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BREAKTHROUGH: Parkinson's Brain Surgery Isn’t What It Used To Be · Tremor & Parkinson's Surgery Explained with Dr. Wu

• 0:00
  SPEAKER_00: Some of you may have heard of deep brain stimulation surgery or DBS, but what picture do you have in your mind when you hear about DBS surgery?
• 0:08
  SPEAKER_00: What do you see?
• 0:09
  SPEAKER_00: Is it someone awake in the operating room, head completely shaved, hours on the operating room table while surgeons test things in real time?
• 0:17
  SPEAKER_00: Well, that's the picture that almost everyone has.
• 0:20
  SPEAKER_00: And that picture isn't completely wrong because for many years it was the only way to do deep brain stimulation surgery.
• 0:28
  SPEAKER_00: Now let's start with the traditional approach to DBS surgery.
• 0:31
  SPEAKER_00: Once you have a better understanding of that process, the newer approach makes much more sense.
• 0:37
  SPEAKER_00: So for years, DBS usually meant that the patient stayed awake, at least for the most important part of the operation.
• 0:44
  SPEAKER_00: And during the surgery, a surgeon would place a very thin recording wire into the brain.
• 0:50
  SPEAKER_00: And here's the part that can sound a little bit backwards, but patients were usually asked to stop their Parkinson's medication the night before surgery, sometimes a little bit longer, depending on the medication and the center that was performing the surgery.
• 1:02
  SPEAKER_00: The goal was to allow tremor, stiffness, or any other Parkinson's symptom to return.
• 1:07
  SPEAKER_00: But why would we want someone to feel worse right before surgery?
• 1:11
  SPEAKER_00: Well, it's because the surgical team and the surgeon and the neurologist needed to see the symptoms clearly.
• 1:17
  SPEAKER_00: So that thin recording wire that would be inserted would pass through the brain and listen to the electrical activity of individual brain cells, individual neurons as it went down to the deeper parts of the brain.
• 1:31
  SPEAKER_00: Now, in addition to those recordings of those single neurons, having the patient awake would allow for direct testing of stimulation.
• 1:39
  SPEAKER_00: So that thin wire will be replaced with a DBS electrode and stimulation would be applied directly to the areas of the brain so that we could get an early sense of what the effects of the stimulation would be.
• 1:51
  SPEAKER_00: So during that time, we might ask the patient to hold out the hand or move the arm or leg, count out loud, answer questions, or describe what they felt.
• 2:02
  SPEAKER_00: And so a neurologist and a neurosurgeon could use all that information, the brain signals, the examination, the response to the stimulation to decide that's the good spot for the electrode, or no, we're getting some side effects, or it's not as effective as we would hope it would be.
• 2:17
  SPEAKER_00: So let's move it a little bit in one direction or another until we get the best outcome possible.
• 2:23
  SPEAKER_00: This process is not guessing.
• 2:25
  SPEAKER_00: It's a highly developed method and it helped thousands of patients and still does today.
• 2:31
  SPEAKER_00: But it requires a very specific setup.
• 2:33
  SPEAKER_00: It requires an anesthesia team that's comfortable with keeping someone awake or lightly sedated for hours and keeping them comfortable during that time.
• 2:42
  SPEAKER_00: It also requires a surgical team experienced in interpreting those brain signals.
• 2:47
  SPEAKER_00: And most importantly, a patient who could tolerate being off their medications with their symptoms at their worst, lying still and participating during brain surgery.
• 2:56
  SPEAKER_00: So what has changed and why are we able to do it differently today versus the way that DBS was invented?
• 3:04
  SPEAKER_00: Today, many centers, including our own and where I practice, we offer a sleep DBS.
• 3:11
  SPEAKER_00: And what that means is patients are under full general anesthesia during the implantation of the DBS system.
• 3:18
  SPEAKER_00: And with the asleep image-guided, image-verified approach that we use, patients can continue taking their Parkinson's medication right up to the morning of surgery.
• 3:28
  SPEAKER_00: So because we're using a different approach to verifying and making sure the wire is in the right location, we don't need to make you look your worst to decide where the electrode belongs.
