Evaluation of surgery for Parkinson’s disease

Abstract

the Task Force on Surgery for Parkinson's Disease* PD is a common disorder affecting on average 100 per 100,000 population. Despite the large number of medications available for the treatment of early and moderately advanced PD, options specifically designed for the patient with advanced disease are limited. Surgery for PD dates from 1939-1940, when Bucy and Case 1 and Klemme 2 excised parts of the cerebral cortex to treat tremor and dystonia, but this type of surgery produced hemiparesis. Surgical basal ganglia lesions were introduced a few years later by Meyers, 3,4 who found that pallidotomy produced significant relief of tremor, rigidity, and dyskinesias, but with considerable mortality. Stereotaxic techniques to coagulate the globus pallidus in PD were introduced in the 1950s by Spiegel and Wycis, 5,6 and Cooper was an early advocate of pallidal surgery.7 Based on the anatomic connections between the pallidum and the thalamus, Hassler introduced the concept of surgery on the ventrolateral nucleus of the thalamus. 8,9Microelectrode recording allowed Narabayashi 10,11 to find that lesioning the ventral intermediate (Vim) nucleus of the thalamus was the most specific target to control the tremor in PD. Neurosurgery reached its peak in the 1960s, but declined after the introduction of levodopa.The recent resurgence of surgery was initiated by adrenal medullary transplantation. The premise of adrenal medullary transplants was that these cells, when transplanted into patients with advanced PD, would survive and function as a new source of dopamine. The theoretical advantages of adrenal tissue include that the tissue comes from the patient, eliminating the issue of immunologic rejection; dopamine is a normal intermediate compound made by the chromaffin cells; and chromaffin cells may have neuritic morphology when grown in culture. The disadvantages include the non-neuronal source and the rather modest survival rates of cells in laboratory transplantation studies. Isolated case reports of effective treatment of advanced PD with unilateral transplantation of adrenal medullary cells into the striatum in the 1980s led to several clinical trials testing the safety and efficacy of this procedure.Fetal mesencephalon transplantation was introduced subsequently and is based on several considerations. First, PD is associated with relatively selective degeneration of dopaminergic cells located in the substantia nigra, a portion of the mesencephalon. Second, replacement of dopaminergic activity by means of precursor drugs, receptor agonists, or inhibitors of dopamine catabolism improves the signs and symptoms of PD. Third, laboratory evidence in experimental animals has demonstrated that grafts of dopamine-containing neurons improve behavioral models of PD. Fourth, in these animal models, grafts reinnervate the striatum and form synaptic connections with host neurons. As a result, a small number of research teams have developed programs for human fetal mesencephalic cell grafts in PD patients. Several published reports exist,...

Intracranial Delivery of Stem Cells

“…Older studies, including adrenal medulla implants and foetal implant studies, were reviewed by Rehncrona [13]. On behalf of the American Academy of Neurology, Hallett and Litvan reported the evaluation of clinical studies in patients with PD in which a range of experimental functional surgical procedures were employed [14]. Their summary of the evaluation of implantation of human foetal ventral mesencephalon tissue and cells concluded that foetal tissue transplants were well-tolerated and that morbidity and mortality were low.…”

Psychomotor and executive functioning after unilateral posteroventral pallidotomy in patients with Parkinson's disease

“…These motor symptoms are commonly treated with levodopa and dopamine agonists [2], but in medically intractable cases and/or those associated with L-dopa induced dyskinesias, surgical techniques are performed [3]. In addition to motor symptoms, specific cognitive dysfunctions are observed in PD patients, concerning visual perception and visuo-spatial abilities [4][5][6][7][8] habit memory, affected more than declarative memory [9], short-term memory, disturbed to larger extent than long-term memory [10], working memory and executive functions [11][12][13][14][15].…”

“…Among stereotactic ablative surgeries, to alleviate bradykinesia, rigidity and dyskinesias, pallidotomy is recommended [3]. In a previous study, we explored the cognitive outcome of both unilateral stereotactic thalamotomy and pallidotomy [21].…”

“…Pallidotomy generally improves motor functioning-bradykinesia and rigidity decrease in 90% cases [22]. Total Unified Parkinson Disease Rating Scale (UPDRS) scores and contralateral UPDRS motor improvements in the "off" state reach 30% [3]. Motor improvements are most pronounced contralaterally, are of greater magnitude in the "off" than the "on" state [3], and last at least 2 years [23,24].…”

Impact of Posterior GPi Pallidotomy on Leg Tremor in Parkinson’s Disease

“…Stereotactic thalamotomy is a mainstay in the surgical treatment of Parkinson's disease (PD)-related tremor or essential tremor [1][2][3][4][5]. However, to treat lower-extremity tremor, the thalamic ablation surgery is not favored, and is even a matter of potential concern, since selective lesions must be placed dorsolaterally in the thalamic ventral intermediate nucleus (Vim) where they are adjacent to the internal capsule [2,6].…”