Frequently asked questions


When is it too late for DBS?

One of the questions posed to me recently has been, ' When is the best time to have DBS? And when is it too late?" Well, the FDA recently changed their approval for DBS, now making it available for those who have been diagnosed (or had symptoms) for at least 4 years. Previous to this, I think it used to be 6-8 years. But it is now be recognized that having DBS earlier may actually be better; because the earlier DBS is introduced – the greater the benefits . Anyway, according to the doctors, in order to even consider DBS:

  • You must have had symptoms for at least 4 years;
  • Have responded well to the medication levodopa;
  • Still benefit from medication, but it’s becoming less effective or causing intolerable side effects;
  • Require multiple medications, higher dosages, or more frequent doses to manage your symptoms.
  • Ability to remain calm and cooperative during an awake neurosurgical procedure lasting 1-3 hours per brain side.
It's generally considered 'too late' when the following has occurred:
  • Your symptoms no longer respond to medication;
  • Your mobility has deteriorated. Good mobility, with the ability to walk, in the best "on-medication" state is important for a good outcome. In general, surgery makes the "off" medication state more like the "on" state but rarely does better than the best "on" state, so a patient with poor function in best "on" (for example, unable to walk at any time) is a poor surgical candidate.
  • You develop medical conditions that prevent surgery such as cognitive impairment, gait and balance problems. Dementia (significantly impaired memory or thinking) is a major contraindication to surgery, since such patients have great difficulty tolerating the surgery, may have further loss of intellectual function due to the surgery, deal poorly with the complexity of DBS therapy, and realize little overall functional benefit;
  • You become severely disabled. DBS is a poor procedure to rescue someone with end stage Parkinson's disease who is wheelchair bound or in a nursing home, although these are the most desperate patients. It is an excellent procedure for Parkinson's patients who are still employed but may be just at the point where disability would stop them from working;
  • Serious cardiac disease, uncontrolled hypertension, or any major other chronic systemic illness increases the risk and decreases the benefit of surgery. Also, an MRI of the brain should be free of severe vascular disease, extensive atrophy, or signs of atypical parkinsonism.
  • Patient age. The benefits of DBS for PD decline with advancing age, and the risks go up. Rarely is surgery offered to a person over 80 and would only be considered if they are in otherwise excellent health, are cognitively intact, and have good function in the on state. For patients over 75, the benefits are likely to be modest.
Generally DBS will not work when the disease has progressed to the point that the patient may no longer be fit for neurosurgical intervention. This is the reason why one has to go through all the 'pre-op' requirements first, such as speech therapy, cognitive evaluation, mental (psych) evaluation, and of course evaluation by the entire neurological team. Only then can one be 'approved' for DBS surgery. For more info on this pre-op requirements, see the second part of my DBS blog series.

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Hi, I'm Tom, from whose brain these Deep Brain Thoughts flow! Thank you for visiting my blog, and keep coming back to enjoy future ramblings!

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Last Updated: 2019-09-11

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