Prepare for Procedure

Prepare for a Procedure

Deep Brain Stimulation (DBS)

If you have bee scheduled for the DBS procedure, you will be admitted to Johns Hopkins the day before your surgery. All anti-parkinsonian medications will be stopped at 10pm on the day of admission and will not resume until after the surgery. This maximizes our ability to observe the benefit of the placement of the DBS, and minimizes drug-induced dyskinesias that can make being in a headframe more difficult.

This is a breakdown of what the procedure entails. If you'd like to go directly to a particular section, you may click on one of the links below:

Frame Placement

Radiologic Targeting

Physiological Localization

Microelectrode Recording

After Surgery

Frame Placement -- The morning of surgery, you will be taken to the radiology suite for placement of a stereotactic head frame. We utilize the Leksell (Elekta) frame, which allows us to precisely target the area of the brain to be stimulated. Following sterilization of the forehead and back part of the head (occiput), you will be given a local anesthetic to make the process of attaching the frame more comfortable. You are fully awake during the placement, which takes less than 15 minutes. Most patients tolerate the placement of the frame without any difficulty.

Radiologic Targeting -- Following placement of the head frame, you will have a brief MRI or CT scan with the frame in place. This helps us to directly or indirectly identify the coordinates for the area of the brain to be targeted.

Physiological Localization -- After radiologic targeting, you will be taken to the operating suite. We will fix the head frame to the top of the operating table. You will be positioned to a reclining position so that you are comfortable for the next few hours. After shaving a small amount of hair (always behind the hairline), the area is cleaned and sterile drapes are placed. Once again, local anesthetic is applied to the scalp prior to making a small, two inch linear incision. Next, a dime-size 14mm burr hole is drilled in the skull under the anesthesized scalp. You are fully awake during the drilling. Most patients compare the experience to being at the dentist. Patients rarely feel any pain during this part of the procedure. Next, the covering of the brain (dura) is opened, and we are ready for what we believe is the most critical step to local our final target -- microelectrode recording (MER).

Microelectrode Recording -- Microelectrode recording is the most precise method of localizing the surgical site. A member of our team, Dr. Lenz, pioneered the technique of recording activity from single neurons as well as microstimulation with a custom designed microelectrode. The use of this technique has been endorsed by the Task Force on Surgery for Parkinson's Disease of the American Academy of Neurology Therapeutic and Technology Assessment Committee: Evaluation of Surgery for Parkinson's Disease.

MER is used to further define the image-derived target. Because not all brains are the same, the information obtained from MER gives a more accurate target for final DBS placement. As the microelectrode passes along its trajectory, we are able to visualize and hear the neuronal activity from different areas of the brain. You are also able to hear brain activity and discussions of the team throughout your surgery.

As the microlectrode passes through the basal ganglia and the thalamus toward its final target (STN, GPi, Vim), we are able to identify specific structures based on unique patterns of spontaneous neuronal activity. Dr. Lenz will also moves specific joints in your upper and lower extremities to modulate the activity in the sensorimotor portion of the final target. This allows us to create a map of the body within the desired target.

After Surgery -- Three to four weeks after surgery, you are ready to have the stimulator turned on and programmed. Many patients experience some level of benefit from the implant immediately following surgery. This is thought to be due to swelling around the tip of the implanted electrode. However, this effect often diminishes over the following weeks to months. The initial programming session generally takes several hours. The implanted device is checked in order to determine that it is functioning correctly, and various parameters of stimulation (voltage, frequency of stimulator and which electrodes are used) are programmed. This process requires continuous feedback from the patient to ascertain that there are benefits and to identify any side effects.

Patients typically return several times during the following months until the stimulator is programmed optimally. Because this involves a degree of trial and error, the process can be frustrating. Some patients express that not all of their symptoms have been treated as much as they would have liked. Most patients show very significant benefits, as long as the expectations going into the surgery are understood.

Lumbar Puncture

What is a Lumbar Puncture?

Why do I need one?

How do I prepare?

What happens on the day of my appointment?

What happens after my procedure?

Do I need additional help?

What is a Lumbar Puncture?
A lumbar puncture is a procedure used to collect cerebral spinal fluid (CSF) for analysis. Cerebral spinal fluid is a clear fluid that circulates in the space surrounding the spine and brain. It acts like a cushion protecting the brain and spine from injury. During the procedure, a hollow needle, or cannula, is used to penetrate the spinal canal at the level of the third-to-fourth or fourth-to-fifth lumbar vertebra. CSF is then drawn through the needle.

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Why Do I Need a Lumbar Puncture?
A lumbar puncture is most commonly performed to measure the pressure within the cerebrospinal fluid (CSF) and to collect a sample for further testing. The CSF can be evaluated for color, blood cells, bacteria, malignant cells, glucose, protein and many other chemical changes. The results of the evaluation can be used to diagnose some neurological disorders. Lumbar punctures can also be used to decrease spinal fluid pressure in patients with normal pressure hydrocephalus and benign intracranial hypertension. Lumbar punctures can also be used as an access method for spinal anesthesia, introduction of radio opaque contrast (as used in myelograms), corticosteroids, antibiotics, and chemotherapeutic agents.

