Treatment

Breakthrough Procedure for Spinal Cord Injury Patients

Epidural Stimulation Implant

The breakthrough Spinal Cord Injury treatment is centred around the Epidural Stimulation device. The device is surgically connected to the nerve systems. It is not a muscle stimulator or pain management modality.

Once implanted, the patient learns how to control the device and the resulting limb movements.

What is Epidural Stimulation?

Epidural Stimulation applies a continuous electrical current to specific locations on the posterior structures of the lumbar spinal cord. The surgically implanted device sits over the spinal cord protective coating, where it is able to stimulate locomotor-like activity. Epidural Stimulation can be offered to patients with both incomplete and complete injuries.

The Central Pattern Generator (CPG) is a control centre inside the spinal cord that interprets sensory information. Epidural stimulation activates the spinal cord nerve circuitry with impulses that would ordinarily originate in the brain.

Epidural Stimulation Explained

In non-medical language, a stimulator is implanted and wired up to the spinal cord. The stimulator is controlled by a remote control. Whilst on, the stimulator commands can actually bypass the injury side and allow voluntary movements and other secondary improvements.

Over an extensive 30-40 days of rehabilitation in our ward the patient and their brain, muscles and nerves ‘learn’ how to consistently create voluntary movements whilst the device is activated. This is a very delicate process and requires a lot of experience by the therapist. We call this process “Mapping”. The more experienced and knowledgeable the Mapping Therapist is, the quicker progress can be achieved and the more gains the patient can get. Equally important is the support after patients departure. We make sure the patient learns how to use the device and its remote on its own, pre-install tailored exercise programmes and continue to be available at all times to discuss and implement new programmes.

Components of a Spinal Cord Stimulation System

 

An Epidural Stimulation system consists of two implanted components:

  1. Epidural Stimulation Device ComponentsNeuro-stimulator – Rechargeable or non-rechargeable implanted power source that generates electrical pulses according to programmable neuro-stimulation parameters and features
  2. Lead – A set of thin wires with a protective coating and electrodes near the tip (16 plate-electrode array) or on a paddle (surgical lead). The electrodes transmit the electrical pulses to the stimulation site.

Two external components to a Epidural Stimulation system allow the therapy to be customised for each patient:

  1. Clinician Programmer – Used to program the implanted neuro-stimulator. Instrumental in the Mapping process
  2. Patient Programmer – Enables patients to continue the rehabilitation on their own after departing back home.

Epidural Stimulation Surgery – How it is Done

Evaluation

The implantation of electrodes, although on paper a relatively minimally invasive surgery, requires an extremely careful approach. It starts with careful evaluation of spinal MRI findings by the neurosurgeon and other collaborating doctors and selection of a proposed section of the spinal cord to implant the electrodes, and extremely careful analysis of the spinal cord segments before and after the proposed location. Metal plates and screws can further complicate the surgery.

Operation

During the operation, the neurosurgeon is required to spot that specific part of the spinal cord and spinal nerves, and subsequent nerve roots. He then tests different proximal locations by an external stimulator using intra-operative testing to ensure best possible treatment result. In short, implantation of epidural stimulator is a type of neurosurgery and requires careful medical evaluation and experienced neurosurgeon.

Operating Room

Intraoperative Testing

Intraoperatively, the benefits and adverse effects of various stimulation parameters are tested to help confirm proper placement of the lead. Particularly with Spinal Cord Injury patients, one expects to see evidence for limb movements. In addition, it is recommended that the impedances for the lead be checked during surgery to ensure that a defective or faulty lead is not being implanted. The clinician programmer is used for intra-operative testing of impedances of leads at the time of lead placement and prior to neurostimulator implantation. Intra-operative stimulation results may provide a rough guide to the clinician in determining effective parameters. Finding the absolutely perfect lead position is critical in patient’s recovery. That is why our patients will be operated by one of the very top neurosurgeons of Asia.

