Learn more about deep brain stimulation

Listen to or read our educational presentation about deep brain stimulation

Educational presentation about Deep Brain Stimulation - audio file

[Dr. Eleanor Orehek] Good evening. I am the movement disorders neurologist at Noran. DBS is something that you would see me for and talk to me about. I am the first step in the process of evaluating whether you would be a good candidate. It really is one of my favorite therapies and treatments to offer people. It can be life-changing, as long as we do it in the right way and in the right patients. It’s a good topic, and I’m glad you are all able to be here.

This is what comes up when you Google DBS in images. It’s an Aston Martin DBS, so that’s not the DBS that we’re talking about today. It’s probably cooler, in a different way.

Deep brain stimulation is the DBS we’re talking about tonight. It’s called deep brain stimulation because we have to go deep inside the brain, into the brain, to target the structures that affect your symptoms, either your essential tremor or the Parkinson’s symptoms. The stimulation part is that there’s electricity that goes through from a battery into a wire in the brain, and it alters the circuits in your brain so that it can effectively help manage your symptoms.

We’ve been doing this for over 20 years now. DBS was first approved in 1998 for essential tremor, and it was approved for Parkinson’s in 2002. Initially it was more for advanced-stage Parkinson’s. As we’ve gotten better at it, research has shown that it can be effective to perform DBS even earlier. It’s now approved for moderate and advanced-stage Parkinson’s.

The other recent change is that the Medtronic system is approved for whole-body MRI. It’s a recent update that has been helpful for patients who, after they get implanted, may need MRIs for a variety of different things.

I’m going to talk a little bit about Parkinson’s and essential tremor, and briefly go through other treatment options and what options we have other than DBS. If you have Parkinson’s disease or you know somebody with it, you know that it’s a very complex disease. There are motor symptoms, which are the more obvious symptoms. If you think of Parkinson’s disease symptoms as an iceberg, you can think of motor symptoms as the tip of the iceberg. There’s a whole variety of symptoms that lie under the surface, which are called non-motor symptoms, and those also impact people.

When we’re talking about DBS, we’re talking about benefits that are more for the motor symptoms. There are a variety of other treatments that can help the non-motor symptoms. Typically, the tremor, stiffness, and slowness are what we are talking about when we discuss benefits of DBS.

As far as the treatment options, I can’t go through a talk about treatment options for Parkinson’s without talking about exercise. I’ll touch on that first. Along those lines, we have therapies such as BIG and LOUD physical therapy and speech therapy that can help. Incorporating those into your treatment is important. I’ll review medications, and then talk about deep brain stimulation.

For exercise, everyone wants to know, “What should I do?” There really isn’t a best exercise. I say that the one that is best is the one that you’re actually going to do. Try to decide what you enjoy, what motivates you, and what you can do without getting injured. That’s the best thing to try to do. It’s good to change it up and try to do different things on different days. Get some cardio and get your heart rate up a few times a week. Do strength training and flexibility exercises. If you can join a class, that’s a good way to motivate yourself and do different kinds of exercises. There are a variety of ways that you can get on a good exercise program with Parkinson’s.

With medications, all of these are aimed at trying to improve dopamine signaling. That’s one of the big problems that causes the tremor, stiffness, and slowness – the loss of dopamine nerve cells. When we’re treating those motor problems, we’re trying medications that help improve dopamine signaling. Carbidopa-levodopa has been around a long time, but it still tends to be the most effective medication in managing your symptoms.

Then we have different options that we can either use before carbidopa-levodopa, or add the other ones in to help manage your symptoms. With carbidopa-levodopa, pill form is the most common form. There’s now a gel that can be infused into the small intestine that requires a pump, and some other things. That can be an effective option as well, if the pills are no longer working.

