CADTH Health Technology Review

Deep Brain Stimulation Surgery Programs in Canada

Environmental Scan

Authors: Camille Santos, Kendra Brett, Danielle MacDougall, Melissa Walter, Jennifer Horton

Key Messages

• Deep brain stimulation involves the surgical insertion of electrodes to stimulate targeted areas of the brain. It is recommended to help control movement-related symptoms of Parkinson disease with certain indications and contraindications to consider.

• This rapid Environmental Scan describes the landscape of deep brain stimulation surgery across Canada and identifies conditions other than Parkinson disease that can benefit from the therapy. It also provides an overview of cost-effectiveness studies on deep brain stimulation for Parkinson disease.

• Emerging indications for deep brain stimulation include refractory obsessive-compulsive disorder, refractory epilepsy, treatment-resistant Tourette syndrome, certain types of pain, refractory major depressive disorder, tardive dyskinesia, and essential tremor.

• In Canada, there are deep brain stimulation surgery programs in Alberta, British Columbia, Manitoba, Nova Scotia, Ontario, Quebec, and Saskatchewan. The number of qualified neurosurgeons for deep brain stimulation surgery ranges from 1 to 5 (at least) across jurisdictions.

• Overall, deep brain stimulation is considered cost-effective for people living with advanced Parkinson disease. The risk of developing Parkinson disease increases with age, with onset typically occurring in late adulthood. The number of people eligible for deep brain stimulation in Canada is expected to increase with the aging population and emerging indications. Information related to existing surgery programs can help support capacity planning for deep brain stimulation surgery in Canada.

Context

Parkinson disease (PD) is a progressive adult-onset neurodegenerative disease that negatively impacts an individual’s quality of life and function.^1,2 It is characterized by motor-related features, including resting tremor, slowness of movements (bradykinesia), stiffness (rigidity), and postural instability, as a result of a dopamine deficiency from the basal ganglia.^2,3 However, PD can also manifest in nonmotor features, such as cognitive dysfunction, hallucinations, sleep disturbances, and fatigue.²

In 2016, 6.1 million people globally were living with PD and it caused 3.2 million disability-adjusted life-years.⁴ The mortality rate in 2019 was estimated to be 5.67 per 100,000 population worldwide.⁵ In Canada, the prevalence of parkinsonism, which is inclusive of PD, is 0.43% of adults age 40 years and older, with a mortality rate of 3,153 per 100,000.⁶ However, the proportion of the reported prevalence specific to people living with PD is unclear. Statistics Canada reported that approximately 55,000 adult living in Canada in 2015 were diagnosed with PD but cases are expected to grow with the aging population.^6,7

There is no cure for PD, but treatment is available to help control symptoms. Dopaminergic therapy, most often levodopa, is the first line of treatment.^8,9 Long-term use of levodopa can lead to medication-induced dyskinesia (involuntary movements),¹⁰ and as PD progresses, individuals can experience increased motor complications.¹¹ Deep brain stimulation (DBS) therapy is a treatment option available to individuals living with advanced PD. It involves stereotactic brain surgery to implant electrodes that are connected to a neurostimulator and deliver electrical stimulation.¹² Movement-related specialists, such as neurologists and neurosurgeons, determine an individual’s eligibility for DBS therapy before insertion.^13,14 Clinics specialized in DBS make the necessary adjustments to the neurostimulator after insertion.^15,16 In PD, DBS delivers stimulation to targeted areas within the basal ganglia, such as the subthalamic nucleus (STN) and the globus pallidus interna (GPi).¹⁷ DBS can also be used for other movement-related disorders and is being investigated for other indications, such as posttraumatic stress disorder (PTSD), alcohol use disorder, obsessive-compulsive disorder (OCD), and major depressive disorder.¹⁸ Innovations for related devices are also emerging, such as adaptive DBS, which can adjust stimulation based on fluctuations of biomarkers.¹²

