Parkinson Disease (DBS Candidate)

Our Specialists for Parkinson Disease (DBS Candidate)

DBS is a high-volume, high-precision operation, and outcomes track closely with surgeon experience, target selection, and the programming team that follows you afterward. At UChicago, the same surgeons who implant your electrodes work side-by-side with movement disorder neurologists for the lifetime of your device.

Peter Christian Warnke, M.D.

Section Chief, Functional Neurosurgery & Epilepsy

Dr. Warnke is an international leader in functional neurosurgery and has performed over 6,000 stereotactic surgeries and more than 3,000 brain tumor surgeries. He is only the second neurosurgeon worldwide to perform laser hemispherotomy, and he has completed over 400 laser ablation surgeries since arriving at UChicago. He is funded by four NIH grants including the BRAIN Initiative, and he directs the NAUTILUS trial for thalamic stimulation in drug-resistant epilepsy. Dr. Warnke leads the functional neurosurgery program at UChicago and was the first neurosurgeon in Chicago to implant directional DBS electrodes, which allow the stimulation field to be shaped after surgery to maximize benefit and minimize speech and mood side effects. He performs both awake microelectrode-guided and asleep image-guided DBS, and chooses the approach for each patient rather than defaulting to one technique.

David Satzer, M.D.

Functional Neurosurgery & Epilepsy

Dr. Satzer is a functional neurosurgeon specializing in epilepsy surgery, laser ablation, and deep brain stimulation. He is a recipient of the American Epilepsy Society Junior Investigator Award, and his research focuses on local field potentials and aperiodic neural activity as biomarkers for seizures and neuromodulation. His recent work has appeared in Brain Stimulation (2025). Dr. Satzer is a stereotactic and functional neurosurgeon whose research focuses on the electrophysiology of DBS targets and how electrode placement translates into long-term clinical benefit (Journal of Neurology, Neurosurgery & Psychiatry, 2015). At UChicago, he partners with Dr. Warnke on the DBS service for Parkinson disease, essential tremor, and dystonia.

What Is DBS for Parkinson Disease?

Deep brain stimulation is a surgical treatment for Parkinson disease that places thin electrodes into precisely targeted structures deep in the brain. Those electrodes connect to a small battery (a pulse generator) implanted under the skin near your collarbone, similar to a cardiac pacemaker. Once the system is on, it delivers gentle electrical pulses that quiet the abnormal brain activity driving your tremor, stiffness, and slowness.

DBS is not a cure. Parkinson disease is still progressing underneath, and medications usually stay part of the picture. What DBS does — remarkably well in the right patient — is restore the best hours of your day and extend them. The phrase neurologists use is that your "best off" should start to look like your "best on": the function you used to get only when your medication was peaking, you now get most of the day.

For many patients, DBS also means taking 30-60% less levodopa, which in turn reduces the involuntary writhing movements (dyskinesias) that come from years of medication.

Who Should Think About DBS?

DBS is designed for advanced Parkinson disease, not early disease. Most patients have had Parkinson for four years or more, are on a complicated medication regimen, and still struggle with day-to-day function. The key signs that DBS might help include:

Motor fluctuations and dyskinesia

• Wearing off — your medication stops working well before the next dose is due, leaving you slow, stiff, or frozen
• Unpredictable off periods — sometimes a dose works, sometimes it doesn't
• Dyskinesia — involuntary twisting, swaying, or dance-like movements that come on when your medication peaks
• Taking levodopa every two to three hours just to stay functional

Tremor that won't quit

• Tremor that medication can't control, even at high doses
• Tremor that interferes with eating, writing, dressing, or working

What DBS cannot fix

DBS improves the symptoms that levodopa improves. Symptoms that don't respond to levodopa usually don't respond to DBS either. These include balance problems and falls that happen even when your medication is working, swallowing trouble, freezing of gait that persists in the on-state, and cognitive decline or dementia. If your main problem is falling or memory, DBS is probably the wrong tool.

How Are DBS Candidates Evaluated?

Choosing the right patient is the single most important determinant of a good outcome. At UChicago, candidacy is decided by a multidisciplinary team — neurosurgery, movement disorders neurology, neuropsychology, and psychiatry — not a single surgeon. The workup usually takes several visits and is modeled after the international CAPSIT-PD protocol.

