Surgery for Parkinson’s Disease:
Focus on Deep Brain Stimulation
Ramón L Rodríguez, MD
Director of Clinical Services
University of Florida
Movement Disorders Center
ramon.rodriguez@neurology.ufl.edu
Parkinson’s Disease
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Progressive neurodegenerative disease
Affects the substantia nigra, which
produces dopamine
As a result, the patient develops the four
cardinal symptoms of PD:

Resting tremor, slowness, stiffness and balance
problems
Parkinson’s Disease
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Shows a good response to levodopa
(Sinemet)
Medications help improves the cardinal
symptoms of the disease
Patients derive great benefit from the
medication for a period of 5-7 years
Parkinson’s Disease

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With time, patients may develop motor
fluctuations or side effects induced by
levodopa
This motor fluctuations may become the
most disabling aspect of the disease
Parkinson’s Disease

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Wearing off
Unpredictable off
Sudden off
Dose failures
On-Off fluctuations
Parkinson’s Disease

Levodopa induced Dyskinesias

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Diphasic Dyskinesias
Peak dose Dyskinesias
Levodopa induced Dystonia
Parkinson’s disease

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Development of this symptoms may take
the disease from a non disabling to a
disabling state
At this stage, medical management may be
difficult and accompanied by undesirable
side effects
Parkinson’s Disease

What can be done at this stage?
Surgery for Parkinson’s Disease
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Pallidotomy
Thalamotomy
Subthalamotomy
Deep Brain Stimualtion [DBS]
Terapia Activa
What is DBS?

Deep Brain Stimulation

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Device similar to a pacemaker
Provides an electrical discharge to specific brain
area
This stimulation modulates the brain signals that
causes the symptoms of Parkinson’s disease
Deep Brain Stimulation
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Not a cure for PD
Does not replaces medications for PD
Does not alter the mechanism of action of
medications
Deep Brain Stimulation

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Improves the cardinal symptoms of
Parkinson’s disease
Smooth out motor fluctuations
Increase “on” time
Prevents disabling “off” periods
Deep Brain Stimulation

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Reversible procedure
Side effect profile much more benign than
lesioning procedures
Can be done bilaterally
As the disease advances, it can be
modified
Deep Brain Stimulation
Deep Brain Stimulation
Deep Brain Stimulation
Deep Brain Stimulation
Deep Brain Stimulation
Microelectrode Recording
Border
10sec
80ms
STN
10sec
80ms
Border/SN
10sec
80ms
Sagittal Section Through the Thalamus
Microelectrode Mapping
Intraoperative
somatosensory
evoked
responses
Deep Brain Stimulation
Deep Brain Stimulation

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Requires patient commitment for
programming
64,000 different combinations
Patience from both patient and
programmer
Deep Brain Stimulation
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Battery needs to be replaces every 3-6
years
Potential Complications
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Infection
Lead fracture
Lead Migration
Skin erosion
Mood and Behavioral changes
Deep Brain Stimulation
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DBS is not for every patient
Proper patient selection is critical for
success
Proper placement of the device is required
for success
Who is the best candidate?
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Disabling motor fluctuations
Significant proportion of day spent in
disabling “off” state
Symptoms improve with levodopa
Patients suffering from disabling
dyskinesias
Not ideal candidate
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Poor response to levodopa
Cognitive deficits or dementia
Hallucinations not related to medications
Patients diagnosed with Parkinson’s plus
syndromes (MSA, Lewy Body Disease,
Corticobasal Degeneration, Progressive
Supranuclear Palsy)
Thank You!!!