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Deep brain stimulation

Globus pallidus deep brain stimulation; Subthalamic deep brain stimulation; Thalamic deep brain stimulation; DBS; Brain neurostimulation

 

Deep brain stimulation (DBS) uses a device called a neurostimulator to deliver electrical signals to the areas of the brain that control movement, pain, mood, weight, and awakening.

Description

 

The DBS system consists of three parts:

  • One or more, insulated wires called leads, or electrode that are placed into the brain
  • The neurostimulator, which puts out the electric current. The stimulator is similar to a heart pacemaker. It is usually placed under the skin near the collarbone, but may be placed elsewhere in the body
  • In some people another thin, insulated wire called an extension is added to connect the lead to the neurostimulator.

Surgery is done to place each part of the neurostimulator system. In adults, the whole system can be placed in 1 or 2 stages (2 separate surgeries).

Stage 1 is usually done under local anesthesia, meaning you are awake, but pain-free. (In children, general anesthesia is given.)

  • Your head is placed in a special frame using small screws to keep it still during the procedure. Numbing medicine is applied where the screws contact the scalp. Sometimes, the procedure is done in the MRI machine and a frame is on top of your head rather than around your head.
  • Numbing medicine is applied to your scalp at the site where the surgeon drills a small opening in the skull and places the lead into a specific area of the brain.
  • If both sides of your brain are being treated, the surgeon makes an opening on each side of the skull, and two leads are inserted.
  • Electrical impulses may need to be sent through the lead to make sure it is connected to the area of the brain responsible for your symptoms.

Stage 2 is done under general anesthesia, meaning you are asleep and pain-free. The timing of this stage of surgery depends on where in the brain the stimulator will be placed.

  • The surgeon makes a small opening (incision), usually just below the collarbone and implants the neurostimulator. (Sometimes it is placed under the skin in the lower chest or belly area.)
  • The extension wire is tunneled under the skin of the head, neck, and shoulder and connected to the neurostimulator.
  • The incision is closed. The device and wires cannot be seen outside the body.

Once connected, electric pulses travel from the neurostimulator, along the extension wire, to the lead, and into the brain. These tiny pulses interfere with and block the electrical signals that cause symptoms of certain diseases.

 

Why the Procedure is Performed

 

DBS is commonly done for persons with Parkinson disease when the symptoms cannot be controlled by medicines. DBS does not cure Parkinson disease, but can help reduce symptoms such as:

  • Tremors
  • Rigidity
  • Stiffness
  • Slow movements
  • Walking problems

Deep brain stimulation may also be used to treat the following conditions:

  • Arm tremors related to multiple sclerosis
  • Major depression that does not respond well to medicines
  • Obsessive-compulsive disorder
  • Pain that does not go away (chronic pain)
  • Severe obesity
  • Shaking movement that cannot be controlled and the cause is unknown (essential tremor)
  • Tourette syndrome (in rare cases)
  • Uncontrolled or slow movement (dystonia)

 

Risks

 

DBS is considered safe and effective when done in the right people.

Risks of deep brain stimulation placement may include:

  • Allergic reaction to the DBS parts
  • Problem concentrating
  • Dizziness
  • Infection
  • Leakage of cerebrospinal fluid, which can lead to headache or meningitis
  • Loss of balance, reduced coordination, or slight loss of movement
  • Shock-like sensations
  • Speech or vision problems
  • Temporary pain or swelling at the site where the device was implanted
  • Temporary tingling in the face, arms, or legs

Problems may also occur if parts of the DBS system break or move. These include:

  • Device, lead, or wires break, which can lead to another surgery to replace the broken part
  • Battery fails, which would cause the device to stop working properly (the battery normally lasts 3 to 5 years)
  • Wire that connects the stimulator to the lead in the brain breaks through the skin (may occur in very thin people)
  • The part of the device placed in the brain may break off or move to a different place in the brain (this is rare)

Possible risks of any brain surgery are:

  • Blood clot or bleeding in the brain
  • Brain swelling
  • Coma
  • Confusion, usually lasting only for days or weeks at most
  • Infection in the brain, in the wound, or in the skull
  • Problems with speech, memory, muscle weakness, balance, vision, coordination, and other functions, which may be short-term or permanent
  • Seizures
  • Stroke

Risks of general anesthesia are:

  • Reactions to medicines
  • Problems breathing

 

Before the Procedure

 

You will have a complete physical exam.

