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Parkinson’s Brain Surgery Is Safer Than a Knee Replacement? Neurosurgeon Explains · Tremor & Parkinson's Surgery Explained with Dr. Wu

• 0:00
  SPEAKER_00: If I asked you what you thought was safer, a knee replacement or deep brain stimulation surgery, I think most of you would say the knee replacement.
• 0:08
  SPEAKER_00: It seems obvious, right?
• 0:09
  SPEAKER_00: It's just a surgery on your knee.
• 0:11
  SPEAKER_00: Most of us probably know someone who's had one, or at least it's something that almost everybody has heard about.
• 0:15
  SPEAKER_00: The other one, on the other hand, is brain surgery.
• 0:18
  SPEAKER_00: But as someone who performs DBS surgery routinely, my perception is very different.
• 0:22
  SPEAKER_00: And whenever there is such a stark difference in opinions, my reaction is to look carefully into the data and search for the truth.
• 0:28
  SPEAKER_00: So with the help of my research team, we compared deep brain stimulation with some of the most common elective surgeries in the country.
• 0:34
  SPEAKER_00: And since I'm making this video, you can already guess that the results were probably not what most people would expect.
• 0:39
  SPEAKER_00: I'm Dr.
• 0:40
  SPEAKER_00: Chunyan Wu.
• 0:40
  SPEAKER_00: I'm a neurosurgeon specializing in deep brain stimulation or DBS, a treatment that uses thin electrodes placed into very specific areas of the brain to help control symptoms of Parkinson's disease or a central tremor.
• 0:51
  SPEAKER_00: And what I want to talk about today is how safe DBS actually is and why the operation that we perform today may look very different from the picture you have in your head when you hear the words brain surgery.
• 1:02
  SPEAKER_00: Now, what do we actually find in the study?
• 1:04
  SPEAKER_00: First, let's just look at the numbers.
• 1:06
  SPEAKER_00: We used a national surgical database from the American College of Surgeons.
• 1:10
  SPEAKER_00: We looked at surgeries performed between 2015 and 2021 at hospitals across the United States.
• 1:16
  SPEAKER_00: More than 2.85 million patients were included in the analysis, and 4,749 of them, nearly 5,000 of them, underwent DBS.
• 1:25
  SPEAKER_00: When we compared DBS with the 16 most commonly performed elective surgeries, we saw something pretty amazing.
• 1:31
  SPEAKER_00: Now, obviously, someone having DBS and someone having a knee replacement or another kind of elective surgery are not necessarily the same type of patients.
• 1:39
  SPEAKER_00: Parkinson's is a neurodegenerative disease that comes along with other comorbidities, while someone who might need a knee replacement may otherwise be pretty healthy.
• 1:47
  SPEAKER_00: So we adjusted for those differences before comparing the outcomes.
• 1:51
  SPEAKER_00: And the question we had was pretty simple.
• 1:53
  SPEAKER_00: Within 30 days of surgery, how often did someone have a complication?
• 1:56
  SPEAKER_00: So for DBS, the 30-day complication rate was 1.3% in those nearly 5,000 patients.
• 2:03
  SPEAKER_00: Across the other common elective procedures combined, it was 4.1%.
• 2:07
  SPEAKER_00: And if we compare procedures directly, a knee replacement was found to be three to four times more risky than DBS.
• 2:13
  SPEAKER_00: And a hip replacement was almost five times more risky.
• 2:16
  SPEAKER_00: In fact, the surgeries that had more similar risk profiles were tonsillectomies and hernia repairs.
• 2:22
  SPEAKER_00: In addition to complications, we looked at reoperations, and reoperation was also less common after deep brain stimulation, happening at less than 1% versus just over 1%, 1.3% to be specific in other elective procedures.
• 2:36
  SPEAKER_00: And in the large majority, 98.7% of patients having DBS, they went home and not to a rehab facility right after surgery.
• 2:44
  SPEAKER_00: Now, I don't want you to hear those numbers and conclude that DBS is completely risk-free.
• 2:48
  SPEAKER_00: It isn't.
