Parkinson's Disease - Symptoms, Diagnosis, Treatment of Parkinson Disease in India

Parkinson's disease is a chronic, degenerative neurological disorder that affects one in 100 people over age 60. While the average age at onset is 60, some people are diagnosed at 40 or younger. There is no objective test, or biomarker, for Parkinson's disease, so the rate of misdiagnosis can be relatively high, especially when the diagnosis is made by a non-specialist. Estimates of the number of people living with the disease therefore vary, but recent research indicates that at least one million people in the United States, and more than five million worldwide, have Parkinson's disease.

Parkinson's disease was first characterized extensively by an English doctor, James Parkinson, in 1817. Today, we understand Parkinson's disease to be a disorder of the central nervous system that results from the loss of cells in various parts of the brain, including a region called the substantia nigra. The substantia nigra cells produce dopamine, a chemical messenger responsible for transmitting signals within the brain that allow for coordination of movement. Loss of dopamine causes neurons to fire without normal control, leaving patients less able to direct or control their movement. Parkinson's disease is one of several diseases categorized by clinicians as movement disorders.

The exact cause of Parkinson's disease is unknown, although research points to a combination of genetic and environmental factors. If a continuum existed, with exclusively genetic causes at one end and exclusively environmental causes at the other, different Parkinson’s patients would likely fall at many different places along that continuum.

In the past 10 years, researchers have identified a number of rare instances where Parkinson's disease appears to be caused by a single genetic mutation. In these cases, the mutated gene is passed from generation to generation, resulting in a great number of Parkinson's disease cases within an extended family. On the opposite end of the continuum, in the early 1980s, a group of heroin users in California took drugs from a batch contaminated with a substance called MPTP. After ingesting this chemical, the drug users were stricken with a form of Parkinson's disease that was primarily, if not exclusively, "environmental" in origin.

For most Parkinson's patients, the cause lies somewhere in the middle. While many Parkinson’s patients report one or more family members with the disease, it is not always clear that one or several genes are the cause. Similarly, while some patients suspect that exposure to one or another chemical or environmental toxin caused their Parkinson’s disease, this also cannot be conclusively proved. Scientists currently believe that in the majority of cases, genetic and environmental factors interact to cause Parkinson's disease. Research into this subject continues aggressively every day. Unfortunately, however, it is generally impossible to determine what specifically caused an individual's Parkinson’s disease.

The causes of Parkinson’s disease are unknown, there is no scientifically validated preventive course to reduce the risk of its onset. The single biggest risk factor for Parkinson’s disease is advancing age. Men have a somewhat higher risk than women.

That being said, a number of studies have highlighted factors that are associated with either greater or lesser risk of Parkinson's disease. For example, smoking and caffeine consumption have been associated with lower rates of Parkinson's disease, while head injury and pesticide exposure have been associated with higher risk. While such studies do not definitively link these factors with Parkinson's disease one way or another, they highlight areas where further research may guide us to risk-prevention or treatment strategies.

The cardinal symptoms of Parkinson's disease are resting tremor, slowness of movement (bradykinesia) and rigidity. Many people also experience balance problems (postural instability). These symptoms, which often appear gradually and with increasing severity over time, are usually what first bring patients to a neurologist for help. Typically, symptoms begin on one side of the body and migrate over time to the other side.

There is no objective test (such as a blood test, brain scan or EEG) to make a definitive diagnosis of Parkinson’s disease. Instead, a doctor takes a careful medical history and performs a thorough neurological examination, looking in particular for two or more of the cardinal signs to be present. Frequently, the doctor will also look for responsiveness to Parkinson's disease medications as further evidence that Parkinson's is the correct diagnosis. (However, starting on medication right away can limit your ability to participate in clinical trials that urgently need newly-diagnosed Parkinson’s patients.)

Deep Brain Stimulation, Parkinson Surgery, Tremor, Dystonia, OCD Treatment at World's Best Hospital in India

Indian doctors with training in brain conditions (neurologists), brain surgeons (neurosurgeons), doctors with training in mental conditions (psychiatrists), pain specialists, specialized programming nurses and other specialists use an integrated team approach to treating people who have deep brain stimulation. Indian specialists have successfully used deep brain stimulation to treat hundreds of people who have essential tremor, Parkinson's disease and dystonia. Recently, doctors have used DBS to treat people who have cluster headaches, Tourette syndrome, epilepsy and chronic pain that hasn't responded to other treatment.

