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Deep brain stimulation (DBS)

What is deep brain stimulation (DBS)?

  • Electrodes slightly larger than a hair are implanted deep within the brain essentially providing continuous electrical current to (jam) the signal leading to a variety of movements. The movements may be tremor as in the case of Parkinson disease or essential tremor or may be stiffness/slowness as in the case of Parkinson disease.

  • Currently, DBS is approved to treat Parkinson disease, essential tremor, and dystonia.

  • The primary target or bull's-eye for DBS in essential tremor is the thalamus.

  • The primary target or bull's-eye for DBS in Parkinson disease is a structure called the subthalamic nucleus (STN) or the globus pallidus interna (GPI).​

DBS in Parkinson disease

  • In general, DBS is a life-changing treatment option for improving stiffness (rigidity), slowness (bradykinesia) and tremor.

  • We also know that patient's quality of life is better following DBS surgery and the results are sustainable.

  • DBS has been around for many years as a valid treatment option for Parkinson disease and is a very safe and accurate procedure with today's current technology.

  • If we take away side effects of dopamine and increase the dose, the effect this has on the Parkinson disease is often what DBS can do.

  • The goal of deep brain stimulation is to smooth out the off's and on's and allow reduction in medication so that dyskinesia (excessive movements) is minimal.

  • DBS typically does not help with postural instability (the loss of the reflex helping one stay upright)

  • The biggest things to remember:

    • DBS is ​NOT a last resort

    • There is a window of opportunity to have DBS surgery as once cognitive decline or memory issues begin, the risk of these worsening after surgery increases so surgery is typically performed prior to the onset of cognitive decline.

  DBS in Essential tremor

  • For patients who have tried multiple medications in order to treat their essential tremor and have been unable to tolerate the medications or have had poor results, DBS can be an effective and safe option to regain control from the tremor.

  • The target for DBS in essential tremor is the VIM nucleus of the thalamus.

  • Tremor of the arms and legs are easiest to treat but tremor of the face, voice, and head are also treated by DBS.

  • Many times, once the DBS has been placed, turned on, and adjusted, the movement disorder specialist can wean the medications for tremor in order to simplify the patient's regimen.

  • Since patients with essential tremor often have difficulty using objects, many times they will bring in their golf club, screwdriver, or other objects into the office so that we can adjust the tremor more effectively.

What happens before DBS surgery?

  • In general, reaching the goal of DBS is a process with many steps prior to surgery.

    • ​Patients are first seen by the movement disorder specialist to ensure a proper diagnosis is made.

    • In many cases, multiple attempts of medication trials are made prior to a more invasive therapeutic options such as deep brain stimulation. However, the movement disorder specialist will often keep the big picture in mind working with the patient and their family in making the decision on when is the correct time for DBS surgery.

    • If DBS is considered a possible treatment option for the patient, the first step is often detailed cognitive testing (neuropsychometric testing) particularly in the case of Parkinson disease as different targets have different risks of affecting cognition following the procedure.

    • In the case of Parkinson disease, the movement disorder specialist may have the patient come in off dopamine medication to objectively measure the patient's Parkinson's symptoms followed by another appointment after taking the medication to objectively measure the patient's Parkinson's symptoms.  An improvement in symptoms of at least 30% must be seen.

    • Patients will then meet with a skilled neurosurgeon who specializes in the placement of the brain stimulators.

    • The surgeon may have further steps prior to surgery such as cardiac clearance from the patient's primary care physician or cardiologist.

    • If deemed a good candidate from the surgeons perspective, a multidisciplinary meeting is made between the entire movement disorder team to ensure there are no stones left unturned and also to make sure the patient and their family have no questions prior to the procedure.

What happens during DBS surgery?

  • The patient will typically arrive early to the hospital.

  • They will be greeting by the movement disorder specialist to go over details and answer questions.  

  • The neurosurgeon will then come in and prepare the patient for surgery by shaving and cleaning the head.

  • The patient is then brought to the operating room where they will meet the rest of the surgical team.

  • The patient then has CT scan for a quick picture of the brain that will be merged with the detailed MRI of the brain that was taken in the week or two prior to surgery.

  • Throughout the surgery, the patient is awake but kept comfortable. This may sound scary to the patient but the brain as no nerve endings and therefore the patient will not feel pain. In fact, it is often a joyful experience where the patient will chat with the entire team so everyone can learn more about the patient, tell jokes, whatever makes the patient feel comfortable. The movement disorder specialist is at their side and the surgeon is at the head of the bed. Everyone works together as a team.

  • The surgeon will then make two small holes in the skull on either side. The patient will not feel pain but will feel 30 seconds of intense vibration per side.

  • We typically start with the most severely affected side first. The frameless technique is used where there are no restrictive cages or halos the patient wears on their head making it more comfortable for them to move while still maintaining accuracy.  We do not use the traditional "frame" that restricts the patient's head movement and covers the face.

  • At this point, a microelectrode, a device used to record brain waves and soundwaves, is introduced. The movement disorder specialist and team will listen to the brain as the microelectrode is advanced knowing when the target is entered as well as when the target is exited. Should we need to take a different trajectory to maintain better placement, we are able to do so accurately by moving as small as 1 mm. Ultimately, we usually find the perfect target in the brain and then begin testing.

  • During this part of the surgery, the patient is an active participant. Stimulation is turned on and adjusted. Many times, this is the fun part of the surgery where a tremor will cease, stiffness will resolve, and a weight will be lifted so that the patient can move faster. This is the part that never gets old for the surgical team.

  • Should the patient feel any side effects such as tingling, pulling, or blurry vision, we are able to adjust the lead to the appropriate spot to minimize any side effects.

  • Once we like the position of the microelectrode, we will then switch out the microelectrode for the lead (slightly larger than a hair). We will again test to make sure that we are in the correct place. At that time, the electrode is secured and the same thing is done on the other side.

  • Following the surgery, the patient will often stay overnight in the hospital and return home the next day. They will then come back 1 to 2 weeks later for battery placement and then return to clinic one to two weeks after that for initial programming.

What happens after DBS surgery?

  • DBS surgery is done in two stages: stage I is the lead placement and stage II is the battery placement.

  • Following both stage I and stage II, the patient has 1 to 2 weeks to let their brain heal and settle a bit.  Following this period, the patient is seen back in the clinic where the DBS is turned on for the first time.

  • At the first visit, the goal is to adjust the settings in the "ballpark" in order to treat the patient's symptoms.

  • The patient may then be seen back several times for further adjustments, each time fine-tuning the DBS to treat the patient's symptoms.

  • The beauty of DBS is that we are allowed to go up, go down, turn off, turn on all very easily.

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