1. 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

2. Parkinson’s Disease 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

3. Parkinson’s Disease 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

4. Parkinson’s Disease 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

5. Parkinson’s Disease Wearing off Unpredictable off Sudden off Dose failures On-Off fluctuations

6. Parkinson’s Disease Levodopa induced Dyskinesias Diphasic Dyskinesias Peak dose Dyskinesias Levodopa induced Dystonia

7. Parkinson’s disease 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

8. Parkinson’s Disease What can be done at this stage?

9. Surgery for Parkinson’s Disease Pallidotomy Thalamotomy Subthalamotomy Deep Brain Stimualtion [DBS]

10. Terapia Activa

11. What is DBS? Deep Brain Stimulation 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

12. Deep Brain Stimulation Not a cure for PD Does not replaces medications for PD Does not alter the mechanism of action of medications

13. Deep Brain Stimulation Improves the cardinal symptoms of Parkinson’s disease Smooth out motor fluctuations Increase “on” time Prevents disabling “off” periods

14. Deep Brain Stimulation Reversible procedure Side effect profile much more benign than lesioning procedures Can be done bilaterally As the disease advances, it can be modified

15. Deep Brain Stimulation

20. Microelectrode Recording STN Border/SN 10sec 80ms Sagittal Section Through the Thalamus Border

21. Intraoperative somatosensory evoked responses Microelectrode Mapping

22. Deep Brain Stimulation

23. Requires patient commitment for programming 64,000 different combinations Patience from both patient and programmer

24. Deep Brain Stimulation Battery needs to be replaces every 3-6 years Potential Complications Infection Lead fracture Lead Migration Skin erosion Mood and Behavioral changes

25. Deep Brain Stimulation DBS is not for every patient Proper patient selection is critical for success Proper placement of the device is required for success

26. Who is the best candidate? Disabling motor fluctuations Significant proportion of day spent in disabling “off” state Symptoms improve with levodopa Patients suffering from disabling dyskinesias

27. Not ideal candidate 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)

28. Thank You!!!