DBS implant is performed in three stages
By Karen Hales, Neurology Solutions contributing writer
Deep Brain Stimulation (DBS) therapy is used to treat disabling motor symptoms such as tremor, rigidity, stiffness and slow movement, associated with conditions like Parkinson’s disease (PD), tremor and dystonia. In this article, we will describe which areas of the brain are targeted for specific conditions and the process for DBS surgery.
Process for DBS surgery
During DBS surgery a battery-operated medical device called an implantable pulse generator (IPG) is surgically implanted in the chest to deliver electrical stimulation to specific areas in the brain that control movement. The electrical pulses block the abnormal nerve signals that cause the motor symptoms.
Computer-aided scans deliver pre-surgical visualization to the surgeon, and the surgery itself involves a three-stage process.
Stage 1 – Markers and Imaging
The first stage of the DBS implant occurs in the Radiology department at the hospital, where 4-5 bone marker screws are placed into your skull beneath your scalp while you are under anesthesia. One marker will be placed on both sides of your head, and three will be placed in the posterior vertex. Your doctor will also acquire a high-resolution MRI and CT scan of your brain to help map out the best trajectory for the electrodes delivering stimulation to the brain. From this imaging, a stereotactic frame, or platform, will be made just for you that will keep your head in a fixed position to help your surgeon pinpoint areas deep inside your brain. The total procedure will take about 3-4 hours.
Stage 2 – Placing the Macroelectrodes
The placement of the trajectory that will deliver the electric pulses to the brain is crucial to getting the best results with this treatment. The subthalamic nucleus (STN) and the globus pallidus (GPi) are the targets of choice, with the STN being the most common due to the significant medication reduction (approximately 50%) that can be achieved.
Electrodes can be placed in the following brain areas:
- Subthalamic nucleus (STN) – Effective for tremor, rigidity, slowness of movement and postural stability in those patients who respond to medication. Most commonly used to treat Parkinson’s disease, DBS of the STN also is used in treating dystonia and dyskinesia.
- Thalamus (VIM) – Often used to treat essential tremor, this area does not seem to control rigidity, slowness or postural control.
- Globus pallidus (GPi) – Effective for tremor, slowness, rigidity, dystonia and dyskinesia. For dystonia, GPi may be the only effective treatment for debilitating symptoms. It is an alternative to STN when a clear trajectory free from damaged brain tissue is not possible. DBS of GPi is a target for those patients with PD who have notable cognitive decline. This procedure has anti-dyskinesia effects but only allows for modest medication reduction.
The high resolution imaging of the brain helps determine a precise pre-calculated trajectory for the placement of the wires. Your neurosurgeon and neurologist will use live navigational software and Micro Electric Recording (MER) during implant surgery to identify areas of structural damage in the brain and present a clear path to the target site.
Once the target areas are located and the stimulator is turned on, the team will evaluate the lead location and stimulation strength by asking you to perform different functions, such as raising your arm or leg or moving your fingers or wrist. Your speech will be evaluated along with sensations such as numbness or tingling.
The test electrodes are removed once the optimal location has been confirmed, and permanent electrodes are then implanted.
The entire operating room procedure takes about 4-6 hours. Patients usually stay in the hospital for 1-2 days after this surgery.
Stage 3 – Implanting the Neurostimulator
Your neurosurgeon implants the battery pack and connecting wires in the chest 10-14 days after Stage 1. The neurostimulator is typically implanted beneath the collarbone, but possibly placed in other areas of the body such as the lower chest or abdomen. The extension wire is tunneled under the skin of the head, neck, and shoulder and connected to the neurostimulator. This stage is an outpatient surgery performed under general anesthesia that is scheduled one to three weeks after the first surgery. Patients usually can go home the same day.
After You Receive Your Implant
Once you have received your implant, you will be seen at regular intervals by your neurologist or movement disorder specialist to monitor and adjust your stimulator for the best control of symptoms. This may take several sessions, as the brain is still healing. You may have your medications reduced. Initial programming visits are scheduled for one hour. Follow-up programming visits are typically 30 to 45 minutes long.
You will be asked to come back yearly at least to ensure you are getting the most benefit from your DBS system and to test whether your symptoms have progressed, requiring adjustments to your stimulator programming.
Considering DBS surgery?
DBS surgery often helps significantly reduce tremors in patients with essential tremor as well as tremors and other symptoms of PD and dystonia. DBS can reduce the need for medications, which is helpful since many of these drugs cause side effects such as involuntary movement. In one study, 87% of the individuals who had undergone DBS showed improvement in motor control within one year after surgery.
Click here to complete the “Are You A Candidate for DBS?” questionnaire.
Neurology Solutions Movement Disorders Center leads a monthly DBS Support Group the third Friday of every month open to patients who have undergone DBS implant surgery and individuals considering Deep Brain Stimulation surgery to help manage their symptoms.
Neurology Solutions has extensive experience in DBS programming. Neurology Solutions Medical Director Dr. Robert Izor is a neurologist and fellowship-trained movement disorder specialist who practices at St. David’s North Austin Medical Center. Since 2004, Dr. Izor has participated in DBS implant surgeries and programming of over 200 DBS patients in the Austin area. His practice manages treatment of patients with movement disorders such as PD, essential tremor, dystonia and ataxias.
If you are seeking another opinion on managing your symptoms from Parkinson’s disease, dystonia, essential tremor or an age-related movement disorder, call 512-865-6310 to make an appointment with Neurology Solutions.
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