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?
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.
Placement Of The Neurostimulator
This procedure takes place under general anesthesia so that the person is asleep. The surgical team inserts the neurostimulator under the outer layers of skin, usually just under the collarbone, but sometimes in the chest or abdomen. The extension wire from the lead is attached to the neurostimulator.
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During The Deep Brain Stimulation Surgery
In general, heres how surgery for deep brain stimulation works:
Brain surgery
For the brain surgery portion, your care team fits you with a special head frame to keep your head still during the procedure . Then, team members use magnetic resonance imaging to map your brain and identify the area in your brain where theyll place the electrodes.
Surgery can be done under general anesthesia so that youll be unconscious. Or the procedure can be done with you awake and alert. If youre awake for surgery, youll be given a local anesthetic to numb your scalp before the procedure, but you wont need an anesthetic in your brain itself because the brain has no pain receptors.
Your surgeon implants a thin wire lead with a number of contacts at the tips into a specific area of your brain. Or one lead is implanted into each side of the brain . A wire runs under your skin to a pulse generator implanted near your collarbone.
During surgery, both the neurologist and surgeon carefully monitor your brain to help ensure correct electrode placement.
Chest wall surgery
During the second portion of the surgery, the surgeon implants the part of the device that contains the batteries under the skin in your chest, near your collarbone.
General anesthesia is used during this procedure. Wires from the brain electrodes are placed under your skin and guided down to the battery-operated pulse generator.
Deep Brain Stimulation Complications In Patients With Parkinsons Disease And Surgical Modifications: A Single
- 1Department of Neurosurgery, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
- 2Key Laboratory of Brain Function Remodeling, Qilu Hospital of Shandong University, Jinan, China
- 3Humanistic Medicine Research Center, Qilu Hospital of Shandong University, Jinan, China
Background: As a complication-prone operation, deep brain stimulation has become the first-line surgical approach for patients with advanced Parkinsons disease . This study aimed to evaluate the incidence and risk factors of DBS-associated complications.
Methods: We have reviewed a consecutive series of patients with PD undergoing DBS procedures to describe the type, severity, management, and outcome of postoperative complications from January 2011 to December 2018. Both univariate and multivariate analyses were performed to identify statistically significant risk factors. We also described our surgical strategies to minimize the adverse events.
The importance of cumulative experience and relevant technique modifications should be addressed to prevent DBS-associated complications and unplanned readmission.
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When Should I Call My Healthcare Provider Or Go To The Hospital
Because DBS involves surgery especially the procedure on your brain there are some warning signs you shouldn’t ignore. You should call your healthcare provider immediately or go to the hospital outside of business hours if you have the following symptoms:
- Severe headache that happens suddenly or wont go away.
- Bleeding from your incisions.
- Redness, swelling or unusual warmth which are signs of infection around your incisions.
- Sudden changes in your vision, such as seeing double, blurred vision or loss of vision.
- Fever of 101 degrees F or higher.
What Happens During Deep Brain Stimulation
This procedure actually involves two to three surgeries that usually happen at different times. The first one or two procedures are to insert the stimulation leads into each side of your brain at the same or separate times. The second procedure is to implant the stimulator battery known as a pulse generator under the skin of your upper chest.
Before these surgeries happen, your healthcare provider will usually insert an intravenous line to give you IV fluids. An IV also allows them to give you medications during the procedure as needed.
Lead placement
This procedure usually starts with your healthcare provider shaving the hair on your scalp. This makes it easier to place your head into a special frame that will hold your head still. The frame is set with four pins in your skull. This is done while youre under sedation, and you likely wont remember this part.
Once the frame is set, theyll bring in an intra-operative CT scanner to take images of your brain and identify the trajectory used for the electrode placement. Once the CT scan is complete, the entry point is identified, sedation is turned back on and your head is cleaned with surgical prep. Local anesthetic is then injected to numb that area of your scalp and skull. Your neurosurgeon will then make a small cut .
Pulse generator placement
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How Does Deep Brain Stimulation Work
During the DBS surgery, leads are implanted on targeted brain areas and a battery-operated medical device called a neurostimulator is implanted in the chest. The DBS system delivers electrical stimulation to targeted areas in the brain that control movement, thereby blocking the abnormal nerve signals responsible for causing tremor and other symptoms of parkinsons disease.
Stereotactic Dbs Vs Interventional Image
Stereotactic DBS surgery requires the patient to be off their medication. During the procedure, a frame stabilizes the head and provides coordinates to help the surgeons guide the lead to the correct location in the brain. The patient gets local anesthesia to keep them comfortable throughout each step along with a mild sedative to help them relax.
During image-guided DBS surgery, such as with interventional MRI or CT scan, the patient is often asleep under general anesthesia while the surgeon uses images of the brain to guide the lead to its target.
