Preparing For Dbs Surgery
Working closely with your surgeon and your movement disorder clinicians will help you to determine if DBS is right for you. There are currently three DBS systems available that the neurosurgeon should discuss with you â ask for details on each device. Not every DBS surgeon works with all three systems, so it is important that you consider your choice of system and surgeon.
It is beneficial to have a family member or loved one attend DBS-related appointments with you. There are a lot of appointments necessary when considering or receiving DBS, and it is helpful to have an extra person to ensure all the details are covered and necessary questions are asked. If you do get the DBS system surgery, it is extremely important that loved ones or care partners understand the DBS system and how it operates. Older age does not exclude those who are otherwise healthy from being a possible candidate for DBS.
Every person will have unique post-surgery goals. If you are considering DBS, have a clear idea of what may or may not be achieved and manage expectations of how DBS will benefit you.
Having Deep Brain Stimulation
Deep brain stimulation is carried out slightly different at each surgical centre. The team at your hospital will be able to give you information about the specific procedure you will have.
During your surgery, a frame will be positioned around your head to help avoid movement during the procedure. Two thin, insulated wires are inserted into the brain. Rarely, when the symptoms mainly affect one side of the body, these leads are only inserted on one side of the brain. The lead implanted in the left side of the brain controls symptoms affecting the right side of the body and the lead implanted in the right side of the brain controls symptoms on the left side of the body.
Your surgeon will implant the leads into a specific area of the brain that is suitable for your Parkinsons the position will not be the same for everyone. After surgery you might have a detailed scan of your brain to make sure that the leads are in the correct place.
Depending on the technique used, the procedure is either completed during one operation or during two separate operations. This might happen so that the device can be implanted a few days after the leads.
There are several deep brain stimulation devices available that transmit the electrical current needed. These are called pulse generators or neurostimulators. Different manufacturers make different devices and the team at your surgical centre will explain which are available and the advantages of each one.
Non-rechargeable pulse generator
How Does Deep Brain Stimulation Work
Movement-related symptoms of Parkinsons disease and other neurological conditions are caused by disorganized electrical signals in the areas of the brain that control movement. When successful, DBS interrupts the irregular signals that cause tremors and other movement symptoms.
After a series of tests that determines the optimal placement, neurosurgeons implant one or more wires, called leads, inside the brain. The leads are connected with an insulated wire extension to a very small neurostimulator implanted under the persons collarbone, similar to a heart pacemaker. Continuous pulses of electric current from the neurostimulator pass through the leads and into the brain.
A few weeks after the neurostimulator has been in place, the doctor programs it to deliver an electrical signal. This programming process may take more than one visit over a period of weeks or months to ensure the current is properly adjusted and providing effective results. In adjusting the device, the doctor seeks an optimal balance between improving symptom control and limiting side effects.
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Mechanism Of Action Of Dbs
Current hypotheses on the action mechanism of DBS include depolarization blockade , synaptic inhibition , synaptic depression , stimulation-induced disruption of pathological network activity , and stimulation of afferent axons projecting to the STN . Depolarization blockade and synaptic inhibition are likely to explain the similarity between the therapeutic benefit of DBS and lesional surgery. Recordings of decreased somatic activation in the stimulated nucleus favor these hypotheses . However, the increased output of projection neurons does not seem to be mediated by these phenomena . Another and currently favored hypothesis is that DBS overrides abnormal spike train patterns by an unphysiological, high-frequency pattern, and thereby masks pathological signals, which cause dysfunction of the remaining elements of the basal ganglia-thalamo-cortical and brainstem motor loop . The exact nature of the abnormal signals and the interaction between stimulation-induced neuronal responses and intrinsic brain activity remains elusive, but abnormalities of the firing rate and pattern of basal-ganglia neurons, changes in oscillatory activity and excessive synchronization at multiple levels of the motor loop have been proposed as pathophysiological correlates of motor symptoms in PD .
