Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Spinal Cord Stimulation and Intraspinal Infusions for Pain

The first clinical report of spinal cord stimulation (SCS) was published in 1967. These devices were the logical progression of the concept of gate control theory proposed by Wall and Melzack in 1965. This theory proposed that “control of pain may be achieved by selectively activating the large, rapidly conducting fibers.” Since this first report of the use of dorsal column stimulation, the use of implantable…

Spinal Cord Stimulation for Chronic Pain

A theory of pain transmission published in 1965 inspired researchers to develop a reversible, nondestructive pain therapy that relied on equipment adapted from cardiac pacemaker technology to deliver electrical stimulation to the spinal cord. The initial results of this therapy, now known as spinal cord stimulation (SCS), were inconsistent, but many patients benefited dramatically. During the intervening decades, refinements in SCS techniques, stimulation patterns, equipment, and…

Mesencephalic Tractotomy and Anterolateral Cordotomy for Intractable Pain

Acknowledgments The authors wish to thank Mr. Mike Jensen for his valuable assistance with the medical illustrations of this chapter. The management of pharmaco-resistant pain of cancerous or noncancerous origin constitutes a rather challenging issue for the modern functional neurosurgeon. Various open or stereotactic neurosurgical procedures, such as cingulotomy, amygdalotomy, thalamotomy, mesencephalic tractotomy, stimulation of the periaqueductal gray area, anterolateral cordotomy, implantation of opioid-infusion devices, and…

Deep Brain Stimulation for Chronic Pain

Introduction and History Interest in deep brain stimulation (DBS) for chronic pain has waxed and waned over the past half century. Stimulation of the septal region of the brain for pain relief was first attempted in the 1950s. Chronic stimulation of a contemporary target, the sensory thalamus, was first described in the early 1970s for anesthesia dolorosa, inspired by observations made during thalamic ablation. DBS for…

Neurovascular Decompression in Cranial Nerves V, VII, IX, and X

Introduction The pathobiology of vascular compression of the trigeminal (V), facial (VII), glossopharyngeal (IX), and vagus (X) nerves underlies a number of related neurologic disorders. Dandy (1932) first described vascular compression of the trigeminal nerve in the posterior fossa as a potential cause of trigeminal neuralgia, termed tic douloureux . Several decades later, Gardner and Sava (1962) identified vascular compressive lesions of the facial nerve as…

Percutaneous Stereotactic Rhizotomy in the Treatment of Intractable Facial Pain

The disease course of trigeminal neuralgia is varied for each patient and expressed in the pathophysiologic nuances of the facial pain, medical history, treatment preferences, and outcomes. Therefore the treatment paradigm should strive to integrate the full complement of medical and surgical treatment modalities to best target the goals of the patient. Surgical options can be divided into physiologic and ablative procedures. Physiologic procedures include microvascular…

Retrogasserian Glycerol Rhizolysis in Trigeminal Neuralgia

Acknowledgments We are much indebted to Sten Håkanson, MD, PhD, the originator of glycerol treatment for trigeminal neuralgia, who collaborated with the first author in earlier versions of this chapter. Many patients with trigeminal neuralgia (TN) are elderly, often with concurrent diseases; therefore there is a constant search for appropriate therapeutic methods with low surgical risk, little impact on facial sensibility, and the ability to perform…

Surgery for Intractable Spasticity

Spasticity is defined as a velocity-dependent resistance to passive movement of a joint and its associated musculature and is characterized by hyperexcitability of the stretch reflex. Disorders are related to the failure of descending supraspinal inhibition. Spasticity should not be treated just because it is present, as it may compensate for loss of motor power. Spasticity must be treated only when excess of tone leads to…

Thoracoscopic Sympathectomy for Hyperhidrosis

Axillary and palmar hyperhidroses are relatively common disorders that together affect approximately 0.5% to 1% of the population, with possibly higher percentages in those of Asian descent. Hyperhidrosis is an idiopathic overactivation of sweat glands that results in secretion of sweat in excess of that needed for typical autonomically controlled thermoregulation. It is often overlooked or untreated and can cause significant distress that may lead to…

Brain-Computer Interfacing: Prospects and Technical Aspects of Functional Cranial Implants

Background We often perceive human thoughts as powerful forces. However, one can question whether we, as humans, can manipulate the physical world around us just by our thoughts or will. Myths, legends, and science fiction are all full of stories where thought or will is used as a power, thereby capable of moving objects. Throughout the 20th century, science fiction is replete with references to brain-controlled…

