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Typically, there are three types of PD patients who benefit from DBS:
Essential tremor is the most common movement disorder, and DBS can be an effective treatment, especially in severe cases where the tremor can lead to disability and impair daily tasks such as dressing, shaving, eating, or drinking. Since tremor is the sole symptom of essential tremor, DBS can significantly improve the quality of life for individuals with this condition and aid in their normal functioning.
Dystonia is a relatively rare movement disorder, but its symptoms, such as abnormal postures and twisting movements, can respond to DBS when medications do not provide sufficient relief. The response of an individual to DBS can depend on the underlying cause of dystonia (genetic, drug-induced, or other factors). If the cause is unknown, it’s likely that the doctor will conduct further testing as part of the evaluation for DBS.
Recent studies suggest that individuals living with depression, obsessive-compulsive disorder (OCD), or Tourette syndrome may benefit from DBS surgery. Further research is needed to determine whether DBS is effective in treating psychiatric disorders and whether the benefits outweigh the risks and side effects.
Deep Brain Stimulation surgeries are not decisions made by a single physician. To understand if Parkinson’s patients are suitable for surgery, we admit them to our Deep Brain Stimulation center for a few days. During this period, our experienced movement disorder neurologists first check if patients are receiving the most appropriate drug therapy. If necessary, we add new medications. Afterwards, our neurologists apply detailed tests that measure the degree of Parkinson’s disease during medicated and unmedicated phases, i.e., ON and OFF periods. Based on the results of these tests, we decide whether the patient is neurologically suitable for surgery. If we find our patients suitable for surgery, they are then thoroughly examined by our psychiatrist. Additionally, our neuropsychologist applies detailed neuropsychological tests to evaluate our patients’ dementia or cognitive states. We perform screening brain MRIs on all our patients to determine if there is any issue that could hinder the surgery. An in-depth preliminary examination is also carried out by our anesthesiologist to rule out any conditions that could contraindicate the surgery. At the end of this approximately three-day process, the joint decision to proceed with the Deep Brain Stimulation surgery is made or not made by our collaborating neurologists, neurosurgeons, psychiatrists, and neuropsychologist. For patients deemed suitable, we communicate our assessment results, explain the potential benefits and risks of the surgery in detail, and if they accept the deep brain stimulation treatment, we discharge them with a scheduled surgery date set for a reasonable time in the future along with necessary recommendations. For patients found unsuitable for surgery, we explain the reasons for our decision, adjust their medication treatments, and send them home with a follow-up appointment and further recommendations.
Although there is no legal age limit for undergoing Deep Brain Stimulation (DBS) surgery, it is generally not recommended for patients over the age of 80. A decade ago, this limit was around 70 years old, and in the recent past, it had been adjusted to 75. Today, as long as there are no cognitive, psychiatric, or severe chronic diseases that could complicate the surgery, the age limit for DBS candidates has been pushed even further. However, we still advise a more meticulous pre-surgical assessment for patients in advanced age groups.
Deep Brain Stimulation has proven to be a highly effective method for patients deemed suitable after thorough evaluations. It is particularly promising for those with symptoms such as tremors, freezing, stiffness, slowness of movement, and involuntary movements. Above all, patients experience a significant release from the constraints of their daily life. The periods referred to as “off times,” where patients remain mostly inactive, are substantially reduced, granting them a significant increase in quality of life. Additionally, post-surgery, it is often possible to lower the dosages of Parkinson’s medication, thereby reducing known side effects. However, it’s essential for patients and their families to understand that DBS is not a cure that stops Parkinson’s disease completely. The disease unfortunately continues to progress over the years. But for appropriate candidates, DBS is considered the best treatment available, a claim substantiated by numerous scientific studies. In comparative trials with patients undergoing medication therapy, the superiority of DBS has been consistently demonstrated. Thus, for those found suitable, DBS treatment can be seen as a patient’s right.
Deep Brain Stimulation surgeries are typically performed while the patient is awake. This approach has a couple of important reasons. Even though we, as surgeons, make detailed calculations based on preoperative brain MRIs, the goal is to place the electrodes in the most accurate location. The target areas in the brain are deep and small, measured in millimeters, so a placement off by even a millimeter could lead to less favorable outcomes. That’s why we utilize a microelectrode recording technique during the surgery, which allows us to record the activity of individual brain cells electro-physiologically. With this technique, we can listen to the ‘voices’ of individual cells, record them, and pinpoint the brain regions with abnormal activity in diseases like Parkinson’s with virtually no margin of error. During the procedure, we also apply low-voltage electrical stimulation while our neurologist observes the patient’s response to these stimuli, noting both therapeutic effects and potential side effects. Patients themselves can feel the extent to which their symptoms improve during the surgery. In a sense, we perform the surgery in cooperation with our patients. However, some patients may feel anxious about being awake during the procedure and may opt not to. In such cases, we can perform the surgery under anesthesia while still using microelectrode recording to ensure the accuracy of the DBS procedure.
After the surgery, we can turn on the patient’s device at a low voltage the next day, or we can wait for subsequent days depending on the patient’s condition. In some patients, we can make some small adjustments to the medication dosage in the first few days. We discharge our patients within 5 to 10 days after the surgery. Our Parkinson’s nurse provides discharge training to all our patients. We also provide recommendations and give a brochure with the written points they need to pay attention to.
We invite our patients for control on the 1st and 3rd months after surgery to adjust the medication and device settings. Typically, by the end of the 3rd month, we have been able to reduce the medication doses for most of our patients and make the device settings optimally.
After the deep brain stimulation surgery, patients tend to gain weight, especially in the first few months, due to a decrease in joint stiffness and an increase in appetite. We try to prevent this issue by providing nutritional education before the surgery and during control visits by our dietitian. Another problem can be infection at the wound site. To prevent this, our Parkinson’s nurse provides meticulous and detailed information during discharge. Some patients may experience temporary psychiatric complaints after surgery. In this case, we suggest they contact our center. We definitely do not recommend injurious sports such as football, judo, wrestling, boxing. However, we encourage them to do any non-injurious sports they wish. We also advise them not to go through x-ray devices at airports and similar places, and we provide a document stating that they are carrying a deep brain stimulation.
The movement-related symptoms of Parkinson’s disease and other neurological disorders stem from irregular electrical signals in the areas of the brain that control movement. When successful, DBS interrupts the irregular signals that cause tremors and other movement symptoms.
After a series of tests to determine the optimum placement, brain surgeons implant one or more wires, known as “leads,” into the brain. The wires are connected via an insulated wire extension to a very small neurostimulator (an electrical generator), which is placed under the clavicle, similar to a deep brain stimulation. The continuous pulses of electric current from the neurostimulator travel through the wires to the brain.
Once the neurostimulator is in place, the doctor programs it to transmit an electrical signal. The doctor seeks the best balance between improving symptom control and limiting side effects while adjusting the device.
DBS surgery can help individuals with Parkinson’s disease improve symptoms of tremors, stiffness, bradykinesia, and dyskinesia. It can also reduce the dosage of medication needed to manage their PD. Researchers following patients after DBS have found that many experience improvements in symptoms over time, becoming able to eat, use the toilet, and feed themselves independently.