(Also Called 'DBS (Deep Brain Stimulation)', 'Deep Brain Stimulation ', 'Mechanisms of DBS', 'New Applications For Dbs')
Deep brain stimulation is a way to functionally
modulate various nuclei in brain like subthalamic nucleus, the thalamus or
globus pallidus without purposefully destroying or structurally altering the
brain tissue. In deep brain stimulation, electrodes are placed in the thalamus
(for essential tremor and multiple sclerosis) or in the subthalamic nucleus or
globus pallidus (for Parkinson's disease or PD). The electrodes are connected by
wires to a type of pacemaker device (called an impulse generator, or IPG)
implanted under the skin of the chest, below the collarbone.
Once activated, the device sends continuous
electrical pulses to the target areas in the brain, modifying the brain circuits
that are responsible for motor symptoms of PD. This is better than thalamotomy
or pallidotomy as it can be modulated as per needs of the patient and can be
done without actually destroying parts of the brain.
The IPG can easily be programmed using a computer
that sends radio signals to the IPG. Patients are given special magnets so they
can externally turn the IPG on or off.
How is DBS performed?
Patients who are having stimulators placed on both
sides of the brain will have their surgery divided into two parts. Most people
with Parkinson's disease will require the surgery be done on both sides of the
brain unless the symptoms are unilateral or there are other considerations like
cognitive problems or age that dictates a unilateral or staged approach.
During the first surgery, the electrodes are placed into the brain, but left unconnected. This is the most critical part as the
electrodes have to be placed in an exact location. There are several ways in
which the electrodes are placed into the exact target areas of the brain. First
these areas must be located. One way to locate the target areas is to rely only
on CT or MRI scans. While some surgeons stop there, we use an electrode
recording technique to map and target the specific areas that they will need to
reach. Once the correct location is identified, the permanent electrodes are
implanted. The loose ends are placed underneath the skin of the head and the
incision is closed with sutures.
One week later, the patient is readmitted to the
hospital for a very brief time. The patient is placed under general anesthesia
and the extension wires are disconnected from the loose ends of the electrodes
and then connected to the impulse generators. Two to four weeks later, the IPG
is turned on and adjusted. It may take a few weeks until the simulators and
medications are adjusted before patients receive adequate symptom relief. DBS
causes very few side effects.
What is subthalamic nucleus deep brain stimulation?
After extensive clinical trials, stimulation of the
subthalamic nucleus has been recognized as the most effective surgical treatment
for Parkinson's disease, addressing not only tremors, but the full range of the
disease's symptoms, including: rigidity, slowness of movement, stiffness, and
walking concerns. Successful stimulation of the subthalamic nucleus allows
patients to consistently reduce their medication while improving all of their
other disease-related symptoms.
What are the advantages of deep brain stimulation?
Deep brain stimulation has many advantages. First,
it does not require purposeful destruction of any part of the brain and
therefore, has fewer complications than thalamotomy and pallidotomy.
In addition, the electrical stimulation is
adjustable and can be changed as the person's disease changes or his or her
response to medications change. No further surgery is necessary to make the
adjustments.
Another significant advantage of deep brain
stimulation relates to future treatments. Destructive surgery, such as
thalamotomy or pallidotomy, may reduce the person’s potential to benefit from
future therapies.
For example, future brain cell transplantation may
be of great help to people with Parkinson's disease. There is concern that a
pallidotomy or thalamotomy may prevent patients from benefiting from brain cell
transplantation. This would not be the case with deep brain stimulation, as the
stimulator could be turned off. The stimulator can also be turned off at any
time if deep brain stimulation is causing excessive side effects.
How effective is the surgery?
The vast majority of properly selected patients
(over 70%) experience a significant improvement of all their symptoms related to
Parkinson's disease. Most people are able to significantly reduce their
medications.
What kinds of movement problems are helped by DBS?
Deep brain stimulation of the subthalamic nucleus
is effective for all major symptoms of Parkinson's disease, such as tremor,
slowness of movement, rigidity, and problems with walking and balance. People
bothered by involuntary movements such as dyskinesia often experience a marked
reduction of these involuntary movements primarily because they are able to
reduce their medications following surgery.
Deep brain stimulation of the globus pallidus is
effective for a wide range of Parkinson's symptoms. It seems to be somewhat less
effective for problems with walking and balance. Also, patients remain on the
same average dose of medications following surgery.
Deep brain stimulation of the thalamus is only
effective for tremor and rigidity. Consequently, deep brain stimulation of the
thalamus is usually not performed for patients with Parkinson's disease.
As a rule of thumb whatever symptoms improve with
Sinemet® are improved with DBS in PD patients.
