SALT LAKE CITY — Dr. John Rolston is in the middle of conducting a delicate, life-changing brain surgery, but there is no inflection of anxiousness in his voice, no sign of tension in his demeanor.
In fact, to the uninitiated eye, it might appear that Rolston, a neurosurgeon for University of Utah Health, is merely sitting at a computer, looking at highly detailed brain scans.
But in fact, he and his surgical team are working to land a tiny electrode onto a precise region deep inside 71-year-old Art Eichbauer's brain called the subthalamic nucleus, or STN for short.
The electrode, no more than the width of angel hair pasta, is intended to provide an electrical current that is able to cancel out a faulty pulse from Eichbauer's brain that causes his right hand to shake and his right foot to sag.
If the placement is successful, the procedure could extinguish both of those symptoms of Parkinson's disease that plague his day-to-day life.
"When (the pulse) doesn't send out those bad signals, the brain … resorts back normally," Rolston says.
Using real-time MRI imaging, Rolston looks closely at the current trajectory of the tube delivering the electrode, to ensure it is on target.
In order for the procedure to work properly, the device must be positioned within microns of its intended destination. If it isn't, "you'll end up in the wrong place, with the wrong effects from the electrode," he said. "That's why the accuracy is so important."
Rolston instructs the computer program he is using to simulate directional adjustments — left, right, pitch or roll — of the small tube carrying the electron. When he is satisfied with those, he walks to the next room over, and at the operating table, adjusts small knobs extending from the inserted tube, completing the exact amount of turns advised by the software to guide the electron's trajectory.
"We do it on the software and then re-create it in real life," Rolston explains. "It's kind of like playing Battleship."
The approximately three-hour procedure is the leading edge of a series of advancing surgeries known as deep brain stimulation that are designed to restore steadiness and strength of movement in Parkinson's patients by neutralizing their tremors.
The latest version of deep brain stimulation, according to Rolston, is an especially big breakthrough because it uses an electrode that "allows us to steer electrical current into different parts of the brain, reducing side effects and better helping the patients."
It also wasn't until recently that the surgery used advanced enough MRI technology to anesthesize patients and rely on the imaging rather than their feedback, he said.
"We also used to do all these surgeries with the patients awake, but we can now do it in an MRI scanner, and watch the electrode safely get to its target," Rolston explained.
The Deseret News was invited for an inside look at Eichbauer's surgery, conducted July 31 at the University of Utah's Clinical Neurosciences Center, to learn more about the medical field's latest endeavor to reliably restore day-to-day functioning for patients living with Parkinson's.
2 weeks before
Art Eichbauer has never been content sitting on the sidelines when it comes to treating his Parkinson's disease, which he was diagnosed with eight years ago. Armed with his own personal research into the medical industry's improvements in deep brain stimulation surgery, he has sought it tirelessly, pushing his doctors to try it on him.
"I've been after them to do this for three or four years," Eichbauer says.
It is July 17, and Eichbauer is preparing himself to go under the knife, but in reality most of the mental reps are already well behind him. Though he has been warned that the procedure carries a small risk for bleeding inside his brain, infection and more, and that the results on symptoms can vary, he has committed himself to his choice and is stubbornly confident in the result.
"I know sometimes it doesn't work, but I feel like the odds are sufficient to merit doing it," Eichbauer told the Deseret News. "I'm kind of an optimist. I've always had a positive outlook on life. … I don't have any hesitation at all."
Eichbauer, a semiretired school psychologist for Canyons School District living in Sandy, says he has had no choice but to carefully nurture his positivity while living with Parkinson's.
"It affects constantly — throughout the day, constantly — what you're able to do and how you're able to do it," he said. "If you let that get you down, you're going to be down. And I don't expect to be down."
About half a million Americans suffer with Parkinson's disease, a disorder that occurs when certain neurons in the brain responsible for movement begin to weaken or die, according to the National Institute on Aging.
Its numerous symptoms include weakened balance, tremors, difficulty walking, affected memory, stiffness, and complications in swallowing and speaking.
Parkinson's disease can be relentless in depriving a person of daily joys. Eichbauer's shaking right hand makes it "frustrating sometimes when you're trying to get a button undone," he says, and because of that tremor and a sagging right foot, "I've given up riding a bike."
Working on the computer, and eating a meal, seemingly automatic activities, also present obstacles.
