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.
Effectiveness Of Dbs In Advanced Versus Early Pd
The efficacy of DBS in advanced PD is widely reported and assessed using MDS-UPDRS IIV. Stimulation of different targets provides different improvements in symptoms however, most improve motor symptoms and activities of daily living in advanced PD. A meta-analysis of 13 randomized controlled trials found significant improvement in PD symptoms after DBS. However, GPi DBS and STN DBS resulted in similar improvement in motor scores or ADL at 36 months. STN DBS significantly reduced medication use as compared to GPi DBS . GPi DBS, on the other hand, significantly improved Beck Depression Inventory scores as compared to STN DBS .
However, recently efficacy of DBS in early PD is showing promising results. A meta-analysis of eight RCTs , of which two recruited early PD patients showed that the UPDRS, Parkinsons disease questionnaire -39, and LED scores improved significantly with DBS as compared to BMT .4 Patients with early PD had a significantly greater reduction of LED than those with advanced PD . No other differences were found in efficacy outcomes between early and advanced PD.4
A very recent prospective randomized trial in early PD patients followed for 5-years showed that STN DBS given along with ODT significantly reduced LED , polypharmacy and disease progression compared to only on ODT.63 Patients on DBS + ODT had a safety profile similar to patients on only ODT.
However, despite its various benefits, currently, conventionally DBS is not used in early PD.
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.
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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.
What Benefits Does The Procedure Offer
DBS is not a cure for Parkinsons, but it may help control motor symptoms while allowing a reduction in levodopa dose. This can help reduce dyskinesias and reduce off time. DBS does not usually increase the peak benefits derived from a dose of levodopa the best levodopa response before DBS is a good indicator of the best response after DBS. But it can help extend the amount of on time without dyskinesias, which may significantly increase quality of life.
DBS does not provide most patients benefit for their non-motor symptoms, such as depression, sleep disturbance, or anxiety. DBS also does not usually improve postural instability or walking problems. If a symptom you have does not respond to levodopa, it is not likely to respond to DBS.
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Which Brain Targets Should Be Used To Implant The Dbs Lead
- There are three brain targets that the FDA has approved for use in Parkinsons: the subthalamic nucleus and the globus pallidus interna are the most common.
- The target choice should be tailored to a persons individual needs.
- There are many ongoing studies that will help refine target choice for individual people.
- Although the picture is not yet clear on the issue of target choice, the STN seems to provide more medication reduction, while GPi may be slightly safer for language and cognition.
What Makes A Person A Good Candidate
It turns out that DBS is not a simple yes or no selection process, like may be true for a gallbladder surgery, for example. If you have Parkinsons disease and your quality of life is impacted by on-off fluctuations, dyskinesia, tremor, rigidity, or bradykinesia, despite aggressive attempts to adjust timing and dosages of medications, DBS should cross your mind.
The next step is referral to an experienced DBS center and a multidisciplinary evaluation, including on-off dopamine medication testing as well as appointments with a neurologist, a neurosurgeon, a psychiatrist, and a neuropsychologist. Rehabilitation specialists, social workers, and nutritionists may also be needed for an optimal DBS outcome. This group of specialists should talk behind your back to determine whether surgery is appropriate as well as discuss target and approaches.
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How Deep Brain Stimulation Works
Exactly how DBS works is not completely understood, but many experts believe it regulates abnormal electrical signaling patterns in the brain. To control normal movement and other functions, brain cells communicate with each other using electrical signals. In Parkinson’s disease, these signals become irregular and uncoordinated, which leads to motor symptoms. DBS may interrupt the irregular signaling patterns so cells can communicate more smoothly and symptoms lessen.
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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Summary And Future Prospects
The review shows that DBS is an effective and evolving treatment strategy in PD. However, despite its benefits, it is not widely accepted or widely available due to cost and need for highly skilled staff to manage the programming and stimulation. Additionally, there are challenges of repeat surgeries and short battery life. DBS efficacy, accuracy and acceptability can be improved by overcoming these challenges.
