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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


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



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


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



phasephase


phasephase

2. Stereotactic fMRI2. Stereotactic fMRI2. Stereotactic fMRI2. Stereotactic fMRI



phasephase


phasephase

3. Frameless navigation3. Frameless navigation3. Frameless navigation3. Frameless navigation



phasephase


phasephase

4. Open craniotomy4. Open craniotomy4. Open craniotomy4. Open craniotomy



phasephase


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)



phasephase


phasephase

6. Electrode insertion 6. Electrode insertion (Resume, Medtronic)(Resume, Medtronic)

6. Electrode insertion 6. Electrode insertion (Resume, Medtronic)(Resume, Medtronic)



phasephase


phasephase

- Daily stimulationDaily stimulation- ICU stayICU stay- Daily stimulationDaily stimulation- ICU stayICU stay



phasephase


phasephase



phasephase


phasephase

1.1. Electrode internalizationElectrode internalization2.2. GAGA1.1. Electrode internalizationElectrode internalization2.2. GAGA



phasephase


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.

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