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Combination of Frameless Combination of Frameless Navigation and Navigation and Intraoperative Intraoperative
Neurophysiology for Motor Neurophysiology for Motor Cortex StimulationCortex Stimulation
Konstantin Slavin, MD, Konstantin Slavin, MD, and Keith R. Thulborn, MD, PhDand Keith R. Thulborn, MD, PhD
Section of Stereotactic and Functional Section of Stereotactic and Functional Neurosurgery, Department of Neurosurgery, Department of
Neurosurgery, and Center for MRI Neurosurgery, and Center for MRI ResearchResearch
University of Illinois at ChicagoUniversity of Illinois at Chicago
Central Deafferentation Central Deafferentation PainPain
Central Deafferentation Central Deafferentation PainPain
EtiologyEtiology- Post-stroke- Post-stroke- Iatrogenic- Iatrogenic
Other terms Other terms -““Thalamic pain”Thalamic pain”-““Anesthesia dolorosa”Anesthesia dolorosa”
Treatment optionsTreatment options-Strong opioids / antidepressantsStrong opioids / antidepressants-Intrathecal medicationsIntrathecal medications-Further destruction (i.e., cingulotomy, Further destruction (i.e., cingulotomy, tractotomy)tractotomy)-NeurostimulationNeurostimulation
Non-destructive optionNon-destructive option•Motor cortex Motor cortex stimulationstimulation•15 year history15 year history•Long-term effect?Long-term effect?
Mogilner, 2001
Central Deafferentation Central Deafferentation PainPain
Central Deafferentation Central Deafferentation PainPain
Mechanism:Mechanism:
-Cortico-thalamic inhibitionCortico-thalamic inhibition-Cortico-cortical inhibitionCortico-cortical inhibition-Non-opioid dependentNon-opioid dependent-Placebo effect?Placebo effect?-Motor function requiredMotor function required
Mechanism:Mechanism:
-Cortico-thalamic inhibitionCortico-thalamic inhibition-Cortico-cortical inhibitionCortico-cortical inhibition-Non-opioid dependentNon-opioid dependent-Placebo effect?Placebo effect?-Motor function requiredMotor function required
Technique variations:Technique variations:
-Anatomical vs. physiological targetingAnatomical vs. physiological targeting-CT vs. MRICT vs. MRI
-Craniotomy vs. burr holeCraniotomy vs. burr hole-Subdural vs. epidural placementSubdural vs. epidural placement
-Grid placement vs. intraoperative recordingGrid placement vs. intraoperative recording-Awake vs. under GAAwake vs. under GA
-One or more electrodesOne or more electrodes
Technique variations:Technique variations:
-Anatomical vs. physiological targetingAnatomical vs. physiological targeting-CT vs. MRICT vs. MRI
-Craniotomy vs. burr holeCraniotomy vs. burr hole-Subdural vs. epidural placementSubdural vs. epidural placement
-Grid placement vs. intraoperative recordingGrid placement vs. intraoperative recording-Awake vs. under GAAwake vs. under GA
-One or more electrodesOne or more electrodes
Motor Cortex Motor Cortex Stimulation Stimulation Motor Cortex Motor Cortex
Stimulation Stimulation
UIC MCS protocol UIC MCS protocol UIC MCS protocol UIC MCS protocol
1.1. Preoperative phasePreoperative phase2.2. Surgery 1Surgery 13.3. Stimulation trialStimulation trial4.4. Surgery 2Surgery 25.5. Postoperative Postoperative
phasephase
1.1. Preoperative phasePreoperative phase2.2. Surgery 1Surgery 13.3. Stimulation trialStimulation trial4.4. Surgery 2Surgery 25.5. Postoperative Postoperative
phasephase
1.1. Clinic assessmentClinic assessment2.2. Baseline MRI / Baseline MRI /
fMRIfMRI3.3. Neuropsychological Neuropsychological
testingtesting4.4. Repeated Q/A Repeated Q/A
sessionssessions5.5. Medical clearanceMedical clearance
1.1. Clinic assessmentClinic assessment2.2. Baseline MRI / Baseline MRI /
fMRIfMRI3.3. Neuropsychological Neuropsychological
testingtesting4.4. Repeated Q/A Repeated Q/A
sessionssessions5.5. Medical clearanceMedical clearance
