All You Wanted to Know About Deep Brain Stimulation Surgery: Dr. Paresh Doshi
Deep brain stimulation surgery (DBS) involves implantation of an electrode deep within the brain under local anesthesia. In recent times, Subthalamic Nucleus stimulation has emerged as the favored site for DBS.
This electrode is permanently left in place and connected to a small implantable pulse generator (IPG) (Fig.). This remotely programmed pacemaker emits minute pulses of energy through the electrode to block the abnormal activity in the brain that causes the symptoms of Parkinson’s disease.
The first procedure of the modern DBS was performed by Prof. Benabid, in France and reported in 1995 and published in 1997. We started performing DBS in 1999, the first DBS in India, after getting trained by Prof. Benabid. More than 1.5 lac patients have now undergone DBS procedures around the world.
When is the ideal time to undergo DBS (Deep Brain Stimulation surgery) procedure?
In the initial years of disease, PD is controlled by medications. The patient hardly requires surgical intervention to control the disease, the exception being, uncontrolled tremors which are seen in only 10 to 15% of the patients of Parkinson’s disease.
However, a few years down the line the disease progresses and the side effects of medicines are seen.
The most common side effects include motor fluctuations, In the form of sudden periods or unpredictable periods, hallucinations, dyskinesias or symptoms attributable to dopamine dysregulation.
At this time increasing the dose of medication is not helpful as it only brings in more side effects.
The patient usually start changing doctors in search of better control of the disease, however, every change that brings some improvement becomes increasingly short-lived.
Usually period comes 6 to 7 years after the disease progress is, however, it can occur earlier in some patients, especially if the patient got PD at a young age of less than 40. It has been in the opinion of all International experts in the field that the onset of motor fluctuations should initiate the discussions for surgery.
We believe that the surgery should be offered to the patient when his disease is not adequately controlled by medical management and his quality of life is getting impaired.
In 2013, a landmark study was performed across seven centers in Europe which concluded that offering surgery early in the course of the disease, after the motor fluctuations are set in, would not only improve the quality of life but also helped patients to reduce the medication dosage and avoid long term side effects.
One can Google this by the name of the EARLY STIM study for more information. Even the USA FDA has given approval for performing studies early in the disease.
What are the benefits of Deep Brain Stimulation Surgery(DBS)?
It is known that the surgery will improve the duration of your ON period, i.e. the period when you are fully functional without the side effects of medicines and not frozen, as in, without the effect of the medicine.
Typically the surgery will increase the on period to last for 70 to 80% of the day and the rest of the day the patient would experience mild OFF periods which are not as severe OFF periods as they used to suffer from before the surgery.
After successful surgery in most of the patients, we have found that we are able to reduce the medications by 40%, in some patients who have opted for surgery earlier in the disease we have also been able to take them off medications.
Significant benefit on tremors and rigidity alleviation dyskinesias and hallucinations improves depression, increases weight and an overall positive feeling to help in improving the quality of life.
However, all the patients do not benefit equally and hence it is very important that your surgeon understands what he can deliver by surgery and what he can improve by medical management so that you can understand the exact outcome of the surgery.
Most of the centers do not have adequate experience to give you convincing and confident answers to all these questions which are very important to the patient.
Can you describe a typical Deep Brain Stimulation surgical procedure?
The surgical procedure differs from centre to centre. We have perfected the art of surgery and have realised that each patient is an individual we have to cater to the mindset of every patient.
A typical surgical procedure involves the admission of the patient on day 1, followed by MRI under sedation or general anaesthesia on Day 2, surgery of electrode implantation under local anaesthesia on day 3 and pacemaker implantation on day 4 under general anaesthesia.
During the first two days, there are extensive Parkinson’s disease-related assessments, video recordings and patient counselling by our team in order to ensure that the patient can undergo surgery with confidence and with a smile.
Usually, the patient stays in the hospital for the six to seven days until the removal of sutures. During this time he undergoes programming of the pacemaker and simultaneous reduction in medications.
We have different strategies for operating younger patients and elderly patients, and patients with comorbid diseases. We are very particular in our protocol for example, we only perform MRI using 3T MRI machine, navigation system for the surgery is used in the hospital and not procured from outside, the microelectrode recording equipment which is one of the most sensitive tools for guiding the success of therapy also belongs to the hospital and hence chances of error are minimised.
During both the parts of the surgery, i.e. under local anaesthesia on day 3 and general anaesthesia on day 4, the senior-most anaesthetist, who has been a part of our team for the last 20 years, gives anaesthesia, thus ensuring the safety of the patient.
What would be the follow-up schedule after DBS surgery
As we have a large experience of operating patients of Parkinson’s disease we are very confident that our initial programming will give the desired benefit to around 70% of the patient.
However, there are some patients who may need reprogramming in the first three months after surgery once the initial effect of surgery wears off.
We always recommend to the patient that they should be repaired to come back to Our center once in the first three months if required. We do not charge for any reprogramming for the first time and this is covered in the cost of surgery (except if the patient gets admitted).
One’s the patient has reached stable programming parameters we give them two or three different programs so that they can adjust to the requirement after they go back to the routine.
We usually have to see them once a year or once in two years.
What are the different types of pacemakers of DBS and what are their merits and demerits?
Presently there are two companies in the country that have the infrastructure and direct presence to offer DBS solutions.
There are other companies that work through the distributors, which we do not endorse, as we do not know when they will stop the services and the patient may be left with the pacemakers which cannot be serviced.
