How Dbs Surgery Works
Deep brain stimulation is FDA-approved for the treatment of patients with:
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Parkinson’s disease
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Essential tremor
DBS surgery has gained acceptance as an effective treatment for select patients since the FDA approved it in 1997 for treatment of essential tremor, in 2002 for Parkinsons disease and in 2003 for dystonia. Today, with multiple national and international randomized trials the efficacy of DBS is firmly established, and it is the most evidence-based procedure in neurosurgery.
Percept Pc Dbs System
UChicago Medicine is the first hospital in the Chicagoland area to use the new Percept PC DBS system to treat patients with movement disorders and ranks as the most “Percept experienced” DBS program in all of Illinois.
The Percept PC DBS system not only stimulates the brain, but also takes recordings, allowing us to see how the brain responds to the stimulation. This system represents a new area of individualized treatment for our patients and should provide more symptom relief.
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Who Is Suitable For Deep Brain Stimulation
Not everyone will be suitable for deep brain stimulation, and it wont work for everyone who has the operation. If you have responded well to tablet-based medication you may be a suitable candidate. Discussing the options with your neurologist or a DBS specialist neurologist will help identify your suitability.
Experience Fewer Symptoms With Deep Brainstimulation
For patients with movement disorders, such as Parkinson’s disease and essential tremor, an effective treatment is available to help significantly reduce their symptoms and make performing daily activities easier.
For appointments
Deep brain stimulation is a therapy used to treat multiple disorders. The most common disorders include Parkinsons disease and essential tremor. It can be used to improve a patients:
- Abnormal muscle activation
It is also being studied in a few psychiatric conditions such as obsessive-compulsive disorder, Tourettes syndrome, depression and addiction.
About DBS surgery
The procedure involves placement of an electrode or lead into a deep structure of the brain typically, one on each side of the brain. These electrodes are secured in place with a plastic cap and connected to extension wires that are tunneled underneath the skin to an implanted generator placed under the skin just below the collar bone, similar to a pacemaker.
The generators last for 3-15 years depending on type implanted and patient use. They are replaced with a simple outpatient surgery. The overall risk of the operation is very low but not zero. In depth discussion with your neurologist and surgeon is needed to determine if you are an appropriate candidate and your risk of the operation.
For above images: ©2021 Medtronic. All rights reserved. Used with the permission of Medtronic.
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What To Expect On The Day Of Surgery
When you go for your surgery, you will meet with a nurse and have your vital signs checked. You will have an intravenous line placed in a vein, most likely in your arm. You will meet with your anesthesiologist and your surgeon, and you will be taken to the operating room.
Before your surgery, your head will be shaved and cleansed with a sterile solution if you are having invasive surgery. If you are having a device implanted in your brain, you will also have a generator implanted in your chest or abdomen, and this area will be cleansed as well.
You may have general anesthesia or local anesthesia and light sedation. If you are having general anesthesia, you will be put to sleep and you will have a tube placed in your throat to help you breathe. If you are having local anesthesia and light sedation, you will receive medication to make you drowsy, but you will be able to breathe on your own.
During your surgery, you will not feel any pain. Your doctors will monitor your vital signs throughout your procedure. Often, the surgery is done with imaging guidance, and sometimes it is done with electrical signal monitoring of the brain as well.
For some procedures, your surgeon will make a cut in the skin of your scalp and then will make a cut into your skull bone, as follows:
After your surgery is complete, your anesthetic medication will be stopped or reversed. If you have been intubated , this will be removed, and you will be able to breathe on your own.
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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Patient Selection Presurgical Assessment And Safety
Patient selection should be carried out in designated centres by amultidisciplinary team including a movement disorders specialist,neurosurgeon, neuropsychologist, psychiatrist, neuroradiologist, and nurses,all experienced in DBS. DBS candidacy is usually established according toinclusion and exclusion criteria proposed by the core assessment program forsurgical interventional therapies in PD .Reference Defer, Widner, Marie, Remy and Levivier1 The following factors should be carefully assessed before advocatingsurgery to a given patient: disease duration, age, levodopa responsiveness,type and severity of levodopa-unresponsive symptoms, cognitive andpsychiatric issues, comorbid disorders, and brain magnetic resonance imaging findings. In the present article, we review and summarize the currentrecommendations for each given aspect.
