Depression Surgery | DBS Surgery | Dr Paresh Doshi | Jaslok Hospital

                                        Depression Surgery Jaslok Hospital Dr Paresh Doshi

The Deep Brain Stimulation surgery in India has shown successful results in a majority of patients suffering from advanced stages of the Parkinson’s disease and is now a well-accepted treatment. While this surgery showed major improvements in Parkinson’s disease patients for controlling motor movements and the like, until recent time there was no substantial evidence that the same surgery could be used for patients suffering from depression. However, thanks to medical research on the matter, it has been proved that DBS can be a viable option for treatment resistant depression in patients, especially for unipolar major depressive disorder (MDD) or bipolar II disorder (BP). And DBS for depression is now being talked about extensively.

Surgery Procedure

The surgery was done under local anesthesia with stereotactic guidance keeping the patient completely awake during the procedure. Initially, a frame is applied to the patients head and CT scan was done. These images are fused with the previous MRI images of brain using a special software program and the specific target in the brain i.e., subgenual cingulate gyrus area 25 is visualized. Dr. Doshi does the optimum target and trajectory planning for DBS. After that, the patient is brought to the operation theatre. During surgery, Benjamin was tested by asking several questions relating to his mood and feelings. As the lead was inserted and the brain stimulated, Benjamin said he was feeling lighter than before, smiled during the procedure, felt relieved of stress and felt like talking to his old friend to whom he stopped talking for a long time, indicating improvement in feelings. The leads were connected to a pacemaker that delivers continuous stimulation to the brain. As days progress, the effect of stimulation builds up and we look forward to a greater improvement in his mood.

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Major Depression

Biochemical disturbances in certain brain chemicals called neurotransmitters are thought to be the underlying cause of depressive disorders in general. Major depression is a major psychiatric disorder in which, the prominent symptom is a disturbance of mood which is a constant feeling that is experienced internally and that influences a person’s attitudes, thinking, behaviour and perception. The prevalence of Major Depression is about 2%-6%, more commonly in women.

Dr. Paresh Doshi, Director of the functional neurosurgical department at Jaslok Hospital, established this program in 1998 to treat movement disorders, epilepsy, spasticity, pain and psychiatric disorders. The first Deep brain stimulation (DBS) surgery in India was performed here. Dr. Doshi has performed over 250 DBS surgeries at Jaslok Hospital, which is the largest in India and is credited as the only Indian on the task force for “guidelines for psychiatric disorders surgery”.

Dr. Amit Desai, has been a Consultant Psychiatrist at Jaslok Hospital for almost 13 years. He specialises in adult psychiatry. Psychiatric consultant on Jaslok Hospital’s Functional Neurosurgical Department panel for DBS related to Parkinson’s Disease and Obsessive Compulsive Disease.

How is Parkinson’s disease Diagnosed? And What Are the Treatment options?

Parkinson’s disease is caused by the gradual degeneration of nerve cells in the midbrain portion that controls movement. It is very difficult to make an early diagnosis of this disease because they symptoms are not very conspicuous. The most common symptoms that you will see are a feeling of weakness or stiffness in your limb or a slight trembling in one of the hands even when it is at rest. As the disease progresses, the tremor worsens and the shaking increases, muscles tend to become stiff and movements become slow. This hinders normal functioning and the individual faces emotional problems leading to depression.

Diagnosis

Parkinson’s is diagnosed by outward symptoms if they are distinctive enough to be seen easily. However, there is no blood test or scan that confirms the diagnosis.

What are the causes?

Our body movements are regulated by one portion of the brain called the basal ganglia. The cells here require a proper balance of two main substances namely – dopamine and acetylcholine. These two substances are involved in the transmission of the nerve impulses throughout the body. When the cells that produce dopamine begin to degenerate, it causes an imbalance in the two neurotransmitters. Genetics have a major role in the breakdown of the cells. Well, research has also shown that Parkinson’s can be caused by a viral infection or exposure to some kind of pesticides or toxic chemicals.

