Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

OK, so we're now live. Hello, everyone and welcome back to your anatomy collaborative. I'm my, the chair of the collaborative this year and I'm delighted to present our series for this year. Today. We have Mr Heart section two session, four of our speaker series this year, I'll now hand over to Paul who will be inducing our speaker for today. Hi, everyone. Er Thank you very much for joining this evening. So as Marama briefly mentioned, we're running this set series on Medal this year, which means that we have a live audience from all over the world. And we've also decided to rejig the structure of our talk slightly as we work up anatomically from the spinal cord and brain stem and upwards. In the second session of this year's talk, we have now covered the pituitary gland, basal ganglia and cerebellum and to begin to bring all that we have learned together. I'm excited to introduce our speaker for today's session on deep brain stimulation. Mr Michael Hartt Michael is a consultant and senior electorates in George's Hospital with a particular interest in functional neurosurgery. He holds a phd in brain mapping from the University of Cambridge and leverages cutting edge neuroimaging methods to better understand both disease mechanisms and improve patient outcomes. And I'll hand over to him now. Uh Great. Thanks very much. Um So I can't actually see anyone. Um So hopefully you'll enjoy this. Um And if you have any questions then, well, I can't see the chat but hopefully you can speak or just say something. I I'm happy just to um discuss on the way. So don't worry about sort of interrupting my flow or um making things last longer. Do just ask questions as we go along? Hopefully that will work well. Um So a few disclosures but nothing relevant uh to today. Uh Quick bio about myself. Um just because sometimes it's interesting to know about um how people got places um for your own career. Um So this is my journey. So it took some time uh after medical school. That's um fairly par for the course for neurosurgery. You've got to enjoy the journey, not be in a race to get there. Um So the key things are I did something called an FT S ta which now we kind of call an fy three year. It's great, thoroughly recommend it. II wasn't sure between neurology and neurosurgery. I enjoyed them both. That was how I got my uh experience and I was able to make a decision to get into neurosurgery. Uh did my training II wasn't an academic uh trainee. So, um an N HR ACF or CL uh but I did want to do research. So I did a phd um as a sort of inte component of my uh training. And then I did a few fellowships in different areas, some intl with training uh enveloped as they say nowadays and then some at the end. So post CCT, which I thoroughly recommend as well as one in the unit that you want to work in. It's good just to um meet everybody that trial by Sherry and uh see if you fit if the unit fits you um and vice versa. And um that's how I ended up where I am. Um I also changed directions. So up until about this point, I was very much focused on neuro oncology. Then I moved towards uh functional neurosurgery um for a variety of reasons, but it's possible to do that. Some people are very set on one thing right from the start, some from later on. Um Both are fine. Um So brief overview of functional neurosurgery. It encompasses the treatment predominantly of movement disorders, uh pain and epilepsy, but also psychiatric indications. They're still there very much in North America and Europe and spasticity um which isn't always done by functional neurosurgeons. Uh So there's a bit of overlap between these. Now, in terms of the actual treatments, the sort of um rules rice of our treatments is DBS uh for movement disorders, but there's also lesions, different ways of doing that in pain. Um there's a variety of neuromodulation techniques. So, stimulators of which spinal cord stimulation is the most common, but there's a whole variety of others. Deep brain stimulation was initially used for pain, some early uh results there. And now it's not um in a variety of other techniques in epilepsy, you've got um a combination of resective therapy um which sort of overlaps with neuro oncology. Um Some other procedures looking to reduce seizure burden and the neuromodulation, which in the UK is really just vagal nerve stimulation and then spasticity. A variety of techniques depending if you're um uh dealing with adults or the pediatric population. And some of these are found in the NHS. Some of them are not. And one of the many um enjoyments of function in neurosurgery is you're operating in so many different parts of the body, not just the brain, not just the spine, but the peripheral nerve. Um Here you've got your dress, um D RG stimulation, your intrathecal pumps and peripheral nerve stimulation as well. So you get a whole variety of different operations, you need to get chest right. In terms of learning objectives. For today's talk, I'd hope um you could gain from this the appreciation um of the evolution of deep brain stimulation. Understand the underlying neuroscience, apply