New data to reframe the risks of DBS surgery for patients and providers

So welcome, Delaram. Welcome, Chen. Thank you for joining me today.

Dr. Delaram Safarpour: Thank you for having us.

Dr. Chengyuan Wu: Yes. Great to be here.

Dr. Mitra Afshari: I've really been eager to bring these two perspectives together to discuss what I [00:01:00] see as a critical issue in movement disorders. One that unfortunately continues to affect our care of our patients, which is the myths about intraoperative and postoperative risks associated with DBS surgery. Knowledge and unfortunately misknowledge about this topic still remains high, and it affects both patient perceptions on DBS and provider's perceptions, which ultimately influences the rate of DBS referrals and the number of patients who could ultimately benefit from this therapy.

The two articles we would like to discuss today are Dr. Safarpour's, Consensus Expert Recommendations for Referral of Parkinson's Disease Patients for DBS Surgery. This was published in Nature Parkinson's Disease in January, 2026. And Dr. Wu's, Reframing the Risk of DBS: A Comparison of 2.8 million Elective Surgeries from the [00:02:00] NSQIP Database. This was published in the Annals of Neurology in December of 2025.

So we all know that DBS, while it's been shown to be quite effective for many movement disorders, it's most certainly underutilized. So Delaram and Chen, what are the various factors that make that so, from your perspective?

Dr. Delaram Safarpour: I'll go first. You're absolutely right, despite compelling evidence that DBS significantly improves motor symptoms, quality of life, and even some of the non-motor symptoms of Parkinson's disease, it remains to be significantly underutilized. And there's several factors that contribute to this gap, really here.

One of them would be knowledge and perception barriers that we all have. And many patients and even some clinicians is still perceived DBS as the quote unquote last resort therapy for advanced Parkinson's disease [00:03:00] rather than evidence-based option once motor complications or dyskinesia become troublesome for these patients, despite optimized medication therapies.

The consensus really emphasized that diseases stage or duration should not be used as a rigid cutoff. Such misconceptions should not lead to unnecessary delays in referrals. And we continue to see a pattern of variability in referral practices among neurologists in when, and who to refer for DBS evaluations. And some of the referrals rely exclusively on Levodopa responsiveness, Hoehn & Yahr stage and some others underappreciate the indications like medication intolerance, so refractory tremor. Some of these patients are not able to tolerate medications because of the side effects that they have.

And the panel really found that [00:04:00] inconsistent criteria result in missed opportunities for timely evaluation. Another problem is access to specialized DBS centers, factors such as a distance, limited insurance coverages. A lot of us have had denials from insurances based on those rigid criteria I just mentioned, and insufficient multidisciplinary infrastructure can really delay some of these referrals and follow throughs. Surely we have the patient level concerns too. The stigma and fear around brain surgery, that remains to be a powerful limitation and patients often have limited understanding of what the procedure is and what the goals, risks, expected benefits are, and the education about DBS often, in general, occurs too late into the disease. And it may even happen at the stage of the [00:05:00] disease that cognitive or psychiatric features, comorbidities have already started to occur in our patients. And so that will take away the good possibilities that we have earlier.

So this under utilization of DBS reflects not just a lack of efficacy, but just a combination of knowledge gap and referral variability. And these barriers really feed into the misconception of what the DBS is and what it has to offer.

One of the key messages that our consensus paper had was earlier discussions should happen. And patients should be aware.

Dr. Mitra Afshari: I think those are all excellent points, Delaram, and I think it leads beautifully to discussing Chen's paper. So Chen, the retrospective review that you presented in this paper really aims to shed light on that relative risk of DBS surgery and to demystify this topic as Delaram was alluding to.[00:06:00] 

First off, I wanted to ask you, relative to other neurosurgery specifically, where would you put DBS on the general spectrum of surgical risk?

Dr. Chengyuan Wu: Yeah, thanks for that. In general everything is relative. So in the spectrum of what we do, DBS is much less risky. Much of what we do in neurosurgery is not even necessarily elective. We do a lot of trauma, spine surgery, tumor surgery, aneurysm surgery, strokes. So a large portion of neurosurgery is non-elective and inherently going to be higher risk.

