The Functional Neurosurgery department in Jaslok Hospital &Research centre is a sophisticated and well-equipped department for Parkinson’ Disease treatment which is being headed by Dr.PareshDoshi, Functional & Stereotactic Neurosurgeon. Patients will consult the Neurosurgeon in the out-patients department. He will select the best candidates for deep brain stimulation with Parkinson’s disease who had responded well to medical therapy early in the course of their disease. After evaluation and the selection of the candidates he will explain the surgical procedures, its risks and benefits and display some video footage to such candidates and their companions.
These candidates have to be instructed that they must not take drugs like aspirin, disprin or coumadinetc 10 days prior to surgery because these drugs can increase the risk of bleeding during the surgery. It is also very important that at the time of admission patient does not have any dental, urinary or other form of infection. If there is any doubt of this, the surgical team should be informed. Hospitalisation of the candidates for DBS surgery will be for around 10 to 12 days. First day of admission a resident doctor will conduct neurological examination on the patient. He will also conduct a study on the history of the patient to rule out if the patient has any medical conditions such as heart disease, Hypertension and diabetes etc. The patients are advised to disclose about any such illness for better evaluation prior to the surgery. Routine investigation such as blood test, ECG, 2D Echo, X-Ray of chest would be carried out on the patient.
Antiparkinson’s medication is stopped around 9pm on the day of admission. This is required for performing standardized testing using the Unified Parkinson’s Disease Rating Scale (UPDRS) and mini-mental state examination score (MMSES) that will provide information such as how the brain of the patient stores and retrieves information and how it functions. After the tests are performed video recording is also done. This is known as OFF phase evaluation. Thereafter the patient is given 1.5 times his usual L-dopa dose and the same tests are repeated. This is ON phase evaluation. Parkinson’s Disease Questionnaire 39 Items (Global QoL) will be given to the patient and Zerith CaretakerBurden Inventory (ZCBI) will be given to caretaker/s of the patients to be filled by them.
Finally, a pre-operative Magnetic Resonance Image (MRI) of the brain, that is the key to the success of this operation, is examined by the neurosurgeon. It serves as a roadmap which can be followed during surgery by the neurosurgeon to ensure proper electrode placement. Parkinson’s disease nurse helps to promote a relaxed and supportive environment.Patients are encouraged to express his/her needs so as ensure greater patient cooperation and comfort during the surgery. She spends considerable time explaining and going over the surgical procedures with the patient and their relatives. Repeated interaction not only boost confidence in the patient but also bring out important observations that are reported to the surgical team to ensure patient safety and smooth conduct of the operative procedure. Care from an established and knowledgeable team of nurses within the ward allows the patients to gain confidence in those who will look after them during the following admission.
Day two evening the pre-op preparation will start with pre-anaesthetic check up by the anaesthesiologist and head shaving, after obtaining consent. Consent form should be signed by the patients and their spouse or close relatives for surgery also. After midnight patient will not have any food and any Parkinson’s medication. At 4 A.M. patient should be provided a banana and a glass of milk or chocolate.
At 6 A.M. the patient should be bathed and kept ready. Once ready, the resident doctor will pay a visit to the ward and indwell urinary catheter in the ward and the patient will be shifted to Operation theatre at around 7.30 A.M. OT staff will begin preparation for the surgery which will include insertion of an IV administration of antibiotics and IV fluids and monitoring of the patient’s vital signs like BP, pulse. Entire surgery takes around 5 to 6 hours on the first day of surgery. The stereotactic frame will be placed. This is a head ring and is attached at 4 points to the patient’s skull under local anaesthesia. An anaesthesiologist will be present for placement of the frame to offer some light sedation, to ensure patient comfort.
The patient will be awake during the operation as the surgery would be done under local anaesthesia. Surgery begins with drilling a hole on the top of the skull. This is a painless procedure as bone and brain, both are insensitive to pain. Following this tiny electrodes are inserted into the brain to obtain the brain map, this is what is known as micro-electrode recordings. Once the sweet spot is identified, a low voltage current is administered to find out the level of improvement that can be achieved and to also check for side effects. This is the stage where patient cooperation is very useful. In patients experiencing tremors, there will be arrest of tremors, patients with pain will report relief from pain and the most important is the loss of stiffness that is observed on stimulating the correct target site. Once adequate confirmation is obtained by the surgical team, permanent DBS lead is implanted under fluoroscopy guidance.
Following surgery, a check CT scan is quickly performed to confirm the position of electrodes and rule out any complications. The patient is than transferred either to the ward or the ICU for observation. Here he is given the dose of his L-dopa and allowed to have his meals. On the next day a pace maker battery will be implanted under general anaesthesia. A few days after the surgery some patients can experience changes in the symptoms. There may also be a micro lesion effect caused by the actual electrode placement in the brain and the reaction of the brain after the placement. In the next stage the IPG battery will be activated and the programming is set to see response of the contact points and theirs side effects. Settings will be done on good contact points and usual Parkinson’s medications doses will be continued. Once optimum stimulation has been achieved the Parkinson’s Nurse will start involving patients and their family members in educating them on how to use the device therapy and handling post-op care at home once the stitches are removed and the dressing done on the 8th day of post-op and patient is declared fit for discharge.
Patient goes home with the dressing and after two days dressing should be removed and healex spray (waterproof spray) should be applied on the line of the suture. While doing this if they observe any bleeding they should visit their local hospital and get the sterile dressing done by a surgeon and inform the same to us. The list of precautions and the instruction manuals of care should be given to the patients and their family members. Provide ongoing support for the patient, relatives and professionals through telephone contact. A discharge summary detail is provided to the patient, including contact numbers. The patient’s follow-up appointment will be after three months. The neurosurgeon will see the patient at out-patients department in two weeks after discharge to review progress. This level of support continues, particularly during the stabilization period of four to six months. The aim is to achieve a comfortable, effective level of stimulation, which controls symptoms adequately, in combination with drug therapy.
Routine follow up will be yearly (or as and when required). Patient can also operate the device independently at home to adjust the current or the voltage according to their requirement.
Treatment for Parkinson’s disease does not only involve medication and surgery. It also includes diet, exercise, support of family and friends and a healthy attitude. Patients should be advised to have positive and hopeful attitude, do regular exercise, yoga and meditation to improve the quality of life and decrease depression and anxious moods. They should also be advised to have a normal healthy diet which promotes overall well-being for Parkinson’s disease patients. They should also be told that eating fibre rich diet and drinking plenty of fluids also can help alleviate constipation. Connecting with other people who really know what it is like to have Parkinson’s disease can be very helpful in coping. Support groups offer a safe place to talk about your feelings, questions and concerns and to get valuable information. DBS surgery gives the patients and their family a better quality of life and enables them to do things they would not otherwise be able to do.