Movement Disorders

Vol. 21, Suppl. 14, 2006, pp. S247–S258

© 2006 Movement Disorder Society

Deep Brain Stimulation for Parkinson’s Disease: Surgical

Technique and Perioperative Management

Andre Machado, MD, PhD,1* Ali R. Rezai, MD,1 Brian H. Kopell, MD,2 Robert E. Gross, MD, PhD,3
Ashwini D. Sharan, MD,4 and Alim-Louis Benabid, MD5
1
Center for Neurological Restoration, Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
2
Department of Neurosurgery, Medical College of Wisconsin and Clement J. Zablocki VA Medical Center, Milwaukee,
Wisconsin, USA
3
Department of Neurology, Emory University, Atlanta, Georgia, USA
4
Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
5
Functional and Stereotactic Neurosurgery, Joseph Fourier University, Grenoble, France

Abstract: Deep brain stimulation (DBS) is a widely accepted
therapy for medically refractory Parkinson’s disease (PD). Both
globus pallidus internus (GPi) and subthalamic nucleus (STN)
stimulation are safe and effective in improving the symptoms
of PD and reducing dyskinesias. STN DBS is the most com-
monly performed surgery for PD as compared to GPi DBS.
Ventral intermediate nucleus (Vim) DBS is infrequently used
as an alternative for tremor predominant PD patients. Patient
selection is critical in achieving good outcomes. Differential
diagnosis should be emphasized as well as neurological and
nonneurological comorbidities. Good response to a levodopa
challenge is an important predictor of favorable long-term
outcomes. The DBS surgery is typically performed in an awake
patient and involves stereotactic frame application, CT/MRI
imaging, anatomical targeting, physiological confirmation, and
implantation of the DBS lead and pulse generator. Anatomical
targeting consists of direct visualization of the target in MR
images, formula-derived coordinates based on the anterior and
posterior commissures, and reformatted anatomical stereotactic
atlases. Physiological verification is achieved most commonly
via microelectrode recording followed by implantation of the
DBS lead and intraoperative test stimulation to assess benefits
and side effects. The various aspects of DBS surgery will be
presented. © 2006 Movement Disorder Society
Key words: deep brain stimulation (DBS); Parkinson’s dis-
ease; stereotaxis; neuromodulation

Deep brain stimulation (DBS) has become a readily
accepted treatment for medically refractory Parkinson’s
disease (PD). While ablative procedures such as pal-
lidotomy and thalamotomy have been proven to be effi-
cacious,1– 8 they are currently reserved for patients with
contraindications to implantable hardware, those living
in areas without access to programming equipment/ex-
pertise, and in countries with limited economic
resources.
The three structures most commonly targeted for alle-
viating the symptoms of PD are the ventralis intermedius
nucleus of the thalamus (Vim), the posteroventral portion
*Correspondence to: Dr. Andre Machado, 9500 Euclid Avenue,
Desk S31, Cleveland, OH 44195. E-mail: machada@ccf.org
Published online in Wiley InterScience (www.interscience.wiley.
com). DOI: 10.1002/mds.20959
of the internal segment of the globus pallidus (GPi), and
the subthalamic nucleus (STN). Vim is generally chosen
for treating tremor predominant PD with similar efficacy
and lower rates of long-term neurological complications
compared with thalamotomies.9 –11 Alternatively, GPi
and STN are chosen for treating not only tremor, but also
the other cardinal symptoms of PD such as rigidity and
bradykinesia as well as having benefits on reducing dys-
kinesias. In this context, Vim DBS is the least common
surgery for treating PD.
Both GPi and STN have been shown to have similar
efficacy rates.12–14 However, the literature demonstrates
a trend that STN may be more efficient in managing the
symptoms of PD.15 Choice of the STN over the GPi is
often based on institutional experiences, surgical and
programming expertise and preferences, lower current
requirements with resulting longer battery life, and a

