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DEEP BRAIN STIMULATOR (DBS) SURGERY

FOR PARKINSON’S DISEASE 
 

Deep brain stimulation (DBS) is a surgical procedure used to treat several disabling symptoms associated with Parkinson’s Disease, most commonly the debilitating motor symptoms such as tremor, rigidity, stiffness, and slowed movement.  Patients who have been typically diagnosed with Parkinson’s Disease for at least 4 years and who suffer from significant and disabling motor fluctuations may be candidates for DBS surgery. 

 

The DBS system consists of three components: the wire (or electrode), the extension, and the battery, also known as the implantable pulse generator (IPG).  Once the device is implanted, it is programmed to deliver electrical impulses from the IPG through the extension wire to the electrode in the brain.  These impulses modify the abnormal electrical signals in deep areas of the brain to alleviate the disabling motor symptoms. 

 

Asleep DBS surgery is performed in 3 steps in a single day.

  • The first step in the procedure is the precise implantation of two wires into the brain.  After being placed under general anesthesia, you will first be placed in a stereotactic head frame (sometimes called a ‘halo’). This frame helps hold your head still and connects directly to the surgical robot.

  • Once a CT scan of the head is performed to register the frame and your head to the robotic system, the electrodes are carefully placed into the appropriate targets in the brain. Another scan is performed to ensure that the electrodes are in the best location to help with your symptoms.

  • After the electrodes have been implanted, the final step is the implantation of the IPG and extension wires.  The IPG is usually located just under the collarbone on the right side of the chest, unless you have a specific preference to have the battery on the left side.

 

Preparing for your surgery

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Surgical Consultation 

Your neurosurgeon and team will sit down with you and your loved ones to review the details of the surgery.  You will need to bring all pertinent medical records, radiology studies, and the most up-to-date medication list to this visit.

 

Pre-Admission Testing and Evaluation 

When a surgery date has been confirmed, our office will arrange appointments (at least 2 weeks prior to surgery) for the following:

  • Medical history and physical examination by a medical physician    

  • Anesthesia interview, if needed

  • Blood and urine tests

  • Electrocardiogram (EKG)

  • Neurocognitive testing

    • Parkinson’s Disease is known to be associated with many mood and cognitive symptoms

    • In order to best help you with the surgery, we require that you undergo testing with our neuropsychologist to identify the effects of Parkinson’s Disease on your mood, memory, and general thought processes     

      • This testing is important in selecting the best target for the DBS electrodes.   

      • In certain situations, if your symptoms are severe enough, it will not be safe to proceed with surgery

  • MRI of the brain, under anesthesia

    • Our office will schedule the appointment for the MRI

    • The hospital will call after 3pm the day before the MRI to inform you of the arrival time to SPU (short procedure unit)     

      • If you are having your scan performed at the Jefferson Hospital for Neuroscience (JHN) please report to the 5th floor for same-day procedures     

      • If you are having your scan performed at the Gibbon building, please report to the 9th floor for same-day procedures

  • Do not eat or drink after 11pm the evening prior to the MRI     

    • Because you will be receiving anesthesia for the MRI, you should not eat or drink the night prior to the scan     

    • You can still take your medications at your regularly scheduled times with a sip of water.

  • Medications

    • You should continue to take your Parkinson’s medications up to and including the morning of surgery as prescribed.   Once you are in the hospital, your medications will be managed appropriately.

    • Stop any non-steroidal anti-inflammatory medications (NSAIDs) at least one week before surgery, such as: Motrin, ibuprofen, Indocin, naproxen, Aleve, fish oils, or any products taken for pain that contain aspirin.

    • If you are taking Aspirin, Plavix, Coumadin, or other blood-thinning medications, please consult with your cardiologist for further instructions before discontinuing the medication.

    • Herbal medications should also be stopped 1-2 weeks prior to surgery.

    • Tylenol or acetaminophen products are safe to take.

  • Do not eat or drink after 10pm the evening prior to your surgery

    • You can still take your medications at the regularly scheduled times with a sip of water.

  • Stop Smoking!

  • Skin Preparation

    • It is important to “prep” the skin before surgery to help prevent infection.  You will be given written instructions by the nurse in the surgeon’s office.   Please call the office if you have any questions.

