Friday, April 12, 2024

What To Expect After Dbs Surgery

Why Would You Choose The Subthalamic Nucleus As A Site For Parkinsons Disease It Seems That It Is Associated With More Problems Than The Globus Pallidus Interna

After surgery: programming DBS. What to expect.

In a recent large DBS trial comparing STN to GPi DBS for Parkinsons disease, there was not much difference in the effect on motor symptoms. STN had a slight advantage in that people were able to reduce their medications more. In other studies, GPi is reported to have less depression and fewer problems with cognition after surgery, but in the large DBS trial, there really were not any clinically significant differences in outcome with respect to depression or cognition. The STIM team at our center implants leads in the STN for Parkinsons disease. This is mostly due to training and comfort with the procedure.

When Is A Good Time To Consider Dbs Am I A Good Candidate

There are somewhat different criteria for determining if DBS is a good option for you based on your diagnosis and condition. For Parkinsons disease, DBS is typically helpful if you experience motor fluctuations or tremors that interfere with activities that are not already adequately managed by medication, are not improved by changes in medication, or you experience side effects that prevent you from taking higher doses. For ET, DBS may be considered if you have tremors that interfere with your quality of life and cannot be controlled adequately with medications. Other key factors considered are age in combination with general health, a solid support system of family and friends, absence of dementia or an active psychiatric illness such as severe depression, and realistic expectations for treatment outcomes.

Before any patient is considered for DBS surgery, they are evaluated by the U-M Surgical Therapies Improving Movement multidisciplinary team, which has extensive training in DBS. The STIM team includes a neurosurgeon, neurologist, clinical neuropsychologist, speech pathologist, social worker, and other team members who ensure that you and your family understand the procedure and discuss your expectations and concerns.

I Have Essential Tremor That Affects My Voice Will Dbs Help The Tremor In My Voice

Although DBS is excellent for helping the tremor that is experienced in the hands and arms due to essential tremor, it is unlikely that DBS will help your voice with just a unilateral lead. Although there may be patients who notice a slight improvement in voice with unilateral stimulation, most notice no improvement. With bilateral stimulation, the voice tremor may improve, but bilateral stimulation will often cause slurred speech as well. Botulinum toxin injections are generally more effective for voice tremor than DBS.

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Get Answers To More Of Your Questions

Could I be a candidate for DBS?

The ideal candidate is a person with Parkinsons who continues to respond positively to levodopa treatment but is unable to control motor symptoms with medication alone. Ask your neurologist and other physicians if DBS is a suitable therapy for you and your symptoms.2

Is DBS safe?

Two decades of DBS treatment to over 100,000 people has shown both the short- and long-term safety of DBS.3 DBS surgery should be carried out by an experienced neurosurgeon working as part of an interdisciplinary team. As with any surgical procedure, there are risks and potential side effects, which vary by patient. Though most are temporary and will go away as your therapy is optimized, you should discuss these risks with your physicians.

Can I stop my medication after DBS surgery?

Sometimes successful DBS surgery can lead to a decrease in your medication and potentially reduce its side effects, though the treatment is not intended to replace your medication.4

Will my insurance cover DBS therapy?

For Medicare patients, DBS therapy will be covered. Most other health plans will also cover DBS, though your doctor or hospital may need to provide an authorization prior to the procedure. Call our Pre-Authorization Support team at 855-855-4506 to learn what your insurance will and will not cover.

How long will my DBS system last?

Is it possible to have an MRI with a DBS implant?

Can I have a DBS implant if I already have a pacemaker?

What Does Dbs Feel Like When The Device Is On

DBS Appointments for Parkinson

During the initial programming of the DBS, individuals may experience a slight, temporary shock or tingling as placement and levels are adjusted. Identifying the best placement and level enables you to receive the greatest benefit possible based on your unique condition and needs.

Most individuals feel little if any sensation at all during normal use. For the few that do, it is described as a slight tingling down an arm or leg, or mild facial pulling which subsides. This is more common in individuals using DBS for essential tremor as the device can be turned off at bedtime.

