Parkinson’s disease DBS: what, when, who and why? The time has come to tailor DBS targets

Abstract

Deep brain stimulation (DBS) has recently been proven to be an effective therapy for medication-refractory symptoms of Parkinson’s disease. As the evidence base continues to evolve, many important issues have surfaced, including: what operation should be performed (brain target[s], unilateral vs bilateral, simultaneous vs staged); when to operate (how early is too early to intervene?), who should be operated on (disease duration, age, symptom profiles and the use of the interdisciplinary screening team); and finally, why to operate (the rationale of surgery vs medication/apomorphine pumps/duodopa pumps/stem cell trials/gene therapy trials). We will address each of these critical issues, as well make the argument that a tailored approach to DBS and DBS targeting will best serve each potential candidate. We will review the multiple peer-reviewed studies and we will emphasize the recently available data from randomized DBS studies. We will argue that moving away from a single DBS target (e.g., subthalamic nucleus DBS) and a single approach to DBS methodology (e.g., bilateral simultaneous operations) is a reasonable next step for the Parkinson’s disease community. Following careful interdisciplinary DBS screening, a physician–patient discussion has the potential to establish a patient-centered and symptom-specific outcome for each potential DBS candidate. The interdisciplinary DBS team can function together to formulate and to consider an optimal and tailored approach. A tailored approach will allow for the consideration of the complex and numerous variables that may contribute to a positive or negative overall DBS outcome. We will review and provide expert commentary on a potential interdisciplinary approach to selecting unilateral or alternatively bilateral subthalamic nucleus or globus pallidus internus DBS. Our approach is aimed to maximize benefit(s) and minimize risk(s) in order to best tailor therapy for an individual patient.

Keywords::

• candidates
• DBS
• deep brain stimulation
• GPi
• Parkinson’s disease
• STN

Acknowledgements

We would like to acknowledge Ihtsham Haq for his help in refining our thoughts on the early DBS section of the manuscript.

Financial & competing interests disclosure

We would like to acknowledge the support of the University of Florida National Parkinson Foundation Center of Excellence and the Greene and Jacobus family funds.

Michael Okun serves as a consultant for the National Parkinson Foundation, and has received research grants from NIH, NPF, the Michael J Fox Foundation, the Parkinson Alliance, Medtronic peer reviewed fellowship training grants, and the UF Foundation. Michael Okun has in the past received honoraria for DBS educational talks prior to 2010, but currently receives no support (since July 2009). Michael Okun has received royalties for publications with Demos, Manson and Cambridge (movement disorders books). Michael Okun has potential royalty interest in the COMPRESS tool for DBS. Michael Okun has participated in CME activities on movement disorders sponsored by the USF CME office.

Kelly Foote has received research grants from NIH, NPF, Medtronic peer reviewed fellowship training grants and the UF Foundation. Kelly Foote has in the past received honoraria for DBS educational talks, but currently receives no support. Kelly Foote has potential royalty interest in the COMPRESS tool for DBS. Kelly Foote has participated in CME activities on movement disorders sponsored by the USF CME office.

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.