Epidural motor cortex stimulation with functional imaging guidance

Chronic epidural motor cortex stimulation (MCS) has been shown to have promise in the treatment of patients with refractory deafferentation pain. Precise placement of the electrode over the motor cortex region corresponding to the area of pain is essential for the success of this procedure. Whereas standard anatomical landmarks have been used in the past in conjunction with image guidance, the use of functional brain imaging can be beneficial in the precise surgical planning. The authors report the use of functional imaging-guided frameless stereotactic surgery for epidural MCS. Five patients underwent MCS in which functional imaging guidance was used. Prior to surgery, patients underwent magnetic resonance (MR) imaging with skin fiducial markers placed on standard anatomical reference prints, followed by magnetoencephalography (MEG) mapping of the sensory and motor cortices. In two patients, functional MR imaging was also performed using a motor task paradigm. The functional imaging data were integrated into a frameless stereotactic database by using a three-dimensional coregistration algorithm. Subsequently, a frameless stereotactic craniotomy was performed using the integrated anatomical and functional imaging data for surgical planning. Intraoperative somatosensory evoked potentials (SSEPs) and direct stimulation were used to confirm the target and final placement of the electrode. Direct stimulation and SSEPs performed intraoperatively confirmed the accuracy of the functional imaging data. Trial periods of stimulation successfully reduced pain in three of the five patients who then underwent permanent internal placement of the system. At a mean 6-month follow up, these patients reported an average reduction in pain of 55% on a visual analog scale. The integration of functional and anatomical imaging data allows for precise and efficient surgical planning and may reduce the time necessary for intraoperative physiological verification.