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Deep Brain Stimulation (DBS)

Medtronic


Information courtesy of Medtronic Europe

Last reviewed 20 March 2011

This section provides a summary of the deep brain stimulation (DBS) surgical therapy. Not everyone with Parkinson's disease is a candidate for DBS but even for those who are declared suitable by a team of professionals, the decision to undergo DBS is not an easy one. There are many considerations. Before you decide to go forward with DBS, the information within this page will inform you on the general aspects of DBS. Your neurologist and neurosurgeon will provide you with the details about the surgery, programming and the therapy itself.

Deep brain stimulation is available in the following countries:

  • Austria
  • Belgium
  • Bulgaria
  • Canada
  • Croatia
  • Cyprus
  • Czech Republic
  • Denmark
  • Estonia
  • Finland
  • France
  • Georgia
  • Germany
  • Greece
  • Hungary
  • Iceland
  • Ireland
  • Israel
  • Italy
  • Latvia
  • Lithuania
  • Luxembourg
  • Malta
  • The Netherlands
  • Norway
  • Poland
  • Portugal
  • Romania
  • Russia
  • Serbia
  • Slovakia
  • Slovenia
  • Spain
  • Sweden
  • Switzerland
  • Turkey
  • Ukraine
  • United Kingdom


What is deep brain stimulation?

Deep brain stimulation (DBS) is a treatment option for people with advanced Parkinson's disease, Essential tremor and primary Dystonia that experience motor troublesome symptoms and poor quality of life despite having tried several types of medication.

Stimulation of specific areas of the brain appears to block the signals that cause the disabling motor symptoms of Parkinson's disease. As a result, many patients achieve greater control over their body movements and quality of life.

How does deep brain stimulation work?

Deep brain stimulation uses one or two surgically implanted medical devices called neurostimulators, similar to cardiac pacemakers, to deliver electrical stimulation to precisely targeted areas on each side of the brain.

One of two areas may be stimulated: either the subthalamic nucleus (STN) or the internal globus pallidus (GPi). These structures are deep within the brain and involved in motor control. A multidisciplinary team with a neurologist and a neuro-surgeon among others, decide whether to target the STN or GPi. Stimulation of these areas appears to block the signals that cause the disabling motor symptoms of the disease*. As a result, after DBS, many patients achieve greater control over their body movements. The entire system is implanted completely inside the body. Depending on which neurostimulator your doctor recommends, either one or two neurostimulators will be implanted to control symptoms which may affect both sides of the body.

* The Parkinson's disease motor symptoms are:

  • Rigidity: stiffness or inflexibility of the limbs and joints
  • Bradykinesia/akinesia: slowness of movement/absence of movement
  • Tremor: involuntary, rhythmic shaking of a limb, the head or the entire body
DBS Therapy
Kinetra - DBS stimulator
Lead and Extension

What are the components of the deep brain stimulation system?

Neurostimulator - a pacemaker-like device that is the power source for the system. There are several neurostimulators, rechargeable and non-rechargeable. In general they are between 5.5 to 7.5 cm wide and 0.9 to 1.3 cm thick and contain a small battery and a computer chip programmed to send electrical pulses to control Parkinson's disease symptoms. Second generation of neurostimulators are more advanced and iclude new features such as the possibility of being recharged. Rechargeability is an important feature for patients with high energy consumption. The rechargeable device allows almost one decade's peace of mind without surgeries for battery replacement.

Lead - an insulated wire terminating in four electrodes.

Extension - an insulated wire placed under the scalp and outside the skull that connects to the lead and runs behind the ear, down the neck, and into the chest below the collar- bone where it connects to the neurostimulator.

DBS programmer

External components used with the DBS system include:

  • A programmer that the physician uses to non invasively program (transmit instructions to) the neurostimulator.


    People respond to deep brain stimulation in their own way and the program for your neurostimulator will be customized to your needs.
  • A special controller that the patient uses to turn the neurostimulator on or, off.or to adjust the settings within limits set by the physician.
DBS controller

How is the DBS system implanted?

The system is implanted by a functional stereotactic neurosurgeon, that is, a neurosurgeon who specializes in treating central nervous system function disorders using stereotactic techniques. This means that a stereotactic head frame is used to keep the patient's head still during surgery and the neurosurgeon uses special imaging techniques such as magnetic resonance imaging (MRI) or computed tomography (CT) to map the brain and locate the site to be stimulated - either the STN or GPi.

There are two parts to the surgery: the procedure to implant the leads, and the surgery to implant the neurostimulator(s) and extensions. The details of the surgical procedure vary between centers, but the following is what you can expect in most centers.

