State-of-the-Art Neurosurgical Care
Monday, August 01, 2011
Through Lexington Clinic in Lexington, KY, patients have access to all-inclusive, cutting-edge cranial, spine and functional neurosurgical services.
Photo: Matthew Tutt, M.D.
Lexington Clinic is committed to providing high-quality care for patients with a variety of neurological and spinal conditions — including certain neurodegenerative disorders, epilepsy, benign and metastatic brain lesions, trigeminal neuralgia, and degenerative spine disorders — by utilizing the most up-to-date techniques and technologies. Advanced procedures performed by Lexington Clinic include deep brain stimulation, vagus nerve stimulation, minimally invasive spine surgery and radiosurgery utilizing the CyberKnife Robotic Radiosurgery System.
Enhancing Care for Patients With Parkinson’s Disease
According to the Parkinson’s Disease Foundation, nearly 1 million Americans live with Parkinson’s disease. Causing a variety of primary, secondary and nonmotor symptoms, Parkinson’s disease greatly affects patients’ quality of life. For appropriate candidates, deep brain stimulation can help alleviate symptoms, such as tremor, speech difficulties, rigidity and impaired mobility.
Deep brain stimulation is a three-step process that begins with an initial screening performed by the patient’s neurologist. If surgery is deemed the most beneficial choice, the patient undergoes an outpatient procedure that involves placing three skull fiducials using local anesthesia and light sedation. Once the fiducials are placed, an MRI and a CT scan are performed to target the correct nucleus in the brain that will undergo stimulation. One week after fiducial placement, a lead is placed into the appropriate nucleus under sedation. The patient will be admitted overnight for observation.
“Once the lead is placed and stimulated, we generally expect to see immediate results, and the patient’s tremors often improve immediately. Rigidity and dyskinesias are also greatly improved immediately to a few weeks after surgery,” says Matthew Tutt, M.D., Lexington Clinic neurosurgeon practicing at Saint Joseph Hospital.
Following lead placement, the patient undergoes a third and final procedure that involves implanting a battery and generator under the skin in the chest. This generator is then connected to the lead. This is done on an outpatient basis.
“From start to finish, deep brain stimulation is a two-to three-week process, after which the patient follows up with his or her neurologist for any long-term adjusting or programming that might be needed to maximize benefit from the device,” says Dr. Tutt. “In Parkinson’s disease patients, stimulation can be unilateral or bilateral, and the targeted areas of the brain are most commonly the globus pallidus interna or subthalamic nucleus.”
Currently, more than 80,000 Parkinson’s disease patients have been treated with great success using deep brain stimulation.
Managing Essential Tremor and Dystonia
Essential tremor is generally treated using medications; however, if medication therapy is ineffective, patients may be candidates for surgical treatment. To be considered an appropriate surgical candidate, a patient must have a significant functional disability caused by the tremor. The patient must also be unresponsive to medications or unable to take them due to the severity of side effects experienced. Deep brain stimulation is the most common surgical technique utilized for essential tremor management. The target nucleus for essential tremor treatment is the ventral intermediate nucleus of the thalamus.
While deep brain stimulation is most commonly used for treatment of Parkinson’s disease and essential tremor, it is also recently being used for treatment of dystonia and obsessive-compulsive disorder. The device implanted during deep brain stimulation was approved for treatment of dystonia in 2003 through the Humanitarian Device Exemption. In dystonia patients, deep brain stimulation can be used for either unilateral or bilateral stimulation, and the targeted nucleus is the globus pallidus interna or subthalamic nucleus.
Surgical Care for Epilepsy
If epileptic patients are unresponsive to medications or if they experience undesirable side effects, surgical treatment may be indicated. Surgical modalities utilized for epilepsy management include various cranial procedures or vagus nerve stimulation. Some patients are candidates to undergo a lobectomy or resection of their seizure focus via craniotomy; however, for patients not eligible or refusing a craniotomy, other modalities such as vagus nerve stimulation provide a less invasive option.
Vagus nerve stimulation involves placing a battery-powered device under the skin on the left side of the chest, similar to a pacemaker. The lead connected to the device is placed inside the lower part of the neck through a small incision and is attached to the left vagus nerve to provide mild electrical nerve stimulation. The operation is generally performed in less than one hour under general anesthesia, and patients are usually discharged the same day as their procedure. An estimated 60,000 vagus nerve stimulation surgeries have been performed for treatment of epilepsy.
“Approximately two-thirds of patients who undergo vagus nerve stimulation experience significant benefits, including decreased seizure length and frequency,” says Dr. Tutt. “Side effects are generally mild and may include hoarseness, a change in voice tone or a tickling sensation in the back of the throat. As with all surgical procedures, some risks are associated with the operation; however, these are greatly minimized due to its minimally invasive nature.”
In some cases, vagus nerve stimulation may also be used to treat depression. Patients with depression who are candidates for vagus nerve stimulation must have tried at least four antidepressant medications without success. In cases of depression, vagus nerve stimulation has been shown to increase energy. Patients have also reported enhanced relationships with family and friends, as well as improvements in day-to-day functioning.
Advanced Modalities for Treatment of Brain and Spine Lesions
Through Lexington Clinic, in conjunction with Central Baptist Hospital, patients suffering from nonresectable benign or metastatic brain or spine tumors can benefit from radiosurgery utilizing the CyberKnife Robotic Radiosurgery System.
The CyberKnife Robotic Radiosurgery System presents a noninvasive, outpatient treatment modality that involves administration of highly focused beams of radiation directly on a targeted lesion. Because the beams of radiation are precisely focused on the tumor, this technique greatly reduces the dose of radiation delivered to surrounding structures.
CyberKnife radiosurgery has wide clinical indications and can be used for treatment of metastatic tumors in the brain or spine. It may also be used for management of tumors found in the auditory canal, such as vestibular schwannomas, and can lead to better preserved facial function and hearing in this patient population following treatment. Radiosurgery is also a proven treatment to relieve facial pain in patients suffering from trigeminal neuralgia.
Improved Surgical Techniques Through Stereotactic Imaging
Stereotactic imaging has revolutionized surgical technique since it became available approximately 15 years ago. Offering several advantages, including smaller incisions, no radiation exposure and less retraction during cranial surgery, stereotactic imaging benefits both patients and physicians.
“At Saint Joseph Hospital, the system we utilize for stereotactic imaging provides us with 3-D visualization during surgery and also can use electromagnetic waves similar to a small GPS system, which allows physicians to more easily and precisely plan our approach and locate the lesion,” says Dr. Tutt. “Using stereotactic imaging, we are able to minimize the size of the skin incision and craniotomy, which ultimately allows for a more direct, minimally invasive procedure.”
Stereotactic imaging using the electromagnetic system also eliminates the need for skull pin fixation during surgery.
Minimally Invasive Spine Techniques
One of Dr. Tutt’s areas of clinical interest lies in minimally invasive spine surgery. At Lexington Clinic, Dr. Tutt offers minimally invasive lumbar discectomy, laminectomy, posterior cervical keyhole foraminotomy and transforaminal lumbar interbody fusions for relief of radicular pain. New approaches available include minimally invasive surgery from a lateral approach and for fusions performed at the L4, L5 and S1 vertebrae.
For more information about neurosurgical services provided through Lexington Clinic, call (859) 258-6760 or visit www.lexingtonclinic.com.
State-of-the-Art Neurosurgical Care
Lexington Clinic
MD News July/August 2011, Lexington