What Happens Before Deep Brain Stimulation
Before this procedure, your healthcare provider will discuss the advantages and disadvantages of having a DBS device implanted. Theyll also explain the possible risks that come with this surgery. Theyll also verify that you can have this surgery, which can involve other imaging scans or lab tests to look for any reasons you may not be able to have the procedure.
If you still decide you want to have the DBS implanted, your provider will then have you get detailed magnetic resonance imaging and computed tomography scans of your brain. These scans will help your provider decide which location is the best place to place the wires for the DBS.
Before the procedure, your provider will also talk to you about the following:
What Happens During Surgery
For stage 1, implanting the electrodes in the brain, the entire process lasts 4 to 6 hours. The surgery generally lasts 3 to 4 hours.
Step 1: attach stereotactic frameThe procedure is performed stereotactically, which requires attaching a frame to your head. While you are seated, the frame is temporarily positioned on your head with Velcro straps. The four pin sites are injected with local anesthesia to minimize discomfort. You will feel some pressure as the pins are tightened .
Step 2: MRI or CT scanYou will then have an imaging scan, using either CT or MRI. A box-shaped localizing device is placed over the top of the frame. Markers in the box show up on the scan and help pinpoint the exact three-dimensional coordinates of the target area within the brain. The surgeon uses the MRI / CT scans and special computer software to plan the trajectory of the electrode.
Step 3: skin and skull incisionYou will be taken to the operating room. You will lie on the table and the stereotactic head frame will be secured. This prevents any small movements of your head while inserting the electrodes. You will remain awake during surgery. Light sedation is given to make you more comfortable during the initial skin incision, but then stopped so that you can talk to the doctors and perform tasks.
Less Medication More Relief
Medtronic DBS therapy may reduce the need for other Parkinsons medications1 and, consequently, medication-related side effects. DBS delivers therapy 24 hours a day and doesnt wear off while sleeping. Its already working when you wake up.
* Signal may not be present or measurable in all patients. Clinical benefits of brain sensing have not been established.
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What Are The Results
Successful DBS is related to 1) appropriate patient selection, 2) appropriate selection of the brain area for stimulation, 3) precise positioning of the electrode during surgery, and 4) experienced programming and medication management.
For Parkinson’s disease, DBS of the subthalamic nucleus improves the symptoms of slowness, tremor, and rigidity in about 70% of patients . Most people are able to reduce their medications and lessen their side effects, including dyskinesias. It has also been shown to be superior in long term management of symptoms than medications .
For essential tremor, DBS of the thalamus may significantly reduce hand tremor in 60 to 90% of patients and may improve head and voice tremor.
DBS of the globus pallidus is most useful in treatment of dyskinesias , dystonias, as well as other tremors. For dystonia, DBS of the GPi may be the only effective treatment for debilitating symptoms. Though recent studies show little difference between GPi-DBS and STN-DBS.
Patients report other benefits of DBS. For example, better sleep, more involvement in physical activity, and improved quality of life .
Research suggests that DBS may “protect” or slow the Parkinson’s disease process .
How Does Dbs Work
In DBS surgery, electrodes are inserted into a targeted area of the brain, using MRI and, at times, recordings of brain cell activity during the procedure. A second procedure is performed to implant an impulse generator battery , which is similar to a heart pacemaker and approximately the size of a stopwatch.
The IPG is placed under the collarbone or in the abdomen and delivers an electrical stimulation to targeted areas in the brain that control movement. Those who undergo DBS surgery are given a controller to turn the device on or off and review basic parameters such as battery life.
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Incorporating Dbs: Barriers And Opportunities
DBS has traditionally been used to treat motor complications of levodopa therapy in advanced PD and found to be highly effective in improving motor function by greatly reducing the dyskinesias and off times and improving quality of life, according to Dr. DeLong. However, it is now recognized that earlier intervention in the mid-phase of PD, with the onset of motor complications, may both improve motor function and impact quality of life more effectively than best medical therapy alone. Regarding its clinical application, Dr. DeLong says that DBS should be considered in patients at the mid-phase of disease, when dyskinesias begin to appear. For these patients, DBS may offer impressive results. In fact, the similarity the two approaches offer in terms of efficacy is remarkable. The major advantage of DBS is that it provides similar benefits without the side effects of traditional therapies. DBS confers continuous stimulation, which can be particularly effective for off times. It also generally abolishes or greatly reduces the peak dose effects of dyskinesias, he says.
What Is The Prognosis
Although most people still need to take medication after undergoing DBS, many people experience considerable reduction of their PD symptoms and can greatly reduce their medications. The amount of reduction varies from person to person. The reduction in dose of medication can lead to decreased risk of side effects such as dyskinesia.
There is a 1 to 3% chance of infection, stroke, bleeding in the brain, or other complications associated with anesthesia. It is best to discuss associated risks with your neurologist and neurosurgeon, as diabetes and heart and lung conditions all may influence these risks and the decision to pursue surgery.
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What You Need To Know
- Surgeons implant one or more small wires in the brain during a surgical procedure.
- The leads receive mild electrical stimulation from a small pulse generator implanted in the chest.