Therefore, upcoming DBS technologies would need to focus on reducing electrode contact size and stimulation number, and move from an invasive to a non-invasive approach.9,67 Newer technologies like current steering can reduce the VTA.67 The VANTAGE study shows that multiple-source axially asymmetric directional DBS using segmented electrodes can be more efficacious than cDBS technologies without steering.60,61 Newer biomarkers and electrode designs like rhythmic neural activity and evoked potentials for segmented electrodes can reduce the programming time.9 Automated support tools to determine the optimal stimulation parameters can increase the penetration of technology in areas where highly skilled staff are not available.9
Today updated software using imaging technologies allows patient specific reconstruction of DBS leads with fully automated tools such as PaCER.67 Recently, a smartphone based wearable and wireless accelerometer and gyroscope platform was successfully used for quantified feedback for optimal configuration of CL-DBS tuning parameters.68
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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What Does Dbs Feel Like When The Device Is On
In an optimal situation, you set the DBS and forget it . You should pay attention mostly to progression of Parkinsons, medications, and therapies. The on-off fluctuations should smooth out, tremor and dyskinesia usually improve stiffness, and slowness may get better. It is hard to say what will improve as it depends on the list of issues going into the surgery.
Cop Postural Sway Variables
Three uncorrelated CoP variables characterised postural steadiness: root mean square distance , which quantifies the CoP variability around the mean CoP trajectory mean velocity of CoP displacement and 95% power frequency , which represents the frequency below which 95% of the total power is found. These variables were computed for the bidimensional CoP trajectory , and for individual foot CoP displacements. In addition, a 95% confidence ellipse for each trial was estimated, which encloses approximately 95% of the points on the CoP trajectory. The area of the confidence ellipse and the direction of maximum sway were quantified.
Comparisons of CoP variables under each foot allowed measures of postural symmetry. Postural symmetry was examined using the absolute symmetry index. If Pleft and Pright are values of a parameter extracted from CoPleft and CoPright the absolute symmetry index for this parameter is defined as:
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What Happens During Deep Brain Stimulation
This procedure actually involves two to three surgeries that usually happen at different times. The first one or two procedures are to insert the stimulation leads into each side of your brain at the same or separate times. The second procedure is to implant the stimulator battery known as a pulse generator under the skin of your upper chest.
Before these surgeries happen, your healthcare provider will usually insert an intravenous line to give you IV fluids. An IV also allows them to give you medications during the procedure as needed.
Lead placement
This procedure usually starts with your healthcare provider shaving the hair on your scalp. This makes it easier to place your head into a special frame that will hold your head still. The frame is set with four pins in your skull. This is done while youre under sedation, and you likely wont remember this part.
Once the frame is set, theyll bring in an intra-operative CT scanner to take images of your brain and identify the trajectory used for the electrode placement. Once the CT scan is complete, the entry point is identified, sedation is turned back on and your head is cleaned with surgical prep. Local anesthetic is then injected to numb that area of your scalp and skull. Your neurosurgeon will then make a small cut .
Pulse generator placement
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?
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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.
What Is Deep Brain Stimulation
Deep brain stimulation is a medical procedure that involves a mild electrical current delivered to a specific part of your brain. The electricity in that current stimulates the brain cells in that area, which can help several conditions. The current reaches your brain through one or more wires attached to a small device implanted underneath your skin near your collarbone.
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What Are The Benefits
- Symptom reduction: DBS often reduces symptoms significantly. These include motor symptoms like stiffness, tremor, slowness and dyskinesia. DBS has also been shown to aid in on/off fluctuations, improve mood and quality of life, and increase overall energy level.
- Little to no damage: In contrast to previous methods, DBS does not damage portions of the brain, nor remove nerve cells.
- Utilizing DBS in addition to levodopa could decrease a persons need for medication, thus, decreasing medication access and cost issues, as well as levodopa side effects.
- Individualized treatment: Electrodes and stimulation frequency and intensity can be controlled by physicians and the individual with DBS, and can be subjectively altered when needed.
What You Need To Know
- Surgeons implant one or more small wires in the brain during a surgical procedure.
- The leads receive mild electrical stimulation from a small pulse generator implanted in the chest.
- Proper patient selection, precise placement of the electrodes and adjustment of the pulse generator are essential for successful DBS surgery.
- DBS does not fully resolve the symptoms of PD or other conditions, but it can decrease a patients need for medications and improve quality of life.
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