DBS Surgery for Parkinson's Disease
by Dr. Jonathan Carlson, M.D., Ph.D.  
What is DBS? 
​DBS is a surgical treatment for Parkinson’s disease.  
It is NOT a cure for Parkinson’s disease.
It is a medical device that electrically stimulates the brain tissue.  It is composed of an electrode that is implanted in the brain and connected to a pulse generator usually implanted below the collarbone
What are the medical reasons for surgery (Indications)?
  • Tremor
  • Stiffness (Rigidity)   
  • Motor fluctuations (on / off periods)
  • Medication intolerance
  • Dyskinesia (involuntary movement caused by Parkinson’s meds)
  • Slowness of Movement (Bradykinesia)
What are the benefits of surgery?
  • Overall the average patient has a reduction in their Parkinson’s symptoms by 50%.
  • Off periods become less frequent and less severe.
  • Medications are cut by 40% to 50%.
  • Dyskinesia can be markedly diminished by a reduction in medications.
  • Tremor can be nearly completely eliminated.
  • Mobility is improved
  • Dystonia (muscle cramping) may be improved.
What is not often helped by surgery?
  • Gait freezing (sometimes it is helped but not always)
  • Falling (if medications help falls then surgery will also help)
  • Slurred speech (dysarthria)
  • Swallowing difficulties
  • Drooling
  • Urinary and bowel dysfunction
  • Cognitive deficits
  • Obsessive and compulsive behavior
  • Depression
What are the risks of the surgery? 
  • A small bleed in the brain (Hemorrhage)
  • Large bleed in the brain that causes a stroke-like effect
  • Weakness
  • Equipment failure
  • Infection
What are the possible side effects of DBS?
  • Cognitive changes
  • Parasthesia (tingling) caused by programming
  • Falling or balance difficulty
  • Dysarthria (slurred speech)
What are the temporary side effects of surgery?
Patients sometimes are confused or agitated after surgery.  They may stay an extra day or more in the hospital until the confusion resolves. 
Medication side effects
Many patients describe difficulties managing their medication.  Many end up in severe off states, or with severe dyskinesia.  The timing and dosages of their medications need to be adjusted daily, which can be challenging for their caregiver. 
DBS surgery is usually not very painful.  Some patients described a mild headache after the first surgery.  Most patients experience acute pain for several days after the generator is implanted.
How long does the benefit of DBS last?
It depends on your symptoms.  Most patients experience a sustained benefit for at least 5 years.  However, as Parkinson’s disease progresses those symptoms not helped by DBS worsen.  This includes postural instability, slurred speech, cognitive difficulties and memory loss, and a loss in mobility.
Eventually the battery in the DBS generator is depleted.  The length of your battery depends on how much stimulation is used.  It typically lasts from 3 to 5 years.  It is easily replaced in a short outpatient surgery. 
What is the recovery time?
Most patients have returned to normal activity within 3 weeks of the first surgery.  At that point postoperative pain is usually resolved.  It can take longer for their Parkinson’s disease to stabilize.

What testing do I usually need before surgery? 

  • Evaluation by a DBS trained neurologist and neurosurgeon
  • Cognitive testing – to be certain there is no dementia
  • Off-medication and On-medication clinical evaluation
  • MRI scan of brain – to look for other abnormalities such as stroke
  • Medical clearance for those with cardiac or other medical illnesses
  • In some cases a physical therapy, occupational therapy and a psychological evaluation will be advised
What happens after surgery?
The DBS electrodes are typically turned on one to two weeks after the second surgery. By waiting to program the devices Parkinson’s symptoms will have stabilized which allows for faster and easier programming and medication management. 
For several months after surgery the DBS stimulation is adjusted to reach a maximal effect.  This involves multiple visits and phone calls with your physicians. 
