Dr Raymond Cook
"During that 20-year period, we [Dr Silberstein & I] have evolved the surgical techniques presenting data/information quite regularly at the international meetings of the World Society of Stereotactic and Functional Neurosurgery (WSSFN) mainly on efficacy and complications of the technique and the procedure."
My interest in movement disorder surgery in some ways was fortuitous! I had completed my Australian neurosurgical fellowship training in England and North America in Neurosurgery with my work in America focused on 'stereotactic neurosurgery'. That technique of neurosurgery was focused mainly for intracranial navigation which was particularly useful for surgery for brain tumours.
However, some surgeons that I worked overseas with were interested in 'functional neurosurgery' where very small destructive deliberate injuries were made to the brain to alter neurological function mainly for Parkinson's disease. That interest became my interest, the more exposure I had to the surgical treatment of Parkinson’s disease the more I wanted to pursue the development of what has proved to be a new subspeciality of neurosurgery, a new field requiring expertise and dedication.
This sort of surgery was developed mainly in the 1950's and 60's but with the advent of levodopa being used for Parkinson's disease in the late 60's, many of the techniques were lost to the subsequent generations of neurosurgeons. So, at that point in time in the early 90's, there was only the occasional neurosurgeon interested in surgeries for movement disorder such as Parkinson's disease. One such surgeon in Boston, Prof Rees Cosgrove, stimulated my interest in 'pallidotomy' which was an old- fashioned operation but was being done at that point in time with the new equipment, computers, CT and MRI scans, and I trained in that technique which I then brought back to my start up practice in Australia in1993.
On my return to practice neurosurgery in Sydney I was referred by Sydney neurologists’ patients who had movement disorder problems relating to prolonged use of dopaminergic medication in the setting of Parkinson's disease.
I performed numerous pallidal lesion surgeries in the mid 1990's and became quite adept in managing complicated end-stage Parkinson's disease. It was around this time that Prof. Benabid developed deep brain surgery for Parkinson's disease, he visited Sydney in 1996 and from that visit, my practice of lesion surgery became less popular when patients became aware of this potential therapy that was not considered 'destructive' to the brain. After a few years worldwide of its use, it became apparent that this technique of deep brain stimulation was the 'new way forward' for movement disorder surgery /surgery to help people with advanced Parkinson's.
I performed my first deep brain stimulation surgery in 2000 after some discussion with my colleagues around the world who were doing this surgery quite successfully.
My initial practice was with my neurological colleague, Prof Peter Silburn, who used to visit Sydney from Brisbane on a regular basis to help me perform subthalamic nucleus stimulation along with pallidal stimulation and this arrangement occurred for a couple of years whilst we established the service. The service was bolstered with the return of my neurological colleague, Dr Paul Silberstein, fresh from his doctorate in Movement disorders in London (UK) and over time once proficiencies were achieved, eventually Peter Silburn ceased his regular Sydney visits and Paul Silberstein and myself took over the practice from about 2003.
So, for the past 20 years, Paul Silberstein and I have had a flourishing practice of DBS mainly for Parkinson's disease (90%) with the other 10% being deep brain surgery for dystonia, both generalized and segmental, Tourette syndrome and for severe tremor.
During that 20-year period, we have evolved the surgical techniques presenting data/information quite regularly at the international meetings of the World Society of Stereotactic and Functional Neurosurgery (WSSFN) mainly on efficacy and complications of the technique and the procedure.
I was involved with the Australian government in registering (Medicare) DBS for the use in dystonia, Parkinson's disease and familial tremor throughout the mid 2000's and the whole procedure evolved from an unusual experimental last ditch treatment for Parkinson's disease to 20-25 years later now mainstream neurosurgery in a way a new subject that we teach the young neurosurgeons coming through, a very strongly scientifically studied, validated procedure for many neurological conditions and some experimental conditions. It remains registered in Medicare in Australia for the three conditions – familial tremor/essential tremor, dystonia and Parkinson's disease.
Over the years, we have looked after more than 600-700 patients with various neurological conditions, mostly Parkinson's disease, performing deep brain surgery (DBS) for this problem with remarkable success in terms of efficacy and very limited morbidity.
Our serious morbidity rate including stroke and haemorrhage is about 0.3% and we have managed to keep our infection rate (lifelong) for the implant down at around 3% which is better than most reports worldwide in terms of the frequency of infections/haemorrhage relating to this procedure. It became evident 10-15 years ago that we required neuropsychiatric support for our patients who had Parkinson's disease and other conditions needing deep brain stimulation, Linton Meagher (Psychiatrist) joined our team in the late 2000's and reviews/manages every patient that we operate on for movement disorders.
During that time period, we have been ably supported by a number of technicians and for many years, my trusted assistant, Dr George Fracchia, who is now retired, performed many hundreds of procedures from the days of lesions through DBS.
So, much of my neurosurgical life has been dedicated to functional neurosurgery including deep brain stimulation for the various conditions referred above with some super specialising in Parkinson’s disease.