|
Deep brain stimulation
Definition
Deep brain stimulation (DBS) is a surgical treatment in which a device called a neurostimulator delivers tiny electrical signals to the areas of the brain that control movement.
Alternative Names
Globus pallidus deep brain stimulation; Subthalamic deep brain stimulation; Thalamic deep brain stimulation; DBS
Description
The DBS system consists of three parts:
- A thin, insulated wire called a lead, or electrode that is placed into the brain
- The neurostimulator, similar to a heart pacemaker, which is usually placed under the skin near the collarbone, but may be placed elsewhere in the body
- Another thin, insulated wire called an extension that connects the lead to the neurostimulator
DBS requires surgery to correctly place each part of the neurostimulator system. DBS in adults usually involves two separate surgeries.
Stage 1 is usually performed under local anesthesia, meaning you are awake but pain-free. (If the procedure is done in children, general anesthesia is given.)
- Your head is placed in a special frame using screws to keep it still during the procedure. Numbing medicine is applied where the screws contact the scalp. Sometimes, the procedure is done in the MRI and a frame is not used around your head.
- Numbing medicine is also applied to the scalp at the site where the surgeon drills a small opening in the skull and places the lead into a specific area of the brain.
- If both sides of the brain are being treated, the surgeon will make an opening on both sides of the skull, and two leads will be inserted.
- The surgeon may need to send small electrical impulses over the lead to make sure it is connected to the area of the brain responsible for the patient’s symptoms. Different neurological tests may be done.
Stage 2 is done under general anesthesia, meaning you are asleep and pain-free. The timing of this stage of surgery depends on where in the brain the stimulator will be placed.
- The surgeon makes a small opening, usually just below the collarbone and implants the neurostimulator. (Sometimes it is placed under the skin in the lower chest or belly area.)
- The surgeon makes another small opening behind the ear and passes the extension wire under the skin of the head, neck, and shoulder.
- The extension wire connects the lead to the neurostimulator.
- The skin is closed, and the device and wires cannot be seen outside the body.
Once connected, electrical pulses travel from the neurostimulator, along the extension wire, to the lead, and into the brain. These tiny pulses interfere with and block the electrical signals that cause tremors and movement disorder symptoms, such as those that occur with Parkinson’s disease, essential tremor, or obsessive-compulsive disorder.
This surgery may be an option for patients with very severe Parkinson's disease symptoms that cannot be controlled by medications. The surgery does not cure Parkinson’s disease, but can help make reduce the severity of symptoms such as:
- Tremors
- Rigidity
- Stiffness
- Slow movements
- Walking problems
Deep brain stimulation may also be used to treat the following conditions:
- Essential tremor
- Dystonia
- Arm tremors related to multiple sclerosis
- Tourette syndrome (in rare cases)
- Obsessive-compulsive disorder
- Major drepression that does not respond well to medicines
Risks
DBS is considered to safe and effective when performed in properly selected patients.
Risks associated with deep brain stimulation placement may include:
- Allergic reaction to the DBS parts
- Difficulty concentrating
- Dizziness
- Infection
- Leakage of cerebrospinal fluid, which can lead to headache or meningitis
- Loss of balance
- Reduced coordination
- Shock-like sensations
- Slight loss of movement
- Speech or vision problems
- Temporary pain or swelling at the site where the device was implanted
- Temporary tingling in the face, arms, or legs
Problems may also occur if parts of the DBS system break or move. For example, this may include:
- Breakage of the device, lead, or wires, which can lead to another surgery to replace the broken part
- Failure of the battery, which would cause the device to stop working properly (the battery normally lasts 3 to 5 years)
- The wire that connects the stimulator to the lead in the brain breaks through the skin (this usually only occurs in very thin people)
- The part of the device places in the brain may break off or move to a different place in the brain (this is rare)
Possible risks of any brain surgery are:
- Blood clot or bleeding in the brain
- Brain swelling
- Coma
- Confusion, usually lasting only for days or weeks at most
- Infection in the brain, in the wound, or in the skull
- Problems with speech, memory, muscle weakness, balance, vision, coordination, and other functions, which may be short-term or permanent
- Seizures
- Stroke
- Risks of general anesthesia are:
- Reactions to medications
- Problems breathing
Before the Procedure
You will have a complete physical exam.
