What is DBS?

Deep brain stimulation, or DBS, is a type of surgery that can help people with movement disorders. It is FDA-approved to treat Parkinson’s and essential tremor.

OHSU’s Dr. Kim Burchiel was the first surgeon in the United States to perform DBS, in 1991. At the time, DBS was not available for the public, but Dr. Burchiel did the first successful procedure as part of a clinical trial. He was also the first physician to do “asleep” DBS, with the patient under general anesthesia. Before this, patients were always awake during the procedure.

Today, the OHSU team has more than 25 years of experience with DBS, and OHSU is one of the few medical centers offering “asleep” DBS, and doing so exclusively. The information below tells you more about DBS and how it is done at OHSU.

What is DBS, and what does it do?

You probably know someone with a pacemaker – an electrical device implanted in the chest that keeps the heart beating correctly. A DBS system is like a pacemaker for your brain. It uses a small battery-operated device called an internal pulse generator, or IPG, and tiny electrodes. During DBS surgery, your neurosurgeon places the electrodes in specific areas of the brain that control movement. The IPG sends steady, low-voltage pulses of electricity to the electrodes. The pulses help control the abnormal movements caused by Parkinson’s or essential tremor.

Researchers believe DBS works because the low-voltage pulses of electricity block abnormal nerve signals in Parkinson’s and essential tremor. The pulses might also change brain chemicals that cause tremors and other symptoms.

Another way to think about how DBS works
Think of your brain as an electrical circuit. If something interrupts the brain pathways or “circuits” that send messages inside the brain and to different body parts, that brain or body part may stop working correctly. In an appliance, we would say that the circuit has failed.

Researchers have learned that your brain can also have faulty “circuits.” When a brain circuit fails, it sends abnormal signals. Symptoms happen depending on where those signals go. For example, if a circuit that controls hand movements is faulty, you might have hand tremors.

Doctors use DBS to help fix the circuits, just like you might fix a faulty electrical circuit in an appliance. With DBS, the signals can improve, and so can your symptoms. Doctors and researchers believe this is how DBS works, though they are still doing research.

What does the DBS system look like?

A DBS System

A DBS system has three parts:

  • The electrode – Your neurosurgeon places this thin wire in the brain. Before your DBS surgery, the surgeon decides on the best place to put it. This place is called the “target area.”

    The DBS system in the picture has two electrodes, but some just have one.

  • The extension – This wire connects the electrode to the pulse generator, or IPG. The extension goes under the skin of the shoulder, neck and head.
  • The IPG, also called the stimulator – This is the small square device shown in the picture. It is about the size of a tea bag. It creates low-voltage electrical pulses. Your neurosurgeon usually puts it under the skin near the collarbone, but it can also go lower on the chest or near the belly.

    The IPG runs on a battery. This battery lasts three to five years and can be replaced.

The difference between awake and asleep DBS

In "asleep" DBS, developed by OHSU's Dr. Kim Burchiel, the patient is placed under general anesthesia. The patient is not aware of any part of the procedure. The neurosurgeon uses high-resolution scans taken before and during surgery to precisely place the tiny electrodes in the brain. "Asleep" DBS is faster and safer. Patients can also take their medication on the day of surgery.

In "awake" DBS, the patient must remain awake during surgery. This is because the patient needs to respond to help the neurosurgeon correctly place the DBS electrodes in the brain. Many patients are anxious about being awake during brain surgery. They also must refrain from taking their medication on the day of surgery.  OHSU no longer performs awake DBS.

How does my neurosurgeon test the electrodes if I am asleep?

Your neurosurgeon does CT scans, sometimes called CAT scans, during surgery. Your neurosurgeon compares these with the high-resolution MRI you had before surgery. By comparing these precise scans, your neurosurgeon knows when the electrodes are in the right place. He or she can find the best location without having to move the electrodes around, as in awake DBS.

 

Where do the electrodes go in my brain? Why?

For Parkinson’s, the leads go in one of three brain areas:

  • The subthalamic nucleus, or STN
  • The globus pallidus internus, or GPi
  • The thalamus

For essential tremor, the electrode usually goes in the ventralis intermedius nucleus of the thalamus, or VIM.

Where your neurosurgeon puts the electrodes depends mainly on your disease — Parkinson's or essential tremor. It also depends on your specific symptoms. Your neurologist and neurosurgeon will review the results of your pre-surgery evaluation and decide on the area that is most likely to give the result you hope for.

Before you have DBS, you work with our team of experts, have tests and talk with your neurosurgeon and team about your symptoms and goals. This helps the team choose the best placement area for your individual needs.

What are the stages of DBS surgery?

Deep brain stimulation surgery includes two procedures. The surgeries can be as few as two days apart, or about one week apart. In the first procedure, called Stage 1 below, your neurosurgeon places the electrodes in the brain. In the second procedure, called Stage 2 below, your neurosurgeon puts the pulse generator, or stimulator, under the skin of your chest and connects it to the electrodes.

