Evo Terra (Host): This is Community Connect presented by Tampa General Hospital. I'm Evo Terra. Joining me are Doctors Yarema Bezchlibnyk, stereotactic neurosurgeon, and Dr. Mohamed Khattab, radiation specialist, both with Tampa General Hospital. Thanks, doctors, for joining me.

Mohamed Khattab, MD: Thank you.

Yarema Bezchlibnyk, MD, PhD: Thank My pleasure.

Host: We'll start, Dr. B, with you. What type of movement disorders as well as neurologic and psychiatric conditions can be treated with neurosurgical and radiation treatment options?

Yarema Bezchlibnyk, MD, PhD: Sure. So, it is FDA-approved to treat conditions including essential tremor, Parkinson's disease, dystonia, and obsessive compulsive disorder. Those are FDA-approved treatments with DBS, stereotactic radiosurgery. And focused ultrasound is now approved to treat essential tremor and Parkinson's disease.

Mohamed Khattab, MD: Thanks, Dr. Bezchlibnyk. So, with stereotactic radiosurgery specifically, it's been used to treat a variety of functional neurologic and psychiatric diseases. Dr. B discussed a few of them. So, for tremor, that's one that can be essential or parkinsonian tremor; obsessive compulsive disorder and not your garden variety, but the very intractable cases; major depression, it has been used, and we have personal experience with that; trigeminal neuralgia as discussed; certain pain syndromes, both for chronic neuropathic pain, as well as other complex type of pain pictures, it can be used; and even seizure disorder in specific types, it can be used. So, there's a whole variety. And then, there's more rare things, psychiatric disorders like anorexia, Tourettes that are sometimes in rare situations also treated.

Host: Fascinating. I think there are more things about Neurosurgery than we typically think of on the outside. Dr. Khattab, I'll stick with you for a moment. Can you walk me through the process of a typical neurosurgical or radiosurgical procedure for these sorts of conditions?

Mohamed Khattab, MD: So, I think Dr. Bezchlibnyk would best describe the neurosurgical procedures. But for stereotactic radiosurgery, there is no surgery in it despite it being in the name. It's really just focused x-rays. And in order to deliver these focus x-rays in a very precise way, immobilization is required, but it's incisionless. So, the patient usually comes in first for a planning session where we make this mask for them. It's tight, but comfortably so, just like a hockey mask would be, or a little tighter than a hockey mask. We take a scan with that mask on. And we fuse that scan with advanced imaging, such as MRIs and special types of MRIs and special sequences.

And then, about a week later, the patient can come in for the actual treatment wearing that same mask. But now, instead of being on a CAT scanner, they're on the treatment table. And here at Tampa General, we have a machine called the CyberKnife. Again, no knives involved, but they would lay on this table typically for about 45 minutes. They wouldn't feel anything. They wouldn't hear anything. They wouldn't see anything. They would just take a short nap, no anesthesia, and then they would come out of it and we could go back to work immediately, or back to whatever they were doing. They just walk out.

Host: Wow. Fascinating. Okay. That's for the non-surgical surgical options with Radiology. Dr. B, talk to us about actually doing the neurosurgical procedures.

Yarema Bezchlibnyk, MD, PhD: Sure. There are three main ways of doing neurosurgical procedures for these conditions. And I should say in addition to the FDA-approved indications that I talked about, there are also more experimental treatments, that DBS and focused ultrasound are being evaluated. But speaking about those surgeries, as a matter of course, the original surgery from way back in history consisted of something called radiofrequency ablation, which involves passing a very thin, very small probe into a very, very specific part of the brain, which is really exactly where these stereotactic radiosurgical procedures are also focused on to make a small lesion there in a network to help control these movement disorders.