surgically relevant anatomy uh and understand the principles of surgery and use the above to make some sensible decisions about patients and how to treat them and in terms of the knowledge level, I think there's really only two for functional neurosurgery, there's everything up to fellowship and then there's full scholarship. So this is the same talk I'd give to school students, to medical students, to neurosurgery, trainees doing their exam because this is the point where you, you don't actually have responsibility for the patient. You're seeing patients, you're assessing them. But those final decisions and operations and that specialty where this is the bulk of your practice isn't there. Once you do that full CD fellowship and this is what you do day in day, there's different concepts and uh questions that you want to ask and uh issues that you appreciate. And up until that point when you're actually doing it day to day, the nitty gritty, it's harder to appreciate. Um So that's not what we're going to be covering. This isn't a how to do DBS. It's not gonna give you a certificate in being a functional neurosurgeon, but it's gonna give everything up to there. So, uh I think that's all relatively straightforward. So first of all, what is deep brain stimulation? It's good to have that um in a nutshell um description of it and there isn't really one out there, but this is what I call it accurate placement of electrodes and subcortical structures to affect neural function somehow it's treatment for quality of life. So this isn't life saving therapy. Uh It's typically for movement disorders these days, that's the bulk of um everyone's practice and it's a branch but not the only branch of functional neurosurgery. And this is our unit here. Uh We are the newest unit in the UK. These are my two senior colleagues, Professor Morgante, uh Mr Pereira here, the neurology and neurosurgeons who set up the surgeon. This is our first patient uh looking very well a couple of years back now. Uh but this is still a new service. It's been around less than a decade. In terms of the kit you're looking at leading the brain, a battery and some connecting cables. That's it in a nutshell. If you want to expand upon that or the lead itself has got a variety of different electrodes which actually deliver the stimulation. The lead itself is insulated platinum, meridian coated wires. You've got an anchoring device to hold it onto the skull. These connecting cables are called extensions. There's various techniques of these and the battery itself is more than just a battery because it's not just a cell to deliver charge, it's a communicator, it's a quartz crystals and time things and you can adjust it um frequency pulse within amplitude depending on how you want for the patient. So that's why we call it an implantable pulse generator IPG and then you can go next level and embellish upon all of these with different manufacturers and their technology as well. So, deep brain stimulation, how did we get where we are at the moment. I think this is very important to understand. Um, otherwise you're very much technically learning the procedure itself, rote learning it. But if you can understand how we've got here, then you can, uh, you've got that deeper, understanding, more satisfaction. It's interesting in itself and you can understand why we're going in certain directions and why certain things have been dead end. So to make deep brain stimulation an effective therapy, we need to understand essentially four pillars of what we're doing. Uh One is um the surgery for movement disorders. Second is understanding how we use electrical stimulation in the brain to treat patients. Third is how do we get at least in accurately in deep structures that we essentially can't see. Uh the fourth is well, um what's actually happening in the brain? We want to modulate or change what are the basal ganglia circuits? So, first of all surgery for movement disorders. So, Parkinson's disease is described here in London, James Parkinson and initially there wasn't any therapy. And then the first UK neurosurgeon, Victor Horsley er started doing procedures for it. So, right back from the very beginning and what he was doing here was essentially doing um a topectomy of your primary motor cortex and capturing the subcortical structure or the subcortical white matter there gives you hemiplegia. Why would you do that? Why would you give somebody a hemiplegia or uncontrolled tremor means that you're falling off your chair, you can't sit up, you're shaking that bad. You can't feed yourself, you can't do anything. It's awful if you give yourself a hemiplegia, at least you can sit still and somebody can feed you. So that's the stage that we were at. That was a very morbid procedure, um extirpating the entire motor cortex. So people refine that. And one of the next evolutions to hear is something called a pedunculotomy. So, the cerebral peduncle, OK. Or cross cerebra in the midbrain essentially is uh carrying your cortical uh spinal fibers. OK. So, from your pyramidal tracts and other tracts as well as it becomes uh the pyramidal tractor.