Neuro-surgeon

 

Our neurosurgeon, who performs the Epidural Stimulation Surgery, is a highly educated, experienced and caring professional with great expertise and technique. He is currently an Associate Professor and a Consultant Neurosurgeon.
Since graduating with First Class Honors as a Medical Doctor from Mahidol University, our neurosurgeon has acquired many outstanding certificates in his field and has kept up to date with members of his profession by participating in fellowships of functional neurosurgery and epilepsy surgery.
He specialises and has keen interest in Stereotactic and Functional Neurosurgery, Epilepsy Surgery, Pain Surgery, Spasticity Surgery, Peripheral Nerve Surgery, Restorative Neurosurgery and Neuromodulation, Psychosurgery as well as Surgery for Dystonia and Movement Disorders.

 

Moreover, our neurosurgeon has also, in his professional time, worked on remarkable publications and presentations. Some of his publications include:

  • Overview and Outcomes of Movement Disorder Surgery
  • The Neurological Treatment of Spasticity
  • Improvement of sitting ability and ambulation status following selective peripheral neurotomy of the sciatic hamstring nerve together with obturator branches for severe spasticity of the lower extremities
  • Surgical outcomes of microsurgical selective peripheral neurotomy for intractable limb spasticity
  • Dystonia and peripheral nerve surgery in the cervical area
  • Functional peripheral nerve surgery
  • Spinal cord bypass surgery using peripheral nerve transfers to restore elbow flexion in a pediatric patient with central cervical cord syndrome
  • The therapeutic effects of ablative neurosurgical procedures on spinal cord for intractable spinal spasticity
  • Seizure outcomes and factors correlating with seizure freedom following supratentorial brain tumor surgery
  • Excellent pain relief by using spinal cord stimulation after failed bilateral stereotactic anterior cingulotomy in a patient with intractable neuropathic pain of the lower extremities following surgery of Tarlov cyst
  • Efficacy and factors determining the outcome of dorsal root entry zone lesioning procedure (DREZotomy) in the treatment of intractable pain syndrome

 

He is honorably among the best of the best. Our neurosurgeon is hardworking, diligent and customises his treatment according to every individual patient’s specific needs. He pays attention to what’s needed, provides as much information as required and discusses with the patients and their families through every step of the procedure, e.g. what he’s doing and/or what he’s about to do.
Under the medical care of our neurosurgeon, who is a very humble, down-to-earth professional and prefers to remain unnamed, you can be assured of getting the best there is.

Supportive Therapies and Remedies

We make sure the patient gets the supportive remedies, therapies, rehabilitation, detox & immune-boost programmes needed to get the most out of the treatment. The program usually includes:

 

  • Mapping
  • Acupuncture
  • Aquatic Therapy
  • Physiotherapy
  • Occupational Therapy
  • Hemo Oxygen Therapy (HOT)
  • IV Vitamin Drips
  • Immune-Boosting Supplements
  • Special Diet Plans & Consultations
  • Regenerative Medicine (Optional)

Mapping

Discovering the unique pattern of the patient’s physiological injury and then going on to help the patients regain control of their movements is the time consuming process we call Mapping.

 

This process involves several elements:

 

  • Finding out which connections to the spinal cord produce some stimulation
  • Finding each muscle’s myotomes and trying to find the best frequency that the patient responds to
  • Designing tailored exercise programs to build muscle mass
  • Designing tailored exercise programs to allow voluntary movements
  • Designing tailored exercise programs to allow patient to practice controlling voluntary movement themselves
  • Constantly optimising settings and frequencies

 

While implanting the device in the 100% correct position by a neurosurgeon can only be done by a small group of specialists, the actual Mapping can only be done by an even smaller group of people. Worldwide, only a handful of therapists have worked with the Epidural Stimulation device and Spinal Cord Injury patients to regain usage of the limbs.

