The primary goal of surgery for Parkinson's disease is to reduce the motor symptoms and tremors of the disease, as well as the side effects that can come from some of the medications used to treat it, such as dyskinesia (too much involuntary movement after medication) or motor fluctuations (increasing randomness as to when and for how long the medications will work). Another goal of surgery is to increase the number of hours of “on” time (time spent in a better, less symptomatic state) each day and in many cases, to reduce the amount of medication needed each day to maintain the best condition.
Deep brain stimulation (DBS) is a minimally invasive surgical procedure to treat neurological symptoms of Parkinson’s disease, including tremors, rigidity, and movement control.
Dr. Kaplitt and Dr. Stieg talked about DBS for Parkinson's disease on an episode of This Is Your Brain With Dr. Phil Stieg. Listen to that podcast episode below:
DBS uses a neurostimulation device, similar to a heart pacemaker, to deliver electrical pulses to a very precise location in the brain circuits that influence Parkinson’s disease symptoms. Abnormal activity in these circuits is what causes many of the movement problems in Parkinson’s disease; the electrical pulses from the DBS device blocks the activity of these circuits so the rest of the brain can function more normally. This can lead to improvement in many of the symptoms that had previously been helped by medication but that no longer respond adequately. Deep brain stimulation also usually reduces complications often seen with medication. Successful patients often can reduce substantially the amount of medication that they must take each day.
The procedure involves placing battery-operated neurotransmitters under the collarbone. The devices are connected to a wire under the skin that runs up the length of the neck into the scalp, where it is placed into the brain through a small hole in the skull. The tip of this wire sends the electrical impulses generated by the neurotransmitter into the precise spot in the brain that regulates activity of the key circuits in Parkinson’s disease.
The procedure can be done in one or two stages, which can be performed in a single day or on consecutive days.
- The first stage, in which the electrode is placed in the brain based upon MRI guidance, is done while the patient is awake. The patient must be awake to provide feedback during surgery and to permit the surgeon to monitor brain activity to make sure the electrode is placed in the correct place. Other than a brief pinch for an injection of local anesthetic to numb the skin, there is generally no pain associated with this procedure. This first stage usually involves a single overnight hospital stay.
- The second stage, in which the neurotransmitters are placed under the collarbone and connected to the end of the electrode just under the skin, is very similar to that of receiving a heart pacemaker. This second procedure is performed under general anesthesia since it does not require any patient feedback, and it usually requires another overnight stay.
As with all surgical procedures, DBS poses a small risk of bleeding and infection. There are also potential risks related to the device, such as breakage or movement of a wire. The major benefit of DBS, however, is that it does minimal damage to the surrounding brain tissue, as can happen with other surgeries. The implanted device can also be reprogrammed wirelessly and painlessly without additional surgery, so that the treatment is individualized to each patient. The therapy can also be reversed as technologies advance for improved treatments in the future.
The best candidates for DBS are patients who have tremors, stiffness, slowness, and other movement-related symptoms that had previously responded to medication but that are becoming more problematic despite increasing doses and/or numbers of medication. Those who suffer complications from medications — but still respond to them — are also excellent candidates. In these patients, deep brain stimulation usually reduces both the complications and the amount of medication needed.
Our DBS program has successfully treated patients with Parkinson’s disease for the past 20 years under Dr. Kaplitt’s direction. We have found that the best outcomes result from a careful, thoughtful, multi-disciplinary approach, involving expert surgeons, neurologists, radiologists, nurse practitioners, neuropsychologists and physical therapists, Members of our team have many years, and in some cases several decades, of experience with Parkinson’s disease, as well as many years of working together as a team to optimize individual treatment for each of our patients.
MR guided focused ultrasound (MRgFUS) in a groundbreaking technology for non-invasive alteration of brain circuits to improve function and thereby resolve symptoms for neurological disease. Weill Cornell Medicine was the first center in New York to offer MRgFUS to our patients with movement disorders, and we are a leading center in the world in this technology from laboratory research to human clinical trials to treatment of patients with approved indications.
In many disorders, including Parkinson’s disease, key brain regions are either abnormally active or send abnormal information to the rest of the brain. The result is dysfunction of brain circuits regulating important activities. As an alternative to electrical stimulation, destruction (ablation) of these very small, precise brain targets can eliminate the bad information being created by these areas, thereby releasing the remaining parts of the brain circuitry to again function more normally.
