DEEP BRAIN STIMULATION: UNDERSTANDING THE PROCEDURE, BENEFITS, AND RISKS

Medically Reviewed by Dr. Sony Sherpa (MBBS) - July 30, 2024

Deep Brain Stimulation (DBS) is a long-lasting surgical implant and treatment that has been used for decades to treat various neurological and psychiatric disorders. It involves implanting a small pacemaker-like device into the brain that produces electrical impulses to specific areas.

This procedure provides relief from symptoms of Parkinson's disease, essential tremor, dystonia, and other conditions.

This article covers the procedure for deep brain stimulation and the benefits and risks it carries.

How Does Deep Brain Stimulation Work?

DBS works similarly to a pacemaker for the heart, yet it targets the brain and comprises more components.

It delivers electrical stimulation to specific brain areas responsible for controlling movement, mood, and other functions. The electrical impulses emitted from the electrodes help regulate abnormal nervous impulses in targeted brain areas responsible for causing severe symptoms^[1].

There are three components to a DBS system^[2]:

• The electrode, or conduit: This is a slim, shielded wire pushed through a tiny hole in the skull and embedded into a particular brain area.
• The extension cable: This is similarly safeguarded and routed under the head, neck, and shoulder skin. The cable joins the electrode to the internal pulse generator (IPG).
• The internal pulse generator (IPG): Also known as a neurostimulator, the IPG forms the third part of this system and is typically installed beneath the skin in the upper torso.

DBS commonly targets the following parts of the brain^[3]:

1. The subthalamic nucleus: Regulates motor functions and controls movement. Using DBS in this region can help alleviate symptoms of Parkinson's disease and OCD.
2. Globus pallidus interna: Plays a crucial role in motor control by inhibiting the thalamus activity. DBS in this region assists those with Parkinson's, Tourette syndrome, and dystonia.
3. Ventral intermediate nucleus of the thalamus: This brain region controls movement and is a treatment area for deep brain stimulation in those with movement disorders. DBS in this portion of the brain can treat some instances of essential tremor.

Other brain parts worth targeting include the thalamus, hypothalamus, periaqueductal gray matter, and the nucleus accumbens^[4].

Conditions Treated with DBS

DBS primarily treats movement disorders such as Parkinson's disease, essential tremor, and dystonia. It can also treat psychiatric disorders such as OCD and Tourette syndrome, and possibly depression and disorders of addiction^[5].

Additionally, DBS has potential as a treatment for chronic pain, cluster headaches, epilepsy, obesity, and other neurological disorders, including dementia and Huntington's disease.

A specialist will recommend DBS as an alternative surgery when medications and other treatment options fail to improve a patient's prognosis. In some cases, DBS may be indicated early on to improve the prognosis, such as during Parkinson's disease.

Contraindications of DBS

There are few contraindications of DBS:

• Those unable to operate the remote controller, change the settings, or tolerate the surgery are not good candidates. Also, Younger patients might tolerate the surgery better, with improved outcomes.
• DBS surgery might not be an appropriate option for elderly people or those who have severe dementia.
• Dementia, secondary dystonia, atypical parkinsonism, a refractory psychiatric illness, a psychogenic movement disorder, brain parenchyma lesions suggesting a secondary pathologic condition, and predominant parkinsonian symptoms unresponsive to subthalamic or pallidal DBS were among the neurological contraindications to DBS^[6]. 

Benefits of DBS

DBS can provide significant benefits for individuals with movement disorders, psychiatric disorders, and chronic pain.

Some of the benefits of DBS include:

• Improved motor symptoms: Reports suggest DBS can improve motor symptoms in people with Parkinson's disease, essential tremor, and dystonia. Symptoms that DBS improves include reduced tremors, stiffness, and difficulty with movement.
• Reduced medication use: DBS can reduce the need for medication in some individuals, which can help diminish side effects and enhance overall quality of life.
• Improved mood and cognitive function: DBS improves mood and cognitive function in individuals with psychiatric disorders, such as depression^[7]. While not yet approved for treating severe depression, it can help lower medication use and improve symptoms in those with severe obsessive-compulsive disorder (OCD) who fail to respond to conventional treatment^[8].
• Long-term relief: DBS may provide long-term relief from symptoms, with some individuals experiencing benefits for ten years or longer after the surgery^[9].
• Reversible: The effects of the surgery are reversible as the device can be switched on, off, or removed.

More than 160,000 patients use DBS with satisfactory results, allowing them to live with a better quality of life.

The Procedure and What to Expect

Before undergoing DBS surgery, it is vital to have a thorough evaluation by a neurologist and a neurosurgeon, who assess the recipient's condition and perform the procedure.

This evaluation incorporates a review of the patient’s medical history, a physical examination, and imaging techniques, such as magnetic resonance imaging (MRI), to select the best course of treatment^[10].

