COVID-19 information

Visiting is once again welcomed at The Walton Centre. So that we can safely reintroduce visiting, visits should be pre-booked with an allocated appointment slot. Patients can have two visitors each.

General safety measures remain in place at The Walton Centre - and in our other clinic settings within the community – until further notice. These include temperature checks, the wearing of face coverings and social distancing.

Tremor Deep Brain Stimulation

At The Walton Centre, we have been using DBS treatment for a number of years to help patients with tremor and other movement disorders. We are one of the largest implanting centres in the UK.

This information leaflet will give you more information about Deep Brain Stimulation (DBS) treatment in general and answer some of your questions. It is a guide for patients who have been assessed as suitable for the DBS surgery.

DBS for tremor

Deep brain stimulation works by implanting fine, tiny electrodes into the main parts of the brain that control involuntary movements. With a constant electric pulse, we aim to modify the brain activity. By targeting a particular area of the brain, DBS can be programmed to aid suppression of tremor. It provides a non-destructive and reversible means of disrupting the abnormal brain activity responsible for tremor.

Target areas

The electrodes are placed in the area of the brain known as the thalamus. This is a deep brain structure that controls movement and sensory signals. Different zones within the thalamus pertain to different conditions. Common target areas within the thalamus for tremor are the VIM (Ventral Intermedius Nucleus) and ZI (Zona Incerta). These zones are for coordination and planning of movement.

Assessment

Prior to surgical consideration you will meet the DBS team for thorough assessment. The aim of this is to determine if DBS will be of benefit to you or not. These assessments will be performed by a Consultant Neurologist, a Consultant Neurosurgeon and a Clinical Psychologist. Usually, you will meet each consultant on different dates and times. This is to allow for thorough assessment and communication between clinicians.

DBS team

Your DBS team is a multidisciplinary team consisting of your neurosurgeon, neurologist, neuropsychologist, theatre specialist nurse practitioner and specialist nursing and therapist team.

What to expect at each meeting

Each clinician will assess your suitability for DBS surgery and the Neurologist and Surgeon will discuss the DBS surgery benefits and improvements you can expect as an individual. At all these appointments you will be able to ask questions you may have regarding DBS and surgery. If the DBS team recommend DBS surgery for you, you are encouraged to ask questions and discuss the impact on your lifestyle and condition. We are anxious that you feel able to make an informed choice. The clinical neuropsychologist will assess your memory, mood and mental (cognitive) functions- to check that DBS is a suitable treatment for you.

Who’s suitable?

During your assessments, your clinicians will decide with yourself as to the suitability of surgery. As with any surgery, it is advised to be in your best possible state of health to aid recovery.

Can I think about it? Yes!

No pressure will be put on you to make a decision on the day of your appointments. It is very important to think about the DBS surgery and whether it is right for you.

What happens next?

If we recommend DBS surgery and you accept, we will apply to your local Clinical Commissioning Group (CCG) for funding and you will be put on the surgeon’s waiting list. During this time, you will be referred to the Specialist DBS nurses for further assessments.

Criteria

The criteria includes that tou should be medically fit enough to undergo the procedure. This will be determined via the pre op assessment. Also there should be no evidence of significant cognitive issues.

Specialist DBS nurses

You will be sent out an appointment for the specialist nurses. At these appointments, please take the opportunity to discuss any questions you have. During these appointments we will discuss the DBS surgery, follow up care and conduct a pre-operative assessment. These assessments will require us to video your movement disorder. This enables the DBS team to evaluate and audit results. The video is kept safe and access is limited to the DBS team. These assessments, including video are important to note the pre-operative level of your Tremor. They will be carried out post operatively at six months, 12 months and annually then onwards. The specialist nurses will contact you before the appointment to discuss with you particulars about the assessment and preparation.

Date for surgery

We are constantly aiming to reduce waiting times. Due to this procedure being ‘elective’/routine, emergency work always takes priority and thus waiting times vary (On average between 3-6 months). You will be informed of the date from the surgeon’s secretary. You will be asked to come in to see the specialist nurses for a pre-operative assessment for surgery. Here we will discuss again, the procedure, realistic goals and follow-up care and review your medical, surgical and social history. Pre-operative screen, Electrocardiogram (ECG) and bloods will be taken at this appointment.

Things to remember on your pre-operative assessment appointment

  • Please bring with you an up-to-date list of your medications.
  • It may be helpful to write down any questions you have, and we will go through them in this appointment.
  • It is important to be honest about your medical and social history and medication as we can prepare for your admission, theatre and discharge accordingly.
  • If you are on any blood thinning drugs such as aspirin, warfarin and Clopidogrel then we may need to admit you a few days earlier.
  • Let the specialist nurse know if you need transport to and from hospital or any admission concerns you have.
  • Let the specialist nurse know if you are a carer for any dependents.

