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Management of Spasticity by Central Nervous System Infusion Techniques

This chapter includes an accompanying lecture presentation that has been prepared by the authors: Video 127.1 . Key Concepts Spasticity is best understood as a motor impairment that develops slowly after damage to the CNS and results in uncoordinated movements, mass reflexes, spasms, and postural abnormalities. Multiple spinal circuit abnormalities occur in spasticity owing to different types of injuries to the CNS, so the pathophysiology of…

Lesioning Surgery for Spasticity

Key Concepts Surgery for spasticity should aim only to suppress the excess of tone in the muscular groups with harmful components of the disorder. By reequilibrating the balance between agonist and antagonist muscles, surgery may reveal some voluntary motricity if preoperatively hidden behind hypertonia. If botulinum toxin injections are insufficient, peripheral neurotomy (PN) can be indicated when spasticity is limited to one or a few muscular…

Surgery and Neuroscience of Addiction

This chapter includes an accompanying lecture presentation that has been prepared by the authors: Video 125.1 . Key Concepts Addiction has been a major problem worldwide for decades. Alcoholism remains the most widely abused substance, with prescription opiates becoming as problematic in recent years as illegal drugs such as cocaine and heroin. All drugs of abuse ultimately increase mesolimbic dopamine signaling to the nucleus accumbens (NAc)…

Surgery for Anorexia Nervosa

This chapter includes an accompanying lecture presentation that has been prepared by the authors: Video 124.1 . Key Concepts Anorexia nervosa (AN) is a severe refractory psychiatric disorder with high rates of morbidity and mortality. Multiple factors contribute to the development and maintenance of AN, including genetic and epigenetic, biologic, cognitive, and sociopsychological mechanisms and their interactions. Current psychotherapeutic interventions and pharmacologic therapies for AN are…

Surgery for Major Depressive Disorder

This chapter includes an accompanying lecture presentation that has been prepared by the authors: Video 123.1 . Key Concepts Major depressive disorder (MDD) is the most common psychiatric illness, with a lifetime prevalence of 10%–20%. Of those cases, approximately 20% will be refractory to conventional therapies, being termed treatment-resistant depression. Recent advances in neuroscientific research have helped elucidate the neurocircuitry underlying depression. Dysfunctional activity within the…

Surgery for Obsessive-Compulsive Disorder

This chapter includes an accompanying lecture presentation that has been prepared by the authors: Video 122.1 . Key Concepts Obsessive-compulsive disorder (OCD) is a chronic and debilitating neuropsychiatric disorder and it is a key example of obsessive-compulsive and related disorders, a new group of conditions that are now classified together in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). OCD affects about 2%…

Surgery for Tourette Syndrome

Key Concepts Tourette syndrome (TS) is a neuropsychiatric disorder characterized by vocal and motor tics, typically with a childhood-onset and significant symptom reduction in early adulthood. Studies have shown a neurodevelopmental deficit in these patients, especially regarding the cortical-striatal-thalamic-cortical loops. First-line therapy for TS patients should be cognitive behavior therapy and pharmacologic treatment. A significant number of patients fail to experience a decline in tic severity…

History and Ethical Considerations in Functional Neurosurgery

This chapter includes an accompanying lecture presentation that has been prepared by the authors: Video 120.1 . Key Concepts Functional neurosurgery in the first half of the 20th century centered around the treatment of psychiatric disorders as noninvasive therapeutics were ineffective at the time. Surgical ablation was the most efficacious therapeutic method for movement disorders in the era before the discovery of levodopa. Surgical applications for…

Thalamotomy for Focal Hand Dystonia

This chapter includes an accompanying lecture presentation that has been prepared by the authors: Video 119.1 . Key Concepts Thalamotomy is an established treatment for intractable tremor. However, it is not generally used for management of dystonia, as most neurosurgeons regard the globus pallidus internus (GPi) as the stereotactic target for dystonias. There are many types of dystonias, and adult-onset task-specific focal hand dystonia (TSFHD) is…

Selective Peripheral Denervation for Cervical Dystonia

Key Concepts Selective peripheral denervation is an elegant surgical method for the treatment of cervical dystonia that can be tailored to the specific pattern of dystonia for an individual patient. Selective peripheral denervation most frequently consists of a combination of sectioning the peripheral branch of the spinal accessory nerve to the sternocleidomastoid muscle and extraspinal posterior ramisectomy from C1 to C6. Clinical improvement and reduced disability…

