Transcription:
Deep Brain Stimulation (DBS)

Melanie Cole (Host): This is Melanie Cole sitting in for Deborah Howell, and you're listening to Weekly Dose of Wellness brought to you by MemorialCare Health System. My guest today is Dr. Devin Binder. He's a neurosurgeon at Orange Coast Memorial Medical Center. Welcome to the show, Dr. Binder.

Dr. Devin Binder (Guest): Thank you. It's great to be with you.

Melanie: Tell us a little bit about deep brain stimulation. What is it, exactly?

Dr. Binder: Deep brain stimulation is a treatment that involves the insertion what is called a brain pacemaker. Essentially, an electrode is inserted into a deep part of the brain—hence, deep brain stimulation—and it's navigated to a target with extreme accuracy, and that is able to stimulate that target. It's connected to a wire underneath the skin to a battery in the upper chest. Just like the cardiac pacemaker will change the rhythm of the heart, the deep brain stimulation device changes the rhythm of the brain. It's used in a very careful way by neurosurgeons and neurologists to treat a number of disorders.

Melanie: What would those disorders be, Dr. Binder?

Dr. Binder: Primarily, movement disorders. So there's a group of structures deep in the brain and a structure called the basal ganglia, which we target for the deep brain stimulator electrode placement. The treatment involves essential tremor, Parkinson's disease, and dystonia. These are three distinct movement disorders that have all been shown to benefit from deep brain stimulation.

Melanie: So with deep brain stimulation, what's involved in this procedure, exactly?

Dr. Binder: Patients undergoing deep brain stimulation get a very high resolution MRI scan of the brain much more than a typical MRI in order to delineate the structures very carefully deep in the brain that we're going to be targeting. It's very important that we get within one millimeter of the target or right on the target because even several millimeters off in the brain is like a mile away in terms of function, because the brain is so carefully subdivided into different areas. So we identify the structures on the MRI before surgery, and then on the morning of surgery, the patient is sedated, and they're placed in a head frame. We do this all with the patient's comfort at the utmost. They sit in a beach chair-like posture, and we very sterilely open a small opening, and the electrodes and wires, very thin wires that are sent down towards the target, and we listen to the brain activity, something called electrophysiology or neurophysiology. We listen to the brain activity of different structures so that we can be absolutely sure that we're in the correct place.

Melanie: Who might qualify for this, Dr. Binder, and who might not qualify for this?

Dr. Binder: Excellent question. So, people with these conditions—as I mentioned, essential tremor, dystonia, Parkinson's disease—have severe movement disorders. When the disorder is mild, it generally can be treated with medication so that that patient with mild disease would not be considered a good candidate. However, once the disease gets to a point where medications lose effectiveness or the medications themselves can cause severe side effects, then we have to think about deep brain stimulation, because DBS is able to control the symptoms of the movement disorder without the same side effects as medication.

Melanie: And now, if they are in the process of trying to qualify for this, what might disqualify them for this?

Dr. Binder: General medical health is very important, obviously, when you're going through any surgical procedure where electrodes are implanted. Just like you would with any procedure, the health of the heart and the lungs is very important. Secondly, the person's cognitive status, meaning, how with it are they? Do they have any memory loss? Do they have any other neurological problems? Generally, we try to do this in people who are very able to participate in this form of therapy because it requires a lot of active participation on the part of the patient. So overall, though, there's a great number of people that are excellent candidates who are at that stage of the disease where they haven't had severe degeneration of the brain but they're able to really benefit from DBS controlling the symptoms.

Melanie: How long after they have the procedure will they start to see benefits, and what are the benefits? These are movement disorders that we're speaking of—Parkinson's and the tremors, dystonia, as you've been speaking of. What is the benefit? Is it going to reduce the amount of tremors, the severity of the tremors? What's the benefit to the patient?

Dr. Binder: That's exactly right. In the case of tremor, that's a great example. We are able to control tremor extremely well with DBS, so that particular problem that's true in patients with Parkinson's and also patients with this condition with essential tremor, we're able to control tremor extremely well with DBS much better than with the medication. So one of the most exciting things in my professional life is when I have a patient. During the procedure, we actually wake people up temporarily for about 15 minutes to test the effect of stimulating the electrode in the position that it's in in the operating room and looking at the effect on the tremor. What's remarkable is once you hit the right spot—again, in the right millimeter of tissue—you can find that tremor area, get rid of the tremor immediately in the operating room. At that point, you know that that person is going to have a great outcome in terms of control of the tremor. Most often then, we see benefits really immediately, but then over time, together with medication adjustments in the neurologist's office and deep brain stimulation programming of the battery and voltage, we're able to actually get an excellent control over not only the tremor but other things like stiffness and slowness of movements.

Melanie: What about some other diseases that this might possibly help? Are we looking for it towards maybe even MS or something like Tourette's? Any of these other tremor-like diseases, even headaches? Is there on the horizon some other things that it could be used for?

Dr. Binder: That's really a fantastic question. I really think that there's so much on the horizon. First of all, you mentioned Tourette's syndrome. Tourette's syndrome is a condition where people have tics, which are abnormal, involuntary, often vocal tics, like utterances. These things can also be controlled by deep brain stimulation. There are a number of studies for DBS for Tourette's. You mentioned headache. There's a type of headache called cluster headache, in which studies have shown that actually deep brain stimulation of a different part of the brain can actually control the headache. Most exciting, I think, is studies of depression and studies of obesity that are coming out basically indicating we can impact people with severe depression and obesity with DBS. Furthermore, DBS is already approved by the FDA for obsessive-compulsive disorder, which is really quite remarkable that a target was found in the brain that would help with the OCD patient symptoms.

Melanie: I was actually going to ask you about obsessive-compulsive disorder, because again, that's another one of those things that can originate in the brain. Now, how long does it last? Is this a permanent implantation? Is it something that once it there, it's there?

Binder: That's right. Once it's there, it's there. For example, I had a patient with a whiplash injury. Several months after surgery, and the electrode was pulled from the battery and had to be replaced. That type of thing can happen, but generally, once it's in place under the skin, everything's healed up, a few weeks after surgery, it's in place. It can be adjusted though, externally, in the neurologist's office in terms of the programming. But the studies are actually up to at least 10 years, we have good effects on the symptoms, and that's approximately how long the studies have gone so far. But it appears to be durable for quite some time.

Melanie: Has it changed over the years, this surgery?

Dr. Binder: Yes. The most important advances in surgery in general and DBS in particular are more precise targeting to make sure we're at the right place and—very important—that we don't damage any other areas of the brain; fewer complications; reducing the bleeding rate and reducing the infection rate; and overall, making the device much more reliable. So, over the past decade or so, DBS has really grown in the United States and worldwide. There's been a great attention paid to making this quite a safe procedure.

Melanie: It's really amazing. What about any side effects? Are there any?

Dr. Binder: Yes. With the stimulating the brain, you have to be very cognizant of the fact that you could stimulate unwanted areas. So if you stimulate at too high a voltage or too high an amplitude, you could end up stimulating areas that you don't want to, and patients could have side effects such as tingling or numbness in the arms or legs, or certain other things like effects on the voice, like vocal articulation problems. But that's something that we carefully adjust with the external programmer in the office to try to minimize the side effects and maximize the effects on the tremor.

Melanie: Thank you so much, Dr. Binder. That's amazing information. What an amazing surgery that you do. You're listening to Weekly Dose of Wellness. It's brought to you by MemorialCare Health System. If you want more information about DBS as a treatment option, go to memorialcare.org. You can get more information about this amazing procedure. This is Melanie Cole. Thanks for listening.