Movement Disorders

Deep Brain Stimulation - Frequently Asked Questions

What is deep brain stimulation (DBS)?

Deep brain stimulation (DBS) is a surgical procedure used to treat movement disorders. With DBS, a device similar to a cardiac pacemaker is implanted in the body to deliver electrical stimulation to precisely targeted areas in the brain. Continuous stimulation to these regions in the brain blocks the signals that cause movement problems. Deep brain stimulation is sometimes called a “brain pacemaker.”

What are the components of the deep brain stimulator?

The Deep Brain Stimulator has three parts:

How long has DBS been used?

Neurosurgeons began implanting deep brain stimulators for movement disorders in the 1980s.

What conditions respond to DBS?

There are two main indications for deep brain stimulation: Parkinson's disease and Essential Tremor. DBS is also used in some cases of dystonia.

How does Deep Brain Stimulation help Parkinson's disease patients?

Deep Brain Stimulation can help decrease the tremor rigidity and slowness of movement that affect most Parkinson's disease patients. Unlike medication, the stimulator remains “on” at all times, providing most patients with relief from the fluctuations they experience with medication. Most patients can reduce their Parkinson's medications significantly—often by half. Patients whose Parkinson’s medications cause dyskinesias (abnormal involuntary movements) often find that decreasing medications after DBS surgery can dramatically reduce this symptom.

Deep Brain Stimulation does not cure Parkinson's disease, but it can effectively treat many of the symptoms and helps improve motor function.

Who is a candidate for surgery?

The best candidates for DBS for Parkinson's disease are patients who have had a good response to SINEMET® (carbidopa-levodopa) but are now developing side effects and fluctuations in functioning related to the medication. Serious medical problems or difficulty with cognitive function (thinking and remembering) may make a patient less likely to do well with surgery. Although there is no upper age limit for surgery, the benefits of DBS for Parkinson's disease seem to decline with advancing age.

Patients with dementia, patients who have no benefit from SINEMET, or patients whose disease mimics Parkinson's disease—often called Atypical Parkinsonism or Parkinson's Plus Syndrome—do not usually benefit significantly from DBS surgery.

How does Deep Brain Stimulation help Essential Tremor patients?

Deep Brain Stimulation can dramatically reduce tremor in the arms and/or legs in patients with Essential Tremor. Head tremor or voice tremor can sometimes be improved as well, although usually not as dramatically as tremor in the limbs. Deep Brain Stimulation is considered a treatment alternative for Essential Tremor patients whose symptoms cannot be managed successfully with medication therapy, or who have intolerable side effects from medication therapy.

Deep Brain Stimulation does not cure Essential Tremor, but it controls the symptoms (shaking). Some patients will choose to have the deep brain stimulator implanted on one side of the brain only. This controls the opposite side of the body (for example, a right-handed person would have their left side of the brain implanted to control their right hand tremor). Other patients will elect to have bilateral deep brain stimulators (on both sides of the brain).

How does the stimulator help dystonia patients?

Deep Brain Stimulation for dystonia is both reversible and adjustable. Unlike DBS, older types of  dystonia surgery, called pallidotomy, created a permanent surgical lesion.

Deep Brain Stimulation can treat chronic, drug refractory (drug resistant), primary dystonia, including generalized dystonia, segmental dystonia, hemidystonia and cervical dystonia. Adults and children within these parameters may be candidates. Certain types of young people with a genetic form of dystonia, the DYT1 mutation, often respond very well to surgery.

It generally takes 3 to 12 months to see improvement in dystonia symptoms after DBS surgery. Symptom improvement may vary depending on the type of dystonia, the length of time the patient has had the symptoms, and the severity of the symptoms. The surgery will not cure dystonia; the goal is some improvement in symptoms.

Do Health Insurers Cover DBS Surgery?

Medicare and most private insurers cover DBS surgery. Insurance authorization is obtained before the patient is admitted to the hospital.

Insurers usually pay for DBS for dystonia, but they may deny payment in some cases because DBS is not a standard dystonia treatment. Deep Brain Stimulation for certain types of dystonia has been designated a Humanitarian Use Device (HUD) by the FDA. An HUD is a device that is intended to benefit patients in the treatment or diagnosis of diseases or conditions that affect fewer than 4,000 individuals per year in the U.S.

What are the Risks and Drawbacks of Surgery?

What are the potential risks of surgery?

Implanting a deep brain stimulator carries the same risks as any other brain surgery. These risks may include:

How long does the neurostimulator battery last?

On average, the neurostimulator battery lasts three to five years. When it needs to be changed, the entire implantable pulse generator, or neurostimulator, is replaced. This is an outpatient procedure and can be done under local or general anesthesia.

Do patients need to take special precautions if they have an implanted deep brain stimulator?

Patients with deep brain stimulators must avoid:

Radiation, electrocautery, ultrasound and electrolysis should not be used directly over the implant site.

Theft detectors and airport/security screening devices are best to avoid. Patients may request a hand search instead. Patients will be given an identification card from Medtronic (the company that manufactures the Deep Brain Stimulators) to carry with them at all times.

Should DBS patients avoid electronics?

Most electrical devices will not harm the DBS system. If the neurostimulator comes within inches of small permanent magnets (such as stereo speakers, radios or refrigerator door magnets), however, it could be turned off or on. The patient will be given a hand-held access review device to turn their stimulator back on if it is deactivated.  Deactivation of the neurostimulator would result in the patient experiencing the same symptoms for which they originally had the procedure (i.e., increased Parkinson’s movement.)

What is the DBS Surgical Process at Stanford Hospital?

The DBS Surgical process includes an initial evaluation, pre-surgical testing and procedures, surgical implantation of the DBS lead, and surgical implantation of the neurostimulator.

The initial evaluation

During the initial evaluation, the patient is seen by a neurologist, a neurosurgeon and a neuropsychologist. The neurologist evaluates the patient in an on- and an off-medication state. The neuropsychologist evaluates the patient for surgical and emotional readiness.  An MRI of the brain may be done, if the patient has not had an MRI recently.

After these evaluations, the Movement Disorders Surgical Review Board meets to discuss whether surgery is appropriate for the patient. The patient is notified of the board's decision either by telephone or by a return clinic visit. The final decision for surgery is made after a discussion between the patient and neurosurgeon about surgical options,  including specific risks.

The week of surgery

The week of surgery, the patient is tested in the Stanford Human Motor Control and Balance Laboratory. The patient also has a consultation with the anesthesia team and an anesthesiologist, has an MRI of their brain taken for surgical targeting, has a pre-operative medical history taken, and has a physical exam.

The day before surgery

The day before surgery, the patient's head is shaved, the patient’s scalp is numbed with anesthetic, and the patient has "fiducials" placed in his or her scalp. Fiducials are small titanium screws that serve as markers and help physicians perform computerized targeting for the exact DBS lead location during surgery. After the fiducials are placed, the patient has a CT scan. The fiducials remain in the scalp until after both DBS leads are placed.

Surgical placement of the DBS lead

Our surgical process is usually staged, with each side of the brain done on a separate day. In certain situations, both sides may be done on the same day.

The patient will have his or her scalp anesthetized before the lead implant procedure. The patient usually has a catheter inserted into his or her bladder and an IV (intravenous catheter) placed in one arm. At the beginning of the operation, sedation is given to improve comfort and decrease anxiety. The patient is awake during the operation and is free to move his or her head, arms and legs.

Implantation of the DBS lead is performed using a state-of-the-art frameless technique pioneered by Dr. Henderson. The physician performs micro-electrode mapping of the target nucleus to determine the exact target for the DBS lead. This helps make the surgery more precise and improves the surgical outcome. The lead is inserted through a small opening in the skull called a burr hole.

During surgery, the patient will be asked questions and may be asked to perform some tasks, such as counting or moving their toes or fingers. This helps the physician test the stimulation and maximize symptom control, while minimizing side effects.

The patient spends one night in the hospital after each DBS lead is placed. Each side of the DBS placement generally takes three to four hours.

Surgical placement of the neurostimulator

The neurostimulator/s is placed when the patient is under general anesthesia. This is an outpatient procedure that usually takes one to two hours. This can be done on a separate day from the DBS lead surgery, or, in some cases, on the same day.

During the procedure, a small incision is made near the collarbone, and the neurostimulator is implanted under the skin. It is connected to the deep brain stimulator lead by an extension, which is passed under the skin of the scalp, neck and shoulder.

The patient may be given the option of having one slightly larger neurostimulator (Kinetra®) placed or two smaller neurostimulators (Soletra®) placed.

The deep brain stimulator(s) are usually programmed three to four weeks after the DBS surgery is completed.

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