Patients with unstable severe health issues are commonly not consideredsurgical candidates thus, there are no data regarding this subset ofpatients. However, although formal studies are lacking, seriouscomorbidities should be regarded as a contraindication to DBS given thenegative influence on the risk-benefit ratio.Reference Pollak5
In conclusion, several factors should be taken into account when consideringsurgery in PD patients and a thorough evaluation of the risk-benefit by aspecialized multidisciplinary team is mandatory in all cases.
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 you’re on and off Parkinson’s 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 person’s experience is unique. It’s 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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Areas Of Controversy And Future Directions
In spite of the thousands of patients implanted worldwide and a fair amountof clinical studies, many areas of controversy are still present. Futureresearches and randomized clinical trials should work on these stillunsolved issues.
When to Define a Medication-Refractory Tremor?
There are no established criteria for the drugs to be used beforeconsidering surgery. One approach is to test all the drugs that have beenproven to be effective in RCTs for a particular tremor in each patient,in a strict evidence-based approach.Reference Fasano, Herzog and Deuschl39 As for ET, its present medical treatment involves numerous drugs,although only some have been properly studied. According to AmericanAcademy of Neurology guidelines, primidone and propranolol should beoffered to patients who desire treatment for limb tremor in ET with levelA evidence.Reference Zesiewicz, Shaw, Allison, Staffetti, Okun and Sullivan54 The maximum tolerated dose and even their combination should betried before considering surgery in ET.
As for PD, a levodopa challenge is useful in confirming the diagnosis,but not for the definition of medication-refractory tremor becauseparkinsonian tremor is highly fluctuating and might only respond to veryhigh doses. Clozapine might be considered in such cases, at least beforeproposing DBS.Reference Bonuccelli, Ceravolo and Salvetti55
What Is the Evidence Supporting Using VIM DBS?
Target of Choice
What Is the Role of Novel Surgical Approaches?
How Is The Surgery Performed
UPMC was one of the first centers to use ROSA robotic assistance for the placement of DBS electrodes. ROSA is similar to a GPS device for the brain. It provides the surgeon with a roadmap to reach the intended brain targets. The patient is sedated for the beginning of the surgery while we make a small opening in the skin and bone at the surgical site. The patient will not feel or remember this part of the surgery, but once these steps are complete, he is awoken for the remainder of the surgery.
Brain MappingWe use neurophysiology recordings from very thin electrodes inserted into the brain to map activity in the intended target and confirm the best spot for the DBS electrode. It is important for the patient to be awake during this part of the surgery so we can obtain the best recordings possible, which will aid in the most accurate placement of the DBS electrode. The brain mapping is not painful and the surgical team will be available to provide reassurance and feedback the entire time.
Intra-Operative Stimulation TestingWhen the best site is identified from the brain mapping, the DBS electrode is inserted and tested. We monitor the patient for improvement in his symptoms, for example tremor, and also ask him to report any new sensations he experiences. Again, this part of the procedure is not painful, but provides valuable feedback to the surgical team.
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Complication Events And Categories
Generally, operation-related complications are defined as those that could potentially be prevented by a change in DBS surgical technique and hardware-related complications as they are more difficult to relate to surgical technique . In our series, 23 complications were observed in 20 patients, including 10 operation-related complications in nine patients and 13 hardware-related complications in 13 patients .
Table 2. Causes and interventions of complications.
The observed operation-related complication included epileptic seizure combined with intracranial hematoma , intraoperative respiratory distress , severe peri-electrode edema , electrode misplace , acute heart failure and hydrocephalus .
Figure 2. Representative Cases. Cranial CT image of Patient #7 demonstrating the massive intracranial hematoma three days after the surgery, with symptoms of a generalized seizure. Chest X-ray image of Patient #36 showing the fracture of extension wire near the IPG. Enlarged damaged wire in the right upper corner.
Wire fracture/high resistance was the most common hardware-related adverse event . The others included electrode migration , subcutaneous exudate/infection , IPG migration and neck stricture formation . Of note, two patients with subcutaneous exudate were categized into the minor infection, whom both recovered after local pressure and antibiotics administration. No etiological agent was diagnosed from the exudate laboratory examination.
