The Surgical Management of Essential Tremor

Transcription

1 The Surgical Management of Essential Tremor International Essential Tremor Foundation Learning About Essential Tremor: Diagnosis and Treatment Options Albuquerque, NM September 24, 2005 Neurosurgeon Overview: The history of surgery for movement disorders Details of the current surgical procedure (deep brain stimulation), Step-by-step description Risks Ventriculogram/atlas CT/MRI computer planning era 1940 s Ventriculogram/atlas CT/MRI computer planning era 1940 s era 1940 s era 1940 s 1

2 era 1940 s and thalamic era 1950 s Cooper s surgical accident Ventriculogram/atlas CT/MRI computer planning and thalamic era 1950 s Cooper s surgical accident and thalamic era 1950 s Meyer s pallidoansotomy and thalamic era 1950 s Relief of tremor, rigidity, bradykinesia without weakness Ventriculogram/atlas CT/MRI computer planning Development of stereotactic techniques to make surgery less invasive Horsley and Clarke animal device (1908) Spiegel and Wycis human frame (1946) Ernst Spiegel Development of stereotactic techniques to make surgery less invasive Horsley and Clarke animal device (1908) Spiegel and Wycis human frame (1946) Henry Wycis 2

3 Development of stereotactic techniques to make surgery less invasive atlases Pneumoencephalography Development of stereotactic techniques Lars Leksell Target centered frame Ventral posterior pallidotomy Surgical procedures virtually abandoned in 1968 when L-Dopa became available for PD Ventriculogram/atlas CT/MRI computer planning Deep Brain Surgical procedures virtually abandoned in 1968 when L-Dopa became available Re-birth of interest in 1990 s (Laitenen) History Initially used for pain control in 1960s Clinical trials for movement disorders 1990s FDA approved for ET in 1997, PD in 2002 Ventriculogram/atlas CT/MRI computer planning Lauri Laitinen Deep Brain History Initially used for pain control in 1960s Clinical trials for movement disorders 1990s FDA approved for ET in 1997, PD in 2002 Advantages over lesioning Adjustable Reversible Bilateral placement Overview: The history of surgery for movement disorders Details of the current surgical procedure (deep brain stimulation), Step-by-step description Risks 1. Frame placement Overview: 3. Treatment planning 2. Imaging 4. Operating room 3

4 : frame placement (sedation with IV Versed, local anesthesia : frame placement (sedation with IV Versed, local anesthesia Imaging MRI as outpatient without frame CT morning of surgery with frame MRI and CT image sets loaded onto graphic computer workstation in OR Images registered to fiducial markers allowing precise translation of brain anatomy into frame coordinates Targets (right and left Vim) chosen based on indirect and direct techniques Frontal entry points chosen and optimized to avoid cortical vessels, sulci, ventricles Positioning, preparation Arterial line, foley catheter Positioning, preparation Arterial line, foley catheter 4

5 Frame coordinates set to entry and target Frame coordinates set to entry and target Entry burr hole (nickel size) created DBS lead securing device placed in burr hole ording ording ording Border 10sec Sagittal Section Through the Thalamus 80ms DBS implant, test stimulation DBS implant, test stimulation STN 10sec 80ms Border/S N 10sec 80ms Before DBS L DBS test stimulation 5

6 DBS implant, test stimulation Repeat the same steps for opposite side Admission to ARMC: Most patients stay in ICU overnight One-on-one nursing for close neurologic observation Close monitoring of blood pressure Before DBS L DBS test stimulation Second surgery: IPG implant 3 weeks later under general anesthesia Second surgery Either a unilateral IPG (Kinetra) that runs both DBS leads Second surgery or bilateral IPGs (Soletra) that each run a DBS lead Second surgery: Discharge home same day Programming of stimulator by Dr. Marjama-Lyons as an outpatient Risks of the procedure: Brain hemorrhage Infection DBS ineffective Mechanical failure IPG will need replacement in 3 to 5 yrs 6