The Day of the First Surgery
On the day of surgery you will be taken to the preoperative area. You will change into a hospital gown, have an intravenous (IV) line started, and receive medicines. Sedatives will be given to help to help you relax for the surgery.
In the preoperative area a frame will be placed on your head. This frame is a rectangular open box used by the neurosurgeon. It allows DBS electrodes to be placed precisely in the brain. The frame is held in place by four screws placed into the skin against the skull. Before placing the frame, the skin will be numbed with medicine. Some patients are asleep and some patients are awake for frame placement and surgery. This depends on the type of DBS surgery. Your surgeon will decide and inform you prior to surgery. Putting on the frame takes 15 minutes. When in place it will stay on for the rest of the operation. There may be a bit of pain when the frame is first put on. This goes away within 5-10 minutes. After that you will not feel the frame at all.
After the frame is in place you will be taken for a CT scan. Your surgeon will go with you to the scanner. The CT scan is completed in less than 5 minutes. After the scan you will be brought to the operating room for the DBS surgery.
In the operating room there may be a 30-45 minute waiting period. Your CT scan and the MRI scan done several weeks earlier are loaded into a special computer. The 2 studies are then “merged” by the computer. The surgeon plans the exact place to insert DBS electrodes. The surgeon will enter the operating room to start surgery. This takes about 3 hours from the time you arrive at the hospital to the start time of the surgery.
In some DBS procedures the patient will be awake. This allows the surgeon to fine tune the placement of the electrodes. In other cases this is not needed. Your surgeon will decide if you are awake or asleep for the surgery. If you are not sure, ask your surgeon.
In the operating room you will be on a bed in a sitting position. The frame will be attached to the bed so your head will not move and you can relax. Your surgeon will shave a portion of your hair around the sites where the electrodes will be placed. If you prefer, you can ask to shave the entire head. The area will then be carefully cleaned with a sterile solution. A special drape will be placed over your head. You will not be able to see the surgeon during the procedure as he will be standing behind you. The surgeon will mark the exact site where the electrode is inserted and will give more numbing medicine to that area. Once it is fully numb the surgeon will open the skin over that site and drill a nickel-size hole in the skull. The special drill stops instantly when it comes to the end of the bone. The drilling does not hurt. If you are awake it will sound very loud. It takes about 1 minute to drill the hole.
Once the hole is drilled a DBS electrode is carefully passed directly to the target. When putting in the electrode your surgeon will measure the activity of the nerve cells. Nerve cells in the brain make unique electrical signals. Recording them will confirm the electrode is in a perfect location. Your surgeon will turn off the lights in the operating room. You may hear some funny sounds like the electrical static on a radio. Once the electrode is in place, you may be asked to do some simple tests such as writing your name, holding a cup, or touching your finger to your nose. These test are done while stimulating the electrode. This tells us what will happen when the entire DBS system is in place.The surgeon and neurologist doing this testing will see if your symptoms improve.
When the best site for your DBS electrode is found, the electrode is locked into place with a special cap. The same procedure may be done on the other side of your head. Each electrode placement takes about 45 minutes from start to finish. Once all electrodes are in place you will be put to sleep. The ends of the wires coming out of the head will be passed under the skin of your scalp towards the back of your ears. The skin is then closed and dressings are put on. The frame is removed and you will be taken to the post-operative area to recover from surgery.
In the post-operative area you will be given pain medication and your other regular medicines. You will be taken for a second CT scan. The surgeon will look at the CT scan right away to make sure the electrodes are in a good location. You will then be transferred to a hospital room to recover from surgery.
Your cooperation with the nurses after the procedure is important. They want you to receive the best care. They will be watching for any changes in speech, movement, or alertness. It is normal to expect a mild headache for the first day after surgery. There may be pain at the incision site in the scalp. You should report any other change to nurses right away. Activity begins once you will are awake from the anesthesia. First you will sit in a chair, walk in the room and then the hallway. This activity helps to prevent complications such as blood clots in the legs. In some cases, you will be given a piece of equipment called an incentive spirometer. This is used to help clear the lungs and prevent pneumonia. The nurse will teach you how to use this hand held object. Your legs will be wrapped in compression boots during the operation and while you are in bed. The compression boots are attached to a machine and each boot takes turn filling up with air. The boots are removed once the patient is out of bed.
After the first surgery the DBS device is not fully connected and the device has not been turned on. Do not be surprised if there is no change in your symptoms at this point. This is normal.
Most patients stay in the hospital only 1 or 2 days after surgery. Before you go home a Nurse Practitioner or Physician Assistant will give important information to you and your family. You will be asked to watch for signs of infection, to avoid lifting more than 10-15 pounds for one month after surgery. You will restart all of your normal medicines after surgery, but this you should be checked with the doctor or nurse before going home.
The second surgery: Inserting the Pulse generator
DBS surgery is a two-step procedure, each done on different days. In the first part of the procedure, the DBS electrode is inserted into the brain as described above. In part two, the electrode wires are attached to a device called a pulse generator. This produces the electricity needed to stimulate the brain electrodes. The DBS system cannot work without the pulse generator, much the way a car cannot run without a battery or gasoline.
Inserting the pulse generator is a much smaller operation. It is usually scheduled 4-5 days after the first DBS surgery. You will go through the same pre-operative routine as the first surgery, such as not eating food or water after midnight and stopping all medicines. You will arrive at the pre-operative area for the second surgery. You will be put to sleep for this procedure. In the operating room, a small cut will be made on your chest just below the collar bone. A second incision will be made over the end of the electrode placed behind the ear the week before. A cable or wire will be placed under the skin to connect the electrode to the generator. The end of the wire will be connected to the generator. The generator is about the size of a silver dollar and about ½ inch thick. It is placed in the chest wall similar to a heart pacemaker. The skin is then closed. The device may be turned on at the time but at a very low setting.
After the surgery you will recover in the post-operative area for 2-3 hours then be discharged home. You will be asked to keep the incisions dry for 1 week and return to see your surgeon in 1-2 weeks.