Neuro specialists in India use computer-assisted brain surgery, intraoperative MRI and awake brain surgery during deep brain stimulation.

Indian Neurologists are ranked among the Best surgeons for neurology and neurosurgery worldwide. Because the brain can shift slightly during surgery, there is the possibility that the electrodes can become displaced or dislodged. This may cause more profound complications such as personality changes, but electrode misplacement is relatively easy to identify using CT.

After 2–4 weeks, there is a follow-up to remove sutures, turn on the neurostimulator and program it.

What is Deep Brain Stimulation ?

Deep brain stimulation surgery technique involves implanting electrodes inside the deep nuclei of brain called as subthalamus under local anesthesia. These electrodes are then connected to IPG (Pacemaker) implanted underneath the skin below the clavicle through the connecting leads under general anesthesia. To perform any kind of activity, the patient has to switch on the device with the help of a patient programmer. This stimulates the deep brain nuclei, which results in improvement of all the symptoms of Parkinson disease.

With the progress of disease the parameters of stimulation are changed over a period of time so that patients can remain symptom free for long period. The patient himself can change the stimulation parameters with the help of patient programmer. Normally the life of the pacemaker is five years and after that a new pacemaker replaces it. The electrodes remain in position for life long.Rechargeble Pace makers are now available that can be recharged at home.The life of these pace makers are 15-20 years.The stimulation of subthalamic nucleus through this device leads to improvement in all the symptoms of advanced Parkinson disease.

DBS uses a surgically implanted medical device, similar to a cardiac pacemaker, to deliver electrical stimulation to precisely targeted areas within the brain. Stimulation of these areas blocks the signals that cause the disabling motor symptoms of Parkinson's disease. The electrical stimulation can be noninvasively adjusted to maximize treatment benefits. As a result, many individuals may achieve greater control over their body movements.

DBS System consists of three implanted components :

• »
• Lead – A lead consists of four thin coiled insulated wires with four electrodes at the lead tip. The lead is implanted in the brain.
• »
• Extension – An extension connects to the lead and is threaded under the skin from the head, down the neck and into the upper chest.
• »
• Neurostimulator – The neurostimulator connects to the extension. This small, sealed device, similar to a cardiac pacemaker, contains a battery and electronics. The neurostimulator is usually implanted beneath the skin in the chest below the collarbone (depending on the patient, a surgeon may implant the neurostimulator in the abdomen). Sometimes called a "brain pacemaker," it produces the electrical pulses needed for stimulation. These electrical pulses are delivered through the extension and lead to the targeted areas in the brain. The pulses can be adjusted wirelessly to check or change the neurostimulator settings.

The doctor may advise few antibiotics to prevent infection. The patient may need to visit the doctor several times after the surgery to adjust the stimulation with the help of programming. The doctor may prescribe a detailed medication plan to the patient. The patient should take some precautions after the surgery and follow the instructions given by the doctors. He/she should take care of the incisions and the surgical region on the head, by keeping it dry and covered. Heavy physical activities and lifting heavy weights should be avoided for few weeks after the surgery. Regular follow-up with the treating doctor should be done.

Deep Brain Stimulation Surgery Advantage:

• »
• In this surgery we do not injure the brain so it is relatively risk free.
• »
• Completely reversible and programmable
• »
• Parkinson medications are reduced which results in improvement of drug related side effects.
• »
• There is improvement of quality of life in both off and on stage of the disease.

Different Types of Surgery for Parkinson's disease - Parkinson's Disease Surgery in India

Surgery

Surgical procedures are recommended for specific patients with advanced Parkinson’s disease who no longer respond to drug treatments. Surgical treatment cannot cure Parkinson's disease, but it may help control symptoms such as motor fluctuations and dyskinesia. Pallidotomy and thalamotomy are older procedures that destroy tissue in certain parts of the brain. Deep brain stimulation, the current standard surgical practice for Parkinson’s disease, has largely replaced the older operations.

