Pallidal Stimulation Versus Subthalamic Stimulation
As mentioned, there are two main anatomic targets for using DBS to treat PD the STN and the GPi. There have been several large randomized studies comparing STN and GPi DBS in PD. It is suggested that both STN DBS and GPi DBS overall equally and successfully improve motor symptom, and are similar in cost-effectiveness. However, although no differences were observed in the on phase between STN DBS and GPi DBS, significant differences were seen in the off phase STN DBS was more effective in terms of motor function improvement in the off phase. There are different opinions in terms of effects of STN DBS and GPi DBS on quality of life. Some authors have found no significant difference between the STN and GPi targets. However, others agree with that greater improvements in quality-of-life measures are achieved in patients with GPi DBS.
GPi DBS can be used for patients with more axial symptoms, gait issues, dyskinesias, depression, and word fluency problems. STN DBS is often favored in reducing medication post surgery, and for patients with greater tremor. STN-DBS has also demonstrated an improvement in the quality of sleep for patients.
Deep Brain Stimulation Success Rate For Quality Of Life
The goal of reducing your symptoms is to improve your quality of life.
So, the ultimate measure of Deep Brain Stimulation Success rate is an improvement in Quality of Life .
The distinction is crucial. For example, if your slowness decreases by 60-70%, your doctor would be happy. But are you satisfied? Has that enabled you to have a better life?
Does a high Deep Brain Stimulation Success rate enable you to have a better life?
For example, ADL means activities of daily living bathing, dressing etc. Many patients can perform ADLs better after DBS.
For all these symptoms, the progression of underlying Parkinsons itself may worsen QOL and ADL in some patients.
Improvement in movement improves your quality of life. But, if your quality of life is low due to other symptoms such as depression, DBS may not improve it. These other factors need to be separately treated.
Efficacy Of Different Dbs Strategies And Technologies
Efficacy of DBS is also dependent on the strategy and technology used such as cDBS, CL-DBS/aBDS, and the electrode used as these modulate the volume of tissue activated . The VTA in cDBS, CL-DBS/aBDS correlates directly with the accuracy and efficacy of the target stimulated.9 The electrode used for DBS should be designed such that it provides a flexible interface to facilitate the application to different targets and compensate for morphological and surgical variance.9 VTA around an optimal electrode depends on the number of contacts required for stimulation, properties of surrounding tissue and simulation parameters .9
Patient Selection For Improved Efficacy
The efficacy of DBS depends on the expertise of the neurosurgery team9 and on patient characteristics.22,23 The Core Assessment Program for Neurosurgical Interventions and Transplantation in Parkinsons Disease recommends that surgical intervention in PD should be considered in patients with disease duration of at least 5-years.22 However, patients who are adequately controlled by medical management are not candidates for DBS.23
Patients should be critically chosen based on their symptoms, age and cognition status as the right patient selection increases the efficacy of DBS.9 More than 30% of the DBS failures are because of improper patient selection.23 Patients with non-motor symptoms not responsive to medication, also do not respond to DBS too.
The following patients on optimal drug therapy are more likely to have good and sustained response to DBS if they have the following characteristics:9,22,24 idiopathic PD/advanced PD robust response to levodopa ineffective management of symptoms with levodopa can increase risk of DBS rejection by 50% experiencing complications to medical therapy lack of significant psychiatric and/or mood symptoms no history of dementia or depression and < 70 years old.
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 .
Research suggests that DBS may “protect” or slow the Parkinson’s disease process .
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Reduces Dyskinesia And Fluctuations
Medtronic DBS therapy reduces complications of drug therapy, such as dyskinesia and fluctuations in on and off time.3,4,5,6 Medtronic DBS therapy reduces complications of drug therapy by 37% to 61% compared to medication alone.4,5 Without DBS, people receiving best medical therapy experience between a 5.4% reduction to a 13% increase in drug-related complications compared with their baseline.4,5
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Deep Brain Stimulation Results
Deep brain stimulation wont cure your disease, but it may help lessen your symptoms. If deep brain stimulation works, your symptoms will improve significantly, but they usually dont go away completely. In some cases, medications may still be needed for certain conditions.