Levodopa challenge

You'll be asked to come in after holding your Parkinson medications overnight (this is your off state). A movement disorder neurologist scores your motor symptoms on the Unified Parkinson's Disease Rating Scale (UPDRS-III). You then take your usual morning dose and are scored again at peak effect (the on state). The difference between those two scores is the single best predictor of how much DBS will help you. A 30% or greater improvement with levodopa is the threshold most teams look for.

Neuropsychological testing

Significant cognitive impairment or dementia is a contraindication to DBS — the surgery can make thinking problems worse. A full neuropsych battery screens for this and also looks at mood, because uncontrolled depression or psychosis needs to be addressed before surgery.

Brain MRI

A high-resolution MRI confirms the diagnosis is consistent with idiopathic Parkinson disease (not a Parkinson-plus syndrome like multiple system atrophy or progressive supranuclear palsy, which don't respond to DBS) and is used to plan the electrode trajectory.

Medical and surgical screening

Because DBS is an elective operation, your team will make sure you're healthy enough to tolerate anesthesia and that anticoagulants, cardiac conditions, and other medical issues are addressed in advance.

How Is DBS Performed?

DBS is really two decisions braided together: which target and which technique. Both decisions are individualized.

STN vs GPi: choosing the target

The two standard targets are the subthalamic nucleus (STN) and the globus pallidus internus (GPi). A large NIH-VA randomized trial (Follett et al., NEJM 2010) showed that both targets produce similar motor improvement, but there are differences worth knowing:

• STN — allows the biggest reduction in levodopa dose (often more than 50%). Tends to be the preferred target for younger patients with severe dyskinesia whose main goal is getting off high-dose medication. Some patients have more mood changes, speech changes, or impulse control issues with STN.
• GPi — directly suppresses dyskinesia and may be gentler on mood, cognition, and speech. Often chosen for older patients, patients with cognitive vulnerability, or patients whose main problem is medication-induced dyskinesia rather than wearing off.

Your team will pick the target based on your symptoms, age, cognition, medication regimen, and your own priorities.

Awake vs asleep: choosing the technique

There are two well-validated ways to place the electrodes.

Awake surgery with microelectrode recording (MER) has been the traditional approach for three decades. You're sedated for the scalp and skull work but wake up for the deep part of the procedure so the team can record electrical activity from individual brain cells through a tiny microelectrode, map the exact boundaries of the target, and test stimulation in real time — watching your tremor stop and checking for any side effects on speech, vision, or movement. It's demanding for the patient but gives exceptional physiologic feedback.

Asleep, image-guided surgery uses intraoperative MRI or CT to place the electrodes with sub-millimeter accuracy while you're under general anesthesia. Published outcomes for asleep DBS are comparable to — and in some series slightly better than — awake DBS for motor improvement, quality of life, and speech (Brodsky et al., Neurology 2017). Asleep DBS is often the better choice for patients who are anxious about being awake, have severe off-state symptoms that make awake testing miserable, or have airway or medical issues.

UChicago offers both approaches and the choice is based on what's best for each patient, not on what the surgeon prefers.

Focused ultrasound: an alternative for some patients

For patients whose main disabling symptom is tremor — and who don't want a permanent implant — MR-guided focused ultrasound offers an incisionless alternative. The procedure uses hundreds of ultrasound beams focused through the intact skull to create a tiny, permanent lesion in the thalamus (or, in newer protocols, the subthalamic region). No incision, no hardware, no battery. Randomized trials have shown meaningful tremor improvement, though the treatment is typically one-sided, is not usually effective for bradykinesia or rigidity, and the lesion is not reversible the way DBS stimulation is.

Programming and follow-up

The surgery is only half the job. The electrodes start out doing nothing — your movement disorders neurologist programs the device over a series of visits in the first several months, fine-tuning which contacts are active, the voltage, and the pulse width. Over the next year, medication is typically reduced in parallel. Programming continues for the life of the device.

What Are the Outcomes?

DBS is one of the most thoroughly studied operations in neurosurgery, and the outcome data — from multiple randomized trials — is consistent. In well-selected patients, here's what to expect:

Side effects exist and should be discussed honestly. About 1-3% of patients have a serious surgical complication such as bleeding or infection. Stimulation-related side effects — changes in speech, mood, balance, or cognition — are more common but are usually reversible by adjusting the programming. Hardware problems (lead fracture, battery replacement) do occur over years and are fixable.

The most important thing you can control is choosing an experienced DBS team. Patient selection, target choice, surgical accuracy, and long-term programming are all learned skills, and outcomes in high-volume centers are measurably better than in low-volume ones. That's why where you have DBS matters as much as whether you have DBS.

References