Surgery For Parkinson’s Tremor

How Does Focused Ultrasound Work

We use ultrasound to ablate the part of your brain that causes tremor. Using ultrasound means:

• No incisions. This technology lets us perform brain surgery without any cutting. This means no risk of bruising, bleeding or infection.
• Precision and accuracy. This technology lets us create a small lesion in the exact right place. Thousands of ultrasound waves come together in one place smaller than a millimeter. This creates enough heat to cause a lesion.
• Immediate feedback. Throughout the procedure, we test for improvement of your tremor symptoms so we know exactly when the procedure is complete.

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.

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.

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How Will My Doctor Diagnose My Symptoms

Diagnosis of your drug-induced tremors will start with your doctor asking you about your symptoms and medical history. A complete list of the medications youre taking will be extremely helpful during diagnosis. Telling your doctor how often youre having tremors can help aid in your diagnosis. The speed of your tremors can also help your doctor determine their cause.

Some important features of drug-induced tremors that distinguish them from Parkinsons disease include the following:

• The symptoms are on both the left side and the right side. Parkinsons disease typically affects primarily one side.
• The symptoms stop when you stop the medication. Parkinsons disease is chronic and progressive.
• There is no brain degeneration. Parkinsons disease is caused by degeneration in a specific area of the brain.

Your doctor might want to rule out other potential causes of tremors by performing blood tests to check for abnormal levels of certain chemicals in your blood. Problems with your thyroid can also cause tremors, so your levels of thyroid hormones might be checked.

CT and MRI scans are done by a computer and allow your doctor to see your brain. Using these scans, your doctor can potentially rule out defects in your brain that may be causing tremors.

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What Are The Risks

No surgery is without risks. General complications of any surgery include bleeding, infection, blood clots, and reactions to anesthesia. Complications related to placement of the DBS lead include seizures, infection, and a 1% chance of bleeding in the brain.

Reasons for which you might need additional surgery include breakage of the extension wire in the neck parts may wear through the skin and removal of the device due to infection or mechanical failure. If you have a non-rechargeable DBS system, the battery will need to be replaced every 3 to 5 years. Rechargeable DBS systems have a battery that lasts 10 to 15 years.

DBS may also cause worsening of some symptoms such as speech and balance impairments. In some patients with Parkinson’s, DBS may cause or worsen depression. If you develop any side effects from a stimulation adjustment, you need to return to the office for further programming.

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Benefits And Side Effects

FUS is a less invasive approach than others doctors do not need to make incisions or holes in the skull, meaning there is a lower risk of infections and bleeds. The procedure is also incredibly precise, limiting damage to surrounding parts of the brain.

Currently, a doctor may only use FUS for the treatment of tremors due to Parkinsons. Clinical trials are investigating the potential benefits of FUS in targeting other areas of the brain to help treat symptoms such as dyskinesias.

A person can usually return home the same day as the procedure, but they may experience some side effects such as numbness in the face or arms, poor balance, and speech and swallowing problems. However, these side effects tend to be temporary.

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.

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Who Is A Candidate

You may be a candidate for DBS if you have:

• a movement disorder with worsening symptoms and your medications have begun to lose effectiveness.
• troubling “off” periods when your medication wears off before the next dose can be taken.
• troubling “on” periods when you develop medication-induced dyskinesias .

DBS may not be an option if you have severe untreated depression, advanced dementia, or if you have symptoms that are not typical for Parkinson’s.

DBS can help treat symptoms caused by:

• Parkinson’s disease: tremor, rigidity, and slowness of movement caused by the death of dopamine-producing nerve cells responsible for relaying messages that control body movement.
• Essential tremor: involuntary rhythmic tremors of the hands and arms, occurring both at rest and during purposeful movement. Also may affect the head in a “no-no” motion.
• Dystonia: involuntary movements and prolonged muscle contraction, resulting in twisting or writhing body motions, tremor, and abnormal posture. May involve the entire body, or only an isolated area. Spasms can often be suppressed by “sensory tricks,” such as touching the face, eyebrows, or hands.

After your evaluation and videotaping is complete, your case will be discussed at a conference with multiple physicians, nurses, and surgeons. The team discusses the best treatment plan for each patient. If the team agrees that you are a good candidate for DBS, you will be contacted to schedule an appointment with a neurosurgeon.

How Soon After Treatment Will I Feel Better And How Long Will It Take To Recover

The time it takes to recover and see the effects of Parkinsons disease treatments depends strongly on the type of treatments, the severity of the condition and other factors. Your healthcare provider is the best person to offer more information about what you can expect from treatment. The information they give you can consider any unique factors that might affect what you experience.

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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 :

What Is A Parkinsons Tremor

Other health issues can also cause tremors, like multiple sclerosis or essential tremor. But Parkinsonâs tremors are different because theyâre usually:

• Resting. Parkinsonâs tremors happen when your muscles are still. They go away when you move. They also lessen while you sleep. For example, if youâre sitting in a chair with your arm relaxed, you may notice that your fingers twitch. But if youâre using your hand, like when you shake someone elseâs hand, the tremor eases or stops.
• Rhythmic. Parkinsonâs tremors are slow and continuous. They arenât random tics, jerks, or spasms.
• Asymmetric. They tend to start on one side of your body. But they can spread to both sides of the body.

