Deep Brain Stimulation (DBS)

Deep brain stimulation (DBS) is a surgical procedure used to treat a variety of neurological movement disorders that are resistant to medications or other treatments, including essential tremor, Parkinson's disease, and dystonia. It involves implanting a pacemaker-like device in the brain to interrupt the erratic electrical signals that cause movement symptoms.

What Is Deep Brain Stimulation?

Deep brain stimulation is a surgical procedure to help control movement symptoms of neurological disorders. In DBS, a surgeon implants electrodes in your brain that connect to a battery implanted in your chest.

How Does Deep Brain Stimulation Work?

The DBS unit delivers electrical stimulation to the brain to regulate its activity, much like a pacemaker does for the heart. This works because many movement symptoms, such as tremors in Parkinson's, are caused by imbalanced function of networks in the brain, and electrical stimulation at certain locations in those networks can restore normal function.

Components of a DBS Implant

If you get DBS surgery, your implant will consist of three parts:

• Leads: The DBS leads are tiny wires that can deliver precise amounts of current to small areas within the brain.
• Battery: A battery called an implanted pulse generator (IPG) supplies power to the electrodes. It's usually implanted near the collarbone.
• Lead extension: The lead extension is a wire that connects the battery pack to the leads.

Once implanted, the components of your DBS are all under the skin.

What Is Deep Brain Stimulation Used For?

Deep brain stimulation is a valuable therapy for people with movement symptoms or disorders such as:

• Parkinson's disease
• Dystonia
• Essential tremor

A DBS procedure isn't a first-line treatment, though. It's usually reserved for patients who meet specific criteria and have tried other treatment approaches without success.

Deep brain stimulation is a relatively new procedure, and doctors are studying other ways to use it. DBS may also help treat psychological disorders, including depression and obsessive-compulsive disorder.

Deep Brain Surgery for Parkinson's Disease

Deep brain stimulation is an established therapy for Parkinson's disease. It can provide effective relief from Parkinson's symptoms that affect movement, including tremors, muscle stiffness, and slow movement. It's especially useful for Parkinson's cases that resist medication or where the patient has been taking Parkinson's treatment for so long that medications no longer produce the same effect.

While DBS treatment is a powerful tool to control symptoms, it can't cure or reverse progressive conditions like Parkinson's disease. Even with very successful DBS treatment, Parkinson's patients may develop other, non-motor symptoms as the disease progresses.

Why Choose Deep Brain Stimulation Therapy?

DBS is a surgical procedure, so it isn't the first-choice treatment when other, more conservative approaches exist. However, it's been shown to be effective in cases where a condition doesn't respond to medication or other therapies.

Who is a good candidate for deep brain stimulation?

Every patient is unique, and DBS won't be suitable for everyone. Your doctor and neurologist can determine if DBS is the right choice for you. The ideal candidate for DBS:

• Has symptoms that don't respond to medication.
• Can't tolerate the side effects of the medications necessary to treat their condition.
• Has symptoms that significantly impact their quality of life.
• Has insurance that covers the DBS procedure.

Who is not a good candidate for deep brain stimulation?

If your condition is well-controlled with medication, your doctor may advise against getting a DBS implant. Other factors that might make DBS the wrong choice for you include:

• Conditions where movement problems aren't the primary symptom (such as Parkinson's disease that presents balance or speech dysfunction as the primary symptom)
• Psychiatric conditions or cognitive impairments
• Increased risk of surgical complications

Remember that these factors won't automatically disqualify you. For instance, if a psychological condition like depression is an obstacle to getting DBS treatment, your doctor may simply recommend treating your depression first and then moving on to DBS. Talk with your care team to determine whether DBS is a good fit and what you might need to do to qualify.

Deep Brain Stimulation: Benefits and Risks

Deep brain stimulation is a powerful tool that can offer symptom relief for a variety of difficult-to-treat conditions, but it carries risks and side effects, too.

DBS Surgery Benefits

Deep brain stimulation is a long-term solution that can provide life-altering relief from symptoms that significantly reduce quality of life.

Another important advantage is that DBS is flexible and can provide customized relief. DBS units offer adjustable settings to help you fine-tune the stimulation and make changes to find the proper stimulation for your case.

Finally, it's a reversible procedure—the implants can be removed in a future operation if necessary.

DBS Surgery Risks

Deep brain stimulation is brain surgery and carries all the usual risks of a surgical procedure, such as:

• Bleeding
• Infection
• Coma
• Stroke
• Seizure

It may also carry post-surgical risks, such as complications with the device or ongoing cognitive problems after the surgery.

