The previous blog dealt mainly with neurosurgical us of stimulation devices—Deep Brain Stimulation and spinal cord stimulation for a variety of nervous system problem. This blog will deal mainly with minimalized ablative surgery, i.e. removal or destruction of tissue. Prior to the advent of techniques utilizing operative microscopy, radio frequency lesioning, and MRI guided surgery, open procedures were done for a variety of neurosurgical and psychiatric problems. Intractable seizures were treated with open removal of brain tissue—often involving the temporal lobe and sometimes having the patient be awake to test efficacy. Direct lesions were made in the thalamus; prefrontal lobotomies and cingulumotomies were done for intractable psychiatric conditions. Seizure surgery still requires an open procedure in some cases, but usually, the surgical intervention is much less invasive. Brain tumor procedures have improved by the use of small cranial openings and MRI imaging as an adjunct.
The stimulating operations for Parkinsonism and pain described in the previous blog have a counterpart in ablative surgery. The procedures are very similar except that the hardware is almost always removed once the final tissue removal or destruction is completed. MRI guided surgery is used for DBS and for focal laser ablation and for brain tissue biopsy. Visualization is markedly enhanced and surgery made safer utilizing the imaging technique.
Cluster headaches—repeated severe headaches, usually occurring several times a day in clusters separated in time—are extremely detrimental to the enjoyment of life. The recurrent clusters may be years, months, weeks, or just days apart. Investigation is underway to evaluate the implantation of electrodes in the suboccipital area of the brain to treat the headaches. The results are very encouraging in a small study group of sufferers. It is postulated that other, more common types of headache, may also be susceptible to DBS.
Neurosurgeons and vascular surgeons perform surgery on the carotid arteries in the neck to relieve blockages of blood flow to the brain to prevent stroke. Until fairly recently, only an open procedure was available. The surgery was safe and effective, but it is major surgery. Now it is possible to place a stent (artificial vessel canal) starting from a puncture in the femoral artery in the groin. The stent procedure is easier on the patient but somewhat less effective than the open surgery. Most recently, a new procedure is being investigated which is less stressful. It involves a needle puncture in the carotid artery itself—transcarotid stenting with dynamic flow reversal—known popularly as the Silk-Road procedure. It remains to be seen how this new procedure compares to the open procedure and the transfemoral stenting procedure.
Deep vein thrombosis (DVT) is a hazard for any patient who is forced to be at bed rest for prolonged periods of time and is a significant problem for neurosurgical, orthopedic, paralyzed, comatose, and stroke patients, etc. Scientists from the University of Edinburgh are studying stroke patients treated with intermittent pneumatic compression (IPC) around the clock. Early results appear to be promising.
Unless you do not have a television, you no doubt hear and see advertising for laser surgery for spinal problems—especially for back pain—several times a day. The advertisements suggest that the procedures are so minimal that they are scarcely to be considered invasive. Traditional surgery includes an incision of one inch to eight or ten inches depending on the problem. That results in considerable tissue disruption, pain, scarring, and the potential for infections, prolonged bed rest with the risk of DVT and pulmonary emboli. Laser surgery promises great improvement over that scenario because it involves a very small incision, and the operation proceeds with the probe being televised. This limits the amount of tissue damage and scarring. Laser surgery usually involves burning nerve endings to decrease sensitivity. The technique is also useful to shrink the size of herniated or bulging discs to decrease pressure. Laser spinal surgery specialists state that laminotomies, laminectomies, and removal of bone spurs can be done with the technique.
Much the same kind of operation can be done with a small endoscope and the operation performed under direct, magnified vision. It is a fact that open surgery is highly effective and safe; that has been established over many decades of work and evidence-based, peer-reviewed data. Laser burning rather than cutting has not proved to be more or even equally effective in similar clinical trials over time.