DEEP BRAIN STIMULATION

In deep brain stimulation (DBS), also called neurostimulation, an electric pulse generator controls symptoms. The generator is similar to a heart pacemaker. It sends electrical pulses to specific regions of the brain. Candidates for surgery are generally patients who have responded well to levodopa drug treatment. Patients who have had PD for fewer than 16 years may experience greater benefit from DBS than patients who have had the disease longer.

Evidence indicates that DBS improves motor function and reduces dyskinesia best when the procedure targets the subthalamic nucleus (STN) of the brain. Many studies demonstrate the effectiveness of STN stimulation. Procedures that target the globus pallidus interna or ventral intermediate nucleus of the thalamus can also sometimes treat rigidity and tremors. However, there is not yet enough evidence to support stimulation of these parts of the brain.

The procedure is performed as follows:

• The surgeon implants a tiny pulse generator near the collarbone, which is connected to four electrodes that have been implanted in the target area in the brain.
• The generator delivers programmed pulses to this area, which the patient can turn on and off using a magnet held over the skin.
• When on, the pulses suppress symptoms. Complications occur in 2 - 4% of operations. The most serious ones are bleeding in the brain and infection. Depression is common.

When compared to drug therapy, many patients who receive DBS show better improvement in symptoms and quality of life. However, patients who receive neurostimulation may have more serious side effects than those who are treated only with medications. These side effects include infection at the surgical site and nervous system, psychiatric, and heart disorders. Researchers are also studying whether DBS can benefit patients with earlier-stage Parkinson's disease.

PALLIDOTOMY AND THALAMOTOMY

Pallidotomy and thalamotomy are surgical procedures that destroy brain tissue in regions of the brain associated with Parkinson’s symptoms, such as dyskinesia, rigidity, and tremor. In these procedures, a surgeon drills a small hole in the patient’s skull and inserts an electrode to destroy brain tissue. Pallidotomy targets the global pallidus area. Thalamotomy targets the thalamus. Because these procedures permanently eliminate brain tissue, most doctors now recommend deep brain stimulation instead of pallidotomy or thalamotomy.

Surgical complications may include behavioral or personality changes, trouble speaking and swallowing, facial paralysis, and vision problems. Weight gain after surgery is also common.

STEM CELL IMPLANTATION

Scientists are investigating whether stem cells may eventually help treat Parkinson disease. Experimental surgery has shown promise using fetal brain cells rich in dopamine implanted in the substantia nigra area of the brain. Because the use of embryonic stem cells is controversial, researchers are studying alternative types of cells, including stem cells from adult brains and cells from human placentas or umbilical cords. All of this research is still preliminary.

Early diagnosis of Parkinson's disease gives you the best chance of a longer, healthier life.

Early Warning Signs of Parkinson's Disease

Sometimes it is hard to tell that you might have Parkinson'sdisease. Parkinson's disease is when your brain stops making an important chemical called dopamine. This chemical helps your body to move, and helps your mood. If you do have Parkinson's, you can feel better by taking a pill that helps your body to replace that chemical. Parkinson's disease will get worse slowly over time, and your doctor can help you stay healthy longer. Some of the problems listed here could be signs of Parkinson's disease.

No single one of these signs means that you should worry about Parkinson's disease. If you have more than one symptom, you should make an appointment to talk to your doctor. 

What you can do if you do have Parkinson's disease:

·         Work with your doctor to create a plan to stay healthy. This plan might include:

·         A referral to a neurologist, a doctor who specializes in the brain

·         Care from an occupational therapist, physical therapist or speech therapist

·         Meeting with a medical social worker to talk about how Parkinson's will affect your life

·         Start a regular exercise program to delay further symptoms.

·         Talk with family and friends who can provide you with the support you need.

Tremor or Shaking

Have you noticed a slight shaking or tremor in your finger, thumb, hand, chin or lip? Does your leg shake when you sit down or relax? Twitching or shaking of limbs is a common early sign of Parkinson’s disease.

Small Handwriting

Has your handwriting suddenly gotten much smaller than in it was in the past? You may notice the way you write words on a page has changed, such as letter sizes are smaller and the words are crowded together. A sudden change in handwriting is often a sign of Parkinson’s disease.

