DBS Surgery

As part of the DBS evaluation to establish candidacy, you are asked to complete evaluations by a Neurologist, Neurosurgeon, Neuropsychologist, Speech specialist and a Physical therapist. These evaluations help us to determine the best management plan for your care.

Who is a good candidate for DBS surgery?

• Parkinson’s Disease > 5 years
• Age not above 75 years
• Patients experiencing excellent “ON”: those who historically and currently getting good L-dopa effect even for short periods even at evaluation that done years after diagnosis of Parkinson’s disease.
• Fluctuating Parkinson’s disease.
• Patients experiencing drug side-effects limiting their use.
• Disabling dyskinesia & Extreme sensitivity to small L-dopa dose leading to dyskinesia.
• Prolonged “OFF”or Disabling “OFF”.

• Evaluation by a Movement Disorder Neurologist
  

  The movement disorders neurologist who specializes in DBS at our clinic is Dr. Mohit Bhatt. A movement disorder neurologist or their physician assistant may videotape your examination during this evaluation.

  For patients with diagnosis of Parkinson’s disease you will undergo an “ON-OFF evaluation”. You will come to the appointment “OFF”medications. You are asked to hold the medications that you take for Parkinson’s disease 12 hours prior to evaluation. You are to bring your medications for Parkinson’s Disease to this visit.

  You will first be examined using a clinical little scale during an “OFF”medication state. You will then be asked to take your medications. The examination will be repeated during your “ON”medical medication state. The total evaluation often lasts for 1- 2 hours. Please keep in mind that if you have difficulty walking during your “OFF”medication state, then you should bring a wheelchair or walker to the appointment.

  For patients with Essential tremor or Dystonia an “ON”/ “OFF”medical evaluation may not be completed in one sitting. However, these examinations may be videotaped.

• Consultation with Neurosurgeon
  During the initial meeting, Dr. Abhaya Kumar or Dr. Akshat Kayal or their clinical assistants will explain the surgical procedure. They will additionally review potential risks of surgery and benefits, and evaluate your candidacy for surgery. Please note that a consultation with the neurosurgeons does not require you to be committed to DBS surgery. The purpose of initial consultation is so that you may have your questions answered by the surgeon and get to know the team.
• Neuropsychological Evaluation
  This evaluation includes extensive testing of memory, language and attention. This test may take up to 4 hours. Please take your medications as normally scheduled. You may bring your medications to this visit.
• Brain MRI (if needed)
  Imaging of your brain will be ordered and reviewed by a neurosurgeon and neurologist if needed by the team. All Patients undergo MRI for surgical planning at the time of surgery.
• Physical Therapy Evaluation (if needed)
  You may meet with the physical therapist who specialises in management of gait difficulties associated with neurological conditions. She or he will evaluate your gait and motor function prior to DBS surgery and 6 months following DBS surgery / programming.
• Speech Evaluation (if needed)
  You may meet with a speech specialist for evaluation of speech and swallowing prior to DBS surgery and following DBS surgery/programming.
• Anesthesia Evaluation
  You would meet the neuro-anesthesiologist upon admission for surgery.

Once these evaluations are completed, we will discuss your case after Multidisciplinary Movement Disorders Team Meeting. This information will allow the team to determine the best treatment plan for you. After the meeting, we will discuss the plan with you either by phone or in a follow-up clinic visit.

The DBS surgical procedure performed by our neurosurgeons are carried out in two stages.

• Microelectrode Recording (MER) guided electrode placement or “Awake” Stage:
  The surgeon uses preoperative MRI images to plan the procedure. The patient is awake, under local anesthesia and mild sedation for this part of the surgery, but experiences minimal to no pain. In order to verify that the electrode is in the intended location, micro electrode recordings are used to map the target brain region. Once the desired trajectory is verified, the actual DBS electrode is inserted and turned on temporarily to test the symptom improvement and side-effects. Both sides of the brain are implanted in the same session. This part of the surgery does not need General Anesthesia. In a select few cases this part of the surgery can also be done under general anesthesia. The asleep procedure is typically reserved for patients who have dystonia.
• Lead extender and IPG placement or “Asleep” Stage:
  Under general anesthesia the lead extenders are tunneled from the scalp to the chest and internal pulse generator (we commonly referred to this as the “battery” is implanted on the left side of your chest.