Implantation of electrodes

The scans to plan targeting and actual insertion of the electrodes is called ‘Stage 1’

Monday

Please ring the bed managers at 10.30am, who will let you know the time and location of admission ward. When you arrive you will be admitted, by nursing and medical staff, and orientated to the ward. You will be measured for stockings that prevent blood clots forming in your legs. You will be advised to wear these along with a theatre gown on Tuesday and Wednesday. The stockings are advised to be worn until you go home. And there after for two weeks. The anaesthetist will see you either in the evening or the Tuesday morning. You will be seen by the Advanced Nurse Practitioner throughout the stage 1 admission to answer any questions you may have and talk you through the procedure.

Tuesday

CT and/or MRI to plan exact target, and position of adjacent structures. Typically, your hair is shaved off . You will be asleep, and this usually takes place in the morning. You will return to the ward around lunch time. Relatives are welcomed at visiting hours. Out-of-hours – Please obtain permission from the nurse in charge. Into the afternoon, we expect you to be up and moving around to the bathroom and sitting out at tea time. If you have any sickness or soreness, this will be managed well on the ward. Alternative: Instead of having this done on the Tuesday before the operation, you may be booked in for this procedure to be conducted a few weeks before. This is due to availability of the unit/scans.

Wednesday

Depending on whether you are on the morning list or the afternoon list, the medication and eating and drinking advice changes slightly. You will be directed accordingly by the ward staff.

The operation

This procedure is done under general anaesthetic, so you will be asleep, and you will NOT be aware of what is taking place. During the operation you will have neurophysiology monitoring which is used to assist the surgeon with the electrode placement. When the surgeon is satisfied with the electrode placement, the surgeon will secure the electrode in place and he will repeat the same procedure on the other side. After the procedure, a dressing then a bandage will be secured around your head, and you will be moved to the trolley and have a check CT scan, to check positions of the electrodes. You will be monitored for one hour on the recovery unit, and will be given your regular medication, and from then onwards as per your usual regime. You are then taken to the ward, where the nurses will closely monitor you, and in the evening encourage you to move and walk to the toilet/bathroom, with assistance. The next morning you will be encouraged to move and sit out. Depending how you are clinically, you will go home later that day, or the next day. Usually you will recover at home and have the next date for ‘stage 2’ 7-14 days post discharge. This is to allow you to recover and reduces the risk of infection. You will be advised of post op care of your wounds upon discharge.

Impact effect of DBS (Micro lesion effect)

As a result of the DBS electrodes being placed, the target area of the brain may be stunned (impact effect). This can result in a temporary relief of symptoms. Please be aware that this is a temporary phenomenon and will wear off, typically, ranging between a few days to weeks.

Average layout: 

Date

Time

Event

Comments

Monday

 

 

Medical clerking in

 

Familiarise with ward
NBM from midnight

 

Tuesday

 

9am

PM

MRI/ CT Scan under GA


Recovery unit


Transfer patient back to ward

NBM

 


Nursing staff, continue close observation

Wednesday

Theatre morning list

6am

 

Ward staff preparing patient
for operation

Patient is FFM
Give normal medication as per pre op protocol
NBM
If there is a problem, or patient is concerned, please bleep the DBS team - x5336

 

 

9am

DBS surgery

 


NBM
Post op CT scan

 

 

12pm

2pm

Recovery unit

Return to ward

Restart medications and continue as per time on chart

Theatre afternoon list

AM

Ward staff preparing patient
for operation 

6am light early breakfast with normal medication as per pre op protocol
Water till 7am
NBM

 

12.30pm

DBS surgery

NBM

 

5pm

6pm

Recovery unit

Return to ward

Continue all medications as per time on chart

Implantation of battery (Internal Pulse Generator)

The connecting of the electrodes and battery is called ‘internalisation’ and known as ‘stage 2’ You will be given a date for this surgery from the secretary.

Day 1

Typically you are fasted from midnight, but the nursing staff on the ward will direct you regarding this and when to get ready, including a shower

Day 2

You will be taken down to theatre on a trolley and the anaesthetist will put you to sleep, with a general anaesthetic. The surgeon will make two small cuts. One on your head, behind your ear and one on your chest below your collar bone. The wires and battery all stay under your skin and fat layer. The battery is placed where the cut has been made in your chest. You will be closely monitored by nursing staff on the ward post operatively. You will be expected to be sitting out, and walking with assistance to the toilet/bathroom by the evening.

