| Surgery for Parkinson's Disease & Movement
Disorders | Overview |
Procedures | Results
Deep Brain Stimulation (DBS) TREMOR CONTROL
THERAPY
Drug therapy is the traditional treatment
for tremor. Surgical methods that destroy a part of the brain
also are sometimes used. Tremor Control Therapy utilizing the
Activa™ System suppresses tremor through electrical stimulation
delivered by an implanted device. If drug therapy is not effective
in controlling your tremor, you may be a candidate for this
therapy. Deep inside your brain is a walnut-sized structure
called the thalamus, a Greek word meaning "inner room." Through this "Room" pass
most of the messages about body motion that your brain needs
to control movement. In people with tremor, these messages are
not working correctly. If these messages are interrupted by electrical
stimulation, tremor may be suppressed. The Activa™ Tremor
Control Systems delivers that electrical stimulation.
General Benefits of Activa™ Therapy
Activa™ Therapy partially or completely suppresses tremor
in 80% of patients*. Activa™ Therapy delivers electrical pulses
to the brain. You can activate these electrical pulses when you
wish, and your doctor can adjust them as an outpatient to meet
your tremor's severity. The Activa™ System is not implanted
unless your tremor has been suppressed during test stimulation
without undesirable side effects.
Activa™ Therapy helps control tremor, but it does not cure
tremor. When activated, the Activa™ System markedly reduces
tremor in the targeted area, resulting in improved use and function.
Tremor will return when the system is turned OFF.
* Medtronic clinical studies.
ACTIVA Subthalamic Nucleus DBS for Stiffness, Rigidity, Bradykinesia
and Dyskinesia
Deep inside your brain is a dime-sized structure called the
subthalamic nucleus. Through this nucleus pass most of the messages
about body motion that your brain needs to control movement.
In people with the general symptoms of Parkinson's Disease (above),
these messages are not working correctly. If these messages are
interrupted by electrical stimulation, stiffness and rigidity
may be suppressed. The Activa™ Tremor Control Systems delivers
that electrical stimulation.
The Activa™ System Components
The Activa™ System includes an insulated lead wire with four
electrodes at the tip. The lead is implanted in the thalamus
for tremor, or the subthalamic nucleus for the general symptoms
of PD, where the electrodes deliver electrical stimulation.
The lead is connected to an extension, essentially another thin,
insulated wire that connects to the pulse generator. This extension
is threaded under the skin from the top of the skull to the chest
area near your collarbone.
The pulse generator, like an advanced pacemaker, is a small,
sealed, metal and plastic device with a battery. The pulse generator
produces the electrical pulses needed for stimulation. It is
connected to the extension and implanted in the chest area near
your collarbone.
A small, hand-held magnet allows you to turn the system ON and
OFF. Numerous parameters of the stimulator may be changed at
the office using a special programmer.
Will People Notice These Components?
All Activa™ components, with the exception of the hand-held
magnet, are inside the body. The pulse generator may bulge slightly
under your skin, but it isn't noticeable under clothes. There
also may be a slight bump on the top of your head, but it usually
isn't visible under your hair.
This illustration shows a complete system implanted on the
left side of the body, which would control tremor on the right
side of the body.
CHOOSING ACTIVA™ THERAPY
To help you decide if Activa™ Therapy is right for you, Dr.
Duma provides a thorough assessment of your tremor, your general
physical condition, and your neurological status. He will assess
your tremor of general symptoms of PD through rating scales,
handwriting samples, and possibly videotaping.
Activa™ Therapy requires you to assume certain responsibilities.
These include responding to questions during the implant procedure,
following precautions regarding use of the system, and being
available for follow-up programming. You will have an opportunity
to discuss the implant procedure with Dr. Duma who will perform
the operation. He specializes in surgical procedures for the
brain that require the use of a special apparatus called a stereotactic
frame.
Be sure to ask Dr. Duma any and all questions that you may have
so that he may answer your questions regarding safety, expected
outcomes, risks, and side effects.
Talk to People About Activa™ Therapy.
Consider talking with people who are already implanted with
the Activa™ System to learn directly what the procedure is
like and how the therapy has affected their lives. You also can
talk with people for whom the therapy was not successful. Ask
Dr. Duma for the names of patients willing to discuss their experiences
with tremor control therapy.