1.1. Skin fiducialsSkin fiducials1.1. Skin fiducialsSkin fiducials
UIC MCS protocol UIC MCS protocol UIC MCS protocol UIC MCS protocol
1.1. Preoperative phasePreoperative phase2.2. Surgery 1Surgery 13.3. Stimulation trialStimulation trial4.4. Surgery 2Surgery 25.5. Postoperative Postoperative
phasephase
1.1. Preoperative phasePreoperative phase2.2. Surgery 1Surgery 13.3. Stimulation trialStimulation trial4.4. Surgery 2Surgery 25.5. Postoperative Postoperative
phasephase
2. Stereotactic fMRI2. Stereotactic fMRI2. Stereotactic fMRI2. Stereotactic fMRI
UIC MCS protocol UIC MCS protocol UIC MCS protocol UIC MCS protocol
1.1. Preoperative phasePreoperative phase2.2. Surgery 1Surgery 13.3. Stimulation trialStimulation trial4.4. Surgery 2Surgery 25.5. Postoperative Postoperative
phasephase
1.1. Preoperative phasePreoperative phase2.2. Surgery 1Surgery 13.3. Stimulation trialStimulation trial4.4. Surgery 2Surgery 25.5. Postoperative Postoperative
phasephase
3. Frameless navigation3. Frameless navigation3. Frameless navigation3. Frameless navigation
UIC MCS protocol UIC MCS protocol UIC MCS protocol UIC MCS protocol
1.1. Preoperative phasePreoperative phase2.2. Surgery 1Surgery 13.3. Stimulation trialStimulation trial4.4. Surgery 2Surgery 25.5. Postoperative Postoperative
phasephase
1.1. Preoperative phasePreoperative phase2.2. Surgery 1Surgery 13.3. Stimulation trialStimulation trial4.4. Surgery 2Surgery 25.5. Postoperative Postoperative
phasephase
4. Open craniotomy4. Open craniotomy4. Open craniotomy4. Open craniotomy
UIC MCS protocol UIC MCS protocol UIC MCS protocol UIC MCS protocol
1.1. Preoperative phasePreoperative phase2.2. Surgery 1Surgery 13.3. Stimulation trialStimulation trial4.4. Surgery 2Surgery 25.5. Postoperative Postoperative
phasephase
1.1. Preoperative phasePreoperative phase2.2. Surgery 1Surgery 13.3. Stimulation trialStimulation trial4.4. Surgery 2Surgery 25.5. Postoperative Postoperative
phasephase
5. Intraoperative SSEP5. Intraoperative SSEP(look for N20 peak reversal)(look for N20 peak reversal)5. Intraoperative SSEP5. Intraoperative SSEP(look for N20 peak reversal)(look for N20 peak reversal)
UIC MCS protocol UIC MCS protocol UIC MCS protocol UIC MCS protocol
1.1. Preoperative phasePreoperative phase2.2. Surgery 1Surgery 13.3. Stimulation trialStimulation trial4.4. Surgery 2Surgery 25.5. Postoperative Postoperative
phasephase
1.1. Preoperative phasePreoperative phase2.2. Surgery 1Surgery 13.3. Stimulation trialStimulation trial4.4. Surgery 2Surgery 25.5. Postoperative Postoperative
phasephase
6. Electrode insertion 6. Electrode insertion (Resume, Medtronic)(Resume, Medtronic)
6. Electrode insertion 6. Electrode insertion (Resume, Medtronic)(Resume, Medtronic)
UIC MCS protocol UIC MCS protocol UIC MCS protocol UIC MCS protocol
1.1. Preoperative phasePreoperative phase2.2. Surgery 1Surgery 13.3. Stimulation trialStimulation trial4.4. Surgery 2Surgery 25.5. Postoperative Postoperative
phasephase
1.1. Preoperative phasePreoperative phase2.2. Surgery 1Surgery 13.3. Stimulation trialStimulation trial4.4. Surgery 2Surgery 25.5. Postoperative Postoperative
phasephase
- Daily stimulationDaily stimulation- ICU stayICU stay- Daily stimulationDaily stimulation- ICU stayICU stay
UIC MCS protocol UIC MCS protocol UIC MCS protocol UIC MCS protocol
1.1. Preoperative phasePreoperative phase2.2. Surgery 1Surgery 13.3. Stimulation trialStimulation trial4.4. Surgery 2Surgery 25.5. Postoperative Postoperative
phasephase
1.1. Preoperative phasePreoperative phase2.2. Surgery 1Surgery 13.3. Stimulation trialStimulation trial4.4. Surgery 2Surgery 25.5. Postoperative Postoperative
phasephase
UIC MCS protocol UIC MCS protocol UIC MCS protocol UIC MCS protocol
