Deep Brain Stimulation Surgery

• How to Prepare
• Checking In
• Before the DBS Surgery
• During the DBS Surgery
• How Long Will Surgery Be?
• After the DBS Surgery
• Discharge Home

How to Prepare

Pre-Admission Assessment

You have your pre-admission clinic appointment a few days or weeks before your surgery. This visit takes about 3 to 4 hours in order to obtain blood work, an ECG, an x-ray and a consultation with an anesthetist. The pre-admit nurse will review instructions on how to prepare for the surgery.

Please bring the following with you:

• Your Ontario Health Card.
• All medications you take and their containers.

If there are any changes in the booking of your surgery, you will be called by the pre-admission department.

If you cannot go to your surgery, call the doctor's office as soon as you know. If you are unable to reach the doctor, then leave a message at the surgeon's office.

Part of planning for your surgery is making arrangements for someone to:

• Drive you home from the hospital after surgery.
• Stay in your home to care for you the first week after surgery.

Day Before Your Surgery

• Do not eat any food or drink after midnight the night before your surgery. Your stomach must be empty.
• Take a shower the night before or the morning of your surgery.
• Please bring with you a list of your current medications. This includes prescription medications, over-the-counter medications, vitamin or mineral supplements and herbal remedies. The nurse will go over these medications and instruct you on them for the surgery.

Day of Surgery

• Do not take any Parkinson's or tremor medications.

Checking In

When you arrive at the Pre-Operative Care Unit (POCU) in the Fell Pavilion (2^nd floor) at 6:00 am, check-in at the reception desk. Please have the following ready:

• Health card (OHIP card).
• Your name, address and date of birth.
• All the medications you regularly take in their original containers.
• You may also want to bring personal items, such as photos or reading materials

Before the Deep Brain Stimulation

After check in, the nurse will admit you and help you get ready for surgery. They will check your blood pressure, pulse, temperature and breathing. They will also put an intravenous (IV) in your arm and help you change into a hospital gown.

We put a special frame on your head. This frame has 2 pins at the front and 2 at the back to keep your head still during surgery. We give you medication (local anesthetic) with a small needle to numb the areas where the pins are put in.

You will have pictures taken of your brain. You will have a brain MRI (Magnetic Resonance Imaging) or CT (Computed Tomography) scan. These tests create detailed images of your brain that help your neurosurgeon position the DBS electrodes. Please try to stay as still as possible. This helps the technician get the clearest pictures of your brain.

• If you have an MRI, a box and coil are attached to the frame. This may feel heavy. After the MRI, we remove the box and coil. Only the frame will remain on for the surgery. The MRI takes about 45 minutes.
• If you have a CT scan, it will take 15 minutes.

After the tests, you will go to the holding area. A nurse will check that everything is ready for your surgery. You will see the anesthetist, who will give your anesthetic and monitor you during your surgery.

During the Deep Brain Stimulation

When everything is ready, you go to the operating room. The surgical team helps you move onto the operating table and get comfortable. The table is angled so your back is raised, but not all the way. Your head frame is attached to the table to keep your head still.

Step 1: Placing the Electrodes

You may be given a sedative to make you relaxed but awake enough to answer questions about how and what you feel when the electrodes are stimulated. Your answers help the neurosurgeon confirm the right placement of the electrodes.

The neurosurgeon will:

• Shave and wash your head with a special soap that kills germs.
• Numb parts of your scalp so you will not feel pain.
• Make an incision (cut) on the top of your head and a small round opening in your skull (about the size of a nickel). If you are having surgery on both sides of your body, you will have two openings in your skull.
• Put in each electrode so the tip is in the proper area of your brain.
• Stimulate the electrodes and measure how your brain cells react.
• Ask you what or how you feel and whether you feel things like tingling or numbness.
• Check your stiffness, tremor and movement to make sure the proper areas of your brain are stimulated.
• Use plastic caps to close the holes and make sure the electrodes stay in place, and close the incision with staples.
• Remove the frame from your head.