Deep Brain Stimulation for Intractable Psychiatric Illness

Introduction The burden of psychiatric disease in the general population is substantial. Consider just two of the more common diseases. Major depressive disorder (MDD) is thought to affect nearly 17% of the world’s population, and the lifetime prevalence of obsessive-compulsive disorder (OCD) is estimated at 3%. Although there are a variety of therapies available, a large proportion of patients remain refractory to standard behavioral and pharmacologic…

Lesion Procedures for Psychiatric Disorders

Introduction Lesion procedures for psychiatric disorders have been in use for more than half a century. Our current technology certainly surpasses that of the mid-20th century, when these procedures were developed. Current standards for imaging include high-resolution magnetic resonance imaging (MRI) scans rather than the ventriculography procedures of the early era. Our circuit and connectomic understanding of the brain regions implicated in psychiatric disorders is much…

Molecular Therapies for Movement Disorders

Movement disorders, such as Parkinson disease (PD), are currently treated pharmacologically by systemic administration of drugs that replace, mimic, or potentiate lost neurotransmitters, and more recently with neurosurgical procedures such as deep brain stimulation (DBS) of the subthalamic nucleus (STN) or internal segment of the globus pallidus (GPi) , to replace older, more destructive procedures such as lesioning of the basal ganglia. However, advances in understanding…

Novel Targets and Techniques in Deep Brain Stimulation for Movement Disorders

Introduction The surgical treatment of movement disorders has evolved considerably over the past 20 years with the increasing application of deep brain stimulation (DBS), principally for the treatment of Parkinson disease (PD), essential tremor, and dystonia. The sites most commonly targeted for DBS in the treatment of movement disorders have been the subthalamic nucleus (STN), the internal segment of the globus pallidus (GPi), and the motor…

Cervical Dystonia and Spasmodic Torticollis: Indications and Techniques

History of Dystonic Conditions One of the earliest descriptions of dystonia was recorded by Gowers in 1888. Destarac in 1901 used the term “torticollis spasmodique” to describe the twisting neck movements observed in a 17-year-old girl. Dystonic conditions were identified as distinct from other hyperkinesias by Schwalbe in 1908; however, because of the bizarre nature of the movements, dystonias were originally considered a form of “hysterical…

Implantation of Deep Brain Stimulation Electrodes Under General Anesthesia for Parkinson Disease and Essential Tremor

Introduction Deep brain stimulation (DBS) has proven to be an effective treatment for symptoms of Parkinson disease (PD), essential tremor (ET), congenital or acquired dystonias, and other movement disorders. Although not currently practiced outside of clinical trials, DBS for medically refractory psychiatric diseases, including depression, obsessive-compulsive disorder, and posttraumatic stress disorder, have been undertaken or are ongoing, and the efficacy of DBS for these is being…

Extratemporal Epilepsy and Neuromodulation

Introduction The surgical management of patients with drug-resistant epilepsy is changing rapidly as newer methods of diagnosis and treatment are discovered and enter clinical practice. The International League Against Epilepsy defines drug-resistant epilepsy as seizures that continue despite treatment with at least two properly selected antiepileptic medications. Approximately 30% of patients with ongoing seizures meet these criteria. , For these patients, escalating therapy beyond medications to…

Corpus Callosotomy: Indications and Techniques

In 1940, William P. van Wagenen and R. Yorke Herren described a small series of patients with various disruptive lesions of the corpus callosum. Their report highlighted the phenomenologic distinction between generalized convulsive seizures in individuals with tumors near the intact callosum and only partial seizures following insidious invasion of the corpus callosum months to years later. The hypothesis that interruption of the corpus callosum could…

Multilobar Resection and Hemispherectomy in Epilepsy Surgery

Multilobar Resections The rationale of curative surgical procedures aiming at control of focal drug-resistant epilepsy is total inactivation (by resection or disconnection) of the epileptogenic zone (EZ) (i.e., the cortical region of onset and early spread of an ictal discharge). Considering the dynamic features of an ictal discharge, and therefore its spatial-temporal structure, it is not surprising that in a number of patients the EZ may…

Surgical Management of Extratemporal Lobe Epilepsy

Introduction Extratemporal lobe epilepsy (ETLE) comprises debilitating conditions of heterogeneous symptomatology and pathology, both challenging to diagnose and to treat yet amenable to several surgical interventions. ETLE is defined as localization-related epilepsy with the electrophysiological epileptogenic zone outside the temporal lobe of focal epilepsies with and without secondary generalization. ETLE include frontal lobe, parietal lobe, occipital lobe, and multilobar neocortical epilepsies. Depending on the presence or…