2. Deep Brain Stimulation: A Proven Treatment for Movement Disorders
Wendell Lake MD, MS
Assistant Professor
Director of Functional Neurosurgery/Epilepsy surgery

3. Financial Disclosures
None At This Time
Received Fellowship Support From Medtronic July 2014 to July 2015

4. Outline A brief History of Deep Brain Stimulation (DBS)
Parkinson’s Disease
Essential Tremor
Dystonia
Surgical Technique
Future Technologies
Conclusions

5. History
Surgical Treatment began in the Mid-twentieth century with ablative procedures
Introduction of levodopa therapy diminished interest in Surgery
thectr.org

6. Basic Science of Parkinson’s Disease
In the 1980s and 1990s Delong and Bergman study PD with the MPTP primate model
Benabid discovers that high frequency electrical stimulation creates a temporary reversible lesion
A working model of PD helped to usher in the DBS era
Direct pathway
Indirect pathway
E. Eskandar, G. Cosgrove, L. Shinobu. neurosurgery.mgh.harvard.edu

7. Parkinson’s Disease FDA Approved in 2002
Usual targets are the subthalamic nucleus or the Globus Pallidus Interna
Ideal candidates are Levodopa (Sinemet) responsive and have classic Parkinson’s disease
Machado A et al. CCJM Vol 79, No. 2, Feb. 2012

8. Parkinson’s Disease: What DBS Doesn’t Help
Gait or balance
Cognitive problems
Depression (unless situational)
Studyblue.com

9. Parkinson’s Disease: What DBS Does Help
Increases “On” time
Decreases Bradykinesia and Rigidity
Reduces Medication Dose
Improves dyskinesia
Effectively treats tremor

10. Parkinson’s Disease Outcomes
6 Randomized controlled trials support DBS for Parkinson’s Disease
DBS Statistically improves motor function and Quality of Life
Average increase of 4.6 hours per day of “On” time

11. Essential Tremor FDA approved in 1997
Familial or Essential tremor responds well
Improves tremor that is medication refractory
Target is the ventral intermediate (Vim) Nucleus of the thalamus
Costa J et al. Journal of Neurophysiology Published 1 September 2008 Vol. 100 no. 3,
Movementdisorders.florida.edu

12. Essential Tremor: What DBS Doesn’t Help
DBS doesn’t “Cure” tremor
May not eliminate all tremor
Sometimes tremor worsens with aging
Vocal and head tremor may be difficult to eliminate
Some DBS settings may cause dysarthria

13. Essential Tremor Outcomes
Randomized controlled trials demonstrated improved Activities of Daily Living and Improved tremor
80% improvement in tremor 70% improvement in handwriting
Zhang K et al. J Neurosurg Jun;112(6): doi: / JNS09371.

14. Dystonia FDA Humanitarian Device exemption 2003
Patients with medically resistant symptoms
More commonly used for primary dystonias (DYT-1, DYT-6) and torticollis
Target is globus pallidus (Rarely subthalamic nucleus)
Machado A et al. CCJM Vol 79, No. 2, Feb. 2012

15. Dystonia: What DBS Doesn’t Help
DBS doesn’t Cure dystonia
Sometimes symptoms progress despite therapy
May be less effective for secondary generalized dystonias
May not improve speech or swallowing

16. Dystonia: What DBS Does Help/Outcomes
3 randomized controlled trials demonstrated Improved Activities of daily living/quality of life
Effects of stimulation are not immediate
May improve pain in Cervical dystonia
Younger patients may have better outcomes

17. DBS Preoperative Evaluation
Evaluation in the Neurology Movement Disorders Clinic
Neuropsychological testing
Physical Therapy Evaluation
Discussion in Movement Disorders Conference
Neurosurgery Clinic Visit

18. DBS Placement
Usually done awake IV pain medications, local anesthesia and intermittent sedation
Placement of small recording microelectrodes
Above photo Courtesy of Leland Albright

19. Neurophysiology and Intraop Testing
Final lead position is determined from information obtained during microelectrode recording and test stimulation.
Z Williams, J Neimat, G. Cosgrove, E. Eskandar. Timing and direction selectivity of subthalamic and pallidal neurons in patients with Parkinson disease
Exp Brain Res (2005) 162: 407–416

20. 3D Printed Stereotactic Frames
Allow fast, accurate placement of DBS Leads for Awake Cases
Improve Patient Comfort

21. Initial Postoperative Care
Usually stay in the hospital one night following Cranial lead placement
Battery is placed in the outpatient setting under general anesthesia
Light activity for 2 weeks following the operation
Activation of the DBS system 1 month after placement of the Cranial leads

22. Programming and Maintenance
Programming and maintenance of the system is key
Initially the patient has frequent programming visits until they feel that the system is optimized
Batteries are replaced every 3-5 years
Rechargeable options are available

23. Risks of DBS Surgery
Brain hemorrhage: ~3%, most are asymptomatic but some can cause weakness or deficits
Infection: ~5%. Usually treated with removal of the battery and antibiotics.
Slurring of speech in Tremor patients (dysarthria)
Cognitive difficulties (risk increases with age)
Balance Problems

24. Options for Asleep MRI Guided DBS
UW-Madison is a pioneer in this field
Currently Emphasizing Parkinson’s disease patients
Generally reserved for patients unable or unwilling to tolerate awake surgery

25. Future Technologies
Expansion of MRI Guidance techniques for DBS placement
Treating other diseases with DBS: Depression, Alzheimer’s disease, Obsessive-Compulsive disorder
Implants that sense brain activity and adjust stimulation accordingly
Use prior Implantation data for computer modeling
Pierre-Francoise, D et. al. Stereotact Funct Neurosurg 2013; 91 (3):

26. Conclusions
DBS is a proven therapy for select patients suffering from Parkinson’s Disease, Essential Tremor and Dystonia
This exciting technology is undergoing continual improvement and may allow the treatment of many other diseases in the future