This slide gets at what happens as the disease goes on. The longer you’re on carbidopa-levodopa, you can start having more fluctuations. We call those motor fluctuations. Early on, you have less problems with taking your pills, and not as many fluctuations. The moderate stage is when you start to have some dyskinesias, which are abnormal wiggly movements. If you watch Michael J. Fox on TV, he has a lot of these. “Off” periods also take place, but they’re more manageable in moderate stages. In more advanced stages, it gets a lot harder to find that perfect sweet spot window where you feel good without the extra movements and without your medications wearing off.

In the past, we used to wait until advanced stage to start talking about DBS, and now we’re looking at more moderate stages. As medications are starting to cause motor fluctuations, that’s a good time to start thinking about DBS.

Situations where we would not want to do DBS include if there is any dementia. I’ll talk about how we screen for that. Other problems can be contraindications for DBS. If you have depression, that is something we would look for. It’s treatable, potentially, so it is not a complete contraindication, but it is one of the things we want to be aware of before we do brain surgery. There can be impacts on mood and thinking after surgery that are important to be aware of.

Severe balance problems, a lot of the time, are not helped after surgery. We are going to be looking at what your symptoms are, and consider whether they are going to be helped with surgery, and what your goals for surgery are. Those are all conversations that we have in the appointments, to try to sort through whether you are going to get the benefits out of surgery that you are hoping for.

There are atypical forms of Parkinson’s that are not going to respond well to DBS, like multiple system atrophy or PSP, progressive supranuclear palsy.

This is one of the trials that was out in 2013, and it shifted the thinking towards doing DBS earlier. The trial was called EARLYSTIM. It studied whether introducing DBS earlier in the Parkinson’s process helped improve quality of life. The study did show that generally, people were able to show significant improvement in their motor scores and quality of life with DBS plus medications, rather than medications alone, even in moderate-stage Parkinson’s.

Here is a study that is looking at time after DBS. Five years out is the longest that we’ve been able to follow patients and get enough data back. We know that DBS lasts longer, generally, than five years. We know for sure, proven with evidence and long-term follow-up, that we have sustained improvement in all of those motor symptoms of Parkinson’s, including stiffness, slowness, and tremor, five years out after surgery.

This is a video of a patient that has had DBS, just so you can see the difference between having DBS on and off. He has his DBS on right now. Now he’s going in and turning off the battery, which sits in his chest. You can see that within a few seconds, you start to see the tremor and symptoms come back, as the battery is turned off. DBS doesn’t just help tremor; it helps slowness of movement and stiffness. You can see that he also is having a harder time with tapping his feet and hands. It looks fake, but the symptoms do actually go away that fast when you turn the battery back on.

Moving on to essential tremor, essential tremor is different than Parkinson’s. Sometimes people think that tremor is all Parkinson’s, or they have a hard time sorting out the difference between tremor and Parkinson’s. Essential tremor is a separate disease that also is progressive. It can worsen over time. Typically, it just involves tremor, without the other symptoms that are involved with Parkinson’s. It can be really disabling, if the tremor gets bad enough. It generally affects the arms. It can affect other parts of the body, including the head. You can get a really bad head tremor, or a voice tremor. Katharine Hepburn is a recognizable figure who had essential tremor. She was really shaky, and that was because she had essential tremor.

If essential tremor gets bad enough, people have a hard time eating, drinking, writing, and doing regular daily tasks. Parkinson’s does not tend to run in families. Most cases are not genetic. With essential tremor, it does tend to run in families. It’s fairly common to have a variety of family members with essential tremor.

For treatment strategies for essential tremor, you can start with adaptive strategies. There are things like weighted silverware, or different types of spoons, or different pens, that can be helpful. People often live with this for a long time. Oftentimes, by the time I’m seeing them, they’ve already tried some of this. There’s a good website that the International Essential Tremor Foundation has that will show you different coping tips and strategies. It has links to products that can be really helpful. If you’re not aware of that and you have essential tremor, you should check that out.

We don’t have a lot of medications for essential tremor, which is why DBS starts coming into play. There are not really great medication options, and the medications we have can cause side effects that are intolerable. Prinidone and propranolol tend to be the first two that we try. There are some second-line options that can be effective, and we can try those as well.

