Deep Brain Stimulation for Movement Disorders
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What is Deep Brain Stimulation?
Deep Brain Stimulation (DBS) is a procedure in which stimulating electrodes are placed into the deep structures of the brain. The electrodes are connected to an implanted pulse generator which is battery powered.
Selected patients with treatment resistant movement disorders such as Parkinson’s disease, tremor and dystonia can benefit from Deep Brain Stimulation (DBS).
Successful DBS allows a decrease in medication or makes a medication regimen more tolerable in these disorders. There are gains in movement and control. The intervention is used for carefully selected patients, in accordance with clinical eligibility criteria, who cannot be adequately controlled with drugs or whose drugs have severe side effects.
If you have any questions or concerns about DBS Surgery, please contact us (Monday to Friday, 9am to 5pm).
Consultant’s secretary Numbers:
Mr Pereira: 0208 725 4173
Dr Paviour: 0208 725 4627
Dr Morgante: 0208 725 2470
Dr Lucia Ricciardi: 0208 725 2470
Movement Disorder Team Nurses:
Alison Leake: 0208 725 4677
Catherine Parry: 0208 725 2141
Functional Neurosurgery Service Coordinator:
Neurology Ward: 020 8725 4671
Neurosurgical Ward: 020 8725 4644
DBS for Parkinson’s Disease
Why should I have DBS Surgery? – DBS Surgery helps to treat the “motor” symptoms of Parkinson’s disease including stiffness, slowness and tremor and helps reduce fluctuations in these symptoms that occur in people who have had the condition for several years. It’s not a cure, but it may help to control many of your symptoms. It may also mean that you have to take less medication, which can reduce the risk of medication side effects, such as involuntary movements (dyskinesia).
Are there any alternatives? DBS surgery in Parkinson’s disease is a good treatment in appropriate patients. It is usually offered as treatment to control fluctuations in medication response that have not responded well to adjustments.
Treatment options for Parkinson’s Disease
Other treatments in this situation include continuous infusions of jejunal Levo-Dopa (Duodopa) given via a tube into the gut and Apomorphine via a continuous sub-cutaneous infusion. There is no good data directly comparing these treatments but your Neurologist can discuss them with you.
DBS for Dystonia
Dystonia is a disorder which causes abnormal contraction (tightening) of groups of muscles. This results in involuntary, sometimes painful movements of the affected parts of the body. The cause of dystonia is unclear, although some types are hereditary (inherited) and start to develop in childhood. Deep Brain Stimulation can be used to treat some people with the following types of dystonia:
- generalised (involving much of the body)
- segmental (involving just certain parts of the body)
- cervical (involving the neck and shoulders).
Deep Brain Stimulation for dystonia involves implanting fine wires into a place in the brain called the internal pallidum (also known as the Globus Pallidus interna or GPi). A constant electrical pulse is sent through the wire to the brain. This modifies the brain activity and reduces some of the symptoms of dystonia.
Why should I have DBS Surgery? DBS Surgery helps to treat the symptoms of Dystonia. It’s not a cure, but it may help to control many of your symptoms. DBS may be considered for dystonia if the type of dystonia you have has been evaluated by a Movement Disorders Neurologist and if:
- The dystonia adversely affects quality of life by interfering significantly with normal activities or causing social isolation.
- Attempted treatment with a variety of medications including sinemet and anticholingergic medications such as trihexyphenydil have failed to help. Baclofen and muscle relaxants such as clonazepam are also often tried before considering surgery.
- The dystonia affects too large a body area to be treated effectively with injections of botulinum toxin (botox); or attempts at injection with botox have been tried and failed.
Primary dystonias (patients without brain abnormality on MRI) are more likely to benefit than those with secondary dystonia (patients with brain abnormalities seen on MRI that are causing the dystonia).
Are there any alternatives? DBS surgery in Dystonia is a good treatment in appropriate patients. Other treatments include anti-cholinergics (Artane, trihexyphenydil), Levo-Dopa, clonazepam and for focal dystonia, botulinum toxin.
There is no good data directly comparing these treatments but your Neurologist can discuss them with you. DBS is usually considered if these treatments have failed.