Deep brain stimulation isnt successful for everyone. There are a number of variables involved in the success of deep brain stimulation. Its important to talk with your doctor before surgery about what type of improvement you can expect for your condition.
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In How Many Patients Does Dbs Fail Completely
About 10-15 %.
It is difficult to confirm that there is no improvement in ANY of the symptoms mentioned above. Medtronic reports this data on its website .
But that is not the end of the story. Some of these initial DBS failures can be converted into successes.
A recent study looked at 14 patients who initially did not respond to DBS.
This study was conducted by the University of Florida & Harvard University. A majority of these patients had been diagnosed with Parkinsons disease before DBS.
The most common reasons for failure were:
- Incorrectly placed electrode.
- Incorrect programming.
- Incorrect medications
After they rectified these errors, 21 patients improved.
So, with careful post-operative care, the Deep Brain Stimulation Success rate may be higher.
Bottom Line: How Many Patients Are Happy They Had Dbs
Here are the most critical questions. Are people who had the DBS happy with their decision? Would they recommend it to others?
This is an excellent way of measuring the Deep Brain Stimulation Success rate for Parkinsons disease.
The results are very encouraging.
- 92.5% of patients were happy with DBS.
- 95% would recommend DBS to another patient with Parkinsons.
- 75% reported that it still controlled their symptoms.
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|Caution: This information is not a substitute for professional care. Do not change your medications/treatment without your doctor’s permission.|
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What Happens Before Deep Brain Stimulation
Before this procedure, your healthcare provider will discuss the advantages and disadvantages of having a DBS device implanted. Theyll also explain the possible risks that come with this surgery. Theyll also verify that you can have this surgery, which can involve other imaging scans or lab tests to look for any reasons you may not be able to have the procedure.
If you still decide you want to have the DBS implanted, your provider will then have you get detailed magnetic resonance imaging and computed tomography scans of your brain. These scans will help your provider decide which location is the best place to place the wires for the DBS.
Before the procedure, your provider will also talk to you about the following:
Efficacy Of Local Versus General Anesthesia Techniques
A meta-analysis of 145 studies of DBS in PD showed that the mean target error was not significantly different between LA and GA however the mean number of DBS lead passes were significantly less with GA as compared to LA .62 Post DBS complications were significantly lower with GA . The two techniques did not differ significantly in UPDRS II scores off medication, UPDRS III scores off and on medication or LED. UPDRS IV off medication score decreased more significantly in awake DBS versus sleep DBS cohorts .62 Hence, most DBS procedures should ideally be carried out under LA due to the lower side effect profile.
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Which Parts Of The Brain Are Targeted Using Deep Brain Stimulation For Movement Disorders
Before the procedure, a neurosurgeon uses noninvasive diagnostic imagingeither magnetic resonance imaging or computed tomography scanningto identify and locate the exact target in the brain for the surgery. Most surgeons use microelectrode recordingwhich involves insertion of a tiny wire that monitors the activity of nerve cellsto more specifically identify the precise brain area that will be stimulated.
For treatment of Parkinsons disease, deep brain stimulation targets parts of the brain that play a role in the control of movementthe thalamus , subthalamic nucleus , or globus pallidus . Deep brain stimulation for dystonia specifically targets the globus pallidus interna , while deep brain stimulation for essential tremor targets the thalamus. Different areas of the brain may be targeted for individuals with epilepsy who dont respond well to other therapies.
What Happens After Deep Brain Stimulation
Your healthcare provider will schedule a follow-up appointment that will take place within a few weeks of the pulse generator implantation procedure. At this appointment, they’ll start programming the pulse generator.
All pulse generators now in use have a wireless antenna built-in. That allows your healthcare provider to access and program the device from outside your body. Finding the right settings for the pulse generator may take some time and additional visits for adjustments.
