Deep Brain Stimulation - What Has Been Learned and Where it is Going

Deep Brain Stimulation - What Has Been Learned and Where it is Going

Okun Michael S, Saad Siddiqui Mustafa
Published: US Neurology Review 2005 - July 2005
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Medication refractory symptoms and a need for more efficacious therapies for neurological disorders have helped to stimulate the growth of surgical interventions such as deep brain stimulation (DBS). In 1874, Bartholow reported one of the first cases of ‘brain stimulation’; however, the field of therapeutic brain stimulation did not emerge until over a century later, when Benabid and colleagues in 1987 proved that chronic high frequency DBS was useful for the treatment of tremor.1 DBS is now widely accepted as a therapy for advanced Parkinson’s disease (PD) and essential tremor, and it is emerging as a therapy that may be useful in other neurological and psychiatric disorders. In this article the authors will explore what has been learned about DBS and where the field may be heading.

Advantages and Disadvantages of DBS
DBS has many advantages over other surgical approaches to PD. It is a reversible procedure that allows the option for discontinuation for any reason, including better therapies. Many patients prefer this therapy over ‘lesions’.With stimulation the brain can be stimulated on both sides with relative safety, unlike lesion therapy. Settings can be adjusted as often as needed for desired results, and the efficacy of DBS in PD and essential tremor is comparable and perhaps even better than lesion therapy (if used bilaterally).At present, DBS is US Food and Drug Administration (FDA)-approved for essential tremor and PD and has received a Humanitarian Device Exemption (HDE) approval for the treatment of another movement disorder – dystonia.

Ablative procedures, such as unilateral pallidotomy can be performed safely and effectively.2 Some groups believe unilateral pallidotomy to be more effective in improving the motor symptoms of PD, compared with bilateral subthalamic nucleus (STN) stimulation, but a randomized trial comparing the two showed that DBS was more efficacious.3 It is not surprising that a unilateral lesioning procedure (or any unilateral procedure) would be less effective when compared with bilateral DBS, and it may be more fair to compare unilateral pallidotomy with unilateral DBS (which has not been carried out in a large clinical trial to date). Ablative surgery has some advantages over DBS including no requirement for DBS programming, and no long-term infections. Additionally, there are no hardware-related complications. Lesion therapy is costeffective, particularly in countries where DBS cannot be offered.4 Additionally, there are now several studies showing the safety and efficacy of bilateral STN lesions.5–9 There is a need for direct comparison trials between lesion and DBS; however, these trials are unlikely to be performed as most patients prefer nonablative therapy. Future considerations may also include lesion on one side of the brain and DBS on the contralateral side. The relative merits of this mixed lesion-DBS approach have not been carefully investigated.

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