Movement Disorders Center
DBS Risk and Treatment FAQs
Wake Forest Baptist Health pioneered the use of deep brain stimulation, or DBS, to treat certain types of movement disorders. DBS works by blocking the abnormal brain circuitry seen in patients with neurological conditions such as Parkinson’s disease, tremors and dystonia. Our movement disorders multidisciplinary team includes the top DBS experts in the nation.
You probably have many questions about DBS risk, how it works, and whether it’s right for you. Read below to get answers to some of the most frequently asked questions about deep brain stimulation.
Assess your DBS risk. Request an appointment online.
Q. What is deep brain stimulation?
A. Deep brain stimulation, or DBS, is a procedure where electrodes are placed in specific areas of the brain. The electrodes block the abnormal brain circuitry seen in patients with neurological conditions such as Parkinson’s disease, tremors and dystonia.
DBS does not destroy the overactive cells, like other movement disorders treatments such as pallidotomy and thalamotomy surgeries. Rather, it temporarily blocks the abnormal signals and is a reversible process. A lead is permanently implanted into your brain and connected to a pulse generator (IPG), which is attached under the skin of your chest. It is easy to program the IPG by using a hand-held device. The batteries of the IPG will last anywhere from three to five years before needing a replacement, which is done during an outpatient procedure.
Q. How does DBS work?
A. DBS disrupts the abnormal circuits in the brain, thereby reversibly suppressing the abnormal brain cell activity.
Q. Am I a candidate for DBS?
A. Several categories of patients have success with DBS.
The best candidates for DBS are patients with idiopathic Parkinson’s disease (not patients with atypical Parkinson’s, which includes other disorders such as progressive supranuclear palsy, Lewy body disease and multiple systems atrophy), who have responded successfully to L-dopa (Sinemet) treatments.
These patients gained reasonable control of the tremor, freezing and rigidity, but may need increasingly large doses of the medication to find relief. Other patients may find that the medication causes unpleasant side effects that limit their quality of life. Still others may suffer from the effects of the medications wearing off prior to their next dose.
DBS has been shown to improve all the symptoms of Parkinson’s disease that respond to L-dopa. The exception is tremor, which responds well to DBS even if it did not previously respond well to medications.
Essential Tremor (ET)
Patients with ET suffer from a tremor that occurs during an action, such as attempting to perform a task, or when they try to hold their hand or arms in a fixed position. ET affects a patient’s daily life, as it interferes with the ability to get dressed, write, eat or drink. ET can often be confused with other disorders associated with tremor, so it is important to be evaluated carefully. For a tremor patient to be a DBS candidate, the tremor must have failed the maximum doses of medication.
Patients with dystonia, a disease characterized by twisting movements and abnormal postures, can also benefit from DBS if medication has failed to provide relief.
Obsessive Compulsive Disorder
Patients suffering from obsessive compulsive disorder (OCD) may also be candidates for DBS.
It is important to note that patients with dementia in addition to movement disorders are not candidates for deep brain stimulation.
Q. How can I be evaluated?
A. If you have been referred to the Movement Disorders Center, you will undergo a comprehensive evaluation for level of qualification and DBS risk. You will:
- Meet with a DBS-trained movement disorders neurologist. Your neurologist will confirm your diagnosis, grade its severity, ensure your medications are optimized, and determine and explain which symptoms can be expected to respond to surgery. For example, you may want DBS to improve your gait and balance, but it is possible that after a careful screening your doctor will determine that DBS cannot help improve those symptoms.
- Undergo our screening process. This requires the better part of the day. You will undergo a battery of tests, both on and off medications. You will probably be asked to come that day without taking your medication and to bring all of your movement disorders medication with you.
- Be videoed during examination. The video allows us to discuss your case with our multidisciplinary team and to monitor the disease. In addition, video records help us educate and train other physicians.