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Qol And Cognitive Measurement

QoL was assessed using the PDQ-3910 during pre- and postoperative neuropsychological evaluations. It includes 39 questions requiring patients to rate the degree to which they experience negative effects of PD in 8 domains: Mobility, Activities of Daily Living, Emotional Well-being, Stigma, Social Support, Cognition, Communication, and Bodily Discomfort. Index scores range from 0 to 100 with higher scores reflecting poorer QoL.

Analysis included neuropsychological variables in several cognitive domains selected based on clinical experience of sensitivity to PD and frequency of reporting in the STN-DBS literature . Depression symptoms were assessed using the Beck Depression Inventory2nd edition 11 in which higher scores represent more severe levels of self-reported depression symptoms.

How Do I Get Ready For Dbs

DBS requires a commitment to participate in evaluations, procedures, and consultations before and after the procedure. DBS is usually only available in large medical centers. If you do not live close to a medical center that offers DBS procedures, you may need to spend significant time traveling. The procedure and associated appointments can be expensive. It is also important for you to have realistic expectations. Although DBS can improve symptoms, it will not cure the condition.

Before DBS, you will have assessments to determine whether this is a good option for you. You will need tests to evaluate memory and thinking. A psychiatrist may examine you to determine if you have a condition such as depression or anxiety that requires treatment before the DBS procedure.

Ask your healthcare provider about what you might need to do in the days and weeks before your procedure, such as if there are any special dietary or medicine restrictions.

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Why Is Deep Brain Stimulation Performed

Your doctor may recommend deep brain stimulation to treat movement problems. Problems include involuntary muscle contractions, stiffness, difficulty walking, and tremors caused by certain neurological conditions. These conditions include:

  • Parkinsons disease, a degenerative brain disorder that leads to uncontrollable shaking, muscle stiffness, and severe problems with coordination and balance

  • Essential tremor, a neurological condition that causes trembling back-and-forth movements of the hands, head, arms, legs, torso and voice

  • Dystonia, a movement disorder that causes involuntary muscle spasms and contractions throughout the body leading to movements such as contorting, pulling and twisting

Your doctor may only consider deep brain stimulation for you if other treatment options with less risk of complications, such as medications, have failed to prevent or lessen movement problems. Ask your doctor about all of your treatment options and consider getting a second opinion before deciding on deep brain stimulation.

Your Dbs System At Home

Deep Brain Stimulation (DBS): Post-surgery Care

A small number of appliances in your home may have magnets that can cause your device to turn on or off. Other household appliances and electronic devices are grounded properly and will not cause this complication. Your cell phone should not interfere with your system however, its suggested you dont place your phone directly on top of the devicein a shirt or coat pocket, for example.1

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I Live Alone Can I Have Dbs

It depends on whether you have family or friends that are available to stay with you for a few days after surgery. Youll also need help with transportation back and forth for your appointments as well as to and from the hospital. We have found that the outcomes from your DBS are better overall if you have someone helping you. If you have willing family and friends who are interested in helping you until you have recovered from your DBS surgery, you should be able to return to living alone.

Activities To Avoid Or Use Caution During Dbs

Loss of coordination is a potential side effect of DBS therapy. Patients should exercise reasonable caution when participating in activities requiring coordination, including those that they were able to perform prior to receiving DBS therapy .

For the most part, everyday activities shouldn’t interfere with or damage your DBS system. Here are some common ones to avoid. See your patient manual for a full list.

BENDING, TWISTING, STRETCHING

Avoid activities that could place stress on the implanted components of your DBS system. Activities that include sudden, excessive, or repetitive bending, twisting or stretching may cause parts of your system to break or move. Talk with your doctor about what activities are safe for you.

SECURITY DEVICES AND METAL DETECTORS

Walking through some theft detectors or security gates, like those at airports and department stores, may increase the stimulation or turn off your neurostimulator.

