Question 1

Can deep brain stimulation (DBS) help patients with epilepsy, chronic pain or psychiatric disorders?

Dr. Anil Kumar Kansal · Accepted Answer

We do place electrodes for intractable seizures, but not routinely, because other methods are still better. In epilepsy, if we find a lesion, we remove it, or perform a medial temporal lobectomy; sometimes we do a hemispherectomy. If that does not work and no focus can be found, we can place electrodes in the anterior thalamus. In about 70 to 80% of patients it works, and in about 30% it does not. For uncontrolled epilepsy with no identifiable focus there are two options: vagal nerve stimulation or electrode placement.

We have also done a few cases of frontal DBS for psychiatric disorders, but the results are variable: sometimes it works. Patients need to understand that these procedures are not curative. They can control the symptoms, the patient still has to take medication, and the results are not 100%.

Question 2

Is there any major drawback of DBS after 10 or 15 years?

Dr. Anil Kumar Kansal · Accepted Answer

The major problem is the battery. With a non-rechargeable battery, it usually has to be changed after about 5 to 7 years, depending on the settings; a rechargeable battery lasts around 15 years. Second, after trauma or some other event, an electrode may disconnect, or the electrodes may fail. Third, the patient's settings may need to be changed, so patients need to visit frequently, although newer devices now allow settings to be changed from a mobile phone. The main issue remains battery change.

Question 3

Parkinson's disease is managed with long-term medication and deteriorates over time. Where does DBS come in the sequence of treatment, and what advantage does it offer?

Dr. Anil Kumar Kansal · Accepted Answer

We prefer to start with medication at a lower dose, then gradually increase the dose to control the disease and its symptoms. The ideal time for DBS surgery is when the dose required becomes too high, side effects start appearing, or the medication effect wanes. That is usually around 4 to 5 years after the diagnosis of Parkinson's disease. At that point DBS is used to control the symptoms and reduce the drugs.

Question 4

DBS is a costly procedure and may be cost-prohibitive for many patients. What does it cost?

Dr. Anil Kumar Kansal · Accepted Answer

We have different packages. In our hospital it costs around USD 30,000 to 35,000, including everything: stay, medicines, testing, surgery and hospital stay. Equipment from different companies is priced differently. A non-rechargeable device is less costly, but the battery usually has to be changed after 5 to 7 years. Rechargeable devices cost slightly more, and the newer devices that also allow monitoring are costlier still. We use whichever the patient opts for.

Question 5

Among the general population there are many myths that spine surgery is risky. How safe is it, so that doctors can counter these fears with patients?

Dr. Anil Kumar Kansal · Accepted Answer

Major complications in spine surgery are only around 2%. Life-threatening complications are 0.5%, and neurological deficit, from injury or infection, occurs in 1 to 1.5%. Not more than that. 98% of patients do well and 90% do very well. Complications arise when the surgeon is not trained or the infection rate is high. We operate on around 400 to 500 spine patients a year and hardly find an infection in any of them.

Sometimes the patient's expectation is too high: they think every pain will go and they will become absolutely normal. That is not possible, because patients usually come to us at a late stage, when the nerves are damaged and the bone is deformed. We can relieve the pain by 80 to 90%, perhaps 95%; some pain will remain, but the majority goes and they can live their life better. Some patients benefit 70%, some 80%. We may have repaired and fixed two or three vertebrae, so they are near normal, not normal. Muscle weakness, tingling, numbness or weakness can persist after surgery. But the results are definitely good: patients who were unable to walk can walk pain-free and carry on their daily activities.

Question 6

Similarly, many people fear that brain surgery for a tumour could cost them their speech or mental faculties. What are the real risks, to help doctors counsel patients?

Dr. Anil Kumar Kansal · Accepted Answer

In brain surgery, mortality is around 1 to 2%, depending on the tumour. The second risk is deficit, which depends on the location of the tumour: in the speech area there may be difficulty speaking, and in the motor area weakness of the hand. The total risk is 5 to 7%; 93% of patients do very well. We remove the tumour and send it for biopsy. The next problem is malignant tumours, which may come back: removing them is not a cure. Only benign or less aggressive tumours can be cured by removal. We give radiotherapy and chemotherapy, and still they come back. That is the main problem. Today the surgical complication rate with experts is less than 5%, and with newer methods (localisation under a high-end microscope, neuronavigation and intraoperative dye) the risk has become very low.

