Welcome to Bhagwan Mahaveer Jain Hospital


Jain Institute of Movement Disorders & Stereotactic Neurosurgery (JIOSFN)

We are one of the few such institutes in India which is dedicated for this work and has the entire infrastructure (Hardware & Software) required to perform these complex set of surgeries and treatments. We also have the best Neuro Rehabilitation team to help such patients achieve their best possible functional potential.

Our Mantra:NEURO MODULATION with NEURO REHABILITATION




Services Offered

Neuromodulation is a form of Minimally Invasive Neurosurgery (MIN)
The need for high precision surgery with a small or no skull opening and quick post surgery recovery gave birth to MIN.
Two of the big sub-specialties in neurosurgery that fall in the domain of MIN are :

  • Stereotactic and Functional Neurosurgery (SFNS)
  • Stereotactic Radiosurgery (SRS).

It is a surgical intervention to precisely locate small targets deep inside the brain & to perform actions such as Ablation (Radio Frequency or RF), Biopsy, Injections, Stimulation, Implantation, Radiosurgery, etc,. This is done by using an external 3D Frame of reference usually based on the Cartesian Co-ordinate System.


Neurosurgery that helps improving 'functioning' of patients who are 'dysfunctional' due to neurological disorders. It consists of Neurosurgery in 5 Major Categories as follows :

  • Movement Disorders : Dystonia, Tremors & Parkinson's Disease
  • Spasticity Focal or Generalised : Strokes, Multiple Sclerosis (MS), Cerebral Palsy (CP), etc
  • Pain : Severe Neuropathic Pains after Brachial Plexus Injuries, Failed Back Surgery Syndromes (FBSS), Severe Cancer Pain, etc
  • Epilepsy
  • Psychiatry : OCD, Depression, etc

Most of these diseases do not shorten the lifespan but grossly impair the quality of life and the productivity of these patients.
Inspite of significant advances in medical science, research and technology NO MEDICAL CURE OR PREVENTION MEASURES have been discovered ! Also, except for the earlier stages of Parkinson's Disease, Essential Tremors and Milder Spasticity, most of these problems do not have any medical treatment, even for effective symptom management.

This is where FUNCTIONAL NEUROSURGERY comes in to play a big role!
With NEUROMODULATION!

Many of the above problems are as a result of 'misbehaving/misfiring' electrical brain circuits! Neuro modulation attempts to correct this.


WHAT IS NEUROMODULATION ?
  • The International Neuromodulation Society defines Neuromodulation as a field of science, medicine, and bioengineering that encompasses implantable and non-implantable technologies, electrical or chemical, for the purpose of improving quality of life and functioning of humans.
  • Neuromodulation is "technology impacting on the neural interface."
  • Neuromodulation devices and treatments are life changing. They affect every area of the body and treat a wide range of diseases or symptoms from headaches to tremors to spasticity to spinal cord damage to urinary incontinence. With such a broad therapeutic scope, and significant ongoing improvements in biotechnology, it is not surprising that neuromodulation is poised as a major therapy option in the next decade.

Movement Disorders are clinically, pathologically & genetically a heterogenous group of diseases characterized by impairment of PLANNING, CONTROL & EXECUTION of movements.
There are two types:

  • HYPOKINETIC - characterized by Akinesia (paucity of movements), Bradykinesia (slowness of movements) and Rigidity (involuntary increase in muscle tone), cogwheel type (if associated with tremors). Eg: Parkinson's Disease or Parkinsonism
  • HYPERKINETIC - are disorders in which there is EXCESSIVE MOVEMENTS - either spontaneous, in response to volitional movement or to another stimulus. Most often involuntary. Eg: Essential tremors, Dystonia, Chorea, Ballism, Athetosis


The following clinical conditions are classified as Movement Disorders
DISTONIAS
Dystonia is a Movement Disorder in which a person’s muscles contract uncontrollably. The contraction causes the affected body parts twist involuntarily, resulting in repetitive movements or abnormal postures. Dystonia can affect a single muscle, one muscle group or the entire body. The following types of Dystonias can benefit from Stereotactic Functional Neurosurgery :