Your doctor will order many laboratory and imaging tests, including a CT or MRI scan. These imaging tests are done to help the surgeon pinpoint exact what part of the brain is responsible for the tremor and movement disorder symptoms. The images will be used to help the surgeon place the lead in the brain during surgery.
You might have to see more than one specialist (neurologist, neurosurgeon, psychologist, etc.) to make sure that the procedure is right for you and has the best chances of success.
Before surgery, always tell your doctor or nurse:
- If you could be pregnant
- What drugs you are taking, including medicines, herbs or supplements, and vitamins you bought over-the-counter without a prescription
- If you have been drinking a lot of alcohol
During the days before the surgery:
- Your health care provider may tell you to stop taking drugs that make it hard for your blood to clot, such as warfarin (Coumadin), aspirin, ibuprofen, naproxen, and other nonsteroidal anti-inflammatory drugs (NSAIDs) .
- If you are taking other medications, ask your doctor if it is okay to take them on the day of or in the days before the surgery.
- Always try to stop smoking. Ask your doctor for help.
- Your doctor or nurse may ask you to wash your hair with a special shampoo the night before surgery.
On the day of the surgery:
- You will usually be told not to drink or eat anything for 8 to 12 hours before the surgery.
- Take the drugs your doctor told you to take with a small sip of water.
- Arrive at the hospital at the time specified by your doctor or nurse.
Most people who have DBS are in the hospital for about 3 days. The doctor may prescribe antibiotics to prevent a possibly infection.
You will return to your doctor’s office a few weeks after surgery so that the stimulator can be turned on, and the amount of stimulation can be adjusted, if necessary. This can easily be done, without further surgery. It is often referred to as “programming.”
Call your doctor if you develop any of the following after DBS surgery:
- Fever
- Headache
- Itching or hives
- Muscle weakness
- Nausea and vomiting
- Numbness or tingling on one side of the body
- Pain
- Redness, swelling, or irritation at any of the surgery sites
- Trouble speaking
- Vision problems
Outlook (Prognosis)
DBS is generally well tolerated and does not damage nerve cells like other surgical treatments for Parkinson’s disease. Many patients report significant improvement in their symptoms after having this treatment. However, most of them still need to take medication, although at lower doses, which improves their quality of life.
This surgery, and surgery in general, is riskier in people over age 70 and those with health conditions such as high blood pressure and diseases that affect blood vessels in the brain. You and your doctor should carefully weigh the benefits of this surgery against the potential risks.
The DBS procedure can be reversed, if needed.
References
Bartsch T, Paemeleire K, Goadsby PJ. Neurostimulation approaches to primary headache disorders. Curr Opin Neurol. 2009 Jun;22(3):262-8.
Burns B, Watkins L, Goadsby PJ. Treatment of medically intractable cluster headache by occipital nerve stimulation: long-term follow-up of eight patients. Lancet. 2007 Mar 31;369(9567):1099-106.
Weaver FM, Follett K, Stern M, et al. Bilateral deep brain stimulation vs best medical therapy for patients with advanced Parkinson disease: a randomized controlled trial. JAMA. 2009;301(1):63-73.
NINDS Deep Brain Stimulation for Parkinson's Disease Information Page National Institute of neurological disorders and stroke Last updated December 18, 2009 Last updated December 18, 2009 Accessed February 6, 2010
Patterson JT, Hanbali F, Franklin RL, Nauta HJW. Neurosurgey. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 72.
Black KJ. Patient page. Deep brain stimulation for Tourette syndrome. Neurology. 2009 Oct 27;73(17):e87-90.
Holtzheimer PE, Mayberg HS. Deep brain stimulatin for psychiatric disorders. Annual Review of Neuroscience. 2011;34:289-307.
Reviewed By: Luc Jasmin, MD, PhD, Department of Neurosurgery at Cedars-Sinai Medical Center, Los Angeles, and Department of Anatomy at UCSF, San Francisco, CA. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.