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How Do I Prepare For a Lumbar Puncture?
Preparing for your lumbar puncture is easy. Your doctor will probably order several blood tests to be sure that you don’t have any unusual bleeding or clotting. If you take a blood thinner, make sure you ask your doctor when you should stop this medication. If you take Ibuprofen or aspirin frequently, you should stop taking them a few days before your spinal tap.

You should plan to spend at least three hours at the hospital on the day of your procedure. Although the actual spinal tap takes only a few minutes, numbing and cleaning the area and preparation can take about 30 minutes. You will want to wear loose fitting clothing to increase your comfort following your procedure.

You will also need to lie flat following the spinal tap for a minimum of one hour to promote clotting at the site of the puncture.

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What Happens On the Day of the Procedure?
We ask that you arrive as scheduled at the Neurology/Neurosurgery reception desk located on the fifth floor of the Johns Hopkins Outpatient Center. Family members may be allowed to accompany you to the procedure area and join you following the procedure.

If you get lost, or are running late, please call the reception desk at 410.955.7642 for help.

Before the procedure, you will be asked to empty your bladder. You will remove your outer pants only and put on a hospital gown. A healthcare worker will help position you on an exam table so that your back is facing the doctor. Some doctors prefer to have their patients sit on the exam table and hunch your back over a bedside table or pillow. Either way will allow the spaces of the back bones to stretch open for the very small spinal needle to fit in between the bony area. You will be draped and prepped with an antiseptic cleansing solution like iodine. This solution will feel cold. The doctor will use a very small needle to numb the area. You may feel some stinging for a brief time during this process.

Once the area is numb, the doctor will place the needle below the spinal cord level but into the spinal canal. Since the spinal cord ends approximately at the navel, risk of injury to the actual spinal cord is very minimal. Most people report feeling only pressure during this part of the procedure, not pain. Rarely, patients may feel a mild nerve shock as the needle brushes some of the nerve endings. If this does occur the needle can be moved to reduce discomfort. The entire procedure usually takes 15-20 minutes.

Generally three-to-four small vials of fluid are removed.

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What Happens After the Procedure?
Once the needle is removed, a Band-Aid is placed over the hole in your skin. You will be asked to remain flat on the exam table for a minimum of one hour to promote closing of the inner hole. To promote cerebral spinal fluid production, you will be encouraged to drink fluid while you recover. We recommend drinking extra fluids for the next two-to-three days. Although this will certainly result in additional trips to the bathroom, it may reduce the likelihood of headaches.

A headache following spinal tap occurs in five-twenty percent of patients. It typically comes on upon standing and is relieved by lying down. You should lie flat on your back or stomach (but not your side) for as long as you can the first 24 hours after the procedure or if you have a headache. Also, to minimize complications, it is recommended that patients avoid bending and heavy lifting for two-to-three days following the procedure. Even lifting a small child following this procedure can cause the clot formation to become dislodged. Your physician will tell you when it is safe to return to work. Most people can generally return to work in one-to-two days.

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Do I Need Additional Help?
Some post-LP headaches do not resolve with fluids and bed rest. If this happens, a blood patch can be performed to relieve your symptoms. Rarely, the lumbar puncture/spinal tap can cause infection. You should monitor yourself closely for three-to-five days for signs of infection, including: fever/ temperature over 101, drainage or redness at the site, severe stiff neck, persistent head pain that is not affected by acetaminophen (Tylenol), nausea or vomiting.

If you notice any of these symptoms, we advise you to contact your referring neurologist. If it is after hours, you may call the Johns Hopkins Neurologist on Call at 410-955-6070.

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Neuro-Cognitive Assessment in Parkinson's

As their illness progresses, many patients with PD unfortunately experience cognitive difficulties. Early on, subtle signs may be present that can be overlooked by patient and family. Later, problems become more obvious and can significantly interfere with day-to-day activities. The purpose of the neuro-cognitive assessment in PD is to try to assess to what degree these problems exist and how they are impacting the patient and family, and if there is anything that can be done about them. Information is first gathered from the patient and family member on observations about these issues. The patient is then given several brief tests of cognitive function which assess memory, language, mental flexibility, and orientation, among other areas. These tests take about 20-30 minutes to complete. While the patient is
taking the tests, family members are asked to complete forms which rate the patient's abilities to do various activities of daily living, and also their observations of behavioral and emotional traits the patient may be exhibiting, e.g. depression, hallucinations or anxiety. Then, a general neurological examination is performed focusing on the motor symptoms of PD such as coordination, gait and balance testing. Finally, the results of these evaluations are discussed and a treatment plan initiated. In subsequent visits, some of the tests can be repeated so that progress can be assessed.

No special preparation on the part of the patient is needed. If previous cognitive or neuropsychological tests have been performed elsewhere, having them in hand for review would be helpful to the doctor. There is no physical discomfort involved. At worst, patients may experience mild
frustration or anxiety if they are having a hard time answering some of the questions. The whole procedure usually takes around an hour to an hour and a half.