My name is Dr. Chris Kalhorn. I am the director of the Surgical
Movement Disorders Program at Medstar Georgetown Hospital.
That means, I help take care of people with movement disorders, such as
Parkinson's Disease, Essential Tremor and Dystonia.
That also includes caring for people with epilepsy as well.
Surgery is really very effective for movement disorders in particular
Parkinson's Disease, Essential Tremor and Dystonia.
When people are taking medication, but the medications are no longer
working to control their symptoms, then surgery is sometimes appropriate
to help improve their quality of life. I think the most rewarding aspect
of my job is, that we have really fantastic patients at Medstar Georgetown.
They come to us with very difficult problems. Sometimes they are very
challenging to treat. They have extreme difficulty with movement.
They can't get around. They have alot of side effects from their
medication and for some of those patients, we are able to offer them deep brain
stimulation surgery and help restore a more normal life to them.
The technology has really improved drastically over the past five to ten years.
Worldwide we treated approximately 80,000 patients with deep brain stimulation
effectively. For a number of our patients, the surgery can mean the difference between
being able to roll over in bed on their own in the middle of the night, to get out of bed
by themselves in the morning. And just to perform alot of everyday tasks
that all of us take for granted. Eating on their own, brushing their teeth,
going out doing their shopping are some examples.
Medstar Georgetown is a leader within the field of DBS.
We're the very first center recognised as a center of excellence in the
Washington D.C. area for our care of people with Parkinson's Disease.
We have a multidisciplinary team that's uniquely suited to treat patients with
movement disorders. This consists of neurosurgeons, like myself,
movement disorder neurologists, physical therapists, occupational therapists,
speech therapists. All who have dedicated their careers to the treatment of
Parkinson's Disease and other movement disorders.
I love my job because it's very dynamic. Our field is constantly changing.
Being in an academic setting, we're forced to constantly think about new developments
in neurosurgery. We have a really unique privilege
of being able to help care for people with movement disorders.
A movement disorder is characterized by any disease that results in abnormal
movement. A great example of that is Parkinson's Disease which causes tremor,
slowness of movement, stiffness of movement, or what we call, dystonia or sometimes
abnormal dancing, twisting type movements that we refer to as dyskinesia.
These are very unique problems within neurosurgery, and in neurology,
that require sub-specialty level of care.
Deep Brain Stimulation is a surgery that's actually been around for quite some time.
Over twenty years. It's a surgery that consists of placing electrodes in a very
precise manner in different target areas of the brain and then connecting those
electrodes to what we call an IPG which is a brain pacemaker, similar to a cardiac
pacemaker that sits in a small soft tissue pocket overlying the patient's chest.
The real advantage of DBS surgery is that it's effective in treating movement disorders
The surgery can be used to treat symptoms on both sides of the body
and it's also reversible such that if we're able to discover a cure for these movement
disorders in the future the device can be removed.
We can also adjust in a non-invasive way the settings on the deep brain stimulator over
time so that as the patient's symptoms progress, we can still help to treat
their motor symptoms.
DBS specifically in Parkinson's Disease is very effective for tremor.
It's effective for slowness of movement or bradykinesia.
It's effective for dyskinesia, it's effective for dystonia or abnormal muscle cramping.
Unfortunately, DBS is not a cure for Parkinson's Disease and it doesn't
take the place of the medical management of Parkinson's. However, it does represent
very significant quality of life improvement. We know from detailed studies where patients
have either been either selected to undergo a trial of best medical management alone
versus best medical management plus Deep Brain Stimulation - that those patients do
much, much better in terms of their motor symptoms. So, while it's not a cure for
Parkinson's Disease, and as best we know, it doesn't slow the progression
of the disease, it still can substantially restore motor control.
Some centers have an absolute age cut off for DBS and at our center, we feel
that it's very important that you look at the individual patient.
That's one of the missions of our hospital as care for the whole person and
that we don't have an absolute age cut off. We look at the physiology of the individual
person and so long as they are medically able to undergo the surgery then we don't
exclude anyone on the basis of their age.
It's appropriate to consider DBS surgery when people are having more motor symptoms
despite adequate doses of medication. So, for our Parkinson's patients,
when they're having more and more, what we refer to as "off time" or periods of
freezing, periods of bradykinesia, or slow movement - they may take their
dose of sinemet or levodopa and the medication may only work for
fifteen or twenty minutes and until they take their next dose three or four hours
later, they have significant difficulty with their movement.
Or, if people are having motor symptoms that are not being well controlled with
medication alone, then I think it makes sense to at least consider getting an opinion
from a movement disorder neurologist about whether or not DBS is appropriate.
DBS is a very safe operation and experienced hands at our center has done several
hundred DBS procedures. The risk profile of the surgery is very similar to other
surgeries such as elective carotid endarterectomy.
The risks of surgery include things like bleeding, or infection or the possible need
to re-position the electrode if the patient is having alot of side effects when
we go to program them.
So with DBS surgery, often times we can see results while the patient's on the table.
We have our patients awake for the electrode implant and while they are awake with us in
the operating room we connect the electrodes to a temporary battery pack and we can
see improvement, often times, immediately in the operating room.
From placing the electrodes, there can be some microscopic swelling that can occur
that can also lead to symptomatic improvement even before we've implanted
the battery pack or programmed the device. But the ultimate
benefit that patients get from the DBS system does not occur until the device
can be turned on, or what we refer to as programmed in the outpatient office setting.
DBS is a surgery that does not occur in a vacuum and placing the electrodes properly
is just one very critical part of the entire process. Of course, you absolutely cannot
neglect the importance of programming. And our team are really experts
in programming the brain stimulators. In fact, our movement disorder neurologists
are called upon to lecture upon this topic nationally and to help other neurologists
sometimes with programming challenges. So, programming is an art in itself and
without the attention to the proper programming after DBS surgery, the patients
will not have the optimum result.
Our center does use microelectrode recordings intraoperatively.
This is a way that we can verify that the electrode is in the proper position
before we implant the permanent electrode. Not all centers utilise microelectrode
recording. We worked very closely with a dedicated neuro-physiologist, Dr. Alan Mander
who helps us with this process of microelectrode recording and we think
it leads to better surgical outcomes.
So right now the main movement disorders that we are treating with the DBS are
Parkinson's Disease, central tremor and idiopathic general torsion dystonia or what
we refer to as dystonia.
Patients should consider Medstar Georgetown for their DBS surgery.
I would say predominantly because of the multidisciplinary nature of our team.
Medstar Georgetown has been recognized as a center of excellence by the national
Parkinson Foundation. We are the only center of excellence within the Washington DC area.
Our multidisciplinary team of individuals has dedicated their careers to the
treatment of Parkinson's Disease. We consist of a team of neurologists,
neuro-surgeons, anesthesiologists, neuro-physiologists, physical therapists,
occupational and speech therapists who are all uniquely suited to care for
people with movement disorders.
DBS is really a life changing operation for a number of our patients.
It really is the most gratifying operation that I perform within my practice.
It's very satisfying to see patients from their level of function from before surgery
to care for them through the DBS surgical procedure and then see their motor results
afterwards. It's just very satisfying to hear their stories and the things that they
are enjoying doing after surgery.
When we're talking about Parkinson's Disease, we want to make sure that we are
dealing with true Parkinson's Disease. There's some other movement disorders that
can look like Parkinson's or mimic it, but are not Parkinson's Disease and should not be
treated with DBS. Also, if people are having significant
cognitive impediment or dementia then they may not be a candidate for DBS.
This is all part of a pre-operative screening process that we carry
out at our institution.