Surgery for Parkinson

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Surgery for Parkinsons DiseaseFocus on Deep
Brain Stimulation

• Ramón L Rodríguez, MD
• Director of Clinical Services
• University of Florida
• Movement Disorders Center

ramon.rodriguez_at_neurology.ufl.edu
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Parkinsons Disease

• Progressive neurodegenerative disease
• Affects the substantia nigra, which produces
  dopamine
• As a result, the patient develops the four
  cardinal symptoms of PD
• Resting tremor, slowness, stiffness and balance
  problems

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Parkinsons Disease

• Shows a good response to levodopa (Sinemet)
• Medications help improves the cardinal symptoms
  of the disease
• Patients derive great benefit from the medication
  for a period of 5-7 years

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Parkinsons Disease

• With time, patients may develop motor
  fluctuations or side effects induced by levodopa
• This motor fluctuations may become the most
  disabling aspect of the disease

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Parkinsons Disease

• Wearing off
• Unpredictable off
• Sudden off
• Dose failures
• On-Off fluctuations

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Parkinsons Disease

• Levodopa induced Dyskinesias
• Diphasic Dyskinesias
• Peak dose Dyskinesias
• Levodopa induced Dystonia

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Parkinsons disease

• Development of this symptoms may take the disease
  from a non disabling to a disabling state
• At this stage, medical management may be
  difficult and accompanied by undesirable side
  effects

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Parkinsons Disease

• What can be done at this stage?

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Surgery for Parkinsons Disease

• Pallidotomy
• Thalamotomy
• Subthalamotomy
• Deep Brain Stimualtion DBS

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Terapia Activa
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What is DBS?

• Deep Brain Stimulation
• Device similar to a pacemaker
• Provides an electrical discharge to specific
  brain area
• This stimulation modulates the brain signals that
  causes the symptoms of Parkinsons disease

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Deep Brain Stimulation

• Not a cure for PD
• Does not replaces medications for PD
• Does not alter the mechanism of action of
  medications

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Deep Brain Stimulation

• Improves the cardinal symptoms of Parkinsons
  disease
• Smooth out motor fluctuations
• Increase on time
• Prevents disabling off periods

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Deep Brain Stimulation

• Reversible procedure
• Side effect profile much more benign than
  lesioning procedures
• Can be done bilaterally
• As the disease advances, it can be modified

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Deep Brain Stimulation
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Deep Brain Stimulation
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Deep Brain Stimulation
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Deep Brain Stimulation
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Deep Brain Stimulation
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Microelectrode Recording
Border
10sec
Sagittal Section Through the Thalamus
80ms
STN
10sec
80ms
Border/SN
10sec
80ms
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Microelectrode Mapping
Intraoperative somatosensory evoked responses
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Deep Brain Stimulation
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Deep Brain Stimulation

• Requires patient commitment for programming
• 64,000 different combinations
• Patience from both patient and programmer

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Deep Brain Stimulation

• Battery needs to be replaces every 3-6 years
• Potential Complications
• Infection
• Lead fracture
• Lead Migration
• Skin erosion
• Mood and Behavioral changes

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Deep Brain Stimulation

• DBS is not for every patient
• Proper patient selection is critical for success
• Proper placement of the device is required for
  success

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Who is the best candidate?

• Disabling motor fluctuations
• Significant proportion of day spent in disabling
  off state
• Symptoms improve with levodopa
• Patients suffering from disabling dyskinesias

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Not ideal candidate

• Poor response to levodopa
• Cognitive deficits or dementia
• Hallucinations not related to medications
• Patients diagnosed with Parkinsons plus
  syndromes (MSA, Lewy Body Disease, Corticobasal
  Degeneration, Progressive Supranuclear Palsy)

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Thank You!!!