In a general sense, the actual cause of this disease is yet unknown. How the neurons actually become impaired is unknown. There is however an increasing belief that Parkinson’s is inherited.

What are the treatment options for Parkinson’s?

Parkinsons disease treatment includes restoration of proper balance for individuals by increasing the dopamine levels. Drugs are generally used to restore proper balance. If the condition worsens and cannot be controlled by medication alone, other means of treatment such as deep brain stimulation (DBS) can be used to correct the situation.

Parkinson’s can be controlled in initial years without having to resort to DBS. Medication alone can help reduce the symptoms and patients can get back to routine life without any major hindrances.

There are no known ways to prevent the occurrence of this disease. But there are plenty of ways in which it can be treated. The treatment includes drugs that increase the level of dopamine so that it resets the balance of the neurotransmitters. Other surgical options are also available for the treatment of Parkinson’s disease. Well, Deep Brain Stimulation has been found to be highly effective and helps restore the patient to normal life sooner. For more information, you can visit our website: www.neurologicalsurgery.in

Advantages of Deep Brain Stimulation Surgery

Deep brain stimulation surgery inactivates parts of the brain that are known to cause Parkinson’s disease, without actually destroying any part of the brain. This procedure involves the placement of electrodes connected by wires to a pacemaker device. This device is also called as an impulse generator. This device is placed under the skin of the chest and below the collar bone. Continuous electrical pulses are sent to the target area in the brain, thus blocking the pulses causing the tremors. It gives the same results as surgery would, but does not destroy any parts of the brain.

A computer sends signals to the impulse generator and hence it can be programmed to function as per the doctor’s instructions. The impulse generator can be turned on and off externally with the help of special magnets.

Firstly, the areas of the brain – or the target areas must be defined. These can be located with the help of MRI or Computer Tomography (CT). Sometimes micro electrode recording is also used for this purpose. Once the location is identified, the electrodes are placed and the incisions are closed with sutures. The impulse generator is then placed in the chest and the electrodes are connected to it with wires. It takes a few weeks to adjust the stimulation which is enough for the patient to experience symptom relief.

Here are some of the undeniable advantages of Deep Brain Stimulation:

• The complications involved in this procedure are few, because there is no destruction of any part of the brain.
• The electrical stimulation is adjustable as per the patient’s requirements. If the patient responds positively to medications, the impulse can be reduced. There is no further surgery involved in making any kind of adjustments.
• Destructive treatments such as surgeries could reduce a person’s potential for future treatment options.
• Deep Brain Stimulation is a relatively safe option as compared to surgery.
• All the major symptoms of Parkinson’s disease can be minimized.
• The stimulator can be turned off at any time.
• Routine life of the patient is greatly improved and dependency is reduced.

However, there are some concerns from patients about a few risks involved. Especially the risk of infection. Well, if any foreign object is implanted in our body, that risk is always there. If the equipment stops working, and needs a battery replacement, additional surgery may be required. Like any other treatment, there are certain risks involved too, like changes in thinking and memory; sometimes there are changes in personality too. You will need to immediately talk to your doctor if you notice any such after effects, before they aggravate.

It is also a known fact that over 70% of those who have undergone deep brain stimulation surgery, say that they experienced great improvement in their conditions. The medications can then be reduced.

Once the patient has enough trials with medications and other forms of treatment, Deep Brain Stimulation is considered as a great option to restore normal life of the patient.

The other diseases that are amenable to deep brains stiumulation are Depression, Obsessive compulsive disorders, epilepsy etc. Dr. Paresh K. Doshi has been the pioneer of deep brains stimulation surgery in India. He has an experience of over 400 DBS surgery. The dbs cost at the Jaslok hospital and research centre is the lowest in India.

Frequently Asked Questions

Deep Brain Stimulation Surgery is generally used to treat movement disorders especially those caused by the Parkinson’s disease. It can treat the symptoms by interrupting the abnormal patterns of brain activity that cause them. Constant pulses of electrical charge are delivered very precisely to the pre-identified parts of the brain.