• 2:49
  SPEAKER_00: And I'll get to the risks in a minute.
• 2:51
  SPEAKER_00: Ultimately, the goal of our study was to reframe the way that we should think about DBS and the risk associated with DBS.
• 2:58
  SPEAKER_00: And these numbers certainly challenge a very common assumption that just because we're operating in the brain doesn't automatically mean that this is one of the most dangerous elective operations you can have.
• 3:08
  SPEAKER_00: And I think that is the important point.
• 3:10
  SPEAKER_00: The words brain surgery sound dangerous, and it's reasonable that they should get your attention.
• 3:14
  SPEAKER_00: But how dangerous something sounds and how often complications actually happen are not necessarily the same thing, and that's what we've learned from this study.
• 3:22
  SPEAKER_00: More importantly, DBS surgery has improved significantly over the past several years.
• 3:26
  SPEAKER_00: That national study included DBS performed at hospitals all over the country.
• 3:30
  SPEAKER_00: So these patients had DBS surgery done in different ways based on the preference and the expertise of the different surgical teams.
• 3:37
  SPEAKER_00: And even with those differences, we see the numbers showing the safety of DBS come through.
• 3:42
  SPEAKER_00: Of course, like any other surgeon, I like to think that the way that I do things is the best way.
• 3:47
  SPEAKER_00: But in this study, not everyone is having surgery the same way I perform it.
• 3:51
  SPEAKER_00: In my practice, my patients are asleep under general anesthesia.
• 3:54
  SPEAKER_00: Before surgery, I use detailed imaging to decide exactly where the electrode needs to go.
• 3:58
  SPEAKER_00: During the surgery, I use a surgical robot to help me follow that planned path with the highest accuracy possible.
• 4:04
  SPEAKER_00: And once the electrode has been implanted, I obtain imaging again to make sure that the electrode is actually where we wanted it before we leave the operating room.
• 4:11
  SPEAKER_00: Because with DBS, the challenge isn't simply getting an electrode into the brain.
• 4:15
  SPEAKER_00: It's getting it into exactly the right place within a millimeter or so.
• 4:19
  SPEAKER_00: That millimeter accuracy matters.
• 4:21
  SPEAKER_00: A small difference in position can change how well stimulation works.
• 4:25
  SPEAKER_00: It can also change how much room we have before stimulation starts causing side effects.
• 4:30
  SPEAKER_00: So I don't want to finish the operation and assume everything is in the right place.
• 4:34
  SPEAKER_00: I want to see it with my own two eyes.
• 4:36
  SPEAKER_00: And there are other things that I've incorporated into the DBS procedure to make this easier for my patients.
• 4:41
  SPEAKER_00: I generally perform the entire implant in a single stage, so one surgery for the entire system to be implanted.
• 4:47
  SPEAKER_00: And from a cosmetic standpoint, I minimize hair shaving so that people generally look like themselves within a week or so after surgery.
• 4:54
  SPEAKER_00: Now, one thing that this study likely reflects is the gradual adoption of this image-guided, image-verified DBS approach, or asleep DBS as you may hear it called.
• 5:03
  SPEAKER_00: Older DBS techniques often involved having patients awake and making several passes into the brain with smaller electrodes to help identify the right target.
• 5:12
  SPEAKER_00: But with modern MR imaging and improved surgical systems like robots, surgeons are able to place the electrodes with you asleep and usually do it in a single pass.
• 5:21
  SPEAKER_00: And that matters for safety because every additional pass into the brain creates another opportunity for bleeding.
• 5:27
  SPEAKER_00: Ultimately, that national study that we did included DBS performed many different ways.
• 5:32
  SPEAKER_00: So I'm not saying that my particular technique is the reason we see low complication rates.
• 5:37
  SPEAKER_00: What I am saying is that the operation performed today can look very different from the operation many people imagine when they hear brain surgery.
• 5:45
  SPEAKER_00: Now, why am I harping on this?
• 5:46
  SPEAKER_00: Why do I think this skewed perception and this idea of brain surgery being so dangerous is so important?
