Charles Liu, MD, Professor of Clinical Neurological Surgery at Keck Medicine of USC, discusses our unique, integrated approach to epilepsy care and surgery, including our program's goals and key collaborations designed to better serve our patients.
Yeah. Hello. It gives me great pleasure to tell you a little bit about the epilepsy surgery programs here at USC, which is unique in that we take a very integrated approach. I'm Charles Liu. I am a professor of neurological surgery, neurology, urology, bob, medical engineering and back kinesiology. Here at USC, I also served as the director of the U. S. D. No Restoration Center and director of epilepsy surgical programs and also the USC Epilepsy care consortium. Um, at USC, Uh, one of my other important roles is that of being the chair of neurosurgery and orthopedics and chief of Innovation on Greece Search at Rancho Los Amigos National Rehabilitation Center today. We're gonna talk a little bit about the goals of epilepsy surgery here at USC And what the goals of our overall programs are Our programs, uh, goals can be considered in, uh, threefold. First one would be to provide the most advanced surgical care in treatment for epilepsy. The second goal would be thio provide, um, a mechanism by which the public health dimensions of epilepsy across Southern California beyond our addressed, we do this through programs and education and finally to serve as a platform for epilepsy and neuroscience research. So let's talk a little bit about the surgical treatment of epilepsy. When one talks about treating epilepsy through surgery, we can think of it as falling into four general categories. The first category would be those surgical procedures that relate to, um, invasive egg diagnostics. A second would be micro surgical receptions of seizure Fosse third, uh, which is a very important technique now that's gaining wider spread acceptance and certainly, uh, integrated into our programs both on the adults and Children side those related thio laser interstitial thermal therapy, which is a minimally invasive way of a bleeding seizure Fosse, and finally, very importantly, the concepts of neuromodulation neuro stimulation. So when would any patient need, uh, invasive E G diagnostics? As we all know, E G is typically done with electrodes that are placed on the scalp of of a patient. Um, if the, uh, scalp electrodes and the traditional EEG GSR incapable and not precise enough in terms of localizing the seizure Fosse, then we can get much closer and we can do this by, uh, surgical means one way would be to do a craniotomy and put the grids directly on the cortical surface. Other ways again, these air techniques that are done at a very high level here at USC involved the placement of depth electrodes through stereo tactic means. And we can do this either through traditional frame based systems or also using frameless robotic systems such as a rose a robot. When a seizure focus has been identified, and after a group of neurologists, neurosurgeons, neuro psychologists and a multi disciplinary group have decided that a surgical focuses amenable thio reception thio control the seizures, then this can be achieved through either traditional micro surgical means or it can be achieved through laser interstitial thermal therapy, which is a new strategy that is gaining wider spread acceptance across the world. In this strategy, um, a stare attack laser is placed into the seizure focus. And under direct emery visualization, the seizure could be seizure. Focus could be a bladed neuromodulation. Nerve stimulation again very, very important. Now, in the surgical treatment of epilepsy, uh, the first platform for nerve stimulation is the vagus nerve stimulator, and this is, uh, shown here on the image on the left of the slide. In this strategy, a coil is placed on the cervical trunk of the vagus nerve. It's in the neck, and a pulse generator is then attached to this coil and placed in a subcutaneous pocket. Uh, typically in the anterior aspect of the pectoral region and through this, uh, platform stimulation is applied to the vagus nerve to control seizures. The second, uh, neuromodulation platform that is now very important in the surgical manage of epilepsy is that of the responsive nerve stimulator, the neuro pace. And this works in a way that is in fact, quite different from the vagus nerve stimulator. Uh, in this strategy, the electrodes actually placed on the siege of beside themselves and the pulse generator is actually embedded in the skull. Here, you see in the middle image on example of Vegas of a R N s, uh, therapists RNs and planted. And finally, the most recent platform to get FDA approval is the deep brain stimulator for epilepsy, where the entire nuclear thalamus is targeted and this is now starting to become a useful tool for the treatment of epilepsy. I want to spend a few minutes and just talk about the the, uh, unique approach that the U. S. C. Epilepsy programs have taken to really address the public health dimensions of epilepsy. Um, we just talked about