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The Most Important Things to Do Before DBS Surgery · Tremor & Parkinson's Surgery Explained with Dr. Wu

• 0:00
  SPEAKER_00: If you're thinking about DBS surgery or already preparing for it, you probably want to know what happens before the operation.
• 0:06
  SPEAKER_00: Which appointments do you need, what testing is involved, which medications might change, and what should you confirm before the surgery day?
• 0:12
  SPEAKER_00: I'm Dr.
• 0:13
  SPEAKER_00: Chun Yan Wu and I'm a neurosurgeon specializing in deep brain stimulation surgeries.
• 0:17
  SPEAKER_00: In this video, I'll walk you through the preparation process I use with my own patients so that you know what to expect before DBS surgery.
• 0:24
  SPEAKER_00: Now, make sure you take your own team's instructions as a priority, especially when it comes to things like medication, fasting, arrival time.
• 0:32
  SPEAKER_00: But I can tell you what we do at our program.
• 0:35
  SPEAKER_00: So that preparation happens in several stages that I'd like to walk you through now.
• 0:39
  SPEAKER_00: Now, once the surgery date is confirmed, the first step is completing the testing that we need to plan the operation and make sure you are medically ready for the surgery itself.
• 0:48
  SPEAKER_00: And so that includes a visit with our hospital's pre-admission testing team.
• 0:52
  SPEAKER_00: They review your medical history, your medications, your heart and lung health, and anything else that could affect anesthesia or the surgery.
• 0:59
  SPEAKER_00: And that evaluation may include a physical exam, blood testing, EKG, and sometimes additional evaluation by cardiology or another specialist.
• 1:08
  SPEAKER_00: But that exact testing depends on your health, your medical history, and the type of anesthesia you will receive.
• 1:14
  SPEAKER_00: So all of this is the way that we measure and ideally reduce the risk before surgery.
• 1:20
  SPEAKER_00: Now let's talk a little bit more about those appointments before surgery, not only with a neurosurgeon like me, but also with your pre-admission testing team.
• 1:28
  SPEAKER_00: So at that appointment, make sure to bring a current list of everything that you take.
• 1:33
  SPEAKER_00: And that includes your prescription medications, over-the-counter medications, vitamins like fish oil or any herbal supplements, diabetes medications, weight loss medications, and particularly important for any surgical procedure, let us know if you're on blood thinners.
• 1:48
  SPEAKER_00: So write down the dose and how often you take each one.
• 1:51
  SPEAKER_00: Do not rely on remembering everything during an appointment because the pre-admission testing team and the surgical team both need accurate lists so that we can give you accurate instructions of how to manage those medications around the time of surgery.
• 2:04
  SPEAKER_00: Now, specific to the DBS procedure, patients with Parkinson's disease and some patients with essential tremor also undergo what we call a neuropsychological evaluation.
• 2:14
  SPEAKER_00: It looks at things like memory, attention, language, problem solving, mood, and judgment.
• 2:20
  SPEAKER_00: But why does that matter?
• 2:22
  SPEAKER_00: Well, DBS ultimately is supposed to make you better.
• 2:25
  SPEAKER_00: We do not want to improve your tremor, stiffness, or medication fluctuations while making something else worse at the same time.
• 2:32
  SPEAKER_00: And unfortunately, we know that Parkinson's disease can affect more than movement.
• 2:37
  SPEAKER_00: It can also affect things like thinking, memory, mood, and behavior.
• 2:41
  SPEAKER_00: So this neuropsychological testing gives us a good baseline and helps us identify potential problems that could increase the risk of things like worsening memory, thinking, or mood after the surgery.
• 2:52
  SPEAKER_00: It can also help us choose the safest and most appropriate target.
• 2:56
  SPEAKER_00: And sometimes it does tell us that surgery may not be the right next step.
• 2:59
  SPEAKER_00: Now, in addition to pre-emission testing and your neuropsychological testing, you'll need a specialized MRI.
• 3:06
  SPEAKER_00: This is not the same as a routine diagnostic MRI.
• 3:09
  SPEAKER_00: A diagnostic MRI that you may have had before ask questions like, is there something in the brain that shouldn't be there, like a tumor or a stroke or another structural problem?
• 3:18
  SPEAKER_00: The MRI that we get for DBS for planning purposes is really just for that.
• 3:23
  SPEAKER_00: It is a high resolution, what we call stereo tactic planning MRI.
