Combination of Frameless Navigation and Intraoperative Neurophysiology for Motor Cortex Stimulation - PowerPoint PPT Presentation

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Combination of Frameless Navigation and Intraoperative Neurophysiology for Motor Cortex Stimulation

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Combination of Frameless Navigation and Intraoperative Neurophysiology for Motor ... Iatrogenic. Other terms 'Thalamic pain' 'Anesthesia dolorosa' Treatment options ... – PowerPoint PPT presentation

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Title: Combination of Frameless Navigation and Intraoperative Neurophysiology for Motor Cortex Stimulation


1
Combination of Frameless Navigation and
Intraoperative Neurophysiology for Motor Cortex
Stimulation
  • Konstantin Slavin, MD,
  • and Keith R. Thulborn, MD, PhD
  • Section of Stereotactic and Functional
    Neurosurgery, Department of Neurosurgery, and
    Center for MRI Research
  • University of Illinois at Chicago

2
Central Deafferentation Pain
  • Etiology
  • - Post-stroke
  • - Iatrogenic
  • Other terms
  • Thalamic pain
  • Anesthesia dolorosa
  • Treatment options
  • Strong opioids / antidepressants
  • Intrathecal medications
  • Further destruction (i.e., cingulotomy,
    tractotomy)
  • Neurostimulation

3
Central Deafferentation Pain
Non-destructive option
  • Mechanism
  • Cortico-thalamic inhibition
  • Cortico-cortical inhibition
  • Non-opioid dependent
  • Placebo effect?
  • Motor function required
  • Motor cortex stimulation
  • 15 year history
  • Long-term effect?

Mogilner, 2001
4
Motor Cortex Stimulation
  • Technique variations
  • Anatomical vs. physiological targeting
  • CT vs. MRI
  • Craniotomy vs. burr hole
  • Subdural vs. epidural placement
  • Grid placement vs. intraoperative recording
  • Awake vs. under GA
  • One or more electrodes

5
UIC MCS protocol
  1. Preoperative phase
  2. Surgery 1
  3. Stimulation trial
  4. Surgery 2
  5. Postoperative phase
  1. Clinic assessment
  2. Baseline MRI / fMRI
  3. Neuropsychological testing
  4. Repeated Q/A sessions
  5. Medical clearance

6
UIC MCS protocol
  1. Skin fiducials
  1. Preoperative phase
  2. Surgery 1
  3. Stimulation trial
  4. Surgery 2
  5. Postoperative phase

7
UIC MCS protocol
2. Stereotactic fMRI
  1. Preoperative phase
  2. Surgery 1
  3. Stimulation trial
  4. Surgery 2
  5. Postoperative phase

8
UIC MCS protocol
3. Frameless navigation
  1. Preoperative phase
  2. Surgery 1
  3. Stimulation trial
  4. Surgery 2
  5. Postoperative phase

9
UIC MCS protocol
4. Open craniotomy
  1. Preoperative phase
  2. Surgery 1
  3. Stimulation trial
  4. Surgery 2
  5. Postoperative phase

10
UIC MCS protocol
5. Intraoperative SSEP (look for N20 peak
reversal)
  1. Preoperative phase
  2. Surgery 1
  3. Stimulation trial
  4. Surgery 2
  5. Postoperative phase

11
UIC MCS protocol
6. Electrode insertion (Resume, Medtronic)
  1. Preoperative phase
  2. Surgery 1
  3. Stimulation trial
  4. Surgery 2
  5. Postoperative phase

12
UIC MCS protocol
  1. Preoperative phase
  2. Surgery 1
  3. Stimulation trial
  4. Surgery 2
  5. Postoperative phase
  • Daily stimulation
  • ICU stay

13
UIC MCS protocol
  1. Preoperative phase
  2. Surgery 1
  3. Stimulation trial
  4. Surgery 2
  5. Postoperative phase
  1. Electrode internalization
  2. GA

14
UIC MCS protocol
  1. Programming
  2. 1 wk of antibiotics
  3. Re-programming
  4. Re-programming
  1. Preoperative phase
  2. Surgery 1
  3. Stimulation trial
  4. Surgery 2
  5. Postoperative phase

15
Motor Cortex Stimulation
  • Pros
  • Non-destructive
  • Testable
  • Reversible
  • Adjustable
  • 50 success
  • The only option?
  • Cons
  • Price
  • Time consuming
  • Hardware complications
  • 50 success
  • FDA status
  • Mechanism?

16
MCS - Conclusions
  • Using a combination of functional MRI,
    image-guided computer navigation, and
    intraoperative electrophysiological testing, we
    were able to precisely localize the primary motor
    cortex and subsequently achieve excellent pain
    relief in patients with medically intractable
    deafferentation pain.
  • The motor cortex stimulation may be an option for
    patients with chronic pain syndromes due to
    strokes, post-surgical procedures and other
    deafferentative conditions.
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