What Is Deep Brain Stimulation Benefits Cost Risks
Deep brain stimulation is a surgical procedure that uses electricity to treat brain disorders such as Parkinsons disease. It has been used with much-reported success in Parkinson’s patients and is now being trialed to treat everything from depression to disabilities caused by stroke. Many people with symptoms such as tremor and cognitive impairment are attracted to the benefits of deep brain stimulation but are nervous about the risks and costs associated with surgery. Let’s explore the pros and cons of deep brain stimulation as well as who is eligible.
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.
Surgery: What To Expect
Most people who have DBS need two separate surgeries to implant the necessary equipment.
First, the surgeon will implant the electrodes in the brain. Special scanning equipment will guide them to the correct location.
The surgeon typically starts by fitting a stereotactic head frame to ensure that the persons head remains still during the procedure. They apply local anesthesia to numb the scalp,
Next, they implant a thin wire with electrodes into the brain, followed by a neurostimulator near the collarbone.
The person sometimes needs to be awake during the procedure, so that the neurologist and neurosurgeon can ask questions to monitor their brain function.
One day later, the surgeon implants a pulse stimulator in the persons chest during a second procedure involving chest wall surgery. The surgeon will make a small opening behind the ear, pass the extension wire under the skin, and connect it to the neurostimulator.
When the surgery is complete, the neurostimulator will send electrical pulses to the brain.
Researchers have looked at the benefits of DBS for various medical conditions.
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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.
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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Deep Brain Stimulation Programming For Movement Disorders: Current Concepts And Evidence
- 1Department of Neurology, Ludwig Maximilians University, Munich, Germany
- 2Department of Translational Neurodegeneration, German Center for Neurodegenerative Diseases , Munich, Germany
- 3Graduate School of Systemic Neurosciences, Ludwig-Maximilians-Universität München, Martinsried, Germany
- 4Department of Neurosurgery, Ludwig Maximilians University, Munich, Germany
Deep Brain Stimulation At Michigan Medicine
For carefully selected patients with Parkinsons disease, Essential Tremor, and Dystonia, deep brain stimulation offers a therapeutic surgical option that can reduce or eliminate movement-related problems and greatly improve quality of life. At the University of Michigan Health System, our STIM program brings together a team of medical experts who are leaders in their respective fields and on the cutting-edge of the latest research.
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Current Clinical Deep Brain Stimulation Approaches For Dystonia
While the clinical benefit of DBS in cervical and other focal dystonias is well-documented, the underlying therapeutic mechanism remains to be elucidated. Converging evidence points to a modulation of aberrant neural population activity in the basal ganglia through high-frequency stimulation . In recent years, DBS has enabled the unique opportunity to record oscillatory activity as LFPs directly from the basal ganglia during surgery and in a postoperative interval, with the DBS electrodes externalized. Here, oscillatory patterns of pallidal LFPs were found to differ in a disease-specific manner . The best characterized pathological oscillatory phenomenon has been described in patients with PD, where STN oscillatory activity at rest is suppressed by dopaminergic medication and is directly correlated with patient symptom severity . In dystonia, low-frequency activity in the – range is predominant in the GPi and correlates with symptom severity . Indeed, activity in dystonia patients with phasic movements has been shown to be suppressed by high-frequency DBS . Thus, pallidal activity has been proposed as a potential pathophysiological hallmark of dystonia. It can be envisioned that adaptive closed-loop DBS using pallidal activity as a biomarker could be efficiently used for controlling dystonic motor symptoms in patients.
Deep Brain Stimulation: How Awake Brain Surgery Works
Parkinsons disease makes it hard to do many things that people without the condition take for granted. A disorder of the nervous system, Parkinsons affects movement and often includes tremorsuncontrollable shaking of the hands or other body parts that can turn patients lives upside down, robbing them of the motion control they need to do their jobs, or simple tasks like brushing their teeth. Many patients can manage their tremors with medication, but for some, the treatment becomes less effective over time.
