Transcription:
What is DBS?

Scott Webb (Host): This is Palmdale Regional Radio. I'm Scott Webb. And today we're discussing deep brain stimulation for Parkinson's patients, which involves the implantation of electrodes into patient's brains to help with motor function and wean them off of traditional Parkinson's medications. And joining me today for a conversation about DBS is neurosurgeon Dr. Tyler Carson. Doctor, thanks so much for your time today. We're talking about deep brain stimulation and we'll probably abbreviate that as DBS along the way here. So what is usually the first line treatment for tremors resulting from movement disorders, such as Parkinson's and for patients that have not seen positive effects for medications?

Tyler Carson, DO (Guest): As you mentioned, a lot of these patients are on medications and what we have to offer now, other than medications, when the medications are no longer effective, or people are starting to get side effects from the medications, is a procedure called deep brain stimulation or DBS

Host: Yeah. And let's talk about that. This sounds a little like something from a science fiction, something out of Star Trek or Star Wars or something like that, but what is DBS and how does it work?

Dr. Carson: DBS, is basically a procedure where we implant an electrode deep inside a patient's brain directed towards specific targets, depending on what symptoms the patient has. And that electrode applies a small electrical impulse, which is controlled by the doctor to help alleviate the patient's symptoms.

Host: Yeah, it's really cool. So we sort of established that medication is the first-line treatment at the moment and DBS is an option. Are there specific symptoms where DBS is, you know, most effective or is indicated if you will?

Dr. Carson: We kind of break up DBS and we try to compartmentalize specific diseases and then symptoms associated with those diseases. So, one disease state that we see and treat with DBS is called essential tremor or familial tremor. And it's essentially a tremor that is typically worse when people are trying to do things like write or, you know, feed themselves, button clothes, which can be very difficult depending on how bad the tremor is.

And for that type of tremor, we'll start them off on medications to see if it helps control the tremor. And if the medications work, then that's great. But, if they're not providing enough effect, or the patient still has severe tremor, then we discuss deep brain stimulation, specifically to treat that tremor.

Now, patients with Parkinson's Disease may have a variety of other symptoms such as tremor, but they also develop symptoms such as slowness of their gait or walking, where they might walk with short shuffling steps. They might develop rigidity of their extremities where they can't move their arms fluidly.

And those types of symptoms can be treated with DBS as well. And for Parkinson's Disease, patients are often started on a specific type of medication called Sinemet or carbilevodopa which is a medication that helps provide dopamine back into the brain, which is what's missing, a neurotransmitter that's missing from the brain in Parkinson's Disease and the medication, levodopa really works well for these patients at the beginning. However, after years of being on the medication, they typically have to start increasing their doses. And the side effects of these medications can cause unwanted symptoms where people have uncontrolled movements of their arms or face.

And that can be, very, unpleasant for the patients. Not just physically, but also in social settings. And DBS can try to treat all of these different symptoms and we can target different areas within the brain, depending on what symptoms the patient is experiencing the most.

Host: Yeah, I see what you mean. And is it an either or situation? So in other words, once a patient has started on DBS, do they continue on the medication or does it take the place of medication or do you adjust the medications as you say, the higher the dosage, the more the side effects. So do you lower the dosage and then they work in conjunction with each other?

Dr. Carson: So a major goal of treatment with DBS for Parkinson's patients specifically is to try to help them reduce their medication. Typically, it doesn't eliminate the need for medication, but it can oftentimes decrease the amount of medication that they need to take. So they still get the beneficial effects of the medication without the side effects.

Host: Oh, that's great to hear that the goal is to get them off the medication. And if the DBS is effective, that could be achieved, which is really amazing, actually. So what are the advantages? And specifically, I want to ask you also, what are the risks.

Dr. Carson: Obviously, this is an invasive procedure where we're implanting an electrode deep into somebody's brain. The major, I would say risk of this procedure, is that when we're passing things into the brain, there's a small risk that bleeding inside the brain could occur. The studies have shown that risk is about 1%.

Typically, if there is bleeding, it's a small amount of bleeding that doesn't require any more intervention other than time for the vessel to heal up. If there's a major bleed, then it could be an issue or the patient might need more procedures done, or it could result in things like a stroke. However, these risks are very, very low and the benefits of DBS far outweigh those risks.

Host: Yeah, it sure seems that they do. And I want to talk a little bit about the evaluation process, maybe what other providers are involved in that process and also patient selection when it comes to DBS.

Dr. Carson: I am the neurosurgeon and I do the implantation of the device. Part of the team that's with me is also a neurologist and in our group, our neurologist is Dr. Saremi. He often identifies the patients that are sent to him for these disease states.

