Mayfield Neurosurgeon Performs Asleep Surgery for Parkinsons

George Mandybur, MD, a neurosurgeon with Mayfield Brain & Spine, and The Jewish Hospital – Mercy Health now offer deep brain stimulation surgery for patients with Parkinson’s disease while they are asleep. The procedure, designed to reduce Parkinson’s symptoms such as tremor, stiffness and difficulty walking, has traditionally been performed while patients are awake.

Dr. Mandybur is performing the asleep surgery using the MRI-guided ClearPoint® Neuro Intervention System, which is marketed by Memphis-based MRI Interventions, Inc.

The option to undergo the procedure while asleep is expected is to widen the number of patients who choose to undergo the elective surgery.

“The ClearPoint system will allow the patient to be asleep for the entire procedure, so they’re more comfortable,” Dr. Mandybur says. “For many people, it will be less unsettling.”

The Jewish Hospital is the only adult hospital in the Cincinnati region with the new ClearPoint technology. Dr. Mandybur has previously used the system during adult Parkinson’s cases at Cincinnati Children’s Hospital Medical Center. Collaborating neurologists include Brian Maddux, MD, and David Schmerler, DO, both of Riverhills Neuroscience.

Deep brain stimulation surgery, also known as DBS surgery, is the primary surgical treatment for Parkinson’s. During surgery, the surgeon implants electrodes that deliver electrical signals to the subthalamic nucleus, an area the size of a jelly bean that is responsible for movement. The electrodes are connected to a stimulator device that resembles a pacemaker and is implanted under the collarbone. When the electrodes are placed in the optimal position, Parkinson’s symptoms such as tremor subside.

DBS does not cure Parkinson’s disease, nor can it improve declines in memory and thinking that come with Parkinson’s. But DBS surgery can significantly improve a patient’s quality of life. DBS works best for patients who benefit from dopamine-replacement medication but are getting less and less benefit from their medication.

ClearPoint allows surgeons to plan, target, and deliver this intervention, all while the patient is asleep under anesthesia. The patient is immobilized in a fixation headframe and the surgery is performed in an MRI suite, with the surgeon receiving real-time guidance from the MRI.

Dr. Mandybur also will perform awake DBS procedures at The Jewish Hospital.

Both the awake and asleep procedures have advantages. The asleep procedure, in addition to offering greater comfort to patients, has a safety advantage.

“If I’m using an MRI to guide the electrode, I can see exactly where it goes,” Dr. Mandybur says. “And if there are any problems, such as a hemorrhage, I see them happen right away. You can’t see that in the traditional awake procedure.”

The awake surgery, meanwhile, enables the patient to provide instant feedback about the electrode placement’s effectiveness.

“You can test it right away and see how the electrode placement is affecting the patient’s symptoms.”

This is particularly important if the brain shifts after the initial incision is made and air gets into the head.

“This is a naturally occurring phenomenon when you’re doing brain surgery, whether the patient is awake or asleep,” Dr. Mandybur explains. “That’s perfectly OK. The problem is, if the brain moves, your intended target may move also. If I have to adjust my approach, I optimize the approach by testing the awake patient. If the patient is asleep and can’t undergo physiologic testing, we rely on the real-time MRI imaging instead.”

Recent studies have shed light on the outcomes of awake and asleep DBS procedure for people with Parkinson’s. A 2018 review in Brain Science by Rush University faculty reported that retrospective comparisons between asleep and awake DBS “have shown similar short-term efficacy with the potential for decreased complications” in the asleep groups.

A German study of 96 patients (48 awake, 48 asleep) published in the journal Neuromodulation in August 2018 found that while overall motor function improved faster in the awake surgery group, the difference disappeared after one year. The authors concluded that “awake surgery still seems advantageous … although asleep surgery may be considered” for patients not suitable for awake surgery.

At The Jewish Hospital, Dr. Mandybur is utilizing DBS technologies manufactured by Abbott, Medtronic and Boston Scientific. Dr. Mandybur was the first neurosurgeon in Ohio to use the new Abbott multidirectional DBS system.