Deep Brain Stimulation Surgery

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What is deep brain stimulation (DBS)?

This surgical treatment uses electrical stimulation of selected brain areas. It is used for Parkinson’s disease, essential tremor, and dystonia (a neurological movement disorder, in which sustained muscle contractions cause twisting and repetitive movements or abnormal postures).

What symptoms can DBS improve?

Improved control of movement or other symptoms is the goal of DBS. It may result in a reduction of tremor, rigidity, dyskinesia (impaired ability to control movements), or dystonia. Note that DBS is not a cure for any disease. The primary goal of the surgery is to help control the symptoms and provide you with a better quality of life.

What movement disorders can be treated with DBS?

DBS is now used for surgical treatment of several movement disorders including essential tremor, Parkinson’s disease, and generalized dystonia.

How does DBS work?

DBS may be used on one side of the brain or two based on the symptoms. A deep brain stimulator consists of an electrode, a lead extender, and a generator. During DBS surgery, the electrode is inserted into the brain through a small opening in the skull. It is attached under the skin via a lead extender to a generator placed in the chest just below the collarbone. All parts of the DBS system are below the skin. The generator is similar to a heart pacemaker and allows for electrical stimulation of specific brain areas that are involved in movement disorders.

What are the advantage of DBS compared to older surgical techniques?

Previous surgical approaches to movement disorders involved destruction of brain tissue and were irreversible. In contrast, DBS is reversible because the electrodes can be removed. DBS also allows for flexibility since the generator can be adjusted.

What are the risks?

The most serious risk is bleeding into the brain, causing stroke. Less than 1% of patients experience a stroke. The effects of a stroke can include paralysis, loss of speech, coma, or even death. There is also some chance (10%) of less serious complications. These may include infection, malfunction of the stimulator, and movement of the electrode or generator. Any of these problems may require removal of part or all of the DBS system.

Am I a good candidate for DBS surgery?

The following conditions are generally a good guide:

  • You have already tried a reasonable course of medications, as determined by a movement disorder neurologist.
  • You are significantly disabled by your disease.
  • You are in reasonably good health.
  • You do not require routine MRI scans.
  • You can take part in the programming of the device once implanted. This means you can provide feedback during programming sessions and can make clinic sits.
  • You have a good support network of family and friends.

Before the Surgery

I am ready to proceed: what determines whether DBS surgery will actually take place?

  • First, you must have a physical exam to make sure you do not have any health problems that would affect the surgery. Bring a list of all your medicines and prescriptions with you to this physical exam.
  • Your primary care physician should send your medical records and radiology scans to the office before your DBS consult appointment.
  • Additional tests such as head MRI and neuropsychological testing may also be ordered to help determine whether you are a good candidate for this surgery.
  • If you are determined to be a good candidate for the DBS implant, your surgery may take a few months to schedule.
  • Once you’ve decided to proceed with the surgery, notify the neurosurgery office, either at the time of the clinic visit or by calling Semmes Murphey at 901.522.7700
  • If you wish to speak with someone who has had this procedure, we can have someone contact you. If interested, call 901.522.7700 to learn more about this service.
  • We will ask your permission for us to videotape you during these clinic visits. These videos will be used to compare the changes before and after DBS placement.
  • The offer to participate in research may be presented to you. This option will be explained to you during your first visit. You may choose to take part or not.

How do I prepare in the days leading up to surgery?

  • Discontinue taking blood thinners such as Aspirin, Excedrin®, Aleve®, Ibuprofen, Advil®, and Motrin® 14 days before your surgery date.
  • Discontinue taking vitamins and herbal supplements 7 days before you surgery.
  • You should plan to shampoo and bathe with an antibacterial soap the night before and the morning of surgery to lessen the risk of infection.
  • No food or drink should be taken after midnight. You may drink only clear liquids up to four hours before the surgery. Clear liquids can include water, soda, coffee and tea (no creamer), clear broths, juices without pulp or solid material (apple juice), and popsicles.
  • At your pre-surgery visit, you will be told which medicines to take the morning of surgery. If you are on blood pressure medicine, be sure to talk to your surgeon about those medications.

Where do I arrive for surgery?

Location of arrival for your first DBS surgery depends on your condition: (exact times will be determined by your care team prior to admission)

Patients with Parkinson’s disease: On the day before surgery, report to the Admissions Department in the morning for the first electrode placement. You will be admitted to the hospital and your Parkinson’s medication will be withdrawn in the evening. If a second electrode placement is required, arrive at the hospital on the day before surgery (afternoon). You will be escorted to the neurology/neurosurgery unit and stay in a private room the first night. Your Parkinson’s medications will be withdrawn in the evening.
Other Patients: Arrive to the hospital early on the day of surgery. You will need to report directly to the Baptist Ambulatory Center (BAC).