However, I also would evaluate patients myself, who are referred from outside providers. Oftentimes, these patients are cared for by their primary care physician who maybe aren't aware of when or if DBS would be an option for these patients. And in that case, it's best and great if the patients come and see me or Dr. Saremi to get evaluated, to see if they are a candidate for that. So I implant the device once we've identified that the patient would benefit from that both myself and Dr. Saremi. After the device has been implanted, there's a programming stage where the small computer that gets implanted that provides the energy to the stimulation, is programmed using a Bluetooth programmer, basically that communicates with the device and can change the setting, the amount of power, the frequency at which the pulse is generated.

And also turn up, down the amplitude on the device, change the different electrodes that we send power to within the stimulator. And all of that is done with Dr. Saremi typically at about a month and a half after surgery.

Host: You know, I often need to have to remind myself to stretch before I host these, because I'm going to do a lot of head shaking and I'm just listening to you and I'm shaking my head and I'm going, wait, what, what are you even saying? That's amazing. So incredible. And also, you know, with in mind that the goal of getting these patients off medication provided the DBS is effective. And I have so many questions I want to ask you, like, is it both sides of the brain or only one? Tell me more about the lead placement. Like as much detail as you can give listeners.

Dr. Carson: Oftentimes people have the disease that affects both sides of their body. And, as many people may know one side of your brain controls one side of your body. If you're having symptoms on the right side of your body, then that would be the left side of your brain, where we would target, and vice versa for the, right side of your brain.

If you're having symptoms on both sides, then we implant electrodes into both sides of the brain. So two separate electrodes and the process that this goes about, there's a few different ways that it can be done, but I'll explain the way that I do it, which is the patient, once they're identified as a candidate for this undergoes, an MRI of their brain, which is specialized to look very closely with fine detail at the areas where we want to implant the electrodes, the MRI after it's done, I have the patient come and see me in the office and we implant four small screws into the head. Those screws, are through a small opening in the skin. And once those screws are in place, the patient goes back and gets a CT scan of their head. And the CT scan gets combined or merged with the MRI scan using software.

And once those two are merged together, I create a target for the electrode, as well as a trajectory at which I want the electrode to go in to that target. And we build, using a 3D printer, a frame that's specifically for the patient and that frame, when we get to the next part of surgery, will attach to the four screws that are on the patient's head.

So after we have the frame built, the patient comes back about a week after the screws were implanted into their head. And we do the initial implantation of the electrodes into the brain, either one or two electrodes, depending on if we're treating one or both sides of the body. Once those electrodes are implanted, then we will have the patient come back about a week later to have those electrodes connected up to the what's called pulse generator or the battery pack, which is the small computer with a battery in it that provides the power to these electrodes. Now the biggest stage of the surgery I would say is where we have you come in and implant the electrodes. And during that stage of the surgery, the patient's awake for a portion of the surgery so we can test them and see how the electrodes are affecting them so that we make sure that we're not causing any side effects from the electrical impulse that we're providing and that we're treating what we want to treat.

Host: Did you ever imagine doctor, when you were, think back to when you were in medical school, right. And you were studying to become a doctor before residency and all that, did you ever imagine you'd be doing something so cool that were, were you dreaming that big back then?

Dr. Carson: Really this procedure is what made me very interested in becoming a neurosurgeon. It's such a life changing procedure for patients, that they can either get off medications. They don't have the tremor, they can start living life how they remember it years before they had the disease, which is really amazing.

Host: It is, that's the perfect word. That's going to be my takeaway when I step away from the microphone today is just truly amazing. As we wrap up here, doctor, and I literally I could talk to you all afternoon if you had the time, but just want to know about the outcomes for patients. What's life like for them, after the implant, any issues with battery life, you know, just things like that.

When you think about a success story, if you can picture one of those, I'm sure many in your head, what's their quality of life, like after the implantation and you've done your work?

Um,

Dr. Carson: They really start to appreciate the benefit that they get from it, I would say, about two to three months after the surgery has been completed, when they're finally set on the programming, that's helping them the most. And they can think back and at the state that they were in before the surgery, and they're very, very appreciative of how it's changed their lives, allowing them to go out more, do just things that we take for granted with family, and do those without the debilitating disease symptoms that they had before.

Host: Yeah, it's so amazing. And, one of the things I love most about hosting these is learning from experts like yourself, being inspired. But when I hear about the outcomes and improving people's lives, their quality of life, spending more time with family and friends and all of that. So, thank you so much for your time today, doctor you stay well.

Dr. Carson: Thank you very much. You too.

Host: And that concludes another episode of Palmdale Regional Radio with Palmdale Regional Medical Center. Please visit our website at palmdaleregional.com for more information, and to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other Palmdale Regional Medical Center podcasts. For more health tips and updates, follow us on your social channels and please share on your social media and be sure to check out all the other interesting podcasts in our library. Physicians are independent practitioners who are not employees or agents of Palmdale Regional Medical Center. The hospital shall not be liable for actions or treatments provided by physicians.