How Should I Care For The Surgical Area Once I Am Home
- Your stitches or staples will be removed 10 to 14 days after surgery.
- Each of the four pin sites should be kept covered with band aids until they are dry. You will be able to wash your head with a damp cloth, avoiding the surgical area.
- You may only shampoo your hair the day after your stitches or staples are removed, but only very gently.
- You should not scratch or irritate the wound areas.
Global Variability In Deep Brain Stimulation Practices For Parkinsons Disease
- 1Rush Parkinsons Disease and Movement Disorders Program, Chicago, IL, United States
- 2Departments of Psychiatry and Neurology , Johns Hopkins University School of Medicine, Baltimore, MD, United States
- 3Norman Fixel Institute for Neurological Diseases, Department of Neurology, University of Florida, Gainesville, FL, United States
- 4Cleveland Clinic Luo Ruvo Center for Brain Health, Las Vegas, NV, United States
- 5Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
Introduction: Deep brain stimulation has become a standard treatment option for select patients with Parkinsons disease . The selection process and surgical procedures employed have, to date, not been standardized.
Methods: A comprehensive 58-question web-based survey was developed with a focus on DBS referral practices and peri-operative management. The survey was distributed to the Parkinsons Foundation Centers of Excellence, members of the International Parkinsons Disease and Movement Disorders Society, and the Parkinson Study Group between December 2015 and May 2016.
Up To Five Additional Hours Of Good Movement Without Dyskinesia
Good movement control means no troubling symptoms like shaking, stiffness, and difficulty moving. DBS therapy can provide up to five additional hours of good movement control without dyskinesia per day, compared with medication alone.*2,3,4 What would you do with five additional hours every day?
*Measured by the UPDRS IV
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Effectiveness Of Dbs In Advanced Versus Early Pd
The efficacy of DBS in advanced PD is widely reported and assessed using MDS-UPDRS IIV. Stimulation of different targets provides different improvements in symptoms however, most improve motor symptoms and activities of daily living in advanced PD. A meta-analysis of 13 randomized controlled trials found significant improvement in PD symptoms after DBS. However, GPi DBS and STN DBS resulted in similar improvement in motor scores or ADL at 36 months. STN DBS significantly reduced medication use as compared to GPi DBS . GPi DBS, on the other hand, significantly improved Beck Depression Inventory scores as compared to STN DBS .
However, recently efficacy of DBS in early PD is showing promising results. A meta-analysis of eight RCTs , of which two recruited early PD patients showed that the UPDRS, Parkinsons disease questionnaire -39, and LED scores improved significantly with DBS as compared to BMT .4 Patients with early PD had a significantly greater reduction of LED than those with advanced PD . No other differences were found in efficacy outcomes between early and advanced PD.4
A very recent prospective randomized trial in early PD patients followed for 5-years showed that STN DBS given along with ODT significantly reduced LED , polypharmacy and disease progression compared to only on ODT.63 Patients on DBS + ODT had a safety profile similar to patients on only ODT.
However, despite its various benefits, currently, conventionally DBS is not used in early PD.
Deep Brain Stimulation Side Effects
Although deep brain stimulation is minimally invasive and considered safe, any type of surgery has the risk of complications. Also, the brain stimulation itself can cause side effects.
Deep brain stimulation involves creating small holes in the skull to implant the electrodes, and surgery to implant the device that contains the batteries under the skin in the chest. Complications of surgery may include:
- Misplacement of lead
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Some Common Concerns And Misconceptions About Dbs
My condition is not bad enough to necessitate DBS.In Parkinsons disease, there is a window of opportunity wherein one can undergo DBS. If a patient has progressed to moderate or severe dementia, DBS is not an option. Furthermore, DBS is appropriate when medication still has a positive effect but is becoming less reliable, or, when side effects are intolerable. Once medications are ineffective, DBS will not be a treatment option. One should inquire about DBS when PD symptoms and effectiveness of medications change, and before dementia sets in. A neurosurgeon or neurologist can help to monitor your symptoms. DBS does not cure PD, and if it progresses we can fine tune programming for continued effectiveness.
The battery needs to be replaced often and will include an invasive procedure.Generator replacement takes 15 minutes, can be accomplished under local anesthesia and is done every three-to-five years on average.
I cannot afford DBS.DBS is covered by all major insurances, including Medicare and Medicaid.
Who Is Not A Good Dbs Candidate
You are not a good candidate for DBS if:
- You have Parkinsons plus symptoms or do not have a clear diagnosis of Parkinsons.
- You need full-body MRI scans, or certain head and chest MRI scans.
- You cannot operate the internal pulse generator, also called the stimulator or IPG.
- Test stimulation does not work.
- You have certain brain conditions such as ischemic brain disease, demyelinating brain disease or brain tumors.
- You have significant intellectual or memory impairment.
- You are not healthy enough to have surgery or have other untreated or chronic illnesses.
DBS can work well for certain people. But it can make certain symptoms of Parkinsons worse. People with certain symptoms should not have DBS. These include:
- Having Parkinsons that is not a typical form of the disease.
