Mar 31, 2015

What is Deep Brain Stimulation Used For?

Interviewer: Dr. House, how is deep brain stimulation used to make patients' lives better?

Dr. House: Deep brain stimulation is FDA-approved to treat actually several different conditions. So the most common condition statistically is Essential Tremor. That's a very common condition where people have tremors, especially in their hands. It can later go on and affect their voice and their neck, for example, so it's very effective at treating that. Parkinson's disease is actually another common condition. In fact, the largest number of surgeries that we perform is to treat Parkinson's disease. It's really the movements of Parkinson's disease. So, for example, the tremor or the slowness of movement, we call that bradykinesia. It's very good at helping those.

It's very good at helping also with some of the side effects of medication. So there's a symptom called dyskinesia where people get sort of dancing extra movements like you may have seen with Michael J. Fox on the television sometimes. So it's very good at treating that. And then there's another condition called dystonia that has an approval, which is a sort of a cramping, a severe cramping of the muscles where writer's cramp would be sort of the most common thing people might have heard of, but there can be very severe versions of dystonia. So those three are really the most common conditions that we're treating.

How Effective is the DBS Treatment?

Interviewer: And how effective is this treatment?

Dr. House: In general, we don't offer surgery unless we really think there's going to be a profound benefit. So, for example, this should treat tremor better than the medications can. And the hours of a day, for example, that a Parkinson's patient achieves where they're now moving well and they're not limited by dyskinesias or they're not limited by being stuck is generally somewhere around six or seven hours a day of new time with good movement they don't have before. So, so at the end of the day the effects are profound.

Interviewer: And the same for the muscle cramps as well?

Dr. House: Yeah, for the dystonia. So with dystonia, if you actually do the clinical measures of how much better their movements are, that's about a 50% improvement, which doesn't sound that profound, but if you look at secondary measures like quality of life, for example, or improvements in pain, those are even much more dramatic. Some studies show 80 to 90% improvements just in pain associated with dystonia.

Interviewer: Yeah. So most of the time, after people get this, it really does improve their quality of life.

Dr. House: Yeah, getting deep brain stimulation is sort of a long process on purpose. So we, in fact, have folks meet with several different clinicians in different specialties, and then we meet as a group to help determine if it might be a good idea. And, frankly, we only really offer surgery if we expect a profound benefit for a patient.

What is DBS Surgery?

Interviewer: Yeah. Is this a major surgery?

Dr. House: You know, by brain surgery standards, it's actually pretty small, which is good. But, it's still brain surgery and there are still risks to it. So, again, we try to be selective and really choose the patients where this will help them a lot.

Interviewer: Give me a brief idea how this technology works and how you implement it.

Dr. House: So the basic idea with the deep brain stimulation itself is that there's a small electrical wire that's inserted to a deep structure in the brain, typically somewhere called the basal ganglia. And we also implant a part that looks like a pacemaker, essentially a battery in a small computer, and then it's applying electrical stimulation to a small area of the brain.

Now, how it applies that stimulation is prescribed by your doctor, and it's programmed to just stimulate a small area, and basically we're tamping down some abnormal signals that are often present in these areas, and sort of by quieting the storm in certain areas we can allow a more normal motor signal, for example, to come through and allow improvements in movement.

Interviewer: So you mentioned that the process to even determine if this person is a good candidate for it is a lengthy process. About, what, like a month? Couple of months?

Dr. House: Yeah, yeah, that's about right. And so, generally, let's discuss Parkinson's for a second, a patient's going to be treated by a good movement disorders neurologist so that they've tried the optimum medical therapies to see if DBS is really something they even need or if there just may be a simple medication change. They'll also meet with me; they'll meet with one of our physical therapists that will really independently assess their movements, both on and off medications. That's a good predictor of what the stimulation itself might be able to offer. We also have all of our patients meet with our neuropsychologist to make sure that there are not red flags that might indicate, for example, we would cause them memory trouble by inserting the electrodes.

Interviewer: So you try to avoid that.

Dr. House: We try to avoid that.

Interviewer: Yeah, gotcha.

