New deep brain stimulation service for patients with movement disorders such as Parkinson’s disease
The first deep brain stimulation procedure performed at the San marks the start of a new service providing an advanced treatment option for those living with Parkinson’s disease and other movement disorders.
“Deep brain stimulation (DBS) is a procedure that has been around for several decades and we as a team have performed more than 350 DBS procedures at other sites in Sydney,” said Prof Brian Owler, Neurosurgeon with a special interest in cranial neurosurgical conditions and spinal disorders. “We decided to develop a DBS service at the San because there’s actually quite a large number of patients in the area with Parkinson’s disease.”
What is deep brain stimulation?
DBS is an effective, long-term therapy for the management of Parkinson’s disease and other movement disorders.
Dr Jacqueline McMaster, a Neurosurgeon with a special interest in movement disorders, was part of the surgical team who performed the first DBS procedure at the San. “In movement disorders like Parkinson’s disease, the condition is caused when brain cells don’t talk to each other properly,” said Dr McMaster. “With DBS we’re able to bypass that abnormal activity in the brain and therefore block abnormal movements. Many people, including doctors, aren’t aware that DBS is an option for patients with movement disorders. It is important to bring this to their attention, as it can improve quality of life.”
Dr Natalie Palavra, a Neurologist with a sub-specialty interest in movement disorders, describes DBS: “In this procedure, electrodes are implanted into specific deep-brain structures and then routed to a pacemaker device implanted under the skin (usually in the chest). Electrical impulses stimulate specific areas in the brain, thereby targeting specific patient symptoms. DBS is used for several conditions including Parkinson’s disease, essential tremor, dystonia and Tourette syndrome. It is most commonly used for Parkinson’s disease.”
Why deep brain stimulation may be needed
Symptoms of Parkinson’s disease result from a reduction in the ability of the brain to produce dopamine. “The mainstay of medical treatment for Parkinson’s disease is dopamine replacement therapy. This is usually effective at improving symptoms for many years,” said Dr Palavra. “However over time this therapy becomes less effective and motor fluctuations may emerge, such as stiffness, tremor, freezing or involuntary movements.”
Prof Owler noted that with Parkinson’s, patients may ‘freeze’ – when their medications are not effective – or their medications may have side effects like extra movements called dyskinesia. “They have to take a lot of medications at very strict time points to try and smooth out the effects of the medication and reduce these motor fluctuations. The goal of DBS is to reduce motor fluctuations and medication-resistant tremor – which it achieves in more than 90% of people. DBS provides benefits indefinitely and, although it is not a cure for Parkinson’s disease, it can greatly improve quality of life.”
The main benefit of DBS is improved symptom control. “Many Parkinson’s symptoms respond to DBS, with tremor being one of the most responsive symptoms,” said Dr Palavra. “DBS is an effective long-term treatment for Parkinson’s disease, particularly for those patients who are experiencing significant motor symptom fluctuations. Symptom control becomes more consistent and reliable.”
As a neurosurgeon who does many different types of brain surgery, Prof Owler noted that DBS is probably the procedure patients are the most grateful for – in terms of the outcome. “It’s because of the difference in their quality of life. DBS often allows them to continue to work, and do even basic things people take for granted – like eating in a restaurant, socialising without the fear their Parkinsons’s meds will wear off, or dealing with side effects.”
“For some people it is just a matter of being able to roll over in bed without having to wake up their partner and ask for a push, because their Parkinson’s disease is not allowing them to move. These things can really make a huge difference to patients’ quality of life,” added Prof Owler
Patient selection/eligibility
Not every person with Parkinson’s is suitable for DBS, and not all patients who are eligible for DBS choose to undergo the procedure. Prof Owler said that while DBS is not usually offered to patients over 80 years old, each person is considered on an individual basis. “And some patients remain well controlled on their medication and don’t need DBS.”
Prof Owler said timing of the DBS procedure is important. “You don’t want to do DBS when medications are still being very effective. But when people find medications are starting to lose effectiveness, and particularly struggling with motor fluctuations, that’s the time when they should really be assessed for DBS. You don’t want to do it too late in the process. Unfortunately some people develop Parkinson’s disease at a young age, sometimes in their 40s and 50s. And there is some evidence that those patients may benefit from having DBS at a relatively early stage – rather than waiting until it is really debilitating.”
Dr McMaster said it is important to note that DBS is not just for patients with really severe Parkinson’s. “DBS is not a ‘last resort, end-stage’ type of treatment. These days – particularly with younger patients with Parkinson’s – DBS can make a big difference, as they may still have young families, or they might want to stay working. Part of the reason for doing DBS is because it makes such a big difference to their quality of life. Patients are so happy they can go back to enjoying doing things with their kids or go back to work, or lead a more ‘normal’ life, whereas before they’d been quite restricted because the disease or the medication side effects stop them.”
When a patient is referred for DBS, they undergo a number of investigations and reviews to ensure the procedure is appropriate for that individual. These include consultations with neurologist, neurosurgeon, psychiatrist, movement-disorder nurse and a cognitive assessment. Brain imaging is also arranged, as well as testing to assess levodopa responsiveness (how people respond to their medication).
“GPs and specialists are encouraged to simply refer to the DBS service, and further consultations and investigations will be arranged by the team,” said Dr Palavra.
“There are a lot of neurologists at the San who are very experienced with Parkinson’s and other movement disorders,” added Prof Owler. “We’ve got a skilled DBS team assembled, including the neurosurgeons, nurse navigator and anaesthetist, and we are pleased to offer the deep brain stimulation service at the San.”
To refer to the DBS Service please contact Northern Neuroscience via phone (02) 7228 8333 or email bookings@nnpl.com.au.