So in the realm of the neurosurgical spectrum, DBS is mundane. That is something that I have to almost set aside when I talk to patients about that, and it is almost the driving force behind what we wanna do here. In fact, if you look at things in neurosurgery, there are neurosurgical procedures in this paper that we did.

[00:07:00] There's laminectomy, as well as cervical decompression fusion and under very standard elective procedures. So your question is, how does it compare to that? We have numbers on this now where laminectomy and a CDF are two to three times more risky than a deep brain stimulator. 

Dr. Mitra Afshari: So tell us a little bit about the overall premise of the study and a little bit more about this NSQIP database. We're not as familiar with this database as maybe your discipline is.

Dr. Chengyuan Wu: Sure. Yeah. So NSQIP is what we call it affectionately, or unaffectionately, whatever your mood might be. But it is the American College of Surgeons National Surgical Quality Improvement Program. So it's a large national clinical registry that was designed to measure and improve surgical outcomes.

Hospitals will elect to participate and there are currently around 600-700 hospitals that participate and they contribute standardized preoperative data. That's not just claims data, not just [00:08:00] a chart review, but in order to be part of this consortium, you have to have a trained clinical reviewer that is able to collect the exact data points that they want for this quality improvement initiative.

Although the initial intent was quality improvement, others like myself have looked at this as a research tool because it provides a lot more clarity on a much larger scale in terms of this sort of data than Medicare claims data, which I've also done work on as well. And that can get very messy. So this particular data set that we used spanned from 2015 to 2021.

So more recently. You get a lot more granular than you would with a lot of other big data sets. You get patient demographics, baseline medical conditions, comorbidities. You get procedure type operative time. And then most importantly, as you saw here in our study, third day postoperative outcomes including complications, readmissions, reoperations. So the data and [00:09:00] variables that we're able to use are only possible because of what was already established in the NSQIP database.

Dr. Mitra Afshari: So your primary outcomes, you just mentioned them, was comparing in DBS surgical cases versus several other common elective surgeries from elective C-section to hip and knee arthroscopy, were one overall risk of complications within 30 days postoperatively, two risk of readmission within 30 days postoperatively.

And then three, the risk of reoperation within 30 days postoperatively. What were your findings?

Dr. Chengyuan Wu: So that, that's exactly right. And so again, this is acute complications that occurred, and there's a couple ways that we can look at this. If we look at overall complication rates of DBS versus everything else, the overall complication rates were about 1.3% in the first 30 days with DBS versus all the other categories, which as you mentioned, span [00:10:00] from hernia repair, tonsillectomy all the way to prostatectomy and hysterectomy.

Those put together pooled was about 4.1%, so significantly lower for DBS. Readmission rates were similar when you compare DBS versus everything else. And re-operation rates were also lower with DBS. But I think, for even more granularity, what we did was also look at OR ratio of each of these primary outcomes with specific procedures, because I think that helps with the discussion with patients who may have either undergone one of these elective procedures or know someone.

So while, yes, it is lower for DBS versus everything else. And readmission rates are similar. When you peel into the data, we have data now that shows that the overall risk of any complications of DBS is comparable to a tonsillectomy or hernia repair, versus if you look at something like a C-section or hip replacement, you're looking at a 5X [00:11:00] complication rate.

You go to a hysterectomy, that's 6X. And then readmissions are gonna be higher for prostatectomy bariatric surgery. And, more comparable again for a thyroidectomy. So like having specific examples I think helps with that discussion.

Dr. Mitra Afshari: Exactly. I think what the paper really provides is, like you mentioned, a better frame of reference, right? For patients because you're comparing to these common procedures that people know about and maybe have already experienced, like many of our patients have had hip and knee arthroscopies.

There were secondary outcomes that you looked at as well. Which were the 30 day post-op risk of specific complications that are common in surgery, such as wound infection, pulmonary embolism, cardiac arrest, or MI. And also TIA/stroke, which was the outcome variable that encapsulated intracerebral or brain [00:12:00] specific events.

Is that correct?