Step 2: Placing the Extension Wires and IPG

The anesthetist will give you medication (general anesthetic) so you will be asleep during this part of the surgery.

The surgeon will:

• Connect the extension wires to the electrodes.
• Place the extension wires under your skin, from the top of your head, behind your ear, down your neck to your chest.
• Connect the extension wire to the IPG unit.
• Place the IPG under the skin below your collarbone. It will remain off.
• Close the incision in your chest with staples.

How Long Will Surgery Be?

Step 1 takes 4 to 6 hours, depending on the number of electrodes needed and the complexity of the surgery. Some patients have Steps 1 and 2 done together. Others have Steps 1 and 2 done separately, two or three days apart. If you are having Step 2 later, the end of your electrodes will be left outside of your head and covered by a bandage.

Step 2 takes about 45 minutes.

After Surgery

When the surgery is finished, you will go to the Post Anesthetic Care Unit (PACU) for 1 to 3 hours to recover.

• The nurses in PACU check your blood pressure, pulse, temperature and breathing often, as you wake up. If you have pain or nausea, they will give you medication that will help.
• You may have an oxygen mask over your mouth and/or nose.
• There will be a bandage covering the incision on your head and chest.

When you are ready, you will go to your room in the Neurosurgery Unit 5A or 5B.

• In the Neurosurgery Unit, your health care team continues to check your condition and progress.
• You may have a headache, feel pain at your incisions or feel sick (nausea).
• This will gradually get better. The nurses can give you medication to help, if needed.
• In the afternoon or evening, you can start to drink and eat.
• Later in the day or the next day, the nurses will help you get out of bed and walk. You may feel dizzy, so it is important that someone is with you the first few times you get out of bed.
• You will have another MRI or CT scan to check the position of the electrodes.

The day after your surgery, we may invite you to take part in research studies to help us learn more about how the brain works. You can decide whether or not you wish to take part. Your decision will not affect your care in any way.

Discharge Home

You can expect to go home 1 or 2 days after the IPG is placed in your chest.

Before you leave the hospital, we will:

• Teach you how to take care of yourself and your incisions
• Tell you when your DBS system will be turned on
• Tell you about your follow-up appointments

On the day you go home, please arrange to be picked up before 11:00 am.

At home, your medications will remain the same until your DBS is turned on.

In the weeks following surgery, you may feel a temporary improvement in your symptoms, even though your DBS system has not been turned on yet. This is due to swelling caused by the electrodes. As the swelling goes away, your symptoms will likely return.

Please allow 4 to 6 weeks to recover from the surgery. Then you may return to your usual activities. Please talk with us if you have any questions or concerns about returning to work.

Incision (cuts)

• Your incisions will have staples and will be covered with bandages.
• You will need to remove the bandages 3 days after your IPG is inserted in your chest. These sites can be left without a dressing.
• Keep your incision sites dry. Do not put on creams, lotions or ointments to the area.
• Keep your head covered by wearing a scarf or a loose fitting hat when you go outside.
• Never touch, scratch or apply any pressure on the incision sites.

Hygiene (such as bathing and showering)

• You can take a shower and wash your hair with mild soap or shampoo 4 days after your last surgery.
• Do not soak your incisions in water for the first 4 weeks after your surgery. This means you cannot soak in a bathtub or go swimming.
• Make sure your hats, bed linen, pillows and wigs are clean.
• Stop pets from going close to your incisions and wash your hands well after touching them.
• Wash hands frequently.
• Do not dye your hair or use a hair dryer until after you see your neurosurgeon after the surgery.

Physical Activity

• Do not lift anything heavier than 5 pounds (or 2.5 kilograms) with your left arm, right arm or both arms for 3 weeks. This depends on where your IPG stimulator was put in.
• Don't play sports or do tiring activities for 3 weeks.
• After 3 weeks, you can start to increase your activity level as much as you can handle.