Deep Brain Stimulation Surgery
A team of experts, including a movement disorder specialist and a brain surgeon, conducts an extensive assessment when considering DBS for someone. They review your medications and symptoms, examine you when you’re on and off Parkinson’s medication, and take brain imaging scans. They also may do detailed memory/thinking testing to detect any problems that could worsen with DBS. If your doctors do recommend you for DBS and you are considering the surgery, discuss with your care team the potential benefits as each person’s experience is unique. It’s also critical to discuss the potential surgical risks, including bleeding, stroke and infection.
In DBS surgery, the surgeon places thin wires called electrodes into one or both sides of the brain, in specific areas that control movement. Usually you remain awake during surgery so you can answer questions and perform certain tasks to make sure the electrodes are positioned correctly. Some medical centers now use brain imaging to guide the electrodes to the right spot while a person is asleep. Each method has its pros and cons and may not be suitable for everyone or available everywhere.
Once the electrodes are in place, the surgeon connects them to a battery-operated device , which usually is placed under the skin below the collarbone. This device, called a neurostimulator, delivers continuous electrical pulses through the electrodes.
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Consult With A Neurologist And A Neuropsychologist
After learning more about DBS, the next step is to make an appointment at a center that specializes in the surgical treatment of Parkinson’s. It is important that anyone considering this surgery be evaluated by a neurologist who is familiar with the procedure, expected benefits and potential risks. If a neurologist thinks you are a good candidate for surgery, and you decide to proceed, meet the neurosurgeon to learn more and prepare for surgery.
Neuropsychological testing is also strongly recommended before proceeding with DBS. This test is often standard to ensure DBS is a good option and help determine how it could affect memory and thinking. DBS will not improve or worsen non-motor symptoms associated with Parkinson’s.
Major Depression And Obsessive
DBS has been used in a small number of clinical trials to treat people with severe treatment-resistant depression . A number of neuroanatomical targets have been used for DBS for TRD including the subgenual cingulate gyrus, posterior gyrus rectus,nucleus accumbens, ventral capsule/ventral striatum, inferior thalamic peduncle, and the lateral habenula. A recently proposed target of DBS intervention in depression is the superolateral branch of the medial forebrain bundle its stimulation lead to surprisingly rapid antidepressant effects.
The small numbers in the early trials of DBS for TRD currently limit the selection of an optimal neuroanatomical target. Evidence is insufficient to support DBS as a therapeutic modality for depression however, the procedure may be an effective treatment modality in the future. In fact, beneficial results have been documented in the neurosurgical literature, including a few instances in which people who were deeply depressed were provided with portable stimulators for self treatment.
DBS for TRD can be as effective as antidepressants and can have good response and remission rates, but adverse effects and safety must be more fully evaluated. Common side effects include “wound infection, perioperative headache, and worsening/irritable mood increased suicidality”.
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What Happens During The Dbs Procedure
Most DBS procedures are performed with the patient awake under local anesthesia, with their head immobilized in a rigid frame, so that the surgical team can monitor patient response to the electrode placement as it occurs. A few centers are now offering image-guided placement, in which the surgery is performed under general anesthesia without the frame. The pulse generator is usually implanted during a second surgery, scheduled about a week after the first.
Potential Benefits Risks And Side Effects
DBS is not suitable for everyone, so its important to talk with your doctor about the potential benefits and risks. You should also discuss with a DBS neurologist the potential risks relating to not treating Parkinsons, Parkinsons medication and other types of therapies. This information will enable you to make an informed decision on whether DBS is the right treatment to most effectively manage your specific symptoms.
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What To Expect After Dbs
Surgery to implant the leads generally entails an overnight stay, while the IPG is usually implanted as same-day surgery. During recovery, your surgeon will talk to you about caring for your wounds, when you can shower, and any activity restrictions. Its usually recommended that any heavy lifting be avoided for a few weeks.
After another two to four weeks, youll return to have your device programmed. This process will continue for several weeks to ensure the stimulation settings are optimal to control your symptoms. During these visits, you will be shown how to turn the device on and off with the handheld device and check the battery level.
Once the programming has been completed, you will have regular follow-up visits to check and adjust the stimulation to maintain the most benefit for your symptoms.
When Should I See My Healthcare Provider
Your healthcare provider will schedule visits to see you after your procedures. Programming visits occur with your neurologist, and youll need to make appointments to see them. The goal of those visits is to find the settings that work best and don’t cause side effects that disrupt your life.