Dr. House: Yeah, yeah. So then patients need to get a very high-quality MRI scan. We have a special protocol we use here so that I can build a three-dimensional model of the brain to actually plan out the surgery well before the day of the surgery itself. So I don't want to overstate it. It's not too lengthy. We do try to coordinate all of these visits, of course, but it's a step-by-step process and that is explicitly on purpose.

Interviewer: Yeah, when you're dealing with my brain, I would like you to be very diligent and go through a lot of steps, I think.

Dr. House: Yeah.

DBS Surgery Recovery

Interviewer: The surgery happens. How long to recover and then how long until you get the benefits?

Dr. House: Yeah. So the placement of the brain stimulator itself, that's a surgery some people have heard of because you're partly awake through part of the operation so that we can test the effectiveness of the electrode. But most people only spend one night in the hospital after that surgery. It's several weeks after that before we actually turn the device on.

As you can imagine, if you get a paper cut, there's a little bit of swelling right around that on your skin, just a couple millimeters in size. The same way when we place an electrode in the brain, there's just a little bit of swelling right around the tip of the electrode, and so turning it on right away just doesn't work as well. We need to let that heal up. So, the whole process is really a few months to get evaluated, have the surgery and then get the device tuned in to work the right way for you.

Interviewer: And then when it's tuned in and working the right way, how long does that battery last before you have to come in and get that replaced?

Dr. House: Yeah, and even here there's a variety, but on average, the batteries last about five years. We do have rechargeable versions and we're involved with a trial of even a newer device that may even have a longer-lasting rechargeable battery.

Interviewer: Does that require another surgery?

Dr. House: To replace the battery?

Interviewer: Yeah.

Dr. House: Yeah, that would, but it's a small outpatient procedure. And there will be a small scar where we place the device so we just go through that same area.

Interviewer: And that is more in the torso area.

Dr. House: I'm sorry, yeah, that's just a little bit under the clavicle, overlying your chest muscles.

Interviewer: So a little bit further away from the brain?

Dr. House: That's just a little bit further, yeah.

Side Effects of Deep Brain Stimulation

Interviewer: Which is a good thing, yeah. And then, after a patient gets this, are there any side effects or anything they should be aware of in making their decision whether this is right or not?

Dr. House: Sure, and obviously we'd go through a detailed visit to discuss all those issues. If you turn this electrical device up high enough, you'll always get side effects. If the electrode is in the right spot in the brain, if you over-stimulate, it will cause side effects. So this where having an expert programmer, having an expert team is necessary. When you turn this device on, the results are very dramatic, typically. And then, sometimes, a few months down the road, you'll try to turn it up a little more, maybe try to turn it up a little more to keep getting it better and better, but what happens is there's always stimulation-induced side effects if you go too high. Too much can be not a good thing.

Interviewer: After you have this device in you, are there things you can't do anymore?

Dr. House: The main one is you just have to be aware that it's there. So for example, MRI scans have to be done in a special way and they can only be done of the brain, otherwise the MRI can actually heat up the wire and cause an injury to the brain. So that's something you have to know about. But the general idea is that we're doing this surgery to allow people to do everything they want to do, so there are not very many restrictions that are placed because of the device itself.

Interviewer: And you've been doing these for about 10 years yourself, huh?

Dr. House: So I was in resident training when deep brain stimulation actually became FDA-approved and the results that it was able to provide were so dramatic that I became very interested in this technology. I did fellowship training at UCSF and now I've been back in practice here about 10 years.

Interviewer: Yeah. And a great team here, that you work with.

Dr. House: We have a wonderful team. We've been working together for a long time. We're a high-volume center at this point. I do this surgery at least once or twice a week.

Interviewer: That's the guy I want doing it, the guy that does it a lot.

Dr. House: Yeah, and it's nice. Obviously we'll have detailed discussions about the risks that are involved with the patients, but we have a well-practiced machine, so everyone working with you, the nurses, the anesthesiologist are all used to us doing these surgeries and we get through it very smoothly.

Interviewer: If somebody wanted more information, what would you recommend?

Dr. House: So feel free just to contact me or contact our office, would be a great place to start. Our information is on the Internet, our email addresses are on there, as well as our clinic phone numbers. And, really, any of those mechanisms would be a great way to start.

For Patients