An Ethical Framework for Deep Brain Stimulation in Children

Benjamin Davidson, MD; Lior M. Elkaim; Nir Lipsman, MD, PhD; George M. Ibrahim, MD, PhD


Neurosurg Focus. 2018;45(3):e11 

In This Article

The Element of Time: Interaction Between Disease Course and the Child's Development

Timing plays a much larger role in pediatric DBS. Unlike in adults, when the decision to proceed with DBS involves ensuring that the disease is truly refractory to other treatments, the pediatric neurosurgeon must also factor in the child's development. The most common indication for pediatric DBS is dystonia, for which early intervention seems to yield better motor improvements.[25,30] In treating secondary dystonia due to cerebral palsy, those treated before skeletal maturity improved in their BFMDRS scores by 38%, while those treated after skeletal maturity improved by only 9%.[30] Early interventions for dystonia likely mitigate contractures and may prevent or inhibit fixed deformities from developing.[21,30] Advantages of early intervention must be counterbalanced by the various challenges associated with DBS in a younger child.

Ethical challenges are also presented by diseases with an unknown natural history. In Tourette syndrome, a tic disorder whose treatment has shown promising results in adult DBS series, pediatric cases often spontaneously remit in adolescence, making early DBS less appealing.[23,25] While most guidelines recommend against DBS for Tourette syndrome in children for this reason, the result is that a subset of children must endure years of unnecessary suffering until their disease is deemed to be nonremitting.[36,40] Moreover, anorexia nervosa, a common and severe condition often beginning during adolescence, is associated with a high rate of treatment resistance and death and may therefore be amenable to earlier DBS.[26]