Surgical Decision-Marking for Movement Disorders

Podcast Transcript

Dr. Rae-Grant, MD:  Neuro Pathways, a Cleveland Clinic podcast for medical professionals exploring the latest research discoveries and clinical advances in the fields of neurology, psychiatry, neurosurgery, and neuro rehab.

Although functional neurosurgery has been recognized as an effective treatment option for movement disorders for more than four decades, it is estimated that only about 10% of surgical candidates actually undergo surgery to improve their condition. With the arrival of new technology, highly targeted approaches and advent of new communication channels to reach patients, this landscape may be changing. In today's episode of Neuro Pathways, we're discussing surgical decision making in movement disorders. I'm your host, Alex Rae-Grant, neurologist at Cleveland Clinic's Neurological Institute. I'm very pleased to have Dr. Ben Walter joining me for today's conversation. Dr. Walter is head of the deep brain stimulation program and a staff neurologist in Cleveland Clinic's Neurological Institute. Ben, welcome to Neuro Pathways.

Ben Walter, MD:  Thank you. It's a pleasure to be here.

Dr. Rae-Grant, MD:   Let me start by having our listeners get to know a bit about you. Can you tell us about your training and when your practice brought you to Cleveland Clinic?

Ben Walter, MD:  Okay. Well, I've been practicing in Cleveland for 16 years. I came here in 2004 from Emory University, and at that time I joined the Cleveland Clinic and spent several good years at the clinic and then moved away to another institution for about a decade and just came back in 2018, and I'm really excited to be back with friends and colleagues and many familiar faces to help co-direct the deep brain stimulation program and section head for the movement disorders program as well.

Dr. Rae-Grant, MD:   Very good. And we're happy to have you back, Ben. Let's talk about surgical interventions for movement disorders. Like as in epilepsy surgery, these interventions are looked at as being significantly underutilized in the target population. Can you give our audience some perspective on when surgery should be considered for patients with Parkinson's disease and essential tremor?

Ben Walter, MD:  Well, Parkinson's and essential tremor are the two most common disorders that we treat with deep brain stimulation and other surgical therapies. It's a little bit different for the two conditions. Parkinson's patients are good candidates for the procedures when typically they respond well to medication, they have a typical form of the disease, but they've advanced to the point where they have motor fluctuations where the medications are no longer giving them consistent constant benefit and they're starting to wear off between doses, and maintaining good control and quality of life becomes more of a struggle for them. Deep brain stimulation in this case helps give them continuous relief and similar to the impact of medication, but without these fluctuations they're able to control tremor and dexterity, in some cases walking all the time to a much greater degree.

Essential tremor is a bit different in that with essential tremor the medications work in only about half of patients, and the real challenge for these patients is when the symptoms become more of an impact on their quality of life. And for these patients, if they're not responding to medication or if they are when the symptoms are impacting their quality of life, they're a good candidate potentially for a number of different treatments, either deep brain stimulation or a newer procedure that we have called focused ultrasound, and this is predominantly for the tremors in their arms. Some patients will also have head and voice tremor with essential tremor, and that tends to respond to other therapies and not so much deep brain stimulation and focused ultrasound.

Dr. Rae-Grant, MD:   So once surgery is presented as an option for patients, I assume you have a collaboration between a number of providers. Can you talk a bit about the screening process your team uses to determine if the patient is a good candidate for surgery? What makes a person a good candidate and what makes them not a good candidate for surgery?

Ben Walter, MD:  So we have an extensive multidisciplinary team approach to evaluating and treating these patients, and this involves neurosurgeons evaluating the surgical risk and from the surgical perspective, a movement disorder specialist, a neurologist like myself, neuropsychologists that are looking at our patients from the perspective of the impact of the disease on memory, thinking, cognition, psychologists that are looking at our patients and understanding if they have significant depression or anxiety that are impacting or coloring how this condition affects their quality of life. And so really, we look at from all these perspectives. Our team gets together and evaluates these patients as a group. The Parkinson's patients, we will actually take them off their medications, look at their response to medication in the office having not taken it from the night before, and get a good assessment for what their medications do which, to some degree, gives us an indication of how they would respond to DBS or if they are a good responder to therapy in general. The real exception, though, for the Parkinson's patients is some patients with Parkinson's have had very stubborn tremor that doesn't respond to the medication, and those patients will still respond to deep brain stimulation. There are different targets that we may use, and they also respond to the focused ultrasound which is, again, a newer technique that we're also using more and more frequently.

Dr. Rae-Grant, MD:  So are there any sort of major contraindications for surgery that you guys look for or major stumbling blocks in terms of surgery helping patients [inaudible 00:06:23]?