Here are the most common questions asked about Deep Brain Stimulation Surgery or DBS:

What symptoms does DBS help?
As regards to Parkinson’s disease, Deep Brain Stimulation surgery is known to control a number of symptoms such as tremor or shaking. DBS helps in complete or partial relief of symptoms and also helps with other symptoms such as rigidity and slowness of movements. DBS will abolish off period pain and dystonia (curling of toes and fingers). It also helps to control the dyskinesias (involuntary dancing like movements, being side effect of medicine).

Are medications continued for Parkinson’s after DBS?How long do the benefits of DBS last?
Deep Brain Stimulation surgery lasts for many years depending on the condition of the patient. It has been observed that this has worked for over 10 years – of course under close observation and follow up appointments. The DBS settings are rarely changed after the first year of observation. We have patients who even after 15 years of Deep brain stimulation surgery continue to be benefited by DBS.

In some patients the medicines can be totally stopped. However, it is important to understand that the Deep Brain Stimulation is not a substitute for medications. It only helps reduce the symptoms. The underlying cause still needs to be treated with medications. If progress is seen in the patient’s condition, the doctor will automatically reduce the dose of these medications.

What if DBS does not work?
Sometimes DBS does not work due to a number of reasons such as improper selection, hardware dysfunction or problems with the programming. If you do not notice any changes in your symptoms after a DBS, within a specified period of time, you will need to contact your doctor immediately. Most of the time the DBS has not worked because the programming is improper or the lead is not placed in the ideal position. In such cases it is important that you choose the most experienced centre to perform DBS. We have reprogrammed several patients of DBS who have not had benefits after being operated at other centres.

Are there any activities that I need to avoid after DBS?
You can return to normal daily life within a few months of surgery, but it is best to avoid neck manipulation, massage or any direct physical contact with the implanted device.

Can I exercise after DBS?
Yes. You can certainly exercise after DBS. It is however recommended that you include low impact exercises after this surgery. Sports and other rigorous exercises need to be completely avoided. It is recommended that you perform light exercise daily as advised by your doctor.

Are there any electrical devices that I need to avoid?
The most basic household electrical equipment is safe to use after a Deep Brain Stimulation Surgery. Some high power industrial machinery could be dangerous though. Some types of MRI could be dangerous and you must inform your doctor about your DBS before undergoing MRI. Before you undergo any other medical procedure, you must inform your doctor about the DBS surgery.

Sometimes, the device may stop working or malfunction if the battery power depletes. You will notice this when your PD symptoms worsen. All you need to do is contact your doctor and get it fixed. The doctor will definitely schedule regular appointments so that such a situation does not arise!

Overall, DBS is a very effective method to reduce symptoms of tremor and movement disorders and return to normal life as soon as possible.

Parkinson's Disease | Dr.Paresh.Doshi

Treatment of restless leg syndrome by Deep Brain Stimulation

RLS symptoms are improving, and improvement is sustained up to two years despite significant decrease of dopaminergic treatment after deep brain stimulation surgery for Parkinson’s disease -Dr Olga Klepitskaya

People with restless legs syndrome have uncomfortable sensations in their legs (and sometimes arms or other parts of the body) and an irresistible urge to move their legs to relieve the sensations. The condition causes an uncomfortable, “itchy,” “pins and needles,” or “creepy crawly” feeling in the legs. The sensations are usually worse at rest, especially when lying or sitting.

The severity of RLS symptoms ranges from mild to intolerable. Symptoms can come and go and severity can also vary. The symptoms are generally worse in the evening and at night. For some people, symptoms may cause severe nightly sleep disruption that can significantly impair their quality of life.

An intriguing study shows that deep-brain stimulation  may be an effective treatment for symptoms of restless leg syndrome (RLS).

In patients with Parkinson’s disease (PD), devices for DEEP BRAIN STIMULATION of the subthalamic nucleus (STN) were implanted. Among those who also had RLS, follow-up showed substantial reduction in RLS symptoms and benefit on RLS impact.

