Functional Neurosurgery

The conditions for which Dr Ramnarayan offers surgery include

• Movement disorders like Parkinson’s disease, dystonia, essential tremor.
• Some types of autism especially those with severe aggressive behaviour.
• Some psychiatric problems like depression, OCD, Tourette’s syndrome.
• Intractable addiction/ alcoholism
• Intractable epilepsy
• Intractable obesity
• Chronic pain especially the central post stroke pain
• Selected cases of schizophrenia.
• Cases of patients in coma (persistent vegetative state)
• Cancer pains
• Failed back surgery syndromes (Post laminectomy syndrome).
• Other types of noxious pain like osteoporotic pain, rheumatoid arthritis.
• All types of spasticity (stiffness of hands and legs) as in
• Cerebral palsy
• Hypoxic encephalopathy (such as drowning, smoke inhalation)
• Multiple Sclerosis
• Severe head injury
• Spinal cord injury
• Stroke
• Some Neurodegenerative illness
• Patients in persistent vegetative state.
• Cases of spino-cerebellar degeneration
• Patients with cerebellar involvement in Multiple sclerosis
• Refractory .angina/ Intractable heart Failure (Class 3 and 4)
• Patients with failed back surgery syndrome
• Patients with severe painful diabetic neuropathy.
• Patients with brachial plexus injury pain
• Patients with severe peripheral vascular disease (limb saving)
• Some cases of persistent vegetative state
• Urinary incontinence due to nervous diseases
• Urinary retention (non-Obstructive) due to nervous diseases
• Faecal incontinence due to nervous diseases
• constipation due to nervous diseases
• some cases of irritable bowel syndrome
• Pelvic pain in women
• Uncontrolled epilepsy
• Uncontrolled depression including suicidal tendency

Deep Brain Stimulation (DBS) is the surgery where electrodes are inserted through small holes in the skull into various parts of the body for various diseases. The electrodes are the connected through wires under the skin to a battery placed under skin below the collar bone. This battery (also called IPG) stimulates the electrodes and causes improvement in the symptoms of the patients. The common conditions where Deep brain stimulation has been found to be effective include:

• Movement disorders like Parkinson’s disease, dystonia’s, essential tremor.
• Some types of autism (aggressive types with self harm).
• Some psychiatric problems like depression, OCD, Tourette’s syndrome.
• Intractable addiction/ alcoholism
• Intractable epilepsy
• Intractable obesity
• Chronic pain especially the central post stroke pain (only few cases; has still not become routine)
• Selected cases of schizophrenia. (only few cases; has still not become routine)
• Cases of patients in coma (persistent vegetative state)

a) Movement disorders like Parkinson’s disease, essential tremor and dystonia interfere with the free movements of the body. The diagnosis is by clinical features which include tremor of the hands and legs and uncontrolled abnormal movements of the hands, legs and even the whole body. The treatment of these is initially with medications but later the medicines start becoming ineffective. So surgery is another option. The surgery that is offered is called Deep Brain stimulation (DBS) where pacemakers are introduced into various parts of the brain. The results of DBS in the properly selected patients are very good.

b) Autism is a problem of communication and has a worldwide incidence. The symptoms vary from very mild to very severe. That is why it is also called autism spectrum disorder. Other than communication issues the other problem parents face in atleast 40% of patients is very aggressive behaviour. This becomes worse as the patients grow up. By DBS those aggressive behaviour can be controlled. During this process the patient also has improvement in the autism features also.

c) Psychiatric illnesses take a huge toll of our population. Among these Depression and Obsessive compulsive disorders (OCD) are well known. Depression affects a lot of people and many end up in suicide. Medical management is very effective in many of these patients but a significant percentage does not benefit or develop side effects. Surgery is helpful in these patients. For OCD again DBS surgery is very effective. For depression DBS surgery is offered in severe cases and vagal nerve stimulation is offered in moderately severe cases. Two other conditions where DBS surgery is done are in Tourette’s syndrome and in Tardive dyskinesia. Stimulation of the vagal nerve in the neck is also done with good results. It is approved by the USFDA for depression.

d) Addiction is a huge problem all over the world. There are excellent deaddiction regimens but the relapse rates are very high. The relapse is blamed on an area of the brain called nucleus accumbens. This nucleus causes the craving. In those patients who relapse surgery could be an option. DBS of the nucleus accumbens helps these patients to get out of the addiction. The same surgery is very beneficial to people who have obesity or have failed bariatric surgery.

e) Epilepsy is both a medical and a social problem. A good majority of the epileptics do respond to drugs but not all. For these patients with uncontrolled epilepsy either DBS surgery or Vagal nerve stimulation is very effective. These surgeries control and in a few cases could abolish the seizures totally. In DBS the area of the brain called anterior nucleus of the thalamus is stimulated. In vagal nerve stimulation, the vagus nerve in the neck is stimulated.

f) Obesity and other metabolic diseases are a big problem all over the world. Bariatric surgery in the abdomen especially laparoscopically has been done in thousands of individuals but unfortunately relapse of the condition is very common. In this scenario DBS surgery has been offered and has been effective in the few cases that have been operated. More studies are being done and the ideal targets will emerge soon.

g) Chronic pain especially of central origin like after thalamic stroke is very miserable and usually resistant to medicines. In such cases DBS of the thalamus have been given with good results in some patients. Similarly the results of DBS in Schizophrenia also are promising but these are very early days.

h) DBS surgery has been tried in patients who are in a coma for sometime. There has been tremendous success in some situations but it needs a lot of refining and fine tuning before it is applied universally. Cerebrospinal fluid (CSF) is a clear, colourless body fluid found surrounding the brain and spinal cord. It is secreted in the middle portion of the brain and then travels down the brain stem and spinal cord upto the lower end and then comes back to the sides of the brain and gets absorbed there. This is therefore a local circulation of the brain and spinal cord. The advantage of this circulation is that drugs put at the lower back level will find its way into the brain without having to touch the brain. The space where the CSF is found is called intrathecal space.