Maggie McKay (Host): Deep brain stimulation or DBS is a procedure using electricity to treat several movement disorders. It can be a life-changer for patients suffering from things like Parkinson's, OCD and epilepsy just to name a few. In this episode, we'll find out how DBS works, who can benefit from it and what breakthroughs are on the horizon.

My guest today is Dr. Michael Rezak, Medical Director of the Movement Disorders and Deep Brain Stimulation Program at Ascension Illinois. You're listening to “Vital Signs”, The podcast from Ascension Illinois -- I'm your host, Maggie McKay. Dr. Rezak, thank you so much for being here today.

Dr Michael Rezak: My pleasure.

Maggie McKay (Host): Can you please explain what deep brain stimulation is?

Dr Michael Rezak: Well, deep brain stimulation is a procedure that allows us to treat really intractable symptoms of Parkinson's dystonia, OCD and a couple of others, essential tremors as well. And what it entails is implanting electrodes in the exact spot where abnormal signals sort of have a bottleneck. And by doing that, we can stimulate that bottleneck area and we can block the abnormal signals from going forth and we can relieve the symptoms of whatever illness it is. I mean, that's simplification, but it's basically what we do. It's an electrical treatment and there is some hospitalization just overnight for most patients and it can turn around someone's life who really intractable symptoms we can't really help with medications.

Maggie McKay (Host): What are the key factors that determine whether someone's eligible for DBS?

Dr Michael Rezak: Well, first, depending on what illness. Let's say with Parkinson's, we want to make sure they are L-DOPA responsive. That doesn't have to be a good response, but they have to have a response to it. Then, we want to make sure that neuropsychologically, they are stable and intact and we also get a good look at the MRI of the brain and make sure that's good. So I think it's really a situation where patients have a very narrow therapeutic window that we can't help them anymore. Because if we go up on the medicines, patients will have side effects. If we go down just a little bit, then they won't be able to function. So that therapeutic window is so narrow, we really can't help our patients. These are mostly more advanced patients, but sometimes they're not. The tremor of Parkinson's can be very sneaky. It's very hard to treat, and it could be resistant to all the medicines. And so that's the situation where we're going after the tremor and we target a certain area in the brain and we can help people with intractable symptoms, whether it's just tremor or dyskinesias like Michael J. Fox has or other things.

Maggie McKay (Host): What might potentially disqualify a patient from DBS?

Dr Michael Rezak: Well, a disqualification can come from illness, general illness, maybe they're on a blood thinner they can't come off of because they're in atrial fibrillation. They could be very debilitated. Of course, they would not be able to be a candidate for this. And if there's a dementia, even mild, sometimes, mostly we will not want to operate on them because it can make that cognitive problem even worse.

Maggie McKay (Host): Wow. What's recovery like?

Dr Michael Rezak: Recovery, from my point of view, of course, is that it's pretty good. The patients stay in the hospital overnight. They go home. A week or two later, they come into my office and I program the deep brain stimulator to help their symptoms. So it's pretty good. Most patients don't have any post-operative pain or have any disabilities as a result of the surgery.

Maggie McKay (Host): That is amazing. So they're pretty much up and about as normal after a couple of days?

Dr Michael Rezak: They can be up and about even the next day, but there are some restrictions, of course. We don't want them lifting a lot of weights and doing certain things. And driving usually is restricted for a week or so. But otherwise, they can do a lot of things probably that they couldn't do before.

Maggie McKay (Host): How often does a patient have to get it or is it just a one-time procedure?

Dr Michael Rezak: Well, for most people, both sides of the brain have to be implanted. So for many people, it's sort of staged. So we do one side of the brain and get that all programmed and make sure the patient responds. And then about two months later, if needed, we do the second side. It's basically the identical procedure, but without all the preoperative evaluations.

Maggie McKay (Host): And if a patient asks you, "What is the best and worst case scenario after getting the procedure?" What would you tell them?