all the wonderful in advanced ways that we can control seizures through medical and surgical means. We focused a lot on the surgical aspects of it. But what good are these strategies if you can't get these treatments to a large number of people? And I think one of the biggest challenges in epilepsy programs across the country and the world is the failure of these programs to, uh, be easily accessible to large numbers of patients that need these programs. And in this way there's a lot of concern locally, regionally and nationally that the systems of care for epilepsy really failed to address the public health dimensions of epilepsy. And we have to understand that epilepsy is one of the most common neurological disorders worldwide, and surgery is a very effective treatment for many types of epilepsy. So in order to address this challenge, a group of us here at USC have created what we consider to be a patient centered ecosystem for epilepsy care, like to spend just a few minutes and tell you about that So the epilepsy USC epilepsy character source, um, is a unique partnership off many epilepsy centers, starting from central California all the way down to South Orange County. Theme. The character solution was created primarily to integrate the healthcare ecosystem for epilepsy care across our region. The there are nine participating centers, uh, in the U. S. C. Epileptic Care Consortium, and I think it's important to acknowledge each one. Of course, uh, one of the the academic anchor for the care consortium is the the U. S. C. Comprehensive L Pepsi Center, which is based here at USC Keck Hospital. Uh, the anchor on the pediatric side is Children's Hospital of Los Angeles, which is also a n a a C level for center. Like the Keck program. The next program, like Thio, uh, acknowledges Rancho Los Amigos National Rehabilitation Center and L. A county USC department health services programs, which is a very special program that was established by us many years ago and at the time was the first and still remains, the Onley uh, n a C Level four center that is in a safety net hospital. The next programs that like to talk about our three, uh, programs that are based in, uh, private health systems. The first one being hold Hospital down in Newport Beach in Orange County Mission Hospital in Mission, Vallejo and the newest member of the private affiliates, which is Santa Barbara Cottage on the Central Coast. One of the most underserved areas in the state of California is thes Central Valley, and we're very proud to have helped start a program up in Bakersfield at Current Medical, which is the first, um N a C um certified epilepsy center in the Central Valley for adults between Sacramento and Los Angeles. Joining Kern In the next months, the year will be quit Delta Healthcare District up in by Sayliyah and, of course, the uh, primary source for all pediatric care in the central part of California at Valley Children's Medical Center, which has a n a C level for center. So these nine centers form the USC Epilepsy Care consortium. This, uh, large network of practitioners, doctors affiliated experts meet weekly in a surgical conference. Uh, and these conferences have really now largely moved Thio virtual platforms. But even before the social distancing requirements of our current year, we had built in the infrastructure to connect all the doctors and nurses and affiliated experts for epilepsy care across this entire geography. It's interesting to point out that if you take all of the centers and put them together, they represent almost one third of all the epilepsy centers in our state. The epilepsy character sorts, um, gives us a unique reach with high visibility across Southern California and beyond and were able to reach patients and advocacy groups. The photo in the middle is a big event in Orange County, where we were featured, and the photo on the right hand side of the slide is the Carrick your foundation, where our center was again featured as really providing services. Thio very underserved patients theme. The program has been quite visible in our local media, Andi publications, but interestingly and very significantly, our efforts to integrate the healthcare ecosystem for epilepsy care has gained national attention and was featured in in a publication by the National Academy is called the Epilepsy. Across the Spectrum, which was we were represented very well by Dr Kristi Hack, who's the medical director of our USC Epilepsy Center here at Tech. I want to talk about one of the final roles of the epilepsy center and, uh, USC epilepsy programs. Really, uh, serve as a very important component of the U. S. C. No Restoration Center, which is a unique research center that aims to, um, developed transformative treatments for the restoration of neurological function. And we do this through a combination of strategies that include repair, replace and optimize, uh, where we take the, uh, expertise and re sources of neurosurgery, neurology, psychiatry, newer rehabilitation, neural engineering, computational