There is a popular newer treatment called focused ultrasound. That is MRI-guided, so if you can’t have an MRI, then you wouldn’t quality for this. It also is kind of a “one and done” lesion type of surgery. There are still some risks involved. You’re going in and targeting the same areas that we target in DBS, but trying to damage a group of cells there that disrupt the tremor circus. It is not preferred over DBS if you are a DBS candidate.

Who is a candidate for DBS for essential tremor? It’s a little more straightforward than Parkinson’s. If you’ve tried the medications and they are either no longer managing your tremor to the point where you feel that your quality of life is maintained, or you’re getting side effects from the medications, that is the time you would want to start thinking about surgery.

The contraindications are things that we look at that make you not a good candidate are similar to Parkinson’s. Dementia would be a contraindication. If you have a lot of other medical problems that increase your surgery risk, that is something we consider. There is not a clear cut-off for age. We take into account a person’s health and other factors, but as you age, you get an increased risk for complications in general. We do take that into account.

This is a patient I did recently. This is his baseline spiral test. If you have essential tremor, you’ve probably had to do the spiral in the clinic. Here is the baseline. Here is another test within 20 to 30 minutes of programming his DBS device. The spiral is the patient’s.

Here is a flowchart that gives you an idea of what the steps are, if you’re thinking about surgery. If you’re already seeing me, then you skip the referring physician step. If you’re seeing someone else, they would refer you to a movement disorder specialist like myself.

Part of my job is to look at what medications you’ve tried. Have we really optimized your therapy before surgery? Are there other things we can try? There is some risk, and Dr. Nelson is going to go through the details of the surgery. If we can do things that help manage your symptoms before you have to get surgery, then we want to try those things. A lot of that visit is looking at what you’ve tried, and if there are things we can do that might improve things before having to get surgery.

If we’ve gotten to that step and we want to go through the work-up to see if you’re a good candidate for DBS surgery, the big two steps involve something called neuropsychology and on-off testing, if you have Parkinson’s. We have a physical therapist who is trained to do this testing. You would come in off your medications, and the physical therapist would evaluate your symptoms with a motor scale. Then you would take your carbidopa-levodopa, because that’s the quickest acting. Within an hour, typically, you’re going to feel more “on,” or you notice your symptoms are better. They would repeat that same rating scale.

This helps us get a sense of how much you would benefit from the surgery. If we see a good response to the medications, then that gives us the idea that you’ll have a better response to the surgery. That is videotaped, so we use that in our meetings where we talk about whether patients are good candidates.

Then there is neuropsychological evaluation. If you have essential tremor or Parkinson’s, you will go through an assessment of your thinking and memory with a neuropsychologist. This is a 3-4 hour test or exam. It’s not graded, but you will get results back from that that tell us where you’re at from a mood standpoint. There’s a mood questionnaire, so we can look at what anxiety, depression, or other things might be a factor.

We all meet as a team and go through the test results, and decide whether we all think you are a good candidate. If you are a candidate, we talk about what the procedure for the surgery would be, and what areas to target. At that point, you would meet with Dr. Nelson in the clinic and go through things in more detail with him. Then you would get surgery.

I see people a month after surgery. You would see me again in the clinic to actually have the device turned on and programmed. The first visit is a longer visit, to go through and test all of the different combinations of settings. Usually, I like to see people within a month, depending on how things are going after that first visit. There are some sooner visits right after surgery, and then we can extend it back out to your normal 4 to 6-month follow-up timeframe.

Here are some questions. I’ve covered some of this. How long does it work? That’s a common question. People hear that it wears off and that it loses efficacy over time. In Parkinson’s, the disease does continue to progress. It doesn’t halt the progression of the disease. It helps us manage the symptoms much more effectively. As I showed from the study earlier, we know that 5 years out, at least, there are still sustained improvements.

It is similar for essential tremor. The data goes out for 5 years, but we know that tremor control is maintained much longer than that.

