MEDICINE

Parkinson’s patients find relief through surgery

First deep brain stimulation in U.S. performed 25 years ago

By Tara Bannow, The Bulletin, @tarabannow

Madelin Currie assumes a lively trotting pace on the treadmill, her arms swinging at her sides, her dark hair gathered in a bun atop her head.

It’s part of the 67-year-old Bend resident’s usual weekday morning routine at Juniper Swim & Fitness Center, where she also takes yoga classes and swims. Currie, neatly put together with athletic capris and a purple striped shirt, hops off the treadmill and makes her way toward a weight machine, where she pulls two weighted arms together in front of her chest. She pulls and releases in slow, controlled movements with a focused facial expression.

Currie then performs squats using another weight machine, her hands gripping handles on either side of her shoulders. A few more machines, and then a short break before her water aerobics class.

Watching her, it’d be impossible to tell she was diagnosed with Parkinson’s disease in 2003. Parkinson’s is a progressive nervous system disorder that causes uncontrollable tremors in the hands, arms, legs, jaw and face. Rigidity and slow movement are hallmarks. There’s no cure, but patients often use medications to keep their symptoms at bay.

About three years ago, Currie underwent what’s called deep brain stimulation surgery, which is where a doctor places a pacemaker-like device, in this case, below the collarbone. The device is connected to wires that carry a low-voltage current to specific targets within the brain.

These days, she doesn’t tell everybody she has Parkinson’s, although she thinks they’d be surprised to find out. She doesn’t take any of the medications that used to give her terrible side effects.

“It is so friggin’ amazing,” she said.

No need to be awake

This year marks the 25th anniversary of the first modern deep brain stimulation surgery in North America. It was performed in Portland by Oregon Health & Science University neurosurgeon Dr. Kim Burchiel.

The surgery, which is also used to treat conditions like essential tremor, looks a lot different than it did back in 1991, though. In the early days, Burchiel’s patients had to stay awake for the full six hours of the surgery, their heads clamped into a frame. At the time, doctors needed the patients to be awake so that their brains produced the signals necessary to help doctors find the areas within them that controlled specific symptoms, such as tremors.

“Right around 2010, I decided, ‘We need to do this better,’” Burchiel said.

In addition to being the first to perform the surgery in North America, Burchiel also pioneered the use of magnetic resonance imaging — rather than the patient’s own brain signals — to guide doctors to their targets. That was in 2011. As soon as he began letting patients sleep through the surgery, Burchiel said the number of people asking for it doubled.

“Can you imagine lying on the table clamped into a titanium frame that’s holding your head like an iron maiden, and then having someone drill big holes in your skull?” Burchiel said. “I must admit, I always admired patients who would do all that just to get relief, but we don’t require that anymore.”

Currie is among those too scared to have it done awake.

“I thought sitting in a halo for eight hours wasn’t my idea of fun,” she said.

Using MRI also dropped the surgery time to about two hours, Burchiel said.

Burchiel also uses computerized tomography scans in the operating room, which allow him to verify in real time whether he is targeting the correct areas of the brain. Burchiel said he’s not aware of this being done anywhere else.

In fact, OHSU is so ahead of the curve when it comes to deep brain stimulation, that most cases nationwide are still being done with patients awake. That’s the case for most of the surgeries done at the University of Pittsburgh Medical Center, for example, said Dr. Mark Richardson, a neurosurgeon and director of the medical center’s adult epilepsy and movement disorders surgery division.

For most large medical centers, a lack of resources prevents them from being able to perform more of the surgeries with patients asleep, Richardson said. That’s because either they don’t have the MRI or CT technology dedicated to the surgeries or the right surgeons to perform them, he said.

“We tend to reserve our (asleep) spots for patients who are very anxious and who otherwise would not undergo awake surgery because they don’t want to be awake,” Richardson said.

‘We were shocked’

Steve Dale compares first experiencing the effects of his deep brain stimulation device to having the best Christmas ever.

