Parkinson's, the brain pacemaker that can reduce movement disorders

An electrical impulse from a neurostimulator reaches, via two electrodes, the areas of the brain that control movement. This is how the system works, similar to a pace maker, for deep brain stimulation (DBS, Deep Brain Stimulation), which can be implanted by means of a neurosurgical procedure and is able to reduce disorders such as tremors, typical of Parkinson's disease, or dyskinesias, which can generate spasms, slowing down, and rigid postures. The treatment is also effective in some cases of epilepsy and is also being studied for serious psychiatric illnesses.

For patients, the benefits are many: a reduction in the medication they normally take, a marked improvement in their quality of life, greater autonomy, and a consequent easing of caregiver support. The technique was recently introduced for people suffering from Parkinson's disease at the San Camillo Hospital in Rome, the only public hospital in Lazio to offer this method, which has been used in other centres and has been known for thirty years, but is not very widespread in Central and Southern Italy. "It is an ultra-specialist treatment of high complexity and precision that requires the careful selection and management of the candidate patient by a multidisciplinary team, the use of highly refined instrumentation and modern, innovative technologies, as well as the acquisition of specific skills by experienced operators. The innovative aspects related to surgery are the constant development of technology, electrodes and pacemakers, and the development of a 360° integrated clinical management that involves neurologists, neuroanesthetists and neuropsychologists in addition to the neurosurgeon," explains Riccardo Antonio Ricciuti, head of the O.U. of Neurosurgery at the Roman hospital.

It is not an intervention suitable for everyone, therefore. 'In order to select the patient,' the specialist continues, 'collaboration with neurological specialists and experts in the diseases that can be treated with deep brain stimulation is necessary. In the case of patients with Parkinson's disease, those under 70 years of age who have responded well to dopamine therapy over the years, but have experienced side effects attributable to the kinetics of the drug, are eligible'. This technique could benefit about 20 per cent of Parkinson's patients, with positive effects in terms of pharmacoeconomics as well, because the dose of the drug taken prior to surgery is reduced. The Neurosurgery team, in addition to the collaboration with colleagues from Neurology directed by Claudio Gasperini, is supported by the contribution of the Neurology group of the Biomedical Campus, directed by Professor Vincenzo Di Lazzaro, and the continuous assistance for the selection, during the procedure and in the follow up, of Dr. Massimo Marano, an expert in movement disorders.

The procedure also requires specific anaesthesiological skills. In most cases, the first part of the procedure is performed with the patient awake, thanks to the skills acquired by the team's anaesthetists, directed by Fabiola Lapolla. The DBS technique in fact involves two steps. "The first step," Ricciuti specifies, "is that of placing the electrodes in deep nuclei of the brain, 5, 7 or 11 millimetres in size depending on the disorder to be treated, through two one-centimetre holes in the cranial thecae in awake surgery, therefore with the patient feeling no pain, but being able to interact with the neurologist to check the operation of the device already in the operating theatre, which in the second step, with traditional anaesthesia, will be implanted under the clavicle. To orientate himself inside the skull, the neurosurgeon has a neuronavigator, a sort of GPS that allows him to arrive precisely, through the magnetic resonance or CT images returned by a screen, at the areas of the brain to be stimulated and in which to position the cables.

The ward also has two psychologists at its disposal, who are also present in the operating theatre to ensure greater support for the patient. The hospital stay lasts from three to seven days, depending on the complexity of the cases. The 'pace maker' will then be activated by the neurologist approximately three weeks after the operation, the time needed to allow the patient to make an effective recovery, within the framework of the close controls to which the patient is subjected. "It is a great satisfaction," Ricciuti concludes, "to have introduced Parkinson's disease surgery through deep brain stimulation into the routine of neurosurgery in a highly professional and complex setting such as San Camillo, which is mainly dedicated to emergency and urgent pathology. This is made possible by the daily work of my team, composed of mature professionals with proven surgical experience and younger colleagues who are curious and interested in the acquisition of new techniques'.