Regular visits with your healthcare provider are also common to monitor your condition, symptoms and to adjust medications or other treatments as needed. The schedule for these visits is something that your provider will discuss with you.
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How Can Parkinsons New Zealand Help
Parkinson’s New Zealand offers information and professional support to people living with Parkinsons. Our team of Parkinsons Community Educators can provide home visits for personalised sessions.
Community Educators work closely with the person with Parkinsons and their carers to develop a medical plan that upholds their health and lifestyle. Community Educators liaise with health professionals that treat Parkinsons in the community, including speech-language therapists, occupational therapists, and physiotherapists.
Parkinsons New Zealand also has support groups for members for sharing their coping strategies, experiences, and is a chance to establish social networks. Programs for people with Parkinsons include exercise, physiotherapy, hydrotherapy, and art or music therapy sessions.
Deep Brain Stimulation Program
The Deep Brain Stimulation program at Boston University Medical Campus is a collaborative medical and surgical program offered by the departments of Neurology and Neurosurgery for the treatment of Parkinsons disease, Essential Tremor, and Dystonia. This multidisciplinary program combines the efforts of the departments of neurosurgery, neurology, neuropsychiatry, behavioral medicine, anesthesiology, and nursing. Neurosurgical interventions for Parkinsons disease and tremor have been offered at BUMC since 1996.
A multi-step screening process is used to carefully select patients for this procedure. Some patients who may be candidates for surgery include: 1) patients who do not have good movement control despite optimized medical therapy and 2) patients who have dyskinesia or other side effects which limit the use of Parkinsons medications.
In the selection process patients are referred by their neurologist for a screening neurological consultation by the neurological DBS program team members. Patients are evaluated with a brain MRI, neuropsychological testing and movement testing with videotaping. A meeting is also scheduled with the neurosurgeon who provides information on DBS and determines eligibility for surgery.
After DBS surgery, follow up neurological care and adjustments of medications and DBS neurostimulators is conducted by our team. To learn more about the Deep Brain Stimulation program, .
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Conditions And Symptoms Improved By Deep Brain Stimulation
DBS has been shown to improve all the symptoms of Parkinsons disease that respond to L-dopa treatments. The exception is tremor, which responds well to DBS even if it did not previously respond well to medications.
However, not all symptoms of Parkinsons disease improve with surgery.
Patients with essential tremor, dystonia and obsessive compulsive disorder may be candidates for DBS if medication has failed to provide relief.
It is important to note that patients with dementia in addition to movement disorders are not candidates for deep brain stimulation.
Because of the DBS risks, it is only recommended for patients whose quality of life is significantly impaired by their movement disorder. Determining significant impairment is best done by yourself, your physician, and your loved ones.
Risks Of Deep Brain Stimulation
As with any medical procedure, there are genuine risks of getting the DBS procedure done.
General risks are seizures, infections, blood clots, excessive bleeding, and anesthesia reactions.
There is a risk that DBS may lead to speech and balance-related afflictions from Parkinsons to worsen.
DBS can also worsen depression in some people with Parkinsons.
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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.
Theft Detectors
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.
Home Electronics
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
Parkinsons Disease Dbs Surgery
Deep Brain Stimulation is a surgical treatment involving implantation of electrodes into deep structures of the brain involved in motor control.
The Food and Drug Administration approved DBS as a treatment for Parkinsons disease in 2002, but the first DBS surgery was done about 10 years prior. Electrodes are placed in the area of the brain involving motor control, and are connected to a programmable pacemaker-like device implanted under the skin in the chest wall. While it does not cure the disease, it can dramatically improve many symptoms associated with PD and patients quality of life.
Is DBS Right For You?
It is important to understand that DBS is not successful in treating all symptoms of PD. It is a proven and effective treatment for motor problems, caused by PD slowness, muscle stiffness, tremor, etc. Most non-motor symptoms of the disease, including cognitive decline, mood and behavior problems etc.., would not be expected to respond to DBS. In addition, balance problems and freezing of gait do not always improve with DBS.
Risks of DBS
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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.
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.
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