What are the risks?
As with any surgical procedure, there are risks.
There is a 2% to 3% risk of a serious and permanent complication such as brain
hemorrhage causing, death, paralysis, changes in thinking, memory and
personality, 4% risk of infection, and 1% risk of hardware breakdown. Talk to
your doctor to see if these risks apply to you.
Is DBS experimental?
No. Deep brain stimulation is not experimental.
Who should consider DBS?
There are many important issues to be addressed
when considering deep brain stimulation. These issues should be discussed with a
movement disorders expert or a specially trained neurologist. A movement
disorders expert is someone who has trained specifically in movement disorders.
One of the most important criteria is that the
person has had an adequate trial of medications. Surgery is not recommended if
medications can adequately control the disease. However, surgery should be
considered for people who do not achieve satisfactory control with medications.
Talk to your doctor to see if DBS is right for you.
Is age a factor?
DBS has been successful in treating people of
different ages; however, each person should be assessed individually as to their
stamina and overall health before considering surgery.
Where should the procedure be performed?
The first and most important recommendation is that
the DBS procedure is performed in a place where there is a multi-disciplinary
team of experts. This means neurologists, neurosurgeons, and neurophysiologists
who have experience and specialized training in performing these types of
surgeries.
The next most important consideration is how the
surgery is done. Different centers may perform the procedure in different ways.
It is very important to ask how the target (the thalamus or globus pallidus) is
localized. It is clear that the chances of benefit and the risks of
complications are directly related to how close the electrode is to the correct
target.
Will I be asleep during the procedure?
Throughout most of the procedure you will remain
awake. This allows the surgical team to interact with you when testing the
effects of the stimulation. Small amounts of local anesthetic (pain-relieving
medication) are given in sensitive areas. The vast majority of people experience
minimal discomfort during the procedure.
What should I expect after DBS?
You may feel tired and sore but will be given
medication and kept comfortable. Also, you may have irritation or soreness
around the stitches and pin sites.
As with any surgery, there are some guidelines and
limitations that you should follow after DBS. Be sure to discuss these with your
doctor and ask questions before surgery. Understanding what you will be
experiencing and knowing what to expect afterward can help ease some of the
natural anxiety that comes with any medical procedure.
When will I be able to go home?
The average hospital stay for the first part of the
DBS surgery is two to three days. For the second part of the surgery one week
later, you will be in the hospital for less than 24 hours.
How should I care for the surgical area once I am home?
- Your stitches or staples will be removed 7-10 days after surgery.
- Each of the four pin sites should be kept covered with band-aids until
they are dry. These should be changed every day as necessary.
- You will be able to wash your head with a damp cloth, avoiding the
surgical area.
- You may only shampoo your hair the day after your stitches or staples
are removed, but only very gently.
- You should not scratch or irritate the wound areas.
Will I have to limit my activity following DBS?
- You should not engage in light activities for 2 weeks after surgery.
This includes housework and sexual activity.
- You should not engage in heavy activities for 4 to 6 weeks after
surgery. This includes jogging, swimming, or any physical education classes.
Anything strenuous should be avoided to allow your surgical wound to heal
properly. If you have any questions about activities, call your doctor
before performing them.
- You should not lift more than five pounds for at least two weeks.
- Depending on the type of work you do, you may return to work within 4 to
6 weeks.
Warning
Call your doctor immediately if you experience any
of the following symptoms:
- Severe and persistent headaches
- Bleeding from your incision
- Redness or increased swelling in the area of the incision
- Loss of vision
- A sudden change in vision
- A persistent temperature of 101 degrees Fahrenheit or higher
Can I use electrical devices?
While you should be able to use most electronic
devices, you should be aware that:
- Some devices, such as theft detectors and screening devices, like those
found in airports, department stores, and public libraries, can cause your
neurotransmitter to switch on or off. Usually, this only causes an
uncomfortable sensation. However, your symptoms could get worse suddenly.
Always carry the identification card given to you. With this, you may
request assistance to bypass those devices.
- You will be able to use home appliances, computers, and cellular phones.
They do not usually interfere with your implanted stimulator.
- You will be provided with a magnet to activate and deactivate your
stimulator. This magnet may damage televisions, credit cards, and computer
discs. Always keep it at least one foot away from these items.
References
National Institute of Neurological Disorders and Stroke, Deep Brain Stimulation for Parkinson’s Disease Information Page.
www.ninds.nih.gov Accessed 5/16/2011
National Parkinson Foundation. Parkinson’s Disease: Treatment: Surgical Options: Deep Brain Stimulation.
www.parkinson.org Accessed 5/16/2011
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