"It's difficult for me to cut meat," Eichbauer explains matter-of-factly. "I move my glass from the right side of the plate, where it's traditionally placed, to the left side to help me to remember to use my left hand to drink, so I don't spill things."
Eichbauer likes to think about what possibilities will be opened to him after surgery, but is trying not to get ahead of himself.
"I don't expect it to cure everything," he says. "But I think it will have some real powerful positive effects and allow me to continue what I'm doing more efficiently than what I've been able to the last two or three years."
Eichbauer's Parkinson's disease has, fortunately for him, exhibited mostly mild symptoms over eight years. "It limits my ability to function, but it hasn't affected me cognitively," he says.
His work, and traveling frequently, keep him sharp, he says, but preserving his ability to do both those things in the first place is what the surgery is all about.
"There are some risks involved, but I'm 71 — I'm 72 in a month — and quality of life is important to me."
July 31: Surgery day
On the morning of the big day, Eichbauer sits in his hospital room at the U.'s Clinical Neurosciences Center, chuckling serenely at the good-natured jokes his son and daughter are cracking to ease the tension. It seems their efforts are working. He appears calm, even relaxed.
Rolston briefly reviews with Eichbauer what the patient can expect, warmly but bluntly describing the risks inherent in surgery, such as infection. It is clear none of this is news to Eichbauer, who takes it in stride. Eichbaeuer is cautioned to avoid heavy lifting after surgery, and told he can generally expect to leave the hospital after one or two nights.
"But if not, that's fine, we're not going to kick you out," Rolston kindly reassures.
Shortly before Eichbauer is taken away to be put under anesthesia, he continues to refuse to give room for doubt — perhaps even more resolutely than two weeks earlier. Asked how confident he is the procedure will be successful, he offers dispassionately: "I'm certain."
A brief time later, a sedated Eichbauer is under the brilliantly bright lights stationed above his operating table, obscured behind myriad tubes, medical devices and protective bedding.
Inside the spacious operating room, a surgery team numbering about eight bustles around the room at a brisk, though not urgent pace, like an intricately choreographed ensemble.
There are no hands on hips, and no hesitation, waiting around, or drawn out proclamation that the surgery has commenced — just earnest focus on individual tasks, punctuated by even-keeled instructions and repeated back responses that adhere to a safety technique frequently used in surgery called closed loop communication.
Rolston bustles back and forth a few times between the operating room and his computer station on the other side of the wall. He guides the all-important electron's path, first in hypothetical terms on his computer screen, and then in reality, at Eichbauer's side.
The doctor is firmly enough in control of the situation that he can wax conversational about the surgery's benefits, all while carrying it out. The software, he affirms, will "eventually put us on a perfect trajectory."
Before surgeons had sophisticated enough MRI imaging software to place the electrode in its exact right place, Rolston says, they essentially relied on real-time "pscyhophysical experiments" in which patients gave feedback about how the electrode's placement was affecting their body's movement — including side effects and describing both intended changes and unintended side effects that they were noticing.
"There's some patients who have had so much anxiety, they just couldn't do it," he says.
It is not as though this latest deep brain stimulation advancement can avoid the invasive nature of brain surgery altogether — an entry point in the skull about the size of a dime is required — bringing the weightiness of the procedure into clear focus for all in the room as Rolston uses his surgical tools to open a pathway for the electrode to be inserted.
Still, using software to place the electrode is more precise in its effects on patients compared to prior options, according to Rolston, which is in large part why he was eager to first introduce the new procedure to Utah in the spring.
Since then, Rolston has operated on about a dozen patients with the same procedure with encouraging results, he said.
The latest iteration of deep brain stimulation also uses what is called a directional lead, connected to the implanted electrode, which meticulously steers "current toward desired structural areas, helping maximize patient outcomes and reduce side effects." That is according to Abbott Laboratories, the medical technology company that makes the equipment, called the Infinity DBS System.
"It doesn't shoot all the electricity in every direction equally, it shoots it off into one direction preferentially, based upon the neurologist's choice," Rolston said. "So if we find that to the left of the electrode is one of these areas that, when you stimulate, causes a motor side effect, you can stimulate in the opposite direction and not have that side effect, but still get a good benefit from the electrode."
Such side effects that can now be better avoided are "things like muscle contraction, or weird sensations like tingling, that can be really distressing to some patients."
