functional neurosurgical therapies for movement disorders and …/media/files/providence or... ·...
TRANSCRIPT
![Page 1: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/1.jpg)
Functional Neurosurgical Therapies for Movement Disorders and Epilepsy
Seth F Oliveria, MD PhDThe Oregon Clinic Neurosurgery
Director of Functional Neurosurgery: Providence Brain and Spine Institute
Portland, OR
![Page 2: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/2.jpg)
Providence St Vincent’s
Providence Portland
![Page 3: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/3.jpg)
![Page 4: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/4.jpg)
![Page 5: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/5.jpg)
“Functional Neurosurgery” The use of ultra-precise neurosurgical techniques to surgically modulate abnormal physiologic processes in the nervous systemMovement disordersEpilepsyPain disordersPsychiatric disorders
![Page 6: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/6.jpg)
“Functional Neurosurgery” The use of ultra-precise neurosurgical techniques to surgically modulate abnormal physiologic processes in the nervous systemMovement disordersEpilepsyPain disordersPsychiatric disorders
*Therapy is tailored to each individual patient
![Page 7: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/7.jpg)
Deep brain stimulation (DBS)
• DBS is a surgical procedure used to treat many of the debilitating symptoms of Parkinson’s disease and other movement disorders
• DBS is non-ablative: it is reversible and adjustable
• It is currently indicated for movement disorders that are refractory to medical therapy
![Page 8: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/8.jpg)
Parkinson’s Disease
• A complex, progressive degenerative neurologic disorder that causes loss of control over body movements
• Primary motor symptoms:TremorRigidityAkinesia/bradykinesiaPostural instability
![Page 9: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/9.jpg)
Parkinson’s Disease• Motor symptoms arise when the
substantia nigra degenerates and DA neurons die
• Medical treatment: replace dopamine—very effective
• BUT, there are limitations…Increasing dosagesIncreasing side effects • Dyskinesia• Hallucinations• Wearing off• Unpredictability
![Page 10: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/10.jpg)
Parkinson’s Disease
![Page 11: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/11.jpg)
DBS Therapy Provides an Additional 5.1 Hours of On Time to Smooth Out Motor Function*
Without DBS Therapy
With DBS Therapy
*Activa Therapy Clinical Summary, 2009.
![Page 12: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/12.jpg)
For patients <75 with severe motor complications of Parkinson's disease, neurostimulation was more effective than medical management alone at 6 mo
Deuschl et al., 2006 NEJM
![Page 13: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/13.jpg)
https://www.youtube.com/watch?v=CS1_XFtaLEo
![Page 14: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/14.jpg)
The DBS system consists of three components:The lead is a thin electrode inserted into the brainAn extension cable, connecting the lead and neurostimulatorThe neurostimulator is a battery and pulse generator that is
implanted under the skin, usually near the collarbone
![Page 15: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/15.jpg)
There are three brain targets that have been FDA approved for use in Parkinson’s disease.• The most commonly utilized brain targets include the
subthalamic nucleus (STN) and also the globus pallidusinterna (Gpi)
• Target choice is tailored to a patient’s individual needs• The preoperative evaluation helps determine choice of
brain target
![Page 16: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/16.jpg)
DBS surgical procedurePreoperative MRI is used to create a plan to precisely target the area of interest
![Page 17: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/17.jpg)
DBS surgical procedure
A small incision is made in the scalp and a hole drilled through the skull to expose the brain
![Page 18: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/18.jpg)
DBS surgical procedureThere are several strategies to precisely place the DBS lead in the target:
Frame-based
![Page 19: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/19.jpg)
DBS surgical procedureThere are several strategies to precisely place the DBS lead in the target:
Frame-based Frameless
![Page 20: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/20.jpg)
DBS surgical procedureThere are several strategies to precisely place the DBS lead in the target:
Awake surgery
![Page 21: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/21.jpg)
DBS surgical procedureThere are several strategies to precisely place the DBS lead in the target:
Microelectrode recording
![Page 22: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/22.jpg)