With the battery life, there are a couple of different battery options. These were recently updated. There is a rechargeable option that lasts 15 years before it would need to be changed out. There is a non-rechargeable option that lasts between 3-5 years.

The other big question is, “Will I be able to stop my medications?” People want to come off their medications. In Parkinson’s, generally you’re going to stay on some of your dopamine meds, but we can reduce those pretty significantly. A lot of my patients are at least on 50% fewer medications. In essential tremor, generally, yes, we can usually taper off the medications completely.

Here is a slide showing our team, which would include me and Dr. Nelson. We have a care coordinator, Anushka, who you may have met at the registration table. We have a nurse practitioner that works for the clinic. She helps support doing some of the programming. There is Courage Kenny, which is where you would get the on/off testing, and any BIG and LOUD therapy that you would have before or after surgery. We are partnered with them pretty closely. We have our neuropsychologists at Noran, who are all excellent. We are the ones that meet as a team and help work through a lot of the things that you’re questioning, and decide whether things are good to go, or whether there are other options for you.

That is it for me. We’ll have Dr. Nelson come up and get through the nitty-gritty of surgery.

[Dr. Kyle Nelson] Well, good evening, everybody. Thank you so much for showing up. I think it’s really important that we have such a big crowd. It’s great to learn more about some of these different treatment options that we have for these different movement disorders, essential tremor and Parkinson’s disease.

There are a lot of times – and many of you may have experienced this, when you get a diagnosis like this, and you really don’t know which direction to go, and what is going to be the best treatment for you. Sometimes it can be scary, and sometimes you can have limitations in what your life used to be like. You can get some treatments, and a lot of times, those treatments work really well, for a short amount of time. After that amount of time, the treatments become less effective, or you need to take so many medications that you start to get side effects from the different medications.

Those patients are the ones that really benefit from treatments like this. This is obviously a big deal. This is brain surgery that we’re talking about. I don’t want us to think of this as being a very simple procedure. This is a major cranial operation that we do. In doing so, we see the benefits, and you’re going to see some of that firsthand tonight with our guest speakers that we have. I know both of them personally, and they will tell you that this is a life-changing thing. They wish they had done it sooner, and they would do it again if they had do. I think that personal experience that you’re going to hear from them is going to be important. Tonight, we’ll share information and answer some of the questions that you have about this treatment.

Dr. Orehek talked a little bit about some of the surgical indications for DBS. When do you become an actual candidate for surgery? Not everybody is a candidate as soon as they get diagnosed. I don’t think it’s the right treatment for people as soon as they get diagnosed. A lot of times, during the course of your disease, you will become a candidate for this. Then, the question comes up – is that something you want to go forward with? What are the necessary steps to go through that? Are you healthy enough to be a candidate? Do you have other medical conditions or other medical problems that may preclude you from being a surgical candidate? Those are all things that we address on an individual basis. That’s why it’s so important for us to meet as a team, and get my surgical expertise. I operate on people for all different types of neurosurgical issues. The team gets my expertise on who I think is a good surgical candidate. We have discussions about patients about why they would be at higher risk for a certain procedure. I think that is important.

Surgical indications are obviously a diagnosis for Parkinson’s disease, essential tremor, or dystonia. Being medically refractory, meaning that you’ve taken medications and either the medications don’t work, they’re not as effective as they used to be, or you’re having too many side effects, so you can’t tolerate the medications. Either one of those, or sometimes both of those, are a common theme that we see in most of our patients.

Also, your disease has to be disabling, meaning that it’s affecting your daily life, and affecting it to the point where you’re not enjoying some of the things that you used to enjoy, or aren’t able to do the things that you used to do, because of the advancement of your disease. These can be very simple things, and things that most people take for granted, like eating, having soup, drinking coffee, walking in a grocery store, etc. These are very simple things that you can’t do anymore because of some of the limitations. Those are some of the patients that we think are great candidates for DBS treatment.

