Deep Brain Stimulation (DBS)

What is deep brain stimulation?

Deep brain stimulation (DBS) uses electrical stimulation to treat neurological conditions such as Parkinson disease (PD), essential tremor, and multiple sclerosis. DBS is used to treat movement problems such as tremors, stiffness, difficulty in walking, and slowed movement. While it does not cure these conditions, DBS can ease symptoms and decrease the amount of medicine you need.

Movement-related symptoms of PD and other neurological conditions are caused by faulty electrical signals in the areas of the brain that control movement. DBS does not damage brain tissue. Instead, it blocks the faulty signals that cause tremors and other movement symptoms.

DBS is done by placing an electrode inside the brain. The electrode is connected to a very small neurostimulator (electrical generator) implanted in your chest or abdomen. Electric current is delivered from the neurostimulator to the electrode in the targeted area of brain tissue responsible for symptoms.

Why might I need DBS?

DBS may be an option for certain people with neurological conditions when medicines have become less effective or when side effects of the medicines interfere with daily activities.

One of the main uses of DBS is to treat symptoms of Parkinson disease. It can help when medicines become less effective, or when movement problems or side effects worsen.

DBS may also be used to treat:

• Essential tremor. A condition that causes a rhythmic trembling of the hands, head, voice, legs, or trunk.
• Multiple sclerosis (MS). A chronic disease that affects the central nervous system—the brain, spinal cord, and optic nerves. MS is often disabling.
• Intractable pain. This pain can’t be relieved by usual medical or surgical treatment.
• Dystonia. A movement disorder in which muscles contract involuntarily.
• Psychiatric conditions. These are conditions, such as obsessive-compulsive disorder, anxiety, and depression, that don’t respond to medicine or other treatments.

Your healthcare provider may have other reasons to recommend DBS.

Not all people with these conditions are good candidates for DBS. Talk with a neurologist who specializes in movement disorders to determine if you are a good candidate for DBS.

What are the risks of DBS?

As with any surgical procedure, complications can occur. Possible complications include:

• Reactions to anesthesia
• Bleeding in the brain
• Leaking of cerebrospinal fluid; this clear fluid is found around the brain and spinal cord
• Infection
• Stroke
• Pain or swelling at the surgery site
• Movement of the electrode from the original location
• Allergic reaction to parts of the implanted device

Side effects that may occur after the surgery include:

• Temporary tingling in the face and limbs
• Slight paralysis
• Problems with speech or vision
• Jolting or shocking sensation
• Dizziness or loss of balance
• Reduced coordination
• Trouble with concentration

There may be other risks, depending on your specific medical condition. Be sure to discuss any concerns with your healthcare provider before the procedure.

How do I get ready for DBS?

DBS requires a commitment to participate in evaluations, procedures, and consultations before and after the procedure. DBS is usually only available in large medical centers. If you do not live close to a medical center that offers DBS procedures, you may need to spend significant time traveling. The procedure and associated appointments can be expensive. It is also important for you to have realistic expectations. Although DBS can improve symptoms, it will not cure the condition.

Before DBS, you will have assessments to determine whether this is a good option for you. You will need tests to evaluate memory and thinking. A psychiatrist may examine you to determine if you have a condition such as depression or anxiety that requires treatment before the DBS procedure.

Ask your healthcare provider about what you might need to do in the days and weeks before your procedure, such as if there are any special dietary or medicine restrictions.

What happens during DBS?

Implantation of a DBS lead generally requires a hospital stay of a day or longer. Procedures may vary depending on your condition and your healthcare provider’s practices. The lead and neurostimulator may be implanted at the same time, or the neurostimulator may be implanted in a separate procedure after the lead is implanted. Talk with your healthcare provider about what you will experience during your procedure.

Generally, surgery for DBS follows this process:

Implantation of lead

1. Numbing medicine will be injected into your scalp and a head frame placed to keep your head in the right position for the procedure. A computed tomography (CT) scan or magnetic resonance imaging (MRI) scan will be taken to locate the target site in the brain for the electrode.
2. You will be awake during the surgery, as you will be asked to move certain parts of your body as the lead is being placed.
3. After more numbing medicine is injected into your scalp, the neurosurgeon will drill a small hole in the skull to insert the lead.
4. Recordings will be taken as the lead is moved through the brain tissue to help pinpoint the exact placement for the lead. You may be asked to move your face, arm, or leg at certain times while the recordings are being taken.
5. Once the precise location for the lead has been determined, it will be attached to an external neurostimulator. Electrical stimulation will be given through the lead for a short time to see if symptoms improve. Your surgeon may deliberately cause side effects with electrical stimulation to make sure the lead is in the right place. 
6. The lead will be attached after it is in the proper location. A wire to connect the lead to an extension to the neurostimulator will be placed under the scalp.
7. The hole in the skull will be closed with a plastic cap and stitches.

