I’m a pediatric neurosurgeon. Here’s why I’m excited about the technology at our fingertips.

By Dr. Suresh Magge, medical director of neurosurgery at CHOC, and co-medical director of the CHOC Neuroscience Institute

Even as a child, I was fascinated with science, and it was ultimately the concept of using science and technology to help people that drew me to medicine. Today, I’m more excited and optimistic than ever about our ability as clinicians to provide best-in-class treatment to the patients we have the privilege to care for – particularly in a minimally invasive way.

While every effort is made for nonsurgical intervention, neurosurgery can often be the answer to saving or improving a child’s life. At CHOC, we are committed to creating a personalized treatment plan for each child, based on his or her needs.

When surgery is necessary, we strive to perform minimally invasive surgery whenever possible for the myriad benefits it brings our patients. Minimally invasive neurosurgery offers a smaller incision, less pain, minimal blood loss, shorter time spent in the operating room, shorter recovery time, shorter hospital stays and hidden scarring.

There are a number of tools that we use to make surgery less invasive. For example, we can use a small camera, called an endoscope, to look inside the brain without having to make a large incision. In some surgeries, we can use a specialized robot, called a ROSA robot, to allow for precise placement of catheters or electrodes, and to operate on tiny areas of the brain.

Here are four surgeries I’m excited about as a pediatric neurosurgeon. In each surgery, the child is asleep and does not feel any pain during surgery. 

  1. Endoscopic surgery — This option for many types of brain surgery allows the neurosurgeon to identify and treat conditions deep within the brain. A tube-like instrument with a camera is inserted into the brain through a small incision in the skull. In some cases, we can insert the tube through the nose and avoid making any incisions in the skull. This allows the neurosurgeon to have a clear picture of the tumor. Then, we use specialized surgical instruments to remove the tumor or damaged area. When possible, we use this technique for brain tumors, hydrocephalus, arachnoid cysts, craniosynostosis and skull base surgery. In treating craniosynostosis, endoscopic surgery can replace larger and more invasive surgeries but still achieve excellent outcomes.
  2. Responsive neurostimulation (RNS therapy) —The RNS system is similar to a heart pacemaker. By monitoring brain waves, it can detect seizure activity and then the system can respond to stop the seizure. What simultaneously amazes me and comforts families about this piece of technology is that patients can’t feel the device once it’s programmed. They don’t feel pain or anything unusual. Studies show RNS therapy reduces seizures and improves quality of life for most people who have used it.
  3. Deep brain stimulation This surgical treatment can offer lasting relief for many children who experience abnormal movements. CHOC offers DBS surgery for children with movement disorders of all degrees, including very complex cases. We are one of the only centers in the world to use a multiple stage approach that allows us to better target the correct areas of the brain, without the need to wake a child during surgery. DBS surgery at CHOC involves the placement of electrodes in the brain and wires that connect to a stimulator device implanted in the chest. The device is like a pacemaker; it sends impulses to the electrodes that tell the brain to stop or minimize uncontrolled movements throughout the body. Our specialized team places up to 12 electrodes, when needed, to target different areas of the brain to attain a good outcome. Surgeries take place in a state-of-the-art operating room at CHOC, which includes the latest navigation system for safer, more precise procedures and the ROSA 3D-mapping robotic system that aids surgeons in locating the exact areas to operate.
  4. Laser Interstitial Thermal Therapy (LITT) – Also known as laser ablation, this emerging technology provides pediatric patients with epilepsy and other conditions a range of benefits more traditional procedures can’t match and offers a potential solution for brain tumors that are hard to reach with traditional surgery. Instead of doing a craniotomy where a large incision is made to open up the skull, the neurosurgeon first makes a small hole in the skull just a few millimeters in a diameter. Then, under MRI visualization, the neurosurgeon can precisely position the laser probe and deliver heat to the specific area, which destroys the abnormal tissue. Laser ablation is especially useful in patients with tumors or seizure-generating abnormalities deep within the brain. Precision is essential in implanting the catheter, which guides the laser, since it allows the neurosurgeons to limit the thermal energy delivered to the tumor area only. Most LITT is minimally invasive and requires a short time in the operating room, and patients are often able to go home the next day.

Throughout my career, I’ve been fortunate to see firsthand how neurosurgery has advanced tremendously over the years, particularly through research and innovation.