As we talked about, there is a more recent push for earlier surgery. We used to wait until people were at the end stages of their disease. What we’ve actually found is that we can help a lot of people who are in those middle stages. Those people do the best, because they’re not as debilitated from their disease. They bounce back from surgery and recover from surgery much better than patients who are at the late stages of the disease, who are much more disabled and may be not as great of surgical candidates.

This is what we hope to crack open tonight. This is the big black box of mystery of what brain surgery is, and what DBS surgery actually involves. We are going to break it down tonight, so that when you leave, you will have a great understanding of the process of what the surgery entails, and some of the risks and benefits that we can see with DBS surgery.

I always put this slide up there. I think it really describes where people are at, at different parts of their disease process. When you get diagnosed with a movement disorder, it is oftentimes very daunting. Most of the times these things don’t show up overnight. These are things that you’ve seen coming on for some time. Maybe it was months or years. Maybe your family has noticed it, and you finally saw your primary care doctor or neurologist, or somebody who diagnosed you with a movement disorder.

Just hearing that news can be very daunting. You can think that your life is coming to an end, and you’re never going to be able to enjoy the things that you want to do, or that you have done in the past. That’s why I put that diagnosis way at the bottom of this mountain here. When you look up at the top of that mountain, you think, “There’s no way I can ever get back to the life I had before. There’s no way I can do those things that I wanted to do.” That can be very daunting for patients. I think it’s important to recognize that.

Throughout this process, we slowly climb up this mountain until we get to the point where we’re at the top of the mountain. When we’re at the top of that mountain, you’re back to where you want to be, doing the things you want to do with your family, and things that you enjoy. A lot of times, you get stuck at the bottom of that mountain, in the diagnosis and the early stages of treatment with medication and therapy. You can be down there for quite a while and do okay.

At some point in time, you’ll break out of that. Sometimes you have to make a decision. “Is my disease at a point where I need to have surgery? Am I willing to undergo a brain surgery to fix this?” For most people, that’s an easy decision. They see where they’re going, and the disabilities that they’re having. They hope to get back to some normalcy. That is an easy decision to make.

You make that decision, and then you go through a pretty extensive surgical workup to see if you’re a candidate or not. We do on/off testing for Parkinson’s patients, and neuropsych testing for Parkinson’s and essential tremor patients. It generally takes a couple of weeks, sometimes up to a couple of months, to complete some of that. That is not unique to our program; that’s really across the board. One thing that we’ve done for our program is streamline this process as much as possible. We try to keep the patients in mind. Once you decide that you want to go through with surgery, we try to get that expedited as much as possible, to not lose that momentum. I think that’s an important step.

You go through the surgery work-up, and you eventually get to the point where you actually have the surgery. You are in the operating room. We do our DBS procedures in two stages, and we’ll get into that a little bit more. If you meet with other surgery groups, they will do up to four procedures, and take longer than we would. I like to place both leads in at the same setting, and do another stage where we hook up the battery pack or the pulse generator. We do that pretty efficiently.

Finally, you have to get recovered. You have to get over surgery, get recovered from surgery, and get this thing turned on. Dr. Orehek does a very nice job of programming patients, and really using their medications and their DBS to get rid of the symptoms that they need to. I think we have a lot of success with the patients that we implant.

We have a couple of different targets that we use. This is one of the reasons why we meet as a group. This is something we talk about for every patient. Every patient is different, as far as the targets that we want to pick. For essential tremor patients, we almost exclusively pick a target in the thalamus. That is pretty common. For the Parkinson’s patients, we do have two options. One is the STN, or sub-thalamic nucleus. The other is the globus pallidus. They each have their unique treatment goals that we want to achieve with those. We take a lot of information into consideration. We consider that information from the on/off testing, to the neuropsych testing, to age, and symptoms – are patients more bradykinetic? Do they have dyskinesia on their medicines? Do they have more tremor? Those all play a role in our targeting. We come to an agreement, and that is the direction we go from a targeting standpoint.