- Having Parkinsons plus symptoms such as multiple system atrophy, progressive supranuclear palsy or vascular parkinsonism.
- Not functioning well, even with medication for example, not being able to walk even when taking medication.
- Having end-stage Parkinsons.
At OHSU, we are committed to providing the best treatment for everyone with Parkinsons, so our specialists will talk with you about other options if DBS is not right for you.
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Common Misconceptions About Deep Brain Stimulation
Deep Brain Stimulation is a surgical treatment for movement disorders such as Parkinsons disease , essential tremor and dystonia. In Parkinsons disease, DBS is best suited for patients whose medication fails to provide adequate symptom control or in whom medications cause intolerable side effects.
Parkinsons patients who undergo DBS typically experience a dramatic reduction in their medications and more consistent motor function. They typically have a more fluid movement without the highs and lows of medications wearing off. DBS will reduce rigidity, improve bradykinesia , improve akinesia and diminish tremors. The dyskinesias usually resolve due to medication reduction. DBS is also very effective for patients with essential tremor, eliminating the need for medications and reducing tremor by 60-90%.
DBS provides a constant, high frequency electrical signal to a specific area of the brain, which overrides the abnormal circuitry in the brains of patients with movement disorders, providing therapeutic benefits for many symptoms associated with these diseases.
Potential Benefits Of Dbs
According to a 2011 study by the Mayo Clinic, DBS patients often see positive results, including sometimes regaining significant mobility. Stimulation of the ventralis intermedius nucleus of the thalamus has clearly been shown to markedly improve tremor control in patients with essential tremor and tremor related to Parkinson disease, the study said. Symptoms of bradykinesia, tremor, gait disturbance, and rigidity can be significantly improved in patients with Parkinson disease.
The procedure may decrease the use of medications, although patients should work with their doctors to adjust the devices impulses to meet each persons unique needs.
According to a 2019 study published in the Journal of Neurosurgery that addressed long-term outcomes for DBS patients, Tremor responded best to DBS , while other motor symptoms remained stable. Ability to conduct activities of daily living remained stable or worsened . Patient satisfaction, however, remained high .
The study also observes that more than half of the Parkinsons patients who received DBS survived for 10 years or longer. Considering that many individuals undergo DBS when alternative solutions become scant and decline becomes startling, an additional 10 years seems encouraging.
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What Happens During Surgery
For stage 1, implanting the electrodes in the brain, the entire process lasts 5 to 7 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.
Pros Of Deep Brain Stimulation
- Symptom Reduction: DBS often reduces symptoms significantly. These include motor symptoms like stiffness, tremor, slowness and dyskinesia. DBS has also been shown to aid in on/off fluctuations, improve mood and quality of life, and increase overall energy level.
- Little to No Damage: In contrast to previous methods, DBS does not damage portions of the brain, nor remove nerve cells.
- Utilizing DBS in addition to levodopa could decrease a persons need for medication, thus, decreasing medication access and cost issues, as well as levodopa side effects.
- Individualized Treatment: Electrodes and stimulation frequency and intensity can be controlled by physicians and the individual with DBS, and can be subjectively altered when needed.
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What Are The Advantages Of Deep Brain Stimulation
Deep brain stimulation has many advantages:
- DBS does not cause permanent damage in any part of the brain, unlike thalamotomy and pallidotomy, which surgically destroy tiny areas of the brain and therefore is permanent and not reversible.
- The electrical stimulation is adjustable and reversible as the person’s disease changes or his or her response to medications change.
- Because DBS is reversible and causes no permanent brain damage, use of innovative not-yet-available treatment options may be possible. Thalamotomy and pallidotomy result in small, but permanent changes in brain tissue. A person’s potential to benefit from future therapies may be reduced if undergoing these procedures.
- The stimulator can also be turned off at any time if DBS is causing excessive side effects without any long-term consequences.
Minimizing Dbs Side Effects For Improved Efficacy
Efficacy of DBS will be higher if the safety profile is manageable and the procedure is acceptable to the patients. Since it is a surgical procedure, usual surgery associated complications such as hemorrhage, infection, and skin erosion are seen.64 Other than these, hardware-related complications such as electrode fracture and stimulator failure have been reported.65
However, the most annoying, common and important postoperative complication of DBS is the side effects caused by electrical stimulation of the surrounding brain tissue these are largely driven by the DBS target and anatomy and functionality of the surrounding brain tissue.66 However, these side effects are easily manageable in most cases.66 Emerging technologies such as segmented electrodes and CL-DBS aim to minimize these side effects.9
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How Does Dbs Treat Parkinsons
Parkinsons disease causes irregular electrical signals in parts of the brain that control movement. DBS uses electrical stimulation to modulate these control centers deep to the surface of the brain, improving communication between brain cells.
This helps to reduce symptoms such as tremor, slowness, and stiffness. It doesnt have much of an effect on non-motor symptoms or balance issues. Here are some additional tips for improving motor skills with Parkinsons.
DBS is the most commonly performed surgical procedure for symptoms of Parkinsons disease.