As the prevalence of PD increases and indications for DBS expand, there is a need for information on capacity and the demand for DBS surgery programs across Canada. The key objectives of this rapid Environmental Scan are to:

1. describe the landscape of DBS surgery across Canada (this includes the number of neurosurgeons qualified to perform DBS surgery, the volume of surgeries, and information on professional associations that provide support to neurosurgeons conducting DBS surgery)

2. describe the cost-effectiveness of DBS therapy for people living with PD (this includes a narrative summary of economic evaluations)

3. describe populations that may benefit from DBS therapy (this includes guidelines regarding the use of DBS for people living with PD or with other conditions, and the prevalence of each condition in Canada when available).

Previous CADTH work on DBS includes 2 Rapid Response reports (summary with critical appraisal)^8,19 and a Horizon Scan.¹²

Research Questions

1. What is the landscape of DBS surgery programs in Canada?

   1. Which jurisdictions have the capacity to perform DBS surgery?

   2. How many neurosurgeons are qualified to perform DBS surgery?

   3. How many people living in Canada are eligible for DBS surgery?

   4. What is the volume of DBS surgeries performed across Canada?

   5. Are there professional associations in Canada that provide support to neurosurgeons qualified to perform DBS?

   6. How many surgeries are required for neurosurgeons to maintain competency?

2. What is the cost-effectiveness of DBS for people living with PD?

3. What are the guidelines regarding the use of DBS for PD and other conditions?

   1. What is the recommended number of surgeries required for neurosurgeons to maintain competency?

Methods

We provided a narrative summary of the DBS programs in Canada based on information from a limited search and a review of the grey literature, including public-facing websites (e.g., program websites, clinician bios, and news articles) to address question 1. Additionally, we performed a literature search to identify economic evaluations and guidelines to address question 2 and question 3, respectively, and a narrative synthesis of relevant findings was provided.

Literature Search

Information specialists conducted literature searches on key resources including MEDLINE, CADTH, the National Institute for Health and Care Excellence (NICE), relevant websites from CADTH’s Grey Matters: A Practical Tool For Searching Health-Related Grey Literature, as well as a focused internet search. The search approach was customized to retrieve a limited set of results, balancing comprehensiveness with relevancy. The search strategy comprised both controlled vocabulary, such as the National Library of Medicine’s MeSH (Medical Subject Headings), and keywords. Search concepts were developed based on the elements of the research questions and selection criteria. A search for published guidelines was completed on May 3, 2023. The main search concepts were deep brain stimulation and Parkinson disease. CADTH-developed search filters were applied to limit retrieval to guidelines. Results were limited to English-language documents published since January 01, 2013. A supplemental search on the concept deep brain stimulation was completed on May 09, 2023. For this search CADTH-developed search filters were applied to limit retrieval to economic studies. Results were limited to English-language documents published since January 1, 2018. Additionally, focused internet searches were conducted between May 2 and May 8, 2023, to retrieve data on the prevalence of conditions that might be treated with DBS, including PD, dystonia, essential tremor, multiple sclerosis tremor, spasmodic dysphonia, epilepsy, treatment-resistant depression, obsessive-compulsive disorder, neuropathic pain, Tourette syndrome, and tardive dyskinesia. Focused internet searches for DBS programs in Canada were also conducted between May 2 and May 3, 2023.

Screening and Study Selection

One researcher was involved with screening the grey literature for relevance to address objective 1. For this objective, information on the landscape of DBS surgery across Canada was sought, including available surgery programs, the number of qualified neurosurgeons, surgery volumes, professional associations providing support to neurosurgeons, and the number of surgeries required for neurosurgeons to maintain competency. One researcher was involved with screening the literature for economic evaluations to address objective 2. Two researchers were involved with the screening of the literature for relevant guidelines to address objective 3, including guidelines with recommendations on the number of surgeries required for neurosurgeons to maintain competency. Refer to the criteria listed in Table 1 as those used for information gathering and literature selection.

