5 Recent Neurosurgery Advances That Improve Patient Outcomes

Neurosurgery is bathed in a mystique that, while perhaps beneficial to the typical neurosurgeon’s ego, does little to advance a critical field or enhance potential patients’ understanding of its present status, limitations and capabilities. With that in mind, this list of five recent neurosurgery advances that may legitimately improve patient outcomes (or, in some cases, have already done so) is useful reading for anyone who wishes to learn more about the discipline.

  1. Gamma Knife Surgery

Gamma Knife surgery is a form of radiosurgery that utilizes focused beams of radiation to target a small abnormality within the brain. The technique is typically used to treat brain tumors and arterio-venous abnormalities for which open surgical intervention is not optimal or practical. The key innovation of Gamma Knife is its ability to target very specific areas without harming neighboring tissues. This powerful result is achieved with about 200 small beams of radiation that, taken by themselves, have almost no effect on the tissue that they pass through. The point at which they meet, however, receives a meaningful dose of radiation that can shrink tumors and/or treat potentially harmful abnormalities.

  1. Cyberknife Surgery

Cyberknife is a robotic surgery system that, similar to Gamma Knife surgery, utilizes the basic principles of targeted radiosurgery to achieve clinically meaningful results with fewer complications and improved patient outcomes. The Cyberknife uses a linear particle accelerator that can be directed at any area of the body and targets focused anomalies without harming intervening tissues. The robotic component provides critical stability and control, further minimizing the risk of complications.

  1. Physician-in-Training Assists

Historically, experienced clinicians have worried about the presence of inexperienced physicians-in-training in the operating room. While physicians-in-training provide critical assist functions and play important support roles during complex surgery, their presence is often viewed as a distraction or, worse, active impediment to favorable outcomes. New research puts this theory to rest: An exhaustive study by Johns Hopkins found no uptick in rates of complications or death when physicians-in-training are present in the operating room.

  1. Optical Coherence Tomography

Optical coherence tomography (OCT) is a groundbreaking imaging technology that dramatically improves clinicians’ ability to identify neurological structures and diagnose specific disorders with a high level of confidence. It is the latest in a series of technological breakthroughs, complementing functional MRI, CT and PET imaging techniques. Though outcomes vary depending on numerous factors, including clinician competency, OCT is substantially less time-consuming than MRI work.

OCT is particularly promising for cancer diagnosis, where it is critical to distinguish healthy from cancerous tissue with high degrees of specificity. Its ability to produce color-coded maps leads directly to superior surgical outcomes, as surgeons using OCT are better able to achieve clear margins without unnecessarily removing healthy tissue.

  1. Stereotactic Neurosurgery

Stereotactic surgery applies a simple concept to a formidably complex activity: minimally invasive neurosurgery. Using a three-dimensional coordinate system that accurately maps the neurological environment, stereotactic neurosurgeons can pinpoint tiny targets within the brain and central nervous system at a stunning level of accuracy. Stereotactic techniques can be used to identify areas for virtually any time of surgical intervention, including Gamma Knife radiosurgery, biopsy and ablation.

Outcome Based Medicine: Definition & Hidden Perils

The concept of outcome-based medicine is increasingly viewed as critical to the future of the American healthcare system. Outcome-based medicine featured prominently in the debate surrounding the drafting and implementation of the Affordable Care Act, and continues to play a role in discussions of healthcare policy in health systems and among local, state, and federal government bodies. Patients and providers alike would do well to review the concept, its benefits and potential perils that could counteract any perceived advantages.

What Is Outcome-Based Medicine?

Outcome-based medicine is as it sounds: a system of medical care delivery that emphasizes positive patient outcomes. In the United States, outcome-based medicine further describes a payment model in which providers are purportedly compensated in a manner that incentivizes quality care delivery and positive patient outcomes, rather than providing flat payments for services rendered (the status-quo arrangement for U.S. healthcare).

It is important to note that outcome-based medicine is not evidence-based medicine, which describes a clinical approach rather than a reimbursement system. Evidence-based medicine is widely regarded as a best practice for medical providers across the specialty spectrum and is not a subject of serious debate within the community.