S247
S248 A. MACHADO ET AL.
more consistent trend for significant reductions in dopa-
minergic medication intake with the STN target.16 –24
Stimulation of the GPi may be preferred for patients with
borderline cognitive changes present preoperatively.
STN DBS may have a greater impact than GPi DBS on
executive frontal lobe functions.25 Neurosurgical exper-
tise in stereotaxy, modern imaging, widespread use and
ease of image guidance, and consistent patient outcomes
have encouraged the popularity of STN, GPi, and Vim
DBS as a treatment for medically refractory PD. The
number of implants has risen dramatically since the first
reports of the therapy by the Grenoble group.26,27 Cur-
rently, there are over 400 centers worldwide with over
30,000 DBS implants to date. The operative approach
varies from one center to the other, particularly in the
criteria employed for microelectrode-guided recording
and angles of approach to the various subcortical targets.
The authors recognize that there are various surgical
strategies, tools, equipment, and procedures used for
DBS surgery. This is because of the experience and
preference of the surgical team, individual center logis-
tics, and healthcare system constraints. We provide a
general overview of the surgical technique and periop-
erative management realizing these inherent variations.
PATIENT SELECTION
Patient selection is a critical first step as poorly chosen
candidates may not have optimal benefits and have in-
creased morbidity. Several factors must be considered
before determining if a patient is an appropriate candi-
date for DBS surgery. A multidisciplinary approach in-
volving the neurosurgeon, neurologist, and neuropsy-
chologist is important to determine the appropriate
surgical candidate. It is also important that the diagnosis
of idiopathic PD be confirmed prior to proceeding with
DBS surgery. Several neurological disorders can mimic
the signs and symptoms of idiopathic PD. Multiple-
system atrophy28 and progressive supranuclear palsy are
in the differential diagnosis that must be considered.29 A
complete, thorough neurological examination with atten-
tion to cognitive function, eye saccadic movements, pos-
tural hypotension, and postural instability, and signs of
cerebellar or corticospinal involvement is important in
the preoperative evaluation.
Key to this assessment is evaluating the surgical can-
didate in both the on and off medication states with a
corroborating levodopa challenge. Perhaps the best prog-
nostic indicator of a patient’s suitability for DBS surgery
is their response to levodopa.18 In general, a levodopa
challenge following a 12-hour medication withdrawal
should provide at least a 33% improvement in the motor
section of the Unified Parkinson’s Disease Rating Scale
Movement Disorders, Vol. 21, Suppl. 14, 2006
(UPDRS).30 Patients who do not improve significantly
with levodopa are unlikely to improve with surgery, as
the therapy is largely aimed at increasing on time and
decreasing on–off fluctuations. The levodopa challenge is
also useful to demonstrate to the patient and family the
extent that the parkinsonian symptoms are likely to im-
prove after surgery. Patients should be educated not to
expect an improvement in function greater than the best
on medication period with the concomitant reduction in
drug-induced dyskinesias. Tremor is an exception and
can improve with STN DBS even if not significantly
affected by levodopa. Patients should be advised that
axial and gait symptoms are less likely to be impacted
than appendicular symptoms.
One of the most important presurgical assessments is
the neuropsychological evaluation. The team must be
capable of identifying patients with elevated risk for
surgery and those incapable of adjusting to a lifestyle
compatible with implanted neurological hardware. Sur-
gical management may be temporarily deferred or out-
right declined in these patients, depending on their re-
sponse to adjunctive psychological counseling. Deep
brain stimulation for PD does not seem to cause perma-
nent cognitive changes.31 However, patients who present
with cognitive decline preoperatively tend to be poor
candidates and may worsen after surgery. A staged pro-
cedure is a good alternative to simultaneous bilateral
surgery in elderly patients with borderline cognitive
function.
Age is one of the major factors determining how a
patient will cope with the surgical procedure and behave
postoperatively. The risks of cardiopulmonary events are
certainly higher, as in any other major surgery. More
specifically to DBS, advanced age is linked to higher
incidence of cognitive changes after surgery.32 Younger
patients tend to recover faster and are usually fully ori-
ented in the day following surgery. Older patients are
more prone to experience a period of confusion that may
last for several days. We do not recommend a specific
cutoff for age, as the chronological age does not neces-
sarily correlate with the biological aging among individ-
uals. Older patients without many medical comorbidities
who still present good mental and physical function
during the on periods may be considered candidates.
Staged or unilateral implantations may be wise alterna-
tives for those in the eighth decade of life or older.
Depression is common in the PD population. Ideally, the
patient should be counseled and treated prior to surgery,
with the goal of maximizing the individual’s capacity to
cope with the procedure and postoperative recovery pe-
riod. Psychosis may also occur primarily but is often a
manifestation of dopaminergic medication side effects.
 SURGICAL TECHNIQUE, PERIOPERATIVE MANAGEMENTE
Brief periods of medication-induced psychosis may be
medically managed by altering the medication regimen.
However, psychosis not related to medication may be a
reason to defer surgery in a particular patient. The oc-
currence of significant mood changes after bilateral DBS
has been reported33 but is not common in our experience.
Severe anxiety may become a major impediment for
awake stereotactic surgery, especially in prolonged op-
erations. Counseling prior to surgery might be helpful
(see Voon and colleagues in this issue for a more detailed
discussion of these issues).
PREOPERATIVE MANAGEMENT
A full medical assessment is a necessary part of the
preoperative evaluation, as advanced PD patients tend to
be elderly with significant comorbidities. The risk of
discontinuing medications that affect anticoagulation and
platelet aggregation should be weighed against the po-
tential benefits in the quality of life offered by DBS
surgery. However, timely discontinuation of these latter
medications is mandatory for stereotactic surgery since
intracerebral hematomas are the most serious of all po-
tential complications from DBS. Any anticlotting medi-
cations, including aspirin, ticlopidine, clopidogrel, and
all nonsteroidal anti-inflammatory drugs should be dis-
continued at least 7 to 10 days preoperatively to ensure
the return of normal blood clotting function.
Arterial hypertension can also increase the risk of
intracranial bleeding during stereotactic procedures and
must be controlled in the weeks prior to surgery. The
night prior to DBS surgery, the antiparkinsonian medi-
cations are typically held to pronounce the Parkinson’s
symptoms at the time of surgery and the families must be
counseled regarding their role in facilitating the patient
that day. Alternatively, some centers may chose to admit
the patient the night before to aid with rigidity, bradyki-
nesia, and/or freezing that may be profound and dis-
abling with the medications held.
Patients should be willing and able, both physically
and cognitively, to undergo an awake surgical procedure
requiring several hours of immobilization in a stereotac-
tic frame. Moreover, surgical candidates need to be able
to remain attentive and cooperative under stressful con-
ditions. Realistic expectations of outcomes are also par-
amount for both the patient and the family. The patient
and family must be willing and able to bear the respon-
sibilities for maintaining a chronically implanted hard-
ware system.
A prolonged discussion on the short- and long-term
effects of DBS on Parkinson’s disease should be carried
out with the patient, family, and caregivers. DBS often
results in dramatic changes in the patient’s motor func-
S249