• 3:39
  SPEAKER_00: So this raises a very obvious question.
• 3:41
  SPEAKER_00: If you're asleep and we're not testing you during surgery, how do we know where to put the electrode?
• 3:47
  SPEAKER_00: Well, we do much of the work before surgery actually begins, days or weeks before the operation.
• 3:52
  SPEAKER_00: So to do this, we get a specialized detailed MRI that allows us to see your individual brain anatomy.
• 4:01
  SPEAKER_00: Now we know the location where we need to put the DBS electrodes.
• 4:06
  SPEAKER_00: Then once you're asleep, we obtain another scan.
• 4:09
  SPEAKER_00: At our center, we use CT imaging in the operating room and we line up that CT scan with your MRI plan that we spent so much time working on before surgery.
• 4:19
  SPEAKER_00: This tells us exactly how your head and brain are positioned in the OR at that moment.
• 4:25
  SPEAKER_00: Now, once we have that plan of where the electrode should go, it's a matter of executing that plan and placing the electrode in the right place.
• 4:33
  SPEAKER_00: Now, to do that, the electrode has to be placed through a small opening in the skull.
• 4:38
  SPEAKER_00: And at our center, that opening is only about three millimeters in diameter, and that's smaller than the end of a pencil eraser.
• 4:45
  SPEAKER_00: Using that opening, we guide it toward the planned target using the coordinates from your imaging.
• 4:49
  SPEAKER_00: But we don't simply place it, close everything, and hope it landed in the right place.
• 4:54
  SPEAKER_00: Before the operation is finished, we actually get another CT scan right there in the operating room so that we can see exactly where the electrode ended up.
• 5:02
  SPEAKER_00: We compare that final position with the position that we planned.
• 5:06
  SPEAKER_00: And sometimes the electrode goes right where we want it, and other times it doesn't follow the exact path that we expected.
• 5:13
  SPEAKER_00: And that's because the brain is living tissue and it can shift and move as we are interacting with it.
• 5:20
  SPEAKER_00: And an electrode can also deviate as it passes through the brain tissue.
• 5:24
  SPEAKER_00: In our experience and in several published series, repositioning is needed only in a small percentage of electrodes.
• 5:31
  SPEAKER_00: And a reasonable estimate of how often this happens is about one out of every 15 or 20 electrodes.
• 5:37
  SPEAKER_00: Although that number can vary among centers and also depends on how strictly each team defines an acceptable position.
• 5:44
  SPEAKER_00: The way I think about this is like a good pair of prescription glasses.
• 5:48
  SPEAKER_00: As a surgeon, my job is to place the DBS electrode in the most optimal position, just like placing glasses directly over your eyes.
• 5:56
  SPEAKER_00: And that's the same with DBS.
• 5:58
  SPEAKER_00: The most important thing that we have to do is place the electrode in the right place and make sure that we are confident it is in that location before we leave the operating room.
• 6:08
  SPEAKER_00: Now, once the brain electrodes are placed and confirmed, one major piece remains is the battery or implantable pulse generator because it's not really just a battery, but it's a combined implant that has a mini computer as well as a battery.
• 6:23
  SPEAKER_00: So you'll hear it called an IPG or implantable pulse generator, or some will just refer it to it as a battery just for simplicity.
• 6:30
  SPEAKER_00: This is a small device, roughly the size of a cardiac pacemaker, that's placed under the skin, just under the collarbone, usually right about here.
• 6:38
  SPEAKER_00: To connect the electrodes in the brain to that battery, a thin extension wire travels under the skin from the head down the side of the neck and connects the brain electrode to that battery in the anterior chest wall.
• 6:51
  SPEAKER_00: Now, I realize this is easy for me to describe, and going through the nuts and bolts of the procedure is something that I do regularly, and I've performed hundreds of these procedures.
• 7:00
  SPEAKER_00: But I also understand that brain surgery can sound daunting and maybe the scariest thing that someone could electively decide to do.
