Friday, June 16, 2017
DEEP BRAIN STIMULATION (DBS) IN PARKINSON’S DISEASE
Major Symptoms of Parkinson’s disease
Parkinson’s disease (PD) is a progressive neurological disease, characterised by tremors, rigidity, slowness of movements and postural imbalance. Though it is more common after the age of 40, people younger than 40 can also get affected (when it is known as young onset PD).
Other symptoms of PD include low volume speech (sometimes totally incomprehensible), expressionless face, reduced blink rate, reduced arm swing while walking, stooped posture, small handwriting (called micrographia), short-shuffling steps, tendency to fall forwards. Many people also have pain and aches in the affected limbs. Sleep disturbance and restless leg syndrome are common comorbid illnesses in people with PD. Severe memory impairment is NOT a feature of PD, however, in advance PD, mild memory impairment may occur in about 10% of patients. Similarly, loss of bladder control or erectile dysfunction is not a feature of PD. When these features are present, one should suspect multiple system atrophy (MSA).
Diagnosis of PD
The diagnosis of PD is still best made on the basis of clinical examination by an experienced neurologist (preferably trained in movement disorders, though not a must). PET and DaT scans are available to help in the diagnosis of PD, but they are not superior to a good clinical examination by an experienced neurologist.
Treatment of PD
Treatment of PD is still primarily medical and DBS is not the first option.
The most effective medicine is levodopa-carbidopa combination. If a patient does not respond to levodopa treatment, we should doubt the diagnosis (it may not be PD). Even though levodopa is the most effective medication, we should delay starting it by 2-3 years, to avoid side effects and lack of efficacy later on. Other medications in use are pramipexole, ropinirole, trihexiphenydyl, selegiline, rasagiline, amantadine, entacapone, safinamide, etc.
Role of Deep Brain Stimulation (DBS) surgery in PD
DBS was approved for PD in 2002. In the past 15 years, about 1,35,000 patients worldwide have undergone DBS for PD.
What does DBS surgery involve?
A neurosurgeon places the leads (thin wires) that carry electrical signals to specific areas of the brain. Then, the surgeon places a battery-run neurostimulator (like a pacemaker) under the skin of the chest.
The surgeon may use a programming device to adjust the settings. You may have a device, similar to a remote control, which allows you to turn the system on and off and check the battery. You may also be able to adjust the stimulation within options programmed by your doctor.
A neurologist initially evaluates a patient to determine whether he or she is the right candidate for DBS surgery. Then, further evaluations include brain imaging (MRI, CT, PET, etc), neuropsychological testing, UPDRS scoring, etc. Once the patient is found to be suitable for DBS, he is referred to the neurosurgeon.
Which patients are likely to benefit from DBS surgery?
1. The diagnosis of PD should be definite.
2. Patient has had PD for five years or more.
3. Patient continues to respond to levodopa, even though the response may or may not be good.
4. There are motor fluctuations, such as on-off phenomena, with or without dyskinesia.
5. Various medical treatments have not had desired benefit.
6. PD symptoms are severe enough to interfere with activities of daily living.
Which patients are NOT likely to benefit from DBS surgery?
1. Patients with atypical Parkinsonian symptoms,
2. Patients with multiple system atrophy (where bladder and sexual dysfunction are prominent symptoms),
3. Patients with progressive supranuclear palsy,
4. Patients with dementia or severe cognitive impairment,
5. Patients with unstable psychiatric illnesses,
6. Patients with advanced PD, who are confined to bed/wheelchair; despite being on medications,
7. Patients with NO response to levodopa therapy,
Who are the best candidates for DBS surgery in PD?
1. Excellent response to levodopa therapy,
2. Younger age,
3. Mild or no cognitive impairment,
4. Few or no axial (affecting neck or trunk) motor symptoms,
5. Absence of or well controlled psychiatric disease.
Are there any complications of DBS surgery?
DBS surgery is generally safe if performed by a trained group of specialists. However, complications may occur in upto 3% of patients, which include:
1. Bleeding (hemorrhage) in the brain,
4. Speech impairment
5. Erosion, migration or fracture of the lead,
What to expect after DBS surgery?
