Mary (name changed), a 65-year-old from Europe, arrived in Bengaluru in a wheelchair, grappling with the debilitating symptoms of Parkinson's Plus Syndrome (PPS). Having endured years of fruitless medical consultations across France, England and Africa, she found herself at Fortis Hospital Bannerghatta Road, where she was diagnosed and given relief through an innovative treatment.
PPS, a variant of Parkinson's disease, presents a unique set of challenges including early-onset dementia, hallucinations and balance issues, making traditional medication ineffective. Mary's case was particularly severe, marked by a loss of bladder control, speech impediment, and a near-complete loss of mobility. Traditional treatment avenues exhausted, the medical team swiftly formulated a novel approach―high cervical spinal cord stimulation.
“While Parkinson's often responds to medication like Levodopa and deep-brain stimulation surgery, PPS presents a more complex scenario,” said Dr Guruprasad Hosurkar, additional director of neurology at the hospital. “Unlike PD, where brain degeneration is localised, PPS affects a broader range of brain functions. PPS patients develop balance issues and gait freezing early on. In PD, a patient may develop similar symptoms 10 to 15 years after the onset of the disease. If tremors are seen in PD patients, the atypical Parkinsonism patients experience difficulty in swallowing, speech and coordination, and clumsiness. They cannot do regular work like eating or standing.”
Conventional DBS surgery could have potentially exacerbated Mary's condition. The doctors went through literature and found that some centres had tried brain stem stimulation and lower spinal cord stimulation.
“We selected the higher cervical cord stimulation, where we put a lead over the surface of the spinal cord for stimulation,” said Hosurkar. “This would modulate the networks in the spinal cord and improve her condition or restore some of the normal functions like speech, bladder control and movement. She improved and started sleeping through the night without disturbance. We put a lead covering 70 per cent of the spinal cord (from C3 to C8 vertebrae) and used an external battery to stimulate the spinal cord. After adjusting the parameters, we saw nearly 40 per cent improvement in her working abilities.”
Dr Raghuram G., additional director, neurosurgery, at the hospital said, “Our approach involved an initial trial surgery utilising an external pacemaker. This step was crucial as it allowed us to closely monitor the patient's response to the stimulation. Following this, we observed promising results, including improved mobility and reduced symptoms. Encouraged by these outcomes, we proceeded with the spinal cord stimulation surgery, which involved precise placement of electrodes along the spinal cord to modulate neural activity and alleviate symptoms. Spinal cord surgeries are different because they involve placement of an electrode on the spinal cord chosen for a particular condition. It is an epidural (space around the spinal nerves) electrode and is not put within the spinal cord. Unlike the deep brain stimulation electrode, which is placed within the brain.”
The procedure, done in a few centres in the US and China, was carried out in India for the first time. The internal battery lasts seven to eight years. The small devices that conduct electricity are placed near the spinal cord.
“The patient who had come in with the assistance of two people for treatment could walk a few steps independently after the treatment. The stiffness in the limbs reduced, speech became clear and she slept peacefully at night after many years. The new procedure has a window of 10 days before which you can remove the lead and the external battery if you don't see some predictive value of improvement. The cost of the lead is around 02 lakh and the battery would cost 015 lakh,” said Dr Hosurkar, adding that the patient was discharged after ten days.
A patient programmer app helps in the follow-up treatment as it sets parameters for stimulation in the device. If the response to the earlier limit of stimulation is lower, they can increase it. Video consultations are held in follow-up sessions.
With the increase in life expectancy, there are more Parkinson's patients―one in every hundred aged 80-plus. And for every 10 cases of Parkinson's, two to three patients have PPS, said doctors.
The spinal cord stimulation can be used to treat Parkinson's, too, as the patient develops similar complications and the gait might not improve even after DBS. However, it is not advisable if the patient is above 70 and has co-morbidities.
“The achievement represents a significant milestone in the field of neurosurgery,” said Akshay Oleti, business head, Fortis Hospital Bengaluru, “and offers hope to individuals battling this challenging condition.”