All right. And in the other corner, weighing in at 150 pounds, Dr. Andre Machado is going to talk about the other side of the face-off, a blade of procedures for pain. Maybe after this we can certainly take questions kind of for the pair. All right. That will be a tough act to follow. You know that the guy really wants to win the argument when he uses your own work against you. That's always a tough beginning. So I'll be talking about neuroablation, and I can see that I have Dr. Bertsch in the audience. I hope I'll do it well, sir. And you can change the title of this talk for perhaps the devil's advocate. That's not what I would do. The other way to call this is back to the future, and this is the argument that I'm going to try to build here. These are my disclosures. None of them are really pertinent to today's presentation. And why is it that we should continue to focus on neuroablation and in fact develop it further? It is permanent, yes. It's also cheaper. It is effective. It's effective for cancer pain. It can be effective for other pain modalities. And where healthcare is going, which seems to be a transition from volume to value, neuroablation is going to eat neuromodulation for lunch in providing value. And this is very important for countries that have less robust healthcare resources. There is no need for frequent follow-up, which is important in geographical areas without a lot of neuromodulation centers to support the demands of the population. And in the geographical diversity of the world, this also needs to be taken into consideration. And it is time-proven. As my predecessor said, it is time-proven predominantly for cancer pain, but it doesn't mean that the future of neuroablation is going to be limited to cancer pain. The pushback is always around safety. Yes, it's permanent, it's destructive, and it's experience-dependent, but this is what neurosurgeons are here for. We are trained to do things that are technically demanding, that have inherent risk associated with them, and to just run away from this procedure is not necessarily the solution. In fact, when we do shy away from ablation, then these procedures become unsafe. As our combined experience with ablation becomes thin, we are likely to see a higher percentage of complications, which is true for any other type of neurosurgical procedure that we begin to perform less often. We're just not as slick and as experienced. What was the driving force here? What was the driving force that over these years has pushed us away from neuroablation to neuromodulation? I will argue that leeway, reversibility, adjustability is important, and that the perception that neuromodulation is safer is also important to us. And in the next couple of slides, I would like to challenge a couple of assumptions. First, that device implantation is simpler or easier or always safer than ablation. And just like Dr. Viswanathan, I took the liberty of including a couple of his pictures for his courtesy. Most of us will say that implanting a percutaneous electrode will be a simpler process and safer than doing a myelotomy that he beautifully performed. And on the surface, there may be some truth there. Second assumption is that devices are going to be more effective. And what I would like us to question ourselves here for a moment is to what extent this is really true, and to what extent are we driven by our passion for technology? When we see very interesting electrodes, improved pulse generators that have capabilities now for sensing, closed loop stimulation, different types of bursts, the other and the other and the other, and enormous investment in neurotechnologies, are we confusing better technologies with better outcomes? And equally important, is it possible that our patients in their minds mix up a little bit the latest with the most effective? In questioning this, I would say that a procedure that we perform for non-malignant pain, ablation of the gusset and ganglion, again using courtesy of my counterpart, for two percutaneous procedures, as well as gamma knife, which is another way of doing this, I would call this highly effective. And with a couple of highlights here. Sure enough, there is a reduction of efficacy in Kaplan-Mayan curves. I would question us to look at similar reductions in spinal cord stimulation. I'll show some hint of that in a moment. And I would say that 60 to 70 percent improvement by three years, with a relatively flat curve to follow, is not bad at all. And this is all comers. In spinal cord stimulation trials, we have the luxury of doing a percutaneous trial first, we exclude the early failures, and then we account efficacy only for those that we permanently implant. This is all comers. All patients that are treated up front are included in this survival Kaplan-Mayan type curves. I would challenge us to find a way I would challenge us to find a few neuromodulation procedures that can beat this. And in challenging the idea of safety, I would like to put in front of us a few of the complications, not even the bad ones, that we have for spinal cord stimulation. This is from our own series at Cleveland Clinic, where we were managing hardware failure, migration, and insufficient coverage. And the learning that small surgeries beget bigger surgeries. I think we have all been there. Migration of the electrode, insufficient coverage, then we are trying to do a laminotomy or a laminectomy or a two-level laminotomy to be able to break the epidural fibrosis. And we are exposing these patients to increased risk. And my question is, to what end? Look at our own outcomes. This is work that we published a couple of years ago, I think three years ago, showing the amount of benefit that we offered our patients after we converted a percutaneous lead to a pedal lead. After multiple revisions, sure enough, we are providing some benefit, but only two points of improvement in the visual analog scale compared to the preoperative. These devices not only lose efficacy over time, but their revisions do not yield necessarily the same efficacy that we achieve in the first implant. What would be the Kaplan survival? What would be the Kaplan-Meier curve of my outcomes? Would it beat ablation? And what about complications associated with management and removal of hardware? This is something that we published last year. Maldonado is our wonderful senior resident and he evaluated our complications of removing pedal spinal cord stimulation leads. Overall safe, I would call, but not without complication, including CSF leak, postoperative hematoma, and complications that we may call