title: Pallidal surgery for the treatment of primary generalized dystonia: long-term follow-up.
abstract: OBJECTIVE
  To describe the results and long-term follow-up after functional surgery of the internal segment of the globus pallidus (GPi) in 10 patients with primary generalized dystonia.
  
  
  METHODS
  Nine of the 10 patients were positive for the DYT1 gene mutation. Bilateral deep brain stimulation (DBS) of the GPi was performed in three cases, bilateral pallidotomy in two, and combined surgery (unilateral GPi lesion with contralateral stimulation) in the remaining five. All patients were evaluated with the Burke-Fahn-Marsden dystonia scale (BFMDS) before, immediately after surgery, at 3 weeks, 3 and 6 months and then yearly. Follow up time ranged from 15 to 105 months (mean: 66.1 months) with six patients having more than 6 years follow up.
  
  
  RESULTS
  All patients improved after surgery. All patients with unilateral or bilateral DBS experienced an immediate improvement before starting stimulation. The magnitude of this initial micro lesion effect did not predict the magnitude of the long-term benefit of DBS. The mean decrease in the in the BFMDS was 34%, 55%, and 65% in the movement scale; and 32%, 48%, and 49% in the disability scale for patients with bilateral pallidal DBS, combined unilateral DBS and contralateral pallidotomy, and bilateral pallidotomy, respectively. Worsening of dystonia after a plateau of sustained benefit was observed in three patients. Two patients required multiple pallidal surgeries. Adverse events included: permanent anarthria (1), misplacement of the electrode requiring further surgery (2), scalp infection (1), and hardware related problems (3).
  
  
  CONCLUSIONS
  This long-term follow up study confirms the beneficial effect of pallidal DBS or pallidotomy in primary generalized dystonia. In addition, our results extent previous observations by showing that, in these patients, (1) the microlesion effect of DBS is not predictive of long-term benefit; (2) combined DBS with contralateral pallidotomy appears to be more effective than bilateral pallidal DBS; and (3) dystonia can reappear after an initial good response during long term follow up.
authors.affiliation: Parkinson's Disease and Movement Disorder Unit, Hospital de Clínicas, University of Buenos Aires, Argentina. mgcersosimo@gmail.com
authors.forename: Maria G
authors.initials: MG
authors.lastname: Cersosimo
authors.forename: Gabriela B
authors.initials: GB
authors.lastname: Raina
authors.forename: Fabian
authors.initials: F
authors.lastname: Piedimonte
authors.forename: Julio
authors.initials: J
authors.lastname: Antico
authors.forename: Pablo
authors.initials: P
authors.lastname: Graff
authors.forename: Federico E
authors.initials: FE
authors.lastname: Micheli
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D003131:Combined Modality Therapy; D046690:Deep Brain Stimulation / Q000009:adverse effects; D020821:Dystonic Disorders / Q000628:therapy*; D004567:Electrodes, Implanted / Q000009:adverse effects; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D053860:Pallidotomy / Q000009:adverse effects / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome