A novel assistive method for rigidity evaluation during deep brain stimulation surgery using acceleration sensors

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OBJECTIVE

Despite the widespread use of deep brain stimulation (DBS) for movement disorders such as Parkinson's disease (PD), the exact anatomical target responsible for the therapeutic effect is still a subject of research. Intraoperative stimulation tests by experts consist of performing passive movements of the patient's arm or wrist while the amplitude of the stimulation current is increased. At each position, the amplitude that best alleviates rigidity is identified. Intrarater and interrater variations due to the subjective and semiquantitative nature of such evaluations have been reported. The aim of the present study was to evaluate the use of an acceleration sensor attached to the evaluator's wrist to assess the change in rigidity, hypothesizing that such a change will alter the speed of the passive movements. Furthermore, the combined analysis of such quantitative results with anatomy would generate a more reproducible description of the most effective stimulation sites.

METHODS

To test the reliability of the method, it was applied during postoperative follow-up examinations of 3 patients. To study the feasibility of intraoperative use, it was used during 9 bilateral DBS operations in patients suffering from PD. Changes in rigidity were calculated by extracting relevant outcome measures from the accelerometer data. These values were used to identify rigidity-suppressing stimulation current amplitudes, which were statistically compared with the amplitudes identified by the neurologist. Positions for the chronic DBS lead implantation that would have been chosen based on the acceleration data were compared with clinical choices. The data were also analyzed with respect to the anatomical location of the stimulating electrode.

RESULTS

Outcome measures extracted from the accelerometer data were reproducible for the same evaluator, thus providing a reliable assessment of rigidity changes during intraoperative stimulation tests. Of the 188 stimulation sites analyzed, the number of sites where rigidity-suppressing amplitudes were found increased from 144 to 170 when the accelerometer evaluations were considered. In general, rigidity release could be observed at significantly lower amplitudes with accelerometer evaluation (mean 0.9 ± 0.6 mA) than with subjective evaluation (mean 1.4 ± 0.6 mA) (p < 0.001). Of 14 choices for the implant location of the DBS lead, only 2 were the same for acceleration-based and subjective evaluations. The comparison across anatomical locations showed that stimulation in the fields of Forel ameliorates rigidity at similar amplitudes as stimulation in the subthalamic nucleus, but with fewer side effects.

CONCLUSIONS

This article describes and validates a new assistive method for assessing rigidity with acceleration sensors during intraoperative stimulation tests in DBS procedures. The initial results indicate that the proposed method may be a clinically useful aid for optimal DBS lead placement as well as a new tool in the ongoing scientific search for the optimal DBS target for PD.

ABBREVIATIONS AmpQ = quantitatively identified rigidity-suppressing amplitude; AmpS = subjectively assessed amplitude; DBS = deep brain stimulation; FF = fields of Forel; MER = microelectrode recording; OR = operating room; PD = Parkinson's disease; QC = quantitatively assessed change; S-EMG = surface electromyography; STN = subthalamic nucleus; USB = Universal Serial Bus; ZI = zona incerta.

Article Information

Correspondence Simone Hemm, Institute of Medical and Analytical Technologies, University of Applied Sciences and Arts Northwestern Switzerland, Gruendenstrasse 40, Muttenz CH-4132, Switzerland. email: simone.hemm@fhnw.ch.

INCLUDE WHEN CITING Published online December 16, 2016; DOI: 10.3171/2016.8.JNS152770.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Data recording setup used to assist rigidity evaluations performed during DBS surgery. Figure is available in color online only.

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    Graphical representation of the recorded acceleration data synchronized with the stimulation current amplitude (upper) for 1 stimulation test, and outcome measures extracted in a windowed manner from the recorded signal along with the stimulation current amplitude (lower).

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    Filtered acceleration data from the sensors mounted on the evaluator (solid gray line) and on the patient (solid black line). The graphs show data from the passive movements of the elbow (upper) and wrist joint (lower).

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    Box plots showing the interrater variations (E1, E2, E3) for outcome measure 1 for passive movements of the left elbow (A), left wrist (B), right elbow (C), and right wrist (D).

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    Box plot comparing the rigidity-suppressing stimulation current amplitudes (n = 140) identified with subjective evaluation (AmpS) and from the quantitative data (AmpQ). Upper whiskers are at the 95th percentile and lower whiskers are at the 5th percentile. Asterisks represent outliers.

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    Left: Column charts comparing the average stimulation current amplitude required to observe at least a 75% reductionin the mean of the 3 outcome measures (standard deviation, signal energy, and spectral amplitude of the primary frequency). Right: Stacked 100% column charts present the number of stimulation tests where side effects were observed (black) as a percentage of the total number of stimulation tests in the corresponding structure. The numbers inside the black part of the bars indicate the actual count of the side-effect occurrences; the numbers below the bars indicate the total number of stimulation tests.

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