Deep Brain Stimulation (DBS) for Dystonia
What is Deep Brain Stimulation Surgery?
Deep brain stimulation (DBS): a surgical therapy that involves the implantation of stimulating electrodes into select targets in the brain in order to interrupt a faulty communication between brain regions that results in sometimes disabling involuntary muscle co-contractions.
Why choose the University of Florida’s Center For Movement Disorders and Neurorestoration as your center for DBS?
The University of Florida (UF) Movement Disorders Center is an international leader in the use of DBS implants for treating movement disorders, having performed more DBS procedures annually than most medical centers in the United States. The program is supported by the National Institutes of Health and several other funding agencies and performs cutting edge research. UF holds an FDA Humananitarian Device Exemption (HDE) for the treatment of dystonia and has performed the procedure for dystonia over 250 times.
Below is the story of one of our dystonia patients:
How does DBS work?
Understanding DBS for dystonia requires a look at certain parts of the brain. The brain is a complex organ with millions of cells that connect and communicate with one another through a series of electric-like circuits. Like electrical wiring in an appliance, if one or more of the circuits malfunction, the entire system can be disrupted. Research has shown that in dystonia, there are faulty signals in certain brain circuits that result in unacceptable symptoms. When these faulty signals are changed, symptoms may improve. DBS neuromodulates these abnormal signals, but its exact mechanism of action is unknown.
Are you a candidate for DBS?
At the UF Movement Disorders Center, DBS is performed by Dr. Michael Okun in Neurology and Dr. Kelly Foote in Neurosurgery- along with a highly specialized and experienced interdisciplinary team. In order to become a candidate for DBS, you will undergo a preliminary evaluation in Neurology. If the Movement Disorders neurologist feels you are a candidate for DBS, you will be scheduled for a Fast Track Evaluation. Fast Track is a two day well orchestrated procedure that is always scheduled on Monday and Tuesday. The Fast Track begins with an appointment with neurosurgeon, Dr. Kelly Foote. This will be followed by a four-hour neuropsychological exam with Dr. Dawn Bowers, Dr. Russell Bauer or Dr. Catherine Price, that measures your memory, thinking and cognition. The second day of appointments includes an appointment with a psychiatrist, Dr. Ward, a Speech and Swallow evaluation with Dr. Michelle Troche and a data collection visit to the McKnight Brain Institute. Also many patients will need to see physical and occupational therapy.
Following the Fast Track evaluation, the DBS team, which is comprised of specialists in neurology, neurosurgery, psychiatry, rehab medicine, and neuropsychology, meet in an interdisciplinary format and discuss evaluations. This is similar to what is done in the best cancer treatment centers. These meetings occur once per month and surgery is typically scheduled 3-5 months following the Fast Track evaluation.
Things to Consider
DBS is an elective surgery that you may choose as a treatment for your dystonia. Following your Fast Track evaluation, our team will contact you about your candidacy. If you are a candidate, you will need to be sure you understand the risks/benefits both your doctors and with your family.
The DBS surgery and subsequent visits require a commitment of time (once a month visits for a year and regular visits thereafter), energy, travel time and depending on your insurance, you may be required to cover some of the expenses.
Like any surgery, DBS comes with the risk of complications. Although the risk of serious or permanent complications from DBS therapy is low, it is important for you to understand that you could be left with a permanent side effect.
Preparing for Surgery
If you have decided to pursue DBS surgery, your next step is to plan and prepare for the operative procedure and the recovery. The UF Movement Disorders staff specializes in DBS therapy for the treatment of dystonia, and will provide you with support throughout your recovery.
Following your Fast Track evaluation, there may be a few more visits to the DBS center for one or more of the following:
- Magnetic resonance imaging (MRI) of the brain
- Chest X-ray
- EKG, which measures heart rhythm
- Blood pregnancy test if of child bearing age
- Blood work to determine blood type
As your surgery date approaches, it is normal for you to experience nervousness or anxiety. The best recommendation is to plan ahead, stay organized, speak with other patients who have had the surgery and plan to bring a friend or family member to be with you before, during and for at least a month or two following your surgery.
The day prior to your surgery you will visit our Neurosurgery clinic for a pre-operative evaluation and if you are going to be under anesthesia for the procedure, you will have an appointment with anesthesiology. Your preoperative MRI may be taken the day before surgery.
On the day of your surgery, you will arrive at the admissions area. From there, you will be taken to the preoperative area where you will change for surgery, have your vitals (blood pressure, pulse, etc.) taken, and for some patients, have an intravenous line (IV) placed.
Next, the neurosurgeon will administer local anesthesia to specific areas of your head and secure a temporary head frame to your skull in order to keep your head secure and provide precise guidance during the surgery. You will get an MRI or computed axial tomography (CAT) scan following the placement of the head frame.
After the brain scan, you will be taken to the operating room where you will be cared for by nurses, a movement disorders neurologist, and a neurosurgeon. The neurosurgeon will inject anesthesia into your scalp and then use a drill to create a nickel-to-quarter size hole in the skull where the microelectrode will be inserted. The microelectrode recording, a critical part of surgery, is then performed. The recording guides the neurosurgeon and neurologist in placing the lead in the exact area of the brain that will give optimal results. This part of the surgery can take several hours, depending upon the number of microelectrode passes needed to pinpoint the target site.
During the microelectrode recording, you will be awake and the neurologist will ask you to move your face, arm or leg. You may feel twitches, pulling or tingling as electrical current goes through the microelectrode. This is normal. After the microelectrode recording has precisely located the target, the neurologist will put the permanent DBS lead in place, connect it to an external generator, and administer brief electrical stimulation. The actual implantable pulse generator (IPG) is often placed several weeks later as a second surgery.
Adjustment of Stimulation
Programming of the stimulator is performed in an outpatient setting and begins approximately one week following the IPG surgery. Programming is performed by a trained nurse, physician assistant and/or a neurologist who will use a small handheld device to adjust the settings of the DBS system. Most dystonia patients undergoing DBS therapy will require numerous programming sessions to achieve optimized symptom control. We ask our dystonia patients to plan on visiting clinic once a month for the first year as there is often delay in improvement with dystonia cases.
Once the DBS system has been implanted, there are some strict rules to follow regarding other electrical devices. Be sure to speak to your doctor about magnetic and electrical devices as well as magnetic currents in the environment, as they can cause the DBS system to malfunction and potentially be dangerous.
You will receive a hand-held magnet and/or patient control device that will allow you to turn your DBS system on and off as well as check the battery power in your device. It is important to carry your handheld device with you as some types of electromagnet or magnetic fields, including theft detection devices in department stores, may turn off the DBS system.
You should never have diathermy or body MRI’s as these may cause permanent injury. Head MRI’s must be supervised by an experienced team with a head receive coil and under FDA specified conditions.
If you would like to be seen in our clinic to determine if you are a candidate for DBS therapy, please call 352-294-5400. Our team can discuss it with you and get you scheduled.