Project Description

DBS Benefits

Deep Brain Stimulation (DBS) has been shown to be effective as a therapy for essential tremor and involuntary movements seen in a number of medical conditions. According to the Cleveland Clinic, patients with involuntary movements see an improvement of over 80 percent with DBS.[i]

[i] Deep Brain Stimulation: Multiple Sclerosis Treatment. (n.d.). Retrieved February 3, 2019, from https://my.clevelandclinic.org/health/treatments/16910-deep-brain-stimulation-overview

In people with Parkinson’s disease (PD), some brain cells that make an important chemical known as dopamine, are lost. DBS surgery in PD patients takes place in the Subthalamic nucleus section of the brain. DBS is seen as a highly effective and safe option for patients with PD. According to the American Association of Neurological Surgeons[i], it offers steady clinical benefit and helps in decreasing the need for medication, dopamine replacement, by as much as 50 to 70 percent in 100 percent of patients[ii]. DBS treats the symptoms seen with PD, but does not slow or reverse the advancement of PD.

DBS is recommended for patients with PD, with brain function, experiencing involuntary movements, or who may be experiencing medication side effects[iii]. A study published in Geriatrics indicates that approximately ten to twenty percent of PD patients may be eligible for DBS.[iv] There are two published tools currently in use that assist clinicians in determining if a PD patient is eligible for DBS: the Florida Surgical Questionnaire for Parkinson Disease (FLASQ‐PD)[v] and the Stimulus tool.[vi]

FLASQ‐PD is a concise, five‐part assessment that evaluates the following:

  • Criteria for the diagnosis of PD
  • Possible contraindications to DBS surgery
  • Overall patient characteristics, including age, length of symptoms, presence of and involuntary movements
  • Positive or adverse characteristics with regard to DBS surgery, including l‐dopa response
  • A history of previous medication trials

The patients’ scores from parts 3 to 5 are added to get a total FLASQ‐PD score. A score of 0 is seen as poor candidacy for DBS surgery, while a score of 34 shows that the patient is an ideal candidate. A suggested score of 25 and above, has been reported for the most favorable candidate, while a score of 15 or less indicates a less favorable DBS candidate.

Stimulus is a two‐part tool, found online (http://test.stimulus-dbs.org). To screen in, possible DBS candidates must meet all five criteria seen in part 1:

  • Involuntary PD diagnosis
  • Difficult motor symptoms even after being on the best possible medication
  • Obvious motor improvement while on l-dopa
  • The lack of significant medical conditions preventing surgery
  • Patient does not have any serious mental health condition, such as depression or dementia.

PD patients that do not meet the above criteria according to the Stimulus tool, do not qualify for DBS.

Those who meet the criteria are then scored for the following seven main variables in part 2:

  • Age
  • Time period of disease
  • Symptoms severity when not on medication
  • Severity of involuntary movements
  • L‐dopa‐unresponsive axial symptoms
  • Refractory tremor
  • Intellectual impairment

When the responses are recorded, the Stimulus program shows a score from 1 to 9. Patients who score a 7 and above, are seen as ready for DBS. Those who score 4 to 6 are in a grey area, and those who score 3 and below, are considered less favorable for DBS.

[i] Fenoy, Albert & K Simpson, Richard. (2013). Risks of common complications in deep brain stimulation surgery: Management and avoidance. Journal of neurosurgery. 120. 10.3171/2013.10.JNS131225.

[ii] Deep Brain Stimulation. (n.d.). Retrieved February 3, 2019, from http://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Deep-Brain-Stimulation

[iii] Okun, M., Fernandez, H.,Rodriguez, R., Foote, Kelly (2007). Identifying candidates for deep brain stimulation in Parkinson’s disease. Geriatrics, 62(5), 18-24.

[iv] Okun, M., Fernandez, H.,Rodriguez, R., Foote, Kelly (2007). Identifying candidates for deep brain stimulation in Parkinson’s disease. Geriatrics, 62(5), 18-24.

[v] Okun, M. S., Fernandez, H. H., Pedraza, O., Misra, M., Lyons, K. E., Pahwa, R., . . . Foote, K. D. (2004). Development and initial validation of a screening tool for Parkinson disease surgical candidates. Neurology, 63(1), 161-163. doi:10.1212/01.wnl.0000133122.14824.25

[vi] Moro, E., Allert, N., Eleopra, R., Houeto, J., Phan, T., & Stoevelaar, H. (2009). A decision tool to support appropriate referral for deep brain stimulation in Parkinson’s disease. Journal of Neurology, 256(1), 83-88. doi:10.1007/s00415-009-0069-1

Essential tremor is a movement disorder where involuntary shaking occurs(tremors), most common in the hands and legs. DBS is a highly successful treatment option for patients with essential tremor. Patients are considered ideal candidates for DBS if they meet the following criteria[i]:

  • Requires medication adjustment often, no longer well-controlled by medication
  • Diagnosed over 4 years, but less than 25 years

