COVID-19 Shutdowns and the Disruption to Deep Brain Stimulation Treatment

NeurologyLive, April 2022, Volume 5, Issue 2

While shutdowns disrupted care for all patients with Parkinson disease, hospitals were forced to postpone elective procedures such as the initial DBS device implantation and implantable pulse generator replacements.

COVID-19 PANDEMIC SHUTDOWNS disrupted care for all patients, including those with Parkinson disease (PD) treated with deep brain stimulation (DBS). Hospitals, overwhelmed by COVID-19 cases, postponed elective procedures such as the initial DBS device implantation and implantable pulse generator (IPG) replacements for depleted batteries. DBS is the most widely used surgical treatment for patients with PD, with thousands of implantations done each year in the US.

At Wake Forest School of Medicine in Winston-Salem, North Carolina, investigators carried out the largest survey of DBS practices in North America to better understand the impact of COVID-19 pandemic–related shutdowns on DBS care.1 To understand the results of the survey, it is important to understand the processes involved in a DBS surgery. A new DBS implantation typically involves a multidisciplinary evaluation by a movement disorders neurologist, a neuropsychologist, a functional neurosurgeon, and occasionally a psychiatrist. Besides confirming the medical refractoriness of the PD symptoms, a neurologist also examines a patient both with and without PD medications, also known as an OFF/ON evaluation, to confirm which symptoms respond to levodopa. A neuropsychologist administers standardized tests and conducts an interview to evaluate the patient’s cognitive status and identify any psychiatric red flags for undergoing DBS surgery.

DBS surgery has 2 stages. First, the electrode is implanted in the brain, which usually requires the patient to stay overnight after surgery. The second stage, done a few weeks later as an outpatient procedure under general anesthesia, involves implanting and connecting the IPG in the chest to the implanted electrode. Typically, a postoperative CT scan of the brain is done to confirm the location of the DBS leads before the first programming session. After the surgery, a DBS patient undergoes 3 to 4 visits in the first 6 months to optimize settings and adjust medications. Moving forward, most patients need visits only every 6 months. There are 2 types of IPGs: a primary cell that has to be changed in 3 to 5 years because of battery depletion and a rechargeable cell that has a battery life of more than 15 years.

The Wake Forest survey was conducted during the first pandemic-associated shutdown in May 2020. It was carried out on behalf of the Functional Neurosurgical Working Group, part of the Parkinson Study Group (PSG), the largest organization of PD investigators in North America, with representation from most high-volume DBS centers in the US and Canada. The objective was to understand the impact of the pandemic-associated shutdown on care of DBS patients so that contingency plans could be developed in case of a future shutdown. Twenty-three DBS centers, 19 from the US and 4 from Canada, participated in the survey, and all except 2 were academic tertiary care centers. Participating sites reported that COVID-19 shutdown restrictions were in place from 4 to 16 weeks.

DBS care delivery was affected at all sites and levels, including preoperative assessments, surgeries, and postoperative DBS programming. Although all institutions reported that DBS assessments and surgeries were postponed because of institutional policy mandates, 87% of the sites reported that patients also elected to postpone DBS electrode implantation because of concerns for COVID-19 exposure. One-third of the sites discontinued preoperative evaluations, whereas the remaining experienced reduction in the number of preoperative evaluations. Telehealth was widely used for preoperative assessments as well as postoperative care because of restrictions for in-person visits. Although telehealth was used for preoperative assessments by neurology and neurosurgery at two-thirds of the sites, only one-third of the sites reported its use for neuropsychology assessments.

A follow-up study to evaluate the discrepancy of neuropsychology evaluations compared with neurology and neurosurgery identified a lack of support by insurance providers for telehealth neuropsychological assessments, concerns regarding the validity of testing methods via telehealth, and lack of availability of appropriate devices—such as tablets and laptops—for patients to undergo remote testing.2 No site made a surgical decision for patients with PD without an OFF/ON medication evaluation of the PD symptoms, indicating the importance of this test and the limitation of administering this test via telehealth. A telehealth version of this assessment has been reported, though it is unclear whether any sites were familiar with or used it.3

In the Wake Forest study, all sites reported postponement of initial electrode implantations, given that it was an elective procedure.1 In addition, 70% of the sites also postponed IPG battery replacements. Loss of DBS therapy can have serious consequences for patients with PD, and it is recommended that IPG replacement, whether for battery depletion or hardware malfunction, should not be considered an elective procedure. Similarly, IPG removal due to infection should not be considered an elective procedure. In all, 38% of the sites reported a complete halt in postoperative DBS programming, whereas only 25% of the sites reported continuation. All sites reported that remote DBS programming should be available. Moreover, any technical, regulatory, and reimbursement barriers should be addressed to make remote programming more likely to be accepted.

Despite disrupting DBS care, the pandemic-related shutdown offered opportunities to develop contingency plans in case a shutdown occurs again. Suggestions for DBS and other device management during a pandemic have been published.4,5 Many outpatient DBS assessments can be done via telehealth, provided that telehealth examinations are validated against standardized in-person examinations. This is particularly important for neuropsychological testing and OFF/ON medication evaluations. Remote DBS programming can address travel limitations for patients, but its use would depend on wider adoption by DBS device manufacturers and changes in regulatory and reimbursement policies.

REFERENCES
1. Siddiqui MS, Jimenez-Shahed J, Mari Z, et al. North American survey on impact of the COVID-19 pandemic shutdown on DBS care. Parkinsonism Relat Disord. 2021;92:41-45. doi:10.1016/j.parkreldis.2021.10.011
2. York MK, Farace E, Pollak L, et al. The global pandemic has permanently changed the state of practice for pre-DBS neuropsychological evaluations. Parkinsonism Relat Disord. 2021;86:135- 138. doi:10.1016/j.parkreldis.2021.04.029
3. Abdolahi A, Scoglio N, Killoran A, Dorsey ER, Biglan KM. Potential reliability and validity of a modified version of the Unified Parkinson’s Disease Rating Scale that could be administered remotely. Parkinsonism Relat Disord. 2013;19(2):218-221. doi:10.1016/j.parkreldis.2012.10.008
4. Fasano A, Antonini A, Katzenschlager R, et al. Management of advanced therapies in Parkinson’s disease patients in times of humanitarian crisis: the COVID-19 experience. Mov Disord Clin Pract. 2020;7(4):361-372. doi:10.1002/mdc3.12965
5. Miocinovic S, Ostrem JL, Okun MS. Recommendations for deep brain stimulation device management during a pandemic. J Parkinsons Dis. 2020;10(3):903-910. doi:10.3233/JPD-202072