tion and consequently in independence. Patients may no
longer require as much assistance in caring for them-
selves or for the household, which may change the fam-
ily’s routine and dynamics. The preoperative neuropsy-
chological assessment may be useful in identifying these
issues and preventing them with counseling.
Furthermore, while the goal of the surgery is to restore
the patient’s quality of life, it is also important to discuss
safety of indoor and outdoor activities. Releasing the
patient from the severe motor limitations imposed by the
medically refractory disease may give the individual a
sense of aptitude that may be unrealistic due to the
restrictions imposed by the concomitant aging vestibular,
peripheral nervous, and musculoskeletal systems.
The DBS surgical candidate must be educated regard-
ing environmental concerns with implanted hardware.
Patients with DBS hardware should not be exposed to
large magnetic fields. Compatibility exists with only a
limited number of magnetic resonance (MR) sequences
in machines that have undergone safety testing.34 –36 In-
dividuals with other health issues that may require fre-
quent MR imaging may not be ideal candidates for DBS.
Body coils are particularly dangerous for DBS systems
and their need may pose a contraindication for patients
with spinal disease that require future MRIs. Unfortu-
nately, the association of spinal problems with medically
refractory Parkinson’s disease is not uncommon and it
may be necessary to judge along with the patient and
family which disease should be prioritized.
Finally, DBS implantation should be regarded the first
step in an extended management plan. The caretakers
and the patient should be committed to treating the
patient within the specialized center for programming,
and hardware management issues (such as the need for
battery change) in the near and long term.
UNILATERAL VS. BILATERAL SURGERY
There are various approaches to the surgical procedure
depending on the patient’s symptoms, tolerance of sur-
gery, and team preferences. The patients can undergo
simultaneous bilateral DBS lead and pulse generator
implantation the same day, unilateral implantation of the
DBS lead and pulse generator the same day, bilateral
implantation of the DBS lead in 1 day and subsequent
staged implantation of the pulse generators, or unilateral
DBS lead implantation in 1 day and secondary staged
implantation of the pulse generator another day. All these
approaches have been used successfully and depend on
variables such as the patient symptoms, tolerance of
surgery, team preference, and various other health sys-
tem logistics that are individual center– dependent.
Movement Disorders, Vol. 21, Suppl. 14, 2006
S250 A. MACHADO ET AL.
SURGICAL PROCEDURE
Application of Head Frame and Imaging
Surgical strategies and details of procedure vary with
the surgical teams, the equipment they are used to, and
the local healthcare system constraints. Stereotactic sur-
geons typically master the use of their institution’s
equipment of choice, which are used for a variety of
stereotactic procedures. Among them, DBS is probably
one of the most technically challenging and should not
be considered a beginner’s procedure. A variety of head
frames can be used such as the Leksell, CRW, Riechert-
Mundinger, and other commercially available systems.
Placement of the head frame should be done as close as
possible to surgery in order to minimize the duration of
discomfort and risk of displacement. The base of the
frame should be placed parallel to a line extending from
the lateral canthus/orbital floor to the tragus in order to
parallel approximately the anterior commissure–poste-
rior commissure (AC–PC) line. Ear bars (with ear plugs
placed for patient comfort) may be used to balance the
ideal position of the frame while applying the pins.
Ideally, the head should be centered in the frame, so that
the midline falls within the center point of the stereotac-
tic space defined by the head frame system. Care must be
taken such that the edges of the frame should never be in
contact with the nose or the occipital/neck area due to
risk of skin erosion, which could be encountered during
an extended stereotactic procedure. The frame should not
obscure the patient’s eyes since this makes communica-
tion with the patient and assessment of eye movements
more difficult during surgery.
The scalp is shaved and prepared with betadine and
the pins are inserted under local anesthesia of preference,
typically lidocaine and/or marcaine. A small dose of
intravenous midazolam or other sedation can be given
prior to insertion of the pins in order to minimize aware-
ness and memory of frame placement. The anterior pins
can be placed two finger breadths above the orbital rim,
taking care to avoid the supraorbital nerve. Posteriorly,
pins should be located so as to avoid penetration of the
cerebral venous sinuses. The height of the base of the
frame must also be taken into consideration so that
prospective targets lie comfortably within the frame’s
coordinate system, avoiding the extremes, which will
mechanically hamper positioning the arc for targeting. In
addition, since the pins can create significant artifactual
distortion of CT imaging, they should be placed such that
they distort neither the AC, PC, nor the target.
The pins should firmly purchase the outer layer of the
skull to prevent the frame from being displaced during a
prolonged surgery. Alternatively, overtightening is unde-
Movement Disorders, Vol. 21, Suppl. 14, 2006
sirable due to potential for causing distortions in the
frame and consequently in the accuracy of the system.
Finding the right balance may be challenging in patients
with severe tremor, who are more prone to cause dis-
lodgment of the pins. After application of the frame, an
attempt should be made to move the patient’s head and
stress the pins. Any perception of pain by the patient at
this point might imply inadequate insertion of the pins.
Patients with severe anxiety or low tolerance to pain may
not tolerate awake placement of the head frames. In those
instances, the head frame may be placed under heavy
sedation or general anesthesia.
Once the frame is placed, the patient is taken for
preoperative imaging. CT, MRI, and ventriculography
can all be used to construct the stereotactic imaging
database required for DBS implantation. The surgical
team can utilize any of the above imaging modalities for
anatomical targeting of the STN, GPi, and Vim. Many
commercially available image-guided systems offer the
merging and image fusion capabilities that allow for
integration of multiple imaging data sets.
The CT scan should include the upper portion of the
frame, the anterior and posterior limits of the frame, and
vertex up to the skin edge in order to encompass all the
fiducials. The slices are optimally obtained with the
thinnest slice thickness with no gap between slices. If
dislodgment of the frame occurs after the volumetric
stereo CT, the entire procedure has to be restarted due to
the loss of relationship between the fiducials and intra-
cranial structures.
Volumetric, gadolinium-enhanced, T1-weighted MRI,
T2-weighted images, or inversion recovery images can
be obtained with the head frame on, or preoperatively to
expedite the process on the day of surgery. T2 and
inversion recovery images are beneficial for direct tar-
geting of the structure of interest and surrounding areas.
Inversion recovery images can be problematic with cer-
tain imaging software. Often, excessive tremor hampers
the interpretation of the preoperative MRI, and another
one may be obtained with the head frame on, which helps
to stabilize the head during image acquisition. In order to
optimize the chances for a good outpatient MRI, neurol-
ogists can prescribe levodopa to patients in such fashion
as to match on medication time with the time of the
examination (i.e., tremor dominant patients should be in
the on medication state while dyskinetic patients should
be in the off medication state). MRI will be contraindi-
cated in patients with cardiac pacemakers making reli-
ance on CT and ventriculography if necessary. While
MRI has superior soft-tissue resolution, CT is less sus-
ceptible to the distortional artifacts produced by the
inhomogeneities in the magnetic field and thus more
 SURGICAL TECHNIQUE, PERIOPERATIVE MANAGEMENTE S251