• 3:27
  SPEAKER_00: And it's used to determine the exact location, the safest path, and the best way to reach the target with each DBS electrode.
• 3:35
  SPEAKER_00: When it comes to the MRI, we have the option of doing it as we normally would on a diagnostic scan with you awake, or sometimes we do this under anesthesia.
• 3:44
  SPEAKER_00: In fact, the majority of the time in my practice, we do this pre-op planning MRI under anesthesia.
• 3:49
  SPEAKER_00: That scan may take 45 minutes to an hour.
• 3:52
  SPEAKER_00: And during that time, you need to remain extremely still.
• 3:55
  SPEAKER_00: And that can be difficult for anybody, and especially someone with a tremor, with dyskinesias, stiffness, pain, or even if it's just difficult to lay flat for that amount of time.
• 4:05
  SPEAKER_00: Ultimately, if anesthesia will be used, please remember that you will have to treat the MRI a little bit like a surgery.
• 4:11
  SPEAKER_00: What I mean by that is that you'll be receiving anesthesia for the MRI, so you will need to fast or not eat usually the night before the MRI.
• 4:19
  SPEAKER_00: So you'll receive similar instructions about which medications you should or should not take before the MRI and specific arrival instructions.
• 4:27
  SPEAKER_00: Now, when it comes to thinking about what to do with your Parkinson's medications if you're getting DBS for Parkinson's, this is one of the most important parts of preparing for the DBS.
• 4:37
  SPEAKER_00: For the MRI, if you're getting it under aesthesia, as well as for the sleep image guided DBS approach I use, we continue Parkinson's medications.
• 4:46
  SPEAKER_00: I do not ask patients to stop their medications or intentionally arrive with their symptoms at their worst.
• 4:51
  SPEAKER_00: So for my DBS procedures, patients usually take their Parkinson medication even on the morning of surgery with a small sip of water.
• 4:58
  SPEAKER_00: Now, again, this may differ from another surgeon's protocol, so please be sure to follow the instructions from the team performing your surgery.
• 5:05
  SPEAKER_00: Now, the next important medication that we have to think about when we're doing any surgery are blood thinners.
• 5:11
  SPEAKER_00: I do routinely hold blood thinners, and examples include things like aspirin, plavix, cumidin, heparin, lovenox.
• 5:19
  SPEAKER_00: And recently the list has grown to include newer medications like effient, burlinta, agrinox, eloquis, xeralto, perdaxa, and cervesa.
• 5:28
  SPEAKER_00: Now, these medications all increase the risk in bleeding.
• 5:31
  SPEAKER_00: You're probably taking them for something like a stroke or a heart attack or a stent, uh, clots in your lungs.
• 5:39
  SPEAKER_00: So the intent is really to prevent those clots from happening, but they will directly also increase your risk of bleeding with uh surgery like DBS.
• 5:47
  SPEAKER_00: Now, more recently, another type of medication that we have to think about around the time of surgery are GLP1 medications.
• 5:54
  SPEAKER_00: These are things such as osempic, weigovi, rebelsis, manjaro, zepp bound, trulycity, victosa, and sexenda.
• 6:03
  SPEAKER_00: These medications slow down how food leaves the stomach, and that means food may still be present in your stomach after you've followed our typical fasting instructions.
• 6:12
  SPEAKER_00: And under anesthesia, specifically when the breathing tube is placed, this can increase the risk of the stomach contents entering the lungs, and that's called aspiration.
• 6:22
  SPEAKER_00: Because of that concern, the anesthesia team requires these medications to be held before anesthesia.
• 6:27
  SPEAKER_00: Now, the exact timing depends on the medication, but make sure we know that you take one well before both the MRI and the surgery again, because both of those usually require anesthesia.
• 6:37
  SPEAKER_00: Now, to round things out, other medications that we have to think about, some common pain relievers can also affect bleeding, and you may be instructed to stop medications like Motrin, Advil, Aleve, or other similar products known as NZEDs.
• 6:51
  SPEAKER_00: These also affect bleeding, and just to be safe, some vitamins like herbal products, fish oil, and products containing aspirin may also need to be held.
• 7:00
  SPEAKER_00: Talanol is generally okay because it does not affect bleeding.
• 7:03
  SPEAKER_00: Now, in the week leading up to surgery, you should know which medications should I continue, which medications should I stop, when should I stop them, and which medications should I take on the morning of surgery.
• 7:13
  SPEAKER_00: If any part of that plan is unclear, don't be afraid to ask your surgical team.
