What Happens After Surgery
After surgery, you may take your regular dose of Parkinson’s medication immediately. You are kept overnight for monitoring and observation. Most patients are discharged home the next day.
During the recovery time after implanting the electrodes, you may feel better than normal. Brain swelling around the electrode tip causes a lesion effect that lasts a couple days to weeks. This temporary effect is a good predictor of your outcome once the stimulator is implanted and programmed.
About a week later, you will return to the hospital for outpatient surgery to implant the stimulator in the chest/abdomen. This surgery is performed under general anesthesia and takes about an hour. Patients go home the same day.
Step 7: implant the stimulator You will be taken to the OR and put to sleep with general anesthesia. A portion of the scalp incision is reopened to access the leads. A small incision is made near the collarbone and the neurostimulator is implanted under the skin. The lead is attached to an extension wire that is passed under the skin of the scalp, down the neck, to the stimulator/battery in the chest or abdomen. The device will be visible as a small bulge under the skin, but it is usually not seen under clothes.
You should avoid arm movements over your shoulder and excessive stretching of your neck while the incisions heal. Pain at the incision sites can be managed with medication.
How Does Dbs Work
The DBS device is placed by a neurosurgeon during a procedure. Thin wires carry electrical impulses from the neurostimulator device directly to the brain to stop brain signals that causes seizures.
- The neurostimulator device is battery operated. It can be programmed like a tiny computer .
- The device is programmed by your doctor or nurse to deliver electrical currents. The stimulation is delivered in a preset cycle and not directly in response to a seizure.
- These electrical currents affect the excitability of certain circuits of the brain and help prevent seizures or reduce their frequency.
- It can also capture and report information from the brain which can help the epilepsy care team to make other treatment decisions.
Deactivating Addiction With Dbs
Another use of DBS is in the treatment of substance abuse and drug addiction. Substance-related addictions constitute the most frequently occurring psychiatric disease category and patients are prone to relapse following rehabilitative treatment.
Persistent drug use leads to long term changes in the brains reward system.
Understanding of the reward systems affected in addiction has created a range of treatment options that directly target dysregulated brain circuits in order to normalise functionality.
One of the key reward regions in the brain is the nucleus accumbens and this has been used as a DBS target to control addiction.
Translational animal research has indicated that stimulation of the nucleus accumbens decreases drug seeking in models of addiction. Clinical studies have shown improved abstinence in both heroin addicts and alcoholics.
Studies have extended the use of DBS to potentially restore control of maladaptive eating behaviours such as compulsive binge eating.
In one study, binge eating of a high fat food in mice was decreased by DBS of the nucleus accumbens. This is the first study demonstrating that DBS can control maladaptive eating behaviours and may be a potential therapeutic tool in obesity.
Despite its therapeutic use for more than a decade, the neural mechanism of DBS is still not yet fully understood.
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Experience Fewer Symptoms With Deep Brainstimulation
For patients with movement disorders, such as Parkinson’s disease and essential tremor, an effective treatment is available to help significantly reduce their symptoms and make performing daily activities easier.
Deep brain stimulation is a therapy used to treat multiple disorders. The most common disorders include Parkinsons disease and essential tremor. It can be used to improve a patients:
- Abnormal muscle activation
It is also being studied in a few psychiatric conditions such as obsessive-compulsive disorder, Tourettes syndrome, depression and addiction.
About DBS surgery
The procedure involves placement of an electrode or lead into a deep structure of the brain typically, one on each side of the brain. These electrodes are secured in place with a plastic cap and connected to extension wires that are tunneled underneath the skin to an implanted generator placed under the skin just below the collar bone, similar to a pacemaker.
The generators last for 3-15 years depending on type implanted and patient use. They are replaced with a simple outpatient surgery. The overall risk of the operation is very low but not zero. In depth discussion with your neurologist and surgeon is needed to determine if you are an appropriate candidate and your risk of the operation.
Living With A Stimulator
Once the DBS has been programmed, you are sent home with instructions for adjusting your own stimulation. The handheld controller allows you turn the stimulator on and off, select programs, and adjust the strength of the stimulation. Most patients keep their DBS system turned on 24 hours day and night. Some patients with essential tremor can use it during the day and turn off the system before bedtime. Your doctor may alter the settings on follow-up visits if necessary.