  • Spasmodic Torticollis
  • Generalised Dystonia
  • Axial / Segmental Dystonia
  • Focal Hand Dystonia (Writer’s Cramp, Occupational Dystonia (Barber’s Dystonia), Muscician’s Dystonia, etc)

TREMORS
Tremors can be either Rest or Action Tremors.
Types of Tremors that benefit from surgery include :

  • Tremor Dominant Parkinson's Disease
  • Essential Tremors
  • Post MS (Multiple Sclerosis) Tremor
  • Post-stroke Tremor
  • Post Head Injury Tremor
  • Dystonic Tremor


SPASTICITY
Spasticity is a feature of altered skeletal muscle performance with a combination of paralysis, increased tendon reflex activity and hypertonia. It is also colloquially referred to as an unusual "tightness", stiffness, or "pull" of muscles.
Spasticity is a frequently encountered clinical condition. Spasticity may be either useful -by compensating decrease in motor strength - or harmful - by limiting both passive and active motion and, in the extreme, by leading to irreducible contractures and deformities - or as in most cases and harmful and useful in the same patient. A large population of adults and children in developing countries and in wealthy societies as well is suffering from this locomotor disability.
Excess of spasticity leads to a disability that is marked by impaired locomotion and, if not controlled, handicapping deformities, discomfort, and pain. When spasticity is disabling, an effective therapeutic armamentarium is currently available. If spasticity fails to be controlled by relaxant medications and physical therapy and escapes rehabilitation programs, neurosurgical procedures aiming to diminish the excess of tone and rebalance agonist and antagonist muscle groups can be the remedy. They may help improve function and limit irreversible deformities. Complementary orthopedic surgical corrections are often required though.
Spasticity should only be treated when excess of tone leads to further functional losses, impairs locomotion and motricity, or induces deformities. Spasticity is often treated with the drug Baclofen, which acts as an agonist at GABA receptors, which are inhibitory. Spastic cerebral palsy is the most common form of cerebral palsy, which is group of permanent movement problems that do not get worse over time and hence benefits from surgical interventions.
Targets of lesioning procedures are:

  • The Peripheral Nerves (Neurotomies)
  • The Spinal Roots (Dorsal Rhizotomies)
  • The Spinal Cord (Myelotomies)
  • The Dorsal Root Entry Zone (DREZotomy)
Neuromodulation treatment with Intrathecal Baclofen can be achieved thanks to modern technology, namely, the computerized Programmable, Implantable, Pump (ITB). However, before performing any such surgeries, a trial of Chemodenervation with Botulinum Toxin (Botox) followed by intense and aggressive Neuro Rehabilitation is critical.


PARKINSON'S DISEASE (PD)
Parkinson's Disease (PD) is the most common Neurodegenerative cause of Parkinsonism, a clinical syndrome characterized by lesions in the Basal Ganglia, predominantly in the Substantia Nigra. PD makes up, approximately 80% of cases of Parkinsonism.
Levodopa is the mainstay in the Medical Management.
There are two types of Parkinson's Disease :

  • Tremor Predominant - Unilateral and Slow to Progress
  • Rigidity - Bradykinesia Predominant - early bilateral & relatively rapid progress.
Parkinson's Disease has both Motor Symptoms and Non Motor Symptoms. Every Parkinsonism patient needs a detailed clinical evaluation by a specialized Movement Disorder neurologist and have his UPDRS assessments done. Every patient will need a Levodopa challenge test before qualifying them for surgical intervention
Every patient with Movement Disorders & Spasticity will need to be evaluated in detail by a qualified Movement Disorders Neurologist who will establish the right diagnosis, assess the severity of symptoms (by standardised scales) and decide on the need, benefit and timing of surgery.