minor. I'm not sure if the patients would call minor. But look at the top of this slide. The paper starts with the removal of 68 spinal cord stimulation leads. Why are we removing so many leads if the therapy is so remarkably effective? And I wonder if our attitudes toward ablation will change as technology evolves. If we became so interested in neuromodulation with the technological improvements that spinal cord stimulation began to offer, deep brain stimulation began to offer, and with the possibilities ahead of us, I would pose here the question that our attitudes toward ablation may change as new technologies for pain ablation become available. I think a few years ago, if we would have proposed that thalamotomies would come to be a common option and an option of increasing interest for the management of essential tremor, you guys would have kicked me out of the podium. No one would think of doing a thalamotomy in a patient that's eligible for deep brain stimulation that's better, safer, reversible, and adjustable. And sure enough, Dr. Elias, a couple of years ago published a level one, level evidence paper showing the efficacy and safety of thalamotomy performed with a very interesting technology in patients with essential tremor. Can I ask for a show of hands here of how many of you work in an institution that either has one of these machines or is interested in acquiring one of these machines? Four, ablations. Is it possible that this is going to transcend movement disorder and eventually make its way back to the treatment of chronic pain where it probably began? So for my conclusions, accurately placed lesions can be safe and effective. Yes, today the primary evidence and our use is mostly for cancer pain, although trigeminal neuralgia is, of course, a non-malignant, non-cancer condition that ablations are routinely performed. Ablations are practice and experience dependent, and I think it's our job as neurosurgeons to remain trained in something that is practice and experience dependent, and I think that new technologies may change our attitudes towards ablation for chronic pain in the not-so-distant future. And with that, thank you so much. Questions or comments for our fighters? I hardly know where to stand in this particular argument, because I'm right in the middle of it. In my practice, I do both ablative and stimulation surgery, and I do opioid pumps as well. I think that they are, in fact, mutually beneficial, and I think that they provide a variety of options to our patients and that you have to pick, you have to decide how you're going to do it based on your experience to some extent, but also on the disease process. There are diseases for which ablation is a better option. Brachial plexus avulsion, for example. I don't know anybody who's doing stimulation for brachial plexus avulsion pain. Is there anybody in the audience that does that? Well, you're fortunate if it's worked for you, because I see patients all the time that it doesn't work for, and I do ablative procedures for that. Now, I was trained at Duke, and I do Dr. Nashvold's DRES operation for that, and I think that that is the main treatment for that particular illness. Thank you. Thank you. Dr. Birchall? So, I'm glad I'm not the only gray hair here, and I agree with what you just said, that it's more arrows than a quiver. We should not forget the lessons of the past, and particularly DRES, I think it's a great example. It wasn't brought up in your discussions of a procedure for which stimulation doesn't work, I mean, period, whereas ablative surgery has a very good outcome and a sustained good outcome. So, you know, 70% long-term and better even in the shorter term. So, we can't forget about that, and at least in my practice, the DRES lesions have fallen, but I don't think people are not running into trees on their motorcycles. It's just that people have forgotten about it, because Blaine and others have not, you know, promoted this. It's sort of this business… When I was in training, I did 60 DRES operations, and we were doing a week. Right. My point is the patients are still there, but a generation that doesn't see that tends to forget, and certainly the neurologists don't. The patients I see now for DRES are 10 years out. Yeah. So, I wanted to reinforce something that Andre said, even more so, and you really touched on movement disorders a little bit, because the same principle applies to movement disorders that we've tended to forget about, thalamotomy, palatotomy, other things, which are very effective, very cost-effective. I actually do RF thalamotomy. I do about one a month. It's a very good procedure, but I suspect that most of the younger surgeons here haven't done that or seen that procedure. So, there's a general principle at work here that we've got to remember to train our folks to do the procedures the same. You mentioned trigeminal neuralgia, which is a real exception to the rule of ablative surgery not working for benign pain, but how many people that are under 40 or 45, let's go up, do a radiofrequency percutaneous rhizotomy? How many of you have done that? Well, that's gratifying. I mean, we can't for... I'm not in the right age group, sir, but I do that every week. You're not under 45. There you go. So, the point is we've got to train people to do these things. Otherwise, it's evolutionary. It's why palatotomy lay fallow for 40 years or 45 years before it was rediscovered. It's because a whole generation or two simply never learned how to do it. Chordotomy, clearly great for malignant pain. We don't know what role it has, probably none in non-malignant pain. Midline myelotomy, probably the same thing. I think the frontier that I see are things like tractotomy, non-malignant pain, nucleotomy, following the work of Kanpilat and now my colleague, Ahmed Raslan. I think we still don't know the answers to these questions, and when you don't know how to do it and you don't try it, you just don't know. I think we've just got to be careful not to fall into the trap of everything is neuromodulation. So, I would just say, I'm with you. It's another arrow in the quiver. You've got to be able to do both. You can't be a one-trick pony. We're not anesthesiologists. I'm sorry. We do surgery. We can do lots of things. So, let's try to expand our potential rather than contract it. Any other thoughts or comments? All right. Okay, well, great. So, that wraps up the first half of the session. Let's take our half-hour break and reconvene at 345, please.

neuroablation procedures

pain management

cost-effectiveness

safety concerns

trigeminal neuralgia