Bilateral subthalamotomy for advanced Parkinson disease.
BACKGROUND
Unilateral subthalamotomy has been reported to be effective in the treatment of rigidity, bradykinesia, and tremor of the contralateral limb. However, gait, clinical fluctuation, and postural stability are not significantly improved by unilateral lesioning of the STN in the long term. We sought to determine if bilateral surgery of the STN offers more benefits in the treatment of advanced PD.


METHODS
Radiofrequency thermal coagulation was performed bilaterally in the STN in 10 patients. Under microelectrode and stereotactic guidance, surgery was directed at the dorsolateral portion of the STN in stages and followed by MRI in each patient to confirm lesion location. Patients have been followed for a median duration of 26 months as measured from the date of first surgery (range, 6-48 months) with UPDRS before and after surgery.


RESULTS
Bilateral subthalamotomy demonstrated persistent benefits in bradykinesia, rigidity of the limbs, and consequently the improvement in activities of daily living, motor function, Schwab and England scales. In addition, significant improvement in axial motor features, gait, postural stability, and clinical fluctuation were present with bilateral STN surgeries. The benefits were sustained at the last evaluation period of 36 months. Tremor and drug-induced dyskinesia improved in early postoperative period, but the benefits declined over time. The reduction of daily l-dopa equivalent was 34%. No speech impairment was observed. Mild choreic movement occurred in 2 of 20 procedures that resolved spontaneously in 4 to 8 weeks.


CONCLUSIONS
For advanced PD present with bilateral symptoms, axial motor impairment, or clinical fluctuation, staged bilateral subthalamotomy appears as a safe and effective treatment in the long term.
Tseng
Ham-Min
HM
Department of Surgery, Hospital and Medical College, National Taiwan University, Taipei, Taiwan.
Su
Philip C
PC
Liu
Hon-Man
HM
Liou
Horng-Huei
HH
Yen
Ruoh-Fang
RF
D000368:Aged; D017115:Catheter Ablation / Q000379:methods*; D004409:Dyskinesia, Drug-Induced / Q000503:physiopathology / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D007839:Functional Laterality / Q000502:physiology*; D006801:Humans; D018476:Hypokinesia / Q000209:etiology / Q000503:physiopathology / Q000601:surgery; D007980:Levodopa / Q000008:administration & dosage; D008297:Male; D008839:Microelectrodes / Q000592:standards; D008875:Middle Aged; D009127:Muscle Rigidity / Q000209:etiology / Q000503:physiopathology / Q000601:surgery; D009434:Neural Pathways / Q000503:physiopathology / Q000601:surgery; D010300:Parkinson Disease / Q000503:physiopathology / Q000601:surgery*; D016634:Radiosurgery / Q000379:methods*; D020531:Subthalamic Nucleus / Q000503:physiopathology / Q000601:surgery*; D013995:Time; D016896:Treatment Outcome; D014202:Tremor / Q000209:etiology / Q000503:physiopathology / Q000601:surgery
D007980:Levodopa