Surgical Options for PD Treatment
by Dr. Dean P. Sutherland
For properly selected patients, surgery can ease the symptoms of Parkinson disease and may allow for significant reduction in medications, but it is not a cure. Because of the risks associated with any brain surgery, it is usually not considered unless all appropriate medications have been tried unsuccessfully.
Deep Brain Stimulation
The typical patient who benefits from Deep Brain Stimulator implantation has a history of PD that responds well to medication, but the side effects of the medication have become unacceptable (hallucinations, dyskinesia, confusion). Several well-done, peer-reviewed studies have shown that DBS implantation improves motor symptoms by about 50% and allows for an average decrease in medication dosage by more than 30%. Recent studies have also shown that DBS is more effective in younger patients and maybe in patients with moderate disease (whereas we used to reserve it for “end-stage” patients). There is even a suggestion of possible neuro-protective benefit of DBS surgery (slowing down progression), but this remains to be proven.
Risks & Expectations
It should be noted that even in patients with an encouraging pre-operative profile, DBS surgery occasionally has limited success. According to Dr. Michael Okun, Medical Director for the National Parkinson Foundation, and his colleagues, most DBS failures are due to unrealistic expectations, poor follow-up, or incorrect surgical placement of the DBS. When considering surgery, it is important to see both a neurologist and a brain surgeon who specialize in the treatment of Parkinson disease and to inquire about their performance records in the operating room.
DBS Surgery & Followup
Patients who have completed the pre-operative workup and are selected for DBS surgery work closely with their neurosurgeon and neurologist prior to the day of surgery.
Surgery & Initial Programming
Surgical implantation is complicated. Following surgery, patients stay in the hospital overnight just to make sure that they have no complications. There is typically a 1-3 day “honeymoon period” during which the patient feels significant relief of symptoms of PD; this effect is due to the insertion of the DBS electrode, even though it is not activated yet. This effect, which is a good hint of success, usually wears off prior to the actual initial programming of the DBS.
Careful initial programming and close follow-up are the keys to success in DBS patients. At all programming sessions, it is important that the patient take NO PD MEDS within 4 hours of coming into the clinic. The first step is to check the Internal Pulse Generator or IPG (also called the “Battery Pack” by some) to make sure it is working properly. Then, all of the electrodes are checked for effectiveness of therapy as well as for side effects.
After an effective setting has been reached, the patient is allowed to take his or her medications and wait in the clinic to see what the combination of a new DBS unit and the PD medications will be, then the patient is re-evaluated prior to leaving the clinic.
Followup & Additional Programming
Follow-up for DBS programming can be as long as 3 months (for a simple battery check in a stable patient) to as short as 1 week (in new or complicated patients). Of course, post-surgical care for the incision sites and battery pack problems is provided by the neurosurgeon. Complications of DBS after the initial programming, such as pain or unusual movements, can be taken care of by turning off the DBS unit, either at home or in the clinic, followed by re-programming. To this end, patients can obtain a magnet to turn the DBS off or on at home.
Access Review Device
An even better option is the Access Review Device, made by Medtronic, which is similar to a simple TV remote and can be taken anywhere with no problems (whereas the magnets may cause demagnetization of credit cards or electronic devices).
All About Deep Brain Stimulators
Deep brain stimulation is a treatment that can produce remarkable results. Here’s one woman’s story...
"Today I woke up shaking. I cannot even button my blouse. But then I switch on a little miracle. There’s a pacemaker-like device in my chest, you see. Now, I’m getting ready to meet the girls for lunch and I might just eat a bowl of cereal without spilling any milk before I go out. I’m better off today than I have been since Parkinson Disease entered my life a decade earlier."
Many patients are benefiting from a surgical procedure known as deep brain stimulation, which entails implanting one or two stimulators in the brain to deliver precisely targeted electrical impulses. The past ten years have brought significant advances in the treatment of Parkinson Disease, a progressive and degenerative neurological disorder that causes loss of control of body movements. New medications help, but some patients experience significant side effects.
Deep brain stimulation gives neurologists and neurosurgeons another treatment option in our fight against Parkinson Disease. As a neurologist, Dr. Sutherland specializes in identifying good candidates for deep brain stimulation. Skilled and experienced neurosurgeons perform the procedure. Dr. Sutherland makes postoperative adjustments to the stimulators using a portable programmer that controls and monitors the neurostimulator function. The stimulators may require one or two adjustments in the month following the procedure. Later adjustments occur four to six times a year.
Unilateral (one-sided) deep brain stimulation was approved by the Food and Drug Administration (FDA) in 1997 for essential tremor and tremor in Parkinson Disease. In January 2002, the FDA approved the bilateral therapy for advanced Parkinson Disease motor symptoms. Medicare provides coverage for unilateral deep-brain stimulation in all 50 states and for bilateral deep-brain stimulation in more than 30 states. Many other payers cover deep-brain stimulationas well.
“Deep brain stimulation can give patients with Parkinson Disease control over their debilitating slowness, stiffness and shaking.”
Of the estimated 1 million Americans with Parkinson Disease, approximately 100,000 may benefit from this treatment. Deep brain stimulation can give patients with Parkinson Disease control over their debilitating slowness, stiffness and shaking. It reduces the dyskinesia (abnormal and involuntary movements) that is a common side effect of Parkinson medications.