Impact of Procedural Sedation on the Clinical Outcome of Microelectrode Recording Guided Deep Brain Stimulation in Patients with Parkinson’s Disease

Abstract

Background: Subthalamic nucleus (STN) deep brain stimulation (DBS) has become a routine treatment of advanced Parkinson's disease (PD). DBS surgery is commonly performed under local anesthesia (LA) to obtain reliable microelectrode recordings. However, procedural sedation and/or analgesia (PSA) is often desirable to improve patient comfort. The impact of PSA in addition to LA on outcome is largely unknown. Therefore, we performed an observational study to assess the effect of PSA compared to LA alone during STN DBS surgery on outcome in PD patients. Methods: Seventy PD patients (22 under LA, 48 under LA + PSA) scheduled for STN DBS implantation were included. Dexmedetomidine, clonidine or remifentanil were used for PSA. The primary outcome was the change in Movement Disorders Society Unified Parkinson’s Disease Rating Score III (MDS-UPDRS III) and levodopa equivalent daily dosage (LEDD) between baseline, one month before surgery, and twelve months postoperatively. Secondary outcome measures were motor function during activities of daily living (MDS-UPDRS II), cognitive alterations and surgical adverse events. Postoperative assessment was conducted in “on” stimulation and “on” medication conditions. Results: At twelve months follow-up, UPDRS III and UPDRS II scores in “on” medication conditions were similar between the LA and PSA groups. The two groups showed a similar LEDD reduction and an equivalent decline in executive function measured by the Stroop Color-Word Test, Trail Making Test-B, and verbal fluency. The incidence of perioperative and postoperative adverse events was similar between groups. Conclusion: This study demonstrates that PSA during STN DBS implantation surgery in PD patients was not associated with differences in motor and non-motor outcome after twelve months compared with LA only.

The Role of Microelectrode Recording in Deep Brain Stimulation Surgery for Parkinson’s Disease: A Systematic Review and Meta-Analysis

“…This is very much in keeping with the concept of personalized medicine, including a shared decision-making approach where patients are involved in making the choice for the type of surgical procedure. Nevertheless, several studies show that an MER-guide procedure could be performed safely under procedural sedation and GA, even though anesthetic agents have shown to alter firing patterns of the STN [ 4–6 ]. Importantly, while most of the debate in the literature is about asleep versus awake surgery, an equally relevant question is how the final electrode position is verified.…”

“…Intermediate solutions have also been considered. Specifically, some studies show that MER can be used under GA or procedural sedation [ 4–6 ].…”

Peri‐operative management of patients with Parkinson’s disease

“…Attention to detail in titrating the patient to the right level of sedation is perhaps as important as the actual choice of sedative. Indeed, the choice of sedative drug has not been shown to make a difference in clinical outcomes [34,35].…”

“…Attention to detail in titrating the patient to the right level of sedation is perhaps as important as the actual choice of sedative. Indeed, the choice of sedative drug has not been shown to make a difference in clinical outcomes [34, 35]. Regardless of the sedation technique, patient comfort and safety can be enhanced through careful positioning, keeping the patient warm and reassured, avoiding unnecessary bladder catheterisation and maintaining close communication during the procedure.…”

Choice of anaesthesia in microelectrode recording-guided deep-brain stimulation for Parkinson’s disease (CHAMPION): study protocol for a single-centre, open-label, non-inferiority randomised controlled trial

“…LA and/or CS are preferred, and asleep-awake-asleep (AAA) using dexmedetomidine (DEX) is the most commonly used anaesthetic method among clinical centres due to its obvious benefits. Continuous infusion of DEX has been successfully used for DBS under AAA anaesthesia 16–18. DEX is a highly selective alpha-2-adrenoreceptor agonist, and it produces dose-dependent sedation without respiratory depression 19.…”