Colorado Neurosurgeon Offers New Technique for PD

Monday September 29, 2014

By Electa Draper

The Denver Post - For Parkinson's disease patients struggling to control tremors, stiffness and abnormal movements,  a surgical procedure called deep brain stimulation  has provided relief —  and a new technique, recently available in Colorado, is gaining ground.

It's a very different patient experience.

In traditional DBS, the patient is awake under local anesthesia during most of the four- to eight-hour brain surgery so he or she  can  help guide the surgical team. Diminished tremors indicate the surgeon is finding the  sweet spot in the brain.

In recent  years, surgeons at about a dozen  U.S. surgical facilities  have been relying instead on improved imaging of the brain during  a typically much-shorter operation of two to three hours. And the patient is asleep.

"Brain surgery is a pretty scary thing to have, and brain surgery while you're awake is even scarier," said Dr. David VanSickle of South Denver Neurosurgery on the Littleton Adventist Hospital campus. 

In both asleep and awake versions of  DBS, a surgeon  implants thin insulated wires, or electrodes, through a small opening in the skull into  targeted areas of the  brain. The wires or leads  deliver  electrical signals  that block the abnormal nerve signals responsible for  the  most debilitating motor symptoms of Parkinson's. It's  done  only after   medication is no longer consistently effective or if it is causing serious side effects.

Electrode  extensions  are passed under the skin of the head, neck and shoulder and connected to a battery-operated device, about the size of a stopwatch, called an implantable pulse generator. 

For a young patient such as Katie Strittmatter, diagnosed with Parkinson's five years ago at age 30,  DBS has restored quality to life and motherhood. She chose "asleep DBS."

"It's incredible," said Strittmatter, the wife of Colorado Rockies catching coordinator Mark Strittmatter. "I was taking 38 pills a day. Now I take three. You would not know if you saw me that I have Parkinson's. I have no sign of tremors."

One side effect of the heavy medication she was taking was interference with sleep. The mother of two children, ages 9 and 11,  was exhausted all the time, she said. DBS has restored more normal sleep, but the procedure  wasn't a snap.

"The recovery was harder than I thought," she said. "It took three weeks. It was really painful."

Strittmatter, who weighed in at 98 pounds at the time of her surgery,  said the battery pack in her chest hurt her at first, as did the 60 metal staples in her head.

"It is brain surgery," she said. "It is  a risk. And it doesn't help with the  non-motor symptoms of Parkinson's."

VanSickle, her surgeon, has been performing DBS for seven years — and doing "asleep DBS" for two years using an MRI,  CT scans of the brain   and a robot the size of a soda can that places the electrodes in the brain.

Fewer than 10 percent of Parkinson's patients undergo DBS, VanSickle said, a number he and other  neurosurgeons say could be higher. 

Awake DBS has been used on roughly 100,000 patients since it was developed in France in 1987, according to Medtronic, a leading supplier of DBS devices. Oregon neurosurgeon Kim Burchiel was the first to use DBS in North America as part of a 1991 clinical trial.  The Food and Drug Administration approved it for tremors associated with Parkinson's disease in 2002.

Burchiel, chair of neurological surgery at Oregon Health and Science University,  developed the new technique of asleep DBS, publishing details of the procedure last year. He predicts it  will become the dominant technique in the near future.

VanSickle said using  advanced real-time imaging   allows the surgical team to verify that they have hit specific targets in the brain. That means that electrodes don't have to be moved around to find the sweet spot.

"We're making this a minimally invasive surgery," VanSickle said. "Fewer hours in the brain is better. A smaller hole in the brain is better. Less bleeding is better. Cheaper is better."

Dr. Steven Ojemann, an associate professor of neurosurgery at the University of Colorado School of Medicine, performs both awake and asleep procedures and finds benefits and disadvantages to both. Each patient presents different challenges, he said.

In asleep DBS, Ojemann uses near-real-time MRI to place the electrodes.

"The main drawback is that you don't have the feedback  from the patient. You're relying on anatomical precision," Ojemann said. "We're not at a stage where we can make the contention that asleep surgery is superior."

The  advantages of DBS have the neurosurgery world buzzing that it could one day be  used to treat many conditions, including obsessive-compulsive disorders, obesity, Alzheimer's disease and some forms of depression.

Electa Draper: 303-954-1276, edraper@denverpost.com or twitter.com/electadraper

http://www.denverpost.com/news/ci_26624398/colorado-neurosurgeon-offers-new-technique-parkinsons-disease