Motor performance after posteroventral pallidotomy and VIM-thalamotomy in Parkinson's disease: a 1-year follow-up study

Abstract

-Twenty-three patients with Parkinson's disease underwent stereotactic surgery. To study the long-term motor performance, the patients were evaluated at the pre-operative period and at the 1 st , 3 rd , 6 th , and 12 th post-operative months, with the following scales: Unified Parkinson's Disease Rating Scale (UPDRS) motor score and Larsen's Scale for Dyskinesias. The patients under levodopa therapy were assessed both in "on" and "off" periods. Fourteen unilateral ventrolateral thalamotomies (VLT), 4 unilateral posteroventral pallidotomies (PVP), 2 bilateral PVP, and 3 VLT with contralateral PVP were performed. The motor improvement was significant and long-lasting in the "off" period, except for 2 patients. The "on" period quality improved, mainly due to the control of dyskinesias. The improvement of dyskinesias was long-lasting for the majority of the patients. There was no significant decrease in the levodopa dose. Three patients showed permanent complications, but none was severe.KEY WORDS: Parkinson's disease, thalamotomy, pallidotomy.Desempenho motor após palidotomia póstero-ventral e talamotomia ventro-lateral na doença de Parkinson: acompanhamento de um ano RESUMO -Vinte e três pacientes portadores de doença de Parkinson foram submetidos a cirurgia estereotáxica para tratamento da doença. Com o objetivo de estudar o desempenho motor a longo prazo, os pacientes foram avaliados clinicamente no período pré-operatório, no 1°, 3°, 6°, e 12° mês pós-operatório, com as seguintes escalas: Escala Unificada para Doença de Parkinson (Unified Parkinson's Disease Rating Scale-UPDRS), item III, escore motor e com a Escala de Larsen para Discinesias. Os pacientes que utilizavam levodopa foram avaliados nos estados "off" e "on". Foram realizadas 14 talamotomias ventro-laterais (TVL) unilaterais, 4 palidotomias póstero-ventrais (PPV) unilaterais, 2 PPV bilaterais; 3 TVL associadas à PPV contralateral. O benefício motor foi observado de forma significante no estado "off", e manteve-se a longo prazo na maioria dos pacientes, exceto em 2. Houve melhora da qualidade do período "on", devido ao controle das discinesias. A melhora das discinesias se manteve a longo prazo na maioria dos pacientes. As cirurgias não promoveram um decréscimo significante na dose de levodopa.Três pacientes tiveram complicações permanentes, mas nenhuma delas foi considerada grave e nem houve prejuízo funcional importante em decorrência das mesmas. PALAVRAS-CHAVE: doença de Parkinson, talamotomia, palidotomia.Levodopa remains the goldstandard treatment for patients with Parkinson's disease (PD). However, after some years, part of these patients develop complications related to the prolonged use of the drug, such as fluctuations and disabling dyskinesias 1 . In the absence of satisfactory pharmacological therapy, there has been a resurgence of interest for stereotactic surgery in the last

Acoustic voice assessment in Parkinson's disease patients submitted to posteroventral pallidotomy

“…The UPDRS (Part IIImotor score) was used because it allows data comparisons between different studies, as it is a widely used scale. The mean UPDRS score was lower after PVP, which is in accordance with the literature 5,11,14 . The different studies that reported neurological evaluations in the off and on phase observed an improvement only in the off phase 5,11,[14][15][16] .…”

“…The mean UPDRS score was lower after PVP, which is in accordance with the literature 5,11,14 . The different studies that reported neurological evaluations in the off and on phase observed an improvement only in the off phase 5,11,[14][15][16] . Ondo et al 14 speculated that the improvement in the off phase is consistent with the traditional model of the basal ganglia physiology in PD, which determines the presence of tonic thalamic hypo activity resulting from the excessive inhibition induced by the internal palladium.…”

“…Surgical procedure -All patients were submitted to surgical procedures as described by Aguiar et al 11 Neurological evaluation -All individuals were rated by the Unified Parkinson's Disease Rating Scale -UPDRS 12 , focusing on the motor score (items 18 to 31) in the on and off phases of the levodopa effect.…”

Unilateral and bilateral pallidotomy for idiopathic Parkinson's disease: A case series of 115 patients

“…Bilateral pallidotomy might address this issue; however, reports from a few small series19–21 have raised concerns over the incidence of dysarthria, dysphagia, and cognitive impairment. Several other reports of pallidotomy have included cohorts of bilateral procedures but were not sufficiently detailed28, 29 or large enough1, 16, 30–35 to address these concerns.…”

O papel da neurocirurgia na doença de Parkinson

“…Embora o lado do corpo tratado possa estar com os sintomas relativamente ou totalmente controlados, a incapacidade do outro dimídio prejudica o desempenho motor global 13 . Aguiar et al 28 concluiu que um ano após a VIMtalamotomia ou PPV, a maioria dos pacientes apresentou benefícios motores prolongados do período em off e controle de discinesias no período on, com complicações persistentes mínimas 28 . Para Samuel et al 29 , o efeito mais significativo após a palidotomia medial ventral unilateral na DP é a diminuição das discinesias contralaterais, enquanto as discinesias ipsilaterais e axiais melhoraram em graus menores.…”