Awake Deep Brain Stimulation

Deep brain stimulation (DBS) is a type of brain surgery in which electrodes are implanted into specific targets in the brain. The targets are chosen according to the disorder that we are treating. The primary goal of the deep brain stimulation procedure is to improve the patient’s quality of life by managing symptoms, not to cure the disease or disorder.

Deep brain stimulation surgery involves the placement of three device parts into the body. They are all implanted below the skin. The first part is the wire(s) that go into the brain. These are also called leads or electrodes. The second part is the battery pack/generator. This is placed in the chest just below the collar bone. The last part is the wires that connect the leads to the generator.

Target stimulation starts once the device has been turned on. This usually happens approximately two weeks after surgery. Some symptom relief is immediate (such as tremor control) and some results can take several months to occur.

Neuroscientists do not yet know exactly how deep brain stimulation works. Many specialists, however, believe that the electrical stimulation provides relief by interrupting the irregularly firing circuits in the brain. These irregularly firing circuits cause the symptoms, so regulating these circuits could serve to decrease or eliminate symptoms. In a general sense, deep brain stimulation can be described as a pacemaker for the brain.

Unlike other surgical options available, the effects of deep brain stimulation are reversible and do not permanently damage brain tissue. In addition, there is the ability to adjust, or program, the stimulation to better capture symptoms.

As the name suggests, awake (standard DBS) surgery is performed while the patient is awake, and is a surgical option from patients suffering from essential tremor, Parkinson’s, dystonia, and some psychiatric disorders. The surgery takes place in two parts, with the first procedure lasting about four to six hours under local anesthesia.

Before Surgery

Before a patient is approved for and undergoes a deep brain stimulation (DBS) procedure, there are five basic pre-operative steps that take place.

Step 1: Formal appointments during DBS Clinic with each of the following deep brain stimulation specialties – neurology, neurosurgery, psychiatry, and neuropsychology. Our Program Coordinator will make all of these appointments.

Step 2: The patient will get a brain MRI with gadolinium (a contrast agent used to enhance MRI images) and an MRI without gadolinium. In order to obtain the best images, we try to schedule imaging for when the patient is experiencing the least amount of symptoms. Mild sedation may be used if necessary. Please let us know if you have had spine surgery or have chronic back pain.

Step 3: Your case will be discussed at a committee meeting to determine if you are an appropriate surgical candidate and if you will benefit from a deep brain stimulation procedure. The DBS Surgical Planning Committee meets to address movement disorders and the DBS Steering Committee meets to address psychiatric disorders.

Step 4: You will be notified, along with your referring physician, of the committee results. If you are a candidate, we will begin surgical scheduling immediately. If you are not a candidate, we will discuss other potential treatment options with you and your referring physician.

Step 5: You will receive two appointments before your surgery. The first will be at the Weiner Center to get necessary testing and meet your anesthesiology team. The second will be with neurosurgery to sign your surgical consent form and ask any questions. You also will receive written preoperative instructions that explain when to arrive at the hospital on the day of your surgery and which medication(s) you should stop taking at midnight prior to surgery.

During Surgery

In most cases, the patient is expected arrive at the hospital by 5:30 am. At approximately 6:30 am, we will place a frame on the patient that screws into their head (seen in the video). We will inject local numbing medicine so that this process is not painful. You will, however, feel some pressure for about 10 to 15 minutes after placement. This will go away. You then will get a CT scan of your head while in the frame to help us better map our surgical target(s).

By 7:30 am, you will be moved into the operating room. We will attach the head frame to the surgical table and try to make you as comfortable as possible. You will be in this position for several hours. This is often the most difficult part of the day for patients, especially since they won’t be benefitting from their typical medications. Our operating room staff, however, will be very attentive to a patient’s needs during this time and throughout the day.

We shave a portion of the head to expose the area where the burr holes will be placed. Once the surgery begins, we drill two burr holes into the skull. Drilling only lasts about two to three minutes. This is not painful, but the drill is loud and can be disturbing to patients. At certain points during the surgery, we will ask for your help. At one point, we will ask you to hold out your arm or tap your fingers. This helps reassure us that we are in the right spot. Afterward, while stimulating your brain, we will ask you to complete tasks and describe how it feels. This is called “mapping”. If we are doing both sides, once we are happy with the placement of the first lead, we proceed to the second side. Generally, the second side is faster since the burr hole has already been drilled. Once we complete mapping, we will make you sleepy and finish the surgery. The surgical day usually ends around 3:00 pm. Most patients leave the hospital the next day.

After Surgery

Step 1: Approximately two weeks after Step 2 of the surgery is completed, patients will be seen by one of our experts for initial programming. Patients will be asked to temporarily stop taking your medications shortly before this first appointment, which typically lasts two to three hours. If the patient was referred by a neurologist with knowledge of programming, your initial and subsequent programming will probably be with them. It is important to note that during the first couple weeks immediately after surgery, it is not uncommon for your family to notice that you are slightly confused or disoriented. This is temporary and will go away in two to three weeks after surgery.

Step 2: Patients will need to return for several additional follow-up visits for stimulation and battery-life monitoring. These appointments will be more frequent and lengthy during the first 3-6 months. These appointments are important for fine-tuning the programming, allowing us to best capture your symptoms and improve your quality of life. After this three to six month fine-tuning period, your programming appointments will become less frequent and less lengthy.

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