If your DBS has a rechargeable battery, you will need to use a charging unit. On average charging time is 1 to 2 hours per week. You will have a choice of either a primary cell battery or a rechargeable unit and you should discuss this with you surgeon prior to surgery.
Just like a cardiac pacemaker, other devices such as cellular phones, pagers, microwaves, security doors, and anti theft sensors will not affect your stimulator. Be sure to carry your Implanted Device Identification card when flying, since the device is detected at airport security gates.
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Dbs In Movement Disorders
Over the past 25 years, DBS has become the standard of care for patients with treatment-refractory motor circuit disorders most commonly PD, dystonia and essential tremor. DBS is highly effective at controlling motor symptoms but remains very resource intensive. To date, use of DBS has been limited to high-income countries, although use in many developing nations is rising. Analysis of a US database of hospital discharges between 2002 and 2011 showed that more than 30,000 DBS surgeries were performed during that time. The numbers of publications on DBS have also risen steeply over the same period, with more than 7,000 manuscripts published between 1991 and 2014 . A drop in the number of publications in DBS for PD over the past 5 years might represent progressive scholarly acceptance, whereby the number of investigations that refine or improve a procedure eclipses the total number of reports assessing initial efficacy.
What Are The Parts Of A Deep Brain Stimulation Device
A DBS device including a neurostimulator that generates the electrical therapy waveform. The electrical therapy waveform is transmitted with a wire under the skin to a lead implanted through the skull. The lead is insulated except for a certain location near the end call electrodes. The electrical stimulation from the neurostimulator device therefore exits at the electrode and enters the brain there.
The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.
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Conflict Of Interest Statement
PH is the director of the Duke University Parkinson Disease and Movement Disorders fellowship, which receives grant support from Medtronic. MS works for Duke University, and has received consultancy fees from Eli Lilly, Merz, Osmotica, Pfizer, SK Life Sciences, Allergan, Avid, Best Doctors, Biotie, Lundbeck, Neuronova, Novartis Pharma , Saraepta Therapeutics, and Sunovion Pharmaceutics, Inc. Dr. MS has also received grants from the Michael J. Fox Foundation, the NIH, the Parkinson Study Group, and Pharma 2B, royalties from Informa Press for the Handbook of Dystonia and Duke University for the Wearing Off Questionnaire. He has also received payment for development of educational presentations from the University of Kansas, the University of Miami, and the University of Rochester. Dr. MS also received paid travel accommodations from the Cleveland Clinic Neurological Institute, the Movement Disorder Society, and the National Parkinson Foundation.
What To Think About
A neurologist with special training in Parkinson’s disease is most often the best kind of doctor to make a decision about deep brain stimulation. If you might benefit from the operation, your neurologist can refer you to a brain surgeon with experience doing the surgery.
Deep brain stimulation may be considered as an addition to levodopa therapy, not a replacement for it. It does not cure Parkinson’s disease and does not eliminate the need for medicine. The surgery can help maintain and extend the benefits of levodopa therapy. But it should not be considered for people with Parkinson’s disease who also respond poorly to levodopa therapy.
Because of an increased risk of falling in people who have DBS, it’s a good idea to understand the ways you can prevent falls after the surgery.
One of the possible advantages of deep brain stimulation over “lesional” surgery for Parkinson’s disease is that it can be changed or reversed. The effects of lesional surgery, which involves creating a lesion or intentionally destroying a small portion of the brain, are permanent, but the electrodes used in deep brain stimulation can be adjusted, turned off, or removed if they cause problems.
Deep brain stimulation for tremor caused by multiple sclerosis is still experimental, expensive, and not widely available.
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What Equipment Is Involved In Dbs
DBS is like a pacemaker for the brain. Two electrodes travel through nickel-sized holes in the skull into precisely targeted brain regions. These electrodes are placed beneath the skin and connect to a battery just below the collarbone. The battery provides a small amount of electricity delivered through the tips of the electrodes in the targeted brain areas to interrupt brain circuits that are functioning abnormally.
