Deep Brain Electrode Implantation (DBS)

General:This procedure involves insertion of unilateral or bilateral deep brain electrodes under MAC anesthesia followed by subcutaneous placement of a pulse generator under general anesthesia. Most patients have Parkinson’s disease, essential tremor, or dystonia which is refractory to other treatment modalities.
Preop: 6.30 am an IV will be started (by Dr Starr or Larson). After 1-2 mg of midazolam, and local anesthesia a stereotactic frame is placed on the head. Patient will then go to CT. For most patients with Parkinson's disease or essential tremor, no anesthesia presence is needed at the CT. However, for patients with dystonia (about 1 case every 2 months), Dr. Starr or Larson will contact the attending anesthesiologist the day before and request their presence starting with frame placement at 6:30 am. Some of these patients are children who will require general anesthesia for the entire case, starting with frame placement. Adult dystonia patients who do not require general anesthesia usually have severe cervical dystonia, necessitating heavy sedation (propofol) by the anesthesia team for frame placement and CT. Patient arrives to the operating room about 7.45 am. Administer 1-2 gm of Cefazolin unless contraindicated.
Monitors:Routine monitors. BP cuff on ipsilateral calf or an arterial catheter on ipsilateral arm (if unilateral lead). Pulse oximeter on ipsilateral hand (if unilateral lead). Nasal cannula O2. Operating room table will be at 180 degrees.
Anesthesia:Propofol bolus for Foley catheter placement. Propofol and remifentanil infusions for access to the cranium. After insertion of Foley catheter, patient will be positioned in a beach chair (sitting) position. After dural opening, no sedatives should be administered till the electrode(s) have been inserted and neurologic testing completed. No long acting sedatives or narcotics should be used up to this point. Systolic blood pressure should be kept below 140 mmHg at all times (labetalol). For skin closure, propofol infusion may be used. However, surgeons do want to assess patient’s neurologic status at the end of this stage of the operation. For the second stage of the operation, the patient will be supine. General anesthesia of the anesthesiologist choice will be used for the placement of the pulse generator below the
clavicle and for tunneling of the leads from the new electrode to the pulse generator. For this part, the table will be turned so that the pulse generator side is away from the anesthesiologist.
Potential complications:Potential for air embolus (presents as chest pain or coughing) in the sitting position and intracranial bleed (about 2%) from microelectrode mapping or from DBS electrode insertion. Significant tremor may interfere with hemodynamic monitoring. Recovery: Typically in the recovery room. Stimulator will not be turned on on the day of the operation. All patients get a postoperative MRI to confirm electrode location and rule out hematoma (no anesthesia presence required).

Recovery:Typically in the recovery room. Stimulator will not be turned on on the day of the operation. All patients get a postoperative MRI to confirm electrode location and rule out hematoma (no anesthesia presence required).

Last revised 052013 Talke