As Parkinson's symptoms progress, increasing medications to address them can bring significant side effects, such a dyskinesia. Surgical therapies can be explored after medications are optimized, and the side effects of adding more medications start to outweigh the benefits.
Deep Brain Stimulation is an elective neurological surgery for the treatment of Parkinson's disease (PD) symptoms. In DBS surgery, electrodes are placed into a targeted area of the brain that are connected to a battery in a second procedure. The battery then provides electrical impulses to a part of the brain involved in motor function. Thousands of people have received the benefits of DBS.
Are You Considering DBS Surgery? When considering DBS surgery, there are several important steps to take. First, is to learn more about the procedure. Most importantly, talk to your neurologist or movement disorder specialist to see if you could be a good candidate for the surgery. Secondly, try to connect with others who have had DBS to get a good feel for what the procedure will be like and potential results. If you don't know someone who has been through DBS - reach out to the PAA to connect you with someone. Below is a video highlighting one Birmingham, Alabama lady who opted to have DBS and has shared her story.
Consult with Your Neurologist about DBS If you think that you are seriously interested in DBS, the next step is to make an appointment at a center, such as UAB, that specializes in surgical treatment of Parkinson's. It is very important that you be evaluated by a neurologist or movement disorder specialist familiar with the procedure to understand your potential benefits and risks. If your neurologist thinks you are a good candidate for the surgery and you decide to proceed, you will then meet with a neurosurgeon to learn more about preparing for surgery.
A Neuropsychologist test is also strongly encouraged and often required before proceeding with DBS. This test ensures that DBS is a good option for you, determining how it could potentially affect memory and thinking. DBS is only a treatment option for motor-related symptoms of Parkinson's.
Good Candidates for DBS
The best candidates for DBS are people who have been diagnosed with Parkinson's for five years or more, have disabling tremors and dyskinesias, and experience severe motor fluctuations that can't be controlled with medication.
Not everyone will be a good candidate for the surgery, and it is important to know that some symptoms respond well to DBS while others do not. The decision to undergo surgery depends on a critical assessment of each person's specific symptoms. These symptoms include:
Tremor
Stiffness
Bradykinesia (slowness of movement)
Dystonia (sustained or repetitive muscle twisting, spasm, or cramping)
Dyskinesia
Other factors that can influence the outcome of DBS include how your body currently responds to levodopa medications. If you respond well to the drug, you generally respond well to DBS. Surgery is an option which could promise effectiveness for those who experience medication complications, such as dyskinesias but continue to also respond well to levodopa. Reasons that someone may not respond well to DBS or make them a good candidate, includes not responding well to levodopa, and has severe dementia, apathy, depression, poor health, or poor family support. Older age does not exclude those who are otherwise healthy from being a possible candidate for DBS.
How does DBS work? The substantia nigra pars compacta (SNc) is an area deep within the brain where there are more than 400 thousand dopamine-producing brain cells. These are the brain cells that deplete over time with a Parkinson's diagnosis demonstrating PD symptoms. The SNc connects two key areas of the brain that control both motor and non-motor functions where signals are sent that affect movement and other executive functions. Placing DBS leads (wires with tiny electrodes) in either of these areas changes the electrical signals resulting in smoother and more fluid movement in many cases. Depending on where the leads are placed in the brain, symptoms may be reduced. For example:
The Globus pallidus (GPi) reduces tremor, rigidity, bradykinesia, dyskinesia and improves "on/off" fluctuations.
The Subthalamic nucleus (STN) reduces tremor, rigidity, bradykinesia, dyskinesia (indirectly through medication reduction) and improves "on/off" fluctuations.
The Ventral intermediate nucleus (VIM) reduces tremor but usually does not reduce other PD symptoms.
Leads are generally placed on one side of the brain (unilaterally) or on both sides (bilaterally) depending on where symptoms occur. Once the lead is placed, it is attached to an extension wire that runs under the scalp and just beneath the skin of the neck. Then, it is connected to an implantable pulse generator (IPG), also called a neurostimulator.