Some advanced centers offer both the stereotactic and iMRI-guided options for DBS surgery. In this case, the doctor and patient will discuss which procedure is better based on a number of factors.
For instance, the doctor may recommend an image-guided procedure for children, patients who have extreme symptoms, those who are especially anxious or fearful or those whose leads are going into certain parts of the brain.
Generally, DBS surgery follows this process:
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Dbs For Parkinsons Disease
When patients first start taking their Parkinsons disease medicines, the benefits usually last throughout the entire day. However, as PD worsens, the patient may notice that the benefit from the medication doesnt last until the next dose this is called wearing off.
When the medicine wears off, PD symptoms such as tremor, slowness, and difficulty walking may reappear. Then, the symptoms improve once again when the medication is retaken with the next dose. In this scenario, the good period is called an ON period, while the bad period is called the OFF period. Patients may also develop involuntary movements called dyskinesias, which may be troublesome.
Sometimes, your doctor can adjust your medication dose and the timing of the medications to try to reduce OFF periods and dyskinesias. But in other cases, adjusting the medication doesnt alleviate the OFF periods and/or dyskinesias. Its those PD patients that tend to benefit the most from DBS.
Does Insurance Cover Deep Brain Stimulation
Many insurances will cover DBS, especially if it has official approval to treat that condition. Its important that you contact your insurance company to learn if they cover DBS procedures in any way.
A note from Cleveland Clinic
Deep brain stimulation is a treatment option that can help with a wide range of conditions that affect your brain function and mental health. Its almost always an option after other treatments and methods are unsuccessful. Its most common for conditions like Parkinsons disease and epilepsy, but researchers are also exploring the possibility of using it to treat many other conditions. While it does involve two to three surgeries, its also very effective at helping reduce symptoms and treat conditions that severely affect your quality of life.
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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 persons 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 persons 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.
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.
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Why Should A Movement Disorder Patient Consider Dbs
Many more movement disorder patients qualify for a deep brain stimulation surgery than actually go through with the procedure. But why is that?
For starters, DBS is literally brain surgery, and for many people, that is simply a bridge too far. While DBS is generally considered a safe procedure, DBS can nonetheless have potentially serious side effects, such as bleeding or a stroke during the surgery itself. Less serious side effects can result from the device needing an adjustment.
On the other hand, DBS can be extremely effective at helping the patient control their symptoms. One study has shown that 87% of the individuals who had undergone DBS showed improvement in motor control within one year after surgery. Also, DBS has been shown to reduce the need for medications in movement disorder patients a benefit thats over and above what it can do for the inherent motor symptoms.
But its important for people to understand that DBS is not a cure. The goal is to help manage a patients symptoms, and perhaps, to slow the progression of some movement disorders.
Testing Before Deep Brain Stimulation
For patients with Parkinsons disease, the doctor must confirm that the PD is levodopa-responsive and determine which symptoms are most likely to respond to DBS and discuss these with the patient.
To accomplish these two objectives, the movement disorders neurologist will examine the patient in the absence of his or her PD medications, then again after having taken them. Seeing the effect of PD medications on the movement and non-motor symptoms helps the physician and patient identify good target symptoms for DBS.
A cognitive assessment can help determine a persons ability to participate in the procedure, which involves providing feedback to the doctor during surgery and throughout the neurostimulator adjustment process. This assessment also informs the team of the risk of having worsened confusion or cognitive problems following the procedure.
Some hospitals also perform an occupational therapy review or speech, language and swallowing assessment. A psychiatrist may examine the person to determine if a condition such as depression or anxiety requires treatment before the DBS procedure.
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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.
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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How Common Is Dbs
Dr. Sheth describes DBS as a very standard treatment. These are procedures that we do week in and week out, he said. It’s not investigational or experimental. Around the world, more than 150,000 patients have had DBS for Parkinson’s or tremor with a success rate of 95%.
Patients need to know that there are these alternatives. They need to know that they’re not necessarily stuck with these symptoms, that there may be a different way to get better control. That discussion is, of course, individual-specific, but the availability of these types of surgical treatments is important for patients to know about.
Patients And Clinical Data
The patients with PD who had undergone the DBS procedure in our center from January 2011 to December 2018 were retrospectively analyzed. Of note, a DBS procedure was defined as any stereotactic surgery that involved implantation of the new intracranial electrode as well as IPG. A total of 229 DBS procedures of 225 patients were enrolled, and data was cross-checked with the manufacturers records . All DBS operations were performed by two primary surgeons . Follow-up was done at the outpatient service and telephone interview by December 31, 2020. Readmission referred to the unplanned admission to our center for any clinical situation related to DBS procedure after the primary discharge. Appointed readmissions for IPG exchange and contralateral electrode implantation were excluded. Ethical approval was obtained from the Medical Ethical Committee, Qilu Hospital of Shandong University .
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