April is the Parkinson’s Disease (PD) awareness month, commemorating the prevalence of this extremely tenacious, incapacitating and difficult-to-treat chronic degenerative neurological disease.
What is Parkinson’s Disease?
Ever since the description of shaking movements and stooping in certain individuals as ‘paralysis agitans’ by Dr James Parkinson in his famous ‘essay on shaking palsy’ in 1817, Parkinson’s disease has remained the source of great intrigue among patients and doctors alike, mainly due to its relentlessly progressive nature and tenaciousness. Parkinson’s disease is primarily characterized by shaking movements in hands and legs, stiffness, slowness of activities, difficulty in walking, reduced facial expression, softening of voice, among other symptoms. Contrary to common belief, it is rarely genetic and is usually sporadic in occurance in majority of cases.
Conventional management of Parkinson’s Disease
A person with any or all of the above symtpoms is to be initially evaluated by a movement-disorder neurologist and the diagnosis is mainly clinical. A combination of progressively increasing antiparkinsonian-medications along with structured neuro-rehabilitation tides over the first few years. However, with progression of the disease, the efficacy of medicines gradually declines and becomes unpredictable. Eventually the patient tends to become dependent on his care-givers to a large extent, even for his/her routine activities of daily living, thus becoming a source of great economical and psycho-social burden on the care-givers.
Is there a scope for surgery?
Surgical intervention for a cohort of such patients who are suffering from advanced Parkinson’s disease is advised to improve their quality-of-life as well as significantly reduce the need of anti-Parkinsonian medications.
Historically, ‘ablative’ surgeries targeting certain specific brain-areas (depending on the symptoms) were in vogue. However, the concern with such a surgical approach (causing permanent tissue-damage) was in its irreversibility and lack-of-adjustablity so as to counter the progressive nature of the disease.
Thus, emerged the necessity of a reversible and adjustable surgical therapy commensurate with the progressive nature of the disease, which is known as Brain-Pacemaker surgery or Deep Brain Stimulation (DBS) surgery. It is an esoteric therapy whreby a neurosurgeon implants a device that sends electrical signals to specific brain areas, depending on the disease being treated and which can be ‘programmed’ or modulated with time in synchronization with disease progression so that long-term symptoms-control can be achieved.
Since the clinical elucidations by Dr Benabid, who was a pioneering figure in popularizing deep brain stimulation therapy starting in the late 1980s, advanced Parkinson’s Disease is by far the most commonly addressed anomaly for brain pacemaker surgery.
The sine-qua-non for a successful brain-pacemaker surgery is its precision and sub-millimetric accuracy. To this end, the inculcation of cutting-edge technological advances in the conduction of a deep brain stimulation surgery stands to logic.
One of the foremost innovations used in clinical practice of brain-pacemaker surgery is patient-specific direct targeting of neural-circuits (comprising of white-matter pathways interspersed with grey-matter relay stations), which is an emerging approach for refractory Parkinson’s Disease patients as the next step forward. Given that the efficacy of deep brain stimulation surgery probably depends on precise and accurate targeting of these brain-circuits, better surgical planning using information obtained from advanced brain-imaging MRI technologies such as fibre-tracking methods (for example DTI: Diffusion Tensor Imaging), has shown to improve steadily surgical outcomes.
Recently, we performed India’s first successful Robotic brain-pacemaker awake-neurosugical procedure in an intractable Parkinson’s disease patient. Robotic Deep Brain Stimulation (R-DBS) surgery gives the advantage of not only reducing dependence on manual adjustments, but also enhancing overall surgical efficacy.
The application of Artificial intelligemce (AI) via machine learning holds great promise in certain salient aspects of brain-pacemaker surgery such as patient selection, surgical targeting and eventual brain-pacemaker programming optimization.
Another ingenuous technological aspect being explored is a real-time watch-dog feedback analysis of the local field potentials by the brain-pacemaker pulse generator itself which would then automatically release a closed-loop anticipatory stimulation response, as and when needed, back to the brain so as to alleviate any unpredictable manifestation of PD sypmtoms as far as possible. This technology holds the promise of obviating the need of frequent physician-dependent manual brain-pacemaker programming sessions, which were hitherto mandatory following ‘conventional’ brain-pacemaker surgery.
Remote-controlled satellite-aided modulation of the brain-pacemaker straight from the physician’s desk, enabling the fine-tuning of the DBS device of patients sitting at far-off places in the comfort of their living rooms, without the need to travel long-distances for follow-up programming sessions, has proved to be a game-changing innovation as well, by improving overall patient-compliance to this therapy.
In conclusion, a seemless blend of state-of-the-art technological innovations with the quintessential ‘Human-Touch’ (including proper case-selection, adequate target-planning, detailed intra-operative electro-physiological and neurological assessments) is necessary towards accomplishing a successful Brain-Pacemaker surgery and consequently improving the quality-of-life of thousands of severely disabled advanced medications-resistant Parkinson’s disease patients. A balanced holistic approach, including minimal medications, regular exercises as well as appropriate brain-pacemaker neuromodulation, serves best in bringing back such socially ostrasized patients into productive mainstream.
Views expressed above are the author’s own.
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