STEREOTAXIS IN VARIOUS INTRACTABLE CONDITIONS IN PAEDIATRIC PATIENTS
Dr. Vijay R. Sheth, MS, MCh, (Bom) Neurosurgeon, Stereotaxis (Singapore, London) *
Brain & Spine Hospital, Blue Star Complex, Near Income Tax Rly. Crossing, Ahmedabad 380014. *
Definition
Stereotactic Neurosurgery is the method of doing a procedure (e.g., biopsy, aspiration, lesion making, radio-active seed (implanting) in the depth of brain and spinal cord (i.e. target) without damaging nearby vital structures and with very great accuracy (0.2 mm).

Stereotaxis was done previously after doing ventriculogram (invasive procedure), and with help of brain atlas. But now it is done under CT/MRI (or Angio/DSA/X-ray/ventriculogram) guided (and so non invasive) and computer assisted and is therefore more accurate, fast and safe.
Indications
  1. Biopsy of deep seated brain tumours
  2. Aspiration of cystic lesions
  3. Functional Neurosurgery
    • - Movement Disorders
      - Psychiatry disorders
      - Epilepsy
      - Pain
  1. Biopsy -
    Deeply situated brain tumours (e.g., in basal ganglia, thalamus, brainstem, intraventricular, pituitary, pineal region etc.) which are not possible either to excise or take biopsy without damaging nearby vital structures, are biopsied by stereotaxis. Biopsy is safe, fast accurate, 95% histopathological diagnosis can be obtained, with morbidity 1%, and mortality in 0.2% of cases. Biopsy report will guide for further line of treatment viz. Surgery, radiotherapy, weather chemotherapy is needed, and also gives prognosis (without biopsy radio-therapy can not be given).
    Stereotactic craniotomy can also be done, where direction and depth of lesion can be guided by Laser beam or probe.
  2. Aspiration -
    Deeply situated cystic lesions e.g., craniopharyngioma, colloid cyst of third ventricle, cystic brain tumour etc may be difficult for open surgery. They can be safely aspirated, biopsied, and decompressed by Stereotaxis. Thus major surgery (craniotomy) can be avoided. Hypertensive, traumatic bleed in deep areas of brain like basal ganglia, thalamus, brain stem can be stereotaxically aspirated and thus early decompression allows good and fast recovery, low morbidity, and reduces mortality.
  3. Functional-
    Mostly all the following conditions which are not controlled or cured by medicines or other treatment are subjected Stereotactic surgery.

    MRI-guided frame is better for functional Neurosurgery. Radio Frequency Lesion Generator (RFLG) is better method of making accurate predictable size and shape of lesion, and stimulation by it may help to localize target.

    (A) Movement Disorders:
    Chorea, Athetosis, Hemiballismus - In this condition lesions are made in VL nucleus of thalamus, to relieve abnormal movements. Results are excellent. Earlier it is done - better (usually above 4 years of age).

    (B) Psychiatric Disorders:
    1. Schizophrenia: Violent, aggressive, destructive, abusing patients if not controlled with psychiatric treatment after 1 & ½ year of treatment can be subjected to Stereotactic
      Psychosurgery. In this Bilateral lesions are made in Amygdala, Baso Frontal Tractotomy,
      Cingulotomy. Improvement occurs immediately and further till 1 or more year. It makes patient
      cool, calm and manageable, gradually reduces medicines and back to normal life.
    2. Hyperkinetic: If it is not controlled with medicines, interferes in daily activity, study, (attention,
      concentration) and development, then bilateral Stereotactic Amygdalotomy controls, hyperactivity
      of child. It's very important for development of child and social condition of family,.

    (C) Epilepsy:
    1. Temporal Lobe Epilepsy: Stereotactic surgery in Amygdala, controls, TLE, in minimally invasive way in uncontrollable epilepsy. It is first line of treatment then medicine. Early surgery may prevent late psychosis due to TLE and memory impairment
    2. Generalized Epilepsy: If uncontrollable then multiple lesions or Corpus Callostomy may help greatly to reduce frequency, intensity and spread of epilepsy. And there by reduces further damage of brain.
RFTC in Spasticity
In cerebral palsy if there is spasticity in limbs, it interferes in daily activity of child. Severe spasticity makes patient totally dependent. This spasticity if not controlled with physiotherapy and medicines than selective spinal rhizotomy with radiofrequency lesion generator machine (RFLG) greatly reduces spasticity in non-invasive manner, and rehabilitates this patients. Although in D12-SI spinal nerves RFTC is done, still relief occurs in upper limbs, head and neck. Spasticity due to any cause - trauma (head and spine injury), inflammatory (TB arachnoiditis), tumour (brain, spine), vascular (spinal AVM) etc may be relieved with spinal RFTC

Thus, Stereotaxis and RFLG provides significant improvement in intractable pediatric conditions in minimally invasive and safe way.
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