Ask the Expert

There is new hope for some of the millions of individuals who suffer from Parkinson’s disease and other neurological movement disorders. FDA-approved Deep Brain Stimulation (DBS) is the most significant development for the treatment of these disorders in the last few decades. Today, this exciting procedure is available to Suburban Hospital’s patients.

In this month’s column, Dr. Zachary Levine, one of our area’s leading neurosurgeons and an authority on this advanced treatment option, describes DBS and what this procedure has meant to those who have received it. Dr. Levine is one of only three neurosurgeons in the greater Washington area who perform DBS.

What is Deep Brain Stimulation?
FDA-approved Deep Brain Stimulation (DBS) is a surgical procedure that utilizes an implanted, battery-operated device to deliver electrical stimulation to targeted areas in the brain. The FDA approved DBS for the treatment of tremors in 1997 and for the treatment of Parkinson’s disease in 2002.

How does DBS work?
Similar to a heart pacemaker, DBS delivers carefully controlled electrical stimulation to targeted areas deep in the brain. The electrical impulses block the abnormal nerve signals that cause tremor, rigidity, and stiffness, allowing patients to have better control over their movements.

What types of conditions would benefit from DBS?
DBS is currently used to treat a number of medical conditions, including Parkinson’s disease, tremor disorders, dystonia, and Tourette’s syndrome. DBS is also being evaluated as a possible treatment for depression.

In Parkinson’s disease, there is a loss of the brain chemical dopamine, weakening cellular signals that control muscle movement. Increasingly severe symptoms may include tremors, rigidity, slow movement, poor balance, and walking difficulties.

Medication therapy is always the first treatment option, and DBS is considered only when an individual is no longer responding well to medication. The use of long-term medications, however, can cause side effects that are as devastating as the symptoms of the disease itself.

Who would be a candidate for DBS?
Parkinson’s patients make up the largest group of individuals who would benefit from DBS. Individuals who suffer from Idiopathic Parkinson’s disease, the form of the disease for which there is no known cause, would be considered candidates for DBS.

Those who suffer from Parkinson’s syndrome — one of a group of motor system disorders where a cause is known or suspected — would not benefit from the procedure. In addition, if the Parkinson’s disease is very advanced, DBS would not be considered as a treatment option.

Other candidates for DBS include patients who suffer from essential tremor, dystonia, and Tourette’s syndrome. Again, DBS would be considered only when medication therapy is no longer considered a viable option for these individuals.

Where is DBS performed?
Suburban Hospital is one of only a few medical facilities in the Washington, DC, area that make DBS available to patients.

How is DBS performed and how long does the procedure take?
The DBS procedure is done in stages. The first stage involves the placement of the electrodes (also called leads). It is performed under local anesthesia so that the patient is awake with some sedation and can be an active participant in the surgery. The surgeon utilizes sophisticated imaging and recording technology throughout the surgery, with the patient helping to guide the placement of the electrodes to a targeted area that is approximately 5-to-7½ millimeters in length.

Because of the complexity of the surgery, this procedure can take up to eight hours. There is a brand new technique, however, that can cut surgery time nearly in half and is much more comfortable for the patient, as it allows the patient to move his/her head during surgery. It’s called frameless DBS and Suburban Hospital is currently the only hospital in the area to utilize this new technique.

The second stage of the DBS procedure involves the placement of the neurostimulator (the battery pack) and is done on an outpatient basis using general anesthesia. An insulated wire is run from the electrodes in the brain to the patient’s collarbone or abdomen. The placement of the battery pack is done one week after the surgery to implant the electrodes. This procedure takes approximately 30 minutes.

The final stage of DBS takes place two weeks after the implantation of the battery pack. At that time, the neurostimulator is activated and programmed, a process that takes only a matter of minutes. Adjustments in the amount of electrical stimulation the patient receives are made over the following weeks and months.

How quickly do you see results from DBS?
For patients who are suffering from Parkinson’s disease or other tremor disorders, symptoms often improve immediately once the neurostimulator is activated. For conditions like dystonia and Tourette’s syndrome, it may take a few months to see improvement in symptoms.

The neurostimulator can be adjusted as needed, allowing for the maximum amount of benefit. As the stimulation level increases, the patient is able to decrease the use of medications, thereby reducing or eliminating their negative side effects as well.

Does the battery last indefinitely?
No. The battery life is approximately three to seven years. The battery can be changed using local anesthesia in an outpatient procedure that takes only about 15 minutes.

What are the potential risks and side effects of DBS?
There are potential risks associated with any surgery, and especially with surgery that involves the brain. The biggest risk associated with DBS is bleeding in the brain, which is rare, occurring in approximately 2 percent of cases. The other risk associated with DBS is infection at the site of the electrode placement or the neurostimulator. This, too, occurs infrequently, but may require removal of the electrodes and the battery pack.

A common side effect of DBS comes from the fact that bilateral stimulation of the brain can affect speech. This side effect can be minimized through accurate lead placement and programming. That’s why it’s so important to find a surgeon who regularly performs this procedure.

What is the success rate for DBS?
The success rate for DBS is quite high, with the majority of patients seeing significant improvement in the symptoms associated with their disease. In addition, as patients are able to reduce or eliminate the need for medications, they experience a significant reduction in the side effects associated with those medications. The degree to which each patient benefits from DBS will vary depending on the nature of that patient’s particular condition and symptoms.

What happens as the patient’s condition changes over time?
The beauty of DBS is that it is completely adjustable and reversible. Unlike previous surgeries for Parkinson’s disease, the electrical stimulation does not damage healthy brain tissue or destroy nerve cells. As the patient’s condition changes or progresses, the neurostimulator can easily be reprogrammed, or removed entirely to make way for newer treatments or a medical cure. Many consider DBS to be a bridge to a cure.

About Dr. Levine

Zachary T. Levine, M.D., is a board-certified neurosurgeon with advanced training in cranial base surgery and stereotactic/functional surgery for movement disorders. He has extensive experience in Deep Brain Stimulation and has proctored and taught DBS procedures across the country. He also has an interest in spinal surgery, especially endoscopic and microscopic disk surgery and spinal instrumentation for trauma and degenerative disease. He holds a patent for cell transplantation for neuro-degenerative diseases and movement disorders.

Dr. Levine served on the board of the Parkinson Foundation of the National Capital Area and is a member of Washington Brain & Spine Institute, with offices in Washington, DC, Bethesda, and Rockville. To reach Dr. Levine, call 301.718.9611. For more information about Washington Brain & Spine Institute, visit www.brainsurgery.com.