accurately represents the actual position of intracerebral

structures in space. Consequently, reliance on image
fusion and merging will allow for visualization of mul-
tiple imaging data sets.

Frameless Technology
This is a method that is emerging as an alternative to
frame-based stereotaxis. The so-called frameless ster-
eotaxis has been used for brain tumors using skin fidu-
cials for some time, transforming the process for local-
ization of intracranial lesions.37,38 Recently, a
preliminary report was released on frameless navigation
for deep brain stimulation utilizing a new technology
with promising results.39 Holloway and colleagues40
have compared the use of this new frameless method
using skull-based fiducials with standard frame-based
stereotaxis. The authors assessed the actual location of
the electrode with a postoperative CT scan and compared
the location with the expected intraoperative targeting.
There was no statistically significant difference compar-
ing the two surgical methods, suggesting that frameless
stereotaxis may have a future role in the field of deep
brain stimulation. Advantages of this method include a FIG. 1. Frameless stereotactic system. The cranial apparatus and mi-
less restricted position during surgery and convenience crodrive for frameless stereotaxis (Image Guided Neurologics). The
disposable frame is attached to the skull with three self-tapping screws.
for preoperative image acquisition and surgical planning. The image guidance planning/neuronavigation station is used to align
Disadvantages include the consequent risk of intraoper- the entry point to the target. A microdrive is mounted on top of the
ative dislodgment in patients with severe tremor or in- hardware, which allows for microelectrode recording and DBS elec-
trode implantation.
voluntary movements. A learning curve with this new
system should also be expected for surgeons already
accustomed with frame-based systems. At the current
stage of development, frameless stereotaxis is not the Direct Targeting
standard choice for deep brain stimulation given that Direct targeting is based on MRI visualization of the
only limited experience exists with its accuracy. Figure 1 structures. A target within STN can be chosen at the
shows a frameless apparatus and its microdrive mounted ventral part of the somatosensory STN, which is the
in surgery. lateral part of the nucleus. The axial and coronal T2
images are particularly important for adequate visualiza-
tion of the STN as a sharp contrast can often be seen
Target Selection
between the nucleus and the surrounding white matter.
Centers use various combinations of anatomical tar- The red nucleus can also be clearly seen and the STN lies
geting strategies. One can target using an indirect method anterior and lateral to the red nucleus. The anterior
that involves reformatted anatomical atlases as well as border of the red nucleus can be used as a landmark for
formula coordinates based on known distances from the the anteroposterior localization of the STN target.41 This
AC and the PC landmarks. The STN and GPi can also be is best visualized in the axial T2 images, as shown in
chosen on the basis of direct targeting by visualizing the Figure 2.
structure on T2 and inversion recovery images. With The GPi and the adjacent optic tract and internal
current imaging limitations, Vim can only be targeted capsule can be visualized via inversion recovery and T2
indirectly and confirmed with intraoperative physiologi- images. Careful windowing of the images can also pro-
cal data. Emphasis will be given to anatomical targeting vide proper visualization of the internal capsule as well
of the STN since it is the most common target used for as the GPi and the pars externa of the globus pallidum
Parkinson’s disease but a brief description for GPi and (GPe). For GPi DBS, implantation target choice may be
Vim targeting is also included. different from that used for pallidotomies, which are

Movement Disorders, Vol. 21, Suppl. 14, 2006

S252 A. MACHADO ET AL.

missural plane, and 3 to 4 mm posterior to the MCP.