The first is the Medtronic company which offers two types of pacemakers one is non-rechargeable and the other is rechargeable.
These pacemakers are MRI compatible, so one can undergo MRI with certain restrictions. There are specific advantages and disadvantages of rechargeable and non-rechargeable pacemaker which is best explained personally when we meet.
The second company is Boston scientific that offers rechargeable pacemakers who have the duration of life for 25 years.
However, these pacemakers are not MRI compatible and hence if a patient needs to undergo MRI then he will have to find another alternative form of investigation.
Once again there are several subtle advantages and disadvantages of both these systems, that can be discussed personally.
What precautions will be needed after DBS?
After surgery, we will provide you with a detailed list of dos and don’ts that you have to take care of in order to safeguard the pacemaker. Broadly speaking, you can continue to do all the normal activities that you would like to do, e.g. swimming, dancing, jogging or any kind of exercise, use of cell phone, microwave oven, driving, etc.
What are the risks of DBS surgery?
DBS surgery is pretty safe in experienced hands.
The risk of surgery is minimal. We have analyzed and published our own data for the first 150 DBS procedures and we had found that our risk of major complications was less than 1.5 %.
This compared favorably with the best centers around the world. (Fig complications). As a patient, you need to evaluate the risk v/s benefit ratio.
The risk of the procedure reduces with learning, e.g. for the lady of the house to make a mistake whilst cooking is rare, whereas if someone less experienced cooks the same meal, it is going to taste differently each time.
Why is the surgery done in two stages?
We perform surgery in two stages because we feel that this increases the safety of the procedure.
The first surgery is done the local anesthesia, after which the patient can be returned back to the room and given levodopa and meal, so as not to keep him off medications for too long.
The next day we can do the surgery under general anesthesia which is safe for the patient.
We will discuss this more in detail when we meet. We are aware that this increases the cost of the surgery but we do not want to reduce the cost and compromise on Patient Safety.
Is the DBS surgery painful, as it is done under local anaesthesia?
There is an initial pain of a minimal pinprick when we give u local anesthesia, however, once the local anesthesia text effect you will not feel any pain during the surgery.
However, you would realize that we are working on your head and we will be keeping you informed of all the things that we would be doing during the procedure as we go along the procedure.
This increases the patient comfort and confidence in the procedure and none of our patients has ever felt that he had a traumatic experience from the surgery.
I am an elderly patient and I have heard that the surgery is risky or not advisable?
Usually, people are reluctant to offer surgery to elderly patient for several reasons.
One of them being scepticism about getting a good outcome.
However, long-standing experience and the opportunity to probably operate on the largest number of elderly patients in the world has helped us to tailor the treatment to make the surgery safe and effective for elderly patients.
For example, we use different targets if the patient has got some amount of cognitive or memory impairment.
If the patient cannot tolerate surgery under local anaesthesia we can do it with conscious sedation.
We also prepare ourselves, patient and the relatives to ensure that the surgical experience remains as comfortable as one would wish it to be.
We recently published our outcome of elderly patients versus young patient operated at our centre and found that there was no increased rate of complication and the improvement in Parkinson’s disease was more or less similar ‘(fig young vs old)
Will I be required to follow up with my Neurologist? Who adjusts the medical treatment after surgery?
If you are in touch with the movement disorder specialist then we may be able to speak to him and explain to him the parameters that we have set and what we expect in terms of medication changes.
However, if you feel that you are more comfortable with us making both the changes i.e. stimulation parameters and medications we would be happy and confident to do the same.
What is programming and how important is it in the outcome of DBS surgery?
Programming is The Key to the success of DBS.
Even if you have got the surgery done pretty well, if you cannot program the pacemaker correctly, it is like having the best computer at your disposal but not having the skills to use it.
If I have to give an example, Microsoft Excel is a program used by everyone, but the way an analyst/accountant can use that is far different from me using it.
Hence, to extract the full benefit of surgery, correct knowledge to program the pacemaker is very critical.
Our team has 1000s of hours of programming experience and hence we can immediately assess the response of each program subset and offer the best.
In fact, we have been able to capture the benefit of surgery for the patients who have been operated in other centers, just by fine-tuning the pacemaker, which that particular center could not do. (read testimonial)
What do our patients say
Finally, what are the differentiating points in your center?
- DBS is not a procedure for us but it is a religion we practice it with great faith and passion to ensure that the patients were putting trust in the US are awarded to the best of our abilities.
- We have one of the experiences of performing DBS surgery by a single and Esteem over the last 20 years or more than 500 patients.
- The engagement with the center is not limited to the surgical procedure, like this (surgical procedure) can be done by other people also, however, the postoperative management, understanding the Symptoms and Signs of advancing PD, understanding the limitations that you can treat and not treat and having the ability to use all the skills that are needed to program these patients, to achieve benefit out of DBS is the USP of our center, which no other Centre can replicate.
- Apart from offering the best care and support to the patient, we have worked very hard to minimize the risk and complications of surgery and we are confident today to offer this surgery to patients who are usually considered not amenable to surgical treatment e.g. patients above 80 years
- We are the only center in the country that has extensively published our work in Peer-reviewed journals to give credibility to our program.
- There have been several research projects, like comparing the infection rate amongst different categories of room accommodation at our hospital, which method of targeting is foolproof, can we use a resterilized pacemaker, etc. conducted at our hospital in the last 20 years to improve the patient outcome.