Before your DBS, OHSU will call to confirm your surgery.

They will also tell you:

  • When to come to the hospital on the day of surgery.
  • Where to come first.
  • Where you can park, if you drive.
  • Any rules about visitors in the intensive care unit, or ICU.

If you have questions about your hospital stay, please ask. We want to make sure you and your family feel as comfortable as possible.

Stage 1

The surgery in Stage 1 takes two to three hours. You stay overnight in the hospital. Then, you can usually go back home and recover until it is time for Stage 2.

During surgery

You have general anesthesia, so you are asleep and not aware of anything during your DBS surgery. Your surgeon will shave some hair from the top of your head for the surgery. Your hair will grow back.

The team positions your head in a secure frame connected to a CT scanner, and the scanner takes images. Your team matches these images with the high-resolution MRI images taken with OHSU’s 3-Tesla scanner before surgery. Fusing these scans gives your neurosurgeon the most accurate information possible.

Next, your surgeon makes a small incision in your head and places the DBS electrode in your brain, using the high-resolution MRI scans as a guide. Some DBS systems have one electrode and some have two. The electrodes are usually placed in the thalamus, the subthalamic nucleus or the globus pallidus areas of the brain.

After your surgeon puts the electrodes in place, your team takes another CT scan. This helps make sure the electrodes are placed correctly. Your surgeon can adjust the electrodes, if needed. Finally, your team places the extension wire to one side of the head, under the skin. This keeps it ready to attach to the IPG in Stage 2.

After surgery, you go to OHSU’s Neurointensive care unit. You will stay one night in our ICU.

When you go home or back to your hotel, we give you instructions on taking care of the surgery area. We also tell you how to avoid activities that could cause problems after surgery.

Stage 2

The surgery in Stage 2 takes about 45 minutes for each electrode. Your neurosurgeon does it in the OHSU Day Surgery clinic. You will go home the same day.

Your surgeon places the internal pulse generator, also called the stimulator or IPG, under the skin of the chest. It usually goes just below the collarbone. Immediately after surgery, the battery is turned on at a low voltage but will not be programmed until you see your neurologist.

What are the risks of DBS?

DBS is quite safe and effective. But it has some risks, like all surgeries. The risks of DBS include:

  • Infection
  • Bleeding in the brain
  • Stroke
  • Part of the DBS system breaking
  • The implanted pulse generator, also called the stimulator or IPG, not working

Your OHSU team will explain the risks to you, and talk about any specific concerns you might have. If you have questions or do not understand anything, please ask your DBS team.

What are the benefits of DBS?

  • DBS can improve your quality of life by improving your motor function.
  • DBS works 24 hours a day, so you depend less on medication to control your symptoms. But you can still take medication if it helps.
  • DBS is reversible. Your DBS team can turn off the implanted pulse generator, also called the stimulator or IPG. This means you can try other treatments if they are available.
  • DBS is adjustable. Your team can change the settings to make it more effective and reduce any side effects you have.
  • DBS is renewable.  The batteries last three to five years, and your DBS team can replace them.
  • DBS is usually done on both sides of the brain but can be done on one side based on the patient need.

A DBS evaluation at OHSU means you receive a complete movement disorder evaluation by an internationally known team of specialists. Dr. Kim Burchiel pioneered DBS in the United States 25 years ago. Our multidisciplinary team members include neurologists who specialize in movement disorders, neurosurgeons, a neuropsychologist, and physical and speech therapists.

For Parkinson’s

If medication is not controlling your Parkinson’s well, or your medications cause severe side effects, DBS may help motor symptoms such as action tremor and bradykinesia. Learn more about choosing DBS for Parkinson’s.  

For essential tremor

If your medication is not controlling your essential tremor well, or your medications cause severe side effects, DBS might help. Learn more about choosing DBS for essential tremor.

Having surgery safely

Your DBS team will give you and your family detailed instructions before surgery. This includes things to do and avoid so surgery is as safe as possible.

For your safety, it is important to let your care team know about all your medications and medical conditions. Do not go off of your medication without speaking with your primary care provider or cardiologist. Certain medications, like those below, will need to be stopped 1-3 weeks before surgery. 

  • Warfarin (brand name, Coumadin)
  • Plavix
  • Ibuprofen (one brand name is Motrin)
  • Indomethacin (brand name, Indocin)
  • Naproxen (brand names include Naprosyn and Aleve)
  • Ketoprofen (Orudis)
  • Celecoxib (brand name, Celebrex)
  • Aspirin, and any medications that contain aspirin

Tylenol and other medications with acetaminophen are safe to take before surgery.

Talk to your primary care provider or cardiologist about clearance to stop taking Coumadin, Plavix, or other blood thinning medication. 

 

Next: Choosing DBS for Parkinson's disease or essential tremor