For the first part the patient is awake during the placement of the leads so that dialogue with the surgeon can establish precisely which part of the brain is being passed. For the second part, when the surgeon runs the extensions and positions the neurostimulator (generally in the chest wall or in the abdominal area) the patient is fully anesthetised. The duration of the procedure and the specific steps involved may vary. The surgery time will depend upon whether one or two leads are to be placed in the brain. Some surgeries could last up to five hours or more. Discuss the procedure with your neurologist or neurosurgeon.

Although the prospect of surgery is somewhat intimidating because the patient is fully awake throughout the procedure, there is comfort in knowing that patients who have the DBS system usually describe the surgery as demanding and exhausting, but not painful. Fortunately, the brain itself has no pain receptors and feels no pain.


Benefits of Deep Brain Stimulation

DBS

Deep brain stimulation achieves longer periods of symptom relief.

Deep brain stimulation can provide hours of relief from the debilitating slowness, stiffness and/or shaking of Parkinson's disease every day. It can also reduce the duration of the abnormal, involuntary movements (dyskinesia) that are a common side effect of Parkinson's medications.

In Medtronic multicenter clinical studies, neurostimulation leads were implanted in the subthalamic nucleus (STN) or internal globus pallidus (GPi). Deep brain stimulation increased periods of good motor function and symptom relief by an average of more than 6 hours per day at 12 months*.

With the new family of DBS neurostimulators, there is more choice to meet the required needs. Talk to your neurologist or neurosurgeon to help you decide which device would be best for you


* Includes only patient data that were fully verified against medical records. Percentages have been rounded to the nearest whole percent. Data on file at Medtronic, Inc

Risks and side effects of Deep Brain Stimulation (DBS)

Potential side effects of deep brain stimulation

Many side effects related to stimulation are transient and can be managed by adjusting the stimulation settings. Several follow-up visits may be necessary in order to find the right stimulation settings to optimize symptom control and minimize side effects.

DBS therapy has been proven to have a well-established long-term safety profile, particularly in younger patients under 70 -75 years. As with any surgery there are some risks associated with the procedure, but these are very low when DBS therapy is performed by an experienced team. For example, the literature indicates that 6 in every 1,000 people (0.6%) might experience a temporary surgical complication (such as a seizure or trauma to the brain tissue), while skin infections can affect 2 in every 100 patients (2%), same as after a total hip replacement . When complications do occur in DBS, they are generally mild, short-lived and normally resolve around 30–90 days after surgery. The risk of permanent health impairments is also low (1.0%), mainly caused by bleeding within the skull. Like with any other treatment, deaths can occur but again the risk is low (0.4%), the same as the risk of death associated with total hip replacement (0.41%),for example.

DBS Benefit

There seems to be an increased risk of gait disturbances and falls with DBS therapy. However, it is not certain whether DBS therapy increases gait disturbances or fall risk directly, or whether patients are at a higher risk because of the improvement in their overall function and greater activity level. What is clear is that gait, balance and postural stability can improve significantly 6 to 12 months following surgery. In addition, the increased risk of gait disturbances and falls does not seem to have a negative impact on quality of life. Nevertheless, it is essential that all patients are offered physiotherapy to manage any possible gait disturbances, and that they undergo careful assessment by a multidisciplinary team before and after surgery, especially during the first year after the operation.

DBS does not permanently change the thinking or personality of an individual. However, DBS - like antiparkinsonian medication - may have psychiatric side effects, that are more likely to occur in patients, who have been suffering from previous psychiatric conditions due to their Parkinson’s disease or drug treatment. The problems that may occur are emotional disorders, such as depression or mania, confusional states or apathy. They are overall rare and most often transient, if managed appropriately.

Neurologists with experience in DBS should discuss these issues fully with their patients as well as potential risks associated with untreated Parkinson's, anti-Parkinson drugs and other types of therapies. This information will enable patients to balance the potential benefits of DBS therapy against any possible risks, and ensure that they choose the right therapy that will most effectively manage their specific symptoms

Electrodes

Facts about Deep Brain Stimulation (DBS)

