Prospective randomized 1-year follow-up comparison of bilateral subthalamotomy versus bilateral subthalamic stimulation and the combination of both in Parkinson's disease patients: a pilot study

Abstract

It has been suggested that potential risk of hemiballismus after subthalamotomy makes DBS preferable to ablation for IPD treatment; however, cost and the need for regular electrode control have also been observed as disadvantages to stimulation. The objective was to compare efficacy and safety of different surgical approaches to STN, in a prospective randomized pilot study. Sixteen consecutive IPD patients randomized to receive either: bilateral STN-DBS, bilateral subthalamotomy or unilateral subthalamotomy plus contralateral STN-DBS implantation, and followed for 12 months after surgery. One patient died and was excluded from the analysis. Total and motor UPDRS scores, as well as drug-induced dyskinesias improved significantly at 1 year follow-up, regardless of the procedure administered and without statistically significant differences between treatment modalities. Discrete changes were observed on ACE and MMSE scores. Psychiatric examination of patients subjected to bilateral stimulation and lesion, revealed slight increment in apathy and irritability scores, coinciding with significant deterioration of mentation, behaviour and mood as measured using the UPDRS. One patient presented persistent hemiballismus and required ulterior posteroventral pallidotomy. In this small group of patients, overall motor performance significantly improved after all three procedures, without major differences in outcome. Adverse events were, nevertheless, observed after both ablation and stimulation. The role of bilateral subthalamotomy in patients unable to receive a DBS electrode-implant merits further exploration in a larger series of patients with longer follow-up.

Subthalamotomy in the treatment of Parkinson's disease: clinical aspects and mechanisms of action

“…105,130 In fact, no studies using a cognitive test (mini-mental state examination) observed a decline after unilateral or bilateral lesions. 7,8,25,110,170 Slight improvements in verbal fluency, as well as decreases in dementia, apathy, and depression were seen in patients. 7,8 A recent study demonstrated decreased attention, inhibition, and verbal learning in up to 30% of the patients, but these did not affect patients globally.…”

“…Subthalamotomy was not included in the rec- ommended procedures for motor complications because of insufficient evidence. Two studies 41,110 met Level I criteria, depicted by at least 1 high-quality RCT, but these studies were not included in the review because of their small sample sizes. In the first study, 41 unilateral subthalamotomy was compared with unilateral pallidotomy and bilateral STN DBS.…”

“…41 In the second RCT comparing bilateral subthalamotomy and bilateral STN DBS, the 2 surgical procedures had similar benefits on motor symptoms in patients with PD and the results were comparable to previous literature. 110 Although these 2 RCTs provided evidence on the positive effects of STN lesions, larger RCTs are warranted to fully assess the cost-effectiveness and the role of subthalamotomy in the treatment of PD.…”

Parkinson's Disease Therapeutics: New Developments and Challenges Since the Introduction of Levodopa

“…Both STN-and GPi-DBS can have non-motor side effects, especially affecting verbal fluency, cognition and mood (Kumar et al, 1999a, b;Dujardin et al, 2001;Schupbach et al, 2005;Smeding et al, 2005Smeding et al, , 2006Smeding et al, , 2011Castelli et al, 2006;De Gaspari et al, 2006, Merello et al, 2008. Verbal fluency and cognition problems are more often seen in old patients (Hariz et al, 2000;Saint-Cyr et al, 2000;Funkiewiez et al, 2004;Smeding et al, 2011), or in those with poor cognition or depression at baseline (De Gaspari et al, 2006).…”

Possible Mechanisms Involved in Subthalamotomy-Induced Dyskinesia in Patients with Parkinson's Disease

“…Since then, although a very effective procedure, just a few groups around the world have incorporated this technique in their armamentarium for the treatment of Parkinson's disease [1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16]. The main reason for that is the fear of producing operation-induced dyskinesia (OID) such as hemiballism and chorea [1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19]. In the present study, we try to establish the factors involved in the genesis of OID, which happened in 6 out of 54 patients (11%) submitted to unilateral subthalamotomy in our institutions.…”