, one part of the examination includes asking the patient to touch her nose with her finger or walk a straight line with one foot in front of the other. Perplexing to the untrained eye, these tests further help pinpoint where within the nervous system a problem may lie.”

Once they’ve made their determination, the neurologists must explain their often specialized conclusions in an easy-to-grasp, unintimidating way. “I see it as a collaborative effort in which all parties are on the same page, making joint decisions,” says Dr. Behar. It can also be a lifelong relationship, as in the case of Alzheimer’s, Parkinson’s, MS and stroke patients—and potentially Stephens-Alston. Thus far she’s due to return every four months for more injections, because the muscle-soothing effects of Incobotulinumtoxin A eventually wear off.

Complex cases may call for close consultation among group members, and at PRN, the dynamic is warmly collaborative. “We get along very well,” reports Dr. Greenberg. “Patients are often seen by all members of the group. We may call one another into an exam room for another set of eyes and ears, and differing views are encouraged.” The doctors further educate each other via quarterly conferences detailing the specifics of particularly unusual cases. Even better, this non-proprietary attitude of openness benefits the community at large, as all local doctors and medical students are invited to attend and learn from the discussions.

Scientific advancements ensure that medicine is in a constant state of flux, and the neurologists keep up by regularly participating in clinical trials to apply breakthrough findings to their practice—while simultaneously honoring the qualities that first set PRN apart two decades ago. “We’ll always maintain our principles and offer a superior level of quality care,” promises Dr. Behar. “Nothing is more important than our patients.”

—Francesca moisin