Loss of Smell

Have you noticed you no longer smell certain foods very well? If  you seem to have more trouble smelling foods like bananas, dill pickles or licorice, you should ask your doctor about Parkinson’s disease.

Trouble Sleeping

Do you thrash around in bed or kick and punch while you are deeply asleep? You might notice that you started falling out of bed while asleep. Sometimes, your spouse will notice, or will want to move to another bed. Sudden movements during sleep may be a sign of Parkinson’s disease.

Trouble Moving or Walking

Do you feel stiff in your body, arms or legs? Sometimes stiffness goes away as you move. If it does not, it can be a sign of Parkinson’s disease. You might notice that your arms don’t swing when you walk, or maybe other people have said you look stiff. An early sign might be stiffness or pain in your shoulder or hips. People sometimes say their feet seem ‘stuck to the floor.

Constipation

Do you have trouble moving your bowels without straining every day? Straining to move your bowels can be an early sign of Parkinson’s disease and you should talk to your doctor. 

A Soft or Low Voice

Have other people told you that your voice is very soft when you speak in a normal tone, or that you sound hoarse? If there has been a change in your voice you should see your doctor about whether it could be Parkinson’s disease. Sometimes you might think other people are losing their hearing, when really you are speaking more softly.

Masked Face

Have you been told that you have a serious, depressed or mad look on your face more often, even when you are not in a bad mood? This serious looking face is called masking. Also, if you or other people notice that you have a blank stare or do not blink your eyes very often, you should ask your doctor about Parkinson’s disease. 

Dizziness or Fainting

Do you notice that you often feel dizzy when you stand up out of a chair? Feeling dizzy or fainting can be signs of low blood pressure and can be linked to Parkinson’s disease.

Stooping or Hunching Over

Are you not standing up as straight as you used to? If you or your family or friends notice that you seem to be stooping, leaning or slouching when you stand, it could be a sign of Parkinson’s disease.

How is Parkinson’s disease treated now and How could stem cells help?

How is Parkinson’s disease treated now?

Current treatments for Parkinson’s include the drug  It is converted into dopamine in the body, so it acts as a stand-in for the lost dopamine-producing neurons. Some other drugs act like dopamine to stimulate the nerve cells. Patients are also treated with occupational therapy, physiotherapy, healthy diet and exercise. Surgery, such as deep brain stimulation with implanted electrodes, is used to treat advanced symptoms.

These treatments relieve the symptoms of Parkinson's disease, but do not slow down or reverse the damage to nerve cells in the brain. Over time, the symptoms often get worse despite treatment. By the time patients are diagnosed with Parkinson’s they have often had the disease for years and have lost most of the critical nerve cells. Tests that detect Parkinson’s earlier may help, but scientists are searching for a way to replace the damaged cells.

How could stem cells help?

Although the underlying cause of Parkinson's disease is unknown, scientists do know which cells and areas of the brain are involved. Researchers are already using stem cells to grow dopamine-producing nerve cells in the lab so that they can study the disease. Because a single, well-defined type of cell is affected, it may also be possible to treat Parkinson’s by replacing the lost nerve cells with healthy new ones.

Replacing lost cells
Doctors and scientists think cell replacement therapy will work because of the results of transplantation studies done in the 1980s. Scientists took cells from the adrenal glands of four Parkinson’s patients and transplanted them into the patients’ brains. The adrenal glands sit on top of the kidneys and contain some cells that release dopamine and similar substances. After the transplants, there was some improvement in the patients’ condition, but it was only minor and did not last long. This was the first time dopamine-producing tissue had been transplanted into the human brain. In later experiments, researchers have transplanted dopamine-producing neurons from human fetuses into animals and human patients, with major improvements in some cases but only modest changes in others However, there were some side effects in one group of patients and in some cases the disease spread to the transplanted fetal cells more than a decade after surgery.

Scientists still hope that introducing young cells into the brain could delay the onset or progress of Parkinson’s disease, but not enough fetal tissue is available to treat the large numbers of Parkinson’s patients, and the use of foetuses also raises ethical questions. Stem cells could offer an alternative source of new cells for Parkinson’s patients:

·         Embryonic stem (ES) cells could be directed to make dopamine-producing neurons, which could be transplanted into patients. Dopamine-producing neurons have been made from both mouse and human embryonic stem cells in the laboratory.

