Download Deep Brain Stimulation For Movement Disorders

Vanderbilt University Medical Center Departments of Neurosurgery/Neurology
Deep Brain Stimulation
For Movement Disorders
What is deep brain stimulation?
This is a surgical procedure whereby electrodes are permanently
implanted in particular parts of the brain, and continuous
stimulation administered by a small electrical unit (generator),
similar to a heart pacemaker, implanted under the skin of the
chest. The electrodes and generator are connected by wires under
the skin. It is a way to control the abnormal activity of particular
brain cells in the immediate vicinity of the stimulating electrode
without destroying brain tissue. The generator (electrical
stimulator) can be adjusted and/or turned off, allowing for much
flexibility in the treatment of movement disorders.
How will this help movement problems?
Because the right side of the brain controls the left side of the body and the left side of
the brain controls the right side of the body, a stimulator will only help on the opposite
side of the body. Some patients have symptoms on only one side, and therefore need
only one electrode. Most patients, however, have symptoms on both sides and therefore
need electrodes for both sides. This is why bilateral (both sides) implants are commonly
recommended.
The goal of DBS is to improve the control of movement. Depending on the type
of movement disorder, this may result in loss of tremor, loss of rigidity (stiffness),
loss of dyskinesia (excessive movement) or reduced dystonia. Your neurologist and
neurosurgeon will specifically discuss which symptoms they feel the stimulator
will improve.
What are the risks?
The most rare, but serious risk is bleeding into the brain causing a stroke. The effects of
a stroke may range from headache to paralysis, coma or even death. Other rare
complications (less than 10%) include infection (which may require removal of the
system), malfunction of the stimulator or electrode and movement of the electrode.
I’m ready to proceed, what happens next?
DBS implants require extensive, thorough planning and are costly. Under most
circumstances we believe that this technology is superior and safer than other surgical
techniques, such as pallidotomy or thalamotomy. DBS is now considered standard of
care for the treatment of several conditions when medications fail. However,
precertification by your insurance company is still required by most carriers and may
sometimes be difficult to obtain. This does not mean, however, that the treatment is
experimental! At Vanderbilt we have performed over 500 DBS surgeries since 1998.
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The Evaluation Process
In order to obtain an appointment with the Vanderbilt DBS group, please call or have
your doctor refer you to our program at (615) 322-0141.
Once we have your referral, you will be scheduled with one of our neurologists where
your history will be reviewed including all the treatments you have received. If it is
determined that you are a good candidate you will then undergo two examinations:
• Physical therapy assessment: The severity of your symptoms will be rated by asking
you to perform various tasks such as writing and walking. You may be asked to stop
your medications for this test. This session is video recorded for use by the team to
decide how well you may respond to the stimulation as well as for future comparison.
• Neuropsychological testing: Various aspects of your memory and thinking will be
examined by asking you questions and performing certain memory tasks. This test
is primarily used to screen people who may not tolerate the surgery and for
future comparison.
• It is very important that we be able to obtain these tests prior to and at least once in
the following year after surgery so as to understand how the stimulation has impacted
your movement disorder and thinking ability.
• Once you have finished the testing your case will be discussed at the monthly
conference of the Vanderbilt Movement Disorders group. If you are a good candidate,
your insurance company will be asked for precertification. You will also be scheduled
to visit with the neurosurgeon to discuss in further detail the surgery and its stages.
The Surgical Procedures
Stage One: Bone Markers and Images
Date:
The first stage occurs in the Radiology department in the main hospital where you will
be put to sleep and 3 – 4 bone marker screws will be placed into your skull on one or
both sides of your head. They will remain buried beneath the scalp and usually will
have a staple or two placed over the insertion site. While you are still under anesthesia,
we will typically obtain a CT scan and MRI scan. The anesthesia prevents “shaking” or
unwanted movements which could affect the quality
of the pictures. The total time for placement of the
markers and acquiring the brain images will take
about 3 – 4 hours. These bone markers will remain
in place until you return for your second procedure
(Stage Two).
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The CT and MRI scans are used to create a customized plan as to where to place the
DBS electrode(s). Once the target is identified and trajectory planned, this information
is sent to a company that will manufacture a custom platform that will fit on the bone
markers and prepare you for Stage Two.
Pre-Operative Instructions
You should have nothing to eat or drink for at least 8 hours prior to your procedure.
If you take blood pressure medicine, you should take these pills with a SIP of water at
your usual time. You may also take your anti-tremor/anti-Parkinson’s medications prior
to Stage One. Your hair must be cut prior to this procedure using a Clipper Guide #1.
You may do this yourself or have it done at your local salon 2-3 days before your
procedure.
