Deep Brain Stimulation

What is deep brain stimulation?

Deep brain stimulation (DBS) is a medical procedure that involves placing stimulating electrodes in the brain as a treatment for movement disorders.

These include essential tremor, Parkinson’s disease, and dystonia. Your primary care provider may elect to use DBS as the treatment of choice for neuropsychiatric conditions or movement disorders.

This is if side effects from other treatments are affecting your daily activities or when the medication prescribed is less effective.

The procedure involves the delivery of electrical current to a particular section of your brain to stimulate brain cells.

Your surgeon implants a small programmable generator under the skin in your upper chest for the control of brain stimulation.

While DBS is not a cure for the underlying condition, it allows for effective management. It also means you require less medication for your condition and hence fewer side effects.

Who needs deep brain stimulation?

Before you can undergo DBS surgery, your primary healthcare provider will have conducted a battery of tests, procedures, and evaluations to determine that you are the right candidate for this procedure.

You will also have to undergo a series of post-surgery consultations and evaluations to ensure the procedure went on successfully.

This may involve a lot of travel to and from the healthcare facility where DBS is conducted for such appointments. It means also that DBS can be an expensive procedure.

Most insurance products can cover DBS but the extent of coverage is determined by the insurance policy you have taken.

Your primary care provider will prepare you to have realistic expectations regarding this procedure.

DBS can considerably improve the quality of your life besides eliminating or minimizing movement problems. However, it is not a guarantee for the resumption of perfect health.

You may need deep brain stimulation to treat the following conditions:

Essential tremors

A tremor can occur because of various disorders, including inherited conditions. Essential tremors could also be because of a stroke or head injury

DBS has proven to be an effective therapy for the treatment of severe essential tremors, especially where shaking interferes with a person’s daily activities or is disabling

DBS allows such individuals to function normally and their overall health improves significantly.

Parkinson’s disease

Individuals with the following forms of Parkinson’s disease will benefit from DBS:

• Individuals suffering from uncontrollable tremor that does not improve with medication

• Individuals suffering from severe motor fluctuations after medication, as the effects of drugs wear off

• Persons who would benefit from higher mediation dosages but who experience severe side effects from medication adjustments

Psychiatric conditions

DBS surgery can be effective for persons diagnosed with obsessive-compulsive disorder (OCD), depression, or Tourette’s disorder.

Dystonia

This is a rare movement disorder that is characterized by unusual twisting and posture movements.

Patients with dystonia respond well to DBS surgery after medication cannot offer sufficient relief.

Different people respond differently to DBS based on whether dystonia is drug-induced or genetic.

In case your doctor cannot identify the cause of your dystonia, he or she will conduct additional tests as part of the DBS procedure.

Other conditions that DBS can help with:

• Alzheimer’s disease

• Addictions

• Schizophrenia

• Cluster headache

• Tourette syndrome

• Anxiety

• Eating disorders

• Medication-resistant depression

Reasons why you may not be a good candidate for DBS

You may not make a good candidate for DBS surgery if you present with one or more of the following symptoms:

• In case of speech difficulty

• Problems with walking or balance

• Ongoing problems with thinking, memory, and confusion

• If your anxiety or depressive condition fails to stabilize or improve despite other treatments

• In case you have an underlying condition that puts you at risk of surgery complications

Preparing for DBS

Before DBS surgery, your primary healthcare provider will arrange an initial evaluation with the movement disorder team.

This team comprises a neurologist, a neurosurgical physician assistant, a neurosurgeon, a DBS nurse coordinator, a neuropsychologist, and a movement disorders specialist.

The goal of this team is to establish that DBS surgery is the most appropriate treatment for your conditions.

During the evaluation appointment, your primary healthcare provider will order the following tests:

• Computed tomography (CT) scan

• Magnetic resonance imaging (MRI) scan

• Urine and blood tests – These tests are essential for the identification of abnormalities and toxins

• A neuropsychologist will conduct a detailed emotional and physical readiness evaluation for DBS

• A cognitive evaluation allows the surgical team to ascertain that you can take part in the DBS surgery

Such an assessment provides your surgeon with feedback throughout surgery and across the neurostimulator adjustment process.

