From a wheelchair to waltzing — the transformation of deep brain stimulation

Rita Roeshot pulled her husband out of their car and helped him into his wheelchair. Her husband of 56 years was stricken with Parkinson’s disease and couldn’t walk or dress himself. As she wheeled him down the halls of Georgetown Medical Center and into the Neurology Department in May 2013, she hoped the procedure the doctors had performed two months ago would turn out to be worth it. 

They had gone to Georgetown previously for a surgery called deep brain stimulation (DBS): a procedure that uses tiny electrodes attached to long, thin wires called “leads” that send electrical impulses to targeted areas of the brain. The leads are controlled by a device similar to a pacemaker that is implanted in the patient’s chest. 

The stimulation can have a positive impact on a slew of symptoms, ranging from Parkinson’s to epilepsy to obsessive-compulsive disorder. Researchers are hoping it could one day be developed to treat even more conditions.

Today, Roeshot is accompanying her husband as the surgeon performs the final step of the procedure: the turning on and programming of Roeshot’s new wiring. She stands by her husband’s side as she watches his symptoms dissolve.

“Almost immediately, his legs became flexible again, and I could see the muscles in his face changing,” Roeshot said. “The blank mask of Parkinson’s disappeared, and the smiling face I remembered appeared again. He started rolling his wheelchair back and forth right in the office, just like a little kid.”

Georgetown isn’t the only facility performing DBS for patients like Roeshot. Last year, more than 65 DBS procedures were performed at Penn State Milton S. Hershey Medical Center. While brain surgery may have a reputation for being dangerous and complicated, DBS is different. Following the global trend of minimally invasive surgery, DBS is safe, gentle and reversible, and its effectiveness is changing lives one operation at a time.

Dr. James McInerney, who pioneered the DBS program at Penn State Hershey, has been performing the operation for more than 10 years and completes about two surgeries each week. Overall, Dr. McInerney has performed DBS on more than 300 patients, and none have chosen to reverse it. 

“It really seems to work; many patients either lower their medication dosage or completely eliminate it after receiving the procedure,” said Dr. McInerney. “It’s hard not to get excited about that.”

While each surgeon has their own technique, they all have a common goal: to reduce the patient’s symptoms and increase their quality of life. McInerney uses a blend of IT and surgical technologies to carry out the planning, implanting and programming stages of DBS.

Creating a map to recovery

The first step is an appointment to take 3-D pictures of the patient’s brain and create a virtual model of a custom targeting platform — a star-shaped device the patient wears during surgery to aim the electrodes. McInerney uses a system called StarFix, which creates custom targeting platforms instead of the more traditional, manually adjusted ones.

McInerney first takes a series of CT and MRI scans of the patient’s head. Having both is important; CT scans are better at showing bone structure while MRI scans excel at detailing the brain. When combined, the two form a complete picture.

“It’s necessary to have high-quality image guidance when doing the electrode implants. I need to have access to accurate images to make the correct measurements. Our devices are high-tech and extremely precise.”

-- Dr. James McInerney, who pioneered the DBS program at Penn State Hershey

With the data compiled from the scan results, he then plans exactly where the electrodes will be implanted and the trajectories he will use to place them. These targets are millimeters in size, which makes the technology’s precision critical to the operation’s success.

Once the trajectories are planned, the surgeon creates a digital model of the patient’s custom targeting platform. When he’s happy with the model, it’s sent to StarFix where the targeting platform is manufactured and shipped to the hospital within 24 to 72 hours.

Throwing the switch

On the day of implantation, the StarFix is set in place on the patient’s head after he is anesthetized. Trajectories are then aligned, which tell surgeons where to perform incisions. After preparation is completed, the patient wakes up and stays conscious during the procedure.  Due to the brain’s unique properties, the patient doesn’t feel pain. The brain’s electrical patterns fire across brilliantly lit display screens, showing the surgeon the different parts of the brain. 

Surgeons then insert recording microelectrodes, which are inserted into the planned targets in the brain. They provide feedback to the surgeon, allowing him to ensure they’re placed correctly. Once satisfied with the placement, the surgeon removes the recording microelectrodes and replaces them with permanent ones. A neurostimulator also is implanted in the patient’s chest. It will eventually connect to the microelectrodes and control the stimulation sent to the patient.

Once implantation is complete, surgeons have the patient experiment with moving their limbs and speaking to make sure placement is correct and to fine-tune settings. When the surgeon is confident with how the patient is reacting, the electrodes are secured in place.

After this stage, the patient may or may not notice a difference in their symptoms. McInerney said some report immediate improvements, while others, like Roeshot, notice next to no difference — yet.

“Everything was the same immediately after the surgery except now Larry had no hair and two 5-inch scars,” Roeshot explained. “But as an engineer, he understood the procedure on a technical level and was very excited to be a part of that. For this part of the process, his enthusiasm was definitely the highlight.”

Avoiding stimulation overload

Two to four weeks after surgery, patients return a final time for the programming of their electrodes and neurotransmitter. A neurologist does final testing and tweaking and selects an appropriate level of stimulation to ensure the patient gets maximum benefits with minimal side effects.

“A lot of it is turning on the microelectrodes and seeing how the patient reacts,” said McInerney. “We want enough stimulation to provide as much relief as possible but not too much where the sensations become too intense.”

The surgeon also will use a programming device to turn on and fine-tune the patient’s neurostimulator. Via radio waves, the device communicates with the electrodes to regulate the stimulation levels. While adjustments are sometimes needed, the positive effects are usually instantaneous. 

As patients continue to find relief from disorders like Parkinson’s and epilepsy, surgeons are now researching new ways DBS can help sufferers of obesity, depression and even addiction.

“I think we’re just scratching the surface of what DBS can do,” McInerney said. “Consider something like obesity — the only treatments we have currently are procedures like lap band surgery, which can be quite invasive. Wouldn’t it be amazing to modulate this condition without being invasive? By far, that’s the most fascinating thing about DBS.”

As for the Roeshots, the day Larry Roeshot’s neurostimulator was turned on was a life changing event for the couple. He has since regained the ability to take care of himself and drive his car.

“After the procedure, he’s walking, dressing himself, driving, and participating in life more completely,” Roeshot said. “I have my husband of 56 years back.”

For more IT stories at Penn State, go to http://current.it.psu.edu.

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Last Updated December 03, 2013