There is hope. Deep Brain Stimulation is a surgery that canalmost instantaneously in the operating roomstop the tremors. Its the use of stimulation within nuclei deep inside the brain to try to correct dysfunction within neurological circuits, explains Jason Gerrard, MD, chief of functional neurosurgery at Yale.
The procedure involves implanting one or more electrodes into specific areas in the brain associated with the movement disorder. The electrodes, controlled by an external stimulator, send electrical impulses that regulate abnormal or overactive impulses.
Early on, it was identified in Parkinsons disease that neurons within the substantia nigra were being lost, says Dr. Gerrard. And these neurons were known to contain the neurotransmitter dopamine.
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How Is Deep Brain Stimulation Performed
Before the actual procedure begins, a head frame is positioned on your head, which will keep your head still during brain imaging. Surgical pins or screws are used to secure the frame to your head.
Your neurosurgeon will implant the deep brain stimulation system in two stages.
First, a small hole is made in the skull. The leads, which have electrodes at the ends, are passed through this hole and surgically implanted in the areas of the brain identified as the site contributing to the symptoms.
A lead is positioned on one side of the brain unless symptoms occur on both sides of the body . Each side of the brain controls the opposite side of the body, so each lead is inserted on the opposite side of where symptoms are occurring.
In a separate operation approximately 1 week later, one or two battery-powered pulse generator devices are implanted just under the skin in your upper chest area below your collarbone. An extension wire is attached to the lead already positioned in the brain, then tunneled under your skin behind your ear and down your neck to the pulse generator device.
You will return for an office visit about 2 to 4 weeks after the implant surgery. The implanted pulse generator is turned on by a hand-held device and the electrical pulses are adjusted until symptoms improve. The hand-held device can also check the battery level and can turn the device on and off.
Second Procedure: Placing The Neurostimulator
Three to five days after your first procedure, you will come back in a second procedure to have the neurostimulator installed just below your collarbone and attached to the wires that were placed during the first procedure. The anesthesiologist will put you to sleep for this surgery. This procedure is usually performed on an outpatient basis, and you will go home the same day.
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Awake Vs Asleep Surgery
Standard DBS surgery is performed while you are awake and requires that you stop taking the medicines that control your Parkinson’s symptoms. During surgery, you are asked to perform tasks to help guide the electrode to the precise location in the brain.
Being awake during brain surgery, or being off medicine, is unsettling for some people. Asleep DBS is an alternative option at some centers.
Asleep DBS surgery is performed while you are unconscious and under anesthesia. Surgery takes place in an MRI or CT scanner to target and verify accurate placement of your DBS electrodes. Ask your surgeon if asleep DBS is an option for you.
|Must hold medications the morning of surgery||Don’t have to hold medications|
What Does Deep Brain Stimulation Surgery Involve
If you are eligible for deep brain stimulation surgery, doctors will use MRI and CT scans to map your brain. They will then surgically implant electrodes into targeted areas of your brain using a thin probe called a lead. The lead is then attached to a wire that runs through your head, neck and shoulders under the skin, where it connects to a generator in the chest.
When you have woken up from your deep brain stimulation surgery, your doctors will turn on the generator, and electrical impulses will send currents to the brain. Your doctor will then test your reactions by asking you to move limbs or perform basic tasks and functions.
After the procedure, you will need to visit a neurologist to examine the results of your surgery. Deep brain stimulation is an ongoing treatment, so doctors will need to test and tweak the electrical pulses and other settings to meet your individual needs. Continuous stimulation is sent through these electrodes to block the signals that cause physical symptoms. The aim of this surgery for patients with Parkinson’s is to help them regain control over their movement.
