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Deep Brain Stimulation (DBS) surgery for Parkinson's patients

Parkinson's disease primarily causes motor disorders - tremors, stiffness and slowness. As part of the disease, there is difficulty in walking, and slowness of reactions. These symptoms make it difficult for the patients' daily functioning - starting with using a computer mouse, TV remote control and cell phone, continuing with making a cup of coffee and opening cans, and ending with driving, performing physical activity, work, hobbies, relationship and family life and participating in social events. All of these significantly affect the patients' quality of life.

To date, there is no treatment for Parkinson's disease that results in a complete cure from the disease. At the same time, there is an operation that allows a very significant improvement of the main signs of the disease and a reduction in the side effects of the drug treatment.

The surgical treatment simulates 'going back' in time to the first years of the disease when the symptoms were mild and did not significantly interfere with function. The effect of the surgery is long-term and continues for many years after. At the same time, the operation does not prevent the further progression of the disease and the appearance of additional signs of the disease, such as swallowing disorders, speech disorders, memory disorders, balance disorders, and more.

Most patients with Parkinson's disease are treated with dupicare or other dopamine derivatives. Over time, the effect of the pills decreases and it is necessary to increase the dose of the pills and the frequency of taking them.

When the daily dose increases significantly (and in some patients already at a low dose), significant side effects develop from the pills, such as visual hallucinations (seeing things that are only imaginary), dyskinesias (involuntary movements in the limbs and head) and more.

In addition, the drug helps with the time that is getting shorter, and between doses the patient experiences prolonged OFF states. Many hours during the day and night he suffers from Parkinson's symptoms - tremors, stiffness and slowness. The actual effect time of the drugs is getting shorter, and the side effects of the drugs are added to it.

Patients with Parkinson's disease who suffer from significant tremors sometimes experience no improvement or only partial improvement in tremors with drug treatment. Even then, another solution is required to improve the signs of the disease and the quality of life.

DBS surgery for Parkinson's disease exists in Israel and with the approval of the Ministry of Health and the health basket For 15 years and has been carried out in several centers for traffic disorders throughout the country: Ichilov, Beilinson, Hadassah, and Tel Hashomer.

Who is the surgery for? There are several reasons to get surgery:

  1. Many hours during the day when the patient experiences OFF, i.e. multiple parkinsonian symptoms, despite the medication.
  2. Intolerance to the drug treatment or side effects from the drugs.
  3. Symptoms that are resistant to medication (usually tremors).
  4. Significant functional limitation.

Today there is a recommendation by the International Organization for Movement Disorders and the American FDA, following many previously published studies in the field, to recommend the operation not only "when all the summers are over" and the disease is already in very advanced stages, but in earlier stages, 4-5 years after the diagnosis, When the drugs are no longer sufficient to control the symptoms. It is important to note that a referral for surgery when the patient already has an advanced disease including a severe balance disorder, cognitive decline, memory decline and swallowing disorders - is too late. In these situations, there is usually already a contraindication to performing the surgery, so it is important to resort to surgery at an earlier stage.

 

Implantation of the cerebral pacemaker is only done in patients who have been diagnosed by a neurologist specializing in movement disorders as having idiopathic Parkinson's disease, that is, pure Parkinson's disease, which does not arise from diseases or other physiological conditions that create symptoms similar to Parkinson's (parkinsonism). The importance of this comes from the fact that patients with parkinsonism do not react to the same degree of improvement for the implantation of the cerebral pacemaker, and therefore are contraindicated for surgery.

 

How does the cerebral pacemaker help Parkinson's patients?

The brain pacemaker (DBS) is a device that provides electrical stimulation to the brain tissue by a thin electrode (about a millimeter thick) that is inserted with great precision into a target deep in the brain. The electrode is passed under the skin through the neck to the chest, where the pacemaker is implanted under the skin (similar to a pacemaker).

The cerebral purpose of the pacemaker implant is a cluster of cells deep in the brain from which nerve cell extensions come out to several centers in the brain which together are responsible for performing and correcting movement in real time.

In Parkinson's patients, the brain sends unwanted electrical signals that cause the motor impairments, for example - the command to tremble or the command to all the muscles in the body to stiffen and stretch even when they are supposed to be relaxed to allow movement. The electrical currents delivered through the pacemaker block these unwanted commands, creating electrical activity that mimics normal brain activity.

As a result of the electrical stimulation provided by the pacemaker, most of the motor symptoms of the disease - the tremors, stiffness, slowness, the difficulty in walking and freezing in the middle of the road, the difficulty in getting up from a chair and starting to move, and the side effects such as the dyskinesias which cause unwanted hypermobility - all of these go away completely or improve significant as long as the timer is activated.

The operation of the pacemaker is not painful and is not felt by the patient, and the pacemaker works at all hours of the day, even at night.

The activity of the pacemaker continues continuously for several years. Once every 3-5 years it is necessary to replace the pacemaker battery which is implanted as mentioned under the skin in the chest. Changing the battery involves a short procedure in the operating room (about half an hour) after which the patient is released home with a new pacemaker that works in the same way as the previous pacemaker.

 

The surgical procedure

The surgical procedure is carried out in two stages:

A. Electrode implantation: tiny electrical electrodes are implanted in the patient's brain. The implantation is done with anesthesia (local anesthesia, and sometimes also under anesthesia) because the surgeon uses the patient's reactions to the electrical stimulation in order to place the electrodes precisely in the brain (it doesn't hurt - the brain has no sensory nerves).

B. The implantation of the extension wires and the pacemaker: the pacemaker itself is implanted under the skin in the patient's chest (or stomach) area and is connected to the electrodes in the brain and activates them.

The implantation of the electrodes is done through a small opening in the skull which is covered at the end of the surgery. The entire system is implanted under the skin and there are no parts that stick out or are attached from the outside.

The common complications in surgery are infection and bleeding which are caused in 1-2% of patients and can be treated, usually without irreversible damage.

The duration of hospitalization is a few days, after which the patient returns home. In the first period, there may be fatigue, mild headaches, and slight discomfort in the area of ​​the surgical incisions. Full recovery from surgery is expected 2-6 weeks later.

Two weeks after surgery, the patient comes to the clinic for the activation of the pacemaker. After that, several additional clinic visits are required (in the range of once every few weeks-months) for a final balance of the rationing.

The treatment is approved in Israel and is included in the health basket for the treatment of Parkinson's disease, as well as for the treatment of essential tremor, intractable epilepsy, and dystonia. In recent years, additional developments have taken place on the product, state-of-the-art electrodes have come into use that allow for unique ways of transmitting the electric current without side effects, and new pacemakers have been developed that allow for external charging, less frequent battery changes and "smart" pacing, adapted to the brain's electrical activity that is registered at any given moment from the patient's brain.

Dr. Idit Tamir
Director of the functional neurosurgery service
Department of Neurosurgery, Rabin Medical Center - Beilinson Hospital