Deep Brain Stimulation (DBS)

How Does Deep Brain Stimulation Work?
Deep brain stimulation helps curb abnormal brain signals that cause symptoms of movement disorders and epilepsy. Electrodes implanted into specific parts of the brain are connected to a small battery (internal pulse generator), which is placed just under the skin in the chest. The pulse generator delivers electrical impulses to the brain that modify abnormal brain activity.

Who Is a Candidate for Deep Brain Stimulation?
You may be a candidate for DBS if you experience complications or side effects from medications or if your symptoms are not well-controlled. When used in the right candidates, DBS has a high success rate and relatively low risks. Because it is minimally invasive, you will benefit from a short hospital stay and recover in just a few weeks.

For Epilepsy: 

If you are diagnosed with epilepsy, you will undergo an epilepsy-specific surgical evaluation. DBS, a type of neuromodulation, may be also an option for certain children with epilepsy.

For Movement Disorders: 

If you have a movement disorder, you will undergo a unique evaluation process to help your doctors determine whether DBS is a good option for you. For your convenience, we try to schedule appointments across several clinics on the same day, whenever possible. Our patient coordinators work closely with you through each step of this process. 

Neurology Screening 
A specialized neurologist with expertise in diagnosing and treating movement disorders (these doctors are called movement disorder specialists) evaluates your symptoms, educates you about DBS, the surgical evaluation process, and the benefits you may expect after undergoing the procedure. They may also make medication recommendations.

Neurosurgeon Consultation
Your neurosurgeon will discuss the more technical aspects of the surgery, including risks, benefits, and recovery.

On-Off Medication Appointment 
This appointment is only for people with certain types of movement disorders, like Parkinson’s. You will be asked to stop taking your Parkinson’s medications for a short period of time before the appointment. You will be evaluated both before and after taking your medications. This allows your movement disorder specialist to understand the range and severity of your symptoms and to assess your responsiveness to medications, which helps to predict how you might respond to DBS. 

Neuropsychologist Appointment
A neuropsychologist -- a specialist who assesses cognitive functions and behaviors -- will administer detailed tests to screen for dementia, impulsive tendencies, or any other signs of cognitive or behavioral impairment. This is important since DBS is not recommended for people with some of these conditions.

Next Steps
Your doctors will meet to review the results of your evaluations. Together they will decide whether DBS is a good option for you. If so, they will determine the best target site in your brain for DBS implantation and select the most appropriate DBS device for you. They will also make recommendations about whether general anesthesia (“asleep surgery”) or minimal sedation (“awake surgery”) is best for you. 

You will also be scheduled for an MRI scan that will help your doctors plan the surgery. You may complete a pre-anesthesia assessment to ensure you are healthy enough for surgery.

DBS surgery is almost always done in two stages that are usually separated by one to two weeks. In certain circumstances, both surgeries can be performed on the same day. 

Stage One: Lead Placement Surgery
In this first stage, DBS electrodes are implanted into the brain. This surgery usually takes about four hours in the operating room. At least part of your head will be shaved at the beginning of the procedure. 

• If you are undergoing asleep surgery, you’ll remain asleep and unconscious throughout the procedure. People undergoing awake surgery will be awake (but unable to feel pain) for parts of the procedure. This allows you to answer questions and respond to commands, which helps ensure the leads are in the right place and avoid unwanted side effects. Your neurologists and neurosurgeons will work with you to select the procedure type (awake versus asleep) based on your preference and condition.
• After you have received anesthesia and are unable to feel pain, your neurosurgeon will make one or two incisions on the top of your head behind your hairline. Using a sophisticated targeting system as a guide, the surgeon will then implant the electrodes in the brain through nickel-sized holes that have been drilled in the skull. During awake surgeries, a brief 30-45 minute period of testing will be performed. Then the ends of the wires are tucked under the scalp so they can be accessed later during the second stage of surgery. 
• After the procedure, you’ll need to stay in the hospital for one or two nights to recover. 

Stage Two: Neurostimulator Placement Surgery
During the second stage of DBS implantation, your neurosurgeon will place the internal pulse generator (which contains a small computer and a battery) under the skin in your upper chest, just below the collar bone. The pulse generator will be connected to the brain electrodes using an extension wire, which will also be placed under the skin. This second stage of DBS surgery takes about an hour.

Revision Surgery
When needed, Duke also offers DBS revision surgery to change the positioning of one or more implanted electrodes to achieve better outcomes.

About a month after the second stage of the DBS implantation procedures, you will return for a clinic appointment to activate and adjust your device settings. A neurologist will evaluate your symptoms while adjusting the device (wirelessly) to achieve the greatest benefit. The process is not painful, although it might be uncomfortable at times. You may be able to make minor adjustments at home with a handheld device, like a remote control.

In the first six months after surgery, you will attend regular follow-up appointments to further fine-tune device settings and your medications. These visits become less frequent over time. If you live far from Duke, your local neurologist may adjust your device and medications.

Team of Experts
Our team of DBS experts evaluates each DBS candidate from multiple perspectives to make sure that we're considering everything before moving forward with surgery. This thoughtful approach and collaboration amongst neurologists, neuropsychologists, neurosurgeons, and others results in thorough care and excellent outcomes.

We Customize Your Surgery
Our DBS providers are experienced in using various methods and tools for DBS evaluation and surgery. We choose the best surgical approach and device to maximize potential benefit and accommodate your preferences and needs. 

We Offer Asleep DBS Surgery
Duke is one of the few centers that offer “asleep” DBS surgery. Traditionally, DBS implantation surgery has been limited to “awake” surgery, when patients are lightly sedated but awake to participate in testing to ensure optimal lead placement and to avoid side effects. If you are uncomfortable with the idea of being awake during portions of the surgery, Duke offers an MRI-based approach that allows you to remain asleep under anesthesia throughout the surgery. 

Patient Navigators Coordinate Your Care
Our patient navigators are your one-stop shop for scheduling appointments, coordinating your visits, and planning your surgery. It’s their job to make your DBS surgery journey easier by guiding you through it step by step. They are more than willing to answer all of your questions along the way.

Advanced Technology
We use the latest technologies in the operating room and for imaging. This allows us to pinpoint target areas for lead placement and helps us navigate those areas without damaging nearby structures. 

Research Leader
Duke researchers helped develop new DBS technologies and best practices that are being used all over the world. As a Duke patient, you may be eligible to participate in clinical trials that give you access to the latest breakthroughs before they are available elsewhere.