Deep brain stimulation

DBS is usually considered for people with Parkinson's whose levodopa still works, but who have “on/off” swings that are getting more frequent, troublesome extra movements (dyskinesia), or tremor that medicine does not control. There is a “window of opportunity”: after mild symptoms, but before the disease is late-stage. You do not have to wait until your Parkinson's is advanced; earlier surgery may help your quality of life. DBS is usually not a good choice for people with dementia, for people whose health makes surgery unsafe, or for people whose Parkinson's disease has reached a late stage. A team of experts decides, based on testing.

DBS is not a cure for Parkinson's disease, and it does not slow or prevent progression; it treats symptoms, and many people still need medication after DBS. In a randomized study, people who had DBS had a substantial improvement in quality of life in virtually every area measured. For Parkinson's disease, a study with 10 years of follow-up found that stimulation still improved tremor, slowness, and overall movement. For essential tremor, the benefit lasts more than 10 years in many people.

DBS helps the movement symptoms of Parkinson's disease, including stiffness (rigidity), slowness (bradykinesia), and tremor, and it has been shown to increase the amount of good “on” time you have each day. Freezing and falling usually will not improve, and speech difficulty and swallowing problems are also unlikely to improve. Everyone's symptoms are unique, and your movement disorders neurologist is the best person to counsel you on which symptoms you can expect to improve after surgery.

DBS is safe and for the right patient, the benefits far outweigh the risk. But, like any procedure it carries risks. The main risks are infection and bleeding, and less often swelling around the leads, a seizure, or confusion after surgery. Infection occurs in about 1 in 50 patients, and the risk of a bleed that causes symptoms is well under 1%. Serious complications that could be life-threatening are rare, occurring in about 1 in 300 to 1 in 500 patients. Stimulation side effects such as tingling, speech changes, or balance problems can usually be minimized by device programming. Hardware problems are not common. Your care team can tell you how this applies to you.

Surgery can be done either awake or asleep. For essential tremor, it is often helpful for you to be awake for a portion of the surgery so that we are able to test you to make sure the leads are in the best therapeutic spot. For Parkinson’s disease, asleep surgery is equally effective and safe, and microelectrode recording can be used as additional confirmation of lead position.

DBS is usually done in two stages. The first stage places the brain leads and takes about 3–4 hours, and most people stay one night in the hospital. The second stage, usually 1–2 weeks later, places the battery under the collarbone and connects the wires; it takes about 1 hour under general anesthesia and is outpatient. Recovery takes a few days to a couple of weeks. Light activities are usually fine right away, and work, exercise, and full activities usually resume within a few weeks.

Most people with Parkinson's still take some medicine after DBS, but many can take less. STN DBS may allow a larger reduction in your levodopa dose. Medicine and stimulation are adjusted together, slowly, by your care team.

The device is usually turned on about 4 weeks after the lead implantation. Programming means adjusting the device settings with a tablet or computer that talks wirelessly to your stimulator: the team chooses which contacts to use and sets how strong, how fast, and how long the pulses are, then checks your symptoms and side effects. While you may experience some benefit after the first programming session, finding the best settings takes a few months. Programming visits are usually about once a month for the first 6 months, at which point the stimulator is usually optimized.

Focused ultrasound makes a small, permanent lesion in a precise part of the brain. It needs no incision or implanted device, but it requires a fully shaved head and cannot be adjusted later. Focused ultrasound cannot be performed on both sides at one time, though focused ultrasound on the second side can be performed nine months after the first side. DBS places a lead that can be adjusted and turned off, and leads can be placed on both sides of the brain at the same time. The choice of deep brain stimulation versus focused ultrasound for Parkinson’s disease and essential tremor is extremely individualized. We encourage you to speak with your movement disorders neurologist or neurosurgeon about the best option for you.

Most people who undergo deep brain stimulation will have undergone neuropsychological assessment prior to the intervention, which can help in determining if you may be at increased risk for memory or mood changes after surgery. For patients who have been evaluated by a movement disorders neurologist and by a neuropsychologist, the risk of changes to memory and thinking is low. The introduction of directional DBS leads, higher-quality MRIs before surgery, and intraoperative imaging have reduced the chance that DBS may affect your speech. Please discuss any concerns with your neurology and neurosurgery team so we may counsel you appropriately.

Many newer DBS systems allow MRI, including full-body MRI, but only under specific conditions for your exact device; always tell the MRI staff that you have DBS, and check with your DBS team before any MRI. Airport security and airline travel usually do not pose any concerns; the device manufacturer will provide you with a card that indicates you have an implanted device. Regular exercise is encouraged, but avoid contact sports or activities that could hit your head or chest or pull on the neck wires, unless your team says they are OK. Most household items, like microwaves, computers, and cell phones, are safe to use normally.

A non-rechargeable battery usually needs to be replaced every 3–5 years. A rechargeable battery lasts much longer, at least 12–15 years, but needs regular charging, about an hour once a week. At each visit with your neurology team the battery is checked, and a warning appears as a battery moves toward the end of its life, so it is our goal for your battery never to run out unexpectedly. Battery replacement is a short outpatient surgery; the brain leads are not touched.

For most patients whose symptoms are not controlled by medications, deep brain stimulation is covered by most insurance plans, including Medicare. There are certain tests and evaluations that need to be performed before surgery to assist with insurance authorization. While DBS is covered by many insurance plans, you may have to pay a deductible or copayment. Our office can help you understand the cost of DBS.

Tell your care team. Sometimes achieving the benefit we want for you simply requires adjustment of your deep brain stimulator or your medical management. Other times, investigation of the lead placement or the device parts is needed to determine if there is an issue that needs to be addressed surgically.