·         Induced pluripotent stem (iPS) cells could be made from a patient’s adult skin cells in the lab, and then used to make dopamine-producing neurons. In 2010 scientists in the USA treated rats with neurons made from human skin cells using iPS techniques. The transplanted neurons improved symptoms of Parkinson's disease in the rats. However, mice and rats require fewer neurons than humans and it is not yet clear whether this approach would work in patients. More studies are also needed to make sure the cells are safe and would not cause tumours in the brain.

Current research

Stem cell treatments for Parkinson's are still in the early stages of development. Some of the most important recent advances include work on methods for making dopamine-producing neurons in the lab; research on how to improve the effectiveness of transplants and avoid side effects; and studies investigating how the disease works and how cells can help with the development of new drugs.

DBS Therapy for Parkinson's control helps reduce some of the symptoms of Parkinson's disease

DBS Therapy for Parkinson's control helps reduce some of the symptoms of Parkinson's disease and is used in conjunction with medication. Electrical stimulation is delivered to targeted areas on both sides of the brain to help relieve symptoms on both sides of the body. You may be a candidate for this therapy if your symptoms respond to levodopa, but levodopa andor other medications have become less effective or ineffective.

The benefit of deep brain stimulation in controlling tremors and improving motor function for those with Parkinson's disease appears to last at least 10 years, according to a small new study. Parkinson’s disease is one of several conditions called motor system disorders, which are caused by the loss of dopamine-producing brain cells. The main symptoms of Parkinson's disease are tremors or trembling in hands, arms, legs, jaw and face; rigidity or stiffness of the limbs and trunk; slowed movement; and impaired balance and coordination.

As the disease progresses, patients can have difficulty walking, talking or doing other simple tasks, In deep brain stimulation, a surgeon implants a small device called a neurostimulator under the skin near the collar bone. The doctor then positions wires from the device with electrodes on their ends in areas of the brain that control motor function. The device works by electrically stimulating these areas, blocking abnormal nerve signals that cause the tremor in Parkinson's disease patients.

"Deep brain stimulation is still effective in improving motor signs in advanced Parkinson's disease patients 10 years after the surgery". However, this surgery does not stop the slow progression of the disease over time, as documented by the progressive loss of benefit that both deep brain stimulation and the drug levodopa show in improving walking, balance and speech over the years, Parkinson's disease patients who are considering deep brain stimulation surgery should always ask their doctor how long the benefit lasts after surgery

Deep Brain Stimulation, Parkinson Surgery, Tremor, Dystonia, OCD Treatment at World Best Hospital in India

DBS uses a surgically implanted medical device, similar to a cardiac pacemaker, to deliver electrical stimulation to precisely targeted areas within the brain. Stimulation of these areas blocks the signals that cause the disabling motor symptoms of Parkinson's disease. The electrical stimulation can be noninvasively adjusted to maximize treatment benefits. As a result, many individuals may achieve greater control over their body movements.

DBS System consists of three implanted components : 

• Lead – A lead consists of four thin coiled insulated wires with four electrodes at the lead tip. The lead is implanted in the brain.
  
• Extension – An extension connects to the lead and is threaded under the skin from the head, down the neck and into the upper chest.
  
• Neurostimulator – The neurostimulator connects to the extension. This small, sealed device, similar to a cardiac pacemaker, contains a battery and electronics. The neurostimulator is usually implanted beneath the skin in the chest below the collarbone (depending on the patient, a surgeon may implant the neurostimulator in the abdomen). Sometimes called a "brain pacemaker," it produces the electrical pulses needed for stimulation. These electrical pulses are delivered through the extension and lead to the targeted areas in the brain. The pulses can be adjusted wirelessly to check or change the neurostimulator settings.

After the Deep Brain Stimulation procedure

The doctor may advise few antibiotics to prevent infection. The patient may need to visit the doctor several times after the surgery to adjust the stimulation with the help of programming. The doctor may prescribe a detailed medication plan to the patient. The patient should take some precautions after the surgery and follow the instructions given by the doctors. He/she should take care of the incisions and the surgical region on the head, by keeping it dry and covered. Heavy physical activities and lifting heavy weights should be avoided for few weeks after the surgery. Regular follow-up with the treating doctor should be done.

