Scott Webb (Host): It's no surprise that medical treatments have advanced over the last 100 or even 50 years. It's incredible what we're able to accomplish now. We're here today with Dr. Ryder Gwinn and Idil Baysal from EvergreenHealth Neurosurgery, part of the Eastside Neuroscience Institute, to discuss an advanced neurosurgical procedure called deep brain stimulation or DBS.

Hello and welcome to Check-Up Chat with EvergreenHealth. I'm Scott Webb. It's great to have you both here. Dr. Gwinn, I can't wait to have this conversation. I've been looking forward to this one. Tell us briefly, if you can, what deep brain stimulation is and how it works.

Dr. Ryder Gwinn: Deep brain simulation or DBS has been around for about 20 years now. And basically, it's a medical therapy that takes advantage of some properties of the brain. Typically, the brain operates on both chemicals and electrical signals. And historically, we've used drugs which have affected the chemical side of the brain. But now, we have the opportunity to interact on an electrical basis with the brain.

And so, what our goal is, is to find sort of dysfunctional networks within the brain and try to inactivate them on a reversible basis using stimulation. And it's a therapy that has three parts. There's an electrode that goes into the brain to that network that we think is not working well. And then, we hook that to another wire that basically carries down through the neck to a battery. And that's the third part that's placed underneath the skin, below the clavicle typically in the same place that a pacemaker might sit.

Host: Well, it's very cool. I've spoken with you before, and it always sounds a bit like science fiction, but it's actually happening. It's real. And Idil, who's a good candidate for deep brain stimulation and what conditions can it treat?

Idil Baysal: It treats a variety of disorders from Parkinson's to essential tremor, dystonia, depression, OCD, epilepsy. At EvergreenHealth, we implant it mostly for essential tremor and Parkinson's disease. In terms of candidacy, both for PD and ET, we want patients to have trialed a variety of medications and either failed them or didn't get as much improvement in their symptoms as they need. So for ET, for example, at the very least, we want them to have tried propranolol and primidone. If they've tried other treatments like topiramate, gabapentin, that's even better. But we definitely want them to have tried and not gotten sufficient relief or any relief from those medications before we start talking about surgery. We also want to make sure that the degree of tremor is actually impacting patients' quality of life and their activities of daily living.

In terms of candidacy for DBS, for Parkinson's disease, it's a little bit more involved. We still want them to have trialed a variety of medications with minimal or no relief, but there are two other factors that come into play. One is something called off/on testing. So, this is when patients come into the clinic having been off their Parkinson's meds for about 12 hours. I'll test them, give them a score, they'll take their meds. And then, I'll do the same exact thing about an hour later. And then, we're looking for a 30% improvement in their motor symptoms.

The second component is neuropsych testing, so that's half a day to a full day of testing where patients are given various tests, looking at their perceptual reasoning, executive function, their functioning from an emotional perspective. And then, the neuropsychologist will give us the okay and say, "Hey, this patient's a good candidate," or we might want to wait a little bit longer and retest them in a year or, "No, we don't think this candidate will do well with DBS, period." So, the neuropsych testing can assist in the assessment of risk of poor surgical outcomes for a patient post DBS. And we want to make sure that a patient is cognitively intact and there's little to minimal risk of someone having any adverse effects from the surgery.

Host: Sure. Limit the risks, makes sense. Dr. Gwinn, I want to have you, if you can, in this audio format, maybe explain how the procedure to implant the device works.

Dr. Ryder Gwinn: Sure. Yeah. Well, I think the first thing to remember is that this has been around for a long time. We have a team of experts that is very experienced in doing this and we give a lot of education and a lot of thought and planning into doing it. And people tend to be very kind of anxious about the idea of brain surgery, but we really try to make it as straightforward and easy for them as possible. It really takes place in two different surgeries. So, the first surgery, patient will come into the operating room the first day. And then, we'll put a frame on their head. And they may or may not be awake, depending upon the target that we're choosing for the therapy. If they're asleep, they really won't feel anything. If they're awake, we usually have them asleep for a great portion of it, and only wake them up for the portion where we really need to do the testing. So, that first surgery typically takes about two hours, and then, they go to the intensive care overnight, and then go home the next day.

