Ask an Expert: British Columbia’s Newly-appointed Deep Brain Stimulation Neurosurgeon, Dr. Stefan Lang, Discusses Deep Brain Stimulation for People with Parkinson’s

Dr. Stefan Lang (MD, PhD, FRCSC) completed an undergraduate degree in Neuroscience and Cognitive Neuropsychology at the University of Guelph. He then attended medical school at the University of Ottawa, followed by his neurosurgical residency at the University of Calgary. During his residency, he joined the Clinical Investigator Program and completed a PhD with a specialization in Neuroscience and Medical Imaging. He has won multiple national and international awards for his research and has published over 30 peer-reviewed papers. On completion of his neurosurgical residency, he obtained specialized training in Stereotactic and Functional Neurosurgery at the University of Toronto under the supervision of Dr. Andres Lozano, Dr. Suneil Kalia, and Dr. Mojgan Hodaie. He was then recruited to the University of British Columbia as an academic functional neurosurgeon, which involves performing Deep Brain Stimulation surgeries. He will work closely with the existing functional neurosurgery team and the Deep Brain Stimulation (DBS) clinic.

Can you tell our readers a little bit about yourself and your background, including where you studied and what specific training you have acquired to become a neurosurgeon focused on DBS?

After completing my undergraduate degree, I attended medical school followed by a neurological residency and a PhD. This is where I learned how to be a safe and competent neurosurgeon and scientist. I then went back to Ontario and did a yearlong fellowship in DBS at the Toronto Western Hospital. During this fellowship, I performed approximately 100 DBS surgeries.

Can you provide a brief overview of Deep Brain Stimulation, its risks and benefits, and what would make someone a good candidate?

Deep Brain Stimulation is a neurosurgical procedure where electrodes are placed deep in the brain to treat abnormal brain circuits. The electrodes are attached to extension wires that connect to a small battery. Everything is implanted underneath the skin and is minimally visible.

DBS is used in Parkinson’s disease to help treat the movement symptoms. For example, patients with tremor, rigidity, or slowness of movement may have significant benefit. This is especially true if the symptoms are fluctuating during the day. Deep Brain Stimulation can help level out these fluctuations, so that someone spends more time in the ‘on state’ during the day. It can also be helpful for the motor complications from too much levodopa, including dyskinesia (involuntary rhythmic movements). This is a ‘quality-of-life’ surgery – we do not change the course of the disease, but we hope to improve quality of life for many years.

The risks are small but should be considered carefully. These include infection, bleeding, or stimulation-related side effects, such as slurred speech or balance issues. We must determine whether the benefit will significantly outweigh the risks. Unfortunately, not everyone is a good candidate for this procedure.

Can you describe what a Deep Brain Stimulation surgery is like, for both the person with Parkinson’s and the neurosurgeon?

For the neurosurgeon, the surgery is routine. We have performed many of these surgeries and are familiar with each step along the way.

However, for the patient, this is a unique experience. The morning of the surgery, they will meet the team members, who will introduce themselves. A frame is attached to the head to help us with our precise targeting. We perform a short MRI scan with the frame on. They will then be moved into the operating room, where they will meet several other members of the team. Then, patients will be placed on the operating room bed and their head will be secured so that it does not move. None of this is painful and we do our best to keep the person comfortable.

During the procedure, the patient will be looking forward towards one of our highly trained nurse practitioners. They will be with the patient the entire way. In the background, they will hear myself and other members of the surgical team discussing details about the surgery. We will talk to the patient and guide them through each step. We like to have a patient’s cooperation during the procedure to help us safely place the electrodes. We may ask them to speak out loud and will carefully observe their symptoms. After we successfully place the electrodes, the patient will go to sleep with general anesthetic, and we will implant the battery. Typically, they will go home the next day.

Can DBS also help with non-motor symptoms of Parkinson’s?

The effect of Deep Brain Stimulation on non-motor symptoms is complex and an area of active investigation. In some cases, DBS can aggravate pre-existing psychiatric or cognitive issues. This is why we are very careful with patient selection.

It should be clear that the goal of the surgery is to improve movement rather than non-motor symptoms. However, some patients can experience improvements in mood, pain, and sleep following Deep Brain Stimulation. I am particularly interested in trying to figure out why some patients may benefit and why others may not. We will be launching a prospective study of this issue soon.

What inspired you to specialize in neurosurgery, particularly DBS for Parkinson’s disease?

I specialized in Neurosurgery, and specifically in Deep Brain Stimulation, because I am excited about what the future holds for this field. This is an area that we are actively learning about and improving every year. I take pride in the fact that our patients are often very satisfied with the procedures we provide. Most patients who are carefully selected for DBS will have significant improvement in the quality of their life.

For a very long time, British Columbia has only had one neurosurgeon performing DBS, creating significant delays in accessing this life-changing procedure. Your recruitment has given renewed hope to many. What further steps or actions can the province take in continuing to increase access to DBS for individuals in need?

Unfortunately, there are still obstacles present that are limiting our ability to further decrease wait times. This has to do with the fact that the surgeon does not work in isolation. We are part of a multidisciplinary team, including highly-trained nurse practitioners. While the recruitment of an additional surgeon has been an important step towards increasing access, there have not been corresponding increases in the other team members at the DBS Clinic. The nurse practitioners of the clinic now are working harder to accommodate the extra patients being seen by myself. An additional nurse practitioner and additional office space would help facilitate the flow of patients through the system.

The province of British Columbia has been underserved with respect to access to Deep Brain Stimulation. The wait list is now decreasing and patients who have been waiting years are getting timely access to a consultation.

Are there any recent advancements regarding DBS that you find promising or exciting?

There are many recent advances in Deep Brain Stimulation that I find exciting. A recent innovation allows us to record brain signals directly from the electrodes that we implant. This can allow us to better understand abnormal brain activity and to tailor treatments more precisely for individuals.

Another innovation is the compatibility of the new hardware with powerful MRI machines. It is now possible to take pictures of the brain with the stimulators implanted and turned on. We are planning to utilize this to study how the stimulation impacts brain networks.

Lastly, new techniques are allowing us to stimulate and lesion the brain without having to open the skull. These techniques include high-intensity focused ultrasound. We do not have access to this technology in British Columbia at the current time, but are working to see if this is feasible.

What are you looking forward to achieving or exploring further in the future regarding Parkinson’s treatment and DBS?

The long-term goal is to minimize the invasiveness of our procedures to increase safety and to be able to provide these therapies to more patients. We have much work to do and none of it can be done without the involvement of our patients. A major goal of mine is to offer research opportunities to my patients so that we can progress the field for future generations.

This content was published in the Spring 2024 edition of our quarterly magazine, Viewpoints. The content was accurate as of this publication date.