When someone is living with Parkinson’s disease, what once was second nature can become difficult, if not impossible, especially when the benefits of medication begin to diminish. Mark R. Hoeprich, MD, has heard a lot of these stories.
A persistent tremor prevented one of his patients from tying his own flies so he gave up flyfishing. A woman who refurbished dolls could no longer paint the delicate eyelashes on china faces. Another patient had to relinquish her longstanding tradition of writing Christmas cards to her husband because she could no longer use a pen.
These Parkinson’s patients sought out Dr. Hoperich in part because he offers many people a chance to have a better quality of life and get back the things they’ve lost through a procedure called deep brain stimulation. After undergoing DBS, each of these patients was able to get back to their favorite hobbies and traditions. (The husband writing Christmas cards was especially grateful for his wife’s comeback.)
“One of the reasons I love DBS so much is because people love it so much,” says Hoeprich, a Goodman Campbell functional neurosurgeon who practices out of Ascension St. Vincent – Indianapolis Functional Neurosurgery Clinic. His clinical practice focuses on advanced stereotactic and minimally invasive techniques for the treatment of neuropathic pain, movement disorders — such as Parkinson’s disease — and epilepsy.
Timing matters for Parkinson’s patients considering DBS
As with any surgery, a patient should consider DBS only if more conservative ways to manage their Parkinson’s symptoms are no longer sufficient. Most candidates for DBS have had Parkinson’s symptoms for at least four years. But Dr. Hoeprich warns that patients shouldn’t wait until their medication has stopped working. By then, DBS may no longer be a viable option.
“When a patient finds that they need to take their medication more frequently, at higher doses, and are experiencing troublesome peaks and troughs or dyskinesias,” Hoeprich says, “DBS becomes a serious part of the treatment conversation. Calendar age isn’t critical; a candidate’s physiologic age is much more important.”
Whatever a patient’s medication can do, DBS can do. The added benefit is how DBS works inside the body compared to medication.
When a patient ingests an oral medication, it must first pass through the gastrointestinal tract and be absorbed into the bloodstream before it can reach and act upon the nervous system. As a result, the patient experiences the effects of the medication at different concentrations in the body, resulting in peaks and troughs — a few hours of better mobility and control, followed by a period of disconnection and lack of control. Some medications also cause dyskinesias, the involuntary, erratic movements associated with Parkinson’s.
DBS, on the other hand, smooths out the extreme peaks and troughs. Because DBS is consistently, directly targeting the brain center, there are no fluctuations in effectiveness.
“Prior to the advent of newer, higher-detailed MRI sequences and better brain mapping, we didn’t know where to put the electrodes” until surgery was underway, Hoeprich says. DBS was first approved by the U.S. Food and Drug Administration in 1997. The traditional method for executing DBS involved keeping the patient awake during surgery so a neurosurgeon could test where exactly the electrodes should be placed. As such, Hoeprich describes his more advanced approach as “surgery in your sleep.” This newer method also reduces how long a patient is under anesthesia and increases safety.
“Depending on the disease stage, you can take medications and undergo DBS. It’s patient dependent, but for the average patient, DBS reduces their symptoms by 70%,” Hoeprich says. Despite the benefits of DBS, he says many patients aren’t even aware that it’s an option at all. Much more awareness is needed.
How DBS is performed and how it works in the brain
It’s brain surgery, but it sounds so simple. Essentially, DBS sends electrical pulses to specific places inside the brain to reduce the severity of Parkinson’s symptoms. The process starts with a preoperative MRI of the patient’s head, from their scalp through every layer of the brain to the target neurons deep inside the substantia nigra. This advanced “brain mapping” process allows Hoeprich to pinpoint exactly where the damaged neurons are so that during surgery he can insert the electrodes where they will be most effective.
The surgery is made up of two stages. During the first stage, the patient is admitted to the hospital in the morning and given anesthesia. Through small incisions behind the hairline, Dr. Hoeprich makes a nickel-sized hole on each side of the patient’s head and inserts an electrode through the skull to the target area of the brain. This is done for both the right and left hemispheres of the brain. These wires are left coiled under the scalp at the end of this surgery. After one night in the hospital, the patient has breakfast and is discharged.
Two weeks later, the patient returns for stage two. During this 45-minute surgery, the patient is put to sleep, and Dr. Hoeprich makes a small incision to access the wires under the skin. He then attaches the pliable extension wires to a battery placed under the skin near the patient’s collarbone. The battery is similar to that of a pacemaker.
Over the next two to four weeks, the brain is allowed to recover from surgery. Following this period, Dr. Hoeprich activates the battery to power the pulse-emitting electrodes. Dr. Hoeprich says that relief is often immediate — better mobility, diminished tremors, reduced rigidity, fewer dyskinesias.
Dr. Hoeprich says DBS can continue to be effective for patients well past a decade, with little need for maintenance beyond keeping batteries charged. As a patient’s Parkinson’s progresses, changes may be made to a device’s stimulation levels to maintain positive effects, while some devices are programmed to respond to the patient’s brainwaves.
There is still no cure for Parkinson’s disease, but what DBS can do is increase a patient’s mobility, and with better mobility comes a greater quality of life. Patients can fly fish, paint, golf, and simply hold the book they want to read. The ability to get back to the lives they love is a big motivation.
To request an appointment with Dr. Hoeprich, please call Ascension St. Vincent – Indianapolis Functional Neurosurgery at 317-338-9669.
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