A little bit on the staged procedure – there are a number of reasons why we do this in a staged fashion. That is generally how we like to approach these. Most of the time, what we do is bring a patient back to the operating room for their initial procedure. What to expect with that: We do an MRI scan pre-operatively, before we go into surgery. On the day of surgery, you arrive at the hospital quite early in the morning. We start these first thing in the morning, for a lot of different reasons. It’s especially for the Parkinson’s patients who are not on their medicines, and have been off their medicines for a whole day before surgery. When you come in, you want to try and get those medicines on as quick as possible.

The reason we have patients off of their medications beforehand is because we want to do inter-operative testing. As you’ll see here, it says “local anesthesia.” What that means is that you’re awake during this procedure. We get you back to the operating room and we place you in this head frame. We get a scan when you’re in the operating room. We merge that with the MRI scan that you had done previously. Prior to you entering the operating room, I’ve already done planning on that, to locate where we want to target these leads.

We do this in an awake fashion, and the reason we do that is because we want to test these leads when they’re in there. We want you to be off the medications so your symptoms are worse, and we want to put these leads in and see how they stop your tremor, how they change your rigidity, how they change your bradykinesia, etc. The only way to really do that effectively is for you to be awake.

No one has ever left the operating room in the middle of surgery. It is a little bit of a challenge to get through, and I don’t like to give any sedation medicines because it can affect some of the treatment that we get.

Once we get those leads in, we want to test those leads to see if they’re in the right spot. We want to see if they’re going to work. We’ll do those spirals in the operating room, and we’ll have people sign their name in the operating room, just to see how the lead is actually functioning.

We also look for side effects, too. We’ll really ramp up the voltages on those leads, to voltages that we wouldn’t generally treat with, to look for side effects such as pulling in the mouth, troubles with speech, double vision, contractures of hands or arms, etc. Those are all things that we can easily fix in the operating room by moving the lead over just a few millimeters. That makes all the difference in the world, and it makes Dr. Orehek’s job a lot easier when she starts programming. That’s one of the reasons we do this awake – not because we want to torture people, but because it’s really effective and we get really good results when we get people out of the operating room and to programming.

In stage one, we put in both inter-cranial leads. That takes the morning. We generally start first thing in the morning and finish up by about lunch time. That’s getting both sides in. We make two small incisions in the top of the head, and drill two small holes, about the size of a nickel or a dime, in the skull. One goes on the right side and one goes on the left side. We place those leads into the brain, and then test those leads to determine how effective they are and if they have any side effects.

After that surgery, I generally keep people in the hospital overnight for two reasons. One, if they’re a Parkinson’s patient, I want to get them back on their medication and make sure they are okay and are going to be safe to go home. Two, there is a very small risk of bleeding. If you are going to bleed into your brain, I want you in the hospital. I want to know about it. I don’t want you sitting at home. Most of the time, there is nothing we need to do about that, but occasionally there is. A hospital is a good place to be if you have that type of problem.

That’s stage one, getting both those inter-cranial leads. Once we get those leads in and we’ve tested them, we tuck them underneath the skin, close the skin up, and get you out of the operating room in that day. You stay overnight and go home the next day. We bring you back a week later to finish the device off.

For the second stage, you come in, and you can take your medicines as normal, whether you’re on medicines for essential tremor or Parkinson’s disease. You can be on your medicines for that. We do that under general anesthesia. You’re totally asleep for that one; you don’t remember or know anything that’s going on. What we do is, we open up the incision, get those leads out, tunnel extension leads underneath the skin, behind the ear and down through the neck, and we put that little generator in at the right or left side of your collarbone. Everything is underneath the skin. You don’t have any wires hanging out. You can notice the generator; you don’t really notice the extension leads much. You can feel them. They feel like little bumps underneath the skin. It’s very simple and very straightforward.

That is done as an outpatient procedure, meaning that you come into the hospital and it takes about an hour to an hour and a half to do that. You go home later that day.

