DBS surgery and postoperative course.
Parkinson’s is caused by a decrease in dopaminergic neurons in the basal ganglia region. As dopamine levels decline, symptoms such as resting tremor, muscle rigidity, and slowed movement appear one after another. To fully understand the role of DBS in the treatment of Parkinson’s disease, one needs to first understand the three stages of Parkinson’s disease, i.e., early, middle, and late stages. Understanding the progression of the disease and the stage you are in will allow you to better understand the pros and cons of DBS.
Early stage of Parkinson’s
In the early stages of Parkinson’s disease, levodopa medications or dopamine agonist medications are effective in relieving motor symptoms during the day, and patients respond well to the medications with few end-of-dose fluctuations. Few patients actually pay attention to what time they need to take their next medication, or must take their medication on time and on schedule. Of course, early Parkinson’s patients can have a good day and a bad day, and its associated with high stress, exertion, other diseases, etc. In the early stages of Parkinson’s, DBS surgery is less recommended when medication control is effective because the surgery itself carries some risk, which may outweigh the benefits of the surgery. Sometimes other motor symptoms are better controlled with medication, but tremor is difficult to control with medication. If DBS can delay disease progression in some ways, or if the benefits of surgery outweigh the risks, then early DBS surgery can be considered, but this theory has not been proven. In conclusion, if you want to perform DBS surgery early in Parkinson’s, please calm down and think, “Are my symptoms really so severe that I must undergo DBS surgery and ignore its surgical risks?”
Tip.
Think about how well you can move and what you can’t do after the medication takes effect. Do your symptoms improve every time you take the medication? Is there a limit to the amount of medication you can take due to side effects? If you can’t tolerate the side effects of the medication, sooner or later you will need to consider DBS surgery.
Mid-stage Parkinson’s
DBS surgery is most helpful for patients with mid-stage Parkinson’s. During this period, the medication can still improve symptoms such as tremor, rigidity, slowing of movement, and postural disturbances, but the duration of maintenance after the medication starts to work is shortening and does not last until the next dose of medication starts to work, and end-of-dose deterioration can occur. In this case, it is necessary to increase the dosage of each dose or increase the number of daily doses. However, as the dose of the drug increases, anomalies may occur. The oscillations can occur at the peak of the drug’s effect or when it wears off. Similarly, dystonia (e.g., muscle twitching, pain) may occur in both cases.
DBS surgery should be considered when the medication is still working, but the efficacy is diminished, or when the dosage is limited by anomalies, etc. DBS electrical stimulation is as effective as medication. In other words, DBS is as effective as anti-Parkinsonian drugs and does not diminish in efficacy. The difference between the two is that DBS is a more gentle control of Parkinson’s symptoms, while potentially reducing the amount of medication, alleviating drug side effects, and reducing isokinetic movements, tremors, and medication costs.
Tip.
Think about your ability to move and what you can do while the medication is taking effect. This is what DBS can do. If the medication does not improve balance problems, gait freezing, speech problems, or fall problems, DBS will not improve these symptoms, and may even worsen them. And tremor and dyskinesia are problems that are likely to be poorly controlled with medication and that DBS may address.
Late stage Parkinson’s
As the disease progresses, patients in the later stages respond poorly to anti-Parkinsonian medications. During this period, neither medication nor DBS may significantly improve fall problems, balance disorders, gait freezing, speech and swallowing disorders. Medication improves these symptoms almost to the extent that DBS improves them.
Patients in the later stages of Parkinson’s may experience depression, a mood that makes them uninterested in doing anything, and movement disorders that get progressively worse. If you have had DBS surgery or expect DBS to help improve advanced symptoms or slow disease progression, it is important to understand the deficiencies of DBS beforehand.
Timeline for post-operative improvement
This timeline is general for most patients, depending on individual diagnosis, severity of symptoms and medications.
DBS will improve motor symptoms, which may lead to a reduction in medication use after surgery. Our clinical experience suggests that DBS may continue to be effective for more than 10 years after surgery and is superior to drug therapy alone. Understanding the following timeline for postoperative improvement can help you have reasonable expectations after postoperative onset. This timeline is a description of what usually happens and is not set in stone.
Postoperative Month 1: With intracerebral electrode implants, stimulation intensity is low for the first month and medications are difficult to taper during this period. xerostomia can also occur with DBS stimulation, but stimulation-induced xerostomia is different from medication-induced xerostomia, which is a good postoperative phenomenon. This is a good phenomenon in the postoperative period. It will gradually improve over a few days or weeks or will be controlled by a slow increase in voltage and a reduction in medication.
Postoperative period 2-3 months: You will feel better in general during this period, you will not be looking forward to your next dose, the oscillations, stiffness and tremor are slowly improving, but this period is still unstable, too high expectations at this time can easily make you depressed, this will require some patience, because your brain is also slowly adapting to the stimulation, and then it can gradually stabilize. By the third month, the tremor may improve accordingly.
Months 4-5: We are gradually finding the most suitable stimulation parameters and the medication dosage may be reduced, at which point you will feel that the choice of surgery was the right decision and you will be able to appreciate its effects. Patients with preoperative dystonia may no longer feel pain at this time, and abnormal posture and tremor may be relieved accordingly.
Month 6: At this point, tremor and stiffness will be greatly improved, symptoms will be relatively stable, off periods will be less frequent, and excessive adjustment of stimulation parameters may not be required for the next six months. After six months to one year postoperatively, there may be no need to adjust parameters too frequently unless the battery needs to be replaced.
Postoperative program control and medications
The first postoperative program should be performed when the symptoms are obvious during the off period, because the drug effect and electrical stimulation will have a cumulative effect, and taking the drug after the program can observe the cumulative effect of the two.
Your response to the stimulation parameters at the time of the drug’s effect can provide some information for parameter adjustment. Although a smaller dose may counteract odd movements, overstimulation, etc., safety is paramount. If there is significant oscillation, symptom fluctuations, balance disturbances, falls or walking problems, come to consider slowly increasing the stimulus intensity to give the brain a buffer time to accept the new parameters. Consider reducing the dosage when the new parameters are stable in their effect and can replace some of the medication used.
Unlike drug-induced dyskinesia, stimulus-induced dyskinesia can usually be gradually relieved, but if dyskinesia is significant, the time for parameter adjustment should be extended to avoid the appearance of damage. Consider reducing the dosage earlier if the agitation is obvious after start-up.
The process of programmed control until the symptoms are relatively stable is similar to a long marathon run and is a smooth, careful process. He needs the programmed physician to make individualized choices for the patient based on his own experience.