Coordinates for the sensorimotor GPi are selected as 19
to 21 mm lateral to the midline, 2 to 3 mm anterior to the
MCP, and 4 to 5 mm ventral to intercommissural plane.
The Vim is targeted 11 to 12 mm lateral to the wall of the
III ventricle, at the level of the intercommissural plane.
Most commonly, the goal is to target the topography of
the upper extremity, which carries the greatest impact for
quality of life. The upper extremity occupies a more
intermediate position between the more medially located
face representation and the laterally located lower ex-
tremity. In terms of anterior–posterior position, the Vim

FIG. 2. Direct STN targeting. Axial T2-weighed image showing the

subthalamic nucleus (white arrow) anterior and lateral to the red
nucleus (black arrow). Note how the anterior border of the red nucleus
aligns with the posterior third of the STN. The T2 images are crucial for
the direct targeting of the STN and should be windowed carefully to
optimize the accuracy of the nuclei boundaries.

typically located at the posteroventral portion of the

nucleus.1,4,42– 44 Implantation at that position may not be
optimal for DBS since the DBS stimulation field may
require higher amplitudes and potential spread to the
internal capsule. In this regard, for DBS, a more anterior
and lateral target is preferable, which will allow the
stimulation amplitude to be increased without significant
involvement of the descending white matter fibers. The
optic tract courses ventrally to the globus pallidus and
can be used as a landmark for the approach (Fig. 3).45,46

Indirect Targeting
Indirect targeting is based on a standardized stereotac-
tic atlas and on a formula-derived method based on AC
and PC landmarks. While atlas-based coordinates are
biased by the inherent inaccuracies of atlases, coordi-
nates can be derived from the experience of teams and
represent the average values of the coordinates of these
best contacts, gathered in a rather large number of cases.
Referring these coordinates to internal landmarks such as
AC–PC length and height of the thalamus above the
AC–PC plane provides normalized coordinates less de-
pendent on individual variations. The formula uses the
midcommissural point (MCP) or the PC as reference,
which is calculated after selecting the AC and PC coor- FIG. 3. Direct GPi targeting. Direct targeting of GPi. A: GPi (arrow)
dinates (Fig. 4). Typical initial anatomical coordinates is seen on an inversion recovery axial image. B: The optic tract (tip of
the trajectory line) can be identified ventral to the GPi and used as a
for the ventral and sensorimotor STN are 11 to 13 mm landmark for direct targeting. Careful windowing is critical to optimize
lateral to the midline, 4 to 5 mm ventral to the intercom- the resolution and allow accurate identification of the structures.