Most patients report a reduction in severity of symptoms after surgery. Tremors, dyskinesia, slowness all respond to the surgery.
PD medications, however, can not be stopped even after DBS. Most patients still need to take medications, however, at much lower doses.
The benefits are seen at five years after surgery, however, the effect tends to wane in later years.
DBS does not alter the disease progerssion, and disease continues to get worse even after DBS.
Is MRI safe after DBS?
Yes, MRI can be safely done after DBS surgery.
What is the cost of DBS surgery ?
The cost of surgery is approximately INR 9,00,000 to 10,00,000.
Dr Sudhir Kumar MD (Med) DM (Neuro)
Senior Consultant Neurologist
Apollo hospitals, Hyderabad
Sunday, May 4, 2014
CERVICAL AND LUMBAR DISC DISEASE
Disc is the soft tissue located in between the vertebral bodies.
A picture showing different types of disc problems.
Disc problems are common in cervical (neck) and lumbar (lower back) regions. Earlier, it was common in older people, due to more degeneration of discs in them. However, now-a-days, we see several younger people, even in their 20s and 30s, who come with disc problems. This is because of sedentary life style, lack of exercises, prolonged sitting (on account of job, computer use, etc), and sports injuries.
What are the common symptoms of disc diseases?
Disc prolapse or slipped disc can present with several symptoms:
In cervical disc disease, following symptoms are common:
1. Neck pain,
2. Pain in the arm, which may increase on coughing,
3. Tingling or pins and needle sensations in the arm,
4. Numbness in arm,
5. Weakness in the arm.
In lumbar disc disease, the following symptoms may occur:
1. Lower back pain,
2. Pain in the leg, which may radiate from lower back to the leg, also referred to as sciatica,
3. Tingling or numbness in leg,
4. Weakness of leg,
5. Leg pain, numbness or weakness may increase on walking (referred to as claudication), and get relieved on resting.
How is the diagnosis of disc disease confirmed?
1. Clinical history and examination by a neurologist are useful in suspecting the diagnosis.
2. MRI of spine (cervical or lumbar region, as the case may be) is the confirmatory test for disc disease.
An MRI scan of lumbar spine showing a prolapsed disc at L5-S1 level
What are the treatment options for disc disease?
Conservative (without surgery): It is useful to note that surgery is not needed in about 90% of cases.
Several measures are useful in relieving pain in patients with disc prolapse:
1. Rest- in severe cases, bed rest may be advised. In less severe cases, limited mobility within the house (for toilet and dining purposes) may be permitted.
2. Use of analgesics (such as aceclofenac, etoricoxib) and muscle relaxants (such as mobizox and myospaz forte) may help in relieving pain.
3. Specific medications that help reduce the nerve pain are pregabalin, gabapentin, duloxetine, etc.
4. Physiotherapy- measures such as IFT, ultrasound, traction, etc help reduce the pain in several people with disc prolapse.
In 10% of patients, medical treatment fails, then, surgery may be needed. Following are the specific indications for surgery in a patient with slipped disc:
1. Failure of medical treatment to adequately control the pain,
2. Progressive neurological deterioration, such as worsening of weakness or numbness, or bladder/bowel involvement,
Various types of surgeries are:
3. Spine stabilisation with instrumentation.
The choice of surgery depends on patient's symptoms, MRI findings and age.
General advice to patients with disc disease:
1. Avoid forward bending,
2. Avoid lifting heavy weights.
3. Lose weight, if overweight or obese
What is the prognosis of patients with disc disease?
In general, the outcome of patients with disc prolapse is good and most patients return to normal life after proper treatment. They are able to do their activities of daily living and are gainfully employed.
Surgery is also safe, however, I come across many people who have wrong notions about surgery. They have been mis-informed that after surgery, people get paralysed. In practice, this does not happen. However, if the case for surgery is not correctly chosen, there may not be good relief from pain after surgery also, a condition referred to as "failed back syndrome".
If you have any further queries, you may get back to me.
Dr Sudhir Kumar MD (Internal Medicine) DM (Neurology)
Senior Consultant Neurologist,
Apollo Hospitals, Hyderabad, India
Online consultation: http://bit.ly/Dr-Sudhir-kumar