New Frameless DBS Technique Improves Patient Comfort

Deep brain stimulation (DBS) has been a standard treatment for movement disorders and chronic pain for nearly 10 years. But, it has been extremely uncomfortable for patients. Using the conventional stereotactic frame, patients are secured to a table by a halo attached to their head, their vision is blocked, and they are awake and immobile during the procedure. Furthermore, the surgery requires that patients be off their medications
for 12 hours, leaving them rigid or shaking.

Stanford physicians have developed a new frameless DBS technique that makes the procedure more comfortable – removing visual obstructions for patients and providing better access to anesthesiologists managing a patient’s airway during the procedure.

“It’s a lot more comfortable for patients because there is no frame blocking their face,” explains Jaimie Henderson, MD, director of Stereotactic and Functional Neurosurgery at Stanford, “and, patients are free to move and adjust their position throughout the procedure.”

Stanford also has a massage therapist on hand during surgery to work with patients and keep them comfortable, relaxed and able to change their position as needed. The frameless procedure also reduces surgical time. Markers used for navigation are applied to the patient’s skull the day before surgery as opposed to the day of surgery. By eliminating hours of frame placement, imaging, planning, etc. on the day of surgery, doctors lessen the amount of time patients need to spend off their medications.

DBS offers control and predictability
A day in the life of a Parkinson’s patient is unpredictable. They don’t know if they will be frozen and unable to move, or gyrating uncontrollably. As the disease worsens, patients fluctuate between these two states.

With DBS, an electrode implanted in the patient’s brain delivers a continuous electrical impulse that can alleviate these wide symptom fluctuations. It stimulates the brain in a way that medications once did. Deep brain stimulation surgery can help many Parkinson’s patients
regain a sense of control and predictability they lost with their disease. “But it is not a panacea for all patients,” says Henderson.

Comprehensive evaluation improves surgical success
Selecting patients who will respond well to DBS requires comprehensive testing and evaluation. Patients who are referred to the Movement Disorders Clinic at Stanford undergo a full two-day evaluation, one day on their medications and one day off. Stanford also conducts neuropsychological testing on patients to evaluate their cognitive abilities as well. This half-day evaluation has patients perform cognitive tasks that sort out if they have cognitive impairments that might get worse after surgery. Because of the comprehensive evaluation process, Stanford
only recommends surgery for patients who have the best chance of responding well. Typically, patients who undergo DBS surgery at Stanford have a 60 to 80 percent improvement in their
symptoms, and a 50 to 60 percent reduction in their medication use.

“We’re not offering surgery to people for whom the risk is higher than the benefit,” says Henderson. “We’re able to tell the patients with quite a bit of precision what their surgical outcome will be based on our very extensive testing. Our criteria may be more stringent than other centers, but we think that means better results and better outcomes for the patients who do end up having surgery here.”

Criteria for surgical patients
Patients who are ideal candidates for DBS have good medication response, but have developed unacceptable medication side effects and wide fluctuations. Typically, these patients are frozen and rigid when their medicines are not working, and have abnormal, involuntary movements when their medications are working.

Patients who most likely would not be surgical candidates are those who do not respond to medications; those with severe balance, cognitive or speech problems; and those who suffer from conditions that look like Parkinson’s, but aren’t.

In addition to Henderson, Hong Yu, MD, who joined Stanford in July 2009, also has expertise in the frameless DBS technique. She focuses much of her attention on treating dystonia, which is
another type of movement disorder, while Henderson primarily works with Parkinson’s disease, chronic pain and tremor.