Our primary focus in treating movement disorders (Parkinson’s Disease, Dystonia, Essential Tremor) and Epilepsy is to help patients maintain performance and quality of life while limiting the side effects of medications. We believe in a multi-faceted treatment approach that may involve the following, depending on the individual's needs:
Deep brain stimulation (DBS) helps control many symptoms of Parkinson's disease, including shaking, slowed movement, and stiffness. You and your neurologist should discuss the role of DBS in your long-term treatment plan early after your diagnosis with Parkinson’s disease. Most commonly, patients become candidates for DBS once medication alone does not effectively control their symptoms.
DBS uses a small device placed under the skin that looks like a pacemaker to send electrical signals to brain areas involved in Parkinson’s disease. These electrical signals prevent the abnormal brain messages that cause symptoms of Parkinson's.
People with DBS therapy may see improvements in quality of life, activities of daily living, movement control, and medication reduction. DBS can provide several additional hours of movement control per day when compared to medication alone.
People start DBS at the point when medications alone are giving less movement control, or side effects like nausea, dizziness, and unintended movements (dyskinesia) are disrupting their lives.
When should I have DBS surgery?
Parkinson's disease symptoms get worse over time. Many people expect that DBS is a last resort. However, the best time to maximize benefit from DBS is when medications alone aren't providing enough relief, but still have some effect.
Examples of this include:
- Movement symptoms like tremor and stiffness are occurring for more hours each day.
- Medication doses take longer to work, and/or the effect is less predictable.
- The medications' effects wear off between doses.
- You have to take medications more often, including during the night.
- You need higher doses of medications to get the same effect.
- Side effects of your medications are becoming more problematic.
Deep brain stimulation (DBS) helps control the symptoms of Essential Tremor. You may be a candidate for DBS surgery if you have tremor in at least one arm or hand and it is disabling—meaning that it keeps you from doing what you want to do. This can include daily tasks like writing or eating. For many individuals their tremor limits their social interactions because of embarrassment or anxiety. If you have tried medications and they didn’t work, or you could not tolerate the side effects of the medications, then you should discuss DBS with your doctor.
DBS tends to be the most effective for upper extremity (arm or hand) tremors, but can improve tremor in the head, voice and legs in certain situations.
DBS uses a small device placed under the skin that looks like a pacemaker to send electrical signals to brain areas involved in Essential Tremor. These electrical signals prevent the abnormal brain messages that cause symptoms of Essential Tremor.
When should I have DBS surgery?
Essential tremor tends to get worse over time. Many people expect that DBS is a last resort. However, the best time to maximize benefit from DBS is when your tremor becomes disabling despite optimized medical therapy directed by a neurologist.
Deep brain stimulation (DBS) helps control the symptoms of dystonia, a neurological movement disorder characterized by involuntary muscle contractions. These contractions force certain parts of the body into repetitive, twisting movements or painful postures. Dystonia can cause severe involuntary muscle contractions that may interfere often with everyday functions like walking, sleeping, eating, and talking.
There are two types of dystonia:
- Primary dystonia – a condition in which dystonia is the only symptom (no other pathology)
- Secondary dystonia – the result of another health condition such as stroke or infections. It may also result from an injury, such as trauma to the brain.
Dystonia is further classified by the part of the body that is affected:
- Focal dystonia affects one area of the body
- Segmental dystonia affects two or more nearby areas of the body
- Generalized dystonia affects the entire body.
DBS is a treatment option for most forms of dystonia, except for most cases of secondary dystonia.
DBS uses a small device placed under the skin that looks like a pacemaker to send electrical signals to brain areas involved in dystonia. These electrical signals prevent the abnormal brain messages that cause symptoms of dystonia.
When should I have DBS surgery?
Dystonia may get worse over time. Many people expect that DBS is a last resort. However, the best time to maximize benefit from DBS is when your dystonia becomes disabling despite optimized medical therapy directed by a neurologist.
Note: DBS for dystonia is classified as a Humanitarian Device - Authorized by Federal Law as an aid in the management of chronic, intractable (drug refractory) primary dystonia, including generalized and/or segmental dystonia, hemidystonia, and cervical dystonia (torticollis), in patients seven years of age or above. The effectiveness of the devices for treating these conditions has not been demonstrated.
The steps before, during and after DBS surgery are described below. Throughout the process you will followed by a neurologist and neurosurgeon who have special training with DBS, as well as several other members of our team.
- Preoperative evaluation: are you a candidate for DBS?
Your neurologist, typically a movement disorders specialist, will evaluate you to see if you are a candidate for DBS.
The evaluation may include some or all of the following:
- Medical history
- Neurological exam of your movements
- MRI of the brain: to check whether there are any issues with your anatomy that would prevent surgery. This scan is often used to plan placement of your DBS electrodes if you proceed to surgery.