Effect On Motor Symptoms
Before surgery, the motor symptoms were significantly reduced by 52% by medication . STNDBS significantly reduced UPDRS III by 61% when comparing the OFF/off and the ON/off conditions 1 year after surgery and significantly by 39% at the longterm followup 8 to 15years after surgery .
Medicine significantly reduced motor symptoms further when added to the DBS treatment. The effect of both STNDBS and medicine was a reduction of motor symptoms by 69% 1 year after surgery , and by 51% at the longterm followup compared with the OFF/off condition .
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Will I Be Able To Resume My Normal Daily Activities
For the first few weeks after surgery, you should avoid strenuous activity, arm movements over your shoulder, and excessive stretching of your neck. You may gradually want to try activities that were difficult before your surgery. Talk about this with your doctor first, and make sure you follow all of your doctors instructions.
Deep Brain Stimulation Surgery And Implantation
DBS consists of two surgeries, spaced approximately three to six weeks apart to ensure the patient has adequate time to recover. Throughout your experience, you will be attended to by a top team of physicians and other medical experts including a neurosurgeon, an electrophysiologist, and an anesthesiologist.
It should be noted that DBS offers many benefits. The generator can be programmed by a neurologist, and customized to each individual patient. The procedure is also reversible. Most patients experience a significant improvement of symptoms. However, as with any brain surgery, there are risks. With DBS, the risk of stroke is 1 in 100 and infection is 1 in 50.
Today, many more patients could be helped by DBS than are currently benefiting from the procedure. Statistics show only 7 percent of Parkinsons disease and 1 percent of tremor patients in Michigan who would benefit from the procedure have undergone DBS. At U-M, we are proud to have one of the superior DBS programs in the country. We have developed a wide array of ways to improve DBS, including special imaging tools that help doctors more accurately place the electrodes, and lead intraoperative motor and speech testing that result in fewer side effects for the patient.
U-M is also home to an active research program, where our team of experts is always working on ways to make DBS faster and more accurate. We also regularly have clinical trials available for patients interested in participating.
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The Symptoms That Dbs Treats
Deep brain stimulation is used primarily to treat the motor symptoms of Parkinsons disease, but this can vary somewhat between the different placement sites. Symptoms treated include:
- Abnormal movements : Dyskinesias are often a side effect of medications for Parkinsons disease and include involuntary movements such as twisting, head bobbing, squirming, and more.
DBS is not usually helpful with walking problems or balance, though improvements in the symptoms above can indirectly affect walking. It also does not provide significant benefits for non-motor symptoms of Parkinsons such as cognitive changes, mood changes , or problems with sleeping.
The benefits of DBS can be estimated by looking at how a person responds to levodopa. Symptoms that respond to levodopa will often respond to DBS . But symptoms that are not changed with levodopa are unlikely to be improved by DBS.
DBS often allows for a reduction in the dosage of levodopa, which in turn can result in fewer involuntary movements and a reduction in off time. The result is often improved quality of life.
Management Of Depression In The Preoperative And Postoperative Phases
The existence of depressive symptoms is not per se a contraindication to DBS surgery. However, ongoing severe depression, psychotic symptoms, and suicidal ideation should be considered absolute contraindications as they might worsen and increase suicidal risk, particularly in the first year after surgery . Less evidence is available regarding severe depressive patients who were eventually stabilized by psychotherapy and medication, months or years prior to undergoing DBS: a trend toward a slightly worse motor and mood outcome has been described, but this certainly does not constitute an absolute contraindication to surgery . In any case, most groups and guidelines support the recommendation of a thorough psychiatric assessment before DBS surgery, and of a careful post-operative follow-up. Of note, the post-operative psychiatric assessment should not be limited to the immediate post-operative period, as the occurrence of apathy, for instance, peaks at around 4 months after surgery, often accompanied by depressive symptoms . Particularly after STN-DBS, which allows for a steeper reduction of dopaminergic medication, dopamine withdrawal symptoms should be prevented, when possible favoring the continued treatment with dopamine agonists .
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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.