Deep brain stimulation (DBS) is a powerful but underutilised therapy. Many laudable publications focus on improving the quality of DBS surgery, but few are dedicated to ensuring its dissemination to as many patients as possible. Therefore, we thank Pereira et al. [1] for their interest in our recent publication [2] on DBS workflow and for providing insight into their own practice.

The latest UK National audit figures reveal that, from an estimated population of 68 million, only 300 new patients underwent functional neurosurgery procedures in a single year (UK Deep Brain Stimulation Registry 2023–4). Our new workflow allowed our centre to perform 131 (44%) of these. Therefore, DBS therapy probably reaches less than one third of eligible UK citizens. Patients would be best served by increased high-quality activity across several, large volume centres. Pereira et al. [1] should be congratulated for establishing a new DBS service and should be encouraged to grow this service even further.

When it comes to surgical workflow, Pereira et al. [1] acquire a stereotactic CT and a non-stereotactic MRI and then fuse or co-register these images for targeting. While we agree that modern DBS planning software has improved remarkably in recent years, our philosophy is to eliminate all unnecessary steps within the stereotactic procedure. Why obtain both a CT and MRI scan before surgery when one stereotactic MRI will suffice? Why introduce an image fusion error when this can be avoided by targeting on a stereotactic MRI?

Numerous factors can affect image fusion accuracy, including MRI distortion, voxel size of the acquired images, and the fusion algorithm used by commercial software packages. Therefore, we are wary of relying on fused images for surgical planning. Employing a preoperative stereotactic MRI for targeting eliminates some, but not all, of these potential pitfalls. We do accept such errors when fusing a post-implant stereotactic CT with the preoperative stereotactic MRI to make a visual estimation of lead location vis-a-vis the visible anatomical target. However, the stereotactic CT also allows comparison of the actual lead coordinates with those of the intended target, thus avoiding fusion errors when calculating the targeting error. This approach has led to incremental but significant improvements in targeting accuracy over the years [3, 4].

We understand that organising a stereotactic MRI on the day of surgery may be a logistical challenge. It may even be impossible if the available frame is not MR conditional. However, since image quality is fundamental to an image-guided and image-verified approach to DBS surgery, we value the increased accuracy and precision of a stereotactic MRI with neurosurgical oversight of image acquisition.

Pereira et al. [1] prefer a 3-mm twist drill over the standard 11-mm burr hole used by much of the DBS community. While this may work well in their hands and has appeal in terms of cosmesis and surgical speed, we are concerned that even a small deviation of the twist drill hole from the planned trajectory will result in a large error at the target. Indeed, our centre has had to relocate DBS leads in several patients who underwent DBS with the twist drill technique at other centres.

Finally, although there are some disparities in workflow between our centres, there are more similarities than differences. The move towards image-guided and image-verified DBS surgery under general anaesthesia without microelectrode recording can improve safety, accuracy, and efficacy, while reducing the cost of an already expensive therapy. We wholeheartedly agree that each centre must utilise the staff and resources it has at its disposal to the benefit of these patients, so we are pleased that our manuscript is generating discussion on this topic.

L.Z. is a consultant for Medtronic, Brainlab, and Boston Scientific, all outside the submitted work; H.A. is a consultant for FxNeuromodulation, a DBS-related startup company, and Abbott and reports lecture fees from Boston Scientific, all outside of the submitted work; M.T.K. is a consultant for Brainlab, Elekta, and Boston Scientific and has received funding from Medtronic, all outside the submitted work.

This study was not supported by any sponsor or funder.

Conception and design, critically revising the article, and reviewed submitted version of manuscript: L.Z., M.T.K., and H.A.; drafting the article: L.Z.; and approved the final version of the manuscript on behalf of all authors: M.T.K.

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