1.1. Preoperative phasePreoperative phase2.2. Surgery 1Surgery 13.3. Stimulation trialStimulation trial4.4. Surgery 2Surgery 25.5. Postoperative Postoperative
phasephase
1.1. Preoperative phasePreoperative phase2.2. Surgery 1Surgery 13.3. Stimulation trialStimulation trial4.4. Surgery 2Surgery 25.5. Postoperative Postoperative
phasephase
1.1. Electrode internalizationElectrode internalization2.2. GAGA1.1. Electrode internalizationElectrode internalization2.2. GAGA
UIC MCS protocol UIC MCS protocol UIC MCS protocol UIC MCS protocol
1.1. Preoperative phasePreoperative phase2.2. Surgery 1Surgery 13.3. Stimulation trialStimulation trial4.4. Surgery 2Surgery 25.5. Postoperative Postoperative
phasephase
1.1. Preoperative phasePreoperative phase2.2. Surgery 1Surgery 13.3. Stimulation trialStimulation trial4.4. Surgery 2Surgery 25.5. Postoperative Postoperative
phasephase
1.1. ProgrammingProgramming2.2. 1 wk of antibiotics1 wk of antibiotics3.3. Re-programmingRe-programming4.4. Re-programmingRe-programming5.5. ……
1.1. ProgrammingProgramming2.2. 1 wk of antibiotics1 wk of antibiotics3.3. Re-programmingRe-programming4.4. Re-programmingRe-programming5.5. ……
Motor Cortex Motor Cortex Stimulation Stimulation Motor Cortex Motor Cortex
Stimulation Stimulation Pros:Pros:- Non-destructiveNon-destructive- TestableTestable- ReversibleReversible- AdjustableAdjustable- 50% success50% success- The only option?The only option?
Pros:Pros:- Non-destructiveNon-destructive- TestableTestable- ReversibleReversible- AdjustableAdjustable- 50% success50% success- The only option?The only option?
Cons:Cons:- PricePrice
- Time consumingTime consuming- Hardware complicationsHardware complications
- 50% success50% success- FDA statusFDA status
- Mechanism?Mechanism?
Cons:Cons:- PricePrice
- Time consumingTime consuming- Hardware complicationsHardware complications
- 50% success50% success- FDA statusFDA status
- Mechanism?Mechanism?
MCS - Conclusions MCS - Conclusions MCS - Conclusions MCS - Conclusions -Using a combination of functional MRI, image-guided Using a combination of functional MRI, image-guided
computer navigation, and intraoperative electrophysiological computer navigation, and intraoperative electrophysiological
testing, we were able to precisely localize the primary motor testing, we were able to precisely localize the primary motor
cortex and subsequently achieve excellent pain relief in cortex and subsequently achieve excellent pain relief in
patients with medically intractable deafferentation pain.patients with medically intractable deafferentation pain.
-The motor cortex stimulation may be an option for patients The motor cortex stimulation may be an option for patients
with chronic pain syndromes due to strokes, post-surgical with chronic pain syndromes due to strokes, post-surgical
procedures and other deafferentative conditions.procedures and other deafferentative conditions.
-Using a combination of functional MRI, image-guided Using a combination of functional MRI, image-guided
computer navigation, and intraoperative electrophysiological computer navigation, and intraoperative electrophysiological
testing, we were able to precisely localize the primary motor testing, we were able to precisely localize the primary motor
cortex and subsequently achieve excellent pain relief in cortex and subsequently achieve excellent pain relief in
patients with medically intractable deafferentation pain.patients with medically intractable deafferentation pain.
-The motor cortex stimulation may be an option for patients The motor cortex stimulation may be an option for patients
with chronic pain syndromes due to strokes, post-surgical with chronic pain syndromes due to strokes, post-surgical
procedures and other deafferentative conditions.procedures and other deafferentative conditions.