Dr. Chengyuan Wu: Correct. Correct. The thing that I would hear, or when we talked about this was, okay, yeah, the complication rate is the same or lower, but it's my brain, right? So what does that actually mean? If I have a complication in my brain that's different than a complication anywhere else? That is exactly why we wanted to see, could we look at brain specific complications?

'cause we know on, as a medical field that when you do a joint replacement, you're in a hypercoagulable state and that you can have strokes. And that's why patients are placed on Coumadin or blood thinners or so forth. So when we looked at that, now the numbers and incidences are very low, but you're looking at 0.05, 0.04% rates of these brain specific events for both DBS as well as everything else.

So, from this large database, statistically, there's no real difference when you look at [00:13:00] DBS versus everything else.

Dr. Mitra Afshari: And what I found interesting was that the patients in this database who received DBS were actually found to have a higher baseline surgical risk using the American Society of Anesthesiology classification system. So could you remind us what this classification system is, and ultimately what does this mean with respect to the final conclusions of your study?

Dr. Chengyuan Wu: Yeah, so ASA grades are overall health scores. It's what anesthesiologists use a lot to determine risk of a patient undergoing anesthesia. And it's not terribly surprising because our patients with Parkinson's are generally older. That's gonna be the large portion of these patients. And even our essential tremor patients, we think of 'em sometimes as younger, they often delay DBS until later.

So this is not necessarily a younger population. And we saw that is that patients were older. And that's also when you step back to think about it not particularly surprising if [00:14:00] we're looking at procedures like tonsillectomy and appendectomy and the other cohort, right? That's inherently gonna pull that age mean down.

So there's certainly a different comorbidity burden with the DBS patients. Now, we didn't want that to be an unfair advantage, so we did this risk matching in our analysis. But interestingly enough, even without it, the risks are still lower for DBS than everything else. And so we didn't need that advantage, but we said, okay, that's a fair way to look at it.

To say if you had a patient of the same age with the same comorbidity and the same overall health risk go undergoing any of the other elective procedures, what is the comparison? So ultimately it didn't change much, but in, in order to compare apples with apples as much as possible, we did this risk stratification as well.

Dr. Mitra Afshari: Yeah, I thought it was a really. Important finding actually. 

Dr. Chengyuan Wu: Ultimately, I think it strengthens the conclusion that even with or without this risk assessment, and even though patients are [00:15:00] older and they are potentially, they are sicker, that didn't change things that we can safely do these procedures in older patients.

Dr. Mitra Afshari: Exactly. I think one limitation of the study, Chen, which you discussed in the paper, is that the database that you collected the data from did not have detailed information as to how the DBS surgeries were done. Correct. DBS specialists, both myself and Delaram are very familiar with this.

We know that there's more than one technique to performing DBS surgery. There's the standard awake micro electrode recording DBS surgery where patients are awake. There's minimal anesthesia used. Intubation is not needed. And then there's a sleep surgery, which may be less frequent in the United States, but is being done I think with increasing frequency under MRI and CT guidance without micro electric recordings. And patients are under general anesthesia.

And [00:16:00] so unfortunately those details were not included in the database. Do you think that those details of how surgery was performed could delineate potentially higher or lower risk DBS surgical procedures, and what's your hypothesis related to that?

Dr. Chengyuan Wu: Yeah very interesting and absolutely right. It's not there because it's was not one of designated variables. I also joke that if you talk to 10 different DBS surgeons, they're gonna tell you 15 different ways of doing the procedure. So there are these definite nuances.

But ultimately, if I put aside all my biases of how I do it, because again, any neurosurgeon's gonna think the way they do it is gonna be the best way. But if you take away all those biases and look at the objective data. There's a very nice article done by the Cleveland Group, led by Sean Nagel that shows that DBS in the past decade is much safer than it was in the previous decade, independent of technique as well.

And if you look at all the multiple studies [00:17:00] comparing a sleep versus awake we see that there's no significant difference between the techniques in terms of therapeutic outcome and also in terms of side effects. Complications aren't necessarily in that. But overall, the data that we have shows that people do just well, and I think ultimately what it boils down to, and this has become less of a quote unquote debate in our own subspecialty, is that ultimately the surgeon has to be comfortable with the procedure.