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Maintaining Your Normal Pd Medication Schedule

Maintaining your PD medication schedule is crucial for anyone with PD. The correct timing and dosage are essential to your comfort and well-being. However, oftentimes when undergoing surgery, there may be restrictions regarding when you can and cannot take medications. Here are a few tips to navigate this issue:

Parkinsons Disease And Preparing For Surgery

People with Parkinsons disease sometimes face procedures or surgeries due to other medical conditions not related to PD. These could be relatively simple procedures such as a colonoscopy or endoscopy, common surgeries such as cataract removal, gall bladder removal or hernia repair, or more complex surgeries such as open-heart surgery or transplant surgery. I am frequently asked about specific concerns that arise when contemplating surgery for someone with PD.

People with PD, as well as people with other brain disorders, are more prone to side effects from anesthesia as well as negative effects from the stress of the surgery itself. Its important to remember that not everyone is affected in the same way, and this doesnt mean people with PD cannot have the surgeries and procedures they need. It is however important to be educated about what potential problems may arise so that you are as prepared as you can be.

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During And After Treatment

During the treatment, you will lie down on the treatment bed inside the MRI scanner. The medical team will be in the control room and you will be conscious and able to communicate with them. Your head will be positioned in the focused ultrasound helmet which is filled with water, and you will have a blanket to keep you warm.

Is There Surgery For Parkinsons Tremors

If medications donât help, a surgical procedure called deep-brain stimulation may be an option. With DBS, a small current is passed with high frequency through areas of the brain that are believed to block motor function. The procedure has a success rate of about 90% in decreasing or getting rid of Parkinsonâs tremors.

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The Connection Between Pd And Drug

In addition to potentially causing parkinsonism in the general population, these medications should definitely be avoided in people who have parkinsonism from other causes, such as PD. APDA has created a list of Medications to be Avoided or Used With Caution in Parkinsons Disease. It is important to note that there are anti-psychotics and anti-nausea medications which do not cause parkinsonism and can be used safely by people with PD.

Sometimes, a person without a diagnosis of PD is prescribed a medication which leads to a side effect of drug-induced parkinsonism. The prescribing physician may stop the new medication, but the parkinsonism does not resolve. The patient remains off the medication with continuing symptoms, and eventually is given a diagnosis of PD. In this scenario, that person most likely had dopamine depletion in the brain which had not yet manifested as a clinical symptom. The prescription medication that blocked the dopamine receptor, was the proverbial straw that broke the camels back, inducing the full-fledged symptoms of dopamine depletion and revealing that the person did in fact have PD.

The differences of PD vs drug-induced parkinsonism

There are key differences to note between parkinsonism from PD and parkinsonism as a side effect of medication.

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Changes Inside The Brain

In Parkinson disease, nerve cells in part of the basal ganglia degenerate.

The basal ganglia are collections of nerve cells located deep within the brain. They help do the following:

• Initiate and smooth out intended muscle movements

• Suppress involuntary movements

• Coordinate changes in posture

When the brain initiates an impulse to move a muscle , the impulse passes through the basal ganglia. Like all nerve cells, those in the basal ganglia release chemical messengers that trigger the next nerve cell in the pathway to send an impulse. A key neurotransmitter in the basal ganglia is dopamine. Its overall effect is to increase nerve impulses to muscles.

When nerve cells in the basal ganglia degenerate, they produce less dopamine, and the number of connections between nerve cells in the basal ganglia decreases. As a result, the basal ganglia cannot control muscle movement as they normally do, leading to tremor, slow movement , a tendency to move less , problems with posture and walking, and some loss of coordination.

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Motor Neuron And Dopamine Controls

The motor disability symptoms of Parkinsons disease result from the loss of dopamine secreting pigmented cells, in the pars compacta region of the substantia nigra . The substantia nigra is a very small area located deep within the brain and in PD patients these dopaminergic neural cells of substantia nigra degenerates and dies, only few live neurons in this region are observed in PD brain tissues than in the normal brain tissue. The loss of dopaminergic neurons leads to the loss of dopamine and dopamine is the major neurotransmitter which relays neuronal signals from the brain to other motor centers. The lack of dopamine in PD patients disturbs the movement control of the patients and mood, behavior, thinking and sensation of the patients .

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Conflict Of Interest Statement

PH is the director of the Duke University Parkinson Disease and Movement Disorders fellowship, which receives grant support from Medtronic. MS works for Duke University, and has received consultancy fees from Eli Lilly, Merz, Osmotica, Pfizer, SK Life Sciences, Allergan, Avid, Best Doctors, Biotie, Lundbeck, Neuronova, Novartis Pharma , Saraepta Therapeutics, and Sunovion Pharmaceutics, Inc. Dr. MS has also received grants from the Michael J. Fox Foundation, the NIH, the Parkinson Study Group, and Pharma 2B, royalties from Informa Press for the Handbook of Dystonia and Duke University for the Wearing Off Questionnaire. He has also received payment for development of educational presentations from the University of Kansas, the University of Miami, and the University of Rochester. Dr. MS also received paid travel accommodations from the Cleveland Clinic Neurological Institute, the Movement Disorder Society, and the National Parkinson Foundation.

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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