When we are in the operating room for that second stage, we hook everything up, we test everything out, and then we leave that device off. The reason we leave that device off is, we don’t want to let the brain scar around those leads before we get it programmed and on. Generally, what happens is, as the brain is scarring around those leads, the connection and the voltages are much different. It actually makes programming a lot easier if we wait that 3-4 weeks after that surgery. If we do it right away, you end up with voltages being too high. You get side effects, and you have to turn the voltages back down. You end up chasing your tail a little bit with programming. This is the best way to do that.

Here are a couple examples of some of the devices we use. You can touch them when we finish up the presentation, if you want to see what the devices look like, and the size.

This is the frame that we use. It’s a stereotactic frame. It’s extremely accurate, within a millimeter of its target, even at the depths that we do in the middle part of the brain. This is placed in the operating room, and that is what we actually use to coordinate with that MRI scan that you had done previously to identify where that lead needs to go.

This is a little bit of the planning software that we use. This gives us those direct coordinates of where we need to place those leads.

In the operating room, you get this head frame placed. That’s done under local anesthetic. We put a little bit of numbing medicine on the areas. That secures right to the skull. You’re placed on the operating room table. We pad everything up. Everything is pretty comfortable; we make it nice and comfortable for you before we get things started.

We do a little bit of hair trimming, sorry. I only have one tool. It’s unfortunately a hair razor. I do shave people’s hair. The reason we do that is for infection prevention. It’s the best way to decrease our risk of infection. We’ll talk about complications later, but one of the big risks with DBS is infection. We want to do everything we can to try and decrease that rate as much as possible. Unfortunately, that’s one of the ways we do it.

I get those leads placed in that position, and then I get you out of the operating room as soon as we get that done.

For Parkinson’s patients, we do something called micro-electrode recording. It’s just one more tool we use to make sure that lead is in the right spot. What we do is, before we actually place the lead into the brain, we stick this little electrode, or a little wire, into the brain, in the same trajectory that we would put the lead in. We record the brain cell activity. There are very characteristic brain cell activities that we can identify, that come up on the computer. It sounds like static to anybody else, but it is music to our ears when we’re in the operating room.

What that does is, it tells us that we have a big chunk of whatever nucleus we are going over. It makes sure that we have enough of the globus pallidus to get a number of electrodes in where we think it is going to be most effective from a programming standpoint. If we don’t see what we need to see, then sometimes we move the leads. Sometimes it’s a little bit to the middle part of the brain, sometimes it’s a little bit to the outside part of the brain, a little bit forward, or a little bit back. These are all in very small increments – two-millimeter increments, generally.

We will generally find the area that we want. In the majority of patients, we do one or two passes. Rarely do we need to do more than that, because of the preoperative imaging and targeting that we do. That’s pretty effective.

This is an example of the micro-electrode recording equipment that we use.

During the operation, we’ll have you do different tasks, depending on what your symptoms are pre-operatively. Sometimes we’ll have you drink from a cup, draw a spiral circle, sign your name, or do some of the testing for Parkinson’s disease to look for rigidity, bradykinesia, and tremor. We increase those voltages until we get good control of them in the operating room. That’s why we do this awake. We want to make sure that everyone leaves the operating room with those leads in a great place.

We’ve touched on this. There is really good research on a lot of this stuff. People know that it works. There’s a lot of great articles that have been published with big sets of patients that really prove that this does what it’s supposed to do. We’ve been doing this for a long time. All the research goes out for five years, but we know it actually lasts a lot longer than that. This is a treatment that you’re going to be able to utilize for the rest of your life, generally.

This study looks at the different states with DBS vs. just medications alone for Parkinson’s disease. Before surgery, people were “on” with dyskinesias, and having side effects with the medications. Once the surgery was done, and the DBS system was programmed, you have a lot more “on” time without any side effects, including dyskinesias. It is more evidence to show that this is superior to anything else that we have to offer.

Again, this lasts at least five years, but anecdotally, we know that it lasts a lot longer than that. We have really good success with patients, even beyond five years.

We can’t talk about brain surgery without talking about complications. These are real complications that we run into from time to time. Thankfully, in my hands and in most hands of people that do a lot of DBS procedures, the risks of having a major complication from a surgery like this is really pretty low. I generally tell people that it’s less than 1%. But they are real risks, and if it happens to you, it’s a big risk.

There is less than a 1% risk of having a hemorrhage. There’s a word called “asymptomatic” up there. An asymptomatic hemorrhage is, when you place that lead into the brain, there is a little bit of bleeding that happens. We can’t see it, but when we get a post-operative image or head CT – I do that on every patient, just to make sure that the leads are where we want them to be and we don’t have any hemorrhages – sometimes you see small, little hemorrhages that come up. They’re asymptomatic, meaning that patients don’t have symptoms from it. They are incidental. We don’t treat them with anything. The body re-absorbs them. That is something that happens. That generally happens in less than 1% of the cases that we do.

A catastrophic hemorrhage, meaning that there is a major hemorrhage that requires going to the operating room to evacuate, occurs in far less than 1% of patients. It may be a 1 in 1000 sort of number.

Ischemic strokes are less than 1% of a risk. Seizures can occur. The biggest risks are when something goes wrong with lead placement. You place the lead and everything looks great, and we get you out of the operating room and hook everything up. But then you’re getting programmed by Dr. Orehek and you’re having some sort of side effect. Then we have to go back into the operating room and replace that lead. That doesn’t happen to us very often, but that does happen from time to time. That can be a challenge, because you’re going back to the operating room to have that fixed.

The last risk is infection. That is really the most important. Anytime you cut the skin, you run the risk of infection. Anytime you put a foreign body underneath the skin, if that gets infected, the whole system needs to come out. You can’t just treat it with antibiotics, because the bacteria gets into the foreign body and it’s really challenging to get that treated. That’s the biggest risk that we run into. I do everything I can to try and prevent that. The last thing you want to do is have someone have a great success with their DBS system, and you have to pull it out because it gets infected. It has happened; it happens to everyone who does surgery, but we want to reduce that as much as possible. We spend a lot of time working on that.

Looking over things, what I really want you to take away is, for all the things that I tried to scare you with tonight, DBS is a very safe surgery to do. Major complications from this are low. I would say less than or in the 1% range for having a major complication, whether that is infection, bleeding, or some sort of lead failure or mal-positioning of the lead.

It is very effective. Patients will give their story about how they did, and the process. It is life-changing, and very effective. That last part is very true – this is a life-altering thing. Things that you thought you would never be able to do again, you can do again, because of this treatment. Some of the problems that you have with medications are no longer problems because of how effective this can be.

I always finish with this, because again, when you’re standing at the bottom of that mountain and you’re looking up, it seems daunting. It doesn’t seem that you’re going to be able to get to the top. You can. Through my help and Dr. Orehek’s help, and through some of the patients that you’re going to hear today, they’ve gotten to the top of that mountain. They’re going to tell you how great it is when you get there. Don’t be discouraged by that. We’ve done this a lot of times in the past. We have great help with Anushka and some of the other care coordinates that we have at my office and Dr. Orehek’s office, with Noran. We can walk you through the process. We’ve done this before, and we’ll do this again. It’s a very straightforward thing that we do, and we do it all the time.

Thank you, everybody, for coming. If you guys have any questions for what the next steps are, or if you don’t know where to go from here, we are going to be around. The best way to start the process, if you’re interested, would be to get in touch with Dr. Orehek at Noran. You do have some of the care maps that you’ve seen, and that leads you through the process. Getting to see Dr. Orehek is the first step in that process. She can get you all the testing that we need and see if there’s anything else we need to try before we go down the path of DBS, and talk more about it.

We’re going to be up here, if you have any personal questions, and want to talk more about DBS. Again, thank you so much for coming. I think that just showing up tonight and getting more information about the disease and treatment options is great. We’d be happy to answer any questions that you have. Thank you.