Deep Brain Surgery For Parkinson’s Disease

Deep Brain Stimulation For Parkinsons Disease: Essential Facts For Patients

This 1-page fact sheet summarizes the motor symptoms of advanced PD, how deep brain stimulation can help, who should consider DBS and how patients are chosen for the procedure. It talks briefly about the procedure and its risks, what happens after the procedure and the short, medium and long-term results.

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.

Recent research in animals suggest that DBS may “protect” or slow the death of dopamine nerve cells . While the scientific data is inconclusive, observation of DBS patients show potential slowing of the disease relative to their pre-DBS condition.

Predictive Factors For Long

This study was to determine predictive factors for the long-term outcome of STN-DBS. Results showed the PD onset age, age at surgery, preoperative high-level ADL , cognitive function, and axial symptoms are important predictive factors for the long-term outcome of STN-DBS. Pre-registration required with PubMed to view full article.

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Is Deep Brain Stimulation Right For You

While deep brain stimulation is shown to offer long-term benefits, the treatment does come with some risks. According to the Parkinsons Foundation, there is a 1% to 3% chance of developing an infection, cranial bleeding, stroke, or other complications from the treatment.

Furthermore, deep brain stimulation might work better for some people than others. It might be an option worth considering if youve experienced symptoms of Parkinsons for at least five years, are struggling with side effects of Parkinsons medications, or your symptoms make it difficult to perform everyday activities, among other factors.

The decision for or against deep brain stimulation should be made by having the potential candidate evaluated by a multidisciplinary team who can together construct a risk-benefit profile for a potential candidate, explains Dr. Okun. The team commonly is made up of a neurologist, a neurosurgeon, a neuropsychologist, a psychiatrist, and rehabilitation specialists.

Talk with a neurologist if you have Parkinsons disease and youre interested in exploring deep brain stimulation.

How Is Deep Brain Stimulation Used To Treat Parkinsons Disease

Deep brain stimulation delivers electrical impulses to a targeted area of the brain that is responsible for the movement symptoms caused by Parkinsons disease. The electrical impulses disrupt the abnormal activity that occurs in the brains circuitry, which is causing the symptoms.

There are three areas in the brain that can be targets for deep brain stimulation in patients with Parkinsons disease. They are the subthalamic nucleus, the globus pallidus internus, and the ventral intermediate nucleus of the thalamus. Each of these areas plays a role in the brains circuitry that is responsible for the control of movement.

The specific area in the brain to target in an individual with Parkinsons disease depends on symptoms that need to be treated. For example, deep brain stimulation of subthalamic nucleus is effective for all major movement symptoms of Parkinson’s disease, such as tremor, slowness of movement , stiffness , and problems with walking and balance. Deep brain stimulation of globus pallidus is another effective target for a wide range of Parkinson’s symptoms. The thalamic target is sometimes selected for patients with tremor symptoms. The recommended target for each patient is made collaboratively with the neurologist, neurosurgeon and other caregivers involved in the decision making process.

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What Are The Risks And Complications Of Deep Brain Stimulation

As with any surgical procedure, there are risks and complications. Complications of DBS fall into three categories: surgery complications, hardware complications, and stimulation-related complications.

• Surgical complications include brain hemorrhage, brain infection, wrong location of the DBS leads, and less than the best location of the leads.
• Hardware complications include movement of the leads, lead failure, failure of any part of the DBS system, pain over the pulse generator device, battery failure, infection around the device and the device breaking through the skin as the thickness of skin and fat layer change as one ages.
• Stimulation-related complications occur in all patients during the device programming stage. Common side effects are unintended movements , freezing , worsening of balance and gait, speech disturbance, involuntary muscle contractions, numbness and tingling , and double vision . These side effects are reversible when the device is adjusted.

What To Expect After Dbs

Surgery to implant the leads generally entails an overnight stay, while the IPG is usually implanted as same-day surgery. During recovery, your surgeon will talk to you about caring for your wounds, when you can shower, and any activity restrictions. Its usually recommended that any heavy lifting be avoided for a few weeks.

After another two to four weeks, youll return to have your device programmed. This process will continue for several weeks to ensure the stimulation settings are optimal to control your symptoms. During these visits, you will be shown how to turn the device on and off with the handheld device and check the battery level.

Once the programming has been completed, you will have regular follow-up visits to check and adjust the stimulation to maintain the most benefit for your symptoms.

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What Risks Come Along With Doing Deep Brain Stimulation

DBS is a surgical procedure. As with any surgery there are some risks associated with it. Some of the risks of DBS include infection and bleeding. Your neurosurgeon may discuss some additional risks with you. Studies have shown that any risks are relatively small, but they should be kept in mind when considering DBS.