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Details of Asleep DBS Surgery

Asleep DBS surgery is performed such that the entire DBS system is implanted in a single day.

 

Frame Placement

After going through same-day admission, the first part of your procedure involves placing a stereotactic frame on your head. In the operating room, you will be placed under sedation and general anesthesia. After you are placed under general anesthesia, the frame will be placed by your surgeon and his team. This frame allows your surgeon to plan for electrode placement, which is based on your pre-operative MRI, to be transferred to the robotic system on the day of surgery.

 

The risks of frame placement itself are low, but include pin site infection, skull fracture, empyema, meningitis, CSF leak, and persistent pain at the pin sites and numbness at or around the pin sites.

 

CT Scan

With the frame in place, you will be positioned on the operating room table. Your head will be secured to the robotic system with the head frame. Once in position, a CT scan will be performed in the operating room.  This step is necessary to transfer your surgeon’s plans for electrode placement from the preoperative MRI to the CT scan taken on the day of surgery.

 

Implantation of the Electrodes

We will make an approximately 1-inch incision over each of the sites where the electrodes will be implanted at the top of your head. We do not need to shave all of your hair for this procedure. Instead, a minimal hair shave will be performed around these two incisions. To be able to place the electrodes into the brain, a small hole about 3 millimeters in diameter will be made in the skull.

 

We can precisely implant the electrodes with you asleep with the assistance of a stereotactic robot.  Once the electrodes are in place, a CT scan of your brain in the operating room is used to confirm the appropriate position of the electrodes.  If an electrode is not in the ideal position, it is adjusted before the end of surgery.  Less than 1 in 20 electrodes needs to be repositioned in order to ensure the optimal position for DBS therapy.

 

Once the electrodes are in the correct location, they will be secured to your skull with low-profile plates and 4 millimeter screws. After surgery, it is normal to still feel these plates as small bumps at the top of your head.

 

The risks of implanting these electrodes are also low. The main risks include bleeding and infection. The risk of significant bleeding with this surgery is approximately 0.05%. The risk of infection is also low at approximately 3-5%. It is rare for patients to suffer any permanent damage from this surgery.

 

Implantation of the IPG

The final step of the procedure is the implantation of the IPG and extension wires.  In order to get the wires to the IPG, a third incision will have to be made on the side of your head. This incision will also be approximately ½-inch long. A minimal hair shave will be performed around this incision as well. This third incision allows us to bring the two wires together and then tunnel both wires underneath the skin to the chest.

 

The IPG is usually located just under the collarbone on the left side of the chest. The location of the IPG will be decided based on your preference and your discussions with your surgeon.

 

When you are in the Hospital

 

Admission

You will receive a phone call from the hospital the day prior to your surgery to confirm your arrival time.

 

Hospital Length of Stay

Typically, you will stay in the hospital for one night. There is no need to be placed into the Intensive Care Unit (ICU). Instead, you will recover in the post-anesthetic care unit (PACU) before being transferred to a room where your vitals can still be monitored.  The goal of your care after surgery is to become independent and return home safely.  An MRI of the brain should be completed before you leave the hospital.

 

Pain Management

The amount and type of pain you may have will vary.   You will be asked to rate your pain on a scale of 0-10.  IV pain medication or pain pills will be available depending on the severity of pain. When you are discharged, you will be given an appropriate pain medication regimen to follow.

 

The DBS System

The DBS system will not be turned on immediately. Instead, the system will be left off until you see your Neurologist approximately 3-4 weeks after surgery for the initial programming session. This delay allows the brain to completely heal and for the location of the electrode to be more stable before trying to adjust the settings on the stimulator.

 

After You Leave the Hospital

 

Caring for your surgical incisions

  • A bandage will be placed around your head for the first couple of days after surgery. A separate dressing will be placed over your chest where the IPG is located. The dressings may be removed on the second day after surgery.

  • Stitches used are typical dissolvable. The ends of the stitches may not completely dissolve and can be removed approximately 10-15 days after surgery at your first post-op appointment by the surgeon or nurse practitioner.

  • If you have steri-strips (small pieces of tape across the incision), they will fall off on their own as the incision heals.  This can take approximately 2 weeks.