I’ve had the privilege of studying and providing care at a number of institutions – Harvard, the National Institutes of Health, the University of Pennsylvania, Boston Children’s Hospital, and Children’s National Hospital (Washington, DC) — before coming to CHOC. At each of these institutions, it’s evident that through innovative technology and minimally invasive surgery, we as neurosurgeons can alleviate suffering and have a significant impact on the lives of children.

As a team here at CHOC, we always ask ourselves, “What is the best thing we can do for each child in the least invasive method, with the least amount of pain?” and then we try to do it in the most compassionate way possible.

It’s an exciting time in medicine, in part thanks to advances in technology — especially the pieces of technology that allow us to provide these minimally invasive surgical options that make a true impact on children and their families.

For more information about the CHOC Neuroscience Institute, click here.

Related posts:

Wired for hope: deep brain stimulation for dystonia

Every morning when she awakes, Sydney Amato begins her daily battle with her body.

If she’s lucky, the 16-year-old will have gotten a handful of hours of uninterrupted sleep – dreaming, perhaps, of doing what most healthy kids her age take for granted:

Hanging out with friends. Going to school. Learning to drive.

Because of a neurological condition called dystonia, Sydney, who is in excellent cognitive health but speaks and walks with some difficulty, suffers from involuntary and near-constant contraction of muscles in her neck, arms, legs and trunk.

Sydney with her father, Louis

Her mind is unable to control the painful jerking that makes most of her body twist and go rigid, her muscles moving out of normal sequence.

Born a right-hander, she can feed herself with some struggle using her left hand. She wants to dress and put on makeup herself, but those normally simple tasks become lengthy ordeals.

“My body fights me all the time,” says Sydney, trying to distract herself in her hospital bed by watching an old episode of “Keeping Up with the Kardashians.” Listening to her favorite music – Ariana Grande, Lauren Daigle, Drake – can only temporarily transport Sydney away from her debilitating condition.

“She knows what she wants to do,” says her father, Louis. “But her body won’t let her.”

Specialists at CHOC Children’s are working hard to change that.

A first for CHOC

On Aug. 14, 2020, a team led by Dr. Terence Sanger, a physician, engineer, and computational neuroscientist who joined CHOC in January 2020 as its first chief scientific officer, and Dr. Joffre E. Olaya, CHOC’s functional restorative neurosurgeon, implanted several temporary electrodes into Sydney’s brain.

Dr. Terence Sanger, a physician, engineer, and computational neuroscientist and CHOC’s chief scientific officer

The surgery marked the first time a patient with a movement disorder at CHOC underwent a procedure called deep brain stimulation (DBS).

Working in perfect harmony as a team, Dr. Sanger and Dr. Olaya performed the first stage of a three-stage surgery on Sydney. As the surgeon, Dr. Olaya placed the leads following advice from Dr. Sanger, the neurologist, where they should go.

In the procedure, millimeter-thick electrodes were precisely positioned into the basal ganglia region of Sydney’s brain – about three inches deep. The surgery involved the use of the ROSA Robot, the same tool that has been used during brain surgery on epilepsy patients at CHOC since 2015.

Dr. Joffre E. Olaya, CHOC pediatric neurosurgeon

Considered one of the most advanced robotized surgical assistants, ROSA includes a computer system and a robotic arm. It’s a minimally invasive surgical tool that improves accuracy and significantly reduces surgery/anesthesia time.

The ROSA Robot helped with implanting and targeting the electrodes, and a portable operating-room CT scanner confirmed their position.

Turning down the volume

DBS is designed to ease Sydney’s condition by sending electrical currents to jam her malfunctioning brain signals.

Think of turning down the volume on your car radio.

“Nobody really understands the cause of dystonia,” Dr. Sanger explains, “but there’s probably too much electrical stimulation going on in the motor areas of the brain. We’re trying to calm down that extra noise.”

Although DBS dates to the 1960s, it wasn’t until the 1980s that the modern era of using it to treat adult patients with tremor and Parkinson’s disease began.

In 2000, Dr. Sanger, working with engineers, data scientists, neurosurgeons, and others, began implanting electrodes in pediatric patients.

Instead of the established method of placing the leads at predetermined sites and hoping they worked, Sanger and his team, just as they did in Sydney’s case, placed temporary leads to best assess where they should go permanently based on patient response.

