Yale Stereotactic & Functional Neurosurgery Surgery Program

Yale Stereotactic & Functional Neurosurgery Program

Mission

The stereotactic and functional neurosurgery program at Yale encompasses the treatment of movement disorders, spasticity and intractable pain. It is designed to meet the needs of patients who are considered to be refractory to the best medical management and are therefore considered as candidates for neurosurgical interventions requiring a high degree of precision using both neuroaugmentive and neuroablative techniques. As such it involves the collaboration of the Movement Disorder Clinic, physiatrists, and the Yale Center for Pain Management insuring that patients are carefully screened prior to recommending a surgical intervention. This multi-disciplinary effort is only possible in a university based tertiary referral center such as Yale, where the various disciplines can be brought together in the complex management of these disorders, which are at best managed with difficulty in the community setting. Hence, one of the primary aims of the program is to provide a service to neurologists and neurosurgeons at large who are faced with complex functional disorders requiring multi-disciplinary expertise.

Clinical Care

Patients with movement disorders refractory to medication, such as Parkinson's Disease, essential tremor and dystonia, are assessed by a team comprising the neurosurgeon, the neurologist from the Movement Disorder Clinic and a neuropsychologist in order to ascertain whether or not they might be appropriate candidates for a surgical intervention. Only after the records have been thoroughly reviewed and the case discussed, is the decision made regarding the suitability of the candidate for surgery.

The stereotactic intervention is performed with the state of the art equipment and uses a computer work station in order to plan the optimal trajectory to the intracranial target, which can be visualized on the MRI obtained under stereotactic conditions. Physiological mapping of the area targeted is then carried out using a combination of recording and stimulation. When the appropriate target has been identified, a test lesion can be performed to assess the effects of the intervention. A permanent lesion is made only after careful testing of the patient, who remains awake during the entire intervention. Patients typically undergo a repeat MRI within 6 hours of the surgery and are discharged home the following day. Follow-up is maintained with both the neurosurgeon and referring neurologist.

In patients who suffer from severe spasticity secondary to spinal cord injuries, progressive neurological degenerative disorders, or birth defects, a program for the surgical management of spasticity has been in place over the past 7 years. A physiatrist with special expertise in spasticity as it affects spinal cord injuries has been involved with the program over the past 5 years and has been instrumental in assessing patients for an intervention with either the baclofen pump or selective dorsal rhizotomies, both of which are performed here at Yale. The ability to deliver a drug directly to the subarachnoid space using a programmable pump has resulted in dramatic improvements in the patients' spasticity, frequently resulting in improved wound healing and a decrease in the frequency of subsequent hospitalizations and need for medication. Those who have patients who would benefit more from a selective dorsal rhizotomy or myelotomy are admitted for an open surgery, which typically abolishes the spasticity completely, thereby eliminating the need for high doses of anti-spasmodic medications. Patients are subsequently followed by both the neurosurgeon and referring physiatrist or neurologist.

Patients with complex pain disorders refractory to a medication present a special challenge to the medical community requiring the resources of a multi-disciplinary team, which typically involves a neurosurgeon, a neurologist, an anesthesiologist, a physiatrist and a psychologist. The large number of patients presenting with intractable pain, only a minority are usually appropriate candidates for a neurosurgical intervention, be it in the form of a neuro-augmentative procedure such as spinal cord or brain stimulation, or a neuroablative procedure such as a thalamotomy or DREZ procedure. The success of the intervention is more often than not dependent on the careful selection of patients, having insured that interventions of less magnitude have failed to adequately meet their needs. These procedures can only be reasonably undertaken after carefully reviewing their records and discussing the optimal management after they have been carefully examined in detail. The majority of patients are screened by the Yale Center for Pain Management before they are referred for a neurosurgical opinion and then rediscussed prior to any intervention. The results of this approach have been gratifying for many patients in that they have been able to return to productive lives free from the ravages of chronic, debilitating pain, many of them returning to gainful employment. As new and exciting therapies become available to treat these difficult conditions, it is hoped that this multi-disciplinary approach will allow for the early referral and intervention of patients who might otherwise go on to develop intractable chronic pain disorders unresponsive to any modality of treatment.

Education

The stereotactic and functional neurosurgery program directly contributes to the education of medical students and residents through teaching at the medical school level and during the course of training of residents in neurosurgery. The aim is to educate students at the various levels of their training in the ability to recognize the needs of patients with disabling conditions such as Parkinson's disease, spasticity, and chronic pain disorders. In addition, the ability to understand the fundamental neuro-anatomy and neuro-physiology is taught through a series of lectures and by participation in the variety of disorders which fall under the heading of stereotactic and functional neurosurgery. The renewed interest in the role of functional neurosurgery in treating these disorders necessitates an active role in both physician and patient education. The program at Yale is uniquely suited through its collaborative efforts with other disciplines in responding to these needs by taking an active leadership role. Dr. de Lotbinire has participated in symposia on surgical interventions for chronic pain disorders and is a member of the executive committee of the AANS and CNS section of pain.

The Stereotactic & Functional Neurosurgery Program can be reached at 203-785-2808
or email to alain.delotbiniere@yale.edu

Neurosurgery Faculty/Program Menu

Department of Neurosurgery address and phone number

http://info.yale.med.edu/surgery/neurosur/neuroonco.html
credits