A cognitive assessment informs the medical team of a risk such as cognitive problems or worsened confusion after DBS surgery.

A specialist in movement disorders will also undertake a comprehensive assessment of your movements.

Once the team has concluded with the evaluation, you will meet with them and explore whether DBS is the right medical procedure for you, and the likely risk factors that might accompany this procedure.

The next medical visit is with a neurosurgeon. If you have questions regarding the surgical risks or options, feel free to ask your neurosurgeon.

This meeting will help you decide on whether to pursue DBS surgery. Your psychiatrist may assess you for anxiety, depression, or other psychiatric problems that require treatment before undergoing the DBS surgery.

Your healthcare provider may also conduct swallowing, speech, or language evaluation

Before DBS, your healthcare provider will be interested in:

Whether you are on any medication: If you are taking any medication including blood thinner, you will be asked to stop taking these.

In case you are taking other medication such as supplements and vitamins, let your healthcare provider know of this too.

Bathing – You will be instructed on how to bathe before DBS surgery. You will be provided with a special shampoo that will prepare your skin for DBS surgery.

Fasting – your healthcare provider will ask you to fast before DBS surgery due to the use of general anaesthesia.

You may not take any solid foods for at least 8 hours before DBS surgery.

Avoid taking any liquids two hours before the procedure.

Instructions on bathing and grooming – Your doctor will recommend a special shampoo for bathing.

Fasting – For at least 8 hours before DBS

During DBS

DBS surgery consists of two procedures administered at varying times.

The first of these procedures is known as lead placement. It entails inserting the stimulation lead into the brain.

The second procedure is called pulse generator and involves inserting a stimulator battery under the skin.

Before any of these procedures, your healthcare provider starts by inserting an IV line for administering medication during surgery.

Lead placement

Before the lead placement procedure, you will be sedated.

You will be shaven and your head placed on a frame with four pins to keep your head still.

After the frame has been set in place, the surgical team takes images of your brain using an intra-operative CT scanner.

The goal of these images is to reveal the trajectory adopted for placing the electrode.

After identifying the entry point, the surgical team will clean your head with surgical prep.

You will be injected with a local anaesthetic. This will numb the skull and scalp.

Your surgeon makes an incision on your scalp and makes a small opening using a surgical drill. This will aid in inserting the leads.

Your neurosurgeon may wake you up to undergo awake testing, based on the reason for DBS surgery.

After the leads have been placed, your neurosurgeon will ask you questions, and ask you to move your hands, legs, or arms in particular directions.  The goal is to assist the neurosurgeon in ascertaining that the leads are in place.

Your surgeon will order a further CT scan to ascertain the accuracy of the lead placement.

After your surgeon has confirmed your electrodes are secure, he or she will insert plastic caps at the ends of the electrodes for further protection. This is followed by cleaning of the incisions before closing.

As you recover, you will undergo another CT scan to reveal if there is any blood. This also helps to confirm electrode placement.

Your neurosurgeon may ask that you remain in the hospital overnight so that the surgical team can continue to monitor you closely.

Placement of pulse generator

This is the second procedure in DBS surgery.

The procedure is administered under general anaesthesia. It means you will not experience the discomfit or pain that accompanies the procedure.

The pulse generator placement begins with your surgeon making a small incision beneath your collarbone.

The surgeon creates a small space in the form of a punch beneath your skin. This space will hold the purse generator in place.

The next step is inserting an extension wire that is connected to the pulse generator on one end and the DBS electrodes on the other end.

Your neurosurgeon places the extension wire in the punch-like space.

The surgeon will close the incision. You will be allowed to go home on the same day of the procedure.

After DBS surgery

A few weeks after the pulse implantation procedure, your doctor will organize a follow-up appointment. 

The aim of this follow-up appointment is to begin programming the pulse generator.

The device comes with an inbuilt wireless antenna. That way, your healthcare provider can access the pulse generator from outside your body and program it accordingly.

You may require more than one visit to your healthcare provider for the right settings of this device.

Most pulse generators do not require battery replacement. They are equipped with special batteries that can last for a very long time.

Other pulse generators come with rechargeable batteries with a lifespan of nine years. You will need to undergo a surgical procedure to replace the battery.