This neurostimulator is typically inserted under the skin just below the collar bone on one side of the chest. Some people choose for it to be implanted in other areas like the abdomen. This neurostimulator is much like a pacemaker except that it sends electrical impulses to the lead implanted into the brain. Most neurostimulators are connected with two or more leads and can be adjusted to be on or off wirelessly by a patient controller device. A clinician can use a more advanced DBS programmer to adjust the settings until the perfect combination is achieved for optimal symptom management.
Once the system is on, the leads work to normalize signals in areas impacted by the brain. In some cases, stimulation can worsen balance, speech, and cognition, and it is important that the programmer use different strategies to eliminate temporary side effects.
DBS Devices Each DBS system contains a lead, implantable pulse generator (IPG) or neurostimulator and an extension cable. The lead is a thin wire, just over a millimeter in diameter that is inserted into the brain. The neurotransmitter contains the battery and serves as the "brain" of the device. It is programmed and stores the settings the clinician chooses for stimulation. The extension cable connects the DBS lead to the neurotransmitter. The patient controller allows the patient to turn the neurostimulator on and off and to check battery status for future charging.
Preparing for DBS Work closely with your surgeon and movement disorder specialist to determine if DBS is right for you. There are currently three DBS systems available that the neurosurgeon can discuss with you to see which one might be the best fit. Not all DBS surgeons work with all three devices, so it is important that you consider your choice of system and surgeon.
Always have a family member or loved one attend any DBS-related appointments with you. There are many appointments and tons of information provided to you, so having an extra person to be your scribe and help you navigate materials is very important. If you get DBS surgery, you will also need their support throughout the surgery and post-appointments to assist with optimal programming and system understanding.
Each person has unique post-surgery goals. Begin by having a clear expectation of what you would like to achieve to optimize how DBS can best impact symptom management. Use these steps to help guide you through DBS.
Meet with Your Movement Disorder Specialist or Neurologist: During this appointment, your physician will review your medical history and perform a neurological exam. Based on that, you'll discuss whether you're a good candidate for DBS.
Meet with the DBS Team: If the information discovered in step-one indicates you're a good candidate, the next step is to meet others who will assess your readiness. This team will usually include a physical therapist, neuropsychologist, speech-language pathologist, neurosurgeon, and movement disorder specialist or neurologist.
Discuss Your Insurance Options: This may come earlier in the process, or it may be something you address at this point. Your team will guide you on what matters related to timing and how to best move through the process of getting the surgery approved.
Complete Your Pre-surgery Appointments: Once you've been identified as a good candidate, accessed for readiness, and made aware of the financial costs, you will get an MRI, ask your neurosurgeon questions, and complete a comprehensive physical exam to make sure you're healthy enough to have the procedure.
Have Surgery: DBS is a two-step surgery. During the first surgery, the physician will make the incisions and implant the electrodes. During the second surgery, which may happen anywhere from one week to one month after the first, your surgeon will implant the pulse generator under your skin on your chest. Some hospitals will have a one-step surgical option.
Get Programmed: During this appointment, typically in your physicians' office and typically two to four weeks post-surgery, someone trained in DBS programming will work with you to program the device to get the best symptom control possible. Sometimes this happens the first time the device is programmed; however, sometimes, it takes multiple tries to get it right. Again, your physicians may do things slightly differently, but most include the steps outlined above in their DBS process.
Potential DBS Complications and Risks
As with any surgery, there is the risk of complications which can be serious and permanent, or temporary and reversible. While the risk of serious or permanent complications from DBS are very low, they do include a small risk of stroke or lasting effects of weakness, numbness, or problems with vision or slurred speech.
Temporary or reversible complications may result from the surgery or electrical stimulation and can generally be treated or reconfigured during the programming process. This could include changes in mood, memory, and thinking. Some people have had a surgery-related seizure during or within the first week of surgery. Infection is always a risk with any surgery, but antibiotics are administered to minimize the chance of infection at the brain, scalp, or chest surgery sites. Other complications include enhanced or worsening Parkinsonism symptoms.
DBS components can malfunction that includes lead movement within the brain impacting the target site, wire breakage connections, disconnection, or damage and neurostimulator malfunction or damage.
As with most surgeries, there can be pain, inflammation or swelling at the surgery sites, as well as a small risk of swelling or an allergic response to the implanted materials.
Deciding whether to get DBS takes a great deal of research, thought and reflection. You must discuss all your options with your care partners and physicians to make the best decision for you.