Recent Advances in Spine and Neurosurgery

The main issues over time are battery depletion (non-rechargeable batteries need changing every 5 to 7 years, rechargeable systems last around 15 years), electrode disconnection or failure from trauma or mechanical wear, and the need for settings adjustments as the disease progresses. Patients need periodic visits for reprogramming, though newer devices allow remote setting changes via mobile. Battery change is the most common long-term issue.

We always start with medication at a lower dose, increasing gradually to control symptoms. The ideal time to move to DBS is around 4 to 5 years after diagnosis, when the required dose is becoming too high, side effects are a problem, or the medication effect is fading — DBS at that stage can abolish or significantly reduce the drug requirement and restore quality of life. At our hospital, the total package including surgery, anaesthesia, device, medicines, testing and hospital stay runs approximately USD 30,000 to 35,000, with the variation depending on rechargeable versus non-rechargeable devices.

For spine surgery, major complications run around 2%, life-threatening complications around 0.5%, and neurological deficit around 1 to 1.5% — 98% of patients do well, 90% do very well, at a centre doing 400 to 500 spine surgeries a year. Patients should understand that surgery corrects the structural problem but can't always undo pre-existing nerve damage, so some residual tingling or numbness may persist even in a good outcome. For brain surgery, mortality is around 1 to 2% and total risk of neurological deficit is 5 to 7% at expert centres, with 93% of patients doing very well after tumour removal — the main caveat is that malignant tumours can recur despite surgery, since resection alone isn't curative and radiotherapy and chemotherapy are also required.

Complete spinal cord injuries will not result in complete neurological recovery, and some patients recover only minimally. What we can address is the secondary symptoms: pain and spasticity, managed with baclofen or morphine pumps, and dorsal cord stimulators, which can improve sensation and reduce spasticity, with some incomplete-injury patients regaining a degree of leg power combined with physiotherapy. If hand function is preserved, we train patients to manage daily life with their upper limbs and a wheelchair. But for complete injuries specifically, meaningful motor recovery is not something we can promise.

I conducted a study on this myself — we took stem cells from the iliac bone and implanted them at the injury site in around 20 patients. One patient showed some improvement, but it couldn't be separated from natural recovery under medication, and statistically we found no significant benefit. We discontinued the trial. Stem cell therapy for complete spinal cord injury is still not recommended anywhere in the world; for partial injuries there may be some benefit, but meaningful recovery from stem cells in complete injuries has not been demonstrated.

He is Vice Chairman and HOD, Neuro Surgery and Neuro Spine at BLK-Max Super Speciality Hospital, New Delhi. This was his second masterclass with the Jivo doctor network.

The series covers percutaneous discectomy, kyphoplasty and cervical disc replacement, endoscopic brain procedures including third ventriculostomy and colloid cyst removal, deep brain stimulation for Parkinson's disease, microvascular decompression for trigeminal neuralgia, Gamma Knife radiosurgery and robotic spine surgery.

Yes, it includes the complication data a referring doctor can use to counsel a patient who is frightened about undergoing spine or brain surgery.

It closes with Dr. Kansal's answers on how far DBS extends into epilepsy and psychiatric disease, a realistic prognosis for complete spinal cord injury, why stem cell therapy for spinal cord injury was tried and abandoned at his own centre, and why doctor-to-doctor communication changes outcomes for patients referred from Africa.