Such a procedure is quicker and shorter compared to the initial procedure when the pulse generator is implanted.

After battery replacement, you will be allowed to go home later in the day.

Benefits of DBS surgery 

A DBS surgery is associated with several benefits: 

A life-changing procedure – DBS treats various conditions that interfere with our daily routine activities.

A DBS procedure improves your symptoms, resulting in an overall improvement in the quality of your life.

Symptoms reduction: DBS surgery is associated with a considerable reduction in symptoms. For example, tremors, slowness, and stiffness.

For patients diagnosed with medication-resistant epilepsy who cannot undergo surgical resection, DBS minimizes the number of seizures.

Reversible – Your surgeon can remove the pulse generator or leads during a follow-up procedure if DBS is not working. The procedure can also be reversed if you can no longer handle the side effects.

It is an alternative when medication is no longer working: In case medication proves ineffective, DB can be an alternative to treatment.

With movement conditions like Parkinson’s disease, your healthcare provider needs to increase the dosage over time as the medication loses its effectiveness.

DBS surgery helps to increase the effectiveness of lower medication dosages. 

Minimal damage – Compared to other surgical procedures, DBS is not associated with the removal of nerve cells or damage to parts of the brain.

Individualized treatment – Your neurosurgeon may alter the frequency and intensity of stimulation and electrodes to suit your medical needs 

Risks 

DBS surgery may be accompanied by certain risks and complications.

Talk to your healthcare provider about the likely risks and complications that may accompany this procedure.

Some complications that may come with DBS surgery include:

Failure to address all the symptoms: DBS surgery may not resolve all the symptoms triggered by the movement syndrome you have been diagnosed with.

Invasive procedure – You are likely to be awake during DBS surgery and this can be scary for some patients.

The procedure is also invasive as the surgeon uses a scalp to access to deeper section of our brain.

Surgical side effects – DBS surgery is linked to such risks as bleeding, infection, stroke, fluid accumulation, swelling around the brain, and coma. 

Electrode malfunction and battery replacement – Shifting electrodes and wire disconnections can lead to hardware malfunction.

Also, you will need frequent monitoring of the controller and battery life.

Costly – Most insurance companies will cover DBS surgery fully or in part. It is still expensive to attend post-surgical appointments. 

Recovery 

Your recovery time after DBS surgery differs based on several factors such as your overall health, individual circumstances, and whether you have an underlying health condition.

Most patients remain in the hospital overnight after lead placement.

You will also be allowed to go home the same day the pulse generator is implanted.

On the whole, you will probably take several weeks to recover from DBS surgery.

During recovery, your healthcare provider will ask you to do the following:

• Avoid engaging in high-intensity or moderate exercise for several weeks

• Do not engage in household chores and other activities like sexual activity for about a fortnight after each surgery

• You will have any staples or stitches removed about two weeks following the procedure

• You will be advised to cover the pin sites on your head with bandages to permit in drying of the site. You will need to change the bandages daily

• Avoid scratching the site of incision to minimize the risk of infection or causing wound damage

• When showering make sure the water runs over your head

If you experience the following symptoms, call your doctor immediately:

• In case the site of the incision is bleeding

• In case of loss of vision or blurred vision

• If the area around the incision feels swollen or appears red

• Severe headache does not subside with time

• Fever of 38.3°C and above

Cost of DBS in India  

The cost of DBS surgery in India is between Rs. 8,000,000 and Rs. 15,00,000. The price difference is based on several factors including:

• The location of hospital – Hospitals located in metro cities that offer DBS surgery charge more for this procedure than similar healthcare facilities located in remote regions

• Admission fee – The admission fee differs from one healthcare facility to another and this will affect the overall cost of DBS surgery

• Diagnostic tests – Your healthcare provider will order various tests, including ECG and X-ray, and this will impact the overall cost of the DBS procedure

• Admission room chosen – If you choose to be admitted to a deluxe room, you will pay more than someone sharing a room with another patient

• Doctor’s fee – The doctor’s fee differs based on the level of experience and educational qualifications of the surgeon

• Age of the patient – Older patients could be at a higher risk of developing complications after DBS surgery

• This may necessitate extra medical attention to correct such risks and hence an increment in the overall cost of DBS surgery

References

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