Arrival at the Hospital
The Surgery Scheduler will give you specific instructions about where you should go
for placement of the bone markers and imaging. Most patients will arrive at the lobby
of the main hospital where they will be directed to the radiology department for this
procedure. Please arrive 2 hours prior to your scheduled surgery time. After this
procedure is done, you will be taken to the Recovery Room for a brief period of
1-2 hours where you will be allowed to awaken from the anesthesia prior to being
discharged home.
Post-Operative Instructions
Please keep the bone marker insertion sites clean by wiping with hydrogen peroxide on
a Q-tip twice a day until you come back for the electrode implants (Stage Two). Apply
neosporin or polysporin ointment (available at any drugstore) after each cleaning. You
can gently wipe your scalp with a damp wash cloth for general cleaning. DO NOT
GET YOUR HEAD SOAKING WET. If you do shower,
use a shower cap to keep the insertion sites dry. For
sleeping, you may find that a soft pillow helps to keep
pressure off the marker sites. These should cause you
minimal discomfort. Call our office at (615) 322-7417 if
you develop a fever of 101.5º or higher or if you have any
more than slight redness, swelling or drainage from the
bone marker insertion sites. Even though this is very
unlikely, you must notify us if you feel that any of the
bone markers may be loose or have moved.
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Stage Two: Deep Brain Stimulator Electrode Implant
Date:
Pre-Operative Instructions
Along with the instructions on our standard
preoperative handout sheet, stop your antiParkinson’s medications or those used for
tremor or dystonia by 6:00 PM the evening
before surgery.
Arrival at the Hospital
As with the Stage I procedure, the Surgery
Scheduler will give you specific instructions
about your arrival at the hospital the morning of this procedure. Again, most patients
should plan to arrive at the lobby of the main hospital about 2 hours prior to their
scheduled surgery. You will need to check in at the admitting office in the lobby of the
hospital where you will be asked to fill out some forms and then be directed to the Presurgery Unit prior to surgery. In the Pre-surgery Unit area the staff will make sure you
are completely ready for surgery. A Foley catheter (a tube which drains urine from your
bladder into an external bag) may be inserted at this time. An IV (intravenous catheter)
will be inserted into your arm as well to allow medications to be given by the
anesthesiologist.
In the Operating Room
You will be positioned on the operating room table and be made as comfortable as
possible. Most likely you will be awake throughout the procedure. Various pieces of
equipment will be attached such as EKG leads, a blood pressure cuff and a pulse
oximeter on your finger. All of these help the nurses and anesthesiologist to monitor
your vital signs. In addition, there will be various members of the surgical team that
will help your surgeon and neurologist utilize the latest technology and equipment
available at Vanderbilt for DBS surgery. This includes the surgical and neurophysiology
staff who provide technical support that is essential to the success of the surgery.
Your head will be cleansed and draped with
sterile sheets. A special platform, which was made
precisely for you (from the CT & MRI scans)
will be fitted onto the bone markers which were
put in during Stage One. This platform is used to
precisely align the electrodes for testing and
permanent placement. A local anesthetic will be
injected to numb your scalp and then a small,
dime-sized hole will be made in the skull. Your
neurosurgeon will insert a test electrode into the
brain through the planned target area. When
adequately numbed, the remaining procedure is not painful since there is no significant
pain perceived below the scalp. Brain tissue does not sense pain. There are two types of
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test electrodes: one to record electrical activity and “listen”
for the unique sounds of the brain cells to be treated; the
other electrode is to “test stimulate” small areas of the
brain, to observe what effects this has on your movement,
and whether there are any side effects from the stimulation.
When the stimulator is turned on, the team will evaluate
the lead location and stimulation strength by asking you to
perform different functions, eg. bringing your fingers
together or moving your wrist. Your speech will be
evaluated along with sensations such as numbness and
tingling.
Once the desired responses are obtained, the test electrodes
are removed and the final location for the implant is
determined. The actual permanent electrode implant is
then precisely placed into the optimal location which was determined by the testing
done previously. The electrode implant will be secured and the incision closed. The
bone markers will likely be removed at this time unless you are returning for a second
electrode in the near future. Some patients will undergo only one electrode implant,
others will have two electrodes implanted. The entire operating room procedure takes
about 4 – 6 hours, so you may feel tired or become restless after lying in one position
for so long. The staff will do their best to make you comfortable.
Once the surgery is complete, you will be taken to the recovery room, and your
neurosurgeon will talk with your family regarding your surgery. Before moving to a bed
in the hospital, you will be taken for a CT scan which will document the electrode
placement and will also check for any evidence of bleeding or a stroke. After the scan,
you will most likely be taken to a regular room in the hospital and be discharged home
the next morning.
Post-Operative Instructions
• Resume taking your anti-tremor or anti-Parkinson’s medications as before.
• Please keep your wounds dry for 4 days and then you can shower and get your head
wet. Do not apply any ointments or creams.
