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Deep Brain Stimulation

The Department of Neurosciences offers a procedure for patients suffering from Parkinson's disease, essential tremor and dystonia. More than a quarter of a million dollars has been spent on equipment to perform deep brain stimulation (DBS), a surgical procedure that helps with debilitating symptoms such as tremor, rigidity, stiffness, slowed movement and walking problems in patients whose symptoms cannot be adequately controlled with medication. During a year-long Emory University fellowship, Dr. Bryan Payne learned DBS and has since performed more than 300 deep brain stimulation surgeries while division head of Functional Neurosurgery at LSU.

Deep brain stimulation uses a surgically implanted neurostimulator (similar to a pacemaker) to send electrical stimulation to areas of the brain where abnormal nerve signals are causing disease symptoms.

"In Parkinson's, for example, the levels of the neurotransmitter dopamine decline because of progressive cell loss in a particular small region of the brain," Payne explains. "This leads to the symptoms of rigidity, slowness and tremors common in Parkinson's disease due to hyperactivity in very specific circuits in the brain. With DBS a very small, high frequency current is used to disrupt the hyperactive circuit, minimizing the symptoms caused by it."

Deep brain stimulation is FDA-approved to treat three disorders (Parkinson's, essential tremor and dystonia), though it is being used experimentally outside of the United States on patients with epilepsy, depression and memory loss. Payne said new applications are just around the corner for DBS, though Marshall's department will be focusing exclusively on FDA-approved procedures.

Before deep brain stimulation, MRI and CT scans are used to locate the appropriate position in the brain. The procedure utilizes a lead, electrode, extension and neurostimulator. The lead and electrode are inserted through a small hole into the brain, with the extension run under the skin to the neurostimulator, generally implanted near the collarbone, lower chest or abdomen. Almost all patients, according to Payne, go home the following day and follow-up includes programming the stimulator. Every four to six years, the neurostimulator battery needs to be replaced. This is done under local anesthesia and takes 10 to 15 minutes.

Because the nature of Parkinson's disease is so personal from patient to patient, it is imperative that physicians work closely to match the procedure to those best suited to receive it.

"As a surgeon, it's not appropriate for me to diagnose Parkinson's or to treat it medically. That should be done by their neurologist," Payne emphasizes. "If their neurologist thinks they have reached the limits of medical therapy, we consider surgery. Patients who are well-controlled on their medications, or are debilitated for other reasons, such as older age or additional medical problems, are not necessarily good choices for this procedure. If it's not going to significantly improve your quality of life, this is not for you."

"Parkinson's disease, in particular, is tricky because some people have tremors and some don't," Payne continues. "Some develop the disease at age 30 and others at 70. Some are rapidly progressing and others aren’t. Many have diseases with symptoms similar to Parkinson's disease but that do not improve with surgery. It takes a lot of experience to pick out the ones who'll benefit from this and benefit long-term."

Deep brain stimulation is reversible and adjustable and the results generally good, with most patients experiencing significant reduction of their Parkinson's symptoms, while still requiring some – although often reduced – levels of medication. For patients with essential tremor (not related to Parkinson's disease) the results with DBS are generally impressive.

"With essential tremor the patients appear normal at rest but when they attempt to do something with their hands the tremor appears," Payne explains. "It can be minimal or so severe that normal activities such as eating and dressing become impossible. With medical therapy for the more severe cases generally ineffective, DBS can offer a remarkable alternative treatment."

Patients undergo DBS procedures at Cabell Huntington Hospital, performed by an experienced neurosurgeon who has performed hundreds of the procedures. Adjunct Professor Terence Patterson, a clinical neurophysiologist with extensive intraoperative neuromonitoring experience, supports Dr. Payne in the operating room managing the intricate system of filters and amplifiers imperative for accurate placement of the leads.

"You have to set up this program and do it right from the beginning. You really want to make certain that the first patient you do is just like the 1,000th patient you do. This is not something you want to figure out as you go. We did not start offering the procedure until the appropriate equipment, software and personnel were available. They are now," Payne said. "This is a purely elective procedure, and it's a chronic problem that needs management. We cannot operate independent of the rest of a patient's treatment, and right now, we're working closely with the physicians in the community to help them understand how this can benefit the right patients."

For more information or to schedule an appointment with a member of the Marshall University Department of Neuroscience, please call (304) 691-1787.