Neuroscience has been at the forefront of advancing technologies, adapting new techniques and devices successfully in an effort to increase the safety, efficacy of brain and spine treatment. Among these many state-of-the-art technological advances which are being adapted and refined continuously to give better results. Certain innovative research is also being done to find areas/disease conditions in neurosciences which can be made amenable to treatment.

Following are few of the innovations which have been successfully inculcated into clinical practice in neuroscience:

Deep brain stimulation (brain pacemaker)
Deep Brain Stimulation (DBS) is a treatment for selected patient suffering from Parkinson’s Disease and most forms of tremors. This therapy has been in India for almost two decades but has caught the attention of neurologists/neurosurgeons more recently due to its successful use in treatment of various other neurological and psychiatric conditions like tremors, medically refractory epilepsy, dystonia and obsessive compulsive disorder (OCD).

DBS consist of implantation of very thin DBS lead which contains four electrode contacts into the target area in the brain. The lead extends through a small opening in the skull and is connected to the extension that is then connected to an impulse generator or pacemaker which is implanted under the skin over the chest. DBS tends to modify the electrical activity of the brain.

So the challenges which are to be addressed in DBS are namely the refinement of the equipments as well as finding out newer neurological conditions where this technology can be used. Recently, the use of DBS therapy has been approved for the treatment of intractable epilepsy and refractory OCD. Many other conditions like depression and progressive supranuclear palsies, etc. have shown promising results with this treatment and are being evaluated for FDA approval.

The innovation in hardware have been immense in last decade. A directional, segmented lead offers new ways to control stimulation. The stimulation electrode can be programmed to give current in only a specific direction thus eliminating the side effects of 360 degree stimulation. With the development of rechargeable impulse generator, the problem of getting the IPG (Battery) changed every 4-5 years has been practically eliminated. Low profile, yet highly durable coiled extensions have been developed which are flexible and have reported zero breaks since their launch in 2011.

Convenient bluetooth wireless programmer connectivity technology enables easy patient use and clinician programming of impulse generator from anywhere in the world without the patient having to travel to the doctor every time to get the parameters changed. Wireless programming also eliminates wires, potentially enhancing patient comfort and convenience.

Mechanical thrombectomy
The introduction of neurological stroke units and of thrombolysis with the intravenous (IV)/intraarterial administration of recombinant tissue-type plasminogen activator (tPA) have markedly improved the treatment of acute stroke in 'golden period of few hours'. Mechanical thrombectomy (clot removal) has recently been performed using fully expanded intracranial stents (stent retrievers). This procedure promises superior recanalization rates and should lead to positive outcomes more frequently than average in patients with large proximal vessel occlusions. Endovascular mechanical thrombectomy can restore vascular patency of these vessels between 41% and 54% of the time, providing an alternative or synergistic method to restore blood flow.

Spinal cord stimulation
Spinal cord stimulation is a newer innovation developed to treat patients who are having chronic pains like brachial plexopathy, allodynia, neuropathic pains, which are refractory to medicines. While tonic stimulation is effective in many patients, managing chronic pain demands more than just a singular approach. More recently another innovative technique has been developed called Burst stimulation to provide an option for managing chronic pain when tonic stimulation does not provide sufficient pain relief. And to make the targeting more precise, a newer implant has been developed to stimulate the Dorsal root ganglion directly. The Axium neurostimulator system stimulates the dorsal root ganglion (DRG) with precise anatomical targeting.

Robotics in neurosurgery
The need for precision during brain surgery has led to an increase in computer-assisted surgeries (CAS). This technique involves using imaging technologies such as magnetic resonance imaging (MRI), computerised tomography (CT) or positron emission tomography (PET) to generate an image of the patient's brain. The surgeon will use this information to plan the route of surgery.

One definition of a surgical robot is ‘any reprogrammable powered manipulator with artificial sensing'. The most important factors to consider when classifying a surgical robot are in its surgical applications, its level of interaction with the surgeon and the role of the robot in the surgery. Currently, the most common systems in robotic surgery are dependent systems, where the surgeon retains full control of the surgical instruments. This type of surgery is also known as telesurgery and a popular example of a telesurgery robot is the da Vinci Surgical System.

The first commercially available neurorobotic device for stereotactic neurosurgical procedures was the neuromate stereotactic robot. This device can decrease procedure time and increase safety in stereotactic neurosurgery in frame and frameless procedures. The first commercially available neurobotic device for stereotactic neurosurgical procedures was the neuromate stereotactic robot. This device can decrease procedure time and increase safety in stereotactic neurosurgery in frame and frameless procedures.

Cyberknife
As with intracranial radiosurgical applications, the most common robotic subtype in spinal stereotactic radiosurgery is a supervisory-controlled system. Cyberknife (Accuracy, Sunnyvale, CA, USA) relies on a predetermined plan which targets spinal pathology for focused beam radiotherapy. By use of feedback mechanisms this system can adjust its trajectory to correct for patient movement, most of which result from respiration. This novel use of robotics has been expanded to intracranial use also, given the possibility of brain shift. A recent addition to the Cyberknife system is the RoboCouch Patient Positioning System (accuracy), which uses similar technology to reposition the patient during the course of treatment.

Brain mapping
Neuroscientists have worked for decades to better understand how the brain functions. Recent advances in brain mapping technology have made that ambitious task easier. An international team of researchers at the Human Brain Project have created a three dimensional atlas of the brain. The maps resolution is fifty times better than previous efforts. The atlas creators digitally stitched together thousands of brain cross-sections. The map shows details up to 20 micrometers in size - the estimated size of many human cells. While this is a huge advancement, scientists still aim to create a map that shows details at 1 or 2 micrometers, rather than 20.

Neuromorphic chips (artificial intelligence system)
Many companies around the globe are working towards blurring the lines between biological systems and man-made creations. Neuromorphic chips blend neurology into traditional technologies like smartphone chips. These chips are being put in small robots that allow the machines to perform tasks that typically require a custom computer. The chips can process sensory data through sight and sound in order to respond in ways that are not explicitly programmed. They are being tried in Humans to facilitate the different activities of the body where the sensory/motor system of the person is damaged.

Robotics, genetics and precision surgery are advancing the ways that healthcare is delivered today. Computational neuroscience, disease simulations, individualized and precision surgery, advanced imaging are the latest trends in patient care and are aimed to make treatment more effective, personalised as well as more cost effective.

(Author is consultant, neurosurgery, PSRI multi-specialty Hospital, New Delhi)