• 7:17
  SPEAKER_00: We can review the question and see what we can do to clarify the instructions.
• 7:21
  SPEAKER_00: Other than that, there's really not a special formula to being exceptionally well prepared for the surgery.
• 7:26
  SPEAKER_00: You don't need a special exercise program or a special diet before DBS surgery.
• 7:31
  SPEAKER_00: Just continue your normal activities as you are able.
• 7:34
  SPEAKER_00: Stay active, eat normally, and take care of your general health.
• 7:37
  SPEAKER_00: This is not the ideal time to make a drastic change to begin an extreme workout or a restrictive diet.
• 7:43
  SPEAKER_00: The goal is really to arrive in your usual state of health at the time of surgery.
• 7:48
  SPEAKER_00: Now, one thing that should be fairly obvious is that smoking increasing surgical risk, it interferes with wound healing.
• 7:55
  SPEAKER_00: So if you smoke, the sooner you stop, the better.
• 7:58
  SPEAKER_00: And you should certainly check with your surgeon because there are some that would require you to stop smoking around the time of surgery.
• 8:04
  SPEAKER_00: Other than that, make sure you let us know if you become sick before surgery.
• 8:07
  SPEAKER_00: And that includes a fever, cough, respiratory infection, skin infection, open sore, or other meaningful change in your health.
• 8:15
  SPEAKER_00: And that's because DBS involves implanted hardware.
• 8:18
  SPEAKER_00: So preventing infection is particularly important.
• 8:21
  SPEAKER_00: Now, in the spirit of minimizing infection, your surgical team may also give you specific instructions for preparing your skin before surgery.
• 8:29
  SPEAKER_00: Follow these instructions as written.
• 8:30
  SPEAKER_00: Don't add any ointments, lotions, antibiotic creams, or other products unless you are told specifically to use them.
• 8:37
  SPEAKER_00: If the instructions are missing or unclear, again, please check with your surgical team.
• 8:41
  SPEAKER_00: Now, on the day before surgery, the hospital will usually contact you with your arrival time and location.
• 8:47
  SPEAKER_00: Make sure you know exactly where to report.
• 8:49
  SPEAKER_00: Large hospitals may have several buildings, entrances, and different surgical areas.
• 8:53
  SPEAKER_00: So you want to be confident in terms of where you need to show up.
• 8:56
  SPEAKER_00: You'll also receive specific fasting instructions when to stop eating.
• 9:00
  SPEAKER_00: Follow the instructions from our hospital.
• 9:01
  SPEAKER_00: Do not substitute instructions from another hospital or another patient or this video even.
• 9:06
  SPEAKER_00: If you're not having surgery with me or my team, make sure to use the fasting time provided by the hospital.
• 9:12
  SPEAKER_00: Do not substitute the time from this video or from another patient's paperwork.
• 9:16
  SPEAKER_00: The night before surgery, before you go to bed, make sure you confirm your arrival time, your arrival location, your fasting instructions, which medications to take, and who will go to the hospital with you.
• 9:26
  SPEAKER_00: And then in addition to that, make sure that you have your right identification, paperwork, what you need to be able to check in for your surgical procedure.
• 9:34
  SPEAKER_00: So speaking to that specifically, usually you'll need to bring your identification, insurance information, and again your current medication list just to be safe.
• 9:41
  SPEAKER_00: And when you go and report for your surgical procedure, make sure to wear comfortable clothing that is easy to put on and remove.
• 9:48
  SPEAKER_00: Don't put in any hair products in your hair, don't paint your nails.
• 9:52
  SPEAKER_00: There's really no reason to get dressed up for surgery, and these things can actually get in the way.
• 9:56
  SPEAKER_00: Bring any walking aid, glasses, hearing aids, and other devices you regularly use.
• 10:01
  SPEAKER_00: Leave your valuables at home.
• 10:03
  SPEAKER_00: You don't necessarily need to bring those with you.
• 10:04
  SPEAKER_00: On the morning of surgery, again, take only the medications the pre-admission team and your surgical team have approved.
• 10:10
  SPEAKER_00: For Parkinson's medication, that generally means taking them as prescribed as per your regular schedule with a small sip of water.
• 10:16
  SPEAKER_00: Again, do not eat food, do not drink coffee, and do not assume that another drink is allowed unless the hospital specifically approved it.
• 10:24
  SPEAKER_00: When you arrive, the team will review your health, medications, and make sure you haven't eaten too recently and review the surgical plan again with you.