Dr Michael Rezak: The best outcome is that the patient's symptoms are ameliorated with the stimulation. So if it's tremor or dyskinesias or fine motor movements even, that we accomplish what we went after. The worst scenario could be, of course, we're in the brain, somebody could have a hemorrhage in the brain and then it's sort of a stroke, and we don't like that and/or an infection because we are implanting foreign bodies in the brain and in the chest, that's where the battery is, that can get infected. And then, that can be treated. brain Hemorrhage could be, you know, not treated very well and we have to live with that. But we do everything possible to prevent that. We actually have excellent images of the blood vessels. We make sure that coagulation profile is normal and we even do a special test on the platelets to make sure that they're sticky enough, that reduces the risk of having a bleed.

Maggie McKay (Host): Wow. So it sounds like a pretty good success rate.

Dr Michael Rezak: It is. I think the key to having a good outcome is picking the right patient. That's one thing. if somebody has one of the cousins of Parkinson's, a different illness really, but it's related, the DBS is not going to work. And we have to know that the patient is L-DOPA responsive and things like that, that help us get the right patient into the operating room and reverse their lives.

Another thing that's important is having a real experienced team of doctors that are involved in the deep brain stimulator procedure. Our neurophysiologists who help us do microelectrode recording are very experienced, our neurosurgeons are experienced. And having the right people who know what they're doing of course is a large factor in having a great outcome.

Maggie McKay (Host): So, in the future, what's on the horizon? What does the next generation of DBS look like?

Dr Michael Rezak: Most recent DBS system is out now. And it actually can put the electrodes in the brain. The procedures about the same, but the electrodes that stimulate the brain and block the signals are also able to record from that part of the brain. And there are certain patterns that we see that are associated with parkinsonism and then there are certain electrical patterns that we see that are associated with Michael J. Fox kind of movement, so dyskinesias, and we can analyze that. So if we're using electrode, there's four electrodes that we can pick. If we're using an electrode that is not the one that's maybe showing the abnormal patterns, we move it. We can move which electrode we stimulate. It really makes a big difference. We're listening to cells and stimulating them at the same time.

Next step, I think, what I see on the horizon is using deep brain stimulation for psychiatric illnesses, addictions, those sorts of things, depression, anxiety and other more rare illnesses.

Maggie McKay (Host): I read that it may be used in the future for eating disorders.

Dr Michael Rezak: Yes, actually, it was tried for that. Where it has to be implanted is in a very delicate area of the brain in the hypothalamus. And it's very easy to disrupt other things. So could be in the future, maybe we'll get some smaller leads and electrodes. And I hope that we're able to do that. It was tried once and it was not successful. So the options for us using DBS is endless. A lot of illnesses come from the brain. We may be able to alter the signals, reroute them, change their rhythmicity those kinds of things. So there's a bright future for DBS.

Maggie McKay (Host): That's so encouraging. Anything else you'd like to add in closing?

Dr Michael Rezak: Well, I would say, from my point of view, the thing that really hurts me the most is the fact that so many patients could benefit from DBS, but they're not being referred to centers that perform the DBS and they end up suffering needlessly.

Maggie McKay (Host): Why do you think they're not being referred?

Dr Michael Rezak: Some of the doctors aren't fully aware of this or they're scared to send a patient, because it's surgery, scared because they might have a bad outcome or bleed or something like that. But the incidence of these negative outcomes or difficulties is very, very low. It's like 1% of some of these adverse events that occur. So, patients with other illnesses need to be kept in mind. And you mentioned them like OCD, dystonia, essential tremor, which actually essential tremor is one of the most common movement disorders that there is. And patients who have very difficult to manage essential tremor are easily treated with the deep brain stimulator. In fact, there was a first approval by the FDA in 1997, was for essential tremor and Parkinson's tremor. And it wasn't until 2002-ish that we got approval to just treat Parkinson's disease more fully.

Maggie McKay (Host): Dr. Rezak, thank you so much for sharing your expertise on DBS.

Dr Michael Rezak: Well, thanks for having me. I appreciate it.

Maggie McKay (Host): Dr. Michael Rezak is Medical Director of the Movement Disorders and Deep Brain Stimulation Program at Ascension Illinois. If your patient's tremors are resisting medication, find out if DBS is right for them. You can refer them to Dr. Rezak and the Ascension Illinois team by calling 847-981-3630. I’m Maggie McKay – and this is “Vital Signs,” a podcast from Ascension Illinois.