Signs of Infection

Look at your incisions every day and watch for these signs of infection:

It is important to check mood and behaviour after surgery and after DBS programming sessions. You or your family members need to report any changes to your health care providers.​​​​

• How to program your DBS
• Adjusting your medications
• Follow-up care
• IPG battery
• Staying safe with DBS system

Your DBS system will be off for several weeks. Once it is turned on, it will deliver continuous stimulation to the target area of your brain. This helps relieve your symptoms all day and night.

How to Program Your DBS

Programming means adjusting the electrical impulses from your IPG. This can begin when your brain has recovered completely, which is usually within 8 weeks after surgery.

Programming is done in a series of clinic visits over several months.

• Your first programming appointment will take 2 to 3 hours. During this visit, we will test your response to stimulation and record what levels of stimulation cause side effects.
• You will need about 4 to 6 more visits to program your stimulator to the best setting. Getting to the best setting can take as long as 6 to 8 months.
• We will give you a remote control to check that your stimulator is on. The team will teach you how and when to use it during your programming appointments.

Adjusting Your Medications

As your symptoms improve, your neurology team may begin to reduce your PD medications. Your medications must not be stopped suddenly, so carefully follow any instructions to slowly reduce your medications.

Follow-up Care

Family Doctor

Make an appointment with your family doctor to have your staples removed 10 to 14 days after surgery.

Neurosurgeon

You will see your neurosurgeon 6 to 8 weeks after your surgery. They will check your condition and incisions.

Neurology Team

After your IPG is programmed to the best setting, you will have follow-up visits with the neurology team every 4 to 6 months.

Levodopa Challenge Tests

You may have videotaped assessments of your symptoms (while OFF and ON Levodopa) at 1, 3, 5 and 10 years after surgery to monitor your PD or tremor symptoms and responses to brain stimulation over time.

Psychiatrist

You may have follow-up visits to make sure there are no concerns about your mental health after surgery.

Neuropsychiatrist

You may have follow-up appointments and neuropsychological tests to assess your memory and mental abilities after surgery.

Brain MRI

You may have more brain imaging during your recovery and follow-up care.

Your Neurology team will compare the results of all your follow-up tests with the ones you had before surgery to see how well the DBS treatment is working for you.

IPG Battery

Checking the Battery

• The IPG battery lasts about 3 to 5 years, depending on the amount of energy used.
• Each time you visit the DBS clinic, they will check the battery. You will learn how to check it with your own remote control.

Low Battery

• The DBS team will refer you to the neurosurgeon to replace the battery. This will be done in day surgery.
• Your neurosurgeon's office will send you some forms to be filled out by your family doctor. They will arrange for blood tests, an echocardiogram and a chest x-ray to be done at the hospital.
  
• If you do not live near the hospital, they will send you requisitions to have these tests done in your community.
• You may need to see your neurosurgeon to sign a consent form for surgery.

Changing the Battery

• The neurosurgeon replaces the battery during surgery. After surgery, you will go to the Day Surgery Unit.
• A member of the DBS team will program your IPG with the stimulation settings you had before the battery was changed.
• You will go home the same day, usually within 4 hours.

Staying Safe with DBS System

You must follow these rules for your health and safety.

Always carry your DBS Registration Card

• Before you leave the hospital, you will get a temporary registration card for your DBS system from the company that makes it. A permanent card will be mailed to you. Carry this card with you at all times.

Tell all your health care providers that you have a DBS system

• All your health care providers need to know that you have a DBS system implanted in your body so they can take steps to keep you safe.
• Consider getting a Medic Alert bracelet. In an emergency, the bracelet tells medical staff that you have a DBS system.

NEVER apply heat to your DBS system

• Do not put heat on any part of your DBS system as this could damage it and harm you.
• Do not have diathermy treatments (heat therapy), which deliver energy to heat and heal tissues in your body.

Check with your doctors before having an MRI

• The safety of having MRI of your brain or body depends on the type of DBS system you have and the MRI services. This chart is a general guide.

Check with your doctor or the manufacturer of your device before having other medical procedures.

• Most medical procedures are safe (such as CT scans or x-rays), but some need extra precautions, and others are not possible because they could cause serious harm.​