Ben Walter, MD:  I look at it from two perspectives, really. One is hard contraindications would be things like dementia, if we find  excessive surgical risk, if they have a number of different medical problems that would make it difficult for them to have surgery in general, they may not be a candidate for either procedure; certainly maybe more for deep brain stimulation.  Focused ultrasound actually doesn't require anesthesia, and so it is a little more forgiving as far as other medical risks.

One thing that is really important is aligning the patient's goals. So it's really important that we understand how from the patient's perspective the disease is affecting their quality of life, what their goal is for the surgery, and making sure what the surgery can deliver aligns with those goals. So of course, if there's a mismatch where they may have some areas where they could benefit from a procedure but that's not really what they're counting on, then that patient, unless their perspective changes with a greater understanding of what it can deliver, that patient wouldn't be a candidate for the procedure as well.

It's critically important for patient satisfaction and to have a good outcome that we are able to deliver what the patients are looking for, and so that really is our goal to align with what they feel they need to improve their quality of life to the degree that it's necessary.

Dr. Rae-Grant, MD:   So I know it's a pretty topical issue right now, but you guys have published on integrating telemedicine or virtual visits into your process before and even more so it's important during the COVID pandemic. So can you talk a little bit about that work and about how you've used telemedicine in your process?

Ben Walter, MD:  Telemedicine lends quite nicely to the practice of movement disorders because a lot of what we're evaluating, not everything, but a lot of what we're evaluating, is visual. We are looking at how people move and looking at their movements as far as excessive movements or movements that are smaller amplitude and slower than they should be in these different conditions. So we can evaluate that fairly well through video and telemedicine. We can't sense the rigidity, but usually we can make a good diagnosis and come up with a good therapeutic plan with the majority of the information that is present. So our group has used telemedicine for quite a while prior to COVID and as you can imagine that COVID-19 pandemic has really caused, I think, an acceleration of a digital transformation. And that has also impacted us, of course, probably even to a greater degree where even still most of our practice is telemedicine right now. My expectation is into the future that we will have greatly larger predominance of telemedicine in our practice than prior to COVID-19.

So how do we use telemedicine? It's, I think, very useful for patients particularly that are thinking of traveling from other states. We can offer an excellent consult for these patients. And I think probably one of the most important first things that patients are looking for that are interested in something like deep brain stimulation or focused ultrasound is just to understand a bit more about the procedure, which procedure is best for them, what are the differences between the two, when is it time, and looking at their symptoms and their goals and objectives. So we can do that very well through telemedicine. It's really a conversation and taking a look at what the impact is on their lifestyle. And so with that, we can help get them ready for moving through the process a lot faster if they are interested in further pursuing deep brain stimulation or focused ultrasound, and telemedicine is a great way to do that.

Dr. Rae-Grant, MD:   So can we just go back to the actual interventions that you guys look at? Can you talk a bit more about the interventions available? I guess particularly focused ultrasound, which is newer, and how do you guys determine what approach is most appropriate?

Ben Walter, MD:  Well, it comes back to, again, the patient's goals is probably the most pivotal piece of information and helping to guide this decision-making process, so it's really a partnership with our patients. Focused ultrasound, again, is a nonsurgical approach. It's still an intervention on the brain, and one limitation of focused ultrasound is that it can only be done on one side. So we're really targeting this for patients who have... The majority of their impact is typically their dominant hand, and the kinds of things that they can't do is because of the tremor in that dominant hand. They can't write, they can't eat. They're embarrassed when they go out to eat because they can't keep food on a fork or spoon. They can't drink from a cup. They may not be able to dress themselves and have trouble putting makeup on. They might have trouble with their work. But again, really limited by that one hand. If their impairment is really dependent on both hands and their goals are dependent on seeing improvement in both hands, then deep brain stimulation is the only way to achieve that. And quite clearly, then, those patients should be choosing deep brain stimulation instead of focused ultrasound.

Focused ultrasound has the advantage that there is no hardware implanted in focused ultrasound, so you don't have a pacemaker and there's no upkeep necessary for it. The disadvantage in contrast to deep brain stimulation is deep brain stimulation, because it's a pacemaker for the brain and it's programmable and adjustable, that we can change the settings and give patients further improvement as the disease progresses, so it is something that can be adjusted and it's also reversible. If you had permanent side effects from focused ultrasound, those effects would be permanent if they persist after the initial period. Some people might have a little bit of a healing phase in the first week or so, but if they had a side effect from focused ultrasound after that time period, it tends to remain permanent because it's related to a very precise lesion that was placed in the brain using this technology. Deep brain stimulation, while it's a surgical procedure, it's not interrupting the brain tissues except just to pass a tiny little wire into a location in the brain, and really all the effects and benefits and side effects of deep brain stimulation after the initial procedure come from turning it on, which is completely adjustable and reversible.