Transcranial Magnetic Resonance–Guided Focused Ultrasound Thalamotomy for Tremor

Key Concepts Recent advances in the transcranial delivery of acoustic energy and magnetic resonance thermography have allowed neurosurgeons to use ultrasonography for therapeutic purposes. Transcranial magnetic resonance–guided focused ultrasound thalamotomy is an incisionless procedure that has been approved by the U.S. Food and Drug Administration for the unilateral treatment of medication-refractory essential tremor and tremor-dominant Parkinson disease. Focused ultrasonography has been shown to have similar clinical…

Emerging and Experimental Neurosurgical Treatments for Parkinson’s Disease

Key Concepts A classic model of basal ganglia circuitry is used to describe the essential neurophysiology of Parkinson’s disease. This model involves two parallel and antagonistic basal ganglia circuits: the direct and indirect pathways. The direct pathway is responsible for initiation of movement, while the indirect pathway suppresses initiation of movement. Activity in both pathways is modulated by dopaminergic output from the substantia nigra pars compacta…

Neurophysiologic Monitoring for Movement Disorder Surgery

This chapter includes an accompanying lecture presentation that has been prepared by the authors: Video 115.1 . Key Concepts Microelectrode recording (MER) offers the most accurate structure differentiation tool to localize deep nuclei in the brain. MER requires knowledge of anatomy, disease, and anesthetic management for proper localization. The relationship between the surgeon and physiologists is critical for proper MER application in the operating room. Firing…

Complication Avoidance in Deep Brain Stimulation Surgery

This chapter includes an accompanying lecture presentation that has been prepared by the authors: Video 114.1 . Key Concepts Main complications in deep brain stimulation (DBS) surgery are intracerebral hemorrhage (the most feared complication owing to its consequences, but very uncommon), wound infection, and hardware complications (the most common type of complication). How to deal with each complication is key for any functional neurosurgeon. Careful attention…

Deep Brain Stimulation: Mechanisms of Action

Key Concepts Deep brain stimulation (DBS) consisting of high-frequency pulsatile stimulation to target structures (e.g., thalamus, subthalamic nucleus, globus pallidus internus) is a well-established surgical therapy for many neurological disorders, although the mechanism(s) of action underlying its therapeutic efficacy remains under investigation. Studies support multiple possible mechanisms of action of DBS. The prevailing view in Parkinson disease (PD) is that DBS overrides abnormal neuronal activity by…

Deep Brain Stimulation for Dystonia

Acknowledgments R.L. Alterman wishes to thank Donald Weisz, PhD, for his assistance with the production of Figure 112.3 , for his friendship, and for his passionate commitment to patient care. This chapter includes an accompanying lecture presentation that has been prepared by the authors: Video 112.1 . Key Concepts Dystonia is a movement disorder characterized by sustained or intermittent muscle contractions, often elicited by specific actions,…

Deep Brain Stimulation for Parkinson Disease

This chapter includes an accompanying lecture presentation that has been prepared by the authors: Video 111.1. Key Concepts Deep brain stimulation (DBS) is the dominant surgical intervention for Parkinson disease (PD) because of its reversibility, adjustability, and applicability for bilateral intervention. DBS is thought to work by reducing abnormally elevated neuronal synchronization in the basal ganglia-thalamocortical motor loop. DBS can improve bradykinesia, rigidity, and tremor, and…

Ablative Procedures for Parkinson Disease

Key Concepts Radiofrequency ablation, particularly pallidotomy, thalamotomy, and subthalamotomy, has been an effective surgical option for symptomatic relief of Parkinson disease for over 80 years. Ablation is particularly useful in patients for whom implanted hardware is contraindicated (e.g., infection risk, limited access to follow-up) or in patients for whom cost or access to care is prohibitory. Lesioning the posteroventral globus pallidus internus (GPi) or the dorsomedial…

Surgical Management of Tremor

This chapter includes an accompanying lecture presentation that has been prepared by the authors: Video 109.1 . Key Concepts Tremor is probably the most common indication for surgery in patients with essential tremor (ET), symptoms of Parkinson disease, (PD) or any other etiology. Deep brain stimulation (DBS) is currently the most commonly used technique in the surgical treatment of tremor. There is a renewed interest in…

Neuroimaging in Stereotactic Functional Neurosurgery

This chapter includes an accompanying lecture presentation that has been prepared by the authors: Video 108.1 . Key Concepts Neuroimaging is a key component of safe and effective stereotactic intervention. Dedicated structural MRI sequences enable visualization of commonly used anatomic targets. MRI connectivity may compliment structural imaging. Stereotactic imaging allows confirmation of accurate anatomic targeting during the intervention. Neurosurgeons must understand potential neuroimaging pitfalls if they…