Over the years, as that therapy was utilized more frequently, they discovered that they can, instead of burning a hole with that probe, connect it up to a pacemaker and then use electricity to not so much make a lesion, but to use electricity as a language of the brain to control that network without destroying tissue. And so, that's really what DBS is. It's using electrical stimulation through a pacemaker to help regulate movement that passes through these very specific circuits in the brain.

And then, the last way that we do procedures in this area from a neurosurgical point-of-view is something very similar to stereotactic radiosurgery called MRI-guided focused ultrasound. And there, instead of focusing these x-rays that Dr. Khattab talked about, we focus 1,024 individual ultrasound transducers to precisely those same regions. And that's also done without an incision, without a standard surgical procedure.

Host: Dr. B, let's stick with you for a moment and talk about. Patients who can get these sorts of advanced treatments, what's a good patient for you? And then, I'll let you follow up with that, Dr. Khattab.

Yarema Bezchlibnyk, MD, PhD: Yeah. So, the most important thing to realize is that all these different interventions that we've talked about, they cover all our bases, basically, right? we offer the full suite with the inclusion of stereotactic radiosurgery now in managing patients with these conditions that we've discussed. Basically, what we're looking for in a patient is somebody who has one of these conditions that is resistant to medical therapy, either because the patient is getting side effects or because their clinical condition is simply overwhelmed what the medications are able to treat. That's one thing.

The second thing is that we want a neurologist to have made a diagnosis or a psychiatrist in the case of psychiatric conditions, to make sure that we're dealing with the right entity. And then, we talk to the patient and we explain to this patient what the different options are. And in fact, some of these therapies, because they're not surgeries per se, are better served for patients who have other medical conditions versus others. So, it used to be that if somebody was coming in for a surgical procedure, we'd want to make sure that they didn't have any other medical problems that might confound to that. But with now being able to offer all these different interventions, we'd much rather that patients not overthink that and come and talk to us, and then we can lay out the situation to them.

Mohamed Khattab, MD: One of the great things about being here at University of South Florida and Tampa General Hospital is that we have this whole palette of treatment options, and it's part of our responsibility to help guide the patient to the various options, but then also have the patient being the main person that makes a decision for what is the treatment that they would like to pursue. Some conditions may automatically rule out, in some cases, a certain type of treatment. And then, patients also, their choice matters the most. But really, what's sets Tampa General apart is that we are able to do all of these different treatments, so we're not pigeonholed into doing just one.

I'll give you an example, a patient with tremor that's bilateral, for instance, would be best suited for a deep brain stimulation, as a really great treatment option. But some patients may not meet certain criteria for that treatment option. And it's great that we have focused ultrasound as well as stereotactic radiosurgery as other treatments. And of course, as Dr. Bezchlibnyk was mentioning, we don't jump into that. For our patient with tremor, they have to have failed the medical therapies that are less invasive first.

And the good thing here, for instance, the example of tremor, we actually have a whole neuromodulation center that is led by Dr. Bezchlibnyk and the neurologists and can properly guide us and we have pathways to help decide what is the best treatment option for each patient. And that can be similarly applied to all these other disease processes.

But really, what makes us a center of excellence is having all of these approaches in one place and a patient doesn't have to go searching different providers and different organizations and then comparing things. And we don't run into the problem of, if you're a hammer, everything looks like a nail, because we're not just hammers, we have hammers, wrenches, all sorts of things, if that analogy makes sense. And that allows us to be able to look at the same disease but in different patients and decide what's best for that particular patient. So, it's custom-made treatment plans for each patient.

Host: Having all those options in one place is definitely great. Earlier, Dr. Bezchlibnyk talked about collaborating with other medical providers that the patient works. So, I'll stick with you, Dr. Khattab. Can you talk about that a little bit more, about the collaboration between doctors, and as these procedures for patients are underway?

Mohamed Khattab, MD: Absolutely. Yeah. So, we collaborate closely with movement disorder neurologists, as one example. Epilepsy, neurologists, psychiatrists including interventional psychiatrists, ones that, for instance, do treatments called TMS and all sorts of other interventions, electroconvulsive therapy, that sometimes refer patients that are refractory to their treatments. And then, also, just your, kind of more general psychiatrists in the community and in our center as well.