I think less important than the actual technique is the familiarity with the technique and also the familiarity of the team with the technique. So you start getting into a little bit more of a signal in terms of complication rates in high volume centers versus lower volume centers. So it doesn't matter how you do it, as long as it's done in a repeatable, reliable way.

So ultimately, it really is more about surgeon experiences, team consistency, and so forth than outright technique itself.

Dr. Mitra Afshari: And I [00:18:00] think for this, Delaram, you can chime in as well. What I've been taught is that in the past, when DBS first started people were doing more passes with the micro electrode, and really mapping things out with the microelectrode. And I think things have changed over time and we're moving a little bit farther away from the mapping, right?

And so that risk that may come with many microelectrode passes or tracks is gonna change over time. 

Dr. Chengyuan Wu: I think ultimately, just like many aspects of neurosurgery, we have evolved drastically with the improvements in imaging. And so with MRI, that has allowed our tumor colleagues to make smaller craniotomies and we're not doing these large openings anymore. It's allowed our spine colleagues to be a little more specific in terms of the procedures that are done.

And in functional, [00:19:00] absolutely the same where visualization of the targets that you were talking about subthalamic nucleus, or pallidus? Are certainly much better delineated than in the days of you know, ventriculography. If you see it better, you are going to rely less or require less mapping, and you are likely to use MERs more for fine tuned adjustments of depth or confirmation of location, if your macro stimulation is not quite accurate. So yeah, I think you're absolutely right there that we've seen throughout our field.

Dr. Mitra Afshari: It's an excellent point. Delaram, did you wanna chime in?

Dr. Delaram Safarpour: Yeah. I can just speak for the functional neurosurgery world 'cause that's where I collaborate most with our neurosurgeons. And I think we are in the precision era and certainly all these advances that we have really made it much more precise. The lesions that we create with focus ultrasound are [00:20:00] better than the previous more traditional lesioning techniques that we had.

The DBS lead implantations are more precise and certainly the less number of leads or passes that we have will improve the outcomes too. I totally agree with that.

Dr. Mitra Afshari: The final question I had for Chen, and then I wanted to turn to Delaram to speak a little bit more about her consensus paper, is about patient counseling. So of course, both of these papers really influence providers body of knowledge related to DBS surgical risk, but how about how we accurately counsel patients?

Chen, I think our audience would love to hear from you about how you would counsel a patient who you are evaluating for DBS surgery, taking this new knowledge into consideration. What would a sample script be from you?

Dr. Chengyuan Wu: I think, it's easy to get very excited about this, but it's also important not [00:21:00] to overstate the kind of balance of risk benefit, and that's exactly what it is, right? I think first I generally talk about, as Dr. Safapour had mentioned, that the stigma of quote unquote brain surgery and how that skews our perceptions of things and what we do in surgery is we have to always evaluate benefit with risk. And that the benefits are well known and that we know DBS is not a cure, but it can be a very effective tool to improve symptoms, reduce medication burden, and ultimately improve quality of life. And that one point I hear over and over again is that, prior patients frequently say, I wish I did this sooner. I try to get patients away from this idea that quote unquote, brain surgery is inherently more risky. And they understandably worry, but start to then talk about the evolution of DBS as we have here. In more general [00:22:00] terms is that technology has improved the way that we do this and has decreased the risk significantly.

Now as we were putting this paper together, I alluded to it, but now I can confidently say we've compared it exactly in terms that, you know, you or your family might understand and that, overall complications from the surgery are much lower than what is perceived. And that, I can give numbers, in terms of hemorrhage rates and infection rates, and I did that all the time. But I think what is certainly more impactful to say from what our data shows is that DBS is on par with a risk of a tonsillectomy or hernia repair and much less risky than a hip or a knee replacement.

Dr. Mitra Afshari: Exactly. Delaram, I would love to hear from you now. I think it's so nice that we have these two perspectives together on this podcast today, engaging on this topic. Because like you both mentioned earlier, we rarely have these opportunities even at our educational conferences. You know, we just [00:23:00] heard this excellent summary from Chen about all these important findings from his study regarding DBS surgical risk.

When you think about the times that you sat down with your patients in those initial discussions of DBS, how do you think that this new data would facilitate, or strengthen your conversations?