Risks of Surgery
- Implanting the Activa™ Tremor Control
Therapy System carries the same kinds of risks associated with
any other stereotactic neurosurgery. These risks include:
- Bleeding
inside the brain (2%)
- Leakage of fluid surrounding the brain
(1%)
- Seizure (1%)
- Infection (2%)
While these risks are quite low, they could be life-threatening.
After surgery, you might be sleepy, and experience headaches.
Discuss all of these risks with Dr. Duma so you are fully informed.
Possible Side Effects of Activa™ Therapy
Side effects usually are mild, and go away when stimulation
is turned OFF. Dr. Duma can also adjust the stimulation so the
side effects are eliminated or lessened.
Side effects may include:
- Tingling in the limbs
or face (paresthesia)
- Facial and limb muscle weakness or
partial paralysis (paresis)
- Speech problems (dysarthria)
- Dizziness or
lightheadedness
- Movement problems or reduced coordination
- Jolting
or shocking sensation
Before the Procedure
If you decide that Activa™ Therapy is right for you and the
implant is scheduled, Dr. Duma will give you instructions regarding
taking your medications, bringing insurance forms to the hospital,
etc.
UNDERSTANDING THE IMPLANT PROCEDURE
Most likely you will arrive at Hoag Hospital on the morning
of the surgery. You will be asked to sign a surgery consent form.
Then, the first part of the procedure takes place.
The Stereotactic Frame
Dr. Duma attaches a stereotactic frame, a halo-type device,
to your head. This frame stabilizes your head and helps Dr. Duma
to locate the target precisely. Although local anesthetic is
used to numb the areas where the frame is secured, you may feel
pressure and some discomfort as it is attached.
Pinpointing the Position of the Target
Once the stereotactic frame is in place, an image of your brain
will be taken using magnetic resonance imaging (MRI) or computer
assisted tomography (CT). From this image Dr. Duma will check
the position of the frame and take measurements to locate the
position of the thalamus.
In the Operating Room
The operating room is staffed by a team of highly skilled professionals.
You will see Dr. Duma, who leads the team, surgical assistants,
nurses, and the anesthesiologist, who gives you anesthesia or
medication and monitors your vital signs. Other team members
may include a neurologist and/or a neurophysiologist, who will
be involved with the testing of stimulation.
Positioning the Lead
Dr. Duma makes a small hole, about the size of a dime, in your
skull. This is done while you are under local anesthetic and
mild sedation. Still, you may feel some pressure. Remember the
surgical team wants you to be as comfortable as possible, so
always let someone know if you are uncomfortable.
He then inserts the thin lead into the thalamus or subthalamic
nucleus. Since brain tissue itself does not sense pain, you most
likely will not feel any pain during this part of the procedure.
PIC 30
Testing for Tremor Suppression/Rigidity Relief
Dr. Duma uses microelectrode recording prior to implantation.
Once the lead is in place, Dr. Duma connects it to an electrical
stimulator. When the stimulator is turned ON, he and the other
team members evaluate the lead location and stimulation strength
by seeing how well you hold a cup, or stretch your arms out and
bring your fingers together, or draw spirals. You also will be
asked if you feel things like numbness and tingling, and your
speech will be evaluated. Depending upon your responses, Dr.
Duma will adjust the lead placement and the stimulation.
If tremor cannot be suppressed or rigidity relieved or if there
are side effects that cannot be controlled adequately, the lead
will be removed and the procedure will not continue.
Implanting the Activa™ System.
Activa Implant Movie
Clicking the movie link above will launch the movie in a new
browser window.
Movie file size: 1.0mb
If the therapy controls your tremor during intraoperative testing,
the Activa™ System will be implanted - the lead, the extension,
and the pulse generator. This may occur on the same day or some
days later.
For this part of the operation, general anesthesia is typically
used (you'll be asleep). The lead is secured and the pulse generator
is implanted in your chest near your collarbone. The two are
connected by an extension, which is threaded under your skin
from the top of your head to the pulse generator. The incision
in your chest skin is then closed with staples, and you are prepared
for the recovery room. The system may be left OFF until the next
day.
The entire procedure (from the fitting of the frame to the time
you go to the recovery room) may take 2-3 hours, and implanting
of the stimulator (often done on a second visit) may take 1 hour
as an outpatient.