- Proper patient selection, precise placement of the electrodes and adjustment of the pulse generator are essential for successful DBS surgery.
- DBS does not fully resolve the symptoms of PD or other conditions, but it can decrease a patients need for medications and improve quality of life.
Remote Programming Of Deep
The Deep-brain stimulation team at University of Colorado Hospital involves its patients in the choice of hardware to be implanted: Medtronic, Boston Scientific, or Abbott. Each of these device companies offers excellent products but there are some differences, which would make an individual choose one over the other being specific for this persons lifestyle.
For Craig, he chose Abbott as it was not rechargeable and at the time may have the ability to be programmed remotely. Between the DBS surgeries in January and the initial programming in April, Abbott did receive FDA approval for a system enabling the remote programming and adjustment of Craigs controller.
Craig could use an iPhone or iPad to connect with Kern or a nurse. Using secure video links over Wi-Fi or cellular networks, UCHealth providers could do telehealth visits, observing as Craig did finger taps, toe taps, walked, and so on, and make programming adjustments just as if he was in the same room with the physician. Kern even received a medical license in Wyoming to be able to do such remote consultations.
Craig Overman is back at his grandsons games, and his health has returned in time to support another grandchilds youth-sports endeavors: granddaughter Payton is getting into soccer and basketball. Craig is also looking forward to fishing, hunting, and four-wheeling. Hes cut his levodopa dosage by about 75%, has his appetite back, and is feeling a whole lot more energetic.
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Deep Brain Stimulation Surgery
A team of experts, including a movement disorder specialist and a brain surgeon, conducts an extensive assessment when considering DBS for someone. They review your medications and symptoms, examine you when youre on and off Parkinsons medication, and take brain imaging scans. They also may do detailed memory/thinking testing to detect any problems that could worsen with DBS. If your doctors do recommend you for DBS and you are considering the surgery, discuss with your care team the potential benefits as each persons experience is unique. Its also critical to discuss the potential surgical risks, including bleeding, stroke and infection.
In DBS surgery, the surgeon places thin wires called electrodes into one or both sides of the brain, in specific areas that control movement. Usually you remain awake during surgery so you can answer questions and perform certain tasks to make sure the electrodes are positioned correctly. Some medical centers now use brain imaging to guide the electrodes to the right spot while a person is asleep. Each method has its pros and cons and may not be suitable for everyone or available everywhere.
Once the electrodes are in place, the surgeon connects them to a battery-operated device , which usually is placed under the skin below the collarbone. This device, called a neurostimulator, delivers continuous electrical pulses through the electrodes.
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What Happens After Deep Brain Stimulation
Your healthcare provider will schedule a follow-up appointment that will take place within a few weeks of the pulse generator implantation procedure. At this appointment, theyll start programming the pulse generator.
All pulse generators now in use have a wireless antenna built-in. That allows your healthcare provider to access and program the device from outside your body. Finding the right settings for the pulse generator may take some time and additional visits for adjustments.
Most pulse generators have special batteries that have long lifespans. Standard batteries for these devices last about three to five years. Some devices use rechargeable batteries, which can last about nine years. Replacing the battery also takes a surgery procedure, but this is usually shorter and quicker than the original surgery to implant the pulse generator. Youll still go home the same day for battery replacements.
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When Should I See My Healthcare Provider
Your healthcare provider will schedule visits to see you after your procedures. Programming visits occur with your neurologist, and youll need to make appointments to see them. The goal of those visits is to find the settings that work best and dont cause side effects that disrupt your life.
Regular visits with your healthcare provider are also common to monitor your condition, symptoms and to adjust medications or other treatments as needed. The schedule for these visits is something that your provider will discuss with you.
What Is The Success Rate Of Deep Brain Stimulation
In general, deep brain stimulation is usually successful. The success rate depends on the condition involved. For conditions like epilepsy and Parkinsons disease, DBS is very effective. More research is necessary for conditions where DBS is experimental before experts know if DBS is likely to help.
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Is Your Patient A Candidate For Dbs Therapy
Consider deep brain stimulation when a patient has:
- Symptoms of levodopa-responsive Parkinsons disease of at least 4 years duration that are not adequately controlled with medication.
- And motor complications of recent onset or motor complications of longer-standing duration.
The safety and effectiveness of this therapy has not been established for the following:
- Patients with neurological disease origins other than idiopathic Parkinsons disease
- Patients with a previous surgical ablation procedure
- Patients who are pregnant
What Happens Before Surgery
In the doctor’s office you will sign consent forms and complete paperwork to inform the surgeon about your medical history, including allergies, medicines, anesthesia reactions, and previous surgeries. Presurgical tests may need to be done several days before surgery. Consult your primary care physician about stopping certain medications and ensure you are cleared for surgery.You may also need clearance from your cardiologist if you have a history of heart conditions.
Stop taking all non-steroidal anti-inflammatory medicines and blood thinners 7 days before surgery. Stop using nicotine and drinking alcohol 1 week before and 2 weeks after surgery to avoid bleeding and healing problems.