- Undergo a detailed neuropsychological evaluation. This will determine if you have any degree of dementia or behavioral issues. Often, Parkinson’s disease patients suffer from memory problems or are easily disoriented. Unfortunately, a DBS risk may be exacerbation of those conditions, so dementia patients are not candidates.
- Undergo a psychiatric evaluation. Your neurologist may recommend this to determine if you suffer from depression or mood instability and whether this will interfere with a possible successful surgery.
- Meet with the neurosurgeon. Once your neurologist has determined you are a suitable candidate, you will meet with our neurosurgeon, who will determine whether the ratio of DBS risk to benefit is in favor of proceeding with this surgery. Your neurosurgeon will also explain the procedure to you in detail.
- Be evaluated by our team. After the comprehensive evaluation, our multidisciplinary team will meet to discuss your case and DBS risk ratio, after which they will convey the decision to you.
Q. How is the DBS procedure performed?
A. There are two phases to the DBS surgery, performed several weeks apart.
- Phase I. Your neurosurgeon places the electrodes into the brain. You will need to be admitted to the hospital for this procedure.
- Phase II. The pulse generator (IPG), which is the power source, is placed under the skin of your chest and the electrodes are connected to the generator. This is usually an outpatient procedure.
Once the second phase is completed, you will return for three or four follow-up visits during the next six months for DBS programming and to make sure your medications are optimized.
After that six-month period, programming is usually done every six months or as needed. The generator has dozens of settings that are used to improve symptoms and decrease side effects. When your generator battery needs to be replaced, you come to the hospital for an outpatient procedure to replace them.
Q. What type of DBS risk is there?
A. Any surgery comes with risks, and DBS is no exception. However, the DBS risk of morbidity and mortality is relatively low, at approximately 0.5—five percent. The major DBS risk is hemorrhage or bleeding in the brain, equivalent to having a stroke. In addition, a deep brain stimulator is a foreign object implanted in your body, so there is a risk that it could become infected and need to be removed.
Other DBS risks in Parkinson’s patients include such side effects as weakness or coordination problems, which usually improve over time. Some patients report personality or cognitive changes, though most do not. For procedures affecting the thalamus, a speech difficulty called dysarthria may occur.
We are able to minimize most side effects by intraoperative physiologic testing during the procedure.
What symptoms does DBS improve?
A. In general, movement-related symptoms such as slowness and stiffness that responded to medications will respond to surgery. Tremor, even if it did not respond to medication, generally responds well to surgery.
However, not all symptoms of Parkinson’s disease improve with surgery.
- Speech does not improve and may worsen.
- Freezing of gait only improves if it improves with medication.
- Balance may not respond; falls may or may not be reduced, and may even increase.
- There are also no known benefits to memory, depression, drooling, constipation or urinary problems.
DBS for tremor is optimized to reduce arm tremor; it may be less effective for leg tremor and even less effective for head and voice tremor.
Because of the DBS risks, it is only recommended for patients whose quality of life is significantly impaired by their movement disorder. Determining “significant impairment” is best done by the physician, patient and patient’s loved ones.
Q. What is the cost for DBS?
A. The cost for DBS is covered by most insurance companies, just like any other surgery is covered. Ask your insurance company if they cover the FDA-approved deep brain stimulator.
Q. How do I become a patient?
A. Ask your doctor for a referral to our Movement Disorders Clinic. It is located on the Fourth Floor of the Janeway Tower. For more information, or to begin to assess DBS risk, call our Program Coordinator, Kim Gamble Slade at 336-716-4067.
We need the following information sent to us:
- Copy of insurance card (front & back)
- Office notes
- Medication list
- MRI/CT films (not just the report)
This information can be faxed to 336-716-9742.
Q. What should I bring when I come for my DBS risk evaluation?
A. Please ensure your referring physician has sent records to us. Items to bring with you to your appointment:
- MRI films (not just reports)
- Completed forms (received in the mail from us)
- All medications in the bottle
- Caregiver and family involved in your care
If you have any questions, such as to assess your DBS risk, call our Program Coordinator 336-716-4067.