Dr. Delaram Safarpour: I think these data really help us have a more balanced conversation with the patients. The strength of the study that Dr. Wu and their colleagues did is really to show this comparison. 'cause as he was mentioning earlier, when even when you present these numbers to the patient, some of them will say, ah, I'm gonna be that unlucky 1%.

It's just something that some people will bring up. But then when you provide that point of reference comparing to tonsillectomy, comparing to these other surgeries, the risk is so low. And when I talk to them, I will say, I do understand that this is your brain [00:24:00] we're talking about, and we wanna have great outcomes, but here's what we know in big data and these risks are pretty low and you can have improvement of quality of life.

So this really helps me make such a great decision for the patients a little bit more informed and easier that the risks are often perceived greater than they truly are. And I think this kind of reframing support and information earlier to the patients will help us have earlier referrals for the patients and take away the stigma around surgery, and ultimately better shared decision making.

Dr. Mitra Afshari: Wonderful. So I think I wanna pose one final question to both of you. And that would be, how can we do better? Does this discussion today with both of you perhaps spark some new ideas on how we can augment DBS referrals from [00:25:00] providers and how we can make patients a little bit more comfortable.

Does this spark anything potentially new that maybe we should be instituting with our patients and with our providers? Delaram, we'll start with you.

Dr. Delaram Safarpour: I'm really glad you brought this up. This highlights that we have to really work on this perception that you need to have a very large, fully built, multidisciplinary program before you can safely offer DBS. Or actually, this conception can itself be a barrier for expanding access.

What we try to emphasize in our paper is that while multidisciplinary care is essential, it doesn't have to look identical at every institution. There's definitely variability in how programs are structured, and that's okay as long as the core elements are in place. To me, the core team really includes a movement disorder neurologist, a [00:26:00] functional neurosurgeon, and ideally a neuropsychologist who are all experiencing DBS and are working together.

This partnership is really the foundation of success and around that if access allows to have collaborations with physical therapies, speech therapy, preoperative medicine, social work. These would make it the most ideal dream team. But not every center has access to such detailed evaluations.

And it's important to start the collaboration and then find out if some of that can be driven from outside institutions or about different departments, perhaps use of telehealth. There are many different ways that this multidisciplinary team can be built. And in many ways this ties back to the earlier discussion that we just want to lower the threshold for referral, and we want the referring neurologist to understand that you are not referring and committing to a [00:27:00] surgery.

But instead you are sending your patient for an evaluation that can possibly change their quality of life and this should not be a last resort for them.

Dr. Mitra Afshari: I think that's such an important point because I really encourage our movement disorder neurologists to just send patients to talk to me about DBS. Just to talk about it and not necessarily going down this high speed road where they're definitely going to be getting surgery.

I think that's what people worry about. And so it's nice to just talk to someone that's well informed like yourself. And have those initial discussions with us and maybe even have initial discussions to warm the patient up to the idea with the neurosurgeon. What are your thoughts on that, Chen?

Dr. Chengyuan Wu: Yeah, I completely agree. Ultimately it's a matter of starting that conversation as both of you had said, right? I think one thing that we didn't talk about is the elephant in the [00:28:00] room in my mind is the fact that we still call it deep brain stimulation. And to patients that we didn't do ourselves any favors by saying that they hear those words and they said, wow, deep, that sounds terrible.

And in my brain, that sounds worse, right? How do we overcome that barrier? And, with this information, my hope is that this is a easier way to start that conversation and to disseminate this sort of information to patients directly, to general neurologists, to everyone with efforts like this and with the help of the Movement Disorder Society to try to get that word out so that yes, we can start that conversation and say, okay, is this person even a candidate?

'cause we don't have that opportunity then those patients are never gonna be able to even consider this therapy.

Dr. Mitra Afshari: Thank you to both of you. This was such an excellent discussion. Wanna thank Doctors Safapour and Wu for all of the hard work that you're doing and for taking the time out of your busy schedules to chat [00:29:00] with us on this MDS Podcast. It was really a pleasure hearing both of your perspectives.

Thank you. Until next time.

Dr. Chengyuan Wu: Thank you.