Sept. 12 appointment
With the new procedure, the electrode's directional leads make it possible for the effects of the electrode to be finely tuned using an implanted device called a pulse generator, very similar to a pacemaker for the heart, according to Rolston.
After a follow-up procedure to implant the small device in their chest, patients meet with a medical provider who turns it on for the first time, and together they test out how to program the current generated by the electrode in order to precisely restore functionality and avoid side effects such as unwanted muscle contractions.
While the actual deep brain stimulation surgery has the highest stakes, it is the programming appointments where the benefits actually come to life for patients.
Eichbauer's first appointment — his moment of truth — comes Sept. 12 on his 72nd birthday.
The implanted device activates, the electrode implanted deep inside his brain begins signaling — and in a moment, his life changes.
"It's the best birthday present I've had," Eichbauer says, with a touch of emotion. "(It's a) noticeable difference, and I'm really excited about it."
Eichbauer says he can already tell how the new device will restore his day-to-day functioning.
"It appears I will be able to meet all the goals I set for myself. Those were to be able to continue working, and to type, and improve my gait," he says. "I'm extremely pleased."
What comes next is fine-tuning the device's settings so that even minor side effects are avoided and Eichbauer's foot and hand are kept as strong and steady as possible, explains Meghan Zorn, the physician assistant who oversaw the programming appointment.
"What we're looking for are both benefit and side effect and seeing what the best parameters might be for him," Zorn said.
Eichbauer says "it's never bothered me, people looking at the tremor" in his right hand. "That's never been an issue to me."
Even so, he has to chuckle at how much attention he is getting now that the tremor is gone.
"People can't see a tremor. The people at work just shake their head. They can't believe it. My family's that way, too," he says.
It is Oct. 25, and Eichbauer has just left his programming appointment. His next checkup isn't for another three months. With an increased ability to go about day-to-day tasks without a second thought, Eichbaueur has a new lease on life.
"I can't tell you how happy I am to have it," he said.
After some attempts to further adjust his pulse generator, he and Zorn have decided it was just perfect the first time. Turning up the current any further, he said, "made me seem a little bit funny in the stomach."
Avoiding that kind of side effect, while keeping the benefits, is exactly what the new deep brain stimulation aims to do, according to Rolston.
"It really makes our job easier and it's better for the patients," he said.
Rolston called Eichbauer's response to the device's programming "textbook perfect."
"He got the perfect response from everything," Rolston said. "We're very happy with how he looked afterward."
Eichbauer describes his progress since the first programming appointment as mostly smooth sailing. But like expected, it hasn't been a cure-all to every symptom of Parkinson's disease, despite neutralizing his tremor and sagging foot as intended.
"It hasn't done anything for my sense of smell … or taste," he said, but "I knew it wouldn't."
Eichbauer also can't afford to completely forget about the things his deep brain stimulation fixed. To keep his foot strong, he says, he plans to see a physical therapist to keep him from falling into the "habit" he had developed of dragging it.
And Eichbauer still must take some of the medication that helps keep his tremor at bay. But now, he says, taking a smaller dose keeps it completely unnoticeable. Before the surgery, he had to take so much medicine for his tremor that the side effects caused him to sway, while only making marginal improvements to his hand.
"The major thing is my ability to … touch type again," he said. "Still a little error in my right hand, but before it got so bad that I couldn't eat, I couldn't operate a mouse in my right hand, it was shaking so much."
Rolston said deep brain stimulation can dramatically benefit some Parkinson's patients "for many years in the future." But medical professionals do not consider everyone a viable candidate for such a procedure, he said. For now, it is mostly limited to those who are "in otherwise pretty good health."
"If they have something like very bad dementia or a lot of history of strokes, they probably aren't a good candidate for the surgery," Rolston said. "Then we look for people who respond well to medications for Parkinson's, and this just helps us know that's truly Parkinson's, (in part) because there are some diseases that mimic Parkinson's, but don't respond to the brain stimulation."3 comments on this story
As he reflects on what the surgery has done for him, Eichbauer says he would like to see more Parkinson's patients become eligible for deep brain stimulation, and at earlier stages of the disease. He implores others with Parkinson's to be assertive in pursuing it as a treatment option as they review with their doctors what is best for them.
"What I tell people is push — push to get it soon," he said, with genuine urgency in his voice. "If they make that diagnosis of Parkinson's, start in right then."