Discovery

by Jaron Terry, APR

Innovative treatments for chronic disabilities ranging from movement disorders, epilepsy, stroke, headache and pain to psychiatric disorders are being developed and tested at Ohio State under the direction of world-renowned neurosurgeon and neuromodulation expert Ali Rezai, MD. Guided by the amplified sound of electrical activity in the brain, he and his colleagues in neurosurgery, movement disorder neurology, psychiatry, psychology and physical medicine and rehabilitation are performing what some patients describe as “miracles.”

Although many non-physicians are familiar with deep brain stimulation (DBS), also known as a brain pacemaker, neuromodulation actually employs a number of implantable devices and procedures in addition to DBS that can provide relief for the disabling symptoms of a range of chronic disorders and conditions,” says Ali Rezai, MD, a world-renowned neurosurgeon and neuromodulation specialist, who joined Ohio State just over one year ago from the Cleveland Clinic. While there, he performed more than 1,500 DBS procedures and thousands more neuromodulation procedures.

As director of Ohio State’s new Center for Neuromodulation, Rezai, who holds the Julius F. Stone Chair in Cancer Research, is continuing to assemble multidisciplinary teams that will provide comprehensive, integrated care in a unique format.

The Center will serve as a national leader in advancing the field. By combining comprehensive and personalized rehabilitation medicine with neuromodulation procedures, Ohio State’s program represents a fundamental shift in both specialties, that will improve the potential for recovery in patients with various neurological impairments.

“Ohio State is positioned as a world-class center for patient care and innovative research. The Center integrates and synergizes nationally recognized physical medicine and rehabilitation and neuromodulation specialists with experts in neurology, psychiatry, psychology, neuro-radiology and pain management,” says Rezai.

Deep Brain Stimulation

The modern era of DBS began in France in the late 1980s. DBS grew out of ablative techniques wherein neurosurgeons ablated – or burned away – small areas of the brain known to give rise to the involuntary movements that characterize Parkinson’s disease.

DBS does not destroy these areas. Instead, tiny electrodes – about the width of a grain of rice – are surgically implanted in the brain with microscopic precision, using cutting-edge computer and robotic guidance. Electrode wires run under the patient’s skin and are connected to a pacemaker-like battery device implanted under the collarbone. The electrodes continuously deliver tiny electrical signals that relieve the patient of the uncontrollable, uncoordinated movements that make life with Parkinson’s very difficult.

Millions of Americans learned about this phenomenal treatment through the popular CBS news program “60 Minutes,” which featured Rezai demonstrating the remarkable before-and-after experiences of his patients. That public recognition was further strengthened through the PBS series, “Wired Science,” which also featured Rezai.

Mapping Relief

“For patients who have been struggling 24/7 with disabling symptoms that progressively rob them of their quality of life and functioning, the promise – and the reality – of relief through neuromodulation is seen as nothing short of a miracle,” says Ohio State neurologist Punit Agrawal, DO, who specializes in movement disorders.

Agrawal, an expert at mapping the brain immediately prior to neurosurgical implantation of the DBS device, explains that he and Rezai can accurately place the device by actually listening to brain activity through the use of tiny hair-like recording devices. The devices are analogous to microphones that can listen to and display the electrical activity of the neurons.

“Different parts of the brain have different sounds and characteristic physiological signatures,” he says. “What we are hearing in the operating room is the sound of brain neurons speaking to each other, the actual electrical activity generated by the brain.” An opening in the skull slightly larger than a dime allows the probes to be delivered to various areas of the brain. Patients are awake in the operating room and able to respond to the surgeon’s questions during placement. In movement-disorder patients, such as those with Parkinson’s, when the electrode reaches its precise destination and electrical stimulation is applied, unwanted movements are immediately calmed.

Following nearly two decades of clinical trials, DBS was approved by the U.S. Food and Drug Administration (FDA) in 1997 for the treatment of essential tremor, in 2002 for Parkinson’s disease and in 2003 for dystonia.

Psychiatric Celebration

Radu Saveanu, MD, chair of Ohio State’s Department of Psychiatry, notes that, also in 2009, the FDA approved DBS for the treatment of obsessive compulsive disorder (OCD) under a humanitarian device exemption.