  • You may take a shower 2 days after surgery. Do not stand directly under the shower in order to avoid the water hitting the incisions with high pressure. Soap and water may run over the incisions. After getting out of the shower, please be very careful to keep the incisions clean and dry. Do not use a hair dryer to dry your hair. No tub baths or swimming until you are cleared by the surgeon (typically 4 weeks after surgery).

  • Do not put any ointment or lotions over your incisions. It is important for them to remain clean and dry.

  • Monitor the incisions for excessive redness, swelling or drainage.   If you have any of these signs or a fever over 101.5 degrees, please call the office promptly.

 

Activity

  • Do not undertake physical activity that causes excessive lifting (no more than 5 pounds) or straining for at least 2 weeks.  We encourage you to walk as much as you can tolerate.

  • You should gently stretch your neck from side to side.  Avoid quick repetitive neck movements up and down or turning your head too far over each shoulder as this may cause the wires to pull out of place.

  • You will not be allowed to drive for at least the first 2 weeks.  You may ride as a passenger as you feel comfortable.

 

Symptoms

  • Pain is to be expected following surgery and will vary with each patient.  You may have soreness in the head, neck and chest.   When you are discharged from the hospital, you may be given a pain medication regimen to follow.

  • You will notice some swelling around one or both of your eyes a few days after surgery.  This can be normal and usually resolves within a week of your surgery.

  • Patients may also feel easily fatigued.  This is expected and may last for 8-12 weeks following surgery.  Take frequent rest breaks or naps as needed.

 

When To Call The Surgeon

Please call the surgeon’s office if you have any questions or concerns.

 

Notify the office immediately if you experience any of the following:

  • Flu-like symptoms – fevers above 101.5 degrees Farenheight, chills, body aches

  • Severe headaches

  • Increase in redness, swelling, tenderness or drainage from your incision

  • Numbness, tingling or changes in sensation in your arms or legs

  • Weakness or paralysis of arms or legs

  • Sudden loss of bowel or bladder control

 

Living with a DBS Device

 

DBS Programming

The DBS will be turned on during your first visit with the movement disorder neurologist.  Our office will help to arrange this appointment and is scheduled approximately 2-4 weeks after surgery.

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It may take a few visits before the settings for your DBS device are optimized. You may have to visit your programming physician more frequently during the first 4 to 6 months after your surgery. Once the settings for your DBS device have been optimized, you may see your Neurologist according to your routine schedule.

 

Electromagnetic Interference

Since the DBS is an actively functioning device, it can be affected by strong electric fields in your surroundings. This interaction is known as “electromagnetic interference” or “EMI”. Significant EMI may result in the malfunction of the DBS device. We, therefore, recommend that you avoid possible EMI to reduce the risk of device malfunction.  The most common sources of significant EMI include:

  • Metal detectors and security systems – this includes airport security, courthouse security, amusement park security, security checks at sporting events/concerts

    • Any time you encounter a security check, you should tell the staff that you must defer and cannot walk through the detectors.     

      • You also cannot be screened with a hand-held detector or “wand”. This device can actually be more harmful because it delivers more focused EMI to the device.     

      • Instead, you need to undergo a “pat-down screening”

    • Detectors at department stores or at the mall should not cause problems with your DBS device

  • Medical Imaging

    • You can undergo x-rays and CT scans without any issues

    • You can still undergo MRI scans, but this must be done under the correct conditions.     

      • Your device needs to be checked immediately before the MRI to ensure that there are no issues that would cause any interactions between the MRI and your DBS device     

      • You will need to let the radiologist or the technicians performing the MRI that you have a DBS device implanted.     

      • If you have any questions about undergoing an MRI, please contact us.

 

Dental Work

If you are having dental work done within 3 months of your DBS surgery, we recommend that you take antibiotics prior to that procedure. Please contact our office to obtain a prescription for these antibiotics if necessary. After 3 months, no antibiotics are required before dental procedures.

 

Swimming

There have been rare reports of patients having difficulty swimming after DBS. Because this does not happen commonly, it is not clear exactly why this may happen and whom it may affect. After your DBS is activated, we recommend that you first swim under close supervision until you can be sure that your ability to swim has not been affected by DBS.

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