NEUROLOGICAL REVIEW SECTION EDITOR: DAVID E. PLEASURE, MD History, Applications, and Mechanisms of Deep Brain Stimulation Svjetlana Miocinovic, MD, PhD; Suvarchala Somayajula, MD; Shilpa Chitnis, MD, PhD; Jerrold L. Vitek, MD, PhD D eep brain stimulation (DBS) is an effective surgical treatment for medication-refractory hypokinetic and hyperkinetic movement disorders, and it is being explored for a variety of other neurological and psychiatric diseases. Deep brain stimulation has been Food and Drug Administration–approved for essential tremor and Parkinson disease and has a humanitarian device exemption for dystonia and obsessive-compulsive disorder. Neurostimulation is the fruit of decades of both technical and scientific advances in the field of basic neuroscience and functional neurosurgery. Despite the clinical success of DBS, the therapeutic mechanism of DBS re- mains under debate. Our objective is to provide a comprehensive review of DBS focusing on move- ment disorders, including the historical evolution of the technique, applications and outcomes with an overview of the most pertinent literature, current views on mechanisms of stimulation, and de- scription of hardware and programming techniques. We conclude with a discussion of future devel- opments in neurostimulation. JAMA Neurol. 2013;70(2):163-171. Published online November 12, 2012. doi:10.1001/2013.jamaneurol.45 Deep brain stimulation (DBS) has evolved as an important therapy for the treat- ment of essential tremor, Parkinson dis- ease (PD), and dystonia, and it is also emerging for the treatment of medication- refractory psychiatric disease. Food and Drug Administration approval was granted in 1997 for thalamic DBS for essential tremor and PD-related tremor, followed in 2003 by approval for subthalamic nucleus (STN) and globus pallidus internus (GPi) DBS for PD. A humanitarian device ex- emption for STN DBS and GPi DBS for primary generalized and segmental dys- tonia was granted in 2003 and for obses- sive-compulsive disorder, in 2009. Deep brain stimulation has also been used suc- cessfully in the treatment of Tourette syn- drome, depression, and epilepsy, and there are case reports of using DBS for the treat- ment of headache, pain, vegetative state, addiction, obesity, dementia, and stroke recovery. 1-4 New applications continue to emerge, encouraged by past successes and the fact that DBS effects are reversible al- lowing exploration of new targets and ap- plications not previously possible with le- sion surgery. The history of DBS is a fascinating example of the interplay be- tween basic and clinical research. It is the coming together of these 2 arenas that has led to the evolution of DBS for the treat- ment of disease as it is used today and will be used tomorrow. Table 1 summarizes milestones in the evolution of surgical therapy for movement disorders. CURRENT APPLICATIONS AND OUTCOMES Tremor Deep brain stimulation is an attractive al- ternative to surgery for the management of tremor. Surgical ablation of the ventral intermediate nucleus of the thalamus has been used as a therapy for tremor since the 1950s. 8 However, bilateral thalamotomy is not well tolerated because of the risk of Author Affiliations: Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (Drs Miocinovic and Chitnis); and Department of Neurology, University of Minnesota, Minneapolis (Drs Somayajula and Vitek). JAMA NEUROL/ VOL 70 (NO. 2), FEB 2013 WWW.JAMANEURO.COM 163 ©2013 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 02/20/2022