Technology of deep brain stimulation: current status and future directions

The opportunities to use technology to modulate or influence brain circuitry and human behaviour have increased exponentially over the past few years. These developments have spawned the field of electroceuticals, with deep brain stimulation (DBS) being the most important and accepted treatment within this class of therapies1. DBS is commonly indicated for the treatment of movement disorders such as Parkinson disease (PD), tremor and dystonia, and became the standard of care for these conditions after receiving FDA and Conformité Européene (CE) approval2-4. In addition, DBS has been used for pain syndromes, such as neuropathic pain and cluster headache, as well as for epilepsy5-7. A favourable safety profile and demonstration of efficacy in several randomized controlled trials has led to increased interest in the potential application of DBS to psychiatric disorders1. Following a positive randomized controlled trial published in 2008, DBS for obsessive-compulsive disorder (OCD) was granted CE approval and an FDA Humanitarian Device Exemption8,9, and DBS is currently under investigation for a wide range of other treatment-resistant conditions, including depression, Alzheimer disease, Tourette syndrome, addiction, anorexia nervosa and schizophrenia9. The minimally invasive character of DBS, combined with the low incidence of severe, disabling adverse effects, has expanded its potential uses and prompted studies on novel applications for conditions such as tinnitus, arterial hypertension and sleep disorders9. Chronic stimulation not only has direct physiological effects on brain circuits but also produces a range of cellular, molecular and neuroplastic changes1. Our increased understanding of the complex mode of action of DBS is leading to a more comprehensive appreciation of the effects of chronic stimulation in the nervous system.

The technology for DBS was developed by modifying cardiac pacemakers and saw little development or advancement for almost two decades following the inception of the ‘modern’ DBS era in the late 1980s (FIG. 1). Until recently, technological advancements in the field have been driven largely by limitations of DBS technology such as large battery size, limited battery life and the need for frequent battery replacements. However, the appearance of multiple manufacturers of DBS technology on the global market has sparked international competition and we are now seeing progress at an accelerated pace. In the coming years, we anticipate the implementation of new hardware designs, improved technology and refined stimulation algorithms. Advances in DBS technology will no doubt extend the scope of its application and are expected to yield additional benefits, both clinically and scientifically10-12. We expect these advances to lead to enhanced market penetration and a wider accessibility of DBS to the populations and patients who can benefit the most, including those in low-income nations. However, it is important to be aware of new dangers that might arise with advances in electronics and computing, such as the prospect of modulation of cognitive and decision-making processes, and the possibility of acquiring data for misuse and brainjacking 13,14.

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In this article, we review the evolution and current status of DBS technology, anticipate future advances and discuss their clinical implications. We provide a reasoned overview of new DBS electrodes and pulse generators as well as of innovations in stimulation algorithms and programming. We also discuss developments in the imaging of implanted electrodes, which has become relevant not only for practical reasons but also in understanding brain dysfunction and enhancing the efficacy of chronic neurostimulation. Finally, we address the ethical and security issues raised by new technical developments, in particular with regard to potential scenarios of misuse, including by third parties. We conclude by predicting future directions for the field of DBS technology and consider how changes in DBS will enhance the accessibility of this effective surgical technique to those patients who are most in need.

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