DBS surgical procedureThere are several strategies to precisely place the DBS lead in the target:
Microelectrode recording
![Page 23: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/23.jpg)
DBS surgical procedureThere are several strategies to precisely place the DBS lead in the target:
Image guided “asleep” surgery
![Page 24: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/24.jpg)
DBS surgical procedureThere are several strategies to precisely place the DBS lead in the target:
“Directional” DBS leads
![Page 25: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/25.jpg)
DBS surgical procedureThe extension and neurostimulator are placed under general anesthesia: as a second step or stage
![Page 26: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/26.jpg)
DBS surgical procedureTypical DBS incisions
![Page 27: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/27.jpg)
DBS for other movement disordersCommonly seen by PCPs! Responds very well to DBS…Essential Tremor—Thalamus (Vim)Dystonia—Globus Pallidus (GPi)
![Page 28: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/28.jpg)
Surgery for medically refractory epilepsy
Goal: identify an area in the brain that causes seizures and determine whether this area can be removed safely
Noninvasive workup +/- invasive recording craniotomy for resection vs. minimally invasive ablation
Other options are available when:• a specific area of seizure onset is not identified• multiple areas of seizure onset are identified • resection/ablation is not possible without causing new
neurologic problems(responsive neurostimulation, vagus nerve stimulation)
![Page 29: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/29.jpg)
Surgical evaluation for medically refractory epilepsySubdural grid placement: improved spatial resolution of the brain surface compared to scalp EEG
![Page 30: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/30.jpg)
Surgical evaluation for medically refractory epilepsyStereo EEG: multiple depth electrodes placed to monitor superficial and deep structures
![Page 31: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/31.jpg)
Resective surgery for medically refractory epilepsy:The best chance for a surgical cure for seizures
![Page 32: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/32.jpg)
Resective surgery for medically refractory epilepsy:The best chance for a surgical cure for seizures
Wiebe et al., 2001 NEJM
![Page 33: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/33.jpg)
Surgery for medically refractory epilepsyStereotactic laser ablation: minimally invasive epilepsy surgery
![Page 34: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/34.jpg)
![Page 35: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/35.jpg)
MRI-guided ablation
Surgery for medically refractory epilepsyStereotactic laser ablation
![Page 36: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/36.jpg)
MRI-guided ablation
Surgery for medically refractory epilepsyStereotactic laser ablation
![Page 37: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/37.jpg)
Surgery for medically refractory epilepsyResponsive neurostimulation: detects epileptiform discharges and delivers therapeutic stimulation
![Page 38: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/38.jpg)
Surgery for medically refractory epilepsyResponsive neurostimulation: detects epileptiform discharges and delivers therapeutic stimulation
![Page 39: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/39.jpg)
Thank you
![Page 40: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/40.jpg)
![Page 41: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/41.jpg)
What are the risks?DBS is elective brain surgery…• The most common complications are device- or
wound-related: infection, skin erosion, or interruption in therapy because of mechanical or electrical problems
• Stimulation-related side effects: numbness, tingling, worsening of tremor, mood problems, speech/language impairments. Typically, these side effects can be resolved by adjusting the device
• Serious complications are rare, but include stroke, hemorrhage, seizures and brain abscess
![Page 42: Functional Neurosurgical Therapies for Movement Disorders and …/media/Files/Providence OR... · 2017. 11. 15. · Deep brain stimulation (DBS) • DBS is a surgical procedure used](https://reader035.vdocuments.us/reader035/viewer/2022071100/5fd8b999c9c11d5ffd063aaf/html5/thumbnails/42.jpg)
When the patient is experiencing troubling motor symptoms not effectively controlled by medications, characterized by:• “On” time with disabling dyskinesias (or other nonmotorside effects)OR• “Off” time with disabling tremor, rigidity, or akinesia/bradykinesiaOR• Frequent and/or unpredictable “on/off” motor fluctuations
* Medication-resistant tremor
There is a “window of opportunity” for PD when DBS therapy may be most effective in order to obtain maximum benefit