Perceived Benefits

Though some may seem obvious, the perceived benefits of outcome-based medicine bear repeating:

  • Improved patient quality of life
  • Fewer compensatory interventions aimed at rectifying negative outcomes
  • Enhanced trust between patients and providers (i.e. patients do not assume that doctors are simply rendering services to pad billings)
  • More emphasis on preventive care and minimally invasive interventions

Hidden Perils

It is worth exploring the hidden perils of outcome-based medicine as well. In many cases, and perhaps in systematic fashion, these perils may outweigh any perceived or real benefits of an outcome-based approach.

In particular, outcome-based medicine raises a substantial moral hazard. Providers are not omniscient and can’t know to any degree of certainty — other than what they can directly observe in a clinical setting — what their patients are doing when they’re not being monitored.

This is particularly problematic for patients whose recommended treatment courses require proactive (or simply active) work on the part of the patient. For instance, a patient who fails to take a necessary medication and subsequently suffers an adverse outcome may indirectly affect his or her provider’s reputation and income through no direct fault of the provider.

As of yet, there is no systematic answer for this moral hazard. Given what we know about human nature, it seems unlikely that one will arise in the foreseeable future. This, in a nutshell, is the Achilles’ heel of outcome-based medicine — and an indication that, at minimum, the medical community must carefully weigh the obvious need for positive outcomes against the potential risks of blithe adherence to a particular compensation framework. There is a significant risk that patients with lower income and more complex problems will be discriminated against and lose access to care.

A Changing Medical Landscape
The platitude “the only constant is change itself” applies perfectly to the concept of outcome-based medicine. Even the most astute and well-prepared observers remain unsure as to how the concept will develop and change in response to new governmental directives, changing modes of care and other factors — some of which may be unknown to us at present. That said, patients and providers must prepare themselves mentally and professionally for a future in which medical care looks very different — and produces very different results — than it does currently.

Parkinson’s disease Treatment and Management Options

Parkinson’s disease is a common neurological disorder with which many Americans are familiar, if not personally knowledgeable because of family members. The disorder is given substantial visibility by afflicted celebrities, including Muhammad Ali and Michael J. Fox, as well as by its relatively common occurrence and striking symptoms.

Parkinson’s disease is a complex disorder for which current treatments focus largely on symptom management. It remains frustratingly resistant to wholesale control and intervention. That said, ongoing research and clinical work is pushing the bounds of our understanding of and relationship with Parkinson’s disease. Let’s take a look at what we know about the disease and its prevention, management and potential interventions.

What Is Parkinson’s disease?

Parkinson’s is a progressive disorder marked by symptoms that worsen over a period of years or decades. Symptoms typically present after the age of 50, though “young onset” Parkinson’s is also recognised. Symptoms present in several distinct forms:

  • Movement-related issues, such as shaking, rigidity, slowness, and difficulty walking or talking
  • Behavioral problems
  • Cognitive problems, including dementia in later stages of the disease
  • Depression or other psychological issues

Potential Preventive Measures

The research around Parkinson’s prevention is mixed at best. Many studies or areas of inquiry have been contradictory and inconclusive. Hard-and-fast claims that “X prevents or reduces the risk of Parkinson’s” should be taken with a sizable grain of salt.

That said, two of the most promising areas of inquiry involve common stimulants: caffeine and nicotine. Caffeine studies have shown a statistically significant reduction (>30% at >95% confidence) in Parkinson’s incidence among otherwise healthy individuals who consume large amounts of coffee. (It’s not at all clear whether caffeine, another substance, or a combination of substances found in coffee contribute to this effect.)

Somewhat less conclusive studies suggest that tobacco users, and specifically tobacco smokers, develop Parkinson’s at lower rates than non-smokers. However, whatever preventive effect tobacco use may have with regards to Parkinson’s should not be construed to outweigh the myriad well-known adverse effects of smoking.

