Deep Brain Stimulation For The Treatment Of Parkinsons Disease And Other Movement Disorders
Parkinson’s disease is a neurodegenerative disorder that leads to resting tremor, rigidity, slowness of movement, and postural instability. These symptoms are caused by degeneration of neurons in the substantia nigra pars compacta , one of a group of brain structures known as the basal ganglia and part of a circuit crucial for coordinating purposeful movement. This circuit relies on the chemical messenger dopamine, which is produced by SNc neurons. As PD progresses and these neurons are lost, reduced dopamine results in abnormal circuit activity and motor symptoms.
The molecular precursor to dopamine, L-DOPA , is used to treat PD. However, people in later stages of the disease experience off periods when this medication does not work well, and L-DOPA treatment can also trigger uncontrolled involuntary movement, a condition called dyskinesia. deep brain stimulation can offer symptomatic relief in later stages of PD and may reduce requirements for L-DOPA treatment and exposure to its side effects. DBS is also used to treat other movement disorders, including essential tremor, which causes involuntary shaking that worsens during movement, and dystonia, which causes involuntary muscle contractions and slow, repetitive movements or abnormal postures.
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What Happens During Surgery
For stage 1, implanting the electrodes in the brain, the entire process lasts 5 to 7 hours. The surgery generally lasts 3 to 4 hours.
Step 1: attach stereotactic frameThe procedure is performed stereotactically, which requires attaching a frame to your head. While you are seated, the frame is temporarily positioned on your head with Velcro straps. The four pin sites are injected with local anesthesia to minimize discomfort. You will feel some pressure as the pins are tightened .
Step 2: MRI or CT scanYou will then have an imaging scan, using either CT or MRI. A box-shaped localizing device is placed over the top of the frame. Markers in the box show up on the scan and help pinpoint the exact three-dimensional coordinates of the target area within the brain. The surgeon uses the MRI / CT scans and special computer software to plan the trajectory of the electrode.
Step 3: skin and skull incisionYou will be taken to the operating room. You will lie on the table and the stereotactic head frame will be secured. This prevents any small movements of your head while inserting the electrodes. You will remain awake during surgery. Light sedation is given to make you more comfortable during the initial skin incision, but then stopped so that you can talk to the doctors and perform tasks.
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Deep Brain Stimulation Still Effective After 15 Years In People With Parkinson Disease Study Shows
Deep brain stimulation of the subthalamic nucleus was shown to remain effective in treating motor complications of people with Parkinson disease 15 years after initial surgery.
Deep brain stimulation of the subthalamic nucleus may prove effective after more than 15 years in patients with Parkinson disease , according to study findings published last week in Neurology.
Associated with several positive outcomes in patients with PD, including of disease progression, researchers say that STN-DBS has been shown to maintain efficacy in patients up to 11 years after surgery. However, conflicting reports have indicated DBS may lose efficacy over time.
Initial post-operative quality of life improvement has been described to fall to preoperative levels after 5-year stimulation, likely due to the escalation of both levodopa- and stimulation-resistant motor and nonmotor features of PD, such as impairments of gait, balance, speech and cognition, said the study authors.
With a growing rate of PD diagnoses and number of STN-DBS procedures conducted, researchers note that large data examining efficacy after the second and third decades post-procedure is lacking, with small populations having been the focus of previous studies examining motor response from STN-DBS after more than 10 years.
A mean follow-up time of 17.06 ± 2.18 years was reported among the study cohort.
Reference
Who Is A Candidate For Deep Brain Stimulation
DBS is more than just a surgical procedure. It involves a series of evaluations, procedures, and consultations before and after the actual operation, so people interested in being treated with DBS should be prepared to commit time to the process.
For example, those who do not live close to a medical center that offers DBS surgery may need to spend significant time traveling back and forth to appointments.
The procedure, as well as the pre-operative evaluation and post-operative follow-up, can be expensive depending on the persons insurance coverage. DBS surgery is an FDA-approved treatment for Parkinsons disease, and Medicare and most private insurers cover the procedure, but the extent of coverage will depend on each persons individual policy.
Prospective patients should have realistic expectations about DBS results. Although DBS can improve movement symptoms of Parkinsons disease and greatly improve quality of life in properly selected patients, it is not likely to return anyone to perfect health.
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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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Deep Brain Stimulation Side Effects
Although deep brain stimulation is minimally invasive and considered safe, any type of surgery has the risk of complications. Also, the brain stimulation itself can cause side effects.
Surgery risks
Deep brain stimulation involves creating small holes in the skull to implant the electrodes, and surgery to implant the device that contains the batteries under the skin in the chest. Complications of surgery may include:
- Misplacement of lead
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How Is Deep Brain Stimulation Surgery Performed
Identifying the brain target: Before the procedure is done, the exact target brain areas where electrical nerve signals generate PD symptoms, are identified with the help of Magnetic Resonance Imaging or Computed Tomography scanning or microelectrode scanning.
How is DBS surgery performed?
Surgery: The surgery involves two stages:
- First stage: Thin wires or electrodes are placed into the specific target area of the brain. The patient is kept awake to perform certain tasks to ensure that the electrodes are positioned correctly.
