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Two experts at Jefferson Health discuss several topics related to advances in neurosurgery, technology, and the future of minimally invasive procedures.
For patients who are struggling to manage their neurological condition, neurosurgery might be a therapeutic option. There are several surgical procedures used to treat a variety of diseases, ranging in levels of invasiveness. As an integral part of Jefferson University Hospital for Neuroscience, the region’s only dedicated hospital for neuroscience, neurosurgery is one of the busiest academic neurosurgical programs in the country.
At the Vickie & Jack Farber Institute for Neuroscience, neurosurgeons offer state-of-the-art treatment to patients with neurological diseases affecting the brain and spine, such as brain tumors, spinal disease, vascular brain diseases, epilepsy, chronic pain, Parkinson disease, and much more. Additionally, they provide care for other traumatic injuries to the brain, spinal cord, and nerves, as well as to the skull and spine.
As part of a new NeurologyLive® Roundtable discussion, we sat down with Jefferson neurosurgery experts Chengyuan Wu, MD, MSBmE, and Ashwini Sharan, MD. Wu is currently an associate professor of neurosurgery and radiology, codirector of the integrated MRI center, and fellowship director of stereotactic and functional neurosurgery at the Vickie & Jack Farber Institute. Sharan serves as the vice chair of clinical operations neurosurgery, program director for residency in neurological surgery, division chief of epilepsy and neuromodulatory neurosurgery, and vice chair of clinical operations.
Transcript below.
Marco Meglio: We’re going to talk about laser ablation, which is a minimally invasive option that allows for precise targeting of regions for treating epilepsy. Let’s talk about the specifics of what laser ablation is, the capabilities it has, and who may be most eligible.
Chengyuan Wu, MD, MSBmE: In this discussion, we’re going to talk about more than just DBS. The hope is to talk about where the future of stereotactic and functional neurosurgery is, which encompasses a lot of things. It encompasses treatment of not only a patient with movement disorders, which is primarily what we use DBS for, but it is also being used for things like epilepsy. Epilepsy is a big part of what we do in this division. We’ve named our division Epilepsy and Neuromodulation Neurosurgery because we think it provides a little more insight about what we do than just say stereotactic and functional neurosurgery, which is a bit difficult to comprehend exactly what that means.
Ashwini Sharan, MD: Let’s define neuromodulation and I’ll define stereotactic, because I think we’re using terms that a lot of people may not know.
Chengyuan Wu, MD, MSBmE: I would say within the realm of neurosurgery, most people should know what stereotactic functional surgery is, but in terms of what the realm is, it’s a bit ambiguous, right? When we talk about the specialty, stereotaxic is a technique and a big reason why we can do a lot of the things that we do with minimal invasiveness. When we talk about functional neurosurgery, what that implies is that we things we treat are to change or modify or take advantage of the brain networks in terms of their function, as opposed to the other realms of surgery, where it may be tumor. Tumor is self-explanatory. Those type of surgeons only deal with tumors versus vascular where they deal with blood vessels and spine is spine. Functional is dealing with functional disorders. There might not be a structural abnormality, but there is something going on with the networks of the brain, which is why we spend so much time. We’re getting into imaging to understand those networks, which I’ll talk about in a bit.
Ashwini Sharan, MD: The conventional term is functional neurosurgery. Like Dr Wu explained, because we deal with diseases like epilepsy, Parkinson disease, pain, spasticity, obsessive compulsive disorders, those are brain physiological problems. What has happened over the last 10 years is that there’s a renaissance of technology and tools that we’re using today. We renamed the division to Epilepsy and Neuromodulation Neurosurgery to reflect on these tools. Neuromodulation, which most people know has been around for more than 20 years, is the concept of putting an electrical wire in a pacemaker and changing the brain circuits.
Stereotaxis is really a 50- to 60-year-old term now. The part that I think people don’t know is that with modern MRI, we can see one millimeter blood vessels in the brain. And the computing power is such that we can import all those images into the operating room where a robot can help us guide basically a needle through a haystack. Imagine the haystack as all the blood vessels. We can find the one trajectory from the surface to the target where we want to change the network. That is the core basis of neuromodulation and stereotactic surgery. By and large today, we can get an electrode or laser probe anywhere in the brain safely with less than 1 in 200 chance of bleeding.
Chengyuan Wu, MD, MSBmE: It’s interesting I had a patient last week who asked me, "How is it that you’re putting a laser in the brain? It seems like you’re taking something with an ice prick and just stabbing the brain." I said, "well its certainly more elegant than that." The way I explained it was that with the technology we have, we reconstruct the brain in 3 dimensions. When we plan where these wires go, we’re looking millimeter by millimeter, sometimes even half millimeter by half millimeter, along the trajectory that we’re planning. We can look down what we call a “probe’s eye” effectively reconstructing the image of the brain.
We go slice by slice, half millimeter by half millimeter, looking at it each step of the way as we advance that laser or electrode or whatever it may be. We’re finding a safe trajectory away from blood vessels, away from anything that we don’t want to be in, and find some place that we do want to be in. All those three things. If along that whole path, we find that it’s unfavorable, then we go back and we have to rework it, which takes an immense amount of effort to plan each one of these stereotactic trajectories.
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