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Ali Rezai is making a name for himself thanks to his groundbreaking work in “deep brain stimulation.” Columbus Monthly takes you inside the Ohio State neurosurgeon’s operating room.
The list of 555 Best Doctors in Central Ohio is not available online. For the December 2010 issue, contact the Columbus Monthly circulation department.
On an October morning, Vera Merz finds herself on an operating room table engulfed by a team of about 15 doctors and nurses at the Ohio State University Medical Center. They’re here to fix her brain, by drilling a hole in her head and inserting a probe. The patient, who’s 81 years old, remains awake for almost all of the surgery.
Merz suffers from severe tremors. In fact, the shaking got so bad she struggled to feed herself. Too embarrassed, she stopped seeing her friends and became clinically depressed while living alone in Lincolnwood, Illinois, a Chicago suburb.
But she had the strength to search for a solution, learning about a procedure called deep brain stimulation (DBS). A surgeon slides a wire with electrodes on the end of it into the thalamus, the part of the brain that controls muscle movement. That wire is connected to a pacemaker, which is implanted just under the collarbone. It delivers high-frequency stimulation to the thalamus through the electrodes—and that stimulation helps control the chaotic messages and suppress the tremors.
Merz asked her neurologist in Chicago about the surgery and he firmly advised against it. She didn’t give up, consulting with other physicians. They recommended just one doctor in the country: OSU neurosurgeon Ali Rezai.
In the world of functional neurosurgery, Rezai, 45, is a rising rock star. He has been performing DBS since he was a fellow in the late 1990s at the Karolinska Institute in Stockholm, Sweden, and the University of Toronto. Back then, he says, “We would start at 7 am and maybe go until 2 am the next day. Those were the very early days. Now we can get the surgery done within three hours.”
There was a surgeon at the OSU Medical Center who did DBS some time ago, but the surgeries were rare, just a few a year. Now, Rezai, who joined OSU in August 2009, does two or three a week. Much of the recent advancements in the procedure can be linked to Rezai’s research and the improvements he’s made in the methods and equipment used in the surgery. He holds 10 patents involving neurosurgery and neuromodulation.
Rezai, who received his undergraduate degree in biology from the University of California-Los Angeles and his medical degree from the University of Southern California, began to learn about different types of surgery while he was an intern, resident and chief resident at the New York University Medical Center. One specialized field caught his interest: functional neurosurgery.
“Functional was the newest field,” he says. “It was fascinating to me. I saw the potential of it impacting so many different neurological problems.”
Rezai says he could see then how functional neurosurgery could potentially help people with Parkinson’s disease, epilepsy, severe chronic pain, depression, obsessive-compulsive disorder and addiction disorders. “These are areas where there are no optimal therapies,” he says. “It was fertile ground for exploration.”
When Rezai completed his residency at NYU in 1997, he went on to those fellowships in Toronto and Sweden. “It wasn’t developed in the United States yet,” he says. Last year, Rezai—recruited by several hospitals around the world—left the Cleveland Clinic for OSU. He decided the university was serious about increasing its footprint in medical research and advancements in technology. “Part of what I’m doing here is putting Ohio State on the map,” Rezai says. “One of my main goals here is to explore other clinical trials for deep brain stimulation.” (The procedure has been approved by the U.S. Food and Drug Administration to treat essential tremors, Parkinson’s and dystonia.)
Much like he plots out a clear path to the thalamus during surgery, Rezai is investigating how DBS also can treat patients with traumatic brain injuries, alcoholism, anorexia, severe depression, post-traumatic stress disorder, Alzheimer’s and autism. “There are different parts of the brain that are involved in human behavior,” he says. “It’s becoming more clear through scientific research that there are abnormalities underpinning those disorders. . . . Our goal is to take these advanced cases of cognitive behavior or motor function abnormalities and significantly improve the physical disease and emotional and cognitive disabilities that these patients have.”
Rezai is quick to point out that he can’t do any of it by himself. He has assembled a team of physicians and nurses covering several specialties: neurology, neurophysiology, psychiatry, anesthesiology, physical medicine and rehabilitative medicine. In addition to attracting patients from all over the United States and other countries to Ohio State, Rezai’s presence is drawing top-notch doctors to the university.
Chima Oluigbo, a neurosurgeon who finished his residency at a hospital in England, arrived at Ohio State a year ago for a fellowship with Rezai. “He is the man to train with,” Oluigbo says. “He is training and he is treating people as well. We do an average of two of these cases a week. It’s like a well-oiled machine. You’re able to get good teaching and good feedback.”
When Merz first came to Ohio State, she had been taking medicine to treat the essential tumors, which is a progressive neurological disorder. As the disease progressed, Merz continued to have trouble feeding and dressing herself. “With her worsening tremors, her mood was being affected,” says Punit Agrawal, an OSU neurologist who works with Rezai and specializes in Parkinson’s disease and movement disorders. “She was looking at people who are well-known throughout the world for this surgery.”