Question 7

How close are we to restoring function in patients with complete spinal cord injuries?

Dr. Anil Kumar Kansal · Accepted Answer

We have to understand that patients with complete spinal cord injuries are not going to recover completely. Some recover minimally. Then there are the symptoms: stiffness in the legs, pain in the legs and difficulty mobilising. If the hands are working, we train patients to manage their life with their hands and a wheelchair. Leg pain and stiffness can be managed with baclofen pump or morphine pump implantation. A dorsal cord stimulator sometimes gives better sensation and decreases spasticity, and with additional physiotherapy some patients regain some power in the legs, which helps them maintain their daily life. Some patients do this, but not the majority. It is very difficult to say that with a dorsal cord stimulator they will recover completely; there is a chance their symptoms will improve.

Question 8

What role do stem cells play in spinal cord injury management?

Dr. Anil Kumar Kansal · Accepted Answer

One year I ran a project on stem cell implantation for spinal cord injury. We took stem cells from the iliac bone and put them in the spine. Of around 20 patients, one showed improvement, but that patient may have been recovering by himself with medication; we cannot say. Statistically we found no significant benefit with stem cells, so we discontinued the trial. It is still not recommended anywhere in the world. Patients with partial injuries do better; with complete injuries there is not much recovery.

Question 9

An MRI has found a hemangioma in the cervical vertebral region. At what point would the patient benefit from surgery?

Dr. Anil Kumar Kansal · Accepted Answer

It does not require any treatment unless there is a fracture of the vertebra. Small hemangiomas are benign tumours of the vertebra and need no treatment. If it is large enough, involves the pedicle, causes a fracture or weakens the bone, then decompression and fixation of the spine are needed. If it is a bigger one causing destruction of the vertebra, we have to remove it; it is a very vascular tumour, and we put in a cage and bone and fix it. Otherwise no treatment is required.

Question 10

Having treated many international patients, how does the involvement of the patient's own doctor in Africa, in direct contact with a specialist like you, benefit the patient and continuity of care?

Dr. Anil Kumar Kansal · Accepted Answer

Beyond sessions like this one, we can hold meetings on only one topic, for example a tumour or brain tumours, where everyone discusses their experience. We can pass on whatever knowledge we have and also learn from them, because they have a lot of experience too. For lumbar spine, for instance, we could cover tumours, fixation and microdiscectomy, case by case, with everybody sharing their experience and the problems they face.

Second, there should be feedback after surgery. When the patient goes back, they consult the local doctor, who takes note and can communicate with us about what they are prescribing and what problems arise. We can then guide them on when to repeat the MRI or CT. The communication should be more frequent.

Question 11

Many international patients come to India through facilitators or agents and are often misinformed. Is referral through their own doctor, with access to a specialist like you, a better model?

Dr. Anil Kumar Kansal · Accepted Answer

More communication is required. Whether or not the patient comes to us, if the doctor has any problem they can discuss it with us as a colleague. We can give our number; they can chat with us on WhatsApp, send the reports, and discuss what modality they are planning or whether we would do the same or something different. They can discuss with us at any time.

Question 12

What are the current limitations of awake craniotomy, and how are they being addressed?

Dr. Anil Kumar Kansal · Accepted Answer

Awake craniotomy is used when the tumour is in an eloquent area, such as the motor or speech areas. It can become very difficult: in one recent case the patient started shaking during surgery and we had to give complete anaesthesia. Patient cooperation is essential throughout. For international patients it is especially difficult because of the language barrier: with Indian patients it is easier, since they communicate with the anaesthesia team and technicians, but with an international patient we have to keep a translator inside the theatre. We discuss it with patients before surgery and proceed if they are comfortable, but under partial anaesthesia or sedation they sometimes behave abnormally. I am not very fond of awake craniotomy because it is very tough on the patient. What we now do is functional mapping with functional MRI, and we try to preserve those areas during surgery.

Live Discussion with Dr. Anil Kumar Kansal