  • DBS for Parkinson's disease works by electrically stimulating targeted structures in the brain - either the subthalamic nucleus (STN) or the internal globus pallidus (GPi). These structures control movement and muscle function.
  • Electrical stimulation of the brain has been used worldwide since 1987 to treat movement disorders.
  • DBS is used for Parkinson's patients in the medium or advanced stages of the disease or in cases where medication has no effect. In most cases patients should be "levodopa responsive." This means the primary symptoms respond to the drug levodopa. A person's age or pre-existing medical condition does not necessarily exclude him or her from becoming a candidate for DBS. A team of specialists considers all factors before determining if a patient is a good candidate.
  • A Parkinson's care team consisting of a neurologist, neurosurgeon and team of nurses is involved in caring for deep brain stimulation patients.
  • Recent Class I clinical evidence has demonstrated that when drugs become less reliable, Medtronic DBS Therapy provides better quality of life and more than 5 additional daily hours of “on” time without dyskinesias compared to the best pharmacological treatment alone 1,2,3
  • In Medtronic studies, average improvement in periods of good motor function and symptom relief for treated patients was 6 hours per day*.
  • More than 80,000 people worldwide have benefited from Medtronic DBS for Essential Tremor, Parkinson's disease and Dystonia since 1993.
  • Patients who have the DBS system usually describe the surgical procedure as demanding and exhausting but not painful. The brain itself has no pain receptors and feels no pain.
  • The hospital stay is usually a few days for the pre-operative tests, implant surgery and recovery.
  • Many people with a DBS system will not feel the stimulation at all. Some people may feel a brief tingling sensation when the therapy is first turned on. 
  • Deep brain stimulation is adjustable. This means that the stimulation can be changed over time to match the need for symptom control. To adjust the stimulation, a physician uses a programmer that communicates with the neurostimulator through radio frequency. It's completely non-invasive.

* Includes only patients whose data were verified against medical records. Data on file at Medtronic, Inc.

Is Deep Brain Stimulation (DBS) right for you?

DBS

Reasons to consider Deep Brain Stimulation

  • It is a safe and effective treatment that can relieve many of the debilitating symptoms of Parkinson's disease.

  • It can increase the duration and the quality of your periods with good motor function and symptom relief.

  • The drugs are no longer working well and you are suffering from their side effects.

  • Deep brain stimulation is reversible. If a cure for Parkinson's disease is developed, the therapy can be turned off and the system can be removed.

Kinetra Implant

Am I a candidate?

Deep brain stimulation is used for patients:

  • Who suffer from advanced Parkinson's disease. Patients should be carefully screened for other movement disorders, which may not respond to Deep brain stimulation.

  • Who have shown benefit from levodopa therapy. Deep brain stimulation has not been shown to improve symptoms that do not respond also to levodopa.

  • Whose symptoms are not adequately controlled by medications.


Only a neurologist or neurosurgeon can determine if deep brain stimulation is right for you.

Here are some factors which are considered:

  • You must be physically able to endure the surgery, and must be able to cooperate by answering questions and following directions during the surgery.

  • If you have significant cognitive decline or dementia, you may not be considered for this surgery.

  • You must understand the nature of the therapy and be able to operate the neurostimulator controller.

  • You must be available for periodic follow-up visits.

The safety and effectiveness of this therapy has not been established for use in these patients:

  • Patients with neurological disease origins other than idiopathic Parkinson's disease

  • Patients with a previous surgical ablation procedure

  • Patients who are pregnant

  • Patients under the age of 18 years

  • Patients over the age of 75 years

  • Patients with dementia

  • Patients with coagulopathies (blood disorders in which the blood does not clot properly)

  • Patients with moderate to severe depression

Appointment

Questions to ask your neurologist

Here are some questions you might ask. These can be found in the Medtronic DBS For Parkinson's Disease information booklet

What is Parkinson’s disease (PD)?

  • How could PD have an impact on the quality of life? [p4]
  • How can PD be treated? [p7]

Medtronic Deep Brain Stimulation (DBS) Therapy

  • What is Deep Brain Stimulation (DBS)? [p8]
  • Who is a candidate? [p12]
  • When should it be considered? [p14]
  • Why DBS? What are the benefits and risks? [p16]
  • Frequently asked questions [p22]
  • Patient’s story [p26]
  • Questions to discuss between neurologists and patients [p28]
  • Further information [p30]

Providers of Activa® Therapy Around the World

The Medtronic Essential Tremor website provides information on diagnosis, treatment and management of essential tremor.

This section lists many of the physicians who provide Activa® Therapy. Please note that Medtronic provides this listing as a service to potential patients; they have no vested interest in any specific physicians, nor do they provide any assurance or guarantee with respect to their service.

Product Information Downloads

Patient Guides

Useful links

See also DBS in Parkinson's in-depth


References

  1. Deuschl, et al, NEJM, 2006
  2. Weaver et al, JAMA 2009
  3. Williams et al, NEJM 2010