Day 3

If this is Monday – Friday, you will be visited by the specialist nurse/ therapist and your system will be checked and discharge information will be given. The full switch on and programming will take place 6-8 weeks later. This allows for the post op swelling to reduce. If this falls on a weekend, the specialist nurse/therapist team will visit you on the following Monday afternoon for these checks to be completed and discharge information to be given.

Discharge information

On your discharge day you will need someone to take you home. Before you are discharged home, we will check that you are at the same preoperative level of everyday activity; Such as dressing, washing and walking. You may feel tired, and should take the time to recover. This can take up to three months. Removal of sutures/clips will be done by the surgical team on Chavasse Ward which is arranged by the ward staff. You must not have a full shower/bath until they are removed, due to risk of infection. You are advised to wash your hair with the antimicrobial wash lotion 3 days after your operation, but consider that all wounds must be kept clean and dry and you will have dressings on when you are discharged. The nursing team on the ward and the specialist nurse will advise particulars at the pre-operative stage and upon discharge.

Appointments

Following discharge, you will be reviewed depending on your clinical and programming requirements. If more support is required such as extra appointments, we can arrange this.

  • 7-15 days after your operation, review on Chavasse Ward for removal of your sutures by the junior doctor.
  • 6-8 weeks post operation. Review by the specialist nurse/therapist. This appointment can take up to 3 hours on a day ward.
  • 4 months. Review by your Neurologist.
  • 4-6 months. Review by your Neurosurgeon, depending on their protocol.
  • 6 month assessment of dystonia performed on video
  • 12 month assessment of dystonia performed on video

The specialist nurse and therapists offer support over the phone and ‘open’ appointments for review/ programming, regardless of next appointment date.

Frequently asked questions

How long does the procedure last?

Stage 1. Scans – 2 hours

Stage 1. Electrode position – 4 hours, 1 hour in recovery

Stage 2. IPG positioning. 2 hours, 1 hour in recovery

How many scars?

Three

Does it hurt?

The majority of patient report NO pain, but do report some discomfort. The local anaesthetic can sting on injection on your scalp, but there are no pain receptors in your brain. You may feel ‘pulling’ such as you may have experienced at the dentist. The majority of patients experience a headache, the day after stage one, and soreness to the neck and chest, where the battery is implanted, from stage two. There will be bruising here, and it takes weeks to reduce.

When can I drive?

We recommend ceasing driving for up to three months after the operation. This is to allow for you to recover fully. Please check the DVLA website for more information regarding guidelines as they are frequently updated.

How long is the admission each time?

Stage 1. 5-6 days

Stage 2. 3-4 days.

If you are on any blood thinning medication, then admission is prolonged, adding up to 5-10 days more.

What are the side effects of stimulation?

Usual side effects are all reversible by changing the settings on the stimulator. These include tingling in the fingers and face, altered, slurred speech, light headedness

What are the risks?

  • Please discuss latest infection rates with your surgeon
  • Small risk of bleeding
  • Small risk of hardware failure. (Electrode or battery don’t work properly)
  • Balance impairment
  • Changes to speech
  • Some patients don’t respond to stimulation for a number of individual reasons please ask your surgeon about success rates.

How will I improve?

This is very individual, and specific goals are selected by your neurologist. It can take up to 12 months to reach therapeutic levels.

Is it guaranteed to work?

Unfortunately no treatments are guaranteed to work. You have been carefully selected for this treatment by your neurologist and DBS team as they feel you have a reasonable chance of improvement.

Can I talk to someone else who has had it done?

Please let the specialist nurse/therapist know, and they will arrange this.

What are visiting times?

12noon - 8pm (flexible visiting can be arranged via the appropriate Ward Manager).

Contact us

If there is anything else you would like to know that this booklet does not answer, please do not hesitate to contact the Functional Surgery, DBS, movement disorder team.

DBS team

Neurologists

Dr Alusi, Dr Panicker, Dr Damodaran, Dr Bonello, Dr Macerollo

Neurosurgeons

Mr Osman Farah, Ms Bhargava

Secretary

Dr Alusi 0151 556 3543

Mr Osman Farah 0151 556 3351

Dr Panicker 0151 556 3516

Ms Bhargava 0151 556 3350

Dr Damodaran 0151 556 3517

Dr Bonello 0151 556 3370

Dr Macerollo 0151 556 3530

DBS Specialist Nurse / therapists 0151 529 8009

  • Last Updated:
    01 January 2020
  • Review Date:
    01 January 2022
  • Author:
    DBS nurse
  • Summary:

    Information for patients being considered for deep brain stimulation

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