• 5:52
  SPEAKER_00: This is where I think risk perception really starts to affect patients.
• 5:56
  SPEAKER_00: DBS is still significantly underutilized.
• 5:59
  SPEAKER_00: There are many people who could potentially benefit who never even get to the point of even talking with a neurologist or a neurosurgeon about the procedure.
• 6:07
  SPEAKER_00: And one reason, one barrier is certainly fear.
• 6:11
  SPEAKER_00: Years ago, we conducted another study where we asked people with Parkinson's what they thought about DBS before they even met with a surgeon to hear about the procedure.
• 6:19
  SPEAKER_00: More than three out of four thought it was highly invasive.
• 6:22
  SPEAKER_00: Almost half were afraid of being awake during surgery, and more than 60% thought DBS should only be considered as a last resort.
• 6:30
  SPEAKER_00: When we compare this with how DBS is performed today and the risk data from our national study, we see that the actual outcomes data from thousands of DBS procedures doesn't line up with those fears.
• 6:40
  SPEAKER_00: The skewed perception of risk can be paralyzing.
• 6:42
  SPEAKER_00: If you think DBS is something you only consider when everything else has completely failed, you may wait much longer than you should, even to ask the question.
• 6:50
  SPEAKER_00: Now, I want to be balanced, so at the same time, that does not mean everyone with Parkinson's needs surgery.
• 6:56
  SPEAKER_00: They don't.
• 6:57
  SPEAKER_00: The large majority do fine without surgery.
• 6:59
  SPEAKER_00: But if your medication still works and it just doesn't last as long, or your response to those medications is becoming less predictable, or you're spending more of your day dealing with off-time or medication-related side effects, that may actually be the right time at least to ask the question: does DBS belong into conversation?
• 7:17
  SPEAKER_00: Is it something that may benefit me?
• 7:20
  SPEAKER_00: Again, DBS treats the symptoms of Parkinson's disease.
• 7:23
  SPEAKER_00: It does not cure Parkinson's, and it does not stop the disease from progressing over time.
• 7:27
  SPEAKER_00: DBS can control things like tremor, stiffness, slowness, and medication fluctuations for many years.
• 7:33
  SPEAKER_00: But as a neurodegenerative disease, Parkinson's continues to change.
• 7:37
  SPEAKER_00: And symptoms like balance problems, speech problems, and thinking problems are generally much less likely to improve with stimulation.
• 7:44
  SPEAKER_00: So the goal is not to do DBS as early as possible.
• 7:48
  SPEAKER_00: The goal is still to choose the right patient at the right time.
• 7:51
  SPEAKER_00: But if someone never even asks about DBS because the words brain surgery make them assume that procedure is extremely dangerous, then they've already made the decision before they actually know the true risk.
• 8:03
  SPEAKER_00: And that is what I want to change.
• 8:05
  SPEAKER_00: So what are the real risks?
• 8:07
  SPEAKER_00: Now, DBS, just like any other surgery, does have its own risks.
• 8:10
  SPEAKER_00: I don't want to minimize that.
• 8:12
  SPEAKER_00: Anytime we do surgery on the brain or place electrode into the brain, we worry about bleeding.
• 8:17
  SPEAKER_00: Just like any other surgery, the main risks are bleeding and infection.
• 8:21
  SPEAKER_00: And because DBS involves implanted hardware, there can be problems with that hardware over time.
• 8:26
  SPEAKER_00: Then there is another category of side effects that happens after the device is turned on.
• 8:31
  SPEAKER_00: Those come from the stimulation itself.
• 8:33
  SPEAKER_00: Depending on where we stimulate and how the device is programmed, stimulation can sometimes cause some side effects.
• 8:39
  SPEAKER_00: The most common ones people notice are muscle tightness or a sensation of tingling, changes of speech, and less commonly, we can see problems with balance, mood, or thinking.
• 8:49
  SPEAKER_00: But there is an important difference here.