Before walking through a security gate, show your Medtronic Device Identification Card to security and request a hand search. If a security wand is used, ask the security personnel to avoid placing it over your neurostimulator.

If you must pass through a gate, walk through the center at a normal pace, and don’t lean on or linger at the gate.

ELECTRONIC DEVICES

Most household appliances and electronic devices that work properly and are properly grounded, like computers, will not interfere with your deep brain stimulation system.

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What Happens After Surgery

After surgery, you may take your regular dose of Parkinson’s medication immediately. You are kept overnight for monitoring and observation. Most patients are discharged home the next day.

During the recovery time after implanting the electrodes, you may feel better than normal. Brain swelling around the electrode tip causes a lesion effect that lasts a couple days to weeks. This temporary effect is a good predictor of your outcome once the stimulator is implanted and programmed.

About a week later, you will return to the hospital for outpatient surgery to implant the stimulator in the chest/abdomen. This surgery is performed under general anesthesia and takes about an hour. Patients go home the same day.

Step 7: implant the stimulator You will be taken to the OR and put to sleep with general anesthesia. A portion of the scalp incision is reopened to access the leads. A small incision is made near the collarbone and the neurostimulator is implanted under the skin. The lead is attached to an extension wire that is passed under the skin of the scalp, down the neck, to the stimulator/battery in the chest or abdomen. The device will be visible as a small bulge under the skin, but it is usually not seen under clothes.

You will have lifting and activity restrictions for 6-8 weeks while the incisions heal. Follow all discharge instructions and the neck exercises provided. Incision pain can be managed with medication.

Helping You Reach A Better Quality Of Life

What To Expect After Your DBS Procedure

Deep brain stimulation therapy is an opportunity for many to regain their independence. Its being able to cook your favorite meal for the first time in years, brush your teeth, or dress yourself in the morning. Its that moment when you can finally continue your profession and you feel like you have your life back.

While DBS therapy is not a cure for Parkinsons disease or essential tremor, it may reduce your movement symptoms enough to significantly improve your overall quality of life. Ultimately DBS therapy is meant to help you enjoy a fuller, more independent life.

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Will I Come Away With Deficits In Other Areas Cognitive Speech

The great thing about DBS is that it is generally reversible. Unlike lesional procedures, like MR-guided focused ultrasound or stereotactic radiosurgery, you can turn the device off or make adjustments. Often, problems with speech or thinking can be reversed by changing the programming or moving an electrode. However, most studies show a decrease in verbal fluency, e.g., the ability to name as many animals as possible in a certain time period, after DBS . Several studies show that this is an insertional effect that resolves over time. Like many groups, we are still quite cautious and concerned about cognitive deficits after surgery, which is why patients undergo neuropsychological testing prior to surgery to evaluate their cognitive reserves. This is brain surgery and, very rarely, patients may have a sustained cognitive change that persists after surgery.

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Evaluation Determining If You Are A Candidate

Your neurologist typically a movement disorder specialist will evaluate you to see if DBS is a good option for you. The evaluation usually includes:

  • Medical history
  • Neurological exam of your movements, both on and off medications
  • MRI of the brain to check whether there are any issues that would pose a risk during the surgery
  • Lab tests, such as a blood test to make sure your blood clots properly
  • Neuropsychological tests

The doctor will share the results with you, and together you will decide whether or not to go forward with the therapy.

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When Is Deep Brain Stimulation Performed

DBS is most effective for individuals who experience disabling tremors, wearing-off spells, and medication-induced dyskinesia.

  • Tremors Some people with Parkinsons disease have tremors that simple do not respond to medication.
  • Wearing offAfter several years of taking medications, including levodopa, many people experience a shortening of benefit following each oral dose, a problem called wearing off.
  • DyskinesiasMany people with Parkinsons disease develop drug-induced, involuntary twisting and writhing movements, known as dyskinesias.
  • Side EffectsSome patients experience intolerable side effects of their medications.

It is important to recognize that some symptoms of Parkinsons disease respond better to surgery than others. DBS does not help with freezing, backwards falling, dementia, apathy, anxiety, or depression.