The Steps for Deep Brain Stimulation Surgery

If you are considering DBS, you will undergo a multi-step evaluation with a team of specialists that includes a neurological examination, CT or MRI imaging studies, neuropsychological testing, and other evaluations. This testing allows us to determine whether DBS is right for you, establish the type of DBS hardware that is most appropriate, and identify the locations in your brain that are most likely to provide the greatest benefit. This evaluation process also allows us to learn about your symptoms and goals, introduce you to the members of the DBS team, and answer any questions you have. We will also review the risks of DBS surgery.

Although serious complications from DBS surgery are infrequent, it's important to understand the risks of permanent side effects, infection, or device malfunction requiring device removal or replacement.

Device selection

If you are determined to be a candidate for DBS, your neurologist will talk to you about the places in your brain that they recommend targeting and the different DBS devices. Different DBS devices offer different combinations of features. The main factors to consider are:

• Rechargeable: Some DBS units have rechargeable batteries. Rechargeable units are smaller and last 10-15 years before you need to replace them, but they require you to spend a few hours each week charging them by wearing a charging device. Non-rechargeable units last 2-5 years before replacement but don’t need as much maintenance time.
• Current steering: Units with current steering split the leads into smaller contacts so that the DBS programmer can fine-tune where the lead delivers stimulation.
• Independent current control: This feature lets the programmer shape the stimulation field by adjusting the amount of stimulation for each contact separately.
• Sensing-enabled: Some advanced DBS implants can sense and record rhythms in brain activity. This may potentially allow the device to make automatic adjustments to the stimulation to better control symptoms. This feature is still pending FDA approval.

How to prepare for DBS surgery

You'll review your medical history, discuss your symptoms, and determine whether you're a good candidate for DBS. If obstacles (such as other conditions) make you a less-than-ideal candidate, you may need to resolve them before you get DBS. Your care team can help you determine what, if anything, you need to do before you're eligible for the procedure.

What to expect with DBS surgery

Most patients get DBS as two surgeries one to two weeks apart. The first operation implants the electrodes, and the second implants the battery pack. You'll need to stay in the hospital for a day or two after the first surgery, while the second is an outpatient procedure.

Nearly all DBS procedures can be performed while a patient is asleep or awake. Your doctor will discuss both options with you and help you select based on your preference. Patients who undergo DBS surgery while awake will receive a local anesthetic and mild sedation. They will be able to help doctors test the correct placement of the leads. To ensure that you can test the electrodes' effect on your symptoms, you'll need to stop taking your movement disorder medications the day before the surgery.

For patients who choose to be asleep for the procedure, your doctor will use an MRI scanner to determine the location of the leads while you are under general anesthesia. In this version of the procedure, you don't need to stop your medications before surgery.

What happens after DBS surgery

After your operations, you'll need a little time to recover. Your doctors will give you instructions on how to wash yourself and take care of the incisions and stitches, if any.

You'll also need several follow-up visits to program your DBS implant. You'll meet with your neurological care team several times over three to six months. This will help your doctors adjust the electrical stimulation to relieve your symptoms.

Life with DBS

Your DBS implant should help you live a more active, fulfilling life. Many sports and physical activities become easier after DBS surgery. Once your surgery sites are healed, you can exercise and shower normally.

Metal Detectors and DBS

Metal detectors in airports or other public venues will not harm your DBS implant. After your operation, you'll receive a wallet card with information about your DBS. You can show it to security and request a hand pat-down, just as you would for a pacemaker.

Some airports use backscatter X-ray or millimeter wave whole-body imaging machines. These will not interfere with your DBS device and are safe to use normally.

Can I Have Medical Imaging with DBS?

DBS is compatible with X-rays, ultrasounds, CT scans, and nuclear medicine scans (PET, SPECT, etc.). All currently available DBS systems are MRI-compatible to some extent, though there are limitations to the kinds of MRI scanners, study length, and which segments of the body can be imaged. Patients should consult with their neurologist before undergoing any other medical procedures.

If a part of your DBS system is not functioning correctly, your system may no longer be MRI-compatible, and you will need to use other approaches to diagnostic imaging. Before an MRI scan, you should see your DBS neurology team to document that your DBS system is functioning normally and is set to parameters compatible with the scan you need.

Outcomes of DBS Treatment

All patients are different, and each case is unique. Talk to your care team about the results you can expect from a DBS procedure based on the details of your condition and medical history.