A decade ago at UF we realized the deep brain stimulation (DBS) patients required a more comprehensive evaluation prior to surgical consideration– than say a patient with an inflamed gall bladder that required removal. Over the years we have refined the DBS process, which ultimately we named the UF Fast Track evaluation for deep brain stimulation (DBS) surgery. The idea behind the process was to optimize patients with a movement disorders specialist neurologist—and then to provide evaluations from multiple specialists in a single location—over a two day period. We designed the program for patient convenience, and also to ensure high quality comprehensive DBS screening.
Interdisciplinary Team Screening and Interdisciplinary Case Conference Discussion
The inclusion and exclusion criteria for DBS have continued to evolve for various disorders and various syndromes. The first step to ensure success in DBS is to select the appropriate candidate. Patient selection for DBS should in the best case scenario utilize a multidisciplinary team, and preferably an interdisciplinary team. The pre-operative detailed assessment by multiple disciplines should be a prerequisite for surgical consideration. An adequate team usually includes a movement disorders neurologist, a neuropsychologist, and a neurosurgeon. Our group also recommends a psychiatrist be involved if possible, especially since many of the urgent and emergent issues in DBS therapy involve psychiatry. Physical therapists, occupational therapists, speech therapists, social workers and financial counselors should also be involved in an optimal situation. Each member of the interdisciplinary screening team should independently evaluate the patient, and a meeting should be convened to review and discuss findings. The review should be inclusive of the past history, medical imaging studies, and if available a video examination. Standardized rating scales should be performed (such as the Unified Parkinson Disease Rating Scale (UPDRS) (with an on-off dopaminergic evaluation), and co-morbidities should be discussed. Candidacy should also be determined based on an individual patient’s desired expectations and goals. Any level of cognitive impairment should be identified and discussed by the interdisciplinary team as this may affect outcome. The patient should be contacted and apprised of the interdisciplinary discussion(s). Below we summarize the interdisciplinary University of Florida “fast track” process as published in a recent issue of Neurotherapeutics (Okun and Foote, 2010):
See any one of our 7 movement disorders neurologists for medication optimization, movement disorders scales
Two Day Fast Track Schedule
You will see a neuropsychologist, a neurosurgeon, a psychiatrist, a speech/swallowing therapist, a physical therapist, and an occupational therapist.
The interdisciplinary team will then meet the second Tuesday of each month to discuss the cases and patients will be called with the results and/or invited back for a discussion/patient visit. You may be recommended for surgery or not recommended for surgery. You may also be recommended contingent on other factors (follow-up cognitive evaluation, seeing an internist, settling a blood thinner issue, are all examples of potential other factors). The team also must decide on brain targets, side of surgery, approach of surgery, and implantation of the battery (the battery usually goes in a month later).
Patient with leads implanted at other institutions outside of UF need to go through the troubleshooting clinic process described below. If they become a potential candidate for re-operation– they may be referred to the fast track interdisciplinary process described above.
DBS Troubleshooting Clinic Process for Leads not Implanted at UF, but need evaluation for potential re-operation or other management:
On Day 1
You will see a neurologist for a new patient evaluation. Plan to spend 2 hours or more as multiple scales need to be recorded in multiple medication/stimulation state. Come OFF MEDICATIONS to the visit.
Next you will get a MRI to determine lead position and issues. The staff in the clinic will need to turn the device to 0.0 volts and then you will need to return to clinic to have the normal voltage on your device reset after the MRI.
On Day 2
You will meet the expert DBS programmer Pam Zeilman who manages over 700 DBS leads, and has seen over 200 leads with referred issues. She will run each lead and each contact for thresholds for benefit and side effect at each location. She will then attempt reprogramming. You may also receive a medication adjustment.
Within 4 weeks
Your DBS lead will be measured in our state of the art laboratory, and your history, and the results of your scales in each state (medications/stimulation) as well as your lead location (MRI) and thresholds will be discussed. The team may recommend re-programming, medication changes, or re-operation to fix hardware issues/lead locations. You will then either be called with the results or invited back for an appointment to discuss the results.
We THANK patients in advance for their patience with this process. It takes a lot of time and a lot of energy from the entire team to sort out referred DBS problems and DBS failures.