“This is the first observation on 22 patients, which is the largest number so far, that RLS symptoms are improving, and improvement is sustained up to 2 years despite significant decrease of dopaminergic treatment,” Olga Klepitskaya, MD, associate professor of neurology at the University of Colorado Denver Anschutz Medical Campus in Aurora, told Medscape Medical News.

The results were reported here at the 19th International Congress of Parkinson’s Disease and Movement Disorders (MDS).

RLS occurs in up to 50% of patients with PD and often responds well to dopaminergic therapy. DEEP BRAIN STIMULATION is an effective therapy for dopamine-responsive PD symptoms, so it is reasonable to think that RLS may respond to DBS surgery.

However, studies have been inconclusive with variable effects, including improvement in or emergence of RLS after STN DEEP BRAIN STIMULATION. There has also been moderate improvement or no effect after DBS surgery of other basal ganglia areas for various other movement disorders.

In the current study, all patients at this institution undergoing STN DEEP BRAIN STIMULATION surgery for PD between 2008 and 2013 filled out questionnaires about several conditions, including RLS and RLS quality of life preoperatively and out to 2 years after surgery. The study involved patients with moderate to severe RLS (International RLS Study Group rating scale [IRLS] sum scores >10).

In this study of 12 women and 10 men, patients had a mean age of 58.3 years and a baseline mean IRLS sum score of 19.59±6.95. At 6 months, the IRLS sum score diminished by 5.06 and further diminished slightly by 2 years.

We have also seen similar results in our patients undergoing dbs surgery in India.

Other RLS scores also reflected persistent benefit of the DBS out to 2 years. Quality-of-life scores trended toward benefit but were not significantly different from baseline.

Deep Brain Stimulation Surgery Facts and Advantages

Deep brain stimulation surgery is generally used to inactivate the parts of the brain that cause diseases such as Parkinson’s and other associated movement disorders. This procedure is done without causing any damage to the brain. In this procedure, electrodes are placed at specific points in the brain and are connected by wires to a pacemaker. This pacemaker is also called an impulse generator. This pacemaker is placed in the chest under the collar bone. The device is activated and it sends continuous electrical impulses or signals to the targeted areas of the brain. These pulses block the impulses that are the root cause of tremors. The after effects are same as surgery only that it does not have to damage any part of the brain in order to treat the disease.

Patients are provided with special kinds of magnets so that they can turn off the device or turn it on externally as and when required. These stimulators last for around four to five years in patients of Parkinson’s disease. They need to be replaced after that to ensure proper functioning.

How is the surgery performed?

Firstly, the targeted areas are located. MRI is the most common method used to locate these target areas. Some also use the micro electrode recording technique to map the targeted area in the brain where the electrodes need to reach.

As soon as the correct location is identified, the electrodes are implanted in the brain. The loose ends of the electrodes are left under the skin and the incision is closed. All this is done under local anesthesia. On the next day under general anesthesia, the impulse generator is connected with the help of the extension wires to the implanted electrodes.

 How long does it take for patients to see symptom relief?

The stimulators are switched on the next day. The patient feels improvement in his symptoms and the medicines are gradually reduced. The titration to the optimal settings may take upto 3 months. Patients should see significant symptoms relief after a few weeks of this procedure. Overall, there should be very few side effects.

What are the advantages of DBS?

• To begin with, deep brain stimulation does not require a deliberate destruction of any part of the brain.
• There are fewer complications involved as compared to surgery.
• The electrical stimulation is adjustable and can be increased or decreased as required.
• There is no further surgery required for changing anything.
• Destructive surgery limits the chances of further cure or surgery as the part of the brain is already damaged. With deep brain surgery this is not the case. You can easy make changes in the impulses or the intensity of the impulses for further treatment.
• Deep brain surgery is a relatively safe procedure that involves fewer risks.
• The quality of life of the patient can be improved
• You can turn off or turn on the stimulator as per the symptoms observed. You need not go in for surgical procedures each time you need to change something.