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Deep brain stimulation for Parkinson disease: A new chapter in treatment

Spotlight Tuesday, 24 March 2020 12:00
The key categories where deep brain stimulation (DBS) can make the most difference  The key categories where deep brain stimulation (DBS) can make the most difference

Life with a movement disorder such as Parkinson disease is not easy, but it is not impossible. There is also an increasing number of people being diagnosed with Parkinson disease in Singapore and globally. With the appropriate treatment, movement disorders such as Parkinson disease and essential tremor are diseases that you can live well with. Every individual should have a tailored plan for success. For some people, deep brain stimulation (DBS) offers life-changing relief.

What is DBS?

Deep brain stimulation (DBS) uses an implantable device to generate electrical pulses and deliver them to specific areas in the brain. It acts as a pacemaker for the brain.

DBS can be performed on both sides of the brain to control symptoms affecting both sides of the body. Importantly, the effects are reversible and stimulation settings can be programmed to optimise the effect for the individual. DBS provides continuous symptom control 24 hours a day.

Who can have DBS surgery?

To date, more than 150,000 people have received DBS.

  • DBS is an approved treatment by the US FDA for movement disorders (such as Parkinson disease, essential tremor, and dystonia), as well as epilepsy, and obsessive compulsive disorder.
  • DBS is also being studied for use in other conditions such as depression, chronic pain, stroke recovery, addiction and anorexia nervosa.

How does it work?

Chemical imbalances and abnormal brain networks lead to the disease symptoms. DBS works by using electrical impulses to block or change these abnormal nerve signals and chemicals in the brains.

Simply, very much like how a pacemaker for the heart helps to prompt the heart to beat at a normal rate in people with abnormal heart rhythms, DBS does the same for the brain.

Will I benefit from DBS?

In Parkinson disease, DBS improves any symptoms that can improve with levodopa medication.

  • Increase ease of movement 
  • Less freezing of gait (feet are less stuck to the ground)
  • Relief from disabling tremor
  • Relief from severe cramps and pain
  • Less dyskinesia (abnormal uncontrolled movement)
  • Reduction in medication usage

Many people have also reported better sleep, more involvement in physical activity, and overall better quality of life after DBS.

How long does it take before I can see the full benefit of DBS?

Some symptoms (such as tremor, slowness and stiffness) may improve immediately after the battery is switched on, while other symptoms take more time to respond.

Several programming or tuning sessions are required to fully optimise the stimulation settings. This is done using a wireless remote control. It typically takes 3 to 6 months after DBS surgery for the full benefits to be realized.

What is less likely to improve with DBS?

Symptoms that do not respond at all to levodopa, such as balance and swallowing, usually do not improve with DBS. To address these symptoms, additional therapies such as physiotherapy will be required after DBS. Although DBS can improve symptoms and quality of life, it is not able to return anyone to perfect health.

DBS addresses symptoms but is not a cure. The disease will continue to progress and worsen with time. The good thing about DBS is the stimulation parameters can be adjusted to manage symptoms as they change and develop with the disease over time.

Key Points:

Right Mindset for Successful DBS.

  • DBS should not be thought of as a “last resort”.
  • The goal of surgery is to preserve function, rather than to rescue a person from disability.
  • If you experience disability despite optimal medications, then DBS should be considered.

Should I go for DBS?

A commonly asked question by patients with Parkinson disease is whether DBS is suitable for them. In general, you should consider DBS if any of the following statements in the checklist below applies to you:

  • Your medication does not last as long as it once did.
  • You need to take medication more and more often.
  • Your medications fail to kick in or wear off unexpectedly.
  • You find it hard to tolerate the side effects from your current medications.
  • Your symptoms have become disabling and unresponsive to medications.
  • Your symptoms reduce your quality of life or interfere with daily activities.

You can do a self-assessment of your quality of life using our online calculator.

How is DBS surgery performed?

The DBS surgery is a minimally invasive procedure which involves two parts:

  • In the first part, the neurosurgeon places one or more electrodes (thin wires) in specific parts of the brain that controls the symptom.
  • In the second part, the neurosurgeon connects the electrodes to a battery (pulse generator), which is placed under the skin, usually below your collarbone.

What are the risks of the procedure?

DBS surgery is considered a safe and effective procedure. Like any surgery, DBS has its risks which include the risk of infection and bleeding in the brain. Your neurosurgeon will discuss the risks in detail with you.

What is the cost of DBS surgery in Singapore?

In Singapore, the total cost of deep brain stimulation surgery is calculated based on 3 main factors:

  1. Hospitalisation cost
  2. Operation cost
  3. Implant cost

The cost of hospitalisation depends on the type of bed chosen and also on the length of stay in the hospital. The shorter the length of stay, the lower the cost. Operation cost will depend on whether the surgery needs to be performed on one side or two sides (bilateral) and whether the surgery is performed with the patient asleep under general anaesthesia or awake. There are different types of neurostimulator implants that can be chosen and each will have a small difference in their costs.

Given the number of variables involved, please speak to your neurosurgeon to get the most updated information regarding the estimated cost of surgery. 

Our recent study in patients who had DBS in Singapore showed that for the majority of them, there was a sustained reduction in medication usage for over a decade which can in some cases help offset some of the cost of surgery.

How do I get started and find out whether DBS can help me?

Speak to a neurosurgeon or neurologist specialising in DBS.

Summary

  • In DBS, the goal of surgery is to preserve function and improve quality of life.
  • As such, there is a window for DBS before function declines significantly.
  • Every patient should have a tailored plan that is regularly reviewed and is individualised to their needs.

DBS has helped over a hundred thousand patients worldwide with Parkinson disease. We want to bring this effective technology to our patients and make their lives better, starting today.


Dr NICOLAS KON
Neurosurgeon

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