Some technical nuances for deep brain stimulator implantation

Abstract

Protocols for deep brain stimulator (DBS) implantation vary significantly among movement disorders centers despite the need to address similar operative problems. The general steps of this procedure are well accepted, but there are many seemingly minor, yet important nuances not extensively discussed in published descriptions. A classification and the details of the nuances adopted by a single institution may therefore be helpful in providing a basis for discussion and comparison. We describe operative nuances adopted at the Georgia Regents Medical Center (GRMC) for DBS implantation that may not be universally employed. The problems of DBS implantation considered here include stereotactic planning, draping, creation and use of the burhole, physiological testing, anchoring of the electrode, financial considerations, and overall technique. Fourteen categories of operative nuances were identified and described in detail. These include the use of specific anatomical relationships for planning, the use of clear and watertight drapes, countersinking of the burhole, the use of gelfoam and tissue glue to seal the burhole, methods to review the entire microelectrode data simultaneously, blinded communication with the patient during macrostimulation, fluoroscopic marking, MRI compatible protection of the electrode tip, financial considerations effecting choice of operative materials, and restriction to a single operator. The majority of these have not been extensively described but may be in use at other centers. The many operative problems arising during DBS implantation can be addressed with specific technical nuances.