• 8:51
  SPEAKER_00: If the problem is caused by stimulation and not the surgery directly, we can often change the stimulation settings or the programs to lessen that side effect or avoid it altogether.
• 9:02
  SPEAKER_00: That's one reason DBS programming is a process.
• 9:05
  SPEAKER_00: We fine-tune the device over the first several months.
• 9:08
  SPEAKER_00: These stimulation-related effects are different from the surgical complications that we measured in our 30-day study.
• 9:14
  SPEAKER_00: So when I tell you the complication rate was 1.3%, I'm not saying there is only a 1.3% chance related to anything that could ever go wrong with deep brain stimulation.
• 9:25
  SPEAKER_00: That's not what the study measured.
• 9:26
  SPEAKER_00: It measured complications during the first 30 days after the surgery in this particular national database.
• 9:32
  SPEAKER_00: Again, it does not mean that only 1.3% of people will ever have any problem related to DBS.
• 9:38
  SPEAKER_00: And that distinction is important.
• 9:40
  SPEAKER_00: Because if you look across the broader DBS literature, you will find higher complication rates published.
• 9:45
  SPEAKER_00: One review of modern DBS studies reported some type of complication in 17% of patients.
• 9:51
  SPEAKER_00: And at first, 1.3% and 17% sound like completely different stories.
• 9:56
  SPEAKER_00: But when we dive into the details, they really aren't that different.
• 10:00
  SPEAKER_00: They're measuring different things.
• 10:01
  SPEAKER_00: Our national database studies asked what happened in the first 30 days after surgery, while the broader literature follows patients for much longer.
• 10:08
  SPEAKER_00: Some studies follow patients for months, others followed them for years, in some cases four or five years.
• 10:14
  SPEAKER_00: And they looked at a much wider range of problems, things like delayed infection, skin erosion, and hardware problems.
• 10:20
  SPEAKER_00: In addition to the complications that may appear earlier, like neurologic symptoms and surgical complications, these tend to add up over time.
• 10:28
  SPEAKER_00: So I don't want you to hear 1.3% and think DBS is basically risk-free, but I also don't want you to hear 17% and think that means that one out of every six patients has a serious brain complication.
• 10:40
  SPEAKER_00: That isn't what the number actually means either.
• 10:43
  SPEAKER_00: When we count complications, we are combining problems that can be very different in both how serious it is and when it actually happens relative to the surgery.
• 10:51
  SPEAKER_00: A minor hardware problem and bleeding in the brain may both get counted as complications, but obviously they're not the same thing.
• 10:58
  SPEAKER_00: And there's another important point.
• 10:59
  SPEAKER_00: People who have DBS are carefully selected.
• 11:02
  SPEAKER_00: Before surgery, we look at how their Parkinson's responds to medications or their sensual tremor, how well they respond to medication and what type of tremor they have.
• 11:11
  SPEAKER_00: We evaluate memory and thinking, we look at mood, we look at overall health to make sure surgery actually makes sense.
• 11:18
  SPEAKER_00: That screening is part of why the outcomes are so good.
• 11:21
  SPEAKER_00: So this is not a perfect apples to apples comparison between every DBS patient and every patient having another kind of elective surgery.
• 11:28
  SPEAKER_00: So here's the way I think about those numbers.
• 11:31
  SPEAKER_00: Think about driving.
• 11:32
  SPEAKER_00: Driving your car is not risk-free.
• 11:34
  SPEAKER_00: People get into accidents, but we wear seatbelts, we follow traffic laws, we pay attention, and we take precautions to make the risk as small as we reasonably can.
• 11:43
  SPEAKER_00: And in any one year, the chance that you'll have a fender bender or another minor accident where your car actually needs to be repaired is relatively small.
• 11:52
  SPEAKER_00: But most of us still drive every day or at least on a regular basis, year after year.
• 11:57
  SPEAKER_00: Over several years, those small risks that you have every day may add up.
• 12:01
  SPEAKER_00: And eventually the chance that you'll have at least one accident becomes much higher than your risk in any given year.