Hear from patients who have been treated with focused ultrasound for essential tremor:
Alexandra Lebenthal: The CEO talks about the High-Intensity Focused Ultrasound procedure she underwent for essential tremor.
Alexandra Lebenthal and Dr. Kaplitt were featured on an episode of Dr. Stieg's podcast, This Is Your Brain With Dr. Phil Stieg:
The advance with MRgFUS is combining the ability to deliver ultrasound energy to precise brain targets with monitoring the consequences with MRI imaging while the procedure is being performed. Ultrasound can go through the skull and through the brain safely but normally the energy is so low that it cannot have any major effect. With the MRgFUS device, a helmet is placed with 1000 sources of ultrasound arrayed around the head. Each individual beam of ultrasound is pointed at the desired target, with each beam coming through the brain from a slightly different direction. So very little energy is delivered to most of the brain, but at the desired target point, these beams converge so the energy of nearly 1000 beams of ultrasound can all add up only at the target. This is enough energy to heat that area of the brain, and this painless heating can be monitored in real time with the MRI. Patients are awake during the procedure so that they can be tested for both improvement in symptoms and to confirm that no side effects are developing. Increasing energy is delivered in small steps, confirming the location of heating by MRI and the symptoms and side effects by exam each time, until a permanent ablation is created. At the end of the procedure, there is no device implanted and no incisions in the head, and patients usually can go home within one or two hours after the procedure is completed.
NEWS: Find out more about
Weill Cornell Medicine's pioneering work using
Focused Ultrasound for Essential Tremor
MRgFUS was originally FDA approved in 2016 for use in essential tremor, a related disorder in which patients have a severe tremor without other symptoms. More recently, MRgFUS FDA approval was expanded for use in patients with tremor from Parkinson’s disease. The area of the brain targeted for tremor is specific for tremor and therefore is not expected to help other symptoms of Parkinson’s disease. We participated in a clinical trial of MRgFUS to another brain region, called the globus pallidus, for patients with stiffness, freezing and complications of medical therapy. That study has been completed and the data is currently being analyzed. MRgFUS is also currently only FDA approved to treat one side of the brain, so we usually concentrate on the most symptomatic side (or the side that will have the most impact on quality of life). We are currently helping to lead a study treating the other side of the brain in essential tremor patients who already had their first side successfully treated with MRgFUS. That study is ongoing, and if successful, it could be expanded to patients with Parkinson’s disease. FDA approval does not guarantee that your insurance company will cover the treatment, as each insurer has to reach its own conclusions, but we can help with outreach to insurance companies if coverage is desired and if you are a good candidate for this procedure.
Finally, we are actively helping to lead a study using a different method of MRgFUS to not ablate brain tissue but rather to temporarily open the blood-brain barrier at specific targets, which normally prevents treatments from entering the brain from the bloodstream. We recently reported on our first series of patients with Alzheimer’s disease, where we demonstrated safe and very efficient opening of the blood brain barrier in regions responsible for learning and memory, and in a second study we showed evidence of some clearance of the pathology underlying Alzheimer’s disease. Our laboratory is a leading center in the world for application of this technology for non-invasive delivery of genes, cells and other cutting-edge therapies to the brain from a simple injection into the bloodstream without invasive surgery.
The Movement Disorder service of the Weill Cornell Brain and Spine Center is a leader in the diagnosis and treatment of Parkinson’s disease, and also conducts groundbreaking laboratory research and clinical trials to improve our understanding and treatment of this disorder. Led by pioneering researcher and neurosurgeon Michael Kaplitt, MD, PhD, the Movement Disorder service provides state-of-the-art options for Parkinson’s treatment, including minimally invasive deep brain stimulation surgery.
Our Care Team
- Executive Vice Chair, Research, Neurological Surgery
- Professor of Neurological Surgery
- Director, Movement Disorders and Pain
- Director, Residency Program
- Associate Professor of Neuropsychology in Neurological Surgery
- Director of Neuropsychology Services
Reviewed by Michael Kaplitt, MD, PhD
Last reviewed/last updated: January 2021