DBS for Tremor
Tremor can be a symptom of a number of different disorders, some of which are hereditary (inherited). Sometimes tremor can occur as a result of a head injury or stroke but sometimes the cause is not known.
Why should I have DBS Surgery? DBS Surgery may help treat tremor in suitable patients who have not responded to first line drug treatments typically used to treat tremor. In your case, these may have included beta-blockers (propranolol or atenolol), primidone or anti-epileptic drugs (such as clonazepam, pregabalin, gabapentin or topiramate).
DBS is not a cure for the cause of your tremor, but it may help to control many of your symptoms.
Are there any alternatives? DBS surgery for tremor is a good treatment in appropriate patients. It is usually offered when other tablet based treatments have failed to have a good effect
The Atkinson Morley Movement Disorders Group includes a team focussing specifically on the management of people with Movement Disorders that may benefit from DBS Surgery.
These include a Neurosurgeon, Neurologists and a Specialist Nurse. We work together to review and assess suitable patients and will meet patients in a multi-disciplinary setting to plan treatment.
Referrals can be made directly to any of the team members or directly to the DBS service coordinator. An initial appointment with one of the Neurologists will be offered.
How are people with Movement Disorders assessed for DBS surgery suitability?
Preparation for surgery involves a number of visits to the hospital to meet the members of the team that will be looking after you.
Clinic visit You will be seen in clinic first of all by an experienced member of the Movement Disorder team. They will discuss your symptoms with you and any treatment you have tried in the past.
They will discuss with you whether they think that DBS will be the best treatment for you. If the team recommends DBS surgery, then we will talk to you about what this involves. We will not put you under pressure to make a decision on the day of your first appointment.
If you decide to go ahead with the assessments, we will arrange dates for you to come to hospital, just for the day.
There are a number of investigations to fit in, so dates need careful planning.
Further assessment on the Day-Unit Assessment of movement disorders includes video recordings of you during various activities.
These help us to see any differences between when you are ‚”off” and ‚”on” your medication if you are taking any.
Because of this we will ask you not to take your normal medication prior to the morning of your assessment. If you have botulinum toxin injections for dystonia, you will need to have your assessment at least 12 weeks after your last set of injections.
A neuropsychological assessment is also part of the assessments carried out before surgery. This looks at your memory, mood and the way you think. The physiotherapist and speech and language therapist may also assess you.
Magnetic Resonance Imaging (MRI) brain scan. An initial scan is done to make sure there is nothing that would make surgery more risky in your case such as evidence of previous strokes or marked loss of brain volume. A second more detailed scan will need to be done to help the surgeon to see the area they will target during the operation.
Deciding to Proceed. The assessments are an opportunity for the team to have a look at your symptoms to see if they feel DBS will help you. If, after the assessment, we feel that DBS would not be appropriate, the surgery will not be offered.
You will be able to discuss the results with one of the consultants if you wish; this may need to be at another clinic appointment.
If the Movement Disorder Team has decided you would benefit from DBS, we will also then decide which procedure will give you the best results.
What are the risks of DBS Surgery?
As with all types of surgery, DBS involves some degree of risk and the chance of complications.
- There is a chance that the surgery will not benefit you as much as you would like and it is not possible to be certain before the operation how much benefit you will obtain
- The most serious complication is a 0.5% (1 in 200) chance of a bleed into the brain (stroke) from this procedure. This can result in weakness down one side of the body, speech difficulties or impairment of vision. How much a stroke affects a person is related to the position of the bleed and how severe it is.
- There is a risk of infection in the wounds. If treatment with antibiotics does not stop the spread of infection, the whole DBS system may have to be removed.
- It is possible that there could be movement of the electrode. If this occurs, it may need to be replaced. This would mean repeating stage 1 of the procedure.
- There is the possibility of lead fracture (the wire breaking). This would mean repeating stage 1 of the procedure, but may also mean replacing additional parts of the DBS system.
- There is a small risk of the surgery inducing (causing) epilepsy. This risk is less than 1% (less than 1 in 100).
- The risk of death resulting from the operation is very small, at around 0.2% (1 in 500).