And we're happy to do these collaborations, not just with the physicians here at University of South Florida and Tampa General Hospital, but with community partners as well. So even if a neurologist is not part of our neuromodulation center, we can co-manage these patients where we provide this treatment. But that patient can still have that same continuity with their outside psychiatrist or neurologist, so on and so forth.

For the actual treatments, for the neurosurgical procedures, Dr. Bezchlibnyk has a great team and they go to the OR on their own. Sometimes they have different assistants that can come in and also help, when I participate in stereotactic radiosurgery. Actually, all the treatments are a collaboration by design between our department and the Neurosurgery department, so with Dr. Bezchlibnyk or with one of his colleagues, like Dr. Oliver Flouty as an example. So, we work on the design and the targeting together, and everything is about teamwork here.

Yarema Bezchlibnyk, MD, PhD: I should point out that part and parcel of somebody being evaluated for these conditions is that we here at the University of South Florida, Tampa General Hospital will have a clinical case conference where we present all our patients together with Neurology, Radiology, speech-language Pathology, Physical Therapy even, so that we're all on the same page about what we're offering the patient. And then, of course, we then present that recommendation to the patients and get their input and bring that back to the team as well. So, it's not only collaborative with all these other medical providers, but also with the patient and their family, and then with physical therapists, speech-language pathologists, so that we all are on the same page.

Host: It's great to hear. I'll ask this last question about what's next? First off, this is such a fascinating and advanced field as it is. And drastically different I know, than it just was 20 or even 10 years ago. But what do you see as the next frontier in treatments for movement and psychiatric disorders? And Dr. Bezchlibnyk, I'll start with you.

Yarema Bezchlibnyk, MD, PhD: Yeah. So, one of the exciting things, or another one of the exciting things about being part of an academic health center like university of South Florida, Tampa General Hospital is that we're involved on a daily basis in collaborations with thought leaders in movement disorders and engineering, even radiation physicists, this sort of thing.

And so, we are involved in a lot of clinical trials as well as, basic science trials that kind of revolve around this field. And so, we're actively involved in looking again at stem cells in treating these conditions and in looking at other ways of targeting these structures, and also in how to improve our ability to target these structures with the idea that potentially, we can make that process much more straightforward and simpler in the OR, so that we can offer these techniques to more and more patients.

Mohamed Khattab, MD: I agree with Dr. Bezchlibnyk entirely. It's a very exciting time to be in our field of Functional Neurosurgery and Functional Radiosurgery. One of the things I'm particularly excited about is our advanced imaging now and how that will guide treatment design. So at this point, we're able to get a lot of information from special type of MRI called diffusion tensor imaging, and we can actually see the neuronal fibers in the brain. And what's really exciting is we can see these networks pre and post-treatment and can even see functional rewiring that happens.

But ultimately, our hope is to get to the point that while we're using this information to help us now to refine our targets and also predict which areas of targeting are best on an individualized level for each patient. So, there's a lot of excitement here in the imaging world, and how that will guide all of our treatments really, not just one particular type of treatment.

Host: Well, this has been a fascinating and eye-opening conversation for me. Dr. Bezchlibnyk and Dr. Khattab, thank you very much for joining me on the show today,

Yarema Bezchlibnyk, MD, PhD: Thank you, Evo.

Host: And that has been Dr. Jeremy Bezchlibnyk and Dr. Mohammed Khattab.

Evo Terra (Host): So to learn about innovative approaches to treating psychiatric and movement disorders, please visit us at tgh.org/movement disorders.

Host: If you enjoyed this episode, follow Community Connect, presented by TGH on your favorite podcast platform. I'm Evo Terra. And this has been Community Connect, presented by TGH. Thanks for listening.