Awake or Asleep Subthalamic Deep Brain Stimulation for Parkinson's Disease: Further Research Is Needed

BACKGROUND AND OBJECTIVES: This systematic review aims to evaluate the differences in clinical efficacy and quality of life between asleep and awake subthalamic nucleus deep brain stimulation (STN-DBS) procedures in patients with Parkinson's disease. METHODS: A comprehensive search was conducted in PubMed/Medline, Embase, and Cochrane Library databases to identify relevant studies. Inclusion criteria were studies that included patients with Parkinson's disease, who underwent bilateral STN-DBS, comparing outcomes of asleep and awake methods. The outcomes of interest were Unified Parkinson's Disease Rating Scale, levodopa equivalent daily dose and Parkinson's Disease Questionnaire-39. Risk of bias assessment was performed using the Cochrane Risk of Bias tool for randomized controlled studies and the Newcastle Ottawa Scale for cohort studies. RESULTS: The literature search yielded 1339 citations. Quantitative analysis, based on 2 randomized controlled studies, demonstrated no significant difference between asleep and awake DBS in postoperative levodopa equivalent daily dose reduction ( P = 39, mean difference = −66.69, CI 95% = −220.14 to 86.76) or postoperative Parkinson's Disease Questionnaire-39 score ( P = .38, mean difference = −2.00, CI 95% = −6.50 to 2.49). Twenty-five retrospective cohort studies and one randomized controlled trial were included in a qualitative analysis, which supported these findings with no significant difference between asleep and awake. However, substantial heterogeneity in surgical techniques and potential biases because of small sample size, selection bias, and lack of blinded outcome assessments were observed. CONCLUSION: This systematic review and meta-analysis suggest no clear evidence of a significant difference between asleep and awake STN-DBS procedures. However, caution should be exercised when interpreting the finding. There is still a need for larger prospective studies to provide robust assessment of the potential differences in clinical efficacy and risks associated with both the asleep and awake method. Importantly, these terms need to be questioned as both terms cover a range of different methods. Long-term follow-up studies are needed as differences in precision may crystallize over time with disease progression.