Placement of the neurostimulator

This may or may not be done at the same time the electrode is placed.

1. You will receive general anesthesia so that you are asleep during the procedure.
2. The neurostimulator will be inserted into a “pocket” under the outer layers of skin tissue, usually just under the collarbone, or in the chest or abdomen.
3. An extension wire will be attached to the neurostimulator and to the brain lead.
4. After the neurostimulator is implanted, it is programmed to deliver an electrical signal. Programming is usually done a few weeks after the neurostimulator is implanted.

Programming the neurostimulator

Programming the neurostimulator is a process that occurs over time. You will likely return several times for adjustments to the settings. Your medicines may also  be adjusted. The goal is control your symptoms with the most appropriate amount of electrical stimulation and medicine.

Once your “best” settings have been determined, you will need to return periodically for checkups. Your healthcare provider will determine your follow-up schedule based on your particular situation.

You will be given a magnet to turn the neurostimulator on or off under conditions prescribed by your healthcare provider.

The neurostimulator is powered by a long-lasting battery that generally lasts 3 to 5 years. When the battery starts to wear out, the neurostimulator will be replaced with a new one in an outpatient procedure.

 

What happens after DBS?

In the hospital

You will be watched for complications, such as seizures. In general, the hospital stay after a DBS procedure is 24 hours; however, you may stay longer if complications develop. Before you are discharged from the hospital, arrangements will be made for a follow-up visit with your healthcare provider. He or she will also give you instructions for home care.

At home

Once you are home, it’s important to keep the incisions clean and dry. Your healthcare provider will give you specific bathing instructions. If stitches were used, they will be removed during a follow-up office visit. If adhesive strips are used, they should be kept dry and generally will fall off within a few days.

Living with a DBS neurostimulator

Consider these precautions. Discuss the following in detail with your healthcare provider:

• Always carry an ID card that states you have a DBS neurostimulator. In addition, you may want to wear a medical ID bracelet indicating that you have a neurostimulator.
• Let airport security screeners know you have a neurostimulator before going through the airport detectors. In general, airport detectors are safe, but the small amount of metal in the neurostimulator may set off the alarm. If you are selected for additional screening by hand-held detector devices, politely remind the screener that the detector wand should not be held over your neurostimulator for longer than a few seconds, as these devices contain magnets and thus may affect the function or programming of your neurostimulator. You may want to bring a note from your doctor about your implanted device.
• You may not have certain MRI procedures, because these machines use large magnets for imaging.
• You should avoid places with large magnetic fields, such as power generators and automobile junkyards that use large magnets.
• Avoid using heat in physical therapy to treat muscles.
• Avoid high-voltage or radar machinery, such as radio or TV transmitters, electric arc welders, high-tension wires, radar installations, or smelting furnaces.
• If you are scheduled for a surgical procedure, tell your surgeon that you have a neurostimulator long before the operation. Also ask your healthcare provider’s advice on whether anything special should be done before and during the surgery, as the electrocautery device that controls bleeding may interfere with the neurostimulator.
• When participating in a physical, recreational, or sporting activity, protect yourself from causing trauma to the neurostimulator. A blow to the chest near the neurostimulator can affect its functioning. If you are hit in that area, you may want to see your healthcare provider to have it checked.

Long-term effects of DBS

DBS can help improve symptoms of tremors, stiffness, slowness, and movement problems. It can also help with medicine therapy by decreasing the dose needed. Decreasing the dose of medicine can ease side effects of long-term medicine use. Many people continue to have improvements in their symptoms for several years after the procedure. They are able to do basic activities, such as eating, toileting, and dressing. Memory, thinking, and mood may or may not be affected. Many neurological conditions are progressive, so later complications can develop. If these complications develop, the gains obtained from DBS may eventually be lost.

Next steps

Before you agree to the test or the procedure make sure you know:

• The name of the test or procedure
• The reason you are having the test or procedure
• What results to expect and what they mean
• The risks and benefits of the test or procedure
• What the possible side effects or complications are
• When and where you are to have the test or procedure
• Who will do the test or procedure and what that person’s qualifications are
• What would  happen if you did not have the test or procedure
• Any alternative tests or procedures to think about
• When and how will you get the results
• Who to call after the test or procedure if you have questions or problems
• How much will you have to pay for the test or procedure