Management of Referred Deep Brain Stimulation Failures: A Retrospective Analysis From 2 Movement Disorders Centers
Archives of Neurology
Okun MS, Tagliati M, Pourfar M, Fernandez HH, Rodriguez RL, Alterman RL, Foote KD Management of Referred Deep Brain Stimulation Failures: A Retrospective Analysis From 2 Movement Disorders Centers Archives of Neurology, 2005 Jun 13; Epub ahead of print
These authors discuss that currently there is no consensus amongst medical professionals for patient appropriateness for surgery, training of medical professionals completing the surgery or the programming of the implant, patient access to programming, multidisciplinary involvement, and how to treat DBS failures. These authors discuss 41 cases (mean age 63.4 years) of DBS for PD (31), essential tremor (ET; 9), or dystonia (1) that came to 2 clinics (FL and NY) complaining of poor outcome after DBS. They found that a variety of DBS implantation sites had poor outcomes including a mix of unilateral and bilateral subthalamic nucleus, globus pallidus, and ventralis intermedius (all areas in the brain affected by the 3 diseases mentioned above). The authors found that 73% of the patients were evaluated by a movement disorder specialist but they did not agree with the presurgical evaluation of 9 patients. Only 34% of patients underwent neuropsychological testing (testing to evaluate cognitive abilities), 12% had inadequate medication trials, and 12% had significant cognitive dysfunction. 46% of patients had misplaced leads, 17% had poor access to programming, and 37% were inadequately programmed. They also found that 73% of the patients required Parkinson’s medication changes and 5 patients required additional nonParkinson’s medications. Overall, 51% of the patients experienced good outcomes with additional medical management in this study. These authors purport that the best predictor of DBS treatment outcome is appropriate patient selection. They suggest that better screening needs to be implemented with focus on a multidisciplinary approach (e.g. movement disorder specialist, neurology, neurosurgery, and neuropsychology). They also discuss that lead placement is vital for improvement with DBS and that better follow-up and evaluation may help to correct these problems earlier. They suggest imaging should be obtained to evaluate lead placement as well as undergo programming to assess thresholds for adverse effects and benefits. They briefly discuss hardware failures and postoperative medication changes. They also discuss the importance of programming as well as feedback to the entire treatment team regarding individual cases of DBS efficacy to encourage learning from poor outcome DBS to minimize additional poor outcomes in future patients.