Movement Disorders, Vol. 21, Suppl. 14, 2006

 SURGICAL TECHNIQUE, PERIOPERATIVE MANAGEMENTE
FIG. 4. AC–PC coordinate localization. The anterior and posterior
commissures can be identified on this axial T1-weighed images.
is typically located between 2/12 and 3/12 of the AC–PC
distance rostral to the posterior commissure.47 These
coordinates may not represent the ideal location for im-
plantation but are used as initial anatomical targets,
which are verified by physiological recordings. Figure 5
demonstrates a typical digitized version of the Schalten-
brand and Wahren atlas that is morphed, reformatted,
and overlaid onto an MRI to conform to the patient’s
anatomical structures such as the caudate head, thalamic
height, and brainstem. This atlas-and-formula– based tar-
gets are then cross-correlated with the direct visualiza-
tion target.
Indirect targeting has been the traditional method in
stereotactic neurosurgery. The limitation of this method
is that it does not take into account the discrete anatom-
ical variations among individuals. Not all brains corre-
spond to the topographical distribution depicted in a
S253
given atlas. Even the reformattable atlases available in
computerized planning stations may not conform ade-
quately to the patient’s anatomy. In this sense, direct
targeting seems to have obvious benefits over indirect. It
is based on the imaging data set of the individual’s own
anatomy. Imaging techniques have advanced dramati-
cally, allowing for adequate visualization of the STN in
T2 images. However, several pitfalls exist, such as fail-
ure of fusion between CT scans and MRI or magnetic
distortions that may alter the geometry of the nucleus. At
the current stage, it is best to perform all targeting
methods and correlate them prior to surgery.
Entry Point Selection
It is necessary to find an approach that will best
facilitate interpretation of microelectrode recordings
while concomitantly maximizing safety. From an elec-
trophysiological mapping standpoint, a parasagittal ap-
proach is preferable but not feasible in all cases. Entry
points are chosen based on the patient’s anatomy to
provide a safe and optimal trajectory through the areas of
interest. Typical angles of approach for the STN target
are 15 to 30 degrees from the sagittal plane and 50 to 70
degrees in the anterior–posterior direction. The precise
entry point may be refined on the planning console such
that the trajectory passes through the crown of a gyrus
rather than into a sulcus. This avoids inadvertently dam-
aging sulcal or pial vessels, which lie on the cortical
surface. The cortical vessels should be avoided as well as
the F–F2 sulcus. After selecting preliminary entry points,
the images can be reformatted to the trajectory view,
which provides three orthogonal planes positioned with
respect to the trajectory rather than the patient’s anat-
omy. The approach then may be traced at millimeter
intervals to ensure that no deep sulci are transgressed and
that the ventricular ependyma is not scythed. A typical
approach will pass the electrode to course through the
FIG. 5. Digital brain atlas and trajectory. Coronal
and sagittal Schaltenbrand and Wahren digitized at-
las is morphed, reformatted, and overlaid onto the
MRI for the best fit to the individual patient’s anat-
omy. Note that this reformatting is not always an
optimal match. The trajectory is targeted to the pos-
terior portion of the STN nucleus.
Movement Disorders, Vol. 21, Suppl. 14, 2006
S254 A. MACHADO ET AL.
anterior portion of the thalamus, zona incerta, subtha-
lamic nucleus, and substantia nigra (Fig. 5). Any given
trajectory must be altered to avoid major visualized vas-
cular structures. Venous tributaries draining into the su-
perior sagittal sinus or branches of the anterior cerebral
artery may limit a more medial approach. Enlarged ven-
tricles and the presence of ependymal and intraventricu-
lar veins may also force the entry point to be moved
laterally, at the expense of missing the thalamus and
consequently the transition to zona incerta in STN sur-
gery. Gadolinium enhancement of the T1-weighted im-
ages allows visualization of vessels that would otherwise
be unnoticed. It is clear that accounting for these vessels
minimizes the risk of hemorrhage, although other groups
report a low rate of bleeding without this method.16 With
regards to the GPi, it is a more lateral structure than the
STN. As such, it is more often possible to find a more
parasagittal tract that will not approach any of the more
medially located vascular structures.
Positioning and Anesthesia
The patient is positioned supine on the operating room
table, with the knees flexed and the head of the table
elevated to various degrees depending on surgeon pref-
erence. The head frame is fixed to the table with an
adapter to the table or the floor. The patient’s feedback is
used to find a neck position that will best tolerate ex-
tended immobility. Certain teams use intravenous seda-
tion for the incisions and bony opening until electrophys-
iological mapping begins. Although sedation can be
used, there is a potential risk for interference with mi-
croelectrode recording. Agents such as propofol are
quickly reversible and may be preferred over other
longer-lasting agents. Careful control of the arterial
blood pressure is maintained to minimize the risk for
intracranial bleeding. Patients with labile blood pressure
may benefit from invasive monitoring for enhanced ti-
tration of the antihypertensive drugs. Preoperative anti-
biotics should be administered before incision and re-
peated thereafter. Draping should be performed to allow
visual access to the patient’s face, arms, and legs while
maintaining a sterile surgical site.
Older patients or those with degenerative spinal dis-
ease may not tolerate the extended awake immobilization
required for microelectrode recording (MER). In these
cases, epidural blocks or continuous epidural infusion of
opioids may be attempted to ease the pain.
Stereotactic Approach
The coordinates for the X, Y, and Z coordinates are set
and the entry points and the midline are marked on the
skin and the incisions are planned. The stereotactic arc
Movement Disorders, Vol. 21, Suppl. 14, 2006
can be used to mark precisely the incision and the burr
hole site, taking advantage of the trajectory planning.
Depending on the thickness of the skull, the inner rim of
the burr hole will limit the progression of the cannulas if
the hole is drilled perpendicular to the skull surface. In
order to prevent this problem, the holes should be drilled
in the axis of the trajectory, at the same angle chosen for
the stereotactic approach. Some teams prefer to open
both incisions and burr holes before starting physiology
on the first side, in order to expedite the process, but this
may increase the time of exposure of the second side. It
is worthwhile to start implantation on the side contralat-
eral to the patient’s worst symptoms in case the patient
does not tolerate a bilateral procedure.
The dura mater, arachnoid, and pia mater on the first
side are coagulated and opened. Some teams do not open
the dura and insert the tube guide by puncture of the
dura, thus preventing subdural air penetration and CSF
leakage. At this point, sedation can be interrupted to
allow the patient to be awakened for microelectrode
recording. Depending on the equipment and procedures
of the various teams, different accessories are used to
hold the microelectrodes and then the DBS lead. The