RECOVERY
Usually you need to stay in the hospital for
only one night after the operation. The next day, a clinician
will come to your hospital room, turn the Activa™ System
ON, and program the pulse generator. Programming is done with
a computer that communicates with the pulse generator through
telemetry - a non-invasive, painless way of adjusting the stimulation.
The clinician will find the best stimulation setting with the
most symptom reduction and the fewest side effects. You also
will be given an identification card that states you have a medical
device. Be sure to keep this with you at all times!
Tremor doesn't always return immediately after the procedure.
In those cases, the clinician may decide to leave the system
OFF until tremor returns.
You may feel some pain or discomfort after leaving the hospital,
especially headache or neck pain. This may last several weeks.
Dr. Duma can suggest medicine to make you more comfortable. Most
patients, however, recover quickly and have minimal discomfort
during this time.
Be sure to follow Dr. Duma's instructions about self-care after
the surgery.
General Instruction for Self-Care
- Notify Dr. Duma of changes in
side effects, such as tingling in the limbs or face, speech
problems, or changes in symptom control.
- Notify Dr. Duma
if pain, swelling or redness occurs where the devices are
implanted.
- Notify Dr. Duma if you experience dizziness
or lightheadedness.
- Take medicines as prescribed by your doctor.
If you have Parkinson's disease, medicines may help you control
symptoms other than tremor.
- Notify Dr. Duma of persistent
headache not relieved by medication.
Follow-up
When you leave the hospital, you will be scheduled for a follow-up
visit with Dr. Duma, usually 7 to 14 days after the operation.
Dr. Duma or the neurologist will schedule a follow-up visit to
initiate the programming of your Activa™ System to adjust
stimulation if it has already been started.
After that, you'll visit once or twice a year for a check-up.
The timing of these visits is set by the neurologist per Dr.
Duma.
Changing the Pulse Generator
The pulse generator will last about 5 years at typical settings.
Its longevity depends on how many hours a day it is used and
how it is programmed. Your doctor can give you a better estimate
of how long the battery will last once the pulse generator is
programmed. To conserve the battery, turn OFF your pulse generator
when you feel you don't need it and at night if you can sleep
comfortably without it.
During follow-up visits, your doctor will check the battery.
If the battery is depleted, the pulse generator will be replaced.
The lead in the brain is not replaced. Replacing the battery
takes about an hour and is usually done as an outpatient procedure
(you don't have to stay in the hospital).
TAKING CONTROL OF YOUR SYMPTOMS
The Activa™ System is easy to turn ON
or OFF with a control magnet. To turn it ON, grasp the magnet
with the flat end away from you, as shown. Press the flat end
of the magnet directly over and along the length of the pulse
generator. Hold the magnet steady for two seconds. Then move
the magnet away to turn the generator ON.
To turn the Activa™ System OFF, simply repeat the procedure.
Keep the magnet away from the pulse generator when you are not
using it. Also keep it away from credit cards or any other media
including video and cassette tapes, computer disks, VCRs, televisions
and cameras.
A small instruction card with complete directions and precautions
will be given to you after the system is programmed.
Suggestions and Precautions
You can use household appliances, computers, and cellular phones
with the Activa™ System ON.
It is also safe for you to pass through metal detectors in airports.
Your pulse generator may set them off, so always carry your identification
card. You may want to request assistance to bypass the detectors.
Approach theft control devices in stores with caution. They
may cause you to feel uncomfortable stimulation. Walk up to within
a few feet of the theft detector. If you don't feel anything
unusual, walk directly through the theft detector area, keeping
to the middle between the two pillars.
- Avoid the following tests and equipment:
- Magnetic
resonance imaging (MRI)
- Ultrasound, or diathermy (heat ultrasound
treatments)
- Electrocautery
- Diathermy (deep heat therapy)
Tell your family physician and dentist that you have an implanted
device. If you need a special medical test, be sure to tell the
clinician about the system. Do not have medical tests without
first checking with your doctor.
Surgery for Parkinson's Disease & Movement
Disorders | Overview | Procedures | Results
For consultation appointments with Dr. Duma
or for more information regarding his brain tumor, GammaKnife
radiosurgery, and Parkinson's Disease programs at Hoag Memorial
Presbyterian Hospital in Newport Beach, California (Orange County),
please contact:
949-642-6787
Or E-mail Dr. Duma directly: drduma@cduma.com
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