Should All Centers Perform DBS?

By University of Florida Health Physicians Michael S. Okun, M.D., Hubert H. Fernandez, M.D., and Kelly D. Foote, M.D.

The Need for Well Trained Interdisciplinary Teams

A recent large survey of DBS centers revealed that the majority of implanters feel that a well-trained interdisciplinary team is necessary for this type of surgery(14).  In the United States DBS has been FDA approved for the treatment of many disorders, and therefore unlike 5 years ago, any licensed neurosurgeon may perform the procedure.  Additionally, there are no standard requirements for a center performing DBS surgery, and there is currently no standard procedure.  Therefore, there is a wide range of quality of service especially involving patient selection, pre-operative screening, the operative procedure, and post-operative follow-up.

Since there are no specific adopted guidelines for setting up a DBS program we suggest the following elements as important for the short and long term success of DBS in any center.  The center must have a substantial commitment to an interdisciplinary team expert in the medical management of both movement disorders and movement disorders surgery.  Patients often require access to ancillary services, and an experienced PD center can provide these services thereby potentially improving the overall risk benefit ratio prior to surgery and minimizing errors in medical decision making.  We believe the most important element of a successful center is a fellowship trained movement disorders neurologist (or equivalent) to perform screening and medical optimization.

Another crucial element for patient success is a well organized and well trained team to perform neuropsychological screening, neurosurgical screening, psychiatric screening, and advanced imaging.  In our center we utilize a movement disorders trained neuropsychologist, neurosurgeon, and psychiatrist.  It helps tremendously if the neurosurgeon has done specific fellowship training in stereotaxic surgery and movement disorders surgery, beyond a weekend “refresher course,” and has significant experience and/or training with DBS devices.  The neurosurgeon should have at his or her disposal either a neurologist or electrophysiologist to perform detailed microelectrode recording to ensure proper lead placement.  This point cannot be emphasized enough as correct placement is usually measured in millimeters, and no amount of expert programming can make up for a poorly placed lead.

Additionally, most excellent centers prefer a neurologist in the operating room to test the lead and look for side effects and benefits of stimulation.  Once the lead is in place there needs to be a team including an experienced neurologist, neurosurgeon, and dedicated programming nurse available to the patient, often on short notice, for adjustments and medication changes.  This team needs to be prepared to deal with device failures, and to treat the individual needs of each patient.

If you have questions or would like a consultation to see if you are a candidate please call Chris Baughman at 352-294-5431 or email at Christopher.baughman@neurology.ufl.edu.