Neurobehavioral And Psychiatric Disorders

After dbs surgery

Deep brain stimulation is a surgical procedure in which electrodes are implanted in certain areas of your brain. These electrodes deliver electrical impulses that affect abnormal activity in the brain. The stimulation is produced by a pacemaker-like device implanted under the skin in your upper chest. The device is connected to the electrodes in your brain by a wire traveling under the skin.

Deep Brain Stimulation is a treatment option for:

  • Parkinsons disease

The treatment is reserved for people with symptoms not controlled with medication.

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How Does Deep Brain Stimulation Work

Movement-related symptoms of Parkinsons disease and other neurological conditions are caused by disorganized 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 that determines the optimal placement, neurosurgeons implant one or more wires, called leads, inside the brain. The leads are connected with an insulated wire extension to a very small neurostimulator implanted under the persons collarbone, similar to a heart pacemaker. Continuous pulses of electric current from the neurostimulator pass through the leads and into the brain.

A few weeks after the neurostimulator has been in place, the doctor programs it to deliver an electrical signal. This programming process may take more than one visit over a period of weeks or months to ensure the current is properly adjusted and providing effective results. In adjusting the device, the doctor seeks an optimal balance between improving symptom control and limiting side effects.

What Can I Expect With Deep Brain Stimulation Surgery

Throughout the process, you will be followed by a neurologist and a neurosurgeon at Pacific Movement Disorders Center who have special training with DBS, as well as several other members of our team.

Preoperative Evaluations

Your neurologist/movement disorders specialist will evaluate you to see if you are a candidate for DBS. The evaluation may include some or all of the following:

  • Medical history
  • Neurological exam of your movements:
    • MRI of the brain to check for any issues with your brain that would prevent surgery. This scan is also used to plan the placement of your DBS electrode wires if you proceed to surgery.
    • Lab tests such as a blood test to make sure your blood clots properly.
    • Neuropsychological tests to test for underlying problems with thinking or talking that need to be considered during your surgery.
    • Physical, occupational and/or speech therapy to evaluate movement issues prior to surgery, including problems walking or taking care of yourself. Some individuals have swallowing problems before surgery that will be carefully evaluated by our speech therapists.
    • Neurosurgical evaluation you will meet with the neurosurgeon to review your exams and tests and discuss how DBS can help with your symptoms.
    • Medical clearance within 4 weeks of the procedure, you will need to have your primary care physician provide clearance from a medical standpoint. This may include EKG, Chest X-ray, or other tests.
    What Does Deep Brain Stimulation Involve?

    Leads

    Extension Wire

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    Who Is A Candidate

    You may be a candidate for DBS if you have:

    • a movement disorder with worsening symptoms and your medications have begun to lose effectiveness.
    • troubling “off” periods when your medication wears off before the next dose can be taken.
    • troubling “on” periods when you develop medication-induced dyskinesias .

    DBS may not be an option if you have severe untreated depression, advanced dementia, or if you have symptoms that are not typical for Parkinson’s.

    DBS can help treat symptoms caused by:

    • Parkinson’s disease: tremor, rigidity, and slowness of movement caused by the death of dopamine-producing nerve cells responsible for relaying messages that control body movement.
    • Essential tremor: involuntary rhythmic tremors of the hands and arms, occurring both at rest and during purposeful movement. Also may affect the head in a “no-no” motion.
    • Dystonia: involuntary movements and prolonged muscle contraction, resulting in twisting or writhing body motions, tremor, and abnormal posture. May involve the entire body, or only an isolated area. Spasms can often be suppressed by “sensory tricks,” such as touching the face, eyebrows, or hands.

    After your evaluation and videotaping is complete, your case will be discussed at a conference with multiple physicians, nurses, and surgeons. The team discusses the best treatment plan for each patient. If the team agrees that you are a good candidate for DBS, you will be contacted to schedule an appointment with a neurosurgeon.

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