The awake, MER guided procedure is best suited for patients, as they can communicate with the team during the procedure and possibly participate in the neurophysiology recording. This increases the efficacy and reduces the side-effects of electrical stimulation. It also helps doctors to locate the best position to implant and fix the final electrode.

Please discuss with your Neurologist and Neurosurgeon the details of the surgical procedure and the type of procedure best suited for you.

If the DBS team determines that you are a candidate for DBS surgery, and you wish to proceed with surgery, then the following will be arranged by the Neurosurgery team:

• Surgery scheduling.
• A brain MRI for surgical planning.
• Preoperative physical examination and testing
  • Includes a general physical examination which may be completed by our neurophysiologist.
  • Pre-operative testing including blood drawn labs, ECG and Chest x-ray.
  • If you have ongoing medical conditions such as heart disease or diabetes, or if you are taking blood thinners, please discuss this information during your visit with the Neurosurgery team. Heart disease or diabetes, or if you are taking blood thinners, please discuss this information during your visit with the Neurosurgery team.

Continue your medication for Parkinson’s disease during this time. We stop the anti-Parkinson drugs the night before surgery. You will restart and continue these medications after surgery. Medications may be adjusted at the first initial programming visit after surgery.

You are required to complete basic preoperative testing before your upcoming surgery. The testing should be no later than seven days prior to your surgery date. We usually admit the patient on first day of the week and work up the patient. Patient undergoes the planning MRI scan, the neuro-psychological review, gait and speech assessment over the next three days. The history, blood works and other relevant tests are completed within these days. If you need medical clearance by a specialist, such as a cardiologist, the appointments are arranged during this period of time. Any specialized testing that needs to be done prior, for giving clearance for surgery is also conducted.

You need to discontinue your Parkinson’s medications the night before surgery. You may not eat or drink eight hours before your surgery (Wednesday night). Unless otherwise directed, on the morning of your surgery you may take any regularly scheduled medications with a small sip of water. The surgery usually takes place on Thursday morning wherein you will be shifted to the operation theatre.

Remember to discontinue any medication that increases bleeding risks for seven days prior to surgery (see attached list of medications to avoid before surgery). If you do take any blood thinning medication within a week of surgery, the surgery will be cancelled and rescheduled for a later date. If you experience any mild pain or headache within one week of surgery, the only approved over-the-counter pain medication to take is paracetamol or its generic equivalent acetaminophen.

After the surgery you will be monitored for 24 hours in the ICU. The Parkinson’s medication would be re-started. A CT scan of brain is performed the next morning after surgery. Subsequently you will be shifted to the wards with continued to be administration of IV antibiotics. The surgical site would be dressed on day 2 and day 4 from the day of surgery. Discharge from the hospital is usually scheduled a week later (on the next Tuesday) from the day of admission.

Surgical Risks

Potential risks of surgery include complications of bleeding or infection.

INFECTION PREVENTION:

Infection is a risk of any surgery, but an infection can be more serious in surgeries where a foreign device is placed in the body. We take every precaution to prevent this from happening, and now there is something you can do to help.

Bactoscrub/ Microshield (Chlorohexidine Gluconate 4% solution) Bactoscrub is a medicated soap that kills germs that normally live on your skin. Its use has been shown to reduce the risk of surgical infection.

Instructions for use:

• Beginning three days before your surgery and on the date of your surgery Bactoscrub should be used in place of your regular soap or body wash.
• Apply Bactoscrub to wet washcloth and clean your scalp, neck to your toes including your arms and legs, front and back.
• Do not use the solution on your face or genital area.
• Do not use regular soap, powders, lotions or creams and areas where Bactoscrub is applied.

Nasal swab for MRSA:

MRSA is a “superbug” that is resistant to many antibiotics. Many people have this bacterium living on the skin, and it does not cause an infection. However, when the skin is cut, like in surgery, the bacteria can infect the wound. We want to identify the patients who are carriers of MRSA and treat them before surgery to decrease the risk of this particular infection. We can do this by simply taking a culture from your nose with a cotton swab. A negative MRSA culture report is desirable prior to the surgery. Additionally, Mupirocin ointment would be prescribed, to be applied inside both the nostrils twice daily for 3-4 days before surgery.

Some drugs potentially increase the risk of bleeding during surgery.

