Clinical Care

Patients with movement disorders refractory to medication, such as Parkinson's Disease, essential tremor and dystonia, are assessed by a team comprising the neurosurgeon, the neurologist from the Movement Disorder Clinic and a neuropsychologist in order to ascertain whether or not they might be appropriate candidates for a surgical intervention. Only after the records have been thoroughly reviewed and the case discussed, is the decision made regarding the suitability of the candidate for surgery.

The stereotactic intervention is performed with the state of the art equipment and uses a computer work station in order to plan the optimal trajectory to the intracranial target, which can be visualized on the MRI obtained under stereotactic conditions. Physiological mapping of the area targeted is then carried out using a combination of recording and stimulation. When the appropriate target has been identified, a stimulating electrode is utilized to assess the effects of the intervention. A permanent implant of the deep-brain stimulating electrode is made only after careful testing of the patient, who remains awake during the entire intervention. Patients typically undergo a repeat MRI within 6 hours of the surgery and are discharged home the following day. Follow-up is maintained with both the neurosurgeon and referring neurologist.

In patients who suffer from severe spasticity secondary to spinal cord injuries, progressive neurological degenerative disorders, or birth defects, a program for the surgical management of spasticity has been in place. Physiatrists with special expertise in spasticity as it affects spinal cord injuries are instrumental in assessing patients for an intervention with either the baclofen pump or selective dorsal rhizotomies, both of which are performed at Yale. The ability to deliver a drug directly to the subarachnoid space using a programmable pump has resulted in dramatic improvements in the patients' spasticity, frequently resulting in improved wound healing and a decrease in the frequency of subsequent hospitalizations and need for medication. Those who have patients who would benefit more from a selective dorsal rhizotomy or myelotomy are admitted for an open surgery, which typically abolishes the spasticity completely, thereby eliminating the need for high doses of anti-spasmodic medications. Patients are subsequently followed by both the neurosurgeon and referring physiatrist or neurologist.

Neurosurgery has had a long history of providing ablative surgery for psychiatric disease. There has been a recent resurgence of interest in providing reversible, nondestructive neuron-augmentation for psychiatric disorders. Our long experience utilizing Vagal Nerve Stimulation for epilepsy has lead to our participation in the implantation of these same devices in patients with treatment refractory depression. On a limited basis, we are also implanting deep brain stimulators for the treatment of Tourette syndrome. Plans are underway to expand these programs to include deep brain stimulation for the treatment of depression and obsessive compulsive disorder.

Patients with complex pain disorders refractory to medication present a special challenge to the medical community requiring the resources of a multi-disciplinary team, which typically involves a neurosurgeon, a neurologist, an anesthesiologist, a physiatrist and a psychologist. The large number of patients presenting with intractable pain, only a minority are usually appropriate candidates for a neurosurgical intervention, be it in the form of a neuro-augmentative procedure such as spinal cord or brain stimulation, or a neuroablative procedure such as a thalamotomy or DREZ procedure. The success of the intervention is more often than not dependent on the careful selection of patients, having insured that interventions of less magnitude have failed to adequately meet their needs. These procedures can only be reasonably undertaken after carefully reviewing their records and discussing the optimal management after they have been carefully examined in detail. The majority of patients are screened by pain management specialists before they are referred for a neurosurgical opinion and then rediscussed prior to any intervention. The results of this approach have been gratifying for many patients in that they have been able to return to productive lives free from the ravages of chronic, debilitating pain, many of them returning to gainful employment. As new and exciting therapies become available to treat these difficult conditions, it is hoped that this multi-disciplinary approach will allow for the early referral and intervention of patients who might otherwise go on to develop intractable chronic pain disorders unresponsive to any modality of treatment.