Table 1: Components for Literature Screening and Information Gathering

DBS = deep brain stimulation; PD = Parkinson disease.

Findings

Objective 1: Landscape of DBS Surgery Across Canada

Jurisdictions With Programs and Available Wait Times

Information about DBS surgery programs across Canada was gathered from grey literature, including public-facing websites, and may not reflect all programs available in Canada. Based on the programs identified, DBS surgery in Canada is performed in Alberta,^20,21 British Columbia,¹⁵ Manitoba,¹⁴ Nova Scotia,²² Ontario,^13,23-25 Quebec,^26-29 and Saskatchewan.¹⁶ People living in Prince Edward Island, Newfoundland and Labrador, and New Brunswick who need DBS surgery typically travel to Nova Scotia for the procedure.³⁰ Additionally, we did not identify facilities in the territories that perform DBS surgery. Refer to Table 2 for a summary of the information we identified on DBS surgery programs and their associated wait times. It is important to note that we may not have identified all DBS surgical programs in Canada.

All 7 jurisdictions with DBS programs identified provide DBS for movement-related disorders,^{13,15,16,20,31,32} such as PD, essential tremor, and dystonia. British Columbia and Manitoba also provide DBS for pain (e.g., chronic pain). The Psychiatric Neuromodulation Clinic in Quebec performs DBS therapy for people with severe refractory OCD,²⁷ and British Columbia provides DBS surgery to individuals with depression.¹⁵

In Alberta, 2 programs were identified, the Parkinson and Movement Disorder Program (in Edmonton) and the Movement Disorder Clinic (in Calgary), with a total of 3 qualified neurosurgeons in 2021.^14,20,21 In 2018, it was reported that the wait time for DBS surgery in Alberta was 6 to 12 months.³³ The Deep Brain Stimulation Clinic in Vancouver¹⁵ is the only DBS surgery program in British Columbia and there is at least 1 qualified neurosurgeon in the province.³³ There are 2 wait-lists for DBS surgery in British Columbia: the first is to determine an individual’s eligibility for DBS and the second is for the surgery.³³ In 2021, the wait time, inclusive of both wait-lists, was reported to be up to 4 years.^33,34 In 2019, British Columbia announced its plans to expand the program by recruiting additional neurosurgeons for insertion surgery and less specialized surgeries for battery replacements, in addition to increasing available operating room time for procedures, to meet surgical targets.³⁵ Based on the information we identified, a second neurosurgeon for implantation surgery for DBS in British Columbia had yet to be hired as of 2021.³⁴

According to an assessment of DBS access in 2016, Saskatchewan and Nova Scotia were able to perform DBS with no annual budgetary restrictions, whereas other jurisdictions reported having a cap on annual funding available for DBS surgeries.³⁰ The Functional Neurosurgery Program in Saskatoon, Saskatchewan, has 3 qualified neurosurgeons,¹⁶ with virtually no wait-list as of 2021.³⁴ The same assessment of DBS access reported that Saskatchewan has the highest ratio of qualified DBS neurosurgeons in Canada (1 per 0.37 million population).³⁰ In Nova Scotia, the neuromodulation program at Dalhousie University in Halifax conducts DBS surgery.²² Consult and surgery wait times for brain procedures in Nova Scotia as of early 2023 are 168 days and 85 days, respectively.³⁶ However, the reported wait times are inclusive of other brain-related procedures, such as enterocolostomy, cerebrospinal fluid reservoir insertion, and tumour excision.³⁶

