DBS Revision Surgery: Indications and Nuances

Abstract

Deep brain stimulation surgery has become the treatment of choice for appropriately selected patients with Parkinson’s disease, essential tremor, and dystonia. Despite the significant risk associated with minimally invasive brain surgery, the risk-to-benefit ratio for DBS surgery is quite favorable, and the overwhelming majority of patients derive substantial improvement in their motor function and quality of life from well-executed DBS therapy. A nonnegligible number of movement disorders patients, however, report unsatisfactory outcomes after DBS surgery. If we define “DBS failure ” as any case in which the patient and her/his caregivers are dissatisfied with the outcome of DBS surgery, then potential causes of DBS failure include failure to set appropriate expectations preoperatively, inappropriate patient selection, failures of postoperative device programming and medical management, in addition to various surgical and device-related complications including suboptimal lead placement, hardware failures, and rare instances of procedure-related brain injury resulting in permanent neurologic impairment. In this chapter, we focus on the various causes of DBS failure that are potentially correctable through surgical intervention. We review methods for evaluating patients presenting with DBS failure to identify appropriate candidates for various surgical salvage procedures, and we present successful decision-making strategies and surgical techniques for carrying out these operations.