Offering hope to certain movement disorders patients when other treatments fail, our Parkinson’s and Movement Disorders Program provides deep brain stimulation (DBS) surgery as an option for select patients. DBS is a complicated procedure that requires a skilled and knowledgeable surgical team and highly specialized equipment.
Benefits of DBS Surgery
DBS improves symptoms of tremor and Parkinson’s disease, such as:
- Tremor (shaking)
- Slowed movements (bradykinesia)
- Stiffness (rigidity)
How DBS Works
DBS involves implanting a thin wire, or lead, containing one or more electrodes, in the brain. The lead extends through a small opening in the skull and connects to a neurostimulator — a device that is similar to a heart pacemaker, only for the brain. The surgeon then implants the battery-operated neurostimulator under the skin in your upper chest.
After programming, the neurostimulator delivers controlled and adjustable levels of electrical signals to the brain to soothe symptoms of Parkinson’s disease, tremor and dystonia that fail to improve with medications.
When to Consider DBS
There is a window of opportunity when DBS is an effective treatment, typically in the eight to 12-year range. If you wait beyond the window, symptoms may be too severe to respond.
- For essential tremor, DBS should be considered after symptoms have failed to improve with one or more medications and the tremor interferes with daily activities.
- For Parkinson's disease, DBS should be considered if you've had symptoms for at least four years and your symptoms still respond to carbidopa-levodopa, but the medication causes significant fluctuations or side effects (wearing off, dyskinesias, freezing, dystonia).
What to Expect During DBS Surgery and Device Programming
The process begins with a consultation with a movement disorder neurologist to evaluate symptoms and determine if DBS is an option. There is also a neuropsychological evaluation to screen for signs of dementia or mood disorders.
If you are a Parkinson's disease patient, you will have an OFF medication/ON medication evaluation to assess your response to carbidopa-levodopa.
Our team reviews each case to decide if the patient is a good surgical candidate. If the team feels DBS is a good option, we will schedule a meeting with our neurosurgery team.
Computerized brain-mapping technology helps the surgeon find the precise location in the brain that generates the nerve signals that cause tremors and other symptoms. Imaging and recording equipment map both the physical structure and brain function.
To allow the surgical team to assess brain functions, most patients need to be awake during surgery. A local anesthetic numbs the scalp while the surgeon makes the small opening in the skull. Due to the unique nature of the human brain and its inability to generate pain signals, patients experience no pain while the electrodes are being placed in the brain. Asleep DBS surgery may be an option and offered on a specific case-by-case basis.
Most patients stay in the hospital for two or three day after surgery to implant the electrodes in the brain. In a separate surgery, usually within a week of electrode implantation, the surgeon implants the neurostimulator in your chest below the collarbone. The procedure uses general anesthesia and you go home the same day.
Within a week or two, you will return so we can turn the neurostimulator and program it.
Care After DBS Surgery
Over the next weeks or months after we activate the neurostimulator, we will make a series of adjustments in the electrical pulse. You will need to be able to travel to a location where we can make these adjustments. stimulation of their implanted devices can be adjusted, with the first few follow-up visits taking place at the same location as the surgery. After that, electrical programming can take place at any medical facility that has a specialist with the expertise and equipment.
Improved Alternative to Thalamotomy and Pallidotomy
DBS is an improved alternative to two surgeries often-performed previously, a thalamotomy and a pallidotomy. These surgeries involved destroying small parts of the brain within structures called the thalamus and the globus pallidus (GPi). DBS no longer makes it necessary to destroy even small parts of the brain.
DBS Surgery Risks
As with any surgery, the procedure is not risk free. There is about a 1 percent to 3 percent chance of brain hemorrhage that may be of no significance or may cause paralysis, stroke, speech impairment or other major problems. This means that for every 100 patients who undergo surgery, one to three will experience a permanent or severe complication. However, this also means that most patients will have no serious complications.
There is a 15 percent chance of a minor or temporary problem that resolves quickly or over a short period of time. Rarely, infections occur. While treatment of infection may require removal of the electrode, the infections themselves have not caused lasting damage, and we can implant the device again after the infection clears.
The electrode that is implanted in the brain and the electrical systems that provide stimulation are generally very well accepted by the brain with no significant changes in brain tissue around the electrodes. The neurostimulators implanted in the chest that produce the stimulation have a limited life span and will require future surgery to replace them.
Candidates for Deep Brain Stimulation
The Parkinson’s and Movement Disorders team meets weekly to review patient cases, including patients who may be candidates for the deep brain stimulation procedure. Patient selection is based on a thorough analysis of their medical situation and needs, as well as the best evidence available in medical literature and our extensive experience in performing DBS procedures.
Possible candidates for DBS are:
- Patients with Parkinson's disease, essential tremor and dystonia who experience movement-related symptoms that cannot be controlled by medications.
- Patients who have had an adequate and reasonable trial of medications (includes ET, dystonia and PD)
- Patients who experience intolerable side effects from medication may also be candidates.
New uses for DBS are being investigated, including symptom control for patients with epilepsy, Tourette’s syndrome, depression and chronic pain syndromes.
DBS has been successful in treating patients as young as 13 years old. In general, surgery is performed on patients under 75 years old, but this is not a firm guideline. Each patient must be assessed individually in regard to his or her stamina and overall health.
Thanks to significant innovation in DBS therapy, we offer three FDA-approved DBS devices. You and your movement disorder neurologist will thoroughly discuss the differences between the three options and determine which one meets your needs.
Effectiveness of DBS
While results vary from patient to patient, DBS is remarkably safe and effective in properly selected patients. The beneficial effects of symptom control have been demonstrated to last for several years.
- Patients with essential tremor may experience an 80 to 100 percent reduction in their tremors.
- Patients with PD who initially responded well to medications but over time have developed side effects may experience a 60 to 80 percent improvement in symptoms such as tremor and slowness of movement.
- On average, patients report a 50 percent improvement in their walking and balance.
- Patients with involuntary movements (dyskinesia) due to their medications experience a greater than 80 percent reduction in their involuntary movements.
- Most patients are able to significantly reduce their medications following deep brain stimulation.
- On average, DBS doubles the amount of "on-time" without dyskinesia. An important indicator of the effectiveness of any treatment for people with PD, in particular, is the duration of "on-time" without dyskinesia. This means the patient is mobile and can perform everyday tasks without experiencing the involuntary movements.