Deep Brain Stimulation for Parkinson's Disease

Deep brain stimulation is a surgical intervention used to treat movement disorders such as Parkinson's disease when medications and rehabilitation strategies become less effective. This surgical procedure received approval from the Food and Drug Administration to treat tremor in July 1997 and for advanced motor symptoms of Parkinson's disease in January 2002.

For people with Parkinson's disease, deep brain stimulation surgery may be helpful for those experiencing motor fluctuations, including dyskinesias or "off" episodes.

The subthalamic nucleus and the globus pallidus are two locations in the brain that are targeted in the DBS procedure for Parkinson's. Certain symptoms of Parkinson's disease can be reduced when these two areas are turned "off" by the stimulator. These include tremor, rigidity, slowness of movement and difficulty walking, as well as extra movements or dyskinesia that are medication side effects. The amount of daily "on" time during which the Parkinson's symptoms are better controlled can be increased as well.

The best marker of whether people with Parkinson's disease will benefit from DBS is how well they respond to levodopa, an active ingredient in the drug Sinemet™, Rytary™, or carbidopa/levodopa. Patients who benefit most from DBS have had a good response to levodopa. For many, this good response becomes less and less as the disease progresses.

The stimulator produces a more even, consistent effect than medications. This decreases the amount of "off" times and the dyskinesias. It is also effective for tremor even when the medications have never helped.

Unfortunately, DBS does not cure or halt the disease and residual symptoms can increase with disease progression. DBS does, however, continue to provide symptom reduction.

Who may be a candidate for DBS surgery?

People with Parkinson's disease who have:

• Initially had a good response to medications to treat their movement disorder but later developed side effects that limit their effectiveness. Such side effects include:
  • Dyskinesias (extra movements caused by Parkinson's disease medication).
  • Motor fluctuations including “wearing off” periods (medication wears off before the next dose is due).
  • Neuropsychiatric complications such as hallucinations.
  • Other side effects such as nausea and hypotension.
• Significant tremors even if the tremor has never been adequately managed by medications.

Who may not be a candidate for DBS surgery?

• Are too unhealthy to undergo surgery with general anesthesia.
• Have thin or unhealthy skin.
• Cannot stop blood thinners for at least 3 weeks.
• Have significant dementia; these individuals tend to recover more slowly, or not at all from surgery. In addition, improved mobility from surgery, in the face of worsening dementia, often creates many new challenges.
• Are diagnosed with Parkinson's plus or atypical Parkinsonism syndromes such as multiple system atrophy and progressive supranuclear palsy and/or who have never responded to PD medications.

What outcomes can be expected from DBS for people with Parkinson's?

• On average, DBS surgery results in a 40-60% improvement in motor features.
• DBS can improve "off" times (times when medications are providing little or not benefit) to a pre-operative "best on" level of functioning. "On" time is when medications are acting optimally. With DBS, the "best on" periods are expected to improve only slightly or not at all.
  • This does not apply to those who cannot tolerate medications, or for those with dyskinesia or tremor.
• Dyskinesias typically improve by 70-80%.
• Tremor that is difficult to manage with medication is usually well treated with DBS and generally improves by 70-80%.
• DBS does not stop the progression of Parkinson's disease.

What are the benefits and risks of deep brain stimulation surgery?

• Parkinson's disease symptoms that significantly improve:
  
  • Motor fluctuations
  • Tremor
  • Rigidity
  • Dystonia
  • Slow movements or bradykinesia
• Parkinson's disease symptoms that may improve:
  • Freezing episodes
  • Masked face
  • Pain related to tremor, stiffness, or dystonia
• Parkinson's disease symptoms that will not improve:
  • Parkinsonian speech/hypophonic (soft) speech
  • Dementia or cognitive impairment

What are the potential risks of DBS surgery?

• 1% risk of intracranial hemorrhage or stroke which can lead to loss of speech, paralysis, coma or death.
• 1.4% risk of infection that requires removal of the DBS system.
• 5-8% risk that DBS will offer little or no benefit. The chance of this is dependent on the patient's diagnosis or can be due to suboptimal lead placement, requiring revision.
• Risks of anesthesia which are dependent on the patient's overall medical history.

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