cannula is inserted for microelectrode recording to a
predetermined dorsal offset to the chosen anatomical
targeting. A hydraulic or electrical microdrive is used to
advance the microelectrode in submillimetric steps. Ex-
cept when dura is not opened, either gelfoam and/or
fibrin glue is placed around the cannula in the burr hole
to provide a seal, thus minimizing CSF loss and
pneumocephalus.
Electrophysiological Mapping
Intraoperative physiology including microelectrode
recording and stimulation is discussed separately in this
issue (see Gross and colleagues).
DBS Electrode Implantation and Testing
Various implantation approaches are used, from plac-
ing the active contacts in the center of the nucleus, at the
ventral border, beyond the ventral border, or spanning
multiple areas as determined by the team. After the
optimal location for implantation of the electrode has
been decided, the DBS lead (macroelectrode) can be
implanted. The two commercially available electrodes
have four contacts of 1.5 mm height and 1.27 mm
diameter and differ only in the spacing between contacts:
1.5 mm in the 3387 model and 0.5 mm in the 3389 model
(Medtronic, Minneapolis, MN). Contact 0 (the contact at
the electrode’s tip) can be positioned at the physiologi-
cally defined ventral border of the nucleus and the re-
maining contacts will span for 10.5 mm (3387) or 7.5
 SURGICAL TECHNIQUE, PERIOPERATIVE MANAGEMENTE
mm (3389) in the trajectory. When an inserting cannula
is used, the chosen electrode is loaded in such fashion
that the first contact (and not the dead space at the tip of
the electrode) is aligned with the tip of the cannula. Other
systems may have different loading structures, depend-
ing on the distances between the electrode holder and the
offset to target. Fluoroscopy is used by many centers to
monitor DBS lead movement and migration. Some cen-
ters perform AP and lateral X-rays while others perform
lateral only. In dedicated stereotactic operating rooms,
the X-ray tubes and the frame are part of a solid-state
setup, which avoids the instability of portable X-ray
system alignments.
The patient is examined for baseline tremor, rigidity,
and bradykinesia. The microdrive can be used to advance
the electrode to the desired target or, alternatively, man-
ual advancement can be performed to the target. Fluo-
roscopy can be used to confirm that the electrode is
assuming a straight trajectory. A microsubthalamotomy,
thalamotomy, or pallidotomy effect may occur secondary
to the mechanical insertion of the electrode, with im-
provements in PD symptoms.
Testing the DBS electrode for efficacy and side effects
is most commonly performed by all teams. However,
certain groups rely extensively on the microelectrode
recording and stimulation. In STN surgery, reduction in
tremor, rigidity, and bradykinesia is expected during
intraoperative macrostimulation. During implantation at
the GPi, less changes in PD symptoms may be found
intraoperatively, but the thresholds to side effects must
be determined. The electrode parameters for intraopera-
tive testing is similar to those for final programming.
Typically, a pulse width of 60 to 90 microseconds and
rate of 130 Hz are used and bipolar stimulation is per-
formed at various combinations in order to assess the
most commonly used cathodes. Voltage should be in-
creased stepwise and the effects recorded. Particular
attention should be directed to determination of side
effects, including corticospinal activation (upper extrem-
ity, lower extremity, and face/tongue), speech changes,
conjugate (corticospinal activation) and dysconjugate
(activation of the third nerve) eye deviation. For STN
targeting, paresthesias may indicate a more posterior
implantation of the lead and, if transitory, are not con-
sidered a contraindication for implantation. A well-tar-
geted electrode typically allows stimulation up to 4 volts
without causing side effects. Lower thresholds indicate
that the lead may be close to other structures and may
have to be repositioned. For the GPi, thresholds to side
effects should be higher, since higher amplitudes may be
necessary for therapeutic effect. Capsular activation with
subsequent motor contractions should not be achieved at
S255
less than 1 or 2 volts above the voltage yielding signif-
icant beneficial effects. For GPi, the deepest contact may
have visual side effects from stimulation of the optic
tract.
If side effects are found at thresholds lower than
expected, repositioning of the electrode will be neces-
sary. It is advised to move by more than 2 mm, as the risk
of the electrode falling into the previous tract is high. It
should also be noted that multiple macroelectrode pene-
trations may create fluid-filled spaces that may cause
stimulation to spread unpredictably and result in unreli-
able macrostimulation. These problems are reduced by
procedures using simultaneous insertion of several
microelectrodes.
Once the DBS electrode is implanted at the final
location, it must be secured in place while removing the
cannula, carrier, and microdrive. Continuous fluoroscopy
is helpful to monitor the potential of electrode displace-
ment. Anchoring and securing the lead can be achieved
by various techniques depending on the center prefer-
ence and expertise. These include securing the lead to the
skull with ligature embedded in dental cement,
miniplates, and screws, the Medtronic burr hole ring and
cap, as well as the Navigue Stim-Loc device (Image
Guided Neurologics, Melbourne, FL). Advantages and
disadvantages exist to each of these methods. Dental
cement and miniplates are not recommended by the lead
manufacturer. Their use may be necessary in peculiar
scenarios such as when a craniectomy has to be added to
the burr hole due to unexpected findings and the burr
hole rings will not conform to the opening in the skull.
The burr hole ring that is provided by the lead manufac-
turer can be safely used but a tendency exists to drive the
electrodes deeper when inserting the cap. This can be
easily observed on live fluoroscopy. The Stim-Loc de-
vice provides good stabilization of the electrodes without
a tendency to push the electrodes deeper. It is a costly
tool that may not be accessible to many centers. Once
secured, the lead is attached to an extension wire that is
tunneled to the parietal/occipital region. The excess lead
can be coiled around the burr hole device or along the
path of tunneling to serve as strain relief. The burr hole
and the wound should be thoroughly irrigated with rins-
ing solution before closing the skin. Depending on the
time that will be allowed between implantation of the
electrode and the pulse generator in a staged procedure,
scar tissue can form around the excess wire and burr hole
device. In manipulating the DBS lead, sharp instruments
or instruments with “teeth” should always be avoided
since insulation may be inadvertently damaged. Like-
wise, when using metal instruments, care should be taken
to prevent accidental crushing of the wires. Rubber-
Movement Disorders, Vol. 21, Suppl. 14, 2006
S256 A. MACHADO ET AL.
FIG. 6. Intraoperative hemorrhage. Axial CT scan image of a hema-
toma on the left side of a bilateral GPi implantation. Note the already
implanted DBS electrode on the right side. Active bleeding was seen
from the cannula during microelectrode recording and gentle irrigation
was performed with a spinal needle through the cannula. The cannula
was removed only after active bleeding stopped. The patient had no
