As part of a pair of articles on the topic of deep brain stimulation (DBS) in this issue, I met with Dr. Anand Rughani recently to ask a few questions. I hope these articles will give readers a little insight into what it might be like going through the procedure. I also wanted people to know a little about Dr. Rughani, and why we are so lucky to have him here in Maine, not just for the high level of skill he brings with his subspecialty training in functional neurosurgery, but also a bit about the man and his motivations. This interview is not intended to be exhaustive, but focused on a few relevant points. What follows is a transcript of our meeting.
BS: I think a good place to start would be in explaining why you are interested in deep brain stimulation. What drew you to this specific area of medicine?
AR: My pathway to neurosurgery started off with an interest in neuroscience and in understanding the mind-brain interaction. The connection between mind and brain is most visible to me on a daily basis in neurosurgery, and specifically in the area of functional neurosurgery, which deals with mapping the functional areas of the brain to understand how different brain structures lead to different experiences and behaviors. We see that through disease, and in treating some of those diseases, we get insight into how the brain works. That’s what lead me to neurosurgery to begin with and then specifically, functional neurosurgery and deep brain stimulation. Deep brain stimulation itself is a good example of how you see those interactions in a very real way, through implanting electrodes in an awake patient to treat symptoms from various diseases. So, I gain insight on a daily basis as to how the brain leads us to be who we are, and how we work.
BS: Your training started out with undergraduate college, then medical school, then neurosurgery residency. After this, you had a fellowship in functional neurosurgery. Can you tell us about the fellowship?
AR: My fellowship at the University of Toronto offered exposure to a deep enthusiasm for not just doing surgery or DBS for some of the more conventional indications, but really exploring new indications for surgery. Whereas the FDA currently has indications for Parkinson’s disease, tremor, and dystonia, I was also able to be involved in cases for anorexia, for OCD, depression, and for Alzheimer’s disease.
BS: What brought you to Maine?
AR: I grew up in Eugene, Oregon, but then spent ten years in Montreal for my Bachelor’s degree and medical school, and each year that I spent there I grew more nostalgic for the idea of ending up in a small coastal town. However, the more time I spent in Montreal and in my subsequent training, the more I found myself doing increasingly subspecialized training. First, it was neuroscience, then it became medicine, then it became neurosurgery – and there are only so many places you can do that. Then, even more subspecialized was functional neurosurgery. In the process of that training I got to spend a year at Maine Medical Center, and it turned into the ideal opportunity because I could offer surgeries that weren’t previously available in Maine.
BS: Can you walk through what it is like to have the DBS procedure in the operating room?
AR: Deep brain stimulation is a significant undertaking. We do it in a couple different steps, but the most important is the step where we implant the electrodes in the brain. There are a couple of different ways of doing that now. The traditional way of doing that is recording from the neurons in the brain and then stimulating through those electrodes. The way we do that is with the patient awake, and most patients do fantastically well. People are comfortable because we use a local anesthetic, but the surgery itself takes a couple hours. The hardest parts of the operation are probably a couple of things: one is for patients with Parkinson’s disease being off of their medication. That can be quite challenging. Another part is being stuck in one position for two, or three or four, hours. The local anesthetic can burn quite a bit when it goes in. I think the actual operation where we do the work isn’t the biggest source of discomfort, it’s more from being stuck in one position for a couple hours and being off of regular medications for those with Parkinson’s disease.
BS: People complain about the sound of the drill a lot too.
AR: I think the drill is probably like being at the dentist, or an aggressive version of being at the dentist. The drilling takes about 30 seconds. After, some patients may have a mild headache, but there are no pain receptors in the brain, so no discomfort from the next steps.
BS: Tell me a little about the risk of the procedure.
AR: I categorize the risk of surgery into four areas. First, there is the risk of the operation itself. This includes things like bleeding into the brain, which can happen in about 2% of patients, and can lead to new symptoms in about 1% of patients. The second category of risks are related to having implanted hardware, for example a delayed infection could occur, or a disconnection or other device complication can occur. These types of events probably occur in up to 10-15% of patients over the years. The third category of complications that I think of are the stimulation-related complications. We try to minimize these by doing testing in the operating room with patients awake. These depend on the location where the electrode is implanted, but could consist of changes in speech, or mild tingling sensations. The last category of complications are the medical complications, for example things like developing a pneumonia, or blood clot in the leg, or a heart attack.
BS: Who is in the room while the surgery is taking place?
AR: The operating room is busy for this surgery. In addition to the patient and surgeon, there is also the anesthesiologist, or nurse anesthetist, there is an operating room nurse, and there is a scrub tech that passes the sterile instruments. There is also a neurologist, and usually one or two additional people involved in the surgery.
BS: What else would you want people to know about DBS?
AR: It is really important to have a good understanding of the goals of surgery, and the surgery process. Specifically, it’s important to know which symptoms are most likely to respond to surgery, and which aren’t. With that in mind, and a good understanding of the involvement and risks of surgery, patients and their families can make the best decision about whether or not it is right for them. I am always happy to discuss the surgery in detail with patients who think they might want to consider it.