- Second stage: On the same day or next day,the electrodes are connected to a battery-operated device called impulse generator battery or neurostimulator, by an insulated wire passing under the skin of the head, neck and shoulder. The neurostimulator is then implanted under the skin below the collarbone.
Programming: The IPG is turned on and adjusted 2-4 weeks after surgery and may take a few weeks before patients receive adequate symptom relief. The patient receives initial programming of the neurostimulator so that it delivers continuous electrical pulses through the electrodes. These impulses interfere with and block the electrical signals that cause PD symptoms. All parts of the stimulator system are located internally. Patients may also receive a hand held device to check battery and switch on and off the device.
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.
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How Does Deep Brain Stimulation For Parkinsons Work
Deep brain stimulation works by modifying abnormal electrical activity in the brain. It was first approved for Parkinsons tremors in 1997 and has become an established treatment to control additional motor symptoms of Parkinsons disease.
DBS involves three main components:
- Leads: Leads are implanted in the brain in a region responsible for motor activity.
- Implantable pulse generator : A separate procedure is performed to implant a battery-operated device in the chest or in the abdomen. An IPG is similar to a pacemaker for the heart and has been coined by some as a pacemaker for the brain.
- Extension: A thin, insulated wire is passed beneath the skin between the leads and implantable pulse generator to deliver the electrical stimulation from the pulse generator to the leads.
The target area in the brain is first identified by magnetic resonance imaging or computed tomography . Then, the leads are placed via small holes that a surgeon drills in the skull.
This is considered a minimally invasive surgery that is done in the operating room with local anesthesia. It usually requires an overnight stay.
The IPG is inserted in a separate surgical procedure in the operating room roughly a week later.
After a few weeks, a neurologist begins to program the unit. This process can take several additional weeks to months. When this is completed, people are able to manage the device with a handheld remote control.
Deep Brain Stimulation Success Rate For Non
Patients with Parkinsons disease have non-movement problems as well. These include sleep problems, constipation, pain and many others. You can find articles on these problems on the site.
The effect of DBS on some non-motor symptoms is unknown. For example, we dont know if DBS reduces excessive sweating and urinary problems.
Unfortunately, DBS may worsen a few non-motor symptoms.
- If you already have thinking/memory problems, DBS may worsen them.
- If you already have severe depression, DBS may worsen it.
This possible worsening is important to consider. Please read these two articles to know more: .
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Risks And Side Effects Of Deep Brain Stimulation
Like any surgery, deep brain stimulation can have side effects, and it carries potential risks. Its also important to consider the complications and side effects of medications you take since their dosages can often be reduced following surgery.
While DBS may cause side effects, it may also reduce side effects from medications.
How Does Dbs Work
In DBS surgery, electrodes are inserted into a targeted area of the brain, using MRI and, at times, recordings of brain cell activity during the procedure. A second procedure is performed to implant an impulse generator battery , which is similar to a heart pacemaker and approximately the size of a stopwatch.
The IPG is placed under the collarbone or in the abdomen and delivers an electrical stimulation to targeted areas in the brain that control movement. Those who undergo DBS surgery are given a controller to turn the device on or off and review basic parameters such as battery 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.
Awake Vs Asleep Surgery
Standard DBS surgery is performed while you are awake and requires that you stop taking the medicines that control your Parkinson’s symptoms. During surgery, you are asked to perform tasks to help guide the electrode to the precise location in the brain.
Being awake during brain surgery, or being off medicine, is unsettling for some people. Asleep DBS is an alternative option at some centers.
Asleep DBS surgery is performed while you are unconscious and under anesthesia. Surgery takes place in an MRI or CT scanner to target and verify accurate placement of your DBS electrodes. Ask your surgeon if asleep DBS is an option for you.
| Must hold medications the morning of surgery | Don’t have to hold medications |
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Deep Brain Stimulation For Parkinson’s May Help Long Term
HealthDay Reporter
THURSDAY, June 3, 2021 — Parkinson’s disease patients can get symptom relief with deep brain stimulation therapy that lasts over the long term, a new study shows.
Over 15 years, patients who received DBS, which requires surgical implantation, had significant improvement in motor symptoms and less need for medication, researchers found.
“Our study, for the first time, supports the efficacy of deep brain stimulation in the very long term — 15 years after surgery and 25 years since Parkinson’s diagnosis,” said senior researcher Dr. Elena Moro, director of the Movement Disorders Unit at Grenoble Alpes University in France.
“Indeed, after an average of 15 years after surgery, patients could experience improvement, compared to before surgery,” she said. “Moreover, we could still observe a marked reduction of anti-Parkinson’s medication and improvement of quality of life, compared with before the intervention.”
Patients with Parkinson’s disease no longer make dopamine, which affects their speech, walking and balance. Symptoms can be partially relieved by the drug levodopa, which temporarily restores dopamine.
But as levels of dopamine fluctuate during the day, patients can suffer from dyskinesia, a side effect of levodopa that can cause twisting, swaying or head bobbing.
For the study, Moro’s team collected data on 51 patients being treated with DBS. On average, they had the device for 17 years.
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