In 2016, Dr. Sanger began honing DBS to treat children with dystonia. Before the surgery on Sydney, Dr. Sanger had performed DBS on 26 children using the same three-stage technique. He says 80 percent of those children have seen successful results.

Early signs

Sydney began showing symptoms of dystonia – tremors in her hands — when she was 5 ½ years old.

A year later, she was using a wheelchair. She had her first brain surgery at age 7.

Since then, “she’s been all over the U.S.” seeking the right treatment for her condition after several setbacks, says her father.

But her condition was not improving.

Early this year, a neurologist in Kansas City, Mo., recommended that Sydney see Dr. Sanger.

“I asked him, ‘If Sydney was your kid, where would you go?’ Louis Amato recalls. “He said, ‘Hands down, Dr. Sanger.’”

The COVID-19 pandemic pushed Sydney’s surgery to mid-August.

Sydney already had two electrodes in her brain that were only partially working when she came to CHOC in early August for surgery.

After two extensive run-throughs with their team, Dr. Sanger and Dr. Olaya, in a six-hour procedure that at one point had nearly 20 people in the operating room, implanted more electrodes to give her a total of nine.

On Thursday, Aug. 20, six days after Sydney’s surgery, Dr. Sanger stopped by her room at CHOC Children’s Hospital. The room was decorated in purple, Sydney’s favorite color.

Dr. Sanger greeted her as CHOC staff members, joined by members of Sanger Lab, which conducts research in pediatric movement disorders, prepared to have Sydney walk back and forth down a hallway while connected to electrical equipment programmed to record signals in her brain and muscles.

A thick coil of multicolored wires snaked from under a large white bandage covering Sydney’s head. Extending about 6 feet, the wires were plugged into specialized recording equipment controlled by Jennifer MacLean, a pediatric nurse practitioner whose job was to manipulate the strength of electrical charges affecting the four points of contact on each electrode.

The goal: determine which charges worked best and on which electrodes.

“It could have turned out that the DBS procedure made no difference,” Dr. Sanger says. “But we’ve seen a very good response in Sydney.”

For example, her once mostly useless right hand was working much better.

“It gives you goosebumps,” Louis Amato says.

After taking a bite of a veggie burger and sipping some water, Sydney started to walk.

Following her were seven CHOC and Sanger Lab specialists.

“Go nice and slowly,” Jennifer told Sydney. “You’re going too fast for us!”

Perhaps Sydney was anxious to get back to riding Tigger, a quarter horse, in her hometown of Carthage, Mo. She has been riding him for six months.

Sydney is eager to get back to riding her favorite horse, Tigger.

“Her balance isn’t bad on the horse,” says Louis Amato.

Sydney also loves to tan by her pool and swim.

What she wants most, however, is to be freed from her body so she can return to school and do what most teens enjoy.

“It’s stressful,” says her mother, Angie. “She has a lot of friends her age, but she can’t do a lot of the things they do. She has her days when she can get really upset.”

Now, however, working with Dr. Sanger, Dr. Olaya and the entire team at CHOC, the Amatos are more optimistic than ever.

“We’re hopeful that this is going to be a big life-changer for her,” Angie Amato says. “That would be the best thing that could ever happen – better than winning the lottery.”

‘The A Team’

After crunching numbers for a week to assess which of the nine electrodes proved to be the most effective based on how Sydney responded to varying degrees of electrical currents, Dr. Sanger and his team settled on four electrodes that were permanently used to treat her condition – three new ones, and one existing one.

The team performed this second surgery on Sydney in late August.

In the third and final surgery, successfully completed in early September, a rechargeable generator that powers the DBS leads was implanted in Sydney’s chest.

“As we get better and better at this,” says Dr. Sanger, “and as the technology progresses, we’ll be able to do this on kids who are less sick than Sydney.”

Dr. Sanger and Dr. Olaya are poised to dramatically improve the lives of many more patients like Sydney at CHOC.

“I’m really excited that we will be doing more of these procedures to help pediatric patients with movement disorders and significantly improve their quality of life,” says Dr. Olaya. “I look forward to continuing to provide this type of personalized care.”

Angie and Louis Amato say Sydney has never gotten this much special attention during her 11-year-plus medical journey.

“Here at CHOC,” Louis Amato says, “we feel like we’re with the A Team.”

Says Sydney: “I’ve never felt this much confidence and this good about treatment before.”

Learn more about deep brain stimulation (DBS) surgery at CHOC.