Deep Brain Stimulation Surgery Advantage:

• In this surgery we do not injure the brain so it is relatively risk free.
• Completely reversible and programmable
• Parkinson medications are reduced which results in improvement of drug related side effects.
• There is improvement of quality of life in both off and on stage of the disease.

For more information visit:          http://www.medworldindia.com        
                    https://www.facebook.com/medworld.india

Please scan and email your medical reports  to us at care@medworldindia.com and we shall get you a Free Medical Opinion from India’s Best Doctors.

Call Us : +91-9811058159 Mail Us : care@medworldindia.com

Deep Brain Stimulation, Parkinson Surgery, Tremor, Dystonia, OCD Treatment at World Best Hospital in India

How long will I stay in the hospital after the first surgery?

Patients need to stay in the hospital until their incision-related pain can be well controlled with oral pain medications, they are able to eat and drink and can walk. On average, most patients stay only one night after surgery and occasionally a second night. Patients will also receive a CT scan or MRI after the surgery to confirm the location of the electrode(s) and to check for any post-operative bleeding. This CT scan or MRI is done without the head frame.

How long is recovery? What special instructions will I receive after the surgery?

Recovery is fairly uncomplicated for most patients, but in 10% of patients they will feel sleepier and slower and possibly mildly disoriented for several days after surgery. It is essential for all patients that a plan is in place before surgery for additional help in the home during at least the first week after surgery.

In addition, you will receive instructions not to touch the surgical wounds with your hands. These instructions apply to both your 1 ^st stage and 2 ^nd stage surgeries. You will not be able to shower or get the area around the incision wet until the wound has completely healed. You will be scheduled to return to the neurosurgery clinic for a wound check and if applicable, removal of the stitches. If you see any redness, swelling, or leaking fluid, please call the neurosurgeon's office immediately as these can be early signs of infection.

When does the DBS actually get turned on?

DBS programming takes place about 3-4 weeks after your surgery. You will receive a phone call with an appointment and special instructions regarding medication.

The appointment can last anywhere from 1-3 hours, depending on if you have one or two electrodes and whether you have Parkinson's disease, dystonia or tremor. Please be prepared to bring your medications with you and someone to drive you to the appointment and back.

What follow up care is required if I have this treatment?

It is important to understand that patients who have DBS must make frequent visits to the outpatient clinic during the first three months after surgery. These visits are needed so that doctors can "program" your stimulation so that it is just right for you. The doctor can change the strength and frequency of the electrical stimulation that your brain is receiving. These changes are then matched with adjustments in your medications until the right balance is achieved.

At first, you may be coming in as often as every two weeks for adjustments. Once stable settings are found and a new medication schedule has been established, you will not need to come in as frequently.

The initial "breaking in" period, when you require frequent adjustments, may last as long as three months. Over time, you may need additional changes as your Parkinson's disease progresses. If you live far from the hospital or have difficulty arranging transportation, this is something to carefully consider before deciding to have the surgery.

Six months after stimulation is started, we recommend you return for another follow-up visit and neuropsychological testing (if you have Parkinson's disease).

Deep Brain Stimulation, Parkinson Surgery, Tremor, Dystonia, OCD Treatment at World Best Hospital in India

Indian doctors with training in brain conditions (neurologists), brain surgeons (neurosurgeons), doctors with training in mental conditions (psychiatrists), pain specialists, specialized programming nurses and other specialists use an integrated team approach to treating people who have deep brain stimulation. Indian specialists have successfully used deep brain stimulation to treat hundreds of people who have essential tremor, Parkinson's disease and dystonia. Recently, doctors have used DBS to treat people who have cluster headaches, Tourette syndrome, epilepsy and chronic pain that hasn't responded to other treatment.

Neuro specialists in India use computer-assisted brain surgery, intraoperative MRI and awake brain surgery during deep brain stimulation.

Indian Neurologists are ranked among the Best surgeons for neurology and neurosurgery worldwide. Because the brain can shift slightly during surgery, there is the possibility that the electrodes can become displaced or dislodged. This may cause more profound

complications such as personality changes, but electrode misplacement is relatively easy to identify using CT.

