The North American Survey of Placement and Adjustment Strategies for Deep Brain Stimulation

Abstract

Background: Deep brain stimulation (DBS) is gaining wide acceptance as treatment for Parkinson’s disease (PD), essential tremor, and dystonia. Methods: A 40-item questionnaire commissioned by the DBS Study Group was sent to 46 centers that had performed at least 25 DBS implantations. These centers were identified through the DBS Study Group, other professional societies, and with the assistance of the Medtronic Corporation. The results were then tabulated and descriptive analyses were performed. Results: Thirty-six of 47 centers (77%) responded, they had implanted 4,553 patients. The timing for bilaterally implanted patients varied, as 13 sites almost always implanted simultaneously whereas 14 sites almost never implanted simultaneously. Stereotactic frames included Leksell (n = 19), CRW (n = 15) and Compass (n = 2). Post-placement imaging was routinely performed by almost all centers and included MRI (n = 23), CT (n = 4), CT/MRI variably (n = 5), and ventriculography (n = 1). Two centers used more than one electrode per side. The 34 centers that used a single electrode averaged 2.3 ± 1.4 passes per electrode (range: 1–18 passes). Most centers used macro-stimulation to confirm placement by assessing the intra-operative clinical response (n = 34), and to assess for adverse events (n = 26) at high voltages, averaging 6.7 ± 2.3 V (range: 4–10). The initial activation averaged 18 ± 12 days after electrode placement (average range: 11 ± 10 to 28 ± 18 days, absolute range: 1–90 days). Most sites had several programmers; however, the primary programmers were neurology staff (n = 15), the neurologist (n = 13), neurosurgery staff (n = 6), the neurosurgeon (n = 2), or a physiatrist (n = 1). Twelve centers automatically reduced PD medications on the day of initial activation, 9 centers reduced them variably, and 16 centers initially did not reduce them. Eventually, 80.4% of patients were reported to have some dose reduction, and 47.1% had a greater than 50% reduction of PD medications. Conclusions: Strategies regarding DBS placement and adjustment vary in North America.

Analysis of Stereotactic Accuracy in Patients Undergoing Deep Brain Stimulation Using Nexframe and the Leksell Frame

“…This led to the development of the stereotactic frame more than 60 years ago and hence to the introduction of stereotactic surgery in humans [3,4]. To date, the stereotactic frame continues to be the worldwide gold standard for stereotactic procedures, including lesioning and neuromodulation [5]. The frame provides a stable platform and offers a high degree of accuracy [6,7].…”

Neural origin of evoked potentials during thalamic deep brain stimulation

“…Present DBS systems operate in an open-loop fashion, in which patients receive invariant stimulation 24 h/day indefinitely and a physician closes the loop through periodic retuning of stimulation parameters (Kuncel and Grill 2004). The selection of stimulation parameters can be time-consuming and costly (Ondo and Bronte-Stewart 2005), may not result in optimal settings for the patient (Moro et al 2006;Okun et al 2005), and presents a significant clinical burden. The efficacy of therapy can be improved by more frequent parameter adjustment (Frankemolle et al 2010;Lee et al 2010;Moro et al 2006), potentially compensating for progression of the disease state (Deuschl et al 2006;Krack et al 2003;Weaver et al 2012).…”

Health Economics and Surgical Treatment for Parkinson's Disease in a World Perspective: Results from an International Survey

“…Particular attention was given to otherwise unreported, rare but major complications illustrating the actual risk of neurosurgical treatments for movement disorders. Few surveys were published in the last two decades, and those that were are restricted to only specific subgroups of neurosurgeons mainly from North America or to a handful of experts from Europe [4,5,6,7]. …”