Deep Brain Stimulation And Parkinson’s: From Decision Making To Daily Life With The Device

This 24-page guide provides information and tips for thinking about, undergoing, and living with DBS. It answers common questions, discusses the latest research, shares personal stories of people with Parkinsons and their loved ones, and provides a list of questions to ask at every stage of the process. Use it to begin learning about DBS, round out what youve read or heard from others, or start or continue a conversation with your doctor or loved ones.

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What Is Deep Brain Stimulation Or Dbs

Deep brain stimulation, or DBS, is often described as a pacemaker for the brain. It works much like a pacemaker, sending electrical signals to the brain instead of the heart. DBS is primarily utilized for patients who have Parkinsons disease, dystonia, or essential tremor, and who cant adequately control their disease with medication. Before any patient is considered for the surgery, they are evaluated by the U-M interdisciplinary team. That team includes a neurosurgeon, neurologist, clinical neuropsychologist, speech pathologist, social worker, and other team members who ensure that you and your family understand the procedure and discuss your expectations and concerns.

Its important to understand that DBS does not offer a cure for your disease, but a way to manage it more effectively. It can offer many benefits, including the need to take less medication and therefore experience fewer medication side effects.

Open Loop Dbs Or Conventional Dbs

cDBS is the most commonly used strategy in PD with a known efficacy on different targets .6 However, since no sensor is used for feedback control of the electrical stimulation, cDBS is associated with several problems. Programming in cDBS is intricate and time consuming, and therefore needs very skilled staff.6 cDBS needs frequent reprogramming, which adds to the treatment cost of an already costly procedure. Further continuous stimulation is associated with shorter battery life, requiring frequent surgical procedures to change battery.6 Hence, other DBS technologies are continuously being assessed to improve patient experience and reduce treatment cost.

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How Does It Work

A small device placed inside your chest sends electrical pulses to your brain. The pulses block nerve signals that cause Parkinson’s symptoms.

A DBS system has four parts:

• A thin wire, called a lead, that’s placed in the part of your brain causing symptoms
• A pulse generator, like a pacemaker, that sends tiny electrical signals to the lead
• A wire that connects the lead to the pulse generator
• A remote control to program the system — the only part outside your body

After the system is in place and turned on, a DBS expert will adjust it so you get the best relief for your symptoms.

You can also control the system yourself. You can turn it off and on, check the battery, and tweak the settings.

Comparing Stn Dbs With Gpi Dbs

Sustained benefits of DBS of STN and GPi have been reported on motor function, motor fluctuations, dyskinesia and QoL. Several studies have shown that STN DBS can reduce levodopa equivalent daily dose by 48% to > 50%, 1 to 4 years post-surgery31,32 STN DBS is more effective in reducing LED than GPi DBS.33,34 Thomsen et al showed a reduction in medication use by 55% and 44% after 1 year and 8 to 15 years, respectively of STN DBS.8

Though both targets reduce levodopa induced dyskinesia , GPi DBS is more effective in reducing LID than STN DBS .35 Post DBS increase in levodopa dose results in higher rates of dyskinesia with STN DBS than GPi DBS.27,

The overall side effect profile of both targets is similar, but speech related adverse effects, dysphagia and gait disturbances are more common in STN DBS than GPi DBS.

As seen in this comparative review section, both STN DBS and GPi DBS are efficacious and safe targets in PD. Both STN DBS and GPi DBS have similar benefits, but a particular benefit may be more pronounced by targeting one of them. Hence, it is difficult to conclude which is a better target for DBS. Therefore, the choice between these two targets should be carefully based on the outcome desired.

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Quality Of Patient Care

BWH is committed to providing all of our patients with the safest, highest-quality, most-satisfying care possible and follow established protocols that have been shown to improve patient outcomes. Our Inpatient Satisfaction Survey, sent to patients to assess their total care experience, helps us to monitor what we are doing well and areas for improvement. We pride ourselves in the Quality of Patient Care we provide and how we are measured compared with other hospitals.

Will I Have To Limit My Activity Following Deep Brain Stimulation Surgery

• You should not engage in light activities for 2 weeks after surgery. This includes housework and sexual activity.
• You should not engage in heavy activities for 4 to 6 weeks after surgery. This includes jogging, swimming, or any physical education classes. Anything strenuous should be avoided to allow your surgical wound to heal properly. If you have any questions about activities, call your doctor before performing them.
• You should not lift more than 5 lbs. for at least 2 weeks.
• You should not raise your arms above your shoulders or over bend or stretch your neck.
• Depending on the type of work you do, you may return to work within 4 to 6 weeks.