“I had tears running down my cheeks,” said the 59-year-old Prineville resident, “and I’m not a crying person, you know?”

That was about six months ago. Dale was first diagnosed with Parkinson’s in 2003, after about a year of strange tremors that started in his hand.

“I went to a restaurant one day with my boss and all of a sudden I saw it was shaking and I thought, ‘What the devil is that?’” he said.

It was the stiffness and soreness that bothered Dale the most, but the tremors were bad, too, and the slowness. He said it felt like walking through waist-deep water. He was also on a medication that made him sleepy. After a while, it stopped working as well, so he had to take two and a half pills every day.

Medical personnel don’t actually turn on the neurotransmitters — the devices that send the signals to the brain — until a couple weeks to a month after the surgery to ensure the brain has healed and swelling has gone down. Both Dale and Currie had their surgeries at OHSU, and each returned to Portland about a month later to have the devices turned on.

For Dale, it worked immediately. He got up and walked down the hall without the cane he’d been using for about a year. His symptoms haven’t returned, and he stopped taking the medication.

It was the same for Currie, whose boyfriend was in the room with her.

“We were shocked,” she said. “We were stunned at how immediately the symptoms went away. It was instantaneous.”

Currie is back to doing everything she used to do, including hiking and biking. But without the device sending constant signals to her brain, she’d be in bad shape.

“If I were to turn it off, I would rock and roll like you wouldn’t believe,” she said.

Currie demonstrated this for a reporter. Sitting at her kitchen table, completely calm and still, she pressed a button on a small remote-like device while holding a small plastic piece over the neurotransmitter, which is implanted under her skin beneath her left collar bone. Within five seconds, her normally still arms began shaking, mildly at first but progressively worse until her entire upper body shook uncontrollably. Currie pushed the button again to turn the device back on. Within 10 seconds, the shaking stopped completely.

“I know me: I’d be holed up in my house if I was shaking like that,” Currie said once the shaking subsided.

Turning back the clock

Deep brain stimulation surgery does not cure Parkinson’s disease; it still progresses as it normally would.

What it does do, however, is rewinds the disease’s progression. For many patients, it all but eliminates the tremors and other symptoms.

“In effect, we’ve turned the clock back on their symptomatology,” Burchiel said.

The procedure is meant for patients for whom medications to treat the disease have lost their usefulness, like what Dale experienced. It’s also for patients like Currie, who couldn’t take the medications at all because of the side effects they produced. She tried five or six kinds before having the surgery.

Burchiel describes deep brain stimulation as an underutilized surgery. He believes between 100,000 and 200,000 patients in the U.S. are eligible, but only about 10,000 to 15,000 of the surgeries are performed annually. He thinks it’s because there aren’t enough surgeons who know how to do it and patients are intimidated if they’re told they need to stay awake.

Oregon is fortunate to have neurologists who understand the benefit of deep brain stimulation surgery, but in other areas, doctors hesitate to refer Parkinson’s patients for the surgery.

“The neurologists are trying to do everything they can to treat the patients medically, for, sometimes, too long,” he said. “We see a lot of patients.”

Richardson said he thinks some neurologists don’t understand the surgery’s risk-to-benefit ratio.

“There is a bias not to do surgery in chronic conditions like Parkinson’s disease because there is a fear that surgery is an extreme measure,” he said.

The surgery is not cheap — some estimates put it at upward of $100,000 — but most insurances, including Medicare, tend to cover it, both Burchiel and Richardson said.

Some research is exploring using the procedure for things like obesity, depression and Alzheimer’s disease as well.

But for now, Burchiel said he wants people to know about the effects of the surgery on Parkinson’s disease and tremor. He said it gives people their lives back.

“It really gives people back their lives,” he said. “It can extend them for decades.”

— Reporter: 541-383-0304,

tbannow@bendbulletin.com

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