Bilateral subthalamotomy in Parkinson's disease: Initial and long-term response

L. Alvarez, R. Macias, G. Lopez, E. Alvarez, N. Pavon, M. C. Rodriguez-Oroz, J. L. Juncos, C. Maragoto, J. Guridi, I. Litvan, E. S. Tolosa, W. Koller, J. Vitek, M. R. DeLong, Jose A. Obeso

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186 Scopus citations

Abstract

We conducted an open label pilot study of the effect of bilateral subthalamotomy in 18 patients with advanced Parkinson's disease. In seven patients, the first subthalamotomy pre-dated the second by 12-24 months ('staged surgery'). Subsequently, a second group of 11 patients received bilateral subthalamotomy on the same day ('simultaneous surgery'). Patients were assessed according to the CAPIT (Core Assessment Program for Intracerebral Transplantation) protocol, a battery of timed motor tests and neuropsychological tests. Evaluations were performed in the 'off' and 'on' drug states before surgery and at 1 and 6 months and every year thereafter for a minimum of 3 years after bilateral subthalamotomy. Compared with baseline, bilateral subthalamotomy induced a significant (P < 0.001) reduction in the 'off' (49.5%) and 'on' (35.5%) Unified Parkinson's Disease Rating Scale (UPDRS) motor scores at the last assessment. A blind rating of videotape motor exams in the 'off' and 'on' medication states preoperatively and at 2 years postoperatively also revealed a significant improvement. All of the cardinal features of Parkinson's disease as well as activities of daily living (ADL) scores significantly improved (P < 0.01). Levodopa-induced dyskinesias were reduced by 50% (P < 0.01), and the mean daily levodopa dose was reduced by 47% at the time of the last evaluation compared with baseline (P < 0.0001). Dyskinesias occurred intraoperatively or in the immediate postoperative hours in 13 patients, but were generally mild and short lasting. Three patients developed severe generalized chorea that gradually resolved within the next 3-6 months. Three patients experienced severe and persistent postoperative dysarthria. In two, this coincided with the patients exhibiting large bilateral lesions also suffering from severe dyskinesias. No patient exhibited permanent cognitive impairment. The motor benefit has persisted for a follow-up of 3-6 years. This study indicates that bilateral subthalamotomy may induce a significant and long-lasting improvement of advanced Parkinson's disease, but the clinical outcome was variable. This variability may depend in large part on the precise location and volume of the lesions. Further refinement of the surgical procedure is mandatory.

Original languageEnglish (US)
Pages (from-to)570-583
Number of pages14
JournalBrain
Volume128
Issue number3
DOIs
StatePublished - Mar 2005
Externally publishedYes

Bibliographical note

Funding Information:
We wish to thank the CIREN and in particular its director Dr Julian Alvarez and vice-director Dr Ignacio Villa for their encouragement and support, and Mrs M. P. Obanos and Mr J. Allwood who prepared the article for publication. The study was initiated with the support of a Center Grant of the National Parkinson Foundation (Miami, FL) to J.A.O. Work and travel to Atlanta related to imaging studies in the initial patients, as well as J.L.J. were funded in part by a grant from the American Parkinson’s Disease Association to Emory University’s Center for Research Excellence in Parkinson’s Disease.

Keywords

  • Motor complications
  • Parkinson's disease
  • Subthalamic nucleus
  • Subthalamotomy
  • Surgery

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