change in neurological status. The procedure was aborted and the
patient taken to the CT scan.
capped instruments can be used but the surgeon’s fin-
gertips may be the best instruments to deal with these
delicate devices.
INTRAOPERATIVE ADVERSE EVENTS
Clinical hypervigilance is imperative throughout the
procedure. If there is any intraoperative evidence of
hemorrhage, such as bleeding from the cannula, gentle
irrigation down the cannula is performed until the efflu-
ent is clear (Fig. 6). It should be noted that the only path
for the hemorrhage to come out is via the cannula and it
should not be removed prematurely. It is crucial to con-
tinue gentle irrigation until the hemorrhage is cleared
while monitoring the patient for neurological status. Any
neurological deterioration such as the onset of lethargy
or a new focal deficit is cause for stopping the procedure
and proceeding immediately to the CT scanner. If the
patient cannot protect his or her airway, they should be
intubated prior to leaving the operating room. Equipment
to perform an emergent craniotomy should be readily
available at all times.
In addition to neurological changes, changes in neu-
ronal recordings may indicate the presence of an occult
intraoperative hemorrhage. As there are no active neu-
Movement Disorders, Vol. 21, Suppl. 14, 2006
rons within a hemorrhage cavity, a microelectrode that
encounters or produces a hemorrhage along its track will
record only silence. Therefore, unexpected electrical si-
lence not attributable to problems with the electrode
itself or its position (such as in the internal capsule)
should raise the suspicion of an intraoperative hemor-
rhage. In addition, deviation of the electrode tip on
fluoroscopy after placement not only signals the presence
of the development of an intracranial hemorrhage, but
also provides some information as to the magnitude of
the problem.
Implantation of Pulse Generator (IPG)
This is the last step of surgery and is performed under
general anesthesia. It can be performed the same day or
in a delayed/staged fashion. Due to the long duration of
the procedure and the need for general anesthesia, IPGs
can be implanted several days after the DBS lead im-
plantation when the patient has recovered from the in-
tracranial procedure.
For IPG implantation, the patient is positioned supine,
with the head turned to the opposite side of the intended
site of IPG implantation. Preoperative antibiotics are
again administered 30 minutes prior to incision. A sub-
cutaneous pocket is then created for the IPG and this
pocket is connected to the DBS lead tunneled previously
to the parietal/occipital region. The most common loca-
tion for the IPG placement is infraclavicular and typi-
cally marked 2 cm below the clavicle and 4 cm away
from the midline or 2 cm away from the lateral manu-
brial border. However, certain patients may require
placement in other locations due to body habitus (very
thin patients), age (pediatric patients), a history of prior
surgery in the region, or vanity. In addition, certain
activities such as hunting require the use of the chest to
stabilize equipment. The IPG should be placed in a
location that minimizes pressure and trauma to the unit.
Anecdotal reports cite local trauma as an infection risk
with other implanted hardware systems. Other locations
include the subcostal area and the flank as well as the
lumbar region and buttocks. All of these alternate sites
require the use of a longer extension lead. The standard
extension is 51 cm in length, but a 66 cm version is also
available.
Regardless of the location, it is useful to mark the
incisions before the final patient position to achieve
maximal symmetry and cosmetic appeal. Marking the
subclavicular incision in women deserves special atten-
tion for cosmesis. It may be useful to mark the incisions
in the standing or sitting positions in order to best predict
the final location of the incisions and generators. In most
individuals, it is possible to create a subclavicular sub-
 SURGICAL TECHNIQUE, PERIOPERATIVE MANAGEMENTE
FIG. 7. Lateral skull X-ray. A lateral skull X-ray showing bilateral
STN DBS electrodes. Note the location of the connectors in the
retroauricular region how the excess wires were coiled at the burr hole
site.
cutaneous pocket that is deep enough for hardware im-
plantation, just against the pectoral aponeurosis. In very
thin patients, it may be necessary to create the pocket in
between the pectoralis muscle and its fascia, although
extra care must be taken as an increased risk for postop-
erative hematoma formation may exist. Additionally, for
implantation of the IPG in a nonsubclavicular area, ut-
most care should be taken to prevent approximation of
the IPG to any bony prominence such as the rib or the
iliac crest.
A small parietal/occipital incision allows identification
of the connector that protects the DBS electrode. Exter-
nalization of the lead must be carefully performed since
it can be tethered by scar tissue formation. Excessive
force should be avoided to prevent breakage of the elec-
trode or migration of the intracranial portion. A tunnel is
created from the parietal region to the IPG pocket and the
51 cm implantable extension wire is passed and con-
nected to the distal aspect of the DBS lead and IPG. The
connector is internalized and pulled distally but should
never be placed at the level of the neck below the
mastoid, where mobility tends to cause tethering and
resultant hardware failure can occur. A good position for
the connector is the retroauricular region (Fig. 7). When
located too medially, it can cause pain when sleeping
supine and may come in contact with the lesser or greater
occipital nerves. If located too laterally, it may cause
discomfort while wearing glasses. Some teams place it
higher on the head, at the upper part of the temporal
muscle. The excess extension lead is coiled behind the
generator and the IPG is anchored to the fascia with
nonabsorbable sutures. Anchoring of the generator to
subcutaneous fat should be avoided since caudal migra-
tion may occur due to the weight of the IPG. Closure is
performed in layers after copious irrigation. The patient
S257
is re-draped for the contralateral side or when using a
Kinetra, both extension leads are passed under the skin
on the same side. The Kinetra is a larger device that can
be used to control two DBS electrodes, thus allowing for
a single-side IPG implantation. The disadvantages to this
system include the greater volume that may impose a risk
of erosion in very thin patients and the limitation to a
single set of pulse frequencies.
POSTOPERATIVE MANAGEMENT
In the immediate hours after surgery, it is important to
keep arterial blood pressure in the normal range. In
addition, the patient’s preoperative PD regimen should
be restarted immediately after surgery to avoid problems
with dopaminergic withdrawal. Patients should undergo
postoperative CT scans and/or MRI scans to assess the
electrode location and intracranial status. In addition,
plain X-rays are obtained to assess the location and
geometry of the leads and hardware. Parkinson’s medi-
cations may need to be adjusted depending on the pa-
tient’s status. Cognitive and behavioral changes may
occur in the postoperative period, particularly in older
patients. Patients can be discharged as early as 24 hours
after surgery, depending on their neurological and cog-
nitive status.
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