For the second surgery, we bring them into the hospital again, to the operating room. It's about a 45-minute surgery. They're always asleep for this surgery, and that's where we place this secondary wire called the extension wire, and the battery as well. And then, it's all hooked up and ready to go. And then, typically, we wait another three weeks after that before programming starts.

Host: Yeah. So, it's definitely a process. And yeah, I see what you mean. Not everybody would be, you know, immediately open to the idea of brain surgery. But as you say, it's pretty straightforward. You've been doing it for a while. It's proven to be effective and safe, of course. Idil, I want to find out, and I'm sure patients or prospective patients would have this question, what can they expect afterwards, after the procedure?

Idil Baysal: In terms of post-op recovery, since DBS is a two-part surgery, there are technically two post-operative periods. So, patients will have some weightlifting restrictions in place, because we don't want to increase their intracranial pressure after the lead placement. They can expect to change their pillow sheets and towels every day for about a week to minimize risk of infection. In terms of pain management, they're given some narcotic medication post-op. But usually, patients take Tylenol for pain at home and they're totally fine. They're instructed not to submerge their incisions in water for about six weeks, but showering is okay 48 hours later. So, these are all pretty routine recommendations that we make to every patient and go over at their pre-op visit.

With regards to the programming, as Dr. Gwinn said, it's turned on about three to four weeks after the lead placement. So, sometimes patients can get a little bit of a honeymoon effect or a micro-lesion effect post lead placement because of the swelling in the brain, but they're not getting any active stimulation at that time. And then, every programmer spaces out their programmings a little bit differently, but I like to have three programming appointments set up off the bat, once a week for three weeks by our surgery scheduler. And then, at the third programming, I might say, "Hey, you're doing great. Let's see you back in maybe three weeks or a month." For other people, it might be a little bit sooner, but we start kind of spacing things out depending on how the patient's responding to the therapy after the third programming. So because DBS is an adjustable therapy, there's never really an endpoint for patients who come in for programming. We might go to an as-needed basis for some patients once their settings are optimized. But generally, even for my patients who are doing really well, I want to see them at the very least every six months or so.

Host: Sure. And I'm sure they like seeing you as well, right?

Idil Baysal: I would hope so. Yeah.

Scott Webb: Of course. Well, this has been really educational. I said before we got rolling here that I'm just really excited to talk about this. I love medicine and science and DBS, just sort of mind blowing in a way. Dr. Gwinn, just give you a chance here at the end. Any final thoughts, takeaways when you think about DBS and who it's helping and how it's helping them? What would you like folks to know?

Dr. Ryder Gwinn: Sure. Yeah. Well, I think when you look back at heart pacemakers, they've been around for decades now, and nobody really asks questions about their safety or their effectiveness. I think we all know people that have had one. And we appreciate that ability to help their lives. I think right now we're actually in the same place with deep brain stimulation that we were with these cardiac pacemakers many years ago. These devices are very safe. They're very reliable. We have teams of experts that have tons of experience to do these things. And, you know, I really love it. It's fascinating. It's always evolving. And I liken it to kind of putting a toolbox in that's very flexible and we can change the settings. We can adapt to help take care of their symptoms as they change over time. And, Almost everybody that has gone through it says afterwards that it was much easier than they thought and that they just have a tremendous improvement in their quality of life. And I think that's the most important thing to focus on as you're kind of entering this process and thinking about it.

Host: Yeah, that's perfect. You used the word fascinating. And I'm like, "Yeah, that covers it for sure." So, I just want to thank you both for your time today. Thanks for educating us and explaining all this, explaining DBS. And you both stay well.

Idil Baysal: Thanks, Scott.

Dr. Ryder Gwinn: Yeah. Thank you very much, Scott.

Scott Webb: EvergreenHealth Neurological Services offer diagnosis, treatment, therapies, and rehabilitative services. To schedule your appointment, please visit evergreenhealth.com/neuro-care. I'm Scott Webb. And please remember to subscribe, rate, and review this podcast and all the other EvergreenHealth podcasts. For more health tips and updates, follow us on your social channels.