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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.

How Long Will It Take For Me To Feel The Benefits Of Deep Brain Stimulation

The stimulator is not activated immediately after the surgery.

During the appointment with your specialized neurologist within two weeks of the operation, your stimulator will be activated. The medical team will then try different electrical current adjustments to maximize symptom control and minimize side effects.

In the next two months, your medical team will gradually increase the intensity of the electrical current and decrease your doses of levodopa. This adjustment period may take several months before you get the most out of this procedure.

Some devices allow patients to change the current intensity themselves according to their daily activities. In the near future, these DBS systems will be able to automatically adjust their intensity according to your needs.

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Deep Brain Stimulation : What When Why & How

This 1-hour webinar is for people with Parkinsons and their care partners who want to learn how Deep Brain Stimulation works. Kara Beasley, MD, explains the different types of DBS, what symptoms it does and doesnt help, how to decide what DBS device to get, how the evaluation process works, he reality of DBS programming, myths and misunderstanding about DBS, and more.

Resources For More Information

• Surgical option a potential life-changer for patients with OCD: Read and watch Erins story as she, a lively 21-year-old woman, fought her battle with OCD. This article explores how deep brain stimulation gave Erin her life back. The procedure was the first of its kind performed at Albany Medical Center the only facility offering this treatment between New York and Boston. In Erins own words, “Now, I can be who I really am and tell people my story and hopefully inspire people and help people along the way.
• Karen and Jims Story: A Shared Journey of Life, Love and DBS: Read about Karen and Jim. They were each diagnosed with Parkinsons before they met. Follow them on their journey as they fall in love after meeting each other from an online support group. See how they embraced each other and DBS.
• Kays Story A Parkinsons Disease Patient: Read about Kay, a 68-year-old woman suffering from Parkinsons disease. The article and video explore how DBS helped her regain her life. In Kays own words, Its like I had been turned on again. It was like a miracle.

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Are You A Good Candidate For Dbs

The best candidates for DBS surgery are people who:

• Have been diagnosed with Parkinson’s for five years or more
• Have disabling tremors and dyskinesias or severe motor fluctuations
• Experience severe motor fluctuations that cannot be controlled with adjustments to medication schedules
• Often experience significant dyskinesias interspersed with rapids wearing off and off time crises throughout the day

Not everyone is a good candidate for this surgery. It is important to know that some Parkinson’s symptoms respond well to DBS and others do not. The decision to undergo surgery depends on a critical assessment of each person’s specific symptoms.

Symptoms that respond well to intervention include:

• Tremor
• Dystonia (sustained or repetitive muscle twisting, spasm or cramp
• Dyskinesia

Several factors influence the outcome of DBS. One of the best forecasts is your response to levodopa. People whose symptoms still respond well to individual doses of the drug and who have mobility during their “on” periods usually have better results with DBS.

While some people think DBS should not be considered until Parkinson’s medications have become completely ineffective, this is not true. When medications stop working completely, deep brain stimulation won’t work, either. Surgery promises more effectiveness for those who experience complications with medications, such as dyskinesias, but continue to respond well to levodopa.

Those who respond well to DBS tend to be people who:

What Is Parkinsons Disease Surgery

Parkinson’s disease surgery is a brain operation called deep brain stimulation . The surgery is also used to treat epilepsy, obsessive-compulsive disorder and a condition called “essential tremor.” DBS is widely considered one of the most significant neurological breakthroughs in recent history, posing a potential treatment for major depressive disorder, stroke recovery and addiction. Parkinson’s disease brain surgery aims to interrupt problematic electrical signals from targeted areas in the brain and reduce PD symptoms.

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Why A Doctor May Choose Deep Brain Stimulation

According to the National Parkinson Foundation, the ideal Parkinsons disease candidate for DBS surgery has:

• PD symptoms that interfere with activities of daily living.

• Fluctuations in mobility due to PD medications with or without dyskinesia .

• Continued good response to PD medications, even if the medication effects may wear off sooner than they have in the past.

• A history of several different combinations of PD medications while under the supervision of a neurologist specializing in movement disorders.

These factors* may make a person a less than ideal candidate for DBS surgery:

• Difficulty with balance, walking, or freezing as the main disabling symptom.

• A primary symptom of speech difficulty.

• Continuous confusion and problems with memory and thinking.

• A psychiatric condition such as depression or anxiety that has not improved or stabilized with other treatment.

• Another condition that increases the risk for surgery complications.

*Some of these factors may be treatable. Having one or more does not disqualify a person for future DBS surgery, but the doctor may recommend more aggressive therapy focused on these issues before surgery takes place.