• 12:08
  SPEAKER_00: That's one way to understand the difference between the low short-term surgical complication rate and the higher complication rate when we follow people with DBS for years.
• 12:16
  SPEAKER_00: The risk right around the time of the operation is relatively low.
• 12:19
  SPEAKER_00: But DBS is something that you live with over time, hopefully for the rest of your life.
• 12:23
  SPEAKER_00: And when we follow people long enough and count everything infection, hardware issues, neurologic problems, in addition to the surgical complications, the cumulative number is naturally higher.
• 12:34
  SPEAKER_00: And that's how you can have a 30-day complication rate as low as 1.3% in one study and a complication rate around 17% across longer-term published studies.
• 12:43
  SPEAKER_00: Those numbers are not necessarily contradictory.
• 12:46
  SPEAKER_00: They're measuring different things and answering different questions.
• 12:49
  SPEAKER_00: I also like this analogy because we don't expect driving to be completely risk-free.
• 12:53
  SPEAKER_00: We take reasonable precautions, we understand that something can still happen, and then we decide whether the benefit of driving is worth accepting that risk.
• 13:02
  SPEAKER_00: That is really how I want patients to think about DBS.
• 13:05
  SPEAKER_00: The risks are real, they deserve respect, but they also need to be understood in proportion.
• 13:10
  SPEAKER_00: The fact that an operation involves the brain shouldn't automatically make the risk feel much larger than it actually is.
• 13:16
  SPEAKER_00: So if you're considering DBS, I don't want you to make the decision based off of thinking brain surgery sounds just too dangerous.
• 13:24
  SPEAKER_00: Because for some people, that perception alone stops the conversation before it even starts.
• 13:30
  SPEAKER_00: Instead, I want you asking, what is my actual surgical risk?
• 13:33
  SPEAKER_00: Which of my symptoms are likely to improve?
• 13:35
  SPEAKER_00: How much are those symptoms actually affecting my day-to-day life?
• 13:39
  SPEAKER_00: And does the potential benefit justify the relatively low risk for me?
• 13:43
  SPEAKER_00: Those are questions we can actually answer because safety is only half of the decision.
• 13:48
  SPEAKER_00: The other half is what can DBS actually do for you?
• 13:51
  SPEAKER_00: For the right patient, DBS can smooth out the ups and downs of medication and symptoms.
• 13:56
  SPEAKER_00: It can give you several more hours of good movement during the day.
• 13:59
  SPEAKER_00: It can reduce dyskines, those extra involuntary movements that can happen with Parkinson's medications.
• 14:05
  SPEAKER_00: And it can often allow us to reduce medication.
• 14:08
  SPEAKER_00: I go through those benefits and just as importantly, what DBS can't do in a separate video.
• 14:13
  SPEAKER_00: Sometimes, after we go through all of this and look at the specifics for any individual, the answer is DBS may not be the right treatment yet.
• 14:21
  SPEAKER_00: Sometimes it may not be the right treatment at all.
• 14:24
  SPEAKER_00: But all too often I meet people who have spent years getting less and less predictable benefit from medication because they thought surgery had to be their absolute last resort.
• 14:33
  SPEAKER_00: And what really gets me is that by the time they have a DBS surgery, many tell me that they wish they had done it sooner.
• 14:39
  SPEAKER_00: And that's really why this research matters.
• 14:41
  SPEAKER_00: My goal is not to convince everyone that DBS is safe enough for them to consider and that everybody should get it.
• 14:47
  SPEAKER_00: My goal is to make sure that fear of the words brain surgery isn't making that decision for you.
• 14:53
  SPEAKER_00: The operation deserves respect, but also deserves to be judged by what it actually is today and what happens to real patients, rather than by how frightening the phrase brain surgery sounds.
• 15:03
  SPEAKER_00: So if you're wondering whether you've reached that point where DBS should even be part of the conversation, watch my video on whether to consider Parkinson's surgery next.
• 15:12
  SPEAKER_00: That's where I walk through the signs that tell us it may be time to get evaluated.
• 15:15
  SPEAKER_00: Until next time, bye.