You may be asked to wash your skin and hair with Hibiclens or Dial soap before surgery. It kills bacteria and reduces surgical site infections.
No food or drink, including your Parkinson’s medication, is permitted after midnight the night before surgery.
Try to get a good night’s sleep. The DBS surgery involves multiple steps and lasts most of the day, during which you may be awake and off medication.
Morning of surgery
Arrive at the hospital 2 hours before your scheduled surgery time to complete the necessary paperwork and pre-procedure work-ups. An anesthesiologist will talk with you and explain the effects of anesthesia and its risks.
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What Is The Recovery Time
Your healthcare provider is the best person to tell you what to expect regarding your recovery time and when you will notice changes in your symptoms and how you feel. They can tell you the likely recovery time you’ll need, which can vary depending on other factors like your overall health, other conditions you have and your personal circumstances.
Most people will need to stay in the hospital for one day after surgery to implant the DBS leads in their brain. Surgery to implant the pulse generator is usually a procedure where you go home the same day.
Overall, recovery time generally takes several weeks. Your healthcare provider will likely have you do the following:
- Avoid any kind of activity for about two weeks after each procedure: This includes things as minor as household chores or sexual activity. You should not lift anything heavier than 5 pounds .
- Avoid moderate- or high-intensity activity for at least four to six weeks: This includes exercise and physical labor. Most people can return to work or their usual routine after this.
- Use caution when moving or stretching: You should avoid making certain movements, like raising your hands over your head, for several days after surgery to implant the pulse generator. Your healthcare provider will tell you how long youll need to restrict your movements.
How should I care for the surgical area once I’m home?
What Is Deep Brain Stimulation
In deep brain stimulation, electrodes are placed in a specific area of the brain depending on the symptoms being treated. The electrodes are placed on both the left and right sides of the brain through small holes made at the top of the skull. The electrodes are connected by long wires that travel under the skin and down the neck to a battery-powered stimulator under the skin of the chest . When turned on, the stimulator sends electrical pulses to regulate the faulty nerve signals causing tremors, rigidity, and other symptoms.
A DBS system has three parts that are implanted inside the body:
- Neurostimulator a programmable battery-powered pacemaker device that creates electric pulses. It is placed under the skin of the chest below the collarbone or in the abdomen.
- Lead a coated wire with a number of electrodes at the tip that deliver electric pulses to the brain tissue. It is placed inside the brain and connects to an extension wire through a small hole in the skull.
- Extension an insulated wire that connects the lead to the neurostimulator. It is placed under the skin and runs from the scalp, behind the ear, down the neck, and to the chest.
DBS is very effective at reducing dyskinesias, the uncontrolled wiggling movements caused by high doses of levadopa medication. Typically, DBS will help make your symptoms less severe so that lower medication doses may be used.
Electrodes can be placed in the following brain areas :
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What Happens After Surgery
After surgery, you may take your regular dose of Parkinson’s medication immediately. You are kept overnight for monitoring and observation. Most patients are discharged home the next day.
During the recovery time after implanting the electrodes, you may feel better than normal. Brain swelling around the electrode tip causes a lesion effect that lasts a couple days to weeks. This temporary effect is a good predictor of your outcome once the stimulator is implanted and programmed.
About a week later, you will return to the hospital for outpatient surgery to implant the stimulator in the chest/abdomen. This surgery is performed under general anesthesia and takes about an hour. Patients go home the same day.
Step 7: implant the stimulator You will be taken to the OR and put to sleep with general anesthesia. A portion of the scalp incision is reopened to access the leads. A small incision is made near the collarbone and the neurostimulator is implanted under the skin. The lead is attached to an extension wire that is passed under the skin of the scalp, down the neck, to the stimulator/battery in the chest or abdomen. The device will be visible as a small bulge under the skin, but it is usually not seen under clothes.
You will have lifting and activity restrictions for 6-8 weeks while the incisions heal. Follow all discharge instructions and the neck exercises provided. Incision pain can be managed with medication.
Deep Brain Stimulation: Resources
To learn more about Deep Brain Stimulation, Medtronics website contains numerous resources for physicians, including information on acquiring training as well as patient selection. Additionally, the site offers access to peer presentations on DBS, procedure videos, details on reimbursement and prior authorization, as well as patient education resources for both pre- and post-implant care. Physicians can also find guidelines and manuals for various models.
Additionally, in some instances, DBS can offer benefits that medication does not. For example, With tremor, some patients do not respond at all to medication, whereas DBS has shown to be highly effective in this regard. When it comes to drug-induced dyskinesias, we have very few drugs that are effective. According to Dr. DeLong, amantadine is arguably the only one thats really proven to be of significance in this regard.
Regarding adverse events, Dr. DeLong observes that DBS carries a small, but significant risk to patients undergoing this procedure. Overall, there is a one percent risk of bleeding and possible neurologic deficit, resulting from placement of the stimulating electrodes. There is also about a five percent risk of infection involving the pacemaker and leads over the first five years, as well as a small risk of mechanical or lead breakdown, he observes. Therefore, the patient must weigh potential risks versus benefits in deciding on DBS.
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