There are risks to these procedures and certainly there's a risk of a bleed in the brain with deep brain stimulation or infection or hardware breakdown, and certainly something like a bleed in the brain is something that would not necessarily reverse itself over time. So that kind of risk is also different from focused ultrasound where you don't have that particular risk with that.

So as you can see, there are pros and cons to the two procedures and one may be perfect for one patient and the other may be perfect for another, depending on what their goal is and what their risk is coming into it.

Dr. Rae-Grant, MD:   So let's talk a little bit about the kinds of results and outcomes from these procedures and what does success look like and how do you guys try to measure it?

Ben Walter, MD:  Again, success objectively is probably dependent more on the particular disease state. If we're talking about Parkinson's or essential tremor, maybe more generally it's achieving the goals that the patient is looking to achieve. If we've satisfied their goals, they're able to do things that they haven't been able to do in a long time, then we've liberated them from some of the impact of these conditions. For Parkinson's disease, it looks like typically a patient that's not fluctuating from minute to minute, worrying about whether their medication is going to work or not. Sometimes it just doesn't kick in and it doesn't work and they can't go places not so much because they can't function as because of the fear that they can't function which is real, because they don't know if their medication is going to work when they need it to work when they're out and doing things. They may not be able to be employed for the same reason.

When it comes to tremor or even tremor in Parkinson's disease, and we can do either procedure for tremor and Parkinson's or tremor from essential tremor, reducing that level of tremor to something that is very minimal and at least to the point where it's not impairing their ability to do the things that they want to do. I mean, typically we see in the range of 80% reduction of symptoms in tremor with deep brain stimulation, and I think focused ultrasound is relatively similar to that. It's not always complete. There might be a little tremor left, but usually it's either not so noticeable or, ideally, it's not impacting their ability to do things. And most of the time, that's the case.

Dr. Rae-Grant, MD:   So, Ben, are there any other novel techniques on the horizon that you think may improve the ability to select or treat patients? Anything coming along down the pike?

Ben Walter, MD:  Well, these treatments are highly technologically based and the technology is evolving at a very rapid pace, and so it just changes day to day. It's an exciting area to be in because we keep having new tools and new ways to make a bigger impact on our patients' lives. Deep brain stimulation now has what we call directional leads or the wires essentially go in the brain. We're able to steer the current in different directions up and down the lead, but also sideways because the leads have contacts that face in different directions. And we're able to really customize this based on the area of the brain that we need to impact to give them benefit.

In the very near future, we'll have technologies where we can sense the brain activity that's going on in our patient and be able to basically have it automatically adjust the stimulation settings depending on their need based on a signal that's coming from the brain. So that kind of responsive technology is on its way. It's very close to being used in the United States, and it's going to change things dramatically as well.

So we have a lot of different technologies. A lot of wearables are being used now to monitor patients with movement disorders, and so these wearable technologies also can be kind of looped into the treatment algorithm, both in identifying patients for therapy and also potentially for controlling their therapies as well.

Dr. Rae-Grant, MD:   Well, Ben, before we sign off, do you have any closing comments for audience members who face the challenge of treating patients for movement disorders that are unresponsive to medical management? Anything else to advise them before we finish here?

Ben Walter, MD:  I would just say that for those that are good candidates, these surgical options can be very rewarding to offer to patients that are good candidates and to see how happy they are when they're able to relieve symptoms that have been troubling them for five or 10 years, or even sometimes 20 or 30 years in some cases, particularly with essential tremor. We see patients who have been living a good part of their life with a slowly progressive deterioration in function and just to be able to offer them something where it dramatically changes. We see patients come to tears and wondering why they haven't done this earlier because it is so disabling, but these are big decisions to make. But we're happy to evaluate patients, even virtually again. That's very easy to do. We can get people in very quickly without much travel and get them closer to being able to make a decision and then bring them to Cleveland when really it's necessary to go through the rest of the evaluation and move forward with surgery. And that's really what we've been aiming to do with our program.

Dr. Rae-Grant, MD:   Well, Ben, thank you so much for joining us. It's always exciting to learn how treatment options are evolving for our patients, and certainly you're in a very exciting area of medicine. Have a great rest of your day.

Ben Walter, MD:  Thank you. Thank you very much. Thanks for having me.

Dr. Rae-Grant, MD:  This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast or subscribe to the podcasts on iTunes, Google Play, Spotify, SoundCloud, or wherever you get your podcasts. And don't forget you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our consult QD website.

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