Patients like Merz, and those with Parkinson’s, usually are treated with medication, Agrawal says. But eventually the medicine starts to lose its effectiveness or cause side effects—depression, for example. While the surgery doesn’t cure the disease, it does mask the tremors that patients develop. (Most insurance companies will offer some payment for the surgery, which costs between $40,000 and $110,000, depending on several variables, says hospital spokesman David Crawford.)
Merz was a good candidate because, despite her age, she was in good health and the doctors believed the surgery could improve her life. People who develop essential tremors—about 5 million in the United States—have abnormal brain activity in the thalamus. As a person ages, the symptoms—the shaking—may worsen, as they did with Merz.
Some of Rezai’s patients have suffered from tremors so debilitating they couldn’t perform their jobs; the surgery has allowed them to resume their work, for instance, as engineers or artists. He also has a 90-year-old patient who wanted the surgery so he could golf again. “The goal is to help people live better lives,” Rezai says, no matter the age.
Rezai knew he could help Merz regain some control over her hand movements and maybe restore a semblance of normalcy to the life of the retired bank clerk. She says she knew she was in good hands after first meeting Rezai. “I was very impressed,” Merz says.
In March, Rezai operated on the left side of Merz’s brain, blocking the signals that were causing the tremors in her right hand. “The first things that improved were my ability to write legibly and the ability to feed myself,” she says.
The improvement, in fact, was nearly immediate, says her son, Marty Merz. “Her handwriting went from looking like hieroglyphics to looking like it did way back when,” he says, adding that he also observed that a “fairly noticeable” head tremor also diminished after the surgery.
With the ability to use her right hand to eat and drink adequately, Merz felt comfortable enough to accept an invitation to be the guest of honor at someone else’s house to celebrate her 81st birthday. And the feisty octogenarian thought the surgery was so successful she asked Rezai to operate on the right side of her brain to block the tremors to her left hand. He agreed, but told her she had to wait a few months.
By Oct. 12, she’s ready. Before 8:30 am, Rezai’s team is assembled in the operating room, including Agrawal. A stereotactic head frame is bolted to Merz’s skull. The frame has markings on it, much like a ruler, to help the doctors know where to drill the hole— about 16 millimeters—smaller than the size of a dime—to guide the wire. Images of Merz’s brain from a high-resolution MRI flash up on a screen to map the safest route to the thalamus. Meanwhile, a neurophysiologist on Rezai’s team prepares the computerized, robotic equipment that will guide the wire with the electrodes deep into Merz’s brain.
After the general anesthesia wears off Merz is aware of the quiet hum of activity going on around her. Patients can be awake during this surgery because the brain doesn’t feel pain. They also need to be alert so they can respond to tests given by the doctors to see if the tremors have been suppressed.
Rezai and one of his fellows carefully monitor the progress of the probe as the neurophysiologist uses the robotic micro driver. Once it’s in place and connected to an external pacemaker, much like the wires attached to a battery, it begins to send electrical stimulation to the thalamus. Rezai and Agrawal turn their attention to Merz to begin working directly with her to determine if the probe is in the right spot. If not, it could affect sensation in her face and cause her to have tingling. Even being off by half a millimeter makes an extreme difference. The placement has to be exact.
When the wire is connected, it acts as sort of a microphone. Rezai and Agrawal listen to the neurons in Merz’s brain react as they move her hand back and forth quickly, flick her wrist, squeeze her arm and stroke her fingers. Each movement elicits a different sound from the brain as the neurons fire. Rezai hands her a glass of water, which she lifts to her mouth fairly steadily. Then he asks her to draw a straight line, which he compares to the not-so-straight line she drew for him before he turned the device on. The doctors also quiz Merz—her date of birth, count backward by threes starting at 100—to make sure the placement isn’t affecting other parts of her brain. This process repeats itself a few times until Rezai is satisfied the wire is precisely located.
On occasion, Rezai leans in to compliment his patient. “Vera, you’re doing really good. We’re almost done. It’s almost 11 o’clock,” he says. He holds out his right forefinger and asks her to touch his forefinger. She does so successfully. “That’s better than your baseline, Vera. How much better?” he asks.
“I don’t know. Hard to say, much better,” she says. Rezai estimates that about 80 percent of the tremors in Merz’s left hand have been blocked.
It takes doctors just a few minutes to close the hole drilled in Merz’s skull with a plastic plug and to stitch the skin together in her scalp. The probe is left in place. A week later, she returns to have it connected to the pacemaker, which was imbedded in her chest in March, by running a wire between the two under her skin.
If this operation matches the success of the March surgery, the doctors and Merz are optimistic about her chances for improvement. “I’m looking forward to filling in all the many things that one takes for granted,” she says, even if it’s as simple as tying her own shoes or cutting a piece of meat. Merz also would recommend the surgery to anyone who needs it. “But,” she adds, “only if you know who is doing it.”
Michele Lemmon is a freelance writer.