MOVEMENT DISORDERS SURGERY

  • LESIONING - RF Ablation
  • STIMULATION - DBS - Deep Brain Stimulation


LESIONING SURGERY FOR MOVEMENT DISORDERS OR RF ABLATION Radio Frequency Ablation or RF Lesioning (Thalamotomy/Pallidotomy), reduces the symptoms of movement disorders though the permanent inactivation of a precisely targeted region/ circuit of the brain. Principal targets of this therapy are the Thalamus and the Globus Pallidus, two areas of the brain involved in movement.
RF procedures continue to play a role even in patients for whom DBS is the ideal surgery but is contraindicated or who would have difficulty maintaining the DBS device. This is also very cost-effective and in well selected cases, the results are excellent. All Movement Disorders surgeries are done with the patient FULLY AWAKE! Constant feedback is obtained from the patient during surgery.


COMMON LESIONING SURGERIES

  • Pallidotomy or Pallidothalamic Tractotomy (PTT)
  • The pallidal target is used for the surgical treatment of both Dystonia and Parkinson's Disease.
    Pallidotomy has been reported to be effective in various dystonic disorders, including generalized dystonia, segmental dystonia, and hemi-dystonia, yielding about 50-80% improvement in most studies. Patients with genetic dystonias (both DYT-1 positive and DYT-1 negative) consistently demonstrated marked improvement, whereas this was less dramatic and less consistent in secondary dystonia. Whereas improvement of phasic dystonic movements may be seen early after surgery, tonic dystonic postures improve over much longer time, sometimes upto 6 months.
    Pallidotomy for PD, reduces the brain activity in that area, which may help relieve movement symptoms such as tremor and stiffness (rigidity). Before surgery, detailed brain scans using MRI are done to identify the precise location for treatment.
    Pallidothalamic Tractotomy (PTT) is a therapeutic lesion of the Pallidothalamic Tract in the fields H1 and H2 of Forel in patients with Parkinsonian signs. PTT is an effective treatment for chronic therapy-resistant Parkinson's disease, improving symptoms in both on- and off-conditions.
  • When & Why Is pallidotomy or PTT done?
  • Pallidotomy or PTT may be done when a person with advanced Parkinson's Disease has :
    Developed severe motor fluctuations, such as Dyskinesias and On-off Responses, as a result of long-term Levodopa treatment.
    Severe or disabling tremor, stiffness (rigidity), or slow movement (bradykinesia) that medicine can no longer control
  • How well does PTT Work ?
  • Pallidotomy or PTT may reduce tremor, muscle rigidity, slow movements, and other motor symptoms of PD. Balance and speech may also improve. It is not known how long the effects of pallidotomy or PTT can be expected to last. Benefits may fade over time in some people more due to the progress of the disease.


STIMULATION SURGERY FOR MOVEMENT DISORDERS OR DEEP BRAIN STIMULATION (DBS)
DEEP BRAIN STIMULATION (DBS) OR BRAIN PACEMAKER
This is a neurosurgical procedure introduced in 1987, involving the implantation of a medical device called a neurostimulator (sometimes referred to as a 'brain pacemaker'), which sends electrical impulses, through implanted electrodes, to specific targets in the brain (brain nuclei) for the treatment of movement and neuropsychiatric disorders. DBS in select brain regions has provided therapeutic benefits for otherwise-treatment-resistant disorders such as Parkinson's Disease, Essential Tremor, Generalized Dystonia, Chronic Pain, Major Depression and Obsessive Compulsive Disorder (OCD).
DBS directly changes brain activity in a controlled manner and its effects are reversible.
The deep brain stimulation system consists of three components: the implanted pulse generator (IPG), the lead, and the extension. The IPG is a battery-powered neurostimulator encased in a titanium housing, which sends electrical pulses to the brain to interfere with neural activity at the target site.
A hole about 14 mm in diameter is drilled in the skull and the probe electrode is inserted stereotactically. During the awake procedure with local anesthesia, feedback from the patient is used to determine optimal placement of the permanent electrode. The right side of the brain is stimulated to address symptoms on the left side of the body and vice versa.


Our Consultants

Movement Disorders & Stereotactic Neurosurgery
(A Unit of Bhagwan Mahaveer Jain Hospital)

 
  Tel: +91 9738663330
  Email Id: drsharan@gmail.com
  Website: www.jiomsn.com