According to research published in the Journal of Neurosurgery[ii], after DBS, patients with an essential tremor experienced an improvement in average tremor score, from 3.27 to 0.64. In addition, average handwriting score went from 2.94 to 0.89.  In general, this 59.6-months follow-up study recorded a tremor improvement rate of 80.4% and a handwriting improvement rate of 69.7%. In this research study, symptomatic relief was still evident even after almost six years. After DBS, patients with essential tremor experience improvement in quality of life, including the following[iii]:

  • 24-hour therapy – Constant therapy, unlike with mediation alone
  • Easier medication regimen
  • Lesser possible drug-related side effects
  • No daily maintenance
  • No limitations on sleep position, intimacy, bathing or swimming, or clothing

[i] DBS for essential tremor. (n.d.). Retrieved February 3, 2019, from https://www.ohsu.edu/xd/health/services/brain/getting-treatment/deep-brain-stimulation/for-providers/essential-tremor/index.cfm

[ii] Zhang, K., Bhatia, S., Oh, M. Y., Cohen, D., Angle, C., & Whiting, D. (2010). Long-term results of thalamic deep brain stimulation for essential tremor. Journal of Neurosurgery, 1271-1276. doi:10.3171/2009.10.jns09371

[iii] DBS for essential tremor. (n.d.). Retrieved February 3, 2019, from https://www.ohsu.edu/xd/health/services/brain/getting-treatment/deep-brain-stimulation/for-providers/essential-tremor/index.cfm

DBS Risks

According to a research study, while DBS is normally without incident, and effective, some complications can occur. [i] During the DBS procedure, the following adverse events were observed during surgery:

  • Vasovagal response (0.8%)
  • Low blood pressure (0.3%)
  • Seizure (0.3%)

Right after surgery, majority of the patients experienced bleeding, notably[ii]:

  • Bleeding in the brain tissue, with no outward physical sign (0.5%)
  • Bleeding in the brain ventricles, with no outward physical sign (3.4%)
  • Bleeding in the brain tissue, with outward physical signs (1.1%)

Also observed right after surgery, the following is also seen[iii]:

  • Stroke (0.4%)
  • Weakness of the body and/or decreased consciousness in 13 (1.7%)

Long-term complications of DBS[iv] that can occur months after surgery include hardware discomfort  (1.1%), loss of desired effect (1.4%) wound infections (1.7%), wrong positioning of the DBS lead device (1.7%), component fracture(1.4%), component malfunction (0.5%), and loss of effect  (2.6%).

In another research study, a patient experienced further involuntary leg movement after surgery, needed a second surgery, and also experienced the following: comorbid chronic body pain, as well as post-surgery complaints including tremors, balance impairment, and functional leg weakness.[v]

According to the American Association of Neurological Surgeons, patients who undergo DBS can have loss of balance, some paralysis, jolts and shocks, and decreased coordination.[vi] This is especially seen in older patients (above 70) or those who have other medical conditions as well.

Altogether, The National Parkinson Foundation states that, “The risk of serious or permanent complications from DBS therapy is very low.”

Research at Duke University concluded that DBS poses no greater risk of complications among the elderly (older than 75), when compared to younger patients with PD.[vii]

[i] Fenoy, Albert & K Simpson, Richard. (2013). Risks of common complications in deep brain stimulation surgery: Management and avoidance. Journal of neurosurgery. 120. 10.3171/2013.10.JNS131225.

[ii] Fenoy, Albert & K Simpson, Richard. (2013). Risks of common complications in deep brain stimulation surgery: Management and avoidance. Journal of neurosurgery. 120. 10.3171/2013.10.JNS131225.

[iii] Fenoy, Albert & K Simpson, Richard. (2013). Risks of common complications in deep brain stimulation surgery: Management and avoidance. Journal of neurosurgery. 120. 10.3171/2013.10.JNS131225.

[iv] Fenoy, Albert & K Simpson, Richard. (2013). Risks of common complications in deep brain stimulation surgery: Management and avoidance. Journal of neurosurgery. 120. 10.3171/2013.10.JNS131225.

[v]Breen, D. P., Rohani, M., Moro, E., Mayberg, H. S., Zurowski, M., Lozano, A. M., & Fasano, A. (2018). Functional movement disorders arising after successful deep brain stimulation. Neurology, 90(20), 931-932. doi:10.1212/wnl.0000000000005530

[vi] Deep Brain Stimulation. (n.d.). Retrieved February 3, 2019, from http://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Deep-Brain-Stimulation

[vii] Ronel. (2016, November 07). Surgical complications of DBS no higher risk for older Parkinson’s patients. Retrieved from https://dcri.org/surgical-complications-dbs-no-higher-risk-older-parkinsons-patients/

her, The National Parkinson Foundation states that, “The risk of serious or permanent complications from DBS therapy is very low.”

Research at Duke University concluded that DBS poses no greater risk of complications among the elderly (older than 75), when compared to younger patients with PD.[vii]

Asleep DBS

Qualifying candidates will be scheduled to speak with a neurosurgeon by phone.

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Awake DBS

This form of brain surgery is conducted while the patient is awake and is available in surgery centers across the county.

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