• It is not unusual to have swelling around the scalp and eyes a few days after the
procedure, these changes should go away after 3-5 days from the surgery. Call our
office at (615) 322-7417 if you have a fever of 101.5º or higher; if you have any
redness, swelling, or drainage from the incision; if you develop new weakness in any
extremity; if family/friends have difficulty arousing you from sleep; or for a persistent
headache not relieved by medication.
• Call your neurologist for any changes related to movement or questions about your
medications, dosages, etc.
• You will be scheduled to return in 1 – 2 weeks for the generator implant(s) and staple
removal. The staples will be removed in the OR while you’re undergoing the final
generator implant (Stage Three).
• You will be given pain medication appropriate for your level of pain upon discharge
from the hospital.
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Stage Three: DBS Generator (IPG) Implant and Wire Hook-Up
Date:
Pre-Operative Instructions
Again, follow the instructions from your surgical team that
discharged you in Stage Two. You may take your anti-Parkinson’s,
tremor or dystonia medications with a SIP of water in the morning
prior to this procedure if that is your scheduled medication time.
Arrival at the hospital or outpatient surgery center
The Surgery Scheduler will again give you specific instructions
about where you should go for each stage of your surgery. Stage
Three procedures may typically be performed either in the main hospital or a small
outpatient surgery center also located near the hospital on the main campus. Please
arrive 2 hours prior to your scheduled surgery time. As in Stage Two, you and one
family member will be taken to the Pre-surgery Unit. After your surgery is done, you
will be taken to the Recovery Room, then discharged home later that day. (Generally
1 – 2 hours after your surgery).
In the Operating Room
For this operation, you will be given general anesthesia and be asleep. The surgery takes
approximately 2 hours. Depending on what your neurologist and surgeon discussed
with you, either one or two pulse generators will be implanted in your chest, near your
collarbone. An extension wire is then threaded under your skin from the top of your
head to the pulse generator. The incision in your chest will be closed with stitches that
dissolve. The incision is usually glued with DermaBond which will eventually flake off
on its own. Your IPG implants will be left OFF and will be programmed by your
neurologist at a later date. You will then be taken to the Recovery Room.
Post-Operative Instructions
• Please keep your wounds dry for 4 days and after this time period you can shower as
usual. Do not peel off the DermaBond or use ointments or creams on your incisions.
Just keep the incisions clean and dry. Some patients will notice that the new wires
extending from the head to the generator may feel "tight" in the neck. We encourage
patients to move their neck side to side occasionally following this procedure to allow
the wires to heal with less scarring.
• Call our office at (615) 322-7417 if you have a fever of 101.5º degrees or higher, or if
you develop any redness (that spreads out like a sunburn), swelling, or drainage from
your incisions.
• You will have three postoperative appointments. These will include: 1) seeing the
neurosurgeon or his assistant, 2) initial DBS programming and 3) a post-operative
CT/Head. These visits will be scheduled by the Movement Disorders Program
Coordinator approximately 4 to 5 weeks after Stage Two. All three appointments will
be scheduled for one day. Medication orders prior to the above visits will be included
in the appointment information.
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Stage Four: First Time Activation and Programming of Your DBS
Date:
Purpose of this Procedure
Program the implanted device and instruct the patient on the use
of the stimulator and hand held controller.
Your stimulator(s) will not be turned on or activated by your
neurologist until approximately one month after Stage Two
surgery. This gives the brain surrounding the electrodes a chance
to heal, and thus makes the programming of the DBS more
dependable.
8840 NʼVision®
Clinician Programmer
The initial visit to program your
What the doctor uses
stimulators will last for 1 hour and will
usually be scheduled in the morning with
your DBS neurologist. If you need to change your
appointment, please call the DBS coordinator at
615-322-0141. Medication orders prior to the visit will be
included in the appointment information. If you have questions
regarding medications, please call 615-936-0060 and ask to
speak with a triage nurse. Please remember to bring the
hand-held programmer given to you at the time of the surgery
with you every time you visit your DBS neurologist.
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After You Receive Your Implant
After you receive your implant, you will still be seen at regular intervals in order to
adjust your stimulator for the best symptom control. This may take several sessions as
the brain is still healing, and you may be reducing your medications. Your generator
will also be evaluated at future visits in order to determine when it will need to be
replaced. Follow-up programming visits are scheduled for 30 minutes. (Initial
programming visits are scheduled for one hour.)
In order to follow your progress and to ensure that you are getting the best benefit from
your DBS system, you will be asked to come back yearly for repeat testing including
many of the same tests that you went through while being evaluated for DBS. This will
include physical therapy and neuropsychologic testing.
Visit the website at
www.vanderbiltneurosciences.com
or call 615-936-0060
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