“Although we are very excited about the potential for our patients, we are very conservative in that we first want to be sure any psychiatric disorder, such as OCD or depression – that can be incredibly debilitating for patients and their family members – is intractable to medication and that cognitive behavior and talk therapies are unable to provide relief,” he says. Saveanu and colleague Stephen Pariser, MD, recently developed a program for treatment-resistant mood and anxiety disorders.

Patients suffering from OCD and chronic depression travel to Ohio State from around the country for evaluation and consideration for potential DBS surgery.

Collaborative Teams

Also key team members of Ohio State’s Center for Neuromodulation are numerous nationally recognized experts in physical medicine and rehabilitation (PM&R). These include physical, speech, occupational, vocational and exercise therapists, as well as physicians, psychologists, nurses and social workers, all of whom have special training to help patients recover from traumatic brain injury (TBI), spinal cord injury, stroke, spasticity and chronic pain, and who work closely with the Neuromodulation Center to develop a patient’s specific, and integrated rehabilitation recovery program.

W. Jerry Mysiw, MD, interim PM&R department chair, director of Traumatic Brain Injury Rehabilitation and holder of The Bert C. Wiley, MD, Endowed Chair in Physical Medicine and Rehabilitation, is looking forward to the day DBS is a routine procedure for patients with severe brain injury.

“More than half of patients who survive TBI develop a major depressive state and are much more difficult to treat than general cases of chronic depression, because they are also dealing with other debilitating and lasting effects of severe injury, including disinhibition, impulsivity, distraction and amnesia,” he explains.

“John Corrigan and others in our department are closely watching phase I clinical trials – the very earliest stage of research involving patients – where DBS might be used to help this group of patients,” Mysiw explains.

“My colleagues and I are very hopeful that DBS will help address the anxiety, depression and other psychological and cognitive effects of TBI for these profoundly injured patients because, at this point, there is no additional recovery we can offer, and they – and their families – are living very difficult lives,” he adds.

Exciting Future

“Neuromodulation today is not a first line of defense for all conditions,” notes Rezai, who has been an investigator on several National Institutes of Health-funded grants, holds 19 U.S. patents for neuromodulation, and has published more than 100 peer-reviewed articles on the subject. “Rather, it is for patients who become progressively disabled over time despite various treatment modalities, including medications and other approaches. Neuromodulation is for those with intractable disease and chronic disability that causes a decrease in quality of life and functioning.”

Neurological impairments and nervous system disorders create enormous financial burdens on the healthcare system as well as on families. Neuromodulation has the potential to reduce long-term healthcare spending as the population ages and age-related disabilities progress.

In addition to DBS, other neuromodulation devices include cranial nerve stimulators, spinal cord stimulators and peripheral nerve stimulators as well as microinfusion/drug delivery devices that are used to treat a large array of chronic neurological conditions.

“We are excited about future applications for neuromodulation at Ohio State, including research using DBS for the treatment of traumatic brain injury, addiction, eating disorders, Alzheimer’s and autism, as well as peripheral neurological pacemakers for the treatment of cluster and migraine headaches and asthma,” says Rezai. “Neuromodulation has proven to be highly effective and, for some disorders, it is the best and sometimes only hope once medication and other approaches fail and patients become progressively disabled.”

Story Summary
• Ali Rezai, MD, world-renowned neurosurgeon and neuromodulation specialist, joined the Ohio State faculty in 2009. He has performed more than 1,500 deep brain stimulation (DBS) procedures and thousands more neuromodulation procedures.
• DBS and neuromodulation show great promise in treating chronic disabilities ranging from movement disorders, epilepsy, stroke, headache and pain to psychiatric disorders.
• The new OSU Center for Neuromoduation is at the international forefront of expertise in this area and is poised to make a significant impact in numerous medical specialties.

from left: Ali Rezai, MD; Punit Agrawal, DO; Radu V. Saveanu, MD; W. Jerry Mysiw, MD; E. Antonio Chiocca, MD, PhD