Our Mapping Specialist has spent more hours helping Spinal Cord Injury patients recover than anyone else in the world. Experience and knowledge are critical in patients’ recovery. Patients usually stay a limited amount of time with us, hence the quicker effective pathways can be established and tailored programmes designed, the more improvements can be expected. We also teach the patients how to control the device’s settings itself to continue the rehabilitation back home. After returning home our therapists and doctors will always be only one phone-call away for further guidance and optimisation

Rehabilitation Team

Physiotherapy

Once the pathways have been established through the initial mapping process, the hard work begins. We push the patients to the limits to get maximum results.

 

Rehabilitation helps the brain and muscles to coordinate to achieve voluntary control and to give patients the physical and functional platform to regain strength, muscle mass, mobility and control.

Post-Surgery Improvements

All patients have received a successful Epidural Stimulation device implant, meaning perfect positioning of the implant using intraoperative testing, without any side effects. An EMG after the surgery confirms the fact that signal run pass the injury side into the limbs and back.

 

Potential short and long term improvements may include:

 

  • Provided the stimulator is activated, hips, legs, knees, ankles and toes can be moved voluntarily.
  • Eventually, hips, legs, knees, ankles and toes can be moved voluntarily without the stimulator being activated.
  • Provided the stimulator is activated, ability to bear own weight with no or only minimal support.
  • Eventually, ability to bear own weight without the stimulator being activated or with only minimal support.
  • Muscle mass growth.
  • Stabilized blood pressure.
  • Improved bowel and bladder function.
  • Improved sexual function.
  • Improved body temperature regulation.

 

Our patients have experienced significant positive changes in their bodily functions after Epidural Stimulation. Depending on the location of the injury the first rehabilitation milestones while being in our ward can be:

 

  • Ability to stand, provided the stimulator is activated.
  • Ability to take steps, provided the stimulator is activated.
  • Ability to stand, with minimal or no support.
  • Ability to take steps using parallel bars for support.

Regenerative Medicine

The use of regenerative medicine is an optional treatment offered to our Epidural Stimulation patients.

 

Extensive research on Cellular Therapies have been done in the past decade to study and establish the treatment efficacy for treating Spinal Cord Injuries.Regenerative Medicine has emerged as viable treatment option due to proven safety, ability to regulate the immune system’s reaction towards the injury, and to differentiate cell types including neurons and astrocytes. Not only that, it has been used in clinical treatments of SCI patients since 2005. Recent studies by different scientists lead to the conclusion that Regenerative Treatments may result in functional recovery following Spinal Cord Injury (SCI).

 

Most SCI patients treated with the combination of Epidural Stimulation implant, and Regenerative Medicine and supportive therapies including extensive rehabilitation, achieved improvements in the following areas:

 

  • Improved sensation
  • Improved motor function
  • Improved muscle mass and strength
  • Improved balance and coordination
  • Bowel and bladder control
  • Improved neuropathic pain
  • Improved sexual function
  • Increased sweat ability
  • Reduced spasticity and more
  • Replacing damaged, diseased or lost neurons can be done through Regenerative Treatment usage

 

Regenerative Medicine may also have other substantive roles through paracrine effects, including delivery of molecules, such as prosurvival factors, angiogenic factors, growth factors and cytokines that perform the following:

 

  • Modulating immune response
  • Inducing the enzymatic breakdown to reduce inflammation, scarring and the elimination of cellular debris
  • Limiting secondary injury by protecting neurons
  • Promoting regeneration of endogenous Regenerative Treatment
  • Angiogenesis with more blood supply that are required for optimal recovery
  • Enhancing wound healing
  • Providing a cell-based electrical ‘relay’ between neurons above and below the injury; to eventually ameliorate clinical deterioration.

 

A combination of Epidural Stimulation implant with modern regenerative medicine creates the arguably most powerful treatment package for Spinal Cord Injury survivors.

Operating Theater Photo Gallery