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Clinical Updates
Program Update: Neurosurgical Movement Disorders Program
download the complete articleWhen to Consider DBS
For many movement disorder patients, medications manage symptoms very effectively. For some, medications work well initially, but their effect can begin to fluctuate over time. For some movement disorders, including essential tremor and dystonia, few effective medical therapies are available.
When medications alone are not effective, DBS can be combined with medical treatment to help control movement disorders. DBS candidates are seen by a neurologist at UCLA to confirm the diagnosis and check medications before a decision is made regarding DBS surgery. Patients whose movement disorders contribute significantly to their disability may be good candidates for DBS.
A Pacemaker for the Brain
Neurological diseases that produce movement disorders — including Parkinson’s disease, essential tremor and dystonia — cause neurons in the brain to fire in abnormal patterns that produce undesired movements, either too much or too little. When medication alone is not effective in controlling movement symptoms, UCLA neurosurgeons can perform deep brain stimulation (DBS) to interrupt the abnormal brain activity, suppress unwanted movement and improve quality of life. The Neurosurgical Movement Disorders Program offers DBS and other treatments to modulate the nervous system. UCLA movement disorders specialists are also actively investigating new indications for existing therapies and developing new treatment technologies.
The DBS Procedure
DBS treatment begins with the placement of one or two electrodes in the brain. The locations are customized for each patient based on imaging studies done in advance of the procedure. For each electrode, a small incision of about 3 cm is made and the electrode is advanced to the desired location using a precise, individualized roadmap for each patient’s brain. An external frame that surrounds the patient’s head helps provide coordinates for the brain structures revealed in imaging studies.
On the day of surgery, imaging is performed in the operating room, eliminating the back and forth transport between the OR and the imaging facility that is required at many other centers.
In addition to standard anatomical imaging, UCLA physicians are using diffusion tractography imaging (also known as fiber tracking), an advanced imaging technique that allows brain function and connectivity to be taken into account along with anatomical structure when determining optimum electrode placement.
Patients are kept awake during most of the electrode placement surgery so the surgeons can test the effects of stimulating the brain through the electrodes. The electrodes are positioned to have the greatest benefit in controlling the movement disorder with the fewest side effects. This part of the surgery can take several hours due to the precision and extensive testing required.
Because of the complexity of a procedure involving electrode placement with functional imaging guidance and patient feedback to brain stimulation, two neurosurgeons often collaborate in the operating room. The neurosurgeons are able to consult on electrode location to help achieve the best possible placement.
About two weeks after electrode placement, the patient returns to have a battery pack implanted into the chest cavity, like a cardiac pacemaker, and connected to the electrodes. At this time, the electrodes are set to stimulate at a low level based on the neurosurgeon’s experience stimulating the patient’s brain during the first stage of the implantation. The patient returns in another two weeks for custom programming. The neurosurgeon carefully tests the stimulation effect and develops an individualized program to control the movement disorder to the fullest possible extent.
For three to six months following the initial programming, patients have regular follow-up visits either with their neurosurgeon or neurologist to continue optimizing the DBS programming. Some patients may benefit from a program of physical rehabilitation to accelerate their postoperative recovery.
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