Mariel Szapiel, MD, FAANS, is a neurosurgeon on a mission to spread the word to people who suffer from movement disorders like Parkinson's Disease and Essential Tremor - and also for those suffering from epilepsy: You have options.
"There are more options than they've ever thought about" said Dr. Szapiel. "It's very personal for me. Even today, I find patients that have been told, 'You are not a candidate,' or 'There is nothing else we can do for you' when they could have had surgery many years ago. This is particularly true among people with Essential Tremor. They just don't know. They live with the tremor and don't do anything about it because they don't know this is an option.
"More than once I have had a patient crying on the operating table or the day after surgery. And they're crying because they are so happy because the surgery worked."
A board-certified neurosurgeon and the director of functional neurosurgery with Orlando Health Physicians Neurosurgery Group, Dr. Szapiel craves interaction with her patients and finding ways to help brain cells communicate better. "I specialize in functional neurosurgery," she explained. "We concentrate on modulating the nervous system. We don't always go into the brain and take out stuff. We fine-tune the patients, so they can function a little better."
This fine-tuning can mean different kinds of medication, and it can also mean physical intervention, such as placing a device like a neuro-pacemaker inside a patient to help the patient's brain function better, giving the patient a more normal life.
For the areas that Dr. Szapiel focuses on - movement disorders and epilepsy - the causes and treatments differ, of course, but there are some similarities.
In Parkinson's Disease, for example, she said, the brain cells that produce dopamine in the area of the brain that helps to initiate movement - the substantia nigra - actually begin to die. Dopamine is one of the brain's neurotransmitters, helping to carry signals between brain cells. Without enough dopamine, the patient experiences a variety of problems; the most obvious involves certain uncontrollable muscle movements.
"If medication isn't working, one of the most effective treatments is to place a neuro-pacemaker in the brain to stimulate the brain's own production of dopamine," said Dr. Szapiel. "The problem is the dopamine isn't being produced, so the communication isn't happening appropriately. So, we are going to tweak the brain cells with electricity. Once in place, we can fine-tune this activity so it flows a little closer to what Mother Nature intended."
Similarly, a neuro-pacemaker can provide deep brain stimulation to help patients who suffer from Essential Tremor, a condition that produces uncontrollable shaking of the hands or arms. "Some people think that tremors are not a big deal or that some seizures aren't that important. But for the person suffering, these can be major quality of life issues," Dr. Szapiel said, describing situations in which patients stop going out in public because they can't feed themselves, executives who cannot give effective presentations, because their tremors are confused with nervousness, and some people who self-medicate with alcohol, because that seems to bring short-term relief, but which carries all sorts of other health risks, including alcoholism.
In the case of patients with epilepsy, the problem isn't a lack of dopamine, it's abnormal electrical activity in the brain, said Dr. Szapiel. "For patients who are not responding to medication, we can offer them surgery. It can range from pacemakers to stimulators," she said. "Since 2013 we have had a new option for a pacemaker in the brain. This one is called responsive neurostimulation. It is a very interesting device. We put a small wire in the area of the brain that is having the seizures. That electrode is listening all the time to the brain's signals. And when it detects an abnormal brain signal that looks like a seizure is happening, the device sends back a pulse of energy to abort the seizure. It's like having your own epilepsy monitoring unit inside your head. But instead of having to be in a doctor's office, connected to a monitor, the device is there with you. Long term studies are showing that some of those patients are having reductions in seizures of up to 70 percent."
Dr. Szapiel had not always thought of being a doctor. "I came to medicine through the brain," she laughs, describing how a professor in college led her biology class on a tour of the human body. "We went from organ system to organ system, and when we got to the brain and I discovered how cells talk to each other, I was just floored. I was like 'Boom, that's it, I've got to do something with neuroscience.'"
After medical school and a surgical internship at the University of Puerto Rico, Dr. Szapiel was accepted for a fellowship in stereotactic and functional neurosurgery at The Ohio State University Medical School.
About a year ago, she was practicing at a hospital in Colorado when Dr. Robert Hirschl, Chairman and Medical Director of Neurosurgery at Orlando Health, approached her with the idea of building program devoted to functional neurosurgery. "I realized that Orlando has an extreme need for a city this size. I believe right now I may be the only one, or one of only two doctors in the community who have the fellowship training to take care of these patients.
"Both of these specialties (movement disorders and epilepsy) are multidisciplinary practices," she said. "This is not work I do on my own. I work hand-in-hand with my neurology colleagues. It requires a lot of coordination with them, radiology, neuropsychology and many other disciplines. We have all the pieces in place now to get the functional neurology program up and running.
"It's very exciting."