In Ontario, 4 facilities were identified that may perform DBS surgery: the Ottawa Hospital,²³ Kingston Health Science Centre,²⁴ the Deep Brain Stimulation Clinic located at the Toronto Western Hospital,¹³ and the Movement Disorder Centre at Western University (London).²⁵ We identified at least 5 neurosurgeons who are qualified to perform DBS surgery in Ontario from news articles and clinician bios via program websites.^13,23,24 The Harquail Centre for Neuromodulation at the Sunnybrook Hospital in Toronto is investigating the use of DBS for people with PTSD, alcohol use disorder, OCD, and major depressive disorder.¹⁸ Additionally, the first cases of children receiving DBS therapy had surgery done in Ontario. The first child to receive DBS in Canada had their procedure done in 2018 at SickKids to help with treatment-resistant epilepsy.³⁷ Additionally, a child with autism spectrum disorder was provided DBS in 2021 to help prevent self-harm.³⁸ In Quebec, we found 4 programs that may perform DBS surgery: The neurosurgery department at Centre intégré universitaire de santé et de services sociaux de l’Estrie – Centre hospitalier universitaire de Sherbrooke,²⁶ the Psychiatric Neuromodulation Clinic at Centre Hospitalier de l’Université de Montréal (CHUM),²⁷ the CHU de Québec – Université Laval,²⁸ and the Montreal Neurologic Hospital and Institute.²⁹ In 2016, there were 4 qualified neurosurgeons in Quebec.³⁰ According to the assessment of DBS access in Canada, a significant portion of Quebec’s funding for DBS is used for device replacement versus new implants.³⁰ The functional and neuromodulation program was the only program we identified for Manitoba.¹⁴ We did not identify information related to wait times for Manitoba, Ontario, or Quebec.

Number of DBS Surgeries

We did not identify the number of people living in Canada eligible for DBS. However, we identified a retrospective study published in 2018 that evaluated access to surgery for implantation of neural stimulators for DBS.³⁰ In 2015 to 2016, 722 implantation surgeries were performed in Canada.³⁰ No people living in the territories received DBS surgery during this period.³⁰ The authors of the study also calculated the jurisdictional age-adjusted rates of residents receiving DBS surgery to compare to the national average. Results of this analysis found that Saskatchewan’s rate of DBS was significantly higher than the national average, whereas Quebec and Newfoundland and Labrador were significantly below the national average.³⁰ Refer to Table 2 for information on DBS surgery volumes in 2015 to 2016 per jurisdiction as reported by this study.

From 2012 to July 2018, a total of 180 DBS surgeries, with 74 specifically for PD, were performed in British Columbia.³³ The average annual volume of DBS surgeries in British Columbia is 33.4, with 14.4 specifically for PD, with an annual growth of 0.20 between 2012 and 2018.³³

We did not identify information regarding the number of surgeries neurosurgeons are required to perform to maintain their competency.

Professional Associations

We identified 1 professional association, the Canadian Neurosurgical Society, which represents neurologists and neurosurgeons in Canada.³⁹ The organization’s mission is “to enhance the care of patients with diseases of the nervous system through education, advocacy, and improved methods of diagnosis, treatment and rehabilitation.”³⁹ The Canadian Neurosurgical Society provides opportunities for continuing education and networking to encourage collaboration for learning and training.³⁹

Table 2: Identified DBS Surgery Programs Across Canada

CSF = cerebrospinal fluid; DBS = deep brain stimulation; GPi = globus pallidus interna; NA = not available; PD = Parkinson Disease; STN = subthalamic nucleus.

Notes: This table includes parkinsonism prevalence (inclusive of PD) between 2019 and 2020 as reported by the Canadian Chronic Disease Surveillance System (CCDSS).⁶

Prevalence of parkinsonism not included in the table:⁶ Newfoundland and Labrador = 0.29%; Prince Edward Island = 0.35%; New Brunswick = 0.37%; Nunavut = 0.27%.

