Neurosurgery. 2026;99(3):691-699
Whether bilateral stimulation leads should be implanted together or in separate operations remains a consequential planning decision. Hilvert and colleagues examine this question through a retrospective comparison that found no measurable safety advantage from staging, despite greater cumulative operative and hospital use. The findings invite reconsideration of routine staging, but do not remove the need for individualized assessment.
Objective
To compare the clinical safety, subsequent treatment burden and resource utilization associated with staged versus simultaneous bilateral DBS lead implantation for movement disorders.
Methods
The authors retrospectively examined adults undergoing bilateral DBS for Parkinson disease, essential tremor or dystonia at one institution between 2006 and 2023. Patients younger than 18 years, those with previous DBS and those treated for other indications were excluded. Propensity matching used age, sex and diagnosis; the final analysis included 252 patients in each group.
Outcomes included intraoperative events, postoperative complications, delirium, 30-day readmission, medication reduction at one year and reoperation within five years. Additional analyses considered electrode accuracy, anesthesia exposure, operating-room use and hospitalization. Residual differences between groups were addressed through multivariable adjustment.
Main results
Thirty-day complications occurred in 24.2% of staged versus 22.2% of simultaneous cases, without a significant difference. Adjusted principal clinical outcomes likewise did not differ significantly. Staging increased cumulative anesthesia time (approximately 411 versus 254 minutes), operating-room time (388 versus 242 minutes) and hospitalization (2.35 versus 1.57 days), including after adjustment. These totals describe the treatment pathway, not individual operations.
Interpretation
The study questions routine staging without excluding benefit for selected high-risk patients. The median interval between staged lead insertions was seven days; results should not be generalized to protocols allowing months of clinical reassessment.
Simultaneous implantation referred to both leads, not the entire DBS system: pulse-generator placement remained separate. Leads were generally inserted awake with electrophysiological testing. Thus, the findings inform this institutional workflow rather than establish identical safety across alternative anesthetic or targeting strategies. Clinical vulnerability and the purpose of any interval should remain explicit in surgical planning.
Limitations
Allocation was retrospective and nonrandomized, reflecting clinical judgment and changes in institutional practice. Despite matching, staged patients remained older and more frequently had Parkinson disease, while simultaneous patients more often had essential tremor; targets also differed. Adjustment cannot eliminate unmeasured confounding or fully compensate for these imbalances.
Postoperative standardized motor scores were unavailable, so medication reduction cannot establish comparable motor efficacy. Rare adverse events and wide confidence intervals limit the ability to rule out meaningful safety differences. Electrode-accuracy data were available only for a subset, and results from one institution may not transfer to other workflows. Nonsignificant comparisons should not be interpreted as proof of equivalence.
Clinical takeaway
Simultaneous bilateral lead implantation merits consideration when clinically and technically appropriate, because staging did not demonstrate a safety advantage and increased cumulative treatment burden in this cohort. Preserve individualized assessment of cognitive status, comorbidity, diagnosis and patient preference. The study informs shared planning; it does not mandate abandoning staged surgery.