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Deep Brain Stimulation: Benefits And Risks
The benefits of deep brain stimulation include:
- Results can be tailored to your specific needs
- Surgery targets symptoms on both sides of the body
- The effects of surgery are reversible
- Stimulation can be reduced or adjusted to minimize side-effects
- Once implanted, the device provides continuous symptom control, unlike medication
Despite brain stimulation benefits, the procedure also carries certain risks. These include:
- A small risk of brain hemorrhage
- Risk of paralysis, stroke and speech impairment if brain hemorrhage occurs
- Slight risk of cerebrospinal fluid leakage, which can lead to meningitis
- 15% risk of infection after electrodes are implanted
Side-effects of deep brain stimulation surgery also include:
- Swelling or tingling at the site of implantation, or in the face and lips
- Slight paralysis
- Problems with speech of vision
- Dizziness, loss of balance
- Allergic reaction to the implant
- Coordination problems
Your doctor will help you assess the pros and cons of DBS to treat your specific condition. If you want to know more about deep brain stimulation, you should talk to your doctor to find out if you are eligible. He or she can then refer to you to a neurologist for further testing to assess whether deep brain stimulation is right for you.
Will I Have To Limit My Activity Following Deep Brain Stimulation Surgery
- 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 5 lbs. for at least 2 weeks.
- You should not raise your arms above your shoulders or over bend or stretch your neck.
- Depending on the type of work you do, you may return to work within 4 to 6 weeks.
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What Risks Are Associated With Dbs
Although minimally invasive, DBS is a surgical procedure and therefore carries some associated risk. There is a low chance that placement of the stimulator may cause bleeding or infection in the brain. Complications of DBS, such as bleeding and swelling of brain tissue, may result from mechanical stress from the device but are generally reversible. Other complications may include headache, seizures, and temporary pain following surgery. Also, the hardware may erode or break down with use, requiring surgery to replace parts of the device.
Side effects of the stimulation may include numbness or tingling sensations, behavioral changes, as well as balance or speech problems.
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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Automatic Classification Of Pallidal Borders During Awake And Asleep Deep Brain Stimulation Procedures For Dystonia
DBS of the GPi in patients with dystonia can reduce motor symptoms and improve their quality of life . With the current limits of today’s brain imaging techniques in resolution, distortion, and possible brain shift , together with the broad distribution of DBS centers , the outcome of many DBS procedures might be less optimal because of mis-localization of the DBS leads . To enable better localization of the DBS target, pallidal borders can be visibly and audibly detected by electrophysiological microelectrode recordings during DBS procedures. Even given ideal conditions, the detection of the striato-pallidal borders is never an easy task even for an expert electrophysiologist.
In conclusion, as for STN DBS, GPi automated navigation systems can potentially shorten the length of electrophysiological mapping to < 15 min per hemisphere, while implanting the DBS lead within the optimal location. A reduced procedure time and improved targeting would be expected to lead to better clinical outcomes in GPi DBS therapy for dystonia.
How Does It Work
DBS changes brain activity in a controlled way, and its effects are reversible.
DBS may help the brain to release more adenosine triphosphate , an energy-carrying molecule that occurs in the cells of all living things. This release of ATP leads to a buildup of adenosine.
Activating the adenosine A1 receptor triggers a process that reduces both tremor and any adverse effects that DBS may cause. This works because the process dampens excitatory transmission in the thalamus.
The DBS procedure does not destroy any nerve cells or healthy brain tissue, but there can be some adverse effects.
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What Happens Before Surgery
In the doctor’s office you will sign consent forms and complete paperwork to inform the surgeon about your medical history, including allergies, medicines, anesthesia reactions, and previous surgeries. Presurgical tests may need to be done several days before surgery. Consult your primary care physician about stopping certain medications and ensure you are cleared for surgery.You may also need clearance from your cardiologist if you have a history of heart conditions.
Stop taking all non-steroidal anti-inflammatory medicines and blood thinners 7 days before surgery. Stop using nicotine and drinking alcohol 1 week before and 2 weeks after surgery to avoid bleeding and healing problems.
You may be asked to wash your skin and hair with Hibiclens or Dial soap before surgery. It kills bacteria and reduces surgical site infections.
No food or drink, including your Parkinson’s medication, is permitted after midnight the night before surgery.
Try to get a good night’s sleep. The DBS surgery involves multiple steps and lasts most of the day, during which you may be awake and off medication.
Morning of surgery
Arrive at the hospital 2 hours before your scheduled surgery time to complete the necessary paperwork and pre-procedure work-ups. An anesthesiologist will talk with you and explain the effects of anesthesia and its risks.