^aData sourced from the Parkinson and Movement Disorders Program website.²⁰

^bData sourced from the Movement Disorders Program website.²¹

^cData sourced from a Canadian assessment of DBS.³⁰

^dData sourced from a health technology review from British Columbia.³³

^eData sourced from wait times provided by the province of Nova Scotia.³⁶

^fData sourced from a DBS clinic website.¹³

^gData sourced from a news release from The Ottawa Hospital.²³

^hData sourced from a web page dedicated to faculty and staff at the department of surgery.²⁴

ⁱData sourced from Parkinson Society British Columbia.³⁴

Objective 2: Cost-Effectiveness of DBS for PD

We identified 2 cost-effectiveness studies and 3 systematic reviews of economic evaluations that examined the cost-effectiveness of DBS for people living with PD.^40-42 All of the relevant studies in 2 of the systematic reviews were captured in another more recent and more comprehensive systematic review, and were excluded to avoid overlap. Refer to Appendix 1 for economic evaluations of DBS for people living with conditions other than PD.

In general, the economic evaluations and the systematic review found that DBS may be cost-effective for people living with advanced PD.^40-42 One economic evaluation conducted in the context of China’s health care system compared DBS to best medical therapy on a 15-year time horizon.⁴⁰ The other economic evaluation compared STN DBS to medication for a 10-year follow-up in Taiwan.⁴² The systematic review identified economic evaluations in the US, Italy, Germany, Spain, the UK, China, and Japan that compared the cost-effectiveness of DBS to best medical therapy using oral formulations.⁴¹

Objective 3: Summary of Guidelines for DBS

DBS Guidelines for PD

We identified 10 guidelines regarding the use of DBS for individuals living with PD.^43-52 One guideline supports the use of DBS for carefully selected individuals living with PD and with consideration of symptoms known to respond to the therapy.⁴⁸ Among the identified guidelines related to PD, DBS is recommended to help control dyskinesia,^43,44,52 motor fluctuations,^43,44,51,52 and tremor for individuals living with PD.^43,45 However, the guidelines indicate that the following considerations within the context of an individual’s clinical history should be assessed before moving forward with DBS:

• severity of and duration of PD^43,45

• age^45,51,52

• response to presurgery therapy and/or medication (e.g., levodopa)^45,46,48,49

• cognitive function^48,51,52

• type of DBS therapy (i.e., thalamic, STN, GPi).^43,45,46,52

Some guidelines suggest DBS as a potential therapy for excessive daytime sleepiness⁴⁷ and pain in dystonia⁵⁰ for individuals living with PD. However, the authors indicated that more research on the effectiveness of DBS as therapy for these symptoms is required.^47,50

Refer to Table 3 for a detailed summary of recommendations for the use of DBS in PD. Refer to Table 4 for a detailed summary of recommendations for DBS for other conditions, as well as the prevalence of the condition in Canada (when available).

Table 3: Summary of Recommendations for DBS for PD

AAN = American Academy of Neurology; DBS = deep brain stimulation; EFNS = European Federation of Neurologic Sciences; GPi = globus pallidus interna; MDS-ES = Movement Disorder Society – European Section; NICE = National Institute for Health and Clinical Excellence; PD = Parkinson disease; STN = subthalamic nucleus; UPDRS-III = Unified Parkinson Disease Rating Scale part III.

^aGuidance documents were classified as evidence-based (i.e., recommendations were informed using a systematic search of the literature), consensus-based (i.e., recommendations were informed by expert opinion, with or without consideration for evidence collected using nonsystematic methods), or as having an unclear (i.e., not reported in detail) methodology.