During the Procedure

The DBS surgery occurs in two stages.

• The first stage involves the placement of the electrodes in the brain. This stage is done under general or local anesthesia. The patient is usually awake during the procedure to provide feedback to the surgeon.
• The second stage involves the placement of the neurostimulator beneath the skin in the chest or abdomen. A general anesthetic allows the patient to fall asleep during this process.

During the surgery, the neurosurgeon will use MRI or CT scans to place the electrodes in the targeted areas of the brain. Once the electrodes are in place, they are connected to the neurostimulator, programmed to deliver electrical impulses to the brain.

Follow-up appointments are necessary to monitor the recipients' condition for weeks to months following surgery. A neurologist will adjust the settings until an optimal configuration for the device is found.

Risks and Complications

Risks and potential complications associated with DBS include misplacement of electrodes, bleeding, infection, and damage to surrounding brain tissue.

Additionally, there is a risk of side effects from the electrical stimulation, such as muscle contractions, trouble breathing, seizures, speech difficulties, and changes in mood or behavior. It may also give rise to heart problems, headaches, strokes, difficulties concentrating, and nausea. Side effects of brain electro-stimulation depend on the location of the electrodes.

Reports suggest that surgery may interfere with the muscles required for swimming and that those with movement disorders may not be able to swim after surgery.^[11]

Recovery

After the surgery, following your doctor's instructions for recovery and care is essential.

Patients are advised to take medication that prevents infection, avoid strenuous activities, and attend follow-up appointments to monitor the device and adjust the settings.

Precautions

Following safety precautions can ensure the best results and minimize the risk of complications.

These may include avoiding activities that could damage the device, such as contact sports or high-impact activities.

It is also vital to avoid powerful magnetic fields, such as those seen in an MRI scanner, as they can interfere with the device.

Life After DBS

After DBS surgery, many individuals experience significant improvements in their symptoms and quality of life.

However, it is crucial to continue working closely with your doctor to monitor the device and make necessary adjustments. It is also important to continue taking any prescribed medication and attending therapy or support groups as needed.

Alternative Treatments

While DBS is an effective treatment for many individuals, it is not the only option. Some alternatives to DBS include:

• Medication: In some cases, medication may be enough to keep symptoms under control and improve the patient’s quality of life.
• Other surgical procedures: Depending on the ailment in question, there may be other surgical options available, such as deep brain lesioning or gamma knife surgery.
• Neuromodulation: Other forms of neuromodulation, such as spinal cord stimulation or vagus nerve stimulation, may be effective for specific conditions.

It is essential to consult with a doctor about all available treatment options and to weigh the risks and benefits of each before arriving at a decision.

Latest Technology and Advancements

Advancements in technology have led to the development of new types of DBS systems, such as closed-loop DBS, directional DBS, and non-invasive DBS.

Additionally, research is ongoing to investigate minimally invasive surgical procedures for DBS and the use of DBS for other conditions, such as Alzheimer's disease, depression, anorexia, obesity, addiction, and chronic pain.

Closed-Loop DBS: Also known as adaptive DBS, closed-loop DBS uses feedback from the brain to adjust the stimulation in real time, providing more precise and effective treatment.^[12] This system is a game-changer for DBS, allowing the device to adjust stimulation parameters automatically based on the patient's needs and symptoms. This could lead to more effective treatment and fewer side effects. The Medtronic Percept PC is FDA approved and currently the only closed-loop DBS available.

• Currently, researchers are looking at improving closed-loop systems by using better sensors that can detect when the patient requires more or less electrical brain stimulation. Refinements to the technology, such as artificial intelligence integration, may act to normalize brain waves in patients continuously.

Directional DBS: This technique allows more precise targeting of specific brain regions. By using multiple independently controlled electrodes^[13] (versus two in ordinary DBS), directional DBS can improve symptom control while reducing side effects by selectively stimulating or inhibiting specific neural pathways. Future advancements will help physicians to tailor treatment more precisely.

Non-invasive DBS: Another area of future development in DBS lies in non-invasive techniques that do not require surgical implantation. Non-invasive DBS methods, such as transcranial magnetic stimulation (TMS) and focused ultrasound, are being explored as alternatives to traditional surgical approaches. These techniques have the advantage of being less invasive and may offer more flexibility in adjusting stimulation parameters.

• Researchers are looking at nanomaterials, optogenetic stimulation, and focused ultrasound to enhance non-invasive DBS techniques^[14].

Conclusion

Deep Brain Stimulation is a safe and effective treatment for a variety of neurological and psychiatric disorders. It has been shown to provide significant benefits and long-term relief for many individuals. With the latest technology and advancements, DBS continues to evolve and improve, offering hope for those living with these conditions. If you or a loved one is considering DBS, consult a qualified neurologist and neurosurgeon to determine if it is the right treatment option.

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