• 7:08
  SPEAKER_00: So let's separate the emotional picture from what the data actually shows.
• 7:12
  SPEAKER_00: First, there's no such thing as risk-free brain surgery.
• 7:16
  SPEAKER_00: In fact, there's no such thing as risk-free surgery or anything that's risk-free in life at all.
• 7:21
  SPEAKER_00: DBS has real risks, and the most concerning surgical risk is bleeding in the brain.
• 7:26
  SPEAKER_00: With the image-guided approach that we use, without the need for multiple passes through the brain, listening to different areas of the brain with microelectrodes, the risk of symptomatic bleeding, meaning the bleeding that caused side effects or symptoms, has been reported around one half of 1%.
• 7:44
  SPEAKER_00: That's about one out of every 200 patients.
• 7:47
  SPEAKER_00: But that number also needs context because if we count all blood seen on postoperate imaging, so bleeding that may happen in you not having any knowledge or side effects or untoward effects from it, then that risk is slightly higher at about 1%.
• 8:02
  SPEAKER_00: Fortunately, most bleeds are small and many do not cause any lasting problem.
• 8:07
  SPEAKER_00: The other major surgical risk is infection, and that's true for any surgery that we do in neurosurgery, outside of neurosurgery, surgery in general carries a risk of infection.
• 8:16
  SPEAKER_00: Because DBS places permanent hardware under the skin, infection rates are generally in the range of 3 to 5%.
• 8:23
  SPEAKER_00: And that's fairly consistent with data on implantable devices, whether you talk about DBS or other devices like pacemakers, uh, prosthetic knee, hip implants, and so forth.
• 8:35
  SPEAKER_00: So this is not a trivial operation.
• 8:37
  SPEAKER_00: Nothing is risk-free, not even crossing the street.
• 8:40
  SPEAKER_00: But the overall short-term complication rate is lower than many people assume when they hear the words brain surgery.
• 8:47
  SPEAKER_00: And I really want to get into that a little bit more because I think what's important is reframing the context of what the risk of DBS is relative to surgeries that we may be more comfortable hearing about.
• 8:58
  SPEAKER_00: So our group looked at national surgical data comparing DBS with other common elective operations.
• 9:04
  SPEAKER_00: And that included procedures that people rarely think of as extraordinary, something like a hip replacement or a knee replacement.
• 9:11
  SPEAKER_00: Now, the overall short-term complication rate for DBS was lower than the rate for hip and knee replacement, and more similar to the risk for a tonsilectomy or appendectomy.
• 9:23
  SPEAKER_00: So this doesn't necessarily mean that a knee replacement is dangerous, and it doesn't mean that DBS is simple.
• 9:30
  SPEAKER_00: These operations involve different patients, different complications, different parts of the body, but the comparison gives us useful perspective because the words of brain surgery carry enormous emotional weight that is really out of proportion with what I think it should be.
• 9:45
  SPEAKER_00: There's a stigma of understanding of brain surgery saying that it's inherently higher risk because it is the brain.
• 9:52
  SPEAKER_00: And the numbers really just don't show that.
• 9:54
  SPEAKER_00: So the risk is not zero, but the picture many people carry in their minds is often much worse than the reality.
• 10:00
  SPEAKER_00: So if DBS is safer than most people imagine, why do people still picture weeks in the hospital bed?
• 10:05
  SPEAKER_00: Well, that's partly because older DBS pathways could be much longer.
• 10:09
  SPEAKER_00: Patients were sometimes admitted a night before surgery while medication was held so that again we saw the worst symptoms.
• 10:16
  SPEAKER_00: The procedure might be divided into two or three operations on different days, and some patients needed to go to inpatient rehabilitation afterwards.
• 10:26
  SPEAKER_00: Now, some centers still staged operation today, depending on the patient and the surgical approach.
• 10:32
  SPEAKER_00: But for a typical patient undergoing uncomplicated DBS today, the hospital stay is usually short.
• 10:38
  SPEAKER_00: At our center, most patients are up and walking shortly after surgery.
• 10:42
  SPEAKER_00: They spend one night in a hospital.