^bSourced from NICE CG35 recommendations (2006).⁵³

^cSourced from AAN evidence-based recommendations (2006).⁵⁴

DBS Guidelines for Other Conditions

Guidelines for the use of DBS in 9 conditions other than PD were identified: 4 for OCD, 3 for epilepsy, 3 for refractory tremor, 3 for Tourette syndrome, 3 for dystonia, 1 for tardive dyskinesia, 1 for major depressive disorder, 1 for neuropathic pain, and 1 for other types of pain. These identified guidelines suggest that indications for DBS are expanding beyond PD. The following considerations should be assessed before moving forward with DBS for the treatment of these conditions:

• type of DBS^55-60

• response to prior treatment (e.g., refractory cases)^{55,56,58,61-68}

• quantity and/or quality of evidence^{56,57,59,60,69}

• age^60,63,66

• clinical versus experimental context^61,64,70

• expertise and experience of clinicians available^57,58,70

• other indications and/or contraindications specific to the condition.^57,63-65

Refer to Table 4 for a detailed summary of recommendations for DBS for other conditions and the prevalence of the condition in Canada (when available).

Table 4: Summary of Recommendations for DBS for Other Conditions

ASSN = American Society for Stereotactic and Functional Neurosurgery; CNS = Congress of Neurologic Surgeons; DBS = deep brain stimulation; NICE = National Institute for Health and Care Excellence; OCD = obsessive-compulsive disorder; RCT = randomized controlled trial; STN = subthalamic nucleus.

^aGuidance documents were classified as evidence-based (i.e., recommendations were informed using a systematic search of the literature), consensus-based (i.e., recommendations were informed by expert opinion, with or without consideration for evidence collected using nonsystematic methods), or as having an unclear (i.e., not reported in detail) methodology.

Guidelines for Neurosurgeons to Maintain Competency

We did not identify guidelines regarding the number of DBS surgeries recommended for neurosurgeons to maintain competency.

Limitations

There are limitations to note for this rapid Environmental Scan. The information gathered on programs providing DBS surgery is limited to public, online sources identified from grey literature. Due to time constraints, provinces and territories were not consulted to provide information regarding the availability of DBS surgery within their jurisdictions; therefore, we may not have captured the full breadth of programs and resources (including number of neurosurgeons) for DBS surgery across Canada. This rapid Environmental Scan focused on identifying programs that had the capacity to perform DBS surgery in Canada. Programs focused only on providing preservices and postservices, although critical to DBS, were outside the scope of this report. Furthermore, the data on surgery volumes across Canada were from 2015 to 2016, with more recent data for British Columbia (from 2017 to 2018). Thus, the data are outdated and likely not reflective of current surgery volumes in Canada. The data on surgery volumes from 2015 to 2016 was also limited to surgeries for implanting neural electrodes and excluded surgeries for battery replacements.

We did not perform critical appraisal of the guidelines and cost-effectiveness studies included in this rapid Environmental Scan. The quality of the guidelines and its development, as well as the economic evaluations included, is unclear. Some guidelines were developed in other countries, and all the economic evaluations were done within the context of other health care systems. These limitations should be considered in the interpretation of the findings and application of DBS for PD and other conditions.

Conclusions

This report provides an overview of the DBS surgery landscape in Canada, in addition to identifying populations that may benefit from DBS.

A total of 722 DBS insertion surgeries were conducted in 2015 to 2016. Based on publicly available information, jurisdictions in Canada with the capacity to perform DBS surgeries include Alberta, British Columbia, Manitoba, Nova Scotia, Ontario, Quebec, and Saskatchewan. DBS is primarily used to help control movement-related disorders, including PD, in Canada. Some jurisdictions provide DBS for pain, depression, or OCD. The number of neurosurgeons qualified for DBS surgery in Canada ranges from 1 to 5 (at least) across jurisdictions based on incomplete data gathered from public sources. While outside the scope of this report, virtual postsurgery care is available for people to receive adjustments to their DBS devices remotely. Virtual postsurgery care can benefit people who otherwise would have had to travel to access these services, including people living in remote or rural areas or in jurisdictions without facilities specialized in DBS therapy.

