Deep Brain Stimulation

The procedure requires specific personnel. Quintessential to the surgery is an experienced neurosurgeon, along with his associated staff. As DBS is currently indicated for mostly neurologic disorders, it is more likely that the referring physician will be a neurologist. However, for indications such as treatment-refractory OCD, a psychiatrist will often fill the role of the referring physician sometimes in discussion with a neurologist. Moreover, the referring physician, along with the neurosurgeon, will discuss the case and identify the structures of pertinence to be stimulated by the implanted device.[2]

Prior to the procedure, the patient will need to be medically cleared to undergo surgery, to ensure that DBS is a safe and appropriate option. Once cleared, the patient will undergo brain-imaging studies to visualize locations for implantation of the electrodes.[16]

Once underway, the surgical team will fit the patient with a special frame to immobilize head movement during the surgery. This frame is called a stereotactic head frame. Surgery is commonly performed under general anesthesia, but local anesthesia is also a viable alternative. Intriguingly, the brain itself does not require anesthetic itself, as it lacks pain receptors. The surgeon then implants a thin wire lead to the structures that were identified pre-surgery. Tiny electrodes at the end of the wire will contact the aforementioned structures. The lead is then connected to a wire which runs just superficially to the skin, which ultimately connects to a pulse generator within the chest wall. Both the neurosurgeon and neurologist will closely monitor brain function throughout the procedure to ensure appropriate electrode placement.  

The subsequent chest wall surgery involves the placement of the pulse generator just under the skin near the clavicle. Unlike the preceding procedure, the chest wall surgery requires general anesthesia. The pulse generator is then connected to a special remote control.[2]

Of equal ambiguity is the side effect profile of deep brain stimulation. Whereas the surgical complications implicated with deep brain stimulation, such as hemorrhage, surgical revision of hardware, and infection, are more apparent and objective, the assessment of psychiatric and neurologic manifestations of adverse effects tend to be more discreet and protean, from patient to patient. This vagueness is multifactorial in origin. Firstly, patients may simply not relay these complaints to their respective physicians. Reciprocally, the physician, in turn, may not ask the appropriate questions in order to elucidate ongoing adverse side effects. It is plausible that even if side effects are reported, they may not be documented if they do not meet some arbitrary threshold level of severity. Moreover, it is sometimes hard to differentiate between pre-existing symptoms and comorbidities from the precipitating side effects of DBS. Furthermore, certain side effects tend to manifest over time and occur with latency. An example of this insidious onset is axial symptoms in Parkinson disease. Lastly, as science further evolves and behavioral derivatives of neurocircuitry are mapped out, it is possible that what was once celebrated as therapeutic gains from DBS treatment, will now be regarded as red flags. For example, whereas the spontaneous onset of initiative in STN-stimulated Parkinson disease patients was once applauded as progress, it is now, unfortunately, considered to be the pathological manifestation of disturbed impulse control.[17] However, current scientific literature demonstrates that deep brain stimulation is relatively safe overall and is associated with only minimal and perhaps negligible side effect profile. Nonetheless, the following includes a list of reported side effects: mild gait or speech disturbances, affective liability, worsened depression, seizure, difficulty concentrating, confusion, and headache.

Deep brain stimulation has the potential for robust application, and has specifically been heralded as offering "a new life for people with Parkinson disease."[16] DBS has already been awarded FDA approval for essential tremor, dystonia, Parkinson disease, and treatment-refractory obsessive-compulsive disease. Ongoing studies are investigating the possible off-label use in addiction, autism, anorexia nervosa, anxiety disorders, and schizophrenia.

The literature is abundant, with studies demonstrating the benefits of interprofessional collaboration. Patient outcomes such as decreasing morbidity and mortality rates, optimizing medication dosages, and reducing preventable adverse drug events have been shown to improve via interprofessional collaboration.[18][Level 4] Not only does this benefit the patient, but it also benefits the health care workers, by increasing job satisfaction and reducing extra work.[18] Successful DBS requires integrative, collaborative communication, and care. An interprofessional DBS team should include an experienced surgeon (with expertise in functional neurosurgery), a movement disorder neurologist, psychiatrist, neuropsychologist, and neuropsychologist. The nurse plays an integral role in assisting the patient gain maximum benefit from the surgical intervention. All healthcare workers must be engaged and in sync for the patient to achieve optimal results. 

"This research was supported (in whole or part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities."