ReviewDeep brain stimulation of the subthalamic nucleus in Parkinson's disease: Surgical technique, tips, tricks and complications
Introduction
In 1993, Pollak et al. published their first case of deep brain stimulation (DBS) of the subthalamic nucleus (STN) in a patient with advanced Parkinson's disease (PD) [1]. This clinical activity was based on motivating scientific evidence from animal studies suggesting a dysfunctional neuronal activity in the STN [2], [3]. DBS was considered to counteract this abnormal activity and as result produce therapeutic benefit. In 1995, the same group published their results in three patients, establishing the safety and therapeutic potency of DBS of the STN [4]. Since then, many groups started to perform this procedure, obtained their results and shared their experience [5], [6], [7]. Nowadays, DBS of the STN has become a frequently performed surgery in patients with advanced PD. The technique has been further refined throughout the years by improved imaging techniques, advanced neurophysiological recording possibilities, and advances in hardware and software technology. In addition, the complications, which can be divided into surgery-related, target-related, and hardware-related complications, were better recognised and managed.
The procedure of DBS of the STN starts with a careful patient selection, continues with the inpatient period involving surgery and then the activation of DBS [7], [8]. The next period is the outpatient period involving (further) programming of the therapy and further adjusting the drug therapy. The outpatient period does in principle never end, unless the therapy is stopped, since the patient is followed-up with regular intervals by the multidisciplinary team. In this article, we will mainly deal with the surgical procedure of DBS of the STN. Some centers perform DBS of the globus pallidus internus to treat advanced PD, and data show that it's effectiveness might approach DBS of the STN [9], [10]. However, a detailed discussion of target selection is beyond the scope of this article and can be found elsewhere [10], [11].
In the past years, two main schools have appeared in the surgical technique of DBS of the STN. One school advocating the use of anatomical information to target the STN, and the other one proposing the use of intraoperative microelectrode recordings (MER) in combination with anatomical information [12], [13]. Although the groups using MER acknowledge it's usefulness, strong evidence for it's superiority is lacking [7], [14], [15]. Other developments have been the progress from indirect anterior commissure (AC) – posterior commissure (PC) based targeting to the direct targeting of the STN based on high-field and recently ultra-high-field magnetic resonance imaging (MRI) (Fig. 1), and the possibility of doing the surgery under general anesthesia if indicated [16]. In this article, we document our experience specifically with the surgery of STN DBS in the light of the existing literature. Tips and tricks, complications and their management are important elements of this article. In addition, we provide scientific information from our research and other groups in specific sections.
Section snippets
Preoperative period
The patients with PD who are potentially eligible for DBS of STN are usually referred by neurologists in peripheral hospitals and occassionally by family doctors who treat patients with PD themselves to movement disorders neurologists. The neurologist performs the first evaluation and determines for instance whether there are still reasonable drug-based therapy options. If not, than the patient is considered for DBS. If yes, than a period of optimised drug therapy is introduced and usually
Operative period
The patient is after inclusion hospitalised for surgery on the Neurology ward. The team will speak to the patient and family again on the nature of the procedure, expected outcome at both the short-term and long-term period, and potential complications. A preoperative MRI scan is performed and 1 mm T1 axial images with double-dose gadolinium and 2 mm T2 axial images are obtained. The first target and trajectory planning can be done already before the surgery (Framelink 5, Medtronic, Minneapolis,
Inpatient postoperative period
The early postoperative evaluations of patients with STN DBS can be summarised as the evaluation of three domains. The first is the target-related effects. The degree of therapeutic effects and side-effects of DBS should be assessed. This can be typically done by activating the different contacts with a monopolar setting. For the therapeutic effects, concentrating mainly on the cardinal symptoms of PD is sufficient. Usually a satisfactory effect can be obtained on the cardinal symptoms. For a
Outpatient period
In the outpatient period the patient is mainly followed up by the neurologist in close communication with the multidisciplinary team. There is one standard outpatient visit to the neurosurgeon usually 6–8 weeks after surgery. Then, the patients is seen according to our protocol 3 months after surgery and then each year with routine motor and neurospychological evaluations. In between, the patient can be seen for any other reason.
Complications
Although we have mentioned the potential complications briefly in the sections above, here we will discuss these in more detail.
Conclusion
DBS of the STN has become a routine surgical therapy for patients with the advanced stage of PD. The inclusion and exclusion criteria for surgery are extensively described. Recent evidence suggests that patients at an earlier stage of the disease might also benefit from DBS of the STN [41]. The surgical part of the therapy has been refined during the years and this process is still ongoing. Two main approaches are currently being performed: localising the STN with and without MER. There is no
Acknowledgements
We are greatful to the members of the DBS working group in Maastricht University Hospital and Samsun Ondokuz Mayis University Hospital. The DBS programme in Maastricht has started in 1999 and has been introduced in Samsun at 2011. The authors are grateful to Dr. Visser-Vandewalle for her contributions to the DBS programme in Maastricht University Medical Center.
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