Deep Brain Stimulation (DBS) is the main surgical treatment for movement disorders. DBS for the brain is similar to a pacemaker for the heart. It is usually used with, but sometimes in place of, medications. A wire or lead with four tiny electrodes on the end is surgically implanted in the brain. Leads can be placed on one or both sides of the brain, depending on whether symptoms are on one or both sides of the body. The lead is connected by an extension that runs under the skin to a battery implanted in the upper chest. DBS can be turned on and off. When turned on and programmed, DBS sends electrical pulses down the leads into the movement circuits of the brain. This improves the function of those movement circuits and therefore relieves the troublesome symptoms. DBS is considered reversible since no brain tissue is actually damaged by DBS. Although DBS cannot “cure” any of the movement disorders, it can often dramatically improve the quality of life.
When should Deep Brain Stimulation be considered?
Different types of movement disorders are treated with DBS, depending on where the leads are placed in the brain. Parkinson’s disease, Essential tremors, and dystonia are all movement disorders that respond very well to DBS. In certain patients, DBS can be used for severe Tourette’s syndrome or chronic pain. Other uses of DBS are being developed, including treatment-resistant major depression, obsessive-compulsive disorder, Alzheimer’s dementia, and severe epilepsy. Currently, over 100,000 people world-wide have DBS.
Early on, patients with Parkinson’s disease are effectively managed with one or more medications, often including levodopa (Sinemet.) Because Parkinson’s is a progressive disease, these medications may need to be increased over time. At some point for many patients, the medications have troublesome side effects; for instance, many patients develop involuntary extra movements called “dyskinesias.” Also, the medications may no longer be adequately effective, or the effectiveness of medications can vary drastically throughout the day, called “ON-OFF fluctuations.” When medications alone no longer provide an acceptable quality of life, DBS therapy may be added to restore quality of life.
Similarly, patients with early Essential tremors are often effectively managed with various medications. When tremors progress beyond what medications can control, or if side effects of medications prevent adequate control, DBS may be able to restore quality of life.
Deep Brain Stimulation at our program
The keys to a great outcome with Deep Brain Stimulation include choosing the right patient, proper placement of the leads, and optimum programming. Our neurologists and our functional neurosurgeon, Dr. Joseph Christiano, collaborate to choose the right patients for DBS. First, the neurologist does a detailed neurological history and movement disorder exam, often including an exam both off and on medications, to verify a correct diagnosis. Next, the doctors carefully review all aspects of the case, so that they can accurately predict the benefits a person can expect from DBS, as well as predict any side effects that may exclude a person from DBS. In preparation for surgery, neuropsychological testing is done by a neuropsychologist, to verify that the person is both cognitively and emotionally appropriate to go through surgery and subsequent programming. A baseline MRI of the brain is obtained to identify any structural problems that might deter surgery. It also allows Dr. Christiano to plan the surgical “approach” that will be used.
The Carondelet Neurological Institute has a unique operative environment, the first of its kind in the United States, where the DBS surgery is done. Our operating suite features a full integrated diagnostic CT scanner which is connected to a state of the art Brain Navigation system. The Brain Navigation system fuses the pre-op MRI scan with an intra-op CT scan. It then allows Dr. Christiano to determine the precise 3-D trajectory he will use to safely access the desired part of the brain, taking into account each person’s unique anatomy. Our intra-op CT scanner allows Dr. Christiano to verify accurate placement of the DBS electrodes at the time of surgery, in a way that is not available elsewhere.
DBS surgery is traditionally done with the patient “awake.” This can be so daunting to some that they refuse to consider this invaluable treatment option. Dr. Christiano is specially trained and can perform DBS surgery under general anesthesia, as well as in the traditional “awake” manner. Performing DBS surgery under general anesthesia can actually be a significant advantage in many cases, such as in patients with severe tremors.
DBS programming may be done by the movement disorder specialist, the neurosurgeon, or anyone that is specially trained in DBS programming. Most of the programming is done in the first few months after surgery, so the desired balance between stimulation and medication is reached gradually. The end result is the optimum improvement of symptoms and quality of life.
For more information on movement disorders in general and DBS surgery contact us at the Western Neuro Movement Disorders Center.