Drug Management

Depending on the disease stage and symptom progression, various classes of drugs are suitable for managing Parkinson’s symptoms and complications. These include:

  • Sinemet–Levodopa/carbidopa
  • Dopamine Agonists Requip Mirapex Neupro
  • Symmetrel—-increases amount of dopamine available for brain
  • Anticholinergics Artane Cogentin
  • Eldypryl and Azilect MAO-B inhibitors help conserve the amount of dopamine
  • COMT inhibitors—-Tasmar,  Comtan     dopamine is retained

Surgery and Other Interventions

One particularly promising area of Parkinson’s management is deep brain stimulation (DBS), a technique pioneered by Dr. Louis Benabid and others in the 1980s and 1990s, and performed by Dr. John Gorecki, MD. DBS uses a device commonly known as a “brain pacemaker” to stimulate the thalamus, subthalamic nucleus or globus pallidus and control the common motor symptoms of Parkinson’s disease.

Looking Ahead

So far Parkinson’s disease cannot be “cured” like syphilis, tuberculosis or other once-devastating bacterial infections. For the foreseeable future, Parkinson’s treatment will focus on the  management of symptoms. But that should not lead anyone to despair. The progress of research is slow, however, so much more can be offered to patients today compared to 40 years ago or even 10 years ago. For those of us who know someone who suffers from the disease or who worry about developing Parkinson’s, it is an exciting time to be involved in research and treatment, and that elusive breakthrough may yet materialize on the horizon.

A Brief Overview of Epilepsy Morbidity, Presentation & Treatment

Epilepsy is a serious disorder that affects people of all ages and varies widely in its presentation. Unfortunately, a considerable amount of misinformation and stigma continues to surround epilepsy patients and clouds our collective understanding of the disorder’s morbidity and treatment.

Whether you are a parent looking to learn more about treatment options for your children or an aspiring medical professional like John Gorecki MD, looking to separate the facts from the spin, it is worth taking some time to study epilepsy. What follows is a high-level look at epilepsy that, properly used, can serve as the basis for further research and understanding.

An Ancient Disorder

Epilepsy’s ancient pedigree is evident in its name: “Epilepsy” is an ancient Greek word that roughly translates as “to seize” or “to possess.” As one might expect, the ancient world’s relationship with epilepsy was very different from our modern conception of the disorder. Epilepsy and its most obvious symptom — epileptic seizures — were largely seen as a supernatural affliction signifying some sort of imbalance in the universe. Sufferers were often actively ostracized or even subjected to violent persecution, though records of how systematic and widespread such treatment was are difficult to come by.

Presentation and Morbidity

As one of the first widely recognized and diagnosed neurological afflictions, epilepsy has been studied with some rigor for hundreds of years. Epileptic seizures are classified as idiopathic or secondary. Idiopathic seizures have no identified underlying cause or abnormality seen on MRI. Secondary seizures have an underlying cause such as scar or tumor and are also described as lesional seizures.

Epileptic seizures vary in duration and intensity, with more severe seizures involving a substantial risk of aspiration and other potentially life-threatening complications. Causes vary widely; some patients evidence a genetic predisposition, while others appear to develop symptoms after sustaining a neurological injury.

Treatment Options for Patients of All Ages

Separately from acute interventions designed to minimize serious or life-threatening side effects, epilepsy treatment options include:

  • Medication (beneficial in about 70% of cases)
  • Standard or minimally invasive (stereotactic) surgery
  • Neurologic stimulation (various nerve centers, vagal nerve stimulation)
  • Ketogenic diet (high-fat, low-carbohydrate, adequate-protein)
  • Removal of indirect triggers, such as rapid-frame blue light

Cutting-Edge Research May Hold New Promise

There are several promising avenues for epilepsy research, some of which may soon result in new treatments or intervention options. In particular, minimally invasive stereotactic surgery appears to have similar or even superior outcomes to standard surgery without the attendant risks and long-term effects of more invasive interventions. Additionally, EEGs are being used with increasing accuracy to predict seizures and pinpoint their source, though no systematic prediction scheme has yet been achieved.

It is clear that the final chapter in the story of epilepsy has yet to be written. However, our understanding of this affliction is more complete and nuanced than at any time in history. As such, the future for the treatment and management of epilepsy looks brighter than ever before. That is certainly hopeful news for millions of epilepsy sufferers around the world.