Most pulse generators have special batteries that have long lifespans. Standard batteries for these devices last about three to five years. Some devices use rechargeable batteries, which can last about nine years. Replacing the battery also takes a surgery procedure, but this is usually shorter and quicker than the original surgery to implant the pulse generator. You’ll still go home the same day for battery replacements.
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Living With A Dbs Device
Batteries most often last three to five years, but this can vary. Rechargeable batteries may last up to 15 years.
There are several precautions related to electrical/magnetic devices that are important, but usually easy to accommodate. Items such as cell phones, computers, and home appliances do not generally interfere with the stimulator. Keep your stimulator identification card handy when you are out and about, in your wallet or purse.
Be aware that some devices may cause your transmitter to turn on or off. This includes security monitors that might be found at the library and retail shops.
If this occurs accidentally, it is not usually serious, but may be uncomfortable or result in your symptoms worsening if the stimulator is turned off. When you visit stores with these devices, you can ask to bypass the device by presenting your stimulator identification card.
Keep the magnet used to activate and deactivate the stimulator at least 12 inches away from televisions, computer disks, and credit cards, as the magnet could potentially damage these items.
Air Travel/Metal Detectors
Talk to TSA personnel when traveling by plane, as the metal in the stimulator may set off the detector. If you are asked to go through additional screening with a detector wand, its important to talk to the person screening you about your stimulator.
Medical Diagnosis and Treatment
Occupational Electromagnetic Concerns
How Does Dbs Treat Parkinsons
Parkinsons disease causes irregular electrical signals in parts of the brain that control movement. DBS uses electrical stimulation to modulate these control centers deep to the surface of the brain, improving communication between brain cells.
This helps to reduce symptoms such as tremor, slowness, and stiffness. It doesnt have much of an effect on non-motor symptoms or balance issues. Here are some additional tips for improving motor skills with Parkinsons.
DBS is the most commonly performed surgical procedure for symptoms of Parkinsons disease.
DBS isnt a first-line therapy. Its intended for people whose symptoms are still unmanageable even with medication. Learn about other advanced and future treatments for Parkinsons.
You might be a good candidate for DBS if:
- youve had symptoms for at least five years
- your symptoms respond to medication, but the effect doesnt last as long as it used to
- youve tried various doses and combinations of medications
- your symptoms interfere with everyday life
Your doctor is unlikely to recommend DBS if:
- Parkinsons medications havent helped much
- you have memory and thinking problems
- you have anxiety or depression that hasnt stabilized with treatment
- you have dementia
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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?
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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What Happens After Surgery
After surgery, you may take your regular dose of Parkinsons medication immediately. You are kept overnight for monitoring and observation. Most patients are discharged home the next day.
During the recovery time after implanting the electrodes, you may feel better than normal. Brain swelling around the electrode tip causes a lesion effect that lasts a couple days to weeks. This temporary effect is a good predictor of your outcome once the stimulator is implanted and programmed.
About a week later, you will return to the hospital for outpatient surgery to implant the stimulator in the chest/abdomen. This surgery is performed under general anesthesia and takes about an hour. Patients go home the same day.
Step 7: implant the stimulator You will be taken to the OR and put to sleep with general anesthesia. A portion of the scalp incision is reopened to access the leads. A small incision is made near the collarbone and the neurostimulator is implanted under the skin. The lead is attached to an extension wire that is passed under the skin of the scalp, down the neck, to the stimulator/battery in the chest or abdomen. The device will be visible as a small bulge under the skin, but it is usually not seen under clothes.
You should avoid arm movements over your shoulder and excessive stretching of your neck while the incisions heal. Pain at the incision sites can be managed with medication.
Rehabilitation After Deep Brain Stimulation
Rehabilitation programs should not only aim to treat the functions that are impaired but also to prevent the problems that will arise. Beginning the physiotherapy program concurrently with the treatment of the disease from the early stages of the disease may help to avoid such problems that lead to dependence, inactivity, social isolation and reduced quality of life.
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