Original ArticlePatients' Perioperative Experience of Awake Deep-Brain Stimulation for Parkinson Disease
Introduction
Since its first use in 1987 by French neurosurgeon Alim Benabid,1 deep-brain stimulation (DBS) has revolutionized the care of patients with Parkinson disease (PD) and other movement disorders. More than 100,000 procedures have been performed worldwide, and DBS is now an accepted treatment not only for PD and other movement disorders (such as dystonia and essential tremor) but also has a role in the treatment of epilepsy, obsessive-compulsive disorder, and Tourette syndrome.2
The DBS procedure involves a number of steps. First, preoperative anatomic localization of target structures is performed, generally with magnetic resonance brain scanning. Intraoperatively, stimulating electrodes are stereotactically implanted through burr holes created in the skull and guided into position under image guidance. Correct placement in the target nucleus is assisted by intraoperative microelectrode recordings (MERs).3 Intraoperative macrostimulatation can also be performed to assess benefit and threshold for side effects.
The procedure can be carried out either with local anesthesia (with or without sedation) or with the patient under general anesthesia. Neither method has been proven superior, but awake procedures offer a number of advantages, including the ability to use MERs for accurate electrode placement, to macrostimulate, and to avoid general anesthesia and its potential complications. Length of hospital stay and health care resource use also may be reduced by opting for the awake procedure.4
Anesthetic management during awake DBS procedures aims to maintain subjects in a cooperative and comfortable state but is challenging in that many sedative and anesthesia drugs alter the firing characteristics of target nuclei. In our institution, we use dexmedetomidine, a nonamnestic highly selective alpha 2 adrenergic agonist drug, which provides sedation, anxiolysis, and a degree of central analgesia while resulting in minimal respiratory depression. In addition, dexmedetomidine has little effect on the firing characteristics of the subthalamic nucleus (STN), especially if stopped shortly before MERs are carried out.5, 6, 7, 8
Patients' experience of awake craniotomy for tumor resection and epilepsy surgery is a well-studied area. These awake neurosurgical interventions are generally well tolerated, especially if the procedure is thoroughly explained to the patient pre- and intraoperatively.9, 10 Qualitative data on patients' experience of awake DBS procedures are, however, lacking. Our study aimed to collect qualitative data relating to the patient's experience of awake DBS with a view to identifying areas for improvement in the patient's journey through the perioperative period.
Section snippets
Materials and Methods
Forty-one patients underwent awake STN DBS for PD under local anesthesia and conscious sedation at Auckland City Hospital, New Zealand, between 2009 and 2015. All underwent a 2-stage procedure, the first stage consisting of stereotactic electrode implantation with both intraoperative image guidance, MERs from the target nucleus, and macrostimulation of the target area. During this stage, patients were awake but sedated with dexmedetomidine. The second stage, performed some weeks later, involved
Results
The first part of the questionnaire asked about preoperative counseling of patients for the procedure. Overwhelmingly (>90% of cases), patients felt well-informed. More than 95% of patients felt they had a chance to ask questions about local anesthesia and sedation for the procedure and all felt their questions were adequately answered by the anesthetic team. Only 4% of patients reported feeling “very anxious and fearful” on the day of the procedure; a further 63% felt “a bit nervous but OK,”
Discussion
Although studies have examined patient experiences of awake craniotomy, our qualitative study of patient experiences during awake DBS is the first of its kind. Despite the poor amnestic effect from dexmedetomidine,11 most patients welcomed being part of the operation, and almost 90% reported that they were happy they remembered the experience. As one patient put it: “Dare I say it was an enjoyable experience?” This is similar to published data on awake craniotomy, which also is generally well
Conclusions
As with other awake neurosurgical procedures, awake STN DBS for PD is generally well tolerated. Certain characteristics of this group of patients need to be kept in mind however when performing awake DBS, namely the significant off-period physical and psychological symptoms that patients may experience during the procedure. Pain is an issue for many patients, and careful attention must be paid to ensure adequate analgesia at critical times such as stereotactic frame placement and burr hole
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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