Who can benefit from surgery? DBS As a treatment for Parkinson's, expectations and disappointments
DBS as a treatment for Parkinson's is considered a very effective treatment to alleviate motor complications of drug treatment for Parkinson's, such as motor fluctuations (ON OFF phenomenon) resistance to treatment, severe dyskinesias, or severe tremor resistant to drug treatment. In addition, in cases where drug treatment, especially from the group of dopamine agonists (Siprol, Requip), causes complications such as disturbance in impulse regulation (gambling, hypersexuality, compulsive eating, etc.) there is a place for DBS treatment, which often makes it possible to lower the doses of these drugs. DBS treatment is not expected to improve balance disorders, gait stasis that does not go away under medication, dementia, severe and unbalanced psychocognitive disorders, and therefore these conditions are considered a contraindication to DBS treatment. In addition, the treatment was not found to be significantly effective for swallowing disorders and pain in Parkinson's disease and its effects vary regarding sleep and sphincter function. A decision on DBS treatment, similar to a decision on other medical treatments, is derived from a balance between the benefits of the treatment and complications from the surgery itself (bleeding, infection, etc.) or from the timing itself (speech disorders, mood and behavior changes, gait disorders, etc.). The difference is that surgery is a less reversible procedure than drug therapy.
Failure of DBS treatment is based on various factors, among them the selection of unsuitable candidates for treatment, and therefore before surgery, assessments are made that exist in centers all over the world and include: imaging, assessment of motor, cognitive and psychiatric function. However, the aforementioned assessments take time and can cause mental stress for the patient and those around him (Contrino, 2019).
Other factors that influence a decision regarding DBS treatment include underlying diseases (affect surgical risk for example), patient age (according to various studies affects surgical risk as well as possible profit from surgery), years of illness and more.
Several articles referred to criteria that would indicate which patients are suitable for DBS treatment, but these criteria demonstrated good sensitivity and relatively low specificity. In other words, those who meet the criteria will indeed improve, most likely, following the surgery, but those who "do not meet" the criteria can also improve in some cases following DBS surgery for Parkinson's (Monhoes, 2016).
In recent years there have been developments in the diagnosis and treatment of Parkinson's and in medicine in general that also affect the target audience for DBS treatment .
Thanks to the earlier diagnosis, patients reach drug treatment and motor complications at earlier stages than before. Different "types" of Parkinson's are identified today, characterized by unique genetics/nature of symptoms/disease course. The question arises whether the treatment is more effective and recommended for patients with Parkinson's of a certain type and less so for others and how significant is the contribution of certain Parkinson's characteristics. This is the place to point out that the symptomatic treatment of Parkinson's is based on accepted and proven principles in the medical literature and yet varies from person to person: so that it actually serves as an example of "personalized medicine".
DBS treatment is already a valid and well-known medical practice in the world in general and in Israel in particular, and therefore on the one hand there is more confidence and less "fear" to offer it to patients and in addition there are more and more centers and specialists who deal with it than before. The accessibility of information in the modern world has also resulted in the fact that the treatment is much more familiar to the patient population and the general public.
On the other hand, there is currently a lively discussion in Israel and around the world regarding the need to update and refine the criteria for treating DBS for patients with Parkinson's disease so that patients who can indeed benefit from it and improve their quality of life will be entitled to it, and on the other hand, that patients who are not expected to improve to the extent that the benefit outweighs the potential "damage" will not be referred for treatment All of this is of course subject to information obtained from studies that examined long-term results of patients who underwent the surgery.
One example is the patient's age. While in many centers around the world the operation is not recommended for patients over 70 or even 65, in Israel the story of a patient who underwent the operation at an older age of 70 and with (at least short-term) good results was recently revealed in the media.
Another issue that came up for discussion in the world literature and that we are exposed to many times in clinics is the expectations / disappointments. The DBS treatment is a symptomatic treatment like drug treatment for Parkinson's and does not change the course of the disease.
"Brain surgery", "Adam in June" are significant phrases that sometimes cause a certain mental-emotional bias to the fact that, after all, it is a treatment with higher impact capabilities than can be achieved with other treatment methods. Therefore, in cases where there is some improvement but there is no complete disappearance of symptoms / in the case of side effects / in cases of functional improvement for a short period after which other symptoms appear that are not motor or that are motor but not well controlled by DBS (such as stagnation in walking/falls/descending cognitive/apathy/sleepiness and more), may result in bitter disappointment from the treatment.
DBS treatment requires cooperation and commitment from the patient and those around him. Many patients say that the surgery itself is a very difficult and traumatic experience. After the surgery, several sessions must be attended in which the pacemaker is activated in different ways with a varied effect on the symptoms, until the situation where the DBS works and achieves satisfactory relief of the symptoms (even if not perfectly) and all this in combination with medication changes. Sometimes patients are asked to actively make changes in the device's function and report results. One must learn to operate the pacemaker for this and monitor the voltage of the DBS battery using a manual remote control at home or alternatively charge the pacemaker at regular intervals.
In conclusion, the DBS treatment is a very effective treatment under certain conditions. The success of the treatment depends on many factors, including detailed coordination of expectations with the patient before the treatment. The question is pending which candidates the surgery helps. The impression is that the trend is to revise the existing criteria and try to be more precise in selecting candidates for treatment in order to improve their quality of life in the best possible way. In the fall of 2021, there will be important conferences in the world of Parkinson's - the world conference of the Society for Parkinson's and Movement Disorders and the Israeli conference of the Society for Movement Disorders, and certainly the above topic will be discussed in detail.
