Deep Brain Stimulation (DBS)
What is DBS surgery?
Deep brain stimulation (DBS) is a surgical procedure performed for the treatment of a number of immobilizing neurological conditions such as:
- Parkinson's disease (PD) - its most incapacitating symptoms like tremors, slowed movement, stiffness, and
- Obsessive Compulsive Disorder
- Tourette Syndrome
Surgery is advised when the quality of life worsens even after continued medical therapy. It is a quite complex surgical intervention that requires regular follow up with neurologist and also changing of battery every 3 to 4 years.
In this procedure, a pacemaker-like device is implanted and sends electrical signals to brain areas that are responsible for body movement. Electrodes are also located deep in the brain and are connected to a battery device or stimulator. This pacemaker is similar to heart pacemaker as neurostimulators use electric impulses to assist in regulating brain activity.
A DBS system has 3 parts that get implanted inside the body:
A handheld controller is given to the patient for turning the system on and off. The doctor uses a wireless device for programming the stimulator. Depending on the patient's condition, the settings of stimulator can be adjusted. DBS has proved to be very effective procedure for relieving above symptoms.
Deep Brain Stimulation
What happens during DBS surgery?
- Before the patient gets scheduled for surgery, detailed evaluation is done which majorly includes - blood tests, ECG, EEG, chest x-ray and MRI. During the surgery, a stereotactic frame is first attached to the patient's head with four pins.
- The surgeon then uses MRI or CT images with the help of computer software to decide the path of the electrode.
- Patient remains awake during the surgery, only a small amount of sedation is given to make him/her comfortable while making skull and skin incisions.
- The hair is shaved and a skin incision is made to expose the skull. This is followed by making burr holes on the left and right side of the brain. These holes allow the electrodes to pass through the brain.
- On the basis of images from MRI/CT, electrodes are precisely inserted inside the brain. After this, an arc-shaped device is fixed to the frame for plotting the coordinates and driving the electrode to the required depth and location of the brain.
- The recording electrode now listens to the brain cells and displays the waveforms on the computer screen.
- After locating the exact nerve cells, the surgeon inserts a permanent DBS electrode or lead that replaces the recording electrode.
- The surgical team now performs test stimulation. Once they are satisfied with the functioning and placement of electrode/lead, they put a plastic cap over the burr hole so that the lead remains in place its.
- A wire coil is left under the scalp for attaching later on to the extension wire and the stimulator. Eventually, the skull incision is closed with the help of sutures/staples and a bandage is applied at the surgical site.
- Patient gets discharge in a day or two after monitoring and observation. He/she again returns to hospital after a week for implantation of stimulator in the chest or abdomen.
- This is done under general anesthesia. A segment o f skull incision is reopened to get an access to the leads and then an incision is made near the collarbone for implanting neurostimulator under the skin.
- The lead in the skull and stimulator in the chest are connected through an extension wire which passes through the skin of the scalp and reaches the stimulator in the chest through the skin under the neck.
- Patient again revisits the doctor after 10 days. During this visit, the stimulator is programmed and medication dose is adjusted.
Recovery and Post - Op Care
- Recovery after DBS surgery does not involve much complication. Patient may experience dizziness and mild disorientation for few days after surgery. This may go away slowly as the patient recovers.
- Do not touch the surgical site and prevent it from getting wet till the wound has completely healed.
- The stitches get removed during the OPD follow up after a week of surgery.
- The treating doctor needs to be contacted immediately in case there is -
- Redness or swelling at the surgical site.
- Any kind of fluid discharge from the surgical site.
- High fever or sever headache.
- Any difficulty in operating the DBS system.
- Patient ca take normal diet after getting discharged from the hospital.
- Do not drive at least for two weeks after surgery or till the doctor allows.
- Few sessions of programming are required over a period of several weeks after surgery, in order to achieve utmost benefit.
- Patient is not advised to return to work until DBS programming is started after 3 to 4 weeks of surgery.
- Similar to the case in cardiac pacemaker, here also devices like mobile phones, pagers, or security doors, metal detectors and anti theft sensors do not affect the stimulator.
- Patients are also suggested to carry their Implanted Device Identification card while flying, as the device gets detected at airport security gates.
Risks involved in the surgery
Though there are very few side effects of DBS procedure, it involves some risks which are as follows:
- General complications like infection, blood clots, bleeding, and reaction to anesthesia.
- Placement of DBS can lead to seizures, infection and very little chances of internal bleeding in the brain as well.
- There can be chances of infection or mechanical failure of device or breakage of wire in the neck.
- Difficulty in balancing or speech impairment.
- There is also a risk of hurting blood vessels as the wires pass through the brain, and this can lead to stroke.
Patient is required to revisit periodically for battery replacement every 2 to 5 years. The rechargeable battery lasts up to 9 years.
Detailed discussion with the treating doctor regarding the quality of life after surgery should be done before going ahead with the treatment. Patient is required to religiously follow the instructions regarding management of device.
DBS had numerous additional benefits that help in leading improved quality of life and hence, above risks should be discussed with the treating doctor beforehand so that the treatment can be carried out successfully.
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