For more information visit:          http://www.medworldindia.com        
                    https://www.facebook.com/medworld.india

Please scan and email your medical reports  to us at care@medworldindia.com and we shall get you a Free Medical Opinion from India’s Best Doctors.

Call Us : +91-9811058159

Mail Us : care@medworldindia.com

FAQ for Parkinson's Disease Patients for Deep Brain Stimulation

When should one consider surgical therapy? 
 
For patients with early Parkinson's disease, levodopa (sinemet) and other antiparkinsonian medications are usually effective for maintaining a good quality of life. As the disorder progresses, however, medications can produce disabling side effects. Many patients on long-term levodopa develop troublesome dyskinesias, excessive movements that often cause the limbs and body to writhe or jump. In addition, their dose of levodopa no longer lasts as long as it once did. This may lead to "on-off fluctuations," a condition in which the ability to move changes unpredictably between a mobile ("on"), state when medication seem to work, and an immobile ("off") state in which little effect of medication is apparent and normal movement is very difficult. When patients no longer have an acceptable quality of life due to these shortcomings of medical therapy, surgical treatment should be considered. 
 
What are the different types of surgery for Parkinson's disease? 
 
There are several different types of surgery for Parkinson's disease. The first surgical procedures developed were the ablative, or brain lesioning, procedures. Examples of lesioning surgery include thalamotomy and pallidotomy. Lesioning surgery involves the precisely controlled destruction, using a heat probe, of a small region of brain tissue that is abnormally active. It produces a permanent effect on the brain. In general, it is not safe to perform lesioning on both sides of the brain. 
 
We continue to perform some lesioning surgeries for patients who desire it, although in our practice lesioning has been largely replaced by deep brain stimulation (DBS). DBS surgery involves placing a thin metal electrode (about the diameter of a piece of spaghetti) into one of several possible brain targets and attaching it to a computerized pulse generator, which is implanted under the skin in the chest (much like a heart pacemaker). All parts of the stimulator system are internal; there are no wires coming out through the skin. To achieve maximal relief of symptoms, the stimulation can be adjusted during a routine office visit by a physician or nurse using a programming computer held next to the skin over the pulse generator. Unlike lesioning, DBS does not destroy brain tissue. Instead, it reversibly alters the abnormal function of the brain tissue in the region of the stimulating electrode.

 
Many patients inquire about the "restorative" therapies, a category of procedures which includes transplantation of fetal cells or stem cells, growth factor infusion, or gene therapy. These procedures attempt to correct the basic chemical defect of Parkinson's disease by increasing the production of dopamine in the brain. In the future, restorative therapies will hopefully emerge as effective and possibly curative interventions for Parkinson's disease. Growth factor therapy for Parkinson’s disease (using brain injection of modified viruses to deliver the growth factor) is an experimental therapy recently studied in a phase II clinical trial at UCSF and seven other centers. 
 
What are the possible brain targets for DBS?
 
There are now four possible target sites in the brain that may be selected for placement of stimulating electrodes: the internal segment of the globus pallidus (GPi), the subthalamic nucleus (STN), the pedunculopontine nucleus (PPN), and a subdivision of the thalamus referred to as Vim (ventro-intermediate nucleus). These structures are small clusters of nerve cells that play critical roles in the control of movement. Thalamic (Vim) stimulation is only effective for tremor, not for the other symptoms of PD. Stimulation of the globus pallidus or subthalamic nucleus, in contrast, may benefit not only tremor but also other parkinsonian symptoms such as rigidity (muscle stiffness), bradykinesia (slow movement), gait problems, and dyskinesias.

 
How does DBS work? 
 
DBS does not act directly on dopamine producing cells and does not affect brain dopamine levels. Instead, it compensates for one of the major secondary effects of dopamine loss, the excessive and abnormally patterned electrical discharge in the GPi or the STN. The exact mechanism by which the constant frequency stimulation pulse affects nearby brain cells has not been determined. 
 
How is the surgery performed?
 
