Mr Ludic Zrinzo is a Senior Lecturer at UCL and a Consultant Neurosurgeon at The National Hospital for Neurology and Neurosurgery. His specialist interest is in the surgical management of chronic neurological diseases. In particular, he concentrates much of his clinical practice and research on the continued improvement in the surgical care of patients undergoing Deep Brain Stimulation (DBS).
Mr Zrinzo kindly took time this month to speak with us about his work, which he is now bringing to his own private practice at the Queen Square Private Consulting Rooms.
Q: Firstly, perhaps you could tell us a little about your background and what prompted your decision to not only specialise in neurosurgery but specifically, the surgical treatment of chronic conditions?
My family comes from Malta and my parents are both doctors. As a teenager, I was fascinated by Mathematics, Physics and Engineering and had never seriously considered Medicine as a career. That all changed when a hijacked Egyptair Flight was forced to land in Malta. It was a brutal affair with terrorists shooting passengers in the head as they made their demands. The ordeal only came to an end after a bloody assault by Egyptian commandoes. Many passengers lost their lives but two survived gunshot injuries to the head. My father, Laurence, was the neurosurgeon who had operated on them. This darkest of days triggered my resolve to become a neurosurgeon.
As a medical student, I became increasingly fascinated with the human brain and how it gives rise to our movements, feelings and thoughts. When I moved to London for neurosurgical training, I had the opportunity to work with Prof Hariz (neurosurgeon) and Prof Limousin (neurologist) within the Unit of Functional Neurosurgery. Their patient-focused approach and the very positive results that surgery could provide in selected patients were inspiring.
After a fellowship in functional neurosurgery at UCLA, Los Angeles, I was appointed Consultant in Neurosurgery at Queen Square 9-years ago. The Unit has rapidly expanded since to include another two consultant colleagues – Dr Foltynie (neurologist) and Mr Hyam (Neurosurgeon). Our Unit is now the busiest deep brain stimulation (DBS) center in the UK with a track record that has been described as an “international benchmark” in safety and efficacy.
Q: What does DBS surgery involve and what can it be used for?
Deep brain stimulation (DBS) surgery improves brain function by changing the way the brain processes information. It is the most commonly used technique in functional neurosurgery. DBS involves placing tiny electrodes very precisely within the brain and connecting them to a “brain pacemaker” implanted under the skin, below the collarbone (Figure 1). Delivery of a small electrical current can disrupt abnormal brain activity and lead to a dramatic improvement in the symptoms of some chronic neurological conditions.
Figure 1. DBS Placement
Traditionally, DBS surgery had to be performed under local anaesthesia so that doctors could refine the electrode location within the brain by observing the effect that the surgery was having on the patient’s symptoms. However, our pioneering research has changed the way DBS surgery is performed. Neurosurgeons can now rely on detailed MRI sequences to both guide and verify electrode location within the brain. In practice this means that surgery is safer and can be performed under general anaesthesia – while the patient is asleep. Of course, this is much less stressful for patients.
There is a huge amount of scientific evidence supporting the use of DBS in selected patients with Parkinson’s disease, tremor and dystonia. Over 120 000 DBS procedures have been performed worldwide in the last 25 years. The success of DBS in treating patients with these movement disorders has prompted researchers around the world – including our group at Queen Square – to investigate whether DBS can be useful for other brain disorders, including chronic pain syndromes (like cluster headache) and some neuropsychiatric disorders (such as Tourette syndrome and obsessive compulsive disorder). Much more research is required but the results of DBS for some of these other conditions are encouraging.
Q: Which patients might benefit from DBS surgery?
When symptoms respond well to medications, DBS surgery does not need to be considered. However, medications can cause intolerable side effects or may fail to provide adequate symptom control throughout the day. These patients may benefit from DBS.
Parkinson’s disease (PD) is the commonest indication for DBS. Some patients with PD develop “motor fluctuations” where tremor, rigidity and slowness appear in an increasingly unpredictable fashion throughout the day. DBS can “smooth out” these fluctuations, allowing more consistent symptom control and a reduction in the amount and number of medications required.
Essential or familial tremor is another common movement disorder that responds well to DBS.
Ultimately, a detailed assessment by a neurologist and neurosurgeon with a specialist interest in functional neurosurgery is required to determine whether a particular patient will benefit from DBS.
Q: What outcomes might patients who undergo this type of surgery be able to expect/hope for?
DBS surgery does not provide a “cure” for the disease. However, in well-selected patients DBS can have a dramatic positive effect on symptoms and quality of life. DBS surgery needs to be “tailored” to the individual patient and a thorough clinical evaluation combined with a number of specific tests allow the DBS team to counsel individual patients on the likely benefit.
It is important to realise that DBS is not simply an operation – it is a lifelong therapy. A positive outcome requires a meticulous approach to surgery combined with regular optimisation of medication and stimulation parameters in the years that follow.
Q: How does our location in Queen Square aid you and your team?
A multidisciplinary approach is essential to obtaining good outcomes after functional neurosurgery. The National Hospital at Queen Square brings together the country’s foremost experts in functional neurosurgery, neurology and neuroimaging with support from dedicated healthcare specialists when required, including psychologists, specialist DBS nurses and speech and language therapists. We are also fortunate to have the country’s first operating theatre with a built in MRI scanner to facilitate our “MRI-verified” approach to DBS surgery.
This multidisciplinary approach is also extended to other chronic neurological conditions such as trigeminal neuralgia where I work closely with Dr Matharu, consultant neurologist with a specialist interest in headache, to provide a comprehensive service to patients with trigeminal neuralgia, cluster headache and similar problems.
Q: How are patients able to find out whether or not DBS is a treatment option for them?
Patients and their immediate family are seen in joint consultation with a neurologist and neurosurgeon from the DBS team. The symptoms that are causing the most concern are identified. Specific investigations may be requested and the results then reviewed. The DBS team will then counsel the patient and family as to whether DBS is a treatment option for them and what the likely outcome is in their particular case.
Mr Zrinzo holds regular clinics for private patients at the Queen Square Private Consulting Rooms, 23 Queen Square. If you would like to discuss a referral, please contact his secretary Lottie Wade at firstname.lastname@example.org, or contact the Private Consulting Room directly on 020 344 88948.