DBS isnt a first-line therapy. Its intended for people whose symptoms are still unmanageable even with medication. Learn about other advanced and future treatments for Parkinsons.
You might be a good candidate for DBS if:
- youve had symptoms for at least five years
- your symptoms respond to medication, but the effect doesnt last as long as it used to
- youve tried various doses and combinations of medications
- your symptoms interfere with everyday life
Your doctor is unlikely to recommend DBS if:
- Parkinsons medications havent helped much
- you have memory and thinking problems
- you have anxiety or depression that hasnt stabilized with treatment
- you have dementia
How Is Deep Brain Stimulation Performed
Before the actual procedure begins, for most patients, a head frame is positioned on your head, which keeps your head still during brain imaging and is used to deliver the electrode to the target in the brain. Surgical pins or screws are used to secure the frame to your head. Sedation is typically given during this portion of the procedure.
Your neurosurgeon will implant the deep brain stimulation system in one to three stages.
First, a small hole is made in the skull. The leads, which have electrodes at the ends, are passed through this hole and surgically implanted in the areas of the brain identified as the site responsible for the movements caused by Parkinsons disease.
Most people with Parkinson’s disease will require one lead placed on each side of the brain unless symptoms are mostly one-sided . Each side of the brain controls the opposite side of the body, so each lead is inserted on the opposite side of where symptoms are occurring. Sometimes this procedure is done in stages one lead is placed at one time followed by another surgery for the other side. In other patients, both leads are placed during the same operation. Many times patients are awake during lead insertion. An intraoperative MRI is also sometimes used to image the lead location.
How Do I Know If Im A Candidate For Deep Brain Stimulation
Before being considered a candidate for deep brain stimulation , patients with Parkinsons disease must undergo an extensive evaluation process. Ideally, a multidisciplinary team of specialists in the area of movement disorders will assess the patient. This clinical team typically includes a neurologist, neurosurgeon, neuropsychologist and psychiatrist.
If patients are well managed on medications, DBS is not considered. Candidates for DBS are patients who meet one or more of the following criteria:
- Symptoms are not well controlled despite receiving the appropriate dose of levodopa and other medications.
- Symptoms are significantly reducing patients quality of life.
- Abnormal or uncontrolled involuntary movements or motor fluctuations are not improving despite adjustments in medications.
- Four or more doses of levodopa are required a day.
- Tremors that have not been able to be controlled by medications.
Levodopa response test
Patients response to a single dose of levodopa is another test physicians use to identify which patients are likely to benefit from DBS. In this test, patients stop taking levodopa for 8 to 12 hours and then receive a single dose. Patients are likely to benefit from DBS if they have a clear positive response after receiving the single dose of levodopa.
Reduces Dyskinesia And Fluctuations
Medtronic DBS therapy reduces complications of drug therapy, such as dyskinesia and fluctuations in on and off time.3,4,5,6 Medtronic DBS therapy reduces complications of drug therapy by 37% to 61% compared to medication alone.4,5 Without DBS, people receiving best medical therapy experience between a 5.4% reduction to a 13% increase in drug-related complications compared with their baseline.4,5
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Who Is A Candidate For Deep Brain Stimulation
DBS is more than just a surgical procedure. It involves a series of evaluations, procedures, and consultations before and after the actual operation, so people interested in being treated with DBS should be prepared to commit time to the process.
For example, those who do not live close to a medical center that offers DBS surgery may need to spend significant time traveling back and forth to appointments.
The procedure, as well as the pre-operative evaluation and post-operative follow-up, can be expensive depending on the persons insurance coverage. DBS surgery is an FDA-approved treatment for Parkinsons disease, and Medicare and most private insurers cover the procedure, but the extent of coverage will depend on each persons individual policy.
Prospective patients should have realistic expectations about DBS results. Although DBS can improve movement symptoms of Parkinsons disease and greatly improve quality of life in properly selected patients, it is not likely to return anyone to perfect health.
Summary And Future Prospects
The review shows that DBS is an effective and evolving treatment strategy in PD. However, despite its benefits, it is not widely accepted or widely available due to cost and need for highly skilled staff to manage the programming and stimulation. Additionally, there are challenges of repeat surgeries and short battery life. DBS efficacy, accuracy and acceptability can be improved by overcoming these challenges.
Therefore, upcoming DBS technologies would need to focus on reducing electrode contact size and stimulation number, and move from an invasive to a non-invasive approach.9,67 Newer technologies like current steering can reduce the VTA.67 The VANTAGE study shows that multiple-source axially asymmetric directional DBS using segmented electrodes can be more efficacious than cDBS technologies without steering.60,61 Newer biomarkers and electrode designs like rhythmic neural activity and evoked potentials for segmented electrodes can reduce the programming time.9 Automated support tools to determine the optimal stimulation parameters can increase the penetration of technology in areas where highly skilled staff are not available.9
Today updated software using imaging technologies allows patient specific reconstruction of DBS leads with fully automated tools such as PaCER.67 Recently, a smartphone based wearable and wireless accelerometer and gyroscope platform was successfully used for quantified feedback for optimal configuration of CL-DBS tuning parameters.68
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