neuroscience and regenerative medicine. And we put together these resource is to develop transformative treatments. Thistle is a very complex process that involves research, validation, clinical immigration and practice change. The participants are really myriad, and the goals are quite different on you. See here on the slide a list of the goals that include techniques and discovery and regulatory approval and acceptable practice into expected practice. And these are all the things that the U. S. General Restoration Center does to develop these transformative strategies for the comprehensive restoration of neurological function. So these research programs have been highly visible locally, nationally internationally. Here, of course, is, uh, a human brain computer interface program collaboration with Dr Richard Anderson at the California Institute of Technology and are study subject and, uh, patient adviser to the U. S. C. No restoration center Erik Sorto. And here we did with this project was we put micro electrode arrays into critical arrays that decoded Eric's thoughts that allowed him to move robotic devices. We also worked at the level of electrical photography based brain computer interface and theme. The Epilepsy Center epilepsy programs, particularly at USC, Keck and gradualism. Egos contribute significantly to the development of a, uh, bi directional, brain controlled robotic exoskeleton that is designed to allow paralyzed patients. People who are paralyzed from the waist down to be ableto walk and control the robot with just their thoughts. Southern California has really become a one of the epicenters for neuro prosthetics research, and, uh, the USC Epilepsy programs and, uh, no restoration center. And all of the, uh, combined clinical research resource is have really contributed in a very significant way to the evolution of of our region as faras neural prosthetics is concerned. In fact, in 2019, we helped organize a short course for neural prosthetics and brain machine interfaces, and uh, many of the three key experts presenting at the at this course, uh, were collaborators of the USC no restoration center, A swell as, uh, off the epilepsy programs. It's very important to make sure that the work that we dio ultimately reaches out to the patients. And, uh, you know, even our research programs were very extensive patient outreach programs. Uh, this is unexamined of this, uh, shown here at Rancho Los Amigos last year in 2019. We had essentially all of these, uh, study subjects who participated in this transformative research, Uh, speak in a moderated A fashion, uh, to a naughty inst of their peers, and this was very well received, and it will be an ongoing program for us. Wanna keep in mind again? This is talking about the epilepsy surgical programs. And, um, it's really proud of the fact that naturalist amigos is the first and only an a C Level four certified epilepsy center in a safety net hospital. So I like to just acknowledge, uh, the folks that, uh, experts, doctors, uh, that are playing primary leadership roles in the epilepsy programs here. USC and of course, uh, up at the top you see the neurosurgeons, including myself. Dr Jonathan Rushon, Dr Brian Lee, Dr Darren Lee. On the adult side and on the pediatric side, you see Dr Mark Krieger and, uh, Dr Jason Shoe over C h L A. We're talking about surgical programs, but surgical programs can exist without neurologist. This is truly a integrated program and into disciplinary program, and I think it's really important. Oh, acknowledged Dr Kristi Heck, who is the neurologist? Epilepsy ologists that leads the medical side of things on the adult side. And Dr Debbie Holder, who is a EPL apologists and leads the programs at C H L. A. So to summarize, it's ah been great to give the audience an introduction to epilepsy surgery at USC. As I said at the beginning, this'd is a unique approach in that it is a fully integrated approach, and the levels of integration exist across geography, where our programs extend from Central California all the way down to South Orange County and all points in between. The programs are integrated across all different health care delivery models, including academic, community, adult Children, public sector, private sector, urban and rural programs that are all important Thio Thio tie together to take care of epilepsy patients. We're very proud of the fact that our program is integrated across the age spectrum. Epilepsy is not a adult disease or pediatric disease. Uh, many of our patients have epilepsy, is Children or develop the risk factors for epilepsy is Children and then end up adults and having a program that is integrated across the age spectrum not only in the Los Angeles and Orange County areas but even in Central California is a very important facet of our programs. And finally, we're very, uh ah, proud to say that the three missions off USC Keck School of Medicine on our programs are fully integrated across each of these three missions and these missions being patient care, education and research.