There are several available surgical methods. In the most common method, implantation of the brain electrode is performed with the patient awake, using only local anesthetic and occasional sedation. The basic surgical method is called stereotaxis, a method useful for approaching deep brain targets though a small skull opening. For stereotactic surgery, a rigid frame is attached to the patient's head just before surgery, after the skin is anesthetized with local anesthetic. A brain imaging study (MRI or CT) is obtained with the frame in place. The images of the brain and frame are used to calculate the position of the desired brain target and guide instruments to that target with minimal trauma to the brain. After frame placement, MRI/CT, and calculation of the target coordinates on a computer, the patient is taken to the operating room. At that point an intravenous sedative is given, a Foley catheter is placed in the bladder, the stereotactic frame is rigidly fixed to the operating table, a patch of hair on top of the head is shaved, and the scalp is washed. After giving local anesthetic to the scalp to make it completely numb, an incision is made on top of the head behind the hairline and a small opening (1.5 centimeters, about the size of a nickel) is made in the skull. At this point, all intravenous sedatives are turned off so that the patient becomes fully awake. 
 
To maximize the precision of the surgery, we employ a "brain mapping" procedure in which fine microelectrodes are used to record brain cell activity in the region of the intended target to confirm that it is correct, or to make very fine adjustments of 1 or 2 millimeters in the intended brain target if the initial target is not exactly correct. The brain mapping produces no sensation for the patients, but the patient must be calm, cooperative, and silent during the mapping or else the procedure must be stopped. The brain's electrical signals are played on an audio monitor so that the surgical team can hear the signals and assess their pattern. The electronic equipment is fairly noisy, and the members of the surgical team often discuss the signals being obtained so as to be sure to interpret them correctly. Since each person's brain is different, the time it takes for the mapping varies from about 30 minutes to up to 2 hours for each side of the brain. The neurological status of the patient (such as strength, vision, and improvement of motor function) is monitored frequently during the operation, by the surgeon or by the neurologist. 
 
When the correct target site is confirmed with the microelectrode, the permanent DBS electrode is inserted and tested for about 20 minutes. The testing does not focus on relief of parkinsonian signs but rather on unwanted stimulation-induced side effects. This is because the beneficial effects of stimulation may take hours or days to develop, whereas any unwanted effects will be present immediately. For the testing, we deliberately turn the device up to a higher intensity than is normally used, in order to deliberately produce unwanted stimulation-induced side effects (such as tingling in the arm or leg, difficulty speaking, a pulling sensation in the tongue or face, or flashing lights). The sensations produced at high intensities of stimulation during this testing are experienced as strange but not painful. We thus confirm that the stimulation intensity needed to produce such effects is higher than the intensity normally used during long-term function of the device. 
 
Once the permanent DBS electrode is inserted and tested, intravenous sedation is resumed to make the patient sleepy, the electrode is anchored to the skull with a plastic cap, and the scalp is closed with sutures. The stereotactic headframe is removed. The patient then receives a general anesthetic to be completely asleep for the placement of the pulse generator in the chest and the tunneling of the connector wire between the brain electrode and the pulse generator unit. This part of the procedure takes about 40 minutes. 

Deep Brain Stimulation, Parkinson Surgery, Tremor, Dystonia, OCD Treatment at World Best Hospital in India

Indian doctors with training in brain conditions (neurologists), brain surgeons (neurosurgeons), doctors with training in mental conditions (psychiatrists), pain specialists, specialized programming nurses and other specialists use an integrated team approach to treating people who have deep brain stimulation. Indian specialists have successfully used deep brain stimulation to treat hundreds of people who have essential tremor, Parkinson's disease and dystonia. Recently, doctors have used DBS to treat people who have cluster headaches, Tourette syndrome, epilepsy and chronic pain that hasn't responded to other treatment.

Neuro specialists in India use computer-assisted brain surgery, intraoperative MRI and awake brain surgery during deep brain stimulation.

Indian Neurologists are ranked among the Best surgeons for neurology and neurosurgery worldwide. Because the brain can shift slightly during surgery, there is the possibility that the electrodes can become displaced or dislodged. This may cause more profound complications such as personality changes, but electrode misplacement is relatively easy to identify using CT.

After 2–4 weeks, there is a follow-up to remove sutures, turn on the neurostimulator and program it.

 

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