What happens during the DBS surgery process?

Placement of the DBS implant is performed in stages: first, electrode(s) placement; second, generator placement. First, the electrode(s) will be placed in your brain. You and your physician will decide if a second electrode is needed. You will be awake for this procedure. Following the surgery you will spend the first night in an intensive care unit (ICU). Then you will be on a general care unit for one or two more days before you go home. Second, the generator will be placed in your chest.You will be under anesthesia for this procedure. After the placement, you will go to the general care floor and may be able to go home the next day. Note that the device will not be turned on until you return to your managing neurologist about two weeks after your surgery.

What is the process for the DBS electrode surgery?

A nurse from the BAC will call you the day before surgery between 10 am -2 pm to tell you what time to arrive on the day of surgery.

  • Plan to shampoo with an antibacterial soap the night before and the morning of surgery to help lessen the risk of infection.
  • You will be taken to the Operating Room (OR) frame placement (with sedation).The frame, which allows electrode placement will be scanned in a CT scanner and then you will return to the OR.
  • Once back in the OR, your hair will be clipped and you will be placed in a “beach chair” like reclining position.
  • Your surgeon will plan for your electrode placement based upon the MRI and CT scans.
  • Sterile drapes will be placed.
  • You will be awakened for recordings or testing during the surgery and then sedated again after electrode placement.
  • After the surgery, you will spend your first night in the intensive care unit.

What is the process for implantable pulse generator placement?

A nurse from the BAC will call you the day before surgery between 10 am -2 pm to tell you what time to arrive on the day of surgery. Plan to shampoo with an antibacterial soap the night before and the morning of surgery to help lessen the risk of infection. Do not eat or drink after midnight. You should take your Parkinson’s or tremor medicines before surgery. Take all medicines with small sips of water only. On the day of surgery, all patients should report two hours prior to their surgery time. You will be asleep for the generator placement which will take 2-3 hours. An incision will be made in your chest. The incision behind your ear will be re-opened. The doctor will insert the generator into your chest, bring the wire behind your ear down your neck to your chest, and connect the two devices. Once this is done, all parts will be underneath the skin.

When is the generator placement surgery?

Usually about 1-2 weeks following the electrode placement surgery, you will return for the surgery for placement of generator(s) in your chest.

What should I do at home after electrode(s) placement surgery?

After the electrode placement surgery you will have a surgical dressing on top of your head and one behind your ear. You may notice a bump near the incision behind your ear. This is a cap at the end of the electrode which will be taken out during the second surgery (generator placement). The dressings on your head should stay on for two days after surgery. After that, you may remove the dressing. You may shower but do not immerse your head under water for five days after the surgery. You may use a mild shampoo such as baby shampoo and then pat the incision dry (do not rub dry). Do not use hair conditioner. You should not use a comb or brush close to the incision. You may have some oozing of blood from the incision sites especially right after the surgery and after taking the stitches out. Clean the sites with normal saline. Applying firm pressure with a sterile gauze pad or clean washcloth for about 5-10 minutes should stop this bleeding. If you are unable to stop the bleeding, which is unlikely, go to the emergency room.

Additional post-surgery care recommendations:

  • Do not put any ointments or creams on or near the incision.
  • Do not drive until after your two week follow-up visit. Do not drive while you are taking narcotics for pain.
  • Do not lift items that weigh more than 10 pounds (about the weight of a gallon of milk).
  • Walk as much as you are able to each day.
  • Avoid bending your body forward with your head facing down for at least two weeks.
  • You can wear a hat, scarf, or turban after the surgery to cover up the head incision from the sun for 4-6 weeks after the surgery to reduce scarring.
  • Take Tylenol® for any mild pain that you may experience during this time.
  • Watch for these signs and symptoms and call the neurosurgery contact numbers provided in this article if needed: Increased drainage from the incisions; change in the amount of pain at the surgery sites; temperature more than 101.5°F by mouth.

What happens after the generator placement surgery?

Two weeks after your last surgery you will come in to Semmes Murphey Clinic for incision check/suture removal visit. Two to four weeks after the surgeries, the programming of the device will start. This will be done by your managing neurologist. It may take 3-6 months to adjust the device for best possible symptom management.

What else is affected by DBS surgery?

MRI studies should not be done once DBS electrodes have been placed. Many times CT scans, X-rays, or other studies are suitable substitutes for MRI studies.

Who do I call with post-surgery questions or issues?

If it is an emergency, call 911. If you have general questions about your surgery, call Semmes Murphey Clinic: 901.522.7700. If you have questions about your DBS programming or medications for Parkinson’s disease, essential tremor, or dystonia, call your managing neurologist.

 

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