Based on the results of a literature search of guidelines, DBS is recommended to help control the movement-related symptoms of PD. However, certain indications and contraindications should be considered before DBS therapy. Furthermore, DBS may be considered for people with refractory OCD, refractory epilepsy, treatment-resistant Tourette syndrome, pain, major depressive disorder, tardive dyskinesia, and essential tremor. The results of economic evaluations of DBS for PD suggests that DBS is cost-effective. However, none of the cost-effectiveness analyses were conducted in the context of the health care system in Canada and their applicability is unclear. Critical appraisal of the guidelines and economic evaluations is outside the scope of this report.

The findings of this rapid Environmental Scan can help guide decision-makers across Canada when implementing or expanding DBS programs by providing insight into established programs across the country. The information provided on these programs, including the number of qualified neurosurgeons and surgery volumes, was informed by publicly available information, some of which may be outdated, without consultation with program representatives. Therefore, it only provides a snapshot of an evolving landscape.

Given the aging population in Canada, and the growing evidence base for additional indications for DBS, the number of people eligible for DBS is expected to increase. It is crucial that capacity to perform surgery is monitored and assessed to ensure adequate access to DBS. Future investigations could aim to provide a more comprehensive survey of programs across Canada with up-to-date information on program characteristics.

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Appendix 1: References of Potential Interest

Economic Evaluations for Other Conditions

Epilepsy

Ngan Kee N, Foster E, Marquina C, et al. Systematic Review of Cost-effectiveness Analysis for Surgical and Neurostimulation Treatments for Drug-Resistant Epilepsy in Adults. Neurology. 2023 05 02;100(18):e1866-e1877. PubMed

Chan HY, Wijnen BFM, Majoie M, Evers S, Hiligsmann M. Economic evaluation of deep brain stimulation compared with vagus nerve stimulation and usual care for patients with refractory epilepsy: A lifetime decision analytic model. Epilepsia. 2022 03;63(3):641-651. PubMed

Obsessive-Compulsive Disorder

Strouphauer ER, Morris OJ, Soileau KJ, et al. Economic Analyses of Obsessive-Compulsive Disorder Interventions: A Systematic Review. Pharmacoeconomics. 2023 May;41(5):499-527. PubMed

Tourette Syndrome

Dang TTH, Rowell D, Liddle J, Coyne T, Silburn P, Connelly LB. Economic evaluation of deep-brain stimulation for Tourette's syndrome: an initial exploration. J Neurol. 2019 Dec;266(12):2997-3008. PubMed

Investigational Use of DBS

Obesity

Mahajan UV, Ojukwu DI, Azagury DE, Safer DL, Cunningham T, Halpern CH. Can responsive deep brain stimulation be a cost-effective treatment for severe obesity? Obesity (Silver Spring). 2022 02;30(2):338-346. PubMed

Cocaine Use Disorder

Kuijper FM, Mahajan UV, Ku S, et al. Deep brain Stimulation Compared With Contingency Management for the Treatment of Cocaine Use Disorders: A Threshold and Cost-effectiveness Analysis. Neuromodulation. 2022 Feb;25(2):253-262. PubMed

Alcohol Use Disorder

Maatoug R, Bihan K, Duriez P, et al. Non-invasive and invasive brain stimulation in alcohol use disorders: A critical review of selected human evidence and methodological considerations to guide future research. Compr Psychiatry. 2021 08;109:152257. PubMed

Pediatric Populations

Yan H, Siegel L, Breitbart S, et al. The Child & Youth CompreHensIve Longitudinal Database for Deep brain Stimulation (CHILD-DBS). Childs Nerv Syst. 2021 02;37(2):607-615. PubMed

DBS for Rural and Remote areas.

Pinter D, Jardahazi E, Janszky J, Kovacs N. Potential clinical and economic benefits of remote deep brain stimulation programming. Sci Rep. 2022 10 19;12(1):17420. PubMed

DBS During the COVID-19 Pandemic

Miocinovic S, Ostrem JL, Okun MS, et al. Recommendations for Deep Brain Stimulation Device Management During a Pandemic. J Parkinsons Dis. 2020;10(3):903-910. PubMed