• Warfarin (Warf):
  Must be discontinued 5-7 days before surgery under the guidance of your cardiologist or primary care physician. Please contact them for instructions about stopping this medication and to make sure it is safe to do so. Your PT/INR (blood work) must be completely normal the morning of surgery.
• Aspirin (Ecospirin):
  Must be discontinued 7-14 days before surgery under the guidance of the cardiologist or primary care physician. Please contact them to make sure it is safe to stop this medication.
• Clopidogrel (Clopitab/Plavix):
  Must be discontinued seven days before surgery under the guidance of your cardiologist our primary care physician. Please contact them to make sure it is safe to stop this medication.
• Novel Anticoagulants [NOACs] (Xarelto, Pradaxa, Brillianta, Eliquis):
  Must be discontinued 5-7 days before surgery under the guidance of your cardiologist or primary care physician. Please contact them for instructions about stopping this medication and to make sure it is safe to do so.
• Non-Steroidal Anti-Inflammatory Drugs [NSAIDs] (Diclofenac, Acetofenac, Ibuprofen, Naproxen, Etoricoxib, Celecoxib):
  Must be discontinued 7 to 14 days before surgery. Many NSAIDs are available to over-the-counter and some by prescription only. They are commonly used to treat pain, inflammation and fever. Some of these medications are used on topical forms (gel, paste etc.) and also must be discontinued before surgery. Please remember the only over-the-counter pain medication that is safe to use within two weeks of surgery is acetaminophen/ paracetamol.
• Miscellaneous medications:
  continue the following medications 14 days prior to the surgery. Vitamin E supplements, Fish oil or omega-3 supplements, Coenzyme Q10 supplements, Sildenafil, Tadanafil (2 days).

If you have any questions about medication to avoid prior to surgery, please contact the DBS team.

Expectations

• Both the stages of surgery i.e. lead implantation and IPG placement are performed at the same time on the day of surgery.
• During the DBS surgery you are required to stay spend 7-8 days in the hospital. A majority of patients are discharged on the eighth day, but some require a longer hospital stay or require further rehabilitation at rehab facility after surgery.
• Although your DBS is not turned on, you might feel like your symptoms are improved for a few days after surgery. This effect should wear off before your initial programming.
• You will likely experience some facial swelling after surgery. Sometimes this swelling occurs immediately, but sometimes it shows up a few days after surgery. This is NORMAL. It will resolve on its own within a few days. Some things that you can do to help it along:
  • Spend more sometimes sitting /standing upright than lying flat.
  • Apply an ice pack.
  • Take paracetamol if it becomes painful.

Wound Care

• Your bandages will be removed from your head and the chest on the 4th day.
• On day 4, please begin washing your hair once daily, using shampoo. It is okay to get your incisions wet and soapy. Gently rub some shampoo on to the incision with pads of your fingers. Do not scratch or scrub with your nails. Washing the incisions daily helps to keep the area clean and prevent infection.

Restrictions

• Once you get home you may resume your normal activities as tolerated except as below.
  • No lifting greater than ten to fifteen pounds thirty days from your surgery.
  • No vigourous exercises one month from your surgery this includes anything that increases your heart rate such as running.
  • No driving for two to four weeks after your surgery. The exact timing to resume driving can be discussed at your follow-up visit.

Follow-up

• Your post-op visit/ suture removal is scheduled 10 days from the day of surgery.
• DBS initial programming will take place in the Neurosciences Department ten days after the surgery.
• Please come to the initial programming visit “OFF” medication for twelve hours.

The first initial programming visit may take 1.5-2 hours. During the visit the clinician will turn the device therapy “ON”. Each electrode has four contacts. Each contact will be activated individually and the voltage slowly increased. As the voltage is increased you may experience benefit to symptoms or side-effects. The side-effects may be quickly reduced when the voltage is decreased. This process provides the clinician with information regarding the placement of electrode and the settings that will provide the best benefit for your symptoms. The goals of the DBS programming include improving symptoms while avoiding side-effects. Most side-effects of DBS programming are explained at the initial programming visit; however, in some instances Side effects can be delayed. Please call our clinical associate if you experience delayed side-effects.

During the initial programming visit you may experience side-effects of stimulation such as numbness, tingling, slurred speech, balance difficulty, facial pulling, or vision changes. The symptoms may be temporary, but you must let your DBS programmer know so that he or she may change the settings and reduce these symptoms.

Optimizing DBS programming may take up to 6 months. During this period, we are also adjusting the medications. Medications may be reduced once DBS programming is initiated.

Our expert team consists of:

• Neuro Physician
• Neurosurgeon
• Neuro Anaesthetist
• Neuropsychologist