• 10:31
  SPEAKER_00: This is another opportunity to ask questions that you may have forgotten to ask before and confirm anything that remains unclear.
• 10:37
  SPEAKER_00: For the sleep DBS procedure, you'll be placed under general anesthesia before a stereotactic head frame is attached to your head.
• 10:44
  SPEAKER_00: And this frame helps keep your head still and allows the planned electrode to be placed very precisely based on the pre-operative MRI that I talked about earlier.
• 10:54
  SPEAKER_00: In order to do this, a CT scan is done in the operating room and then used to register your anatomy and guide the procedure.
• 11:00
  SPEAKER_00: Once that registration is done, we are able to use the robot to place the electrodes through small openings in the skull, and then imaging is done to confirm and verify the location, making sure that we're exactly where we need to be.
• 11:13
  SPEAKER_00: Ultimately, if we need to adjust and reposition the electrodes so they are in the right place, if they didn't end up in the right place to begin with, the intraoperative imaging is a huge benefit and allows us to do that.
• 11:24
  SPEAKER_00: Once we're happy with where the electrodes are and are confident that they're in the right place in your brain, then we move on to the next parts of the procedure where we place extension wires under the skin, tunneled under the skin in your neck, and then place a battery or implantable pulse generator again under the skin, just under your collarbone.
• 11:41
  SPEAKER_00: Now, an important nuance here, I care about hair.
• 11:45
  SPEAKER_00: I think it's important to a lot of people.
• 11:47
  SPEAKER_00: So the way I do DBS, only a very small amount of hair is removed around the incision sites.
• 11:52
  SPEAKER_00: In my practice, the entire head does not need to be shaved.
• 11:56
  SPEAKER_00: I'll cover the operation, like I said, again in more detail and what happens afterwards in separate videos.
• 12:01
  SPEAKER_00: One other thing I wanted to make sure to cover that you plan for is that you have appropriate transportation both to and from the hospital.
• 12:07
  SPEAKER_00: This is not something you should be going to by yourself.
• 12:10
  SPEAKER_00: Make sure someone drives you to hospital.
• 12:12
  SPEAKER_00: And as you prepare for the surgery, remember, you'll need someone to take you home from the hospital.
• 12:16
  SPEAKER_00: Now, in our practice, a sleep DBS is completed in a single day with the electrodes, the extension wire, and the battery implanted during the same operation.
• 12:24
  SPEAKER_00: And most patients remain in hospital overnight, so one night stay and then go home the following day.
• 12:29
  SPEAKER_00: So make sure you have someone ready to drive you home the day after surgery.
• 12:32
  SPEAKER_00: It is also helpful to have someone available during the first several days at home to help with meals, pets, or any household tasks that require lifting.
• 12:41
  SPEAKER_00: You should also know where your written discharge instructions will be kept and have the surgical office's phone number available just in case.
• 12:48
  SPEAKER_00: So, in all this, hopefully I've helped clarify what you need to do to prepare for your DBS surgery.
• 12:54
  SPEAKER_00: You do not need to learn every technical of DBS before surgery.
• 12:58
  SPEAKER_00: That's my job and what I should be focused on.
• 13:02
  SPEAKER_00: You do not need to arrive with your symptoms intentionally worse.
• 13:05
  SPEAKER_00: You do not need to stop your Parkinson medication to help me find a target.
• 13:08
  SPEAKER_00: You don't need to prepare to stay in the hospital for weeks after the surgery.
• 13:13
  SPEAKER_00: And you do not need to solve complicated instructions by yourself.
• 13:17
  SPEAKER_00: Your job is to do the required testing, give us accurate medical information, follow the medication and fasting plan, and speak up, ask questions if something is unclear.
• 13:26
  SPEAKER_00: Our job is to evaluate you carefully, plan the surgery precisely, and make the process as safe, accurate, and minimally disruptive as possible.
• 13:35
  SPEAKER_00: So hopefully this has helped preparing for DBS surgery become more manageable, especially if you think about it one step at a time.
• 13:42
  SPEAKER_00: And again, stay in communication with your surgical team.
• 13:45
  SPEAKER_00: Now, to see what modern asleep DBS surgery actually looks like and how it differs from the older version of surgery for Parkinson's disease, watch this video next.
• 13:53
  SPEAKER_00: And if you're considering DBS and would like to speak with our team, please feel free to reach out using the email address below.
• 13:59
  SPEAKER_00: Until next time.
• 14:00
  SPEAKER_00: Bye.