• 10:44
  SPEAKER_00: We make sure their pain is well controlled, that they can eat, feed themselves, walk, go to the bathroom, basic things.
• 10:50
  SPEAKER_00: And then they go home the following morning, usually before lunchtime.
• 10:54
  SPEAKER_00: Going even further than that, some centers have even published protocols for sending carefully selected patients home on the same day, so same-day DBS surgery.
• 11:03
  SPEAKER_00: And this is in fact something that we have done on rare occasions in the right patient.
• 11:07
  SPEAKER_00: But weeks in the hospital are not the usual experience for modern DBS.
• 11:12
  SPEAKER_00: Another thing I wanted to talk about is the cosmesis or the appearance after DBS, because many people imagine that their entire head will be shaved.
• 11:20
  SPEAKER_00: In our center, that is usually not necessary.
• 11:23
  SPEAKER_00: With our approach, we shave only a small area around each incision, really a minimal hair shave to the point where you might not even notice that much hair was shaved at all.
• 11:32
  SPEAKER_00: These are typically two small scalp incisions, about one inch long at the top of the head, one for each electrode for each side of the brain.
• 11:39
  SPEAKER_00: There's usually a third incision on one side of the head that's about half an inch long.
• 11:44
  SPEAKER_00: That's where we need to bring the brain wires and connect them to the extension or neck wires.
• 11:50
  SPEAKER_00: And then the fourth incision is on the chest, just under the collarbone, and is about two inches long in order to be able to fit that implanting propulse generator in a pocket underneath the collarbone.
• 12:01
  SPEAKER_00: Now, after surgery, there may be a little bit of swelling, there may be a little bit of bruising.
• 12:06
  SPEAKER_00: The pain is fairly minimal.
• 12:08
  SPEAKER_00: Usually the incisions at the top of the head are not particularly painful, and the incisions do need time to heal.
• 12:14
  SPEAKER_00: But most patients look more like themselves within a week or two after surgery.
• 12:18
  SPEAKER_00: The scars will continue to fade and the hair grows back.
• 12:21
  SPEAKER_00: Again, it's still surgery, but it doesn't have to look like the dramatic image people have carried for decades of large incisions and shaved heads for DBS surgery.
• 12:30
  SPEAKER_00: So none of this means that every person with Parkinson's should have DBS.
• 12:34
  SPEAKER_00: DBS works best for specific symptoms in carefully selected patients.
• 12:39
  SPEAKER_00: It's generally considered when Parkinson's medications still work but don't work consistently enough, or in patients with a central tremor when medications are not effective and the tremor is affecting your ability to do regular daily activities.
• 12:53
  SPEAKER_00: And this is why the evaluation involves more than meeting a surgeon.
• 12:57
  SPEAKER_00: It usually involves a multidisciplinary team that involves a neuropsychologist or movement disorder neurologist to better understand whether or not you are well suited for DBS.
• 13:10
  SPEAKER_00: Talk to a neurosurgeon, a movement disordered neurologist about being evaluated if you think that it's right for you.
• 13:16
  SPEAKER_00: And remember this seeing a neurosurgeon is not signing up for surgery.
• 13:20
  SPEAKER_00: An evaluation is simply that, a conversation and getting more information.
• 13:25
  SPEAKER_00: It's a chance to learn what DBS might help, what it probably won't help, and whether it makes sense for you.
• 13:31
  SPEAKER_00: Again, referral does not equal surgery.
• 13:33
  SPEAKER_00: It simply means that you're making the decision based on what is true today rather than what brain surgery looked like 30 years ago.
• 13:40
  SPEAKER_00: And once you understand how the surgery is performed, the next question becomes when should someone actually consider it?
• 13:45
  SPEAKER_00: I made another video that walks through the signs I look for when deciding whether someone may be a good DBS candidate.
• 13:50
  SPEAKER_00: And just as importantly, the reasons I sometimes tell patients that they are not ready yet.
• 13:55
  SPEAKER_00: You can watch that next.
• 13:56
  SPEAKER_00: Until next time, bye.