Types Of Deep Brain Stimulation
Deep brain stimulation therapy is part of a broader scope of brain stimulation therapies. Deep brain stimulation is one of the most commonly known stimulation therapies. Electroconvulsive therapy is a highly controversial and widely studied brain stimulation therapy that is still used to this day. Electroconvulsive therapy is used in the treatment of major depressive disorder and bipolar disorder.
Other forms of brain stimulation therapies include:
- Vagus nerve stimulation : Vagus nerve stimulation was initially used to treat epilepsy, though it is also now used to treat depression. It is similar to deep brain stimulationit also uses a device planted under the skin that triggers electrodes to deliver electric pulses. However, the electrodes are planted on the vagus nerve, instead of the brain.
- Repetitive transcranial magnetic stimulation : Repetitive transcranial magnetic stimulation can treat depression, psychosis, anxiety, and other mental illnesses. It was developed in 1985 and uses a magnet to activate the brain. The part of the brain that is activated is dependent upon the presenting condition.
- Magnetic seizure therapy : Magnetic seizure therapy is a newer form of brain stimulation that is used to treat mental disorders, such as major depression and bipolar disorders. Magnetic seizure therapy uses magnetic pulses to stimulate the brain to induce a seizure.
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Surgical Relief For Neurological Disorders
When medication isnt enough to control symptoms of certain neurological disorders, deep brain stimulation can be a viable option for symptom relief. For those who experience tremors, stiffness, slowness and involuntary movements, performance of daily tasks can be difficult or frustrating.
While DBS doesnt provide a cure, it can be used to significantly control symptoms for a number of conditions for many years. For example, DBS is the most commonly performed surgical treatment for Parkinsons disease and can help reduce symptoms such as tremor, stiffness and slowed movement while allowing a reduction in medication. Often, the reduction in medication improves many side effects.
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 many of the 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.
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Approved Conditions And Use
DBS is currently FDA-approved to treat symptoms of Parkinson’s disease, Essential Tremor and Epilepsy. Dystonia and Obsessive-Compulsive Disorder are also approved under an FDA Humanitarian Device Exemption. Studies on the effectiveness of DBS in minimizing symptoms of other neurological and psychiatric disorders are underway.
DBS is not suitable for patients with dementia or unresolved psychotic symptoms, as it may produce a worsening of cognitive symptoms. Patients with uncontrolled high blood pressure, bleeding tendencies, severe brain atrophy, or MRI evidence of large vessel ischemia are not candidates for DBS, as these conditions may increase the risk of stroke or other cerebrovascular accident.
Surgery for DBS uses the latest minimally invasive techniques, which can reduce the risk of complications, facilitate faster recovery times, and result in less discomfort compared to traditional open surgery.
The three-part DBS system includes:
- One or two leads , implanted in the brain
- One or two neurostimulators, implanted beneath the collarbone
- Connectors, or extensions, threaded under the skin to connect the leads to the neurostimulators.
Although patient pre-screening helps minimize risks, it is important to note that there are some risks and side effects associated with DBS. These include:
- Surgical risks, such as pain, bleeding, or infection
- Neurobehavioral side effects, such as depression, anxiety, and confusion
- Device-related complications.
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 cell 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 1 foot away from these items.
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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.
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.
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About Deep Brain Stimulation Therapy
Boston Childrens Hospital is now offering deep brain stimulation for children with primary dystonia, a type of movement disorder in which faulty brain signals cause involuntary muscle contractions. These lead to abnormal, taxing movements, typically repetitive twisting or contorting of the arms, legs, neck or other body parts. Primary dystonia, unlike secondary dystonia caused by a brain injury, is thought to be genetic in origin.
Dystonia may occur only in a specific part of the body, like the eyelid or hand, or it may affect many body regions. Often, the dystonia progresses and spreads most rapidly in the first five years after its onset, then begins to stabilize. Dystonia may be present at rest, but often becomes much worse when the child is doing a specific task or motion, like writing or walking. As a result, dystonia can become highly disabling.
Primary dystonia is often painful, and the abnormal movements and postures may embarrass the child and make it difficult to perform well in school. Some children become wheelchair-bound, and if dystonia is left untreated for years, it can cause permanent damage to joints and muscles as the limb freezes into the dystonic position. Most children with primary dystonia have a normal life expectancy.