Your doctor will order many laboratory and imaging tests, including a CT or MRI scan. These imaging tests are done to help the surgeon pinpoint the exact part of the brain responsible for the symptoms. The images are used to help the surgeon place the lead in the brain during surgery.

You might have to see more than one specialist, such as a neurologist, neurosurgeon, or psychologist, to make sure that the procedure is right for you and has the best chance of success.

Before surgery, tell your surgeon:

  • If you could be pregnant
  • What medicines you are taking, including herbs, supplements, or vitamins you bought over-the-counter without a prescription
  • If you have been drinking a lot of alcohol

During the days before the surgery:

  • Your health care provider may tell you to stop taking medicines, called blood thinners, which make it hard for your blood to clot. These include warfarin (Coumadin), dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), clopidogrel (Plavix), aspirin, ibuprofen, naproxen, and other non-steroidal anti-inflammatory drugs (NSAIDs).
  • If you are taking other medicines, ask your doctor if it is OK to take them on the day of or in the days before surgery.
  • If you smoke, try to stop. Ask your health care provider for help.

The night before and on the day of surgery, follow instructions about:

  • Not drinking or eating anything for 8 to 12 hours before the surgery.
  • Washing your hair with special shampoo.
  • Take the medicines your doctor told you to take with a small sip of water.
  • Arriving at the hospital on time.

 

After the Procedure

 

You may need to stay in the hospital for about 3 days.

The doctor may prescribe antibiotics to prevent infection.

You will return to your doctor's office at a later date after surgery. During this visit, the stimulator is turned on and the amount of stimulation is adjusted. Surgery is not needed. This is process is also called programming.

Call your doctor if you develop any of the following after DBS surgery:

  • Fever
  • Headache
  • Itching or hives
  • Muscle weakness
  • Nausea and vomiting
  • Numbness or tingling on one side of the body
  • Pain
  • Redness, swelling, or irritation at any of the surgery sites
  • Trouble speaking
  • Vision problems

 

Outlook (Prognosis)

 

People who have DBS usually do well during the surgery. Many people have great improvement in their symptoms and quality of life. Most people still need to take medicine, but at a lower dosage.

This surgery, and surgery in general, is riskier in people over age 70 and those with health conditions such as high blood pressure and diseases that affect blood vessels in the brain. You and your doctor should carefully weigh the benefits of this surgery against the risks.

The DBS procedure can be reversed, if needed.

 

 

References

Altinay M, Estemalik E, Malone DA Jr. A comprehensive review of the use of deep brain stimulation (DBS) in treatment of psychiatric and headache disorders. Headache. 2015;55:345-50. PMID: 25660121 www.ncbi.nlm.nih.gov/pubmed/25660121.

Ho A L, Sussman E S, Zhang M, et al. Deep brain stimulation for obesity. Cureus. 2015;7(3):e259. PMID: 26180683 www.ncbi.nlm.nih.gov/pubmed/26180683.

Kumar A, Pandey AK, Okun MS. Clinical neurophysiology: neuromodulation. In: Daroff RB, Fenichel GM, Jankovic J, Mazziotta JC, eds. Bradley's Neurology in Clinical Practice. 6th ed. Philadelphia, PA: Elsevier Saunders; 2012:chap 32D.

Schrock LE, Mink JW, Tourette Syndrome Association International Deep Brain Stimulation (DBS) Database and Registry Study Group, et al. Tourette syndrome deep brain stimulation: a review and updated recommendations. Mov Disord. 2015;30:448-71. PMID: 25476818 www.ncbi.nlm.nih.gov/pubmed/25476818.

Whitworth LA, Burchiel KJ. Deep brain stimulation in movement disorders: Parkinson's disease, essential tremor, and dystonia. In: Quiñones-Hinojosa A, ed. Schmidek and Sweet's Operative Neurosurgical Techniques. 6th ed. Philadelphia, PA: Elsevier Saunders; 2012:chap 114.

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                Review Date: 10/22/2015

                Reviewed By: Luc Jasmin, MD, PhD, FRCS (C), FACS, Department of Surgery at Providence Medical Center, Medford OR; Department of Surgery at Ashland Community Hospital, Ashland OR; Department of Maxillofacial Surgery at UCSF, San Francisco CA. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Isla Ogilvie, PhD, and the A.D.A.M. Editorial team.

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