What should I expect from surgery? - It depends on your type of Parkinson's disease
A key to successful treatment of your Parkinson’s disease with DBS is to have realistic expectations.  Each person’s Parkinson’s disease is different.  So each person’s clinical benefit is different.  The following types and severity of Parkinson’s disease have typical outcomes
Tremor dominant, L-dopa intolerant, slowly progressive Parkinson’s disease
This is the patient with mainly tremor, ongoing for years, that has intolerable side effects such as nausea when taking sinemet.  These patients often have dramatic benefit from DBS.  Stimulation in the subthalamic nucleus is much like taking Parkinson’s medications that are not tolerated in this group.  If bilateral electrodes are placed tremor can nearly be eliminated.  Often the shuffling gait and stooped posture are improved as well.  These patients often experience very long-term benefit since their other symptoms of Parkinson’s disease progress slowly.
Young Onset Parkinson’s disease with dyskinesia and on/off fluctuations
Medications in these patients often become worse than the original Parkinson’s disease.  When they take their medications they experience severe dyskinesia.  Without them they have severe off periods.  Even while taking their medications they can experience unpredictable off periods.
These patients often have a dramatic improvement.  By reducing their medications the dyskinesia is eliminated.  And even with less medication the off periods are much less severe and less frequent.  They are no longer disabled in the off state by bradykinesia, rigidity, and mobility difficulties.  Since they are young some can even return to work, and have a nearly normal neurological appearance.
Unilateral Parkinson’s disease
These patients have tremor, rigidity, slowness, and possibly shuffling gait on one side of their body.  They typically have had Parkinson’s disease for less than 7 years.  Their medications work well, but are no longer eliminating their symptoms.
These patients have a good benefit from surgery.  Usually only one DBS electrode is implanted to treat the one side.  They experience an improvement in their mobility, a reduction in their medication, excellent control of their tremor, and can often look fairly normal.  From a clinical perspective is moves the time clock back about 5 years in their Parkinson’s disease.
Some of these patients may feel that their Parkinson’s disease is not severe enough to justify the risks of the surgery.  Most patients wait until they are experiencing symptoms and signs of the disease on both sides of their body before considering DBS.
Moderate Parkinson’s disease with tremor, mild dyskinesia, medication wearing off, and shuffling gait
This is the most common patient that comes to surgery.  Their Parkinson’s disease has progressed to involve both sides of their body, and to produce moderate to disabling mobility issues.  They have medication wearing off phenomena and mild to moderate dyskinesia for part of the time that medications are on.
These patients have a good and sustained improvement in their Parkinson’s disease.  The dyskinesia is eliminated, the tremor is controlled.  The off periods are reduced.  Their speed of walking and gait are improved.  Essentially they can be as good as their best medicated on state. 
However, they still have other symptoms of Parkinson’s disease.  DBS won’t quite make them look normal.  They may continue to have falling difficulties, or gait freezing if they did before surgery.  And if they have speech difficulties they may persist or be worsened.  These patients do experience an improvement in their activities of daily living since their off periods are improved.
Non-tremor type Parkinson’s disease with bradykinesia, stooped posture, shuffling gait, gait freezing
These patients typically have a more rapid progression of their Parkinson’s disease.  And they have never had much of any tremor.  They are still good candidates for DBS surgery.  Their slowness is improved, but not normalized.  The stooped posture and shuffling gait is improved if it is present mostly when in an off state.  If they have dyskinesia this can be eliminated by reduction in their medications.  However, the gait freezing is not typically helped.  And if their mobility is a major problem it may not improve enough to have an impact on their quality of life.  Because this type of Parkinson’s disease progresses more rapidly the long-term benefit of DBS is shortened.  The depression more commonly associated with this type of Parkinson’s disease is usually not helped.
Severe advanced Parkinson’s disease – wheelchair bound, requiring full care
These patients have reached an advanced stage of Parkinson’s disease, whether over 8 years or 30 years.  The medications still have benefit, but many of their symptoms are not well treated by the medicine at this point.  They use a wheelchair when outside the home.  They need assistance at home to dress and eat.  They have motor fluctuations with off periods that are severely disabling.
These are the most challenging patients to treat with DBS surgery.  In general, DBS surgery can make you only as good as you are when the medicine is working best.  The off states in these patients can be significantly improved.  So if there are only disabled in the off state these patients may have a good benefit.  These patients are still surgical candidates.  However, the patient and their family must carefully consider the expectations from the surgery.  In some of these patients surgery makes their gait freezing, postural instability, and speech problems, and in particular mild cognitive dysfunction worse.
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