Deep brain stimulation (DBS) uses electrical impulses to stimulate a
target area in the brain. The stimulation affects movement by altering the
activity in that area of the brain. The procedure does not destroy any brain
tissue. And stimulation can be changed or stopped at any time.
Surgery is required to implant the equipment that produces the
electrical stimulation. You are awake during the procedure (your scalp is
numbed and you won't feel any pain), because you must work with the surgeon in
placing the electrodes where they will have the most benefit. A small hole is
drilled in your skull, and tiny wire electrodes are placed in your brain. A
small battery-powered device (generator) similar to a pacemaker is implanted in
your chest and connected to the electrodes in your brain by a wire. The
procedure usually takes 3 to 4 hours, although it may take as long as 8 hours. The surgery may also be done in two steps where the electrodes are put in during one surgery and the control unit is connected and placed under the skin in a second surgery.
The device can be
programmed so that it delivers the correct level of stimulation to provide the
greatest relief of symptoms.
You will remain in the hospital for several days after the
procedure while your doctor checks the effect of deep brain stimulation.
Deep brain stimulation may be used to relieve symptoms of
Parkinson's disease, especially tremor, when they
cannot be controlled with medicine. It is considered the surgical treatment of
choice for Parkinson's disease, because it is more effective, safer, and less
destructive to brain tissue than other surgical methods.
Deep brain stimulation of the thalamus is done to treat both disabling
tremor caused by Parkinson's disease and essential tremor.
Procedures that stimulate the subthalamic nucleus and the globus
pallidus are done to help control a wider range of symptoms (in addition to
tremor) and are used more often than stimulation of the thalamus. Symptoms that are most often helped (besides tremor) include problems with changes between "on" and "off" time and dyskinesia. Symptoms that are less likely to get better include problems with walking, balance, and speech. In some cases, DBS can make these problems worse.
Deep brain stimulation may also be used to treat severe tremor related to multiple sclerosis (MS). Deep brain stimulation usually
is a last resort after all other options have been tried without success to
treat MS tremor. Only people with severe tremor are candidates.
Deep brain stimulation of the thalamus is effective in reducing
tremor. It does not affect slow movement (bradykinesia), stiffness (rigidity),
or other symptoms.1
Compared to medicine for Parkinson's disease, DBS of either the subthalamic nucleus (STN) or globus pallidus (GPi) gave people almost 5 more hours of "on" time on average each day.2
Two studies comparing DBS of the STN to DBS of the GPi showed equal effects on the symptoms of Parkinson's disease after 2 and 3 years.3, 4
Risks of deep brain stimulation include:
A neurologist with special training in Parkinson's disease is most
often the best kind of doctor to make a decision about deep brain stimulation.
If you might benefit from the operation, your neurologist can refer you to a
brain surgeon with experience doing the surgery.
Deep brain stimulation may be considered as an addition to levodopa
therapy, not a replacement for it. It does not cure Parkinson's disease and
does not eliminate the need for medicine. The surgery can help maintain and
extend the benefits of levodopa therapy. But it should not be considered for
people with Parkinson's disease who also respond poorly to levodopa
Because of an increased risk of falling in people who have DBS, it's a good idea to understand the ways you can prevent falls after the surgery.
One of the possible advantages of deep brain stimulation over
"lesional" surgery for Parkinson's disease (such as pallidotomy) is that it can
be changed or reversed. The effects of lesional surgery, which involves creating
a lesion or intentionally destroying a small portion of the brain, are
permanent, but the electrodes used in deep brain stimulation can be adjusted, turned off, or
removed if they cause problems.
Deep brain stimulation for tremor caused by multiple sclerosis (MS) is still experimental, expensive, and not widely available.
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CitationsSamii A, et al. (2004). Parkinson's disease.
Lancet, 363(9423): 1783–1793.Weaver FM, et al. (2009). Bilateral deep brain stimulation vs best medical therapy for patients with advanced Parkinson disease. JAMA, 301(1): 63–73.Follett KA, et al. (2010). Pallidal versus subthalamic deep-brain stimulation for Parkinson's disease. New England Journal of Medicine, 362(22): 2077–2091.Weaver FM, et al. (2012). Randomized trial of deep brain stimulation for Parkinson disease: Thirty-six-month outcomes. Neurology, 79(1): 55–65.
December 5, 2012
Anne C. Poinier, MD - Internal Medicine & G. Frederick Wooten, MD - Neurology
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