Kinematic evaluation of gestural and repetitive single joint movements of the arm after posteroventral pallidotomy, subthalamotomy or both procedures combined in two Parkinson’s disease patients: two case studies

Abstract

Two patients with severe Parkinson's disease undergoing partial or complete ablative interruption of basal ganglia (BG) output are presented. One patient who underwent bilateral subthalamotomy, and a second who underwent unilateral posteroventral pallidotomy, followed 7 years later by a bilateral subthalamotomy because of contralateral disease progression, were studied. In addition to the usual clinical evaluation, changes in joint kinematics observed during unconstrained, skilled multi-joint movement and repetitive single joint (RSJ) movement of the wrist were studied. Clinical UPDRS items referred to hand movements contralateral to the procedure, and instrumental measurement of RSJ improved in both patients after either pallidotomy or subthalamotomy. When both BG outflow paths were interrupted as was the case in the second patient (bilateral subthalamotomy after the initial pallidotomy), no added clinical improvement was observed, RSJ even deteriorated slightly. Instrument-based studies for movement alteration detection after simultaneous ablation of the globus pallidus and the subthalamic nucleus of these two patients showed greater sensitivity than clinical evaluation alone. Complex gestural movement performance remained unaffected after partial (subthalamotomy or pallidotomy) or complete interruption of BG outflow (case 2), indicating BG compensatory capacity after total outflow interruption remained intact.

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“…Surgical disruption of the basal ganglia–thalamocortical connections by lesioning or DBS would free cortical operations from subcortical “noise.” Of course, surgical elimination of basal ganglia output would also be expected to eliminate the contribution of the basal ganglia–thalamocortical system to normal behavior, potentially resulting in deficits in motor learning and an inability of directing actions to novel events. In fact, recent studies have documented that patients with PD preferentially lose functions of the dorsolateral striatum, including specifically the learning and execution of habits and procedures (reviewed in Redgrave et al100) and that PD patients with therapeutic near‐complete lesions of the basal ganglia motor output through combined pallidotomy/subthalamotomy procedures101, 102 show further reductions in implicit learning.…”