- Lab tests, such as a blood test to make sure your blood clots properly
- Neuropsychological tests: to test for underlying problems with thinking or talking that need to be considered during your surgery.
- Physical, occupational and/or speech/language therapy: to evaluate movement issues prior to surgery, including problems walking or taking care of yourself. Some individuals have swallowing problems before surgery that will be carefully evaluated by our speech and language therapists.
Once the preoperative evaluation is complete, your neurologist and neurosurgeon will discuss your case in detail.
- MRI for surgical planning
Your doctor will use images to create maps of your brain that guide accurate placement of DBS leads during the surgery. You will have a special high-resolution MRI scan of the brain prior to surgery.
There are two parts to DBS surgery:
- Part 1: DBS electrode (lead) implantation into the brain. The MRI prior to surgery is used to perform ultra-precise placement of electrodes into specific brain structures. To do this, we place your head into a frame that allows for accurate electrode placement, and then drill small holes through the skull to reach the brain. This is not painful: we use local anesthetic to numb the scalp and sedating medication through your IV for this part of the procedure. Once the drilling is complete we gradually let you wake up enough to test the placement of the DBS electrodes—this process provides the highest level of confidence that you will have the best possible result from your DBS surgery. When necessary, we can perform the procedure completely asleep for individuals who cannot tolerate the surgery with IV sedation. However, in our experience we can make virtually all patients comfortable during the procedure in the operating room. Most patients spend 1-2 nights in the hospital after surgery, then spend 1-2 weeks recovering at home.
- Part 2: Neurostimulator and extension cable implantation. 2-4 weeks after Part 1*, a neurostimulator (similar to a pacemaker), is placed under the skin of the chest. The neurostimulator in the chest is connected to the lead in the brain by an extension cable, which runs under the skin of the neck. This procedure is done under general anesthesia. You go home the same day after this surgery and take medication for a few days afterward for pain and discomfort. We will usually turn on your new DBS system at low settings before you go home, and then have you follow up very soon with your neurologist to start programming the device.
*Part 1 and Part 2 are typically done on two different days, but may be done at the same time in certain situations.
- DBS programming
A few weeks later, your neurologist will begin to adjust your DBS settings to best control your symptoms and minimizing side effects. It will take a few programming sessions to find the stimulation levels that work best for you. You will have more frequent follow-up visits for the first few months to check your results and adjust as needed. These appointments are key to getting the results you want over time.
You can typically return to all of your usual activities, always following your doctor's guidance regarding any specific limitations after surgery. DBS has little impact on your daily activities, the clothes you can wear, or how you travel. DBS delivers therapy 24 hours a day, so it's working to control your symptoms when you wake up first thing in the morning. DBS doesn’t require any maintenance from you (except for recharging if you have a rechargeable system).
- Ongoing care
You will continue to have regular checkups with the neurologist who manages your DBS therapy, similar to before surgery. Your neurologist will make sure that your DBS system is working properly, adjust your stimulation to best control your symptoms and check the battery of your neurostimulator to determine when you will need a replacement.
At the Providence Brain and Spine Institute we value our network of referring physicians, and make every effort to tailor DBS surgery to the patient and to the practice of their managing neurologist. We strive to actively communicate before and after surgery regarding the individual needs of patients undergoing DBS. We make it a priority to streamline the preoperative evaluation process, to minimize perioperative stress and discomfort and to facilitate recovery after surgery.
It is our goal to be your partner as your patient goes through DBS surgery, and to transition the patient back to your care once appropriate. However, if you would prefer, our movement disorders neurologists can also assume patient management before and/or after DBS. We can also make arrangements for device representatives to assist you in person for the initial DBS programming sessions as necessary.
It is our preference to perform DBS lead implantation with patient participation in the procedure. We typically use intravenous sedation during headframe placement and drilling, then gently awaken the patient for physiologic testing. This testing provides the highest level of confidence that the patient will have therapeutic benefit from stimulation without intolerable side effects. We further combine physiologic testing with intraoperative CT imaging to achieve excellent accuracy and safety for DBS procedures. We routinely are able to do so while keeping the patient very comfortable. However, for a small subset of patients who are unable to tolerate this process, we are also offer asleep DBS under general anesthesia.
For patients traveling a significant distance to Portland, our goal is to minimize their transportation burden. We can help direct local presurgical evaluations and coordinate appointments across disciplines when a visit to Portland is necessary. While we typically stage DBS procedures (with DBS lead and neurostimulator placement spaced several weeks apart), we will perform single-step procedures for patients who have traveled to Portland for surgery whenever it is reasonable to do so.