Abstract
Objective: Bilateral stereotactic neurosurgery for advanced Parkinson's disease (PD) has a long history beginning in the late 1940s. In view of improved lesioning accuracy and reduced bleeding risk and in spite of long-standing caveats about bilateral approaches, there is a need to investigate bilateral MR-guided focused ultrasound (MRgFUS) interventions. We hereby present the clinical results of bilateral pallidothalamic tractotomy (PTT), i.e., targeting of pallidal efferent fibers below the thalamus at the level of Forel's field H1, followed for 1 year after operation of the second side.Methods: Ten patients suffering from chronic and therapy-resistant PD having received bilateral PTT were followed for 1 year after operation of the second side. The primary endpoints included the Unified Parkinson's Disease Rating Scale (UPDRS) scores in on- and off-medication states, dyskinesias, dystonia, sleep disturbances, pain, reduction in drug intake, and assessment by the patient of her/his global symptom relief as well as tremor control.Results: The time frame between baseline UPDRS score and 1 year after the second side was 36 ± 15 months. The total UPDRS score off-medication at 1 year after the second PTT was reduced by 52% compared to that at baseline on-medication (p < 0.007). Percentage reductions of the mean scores comparing 1 year off- with baseline on-medication examinations were 91% for tremor (p = 0.006), 67% for distal rigidity (p = 0.006), and 54% for distal hypobradykinesia (p = 0.01). Gait and postural instability were globally unchanged to baseline (13% improvement of the mean, p = 0.67, and 5.3% mean reduction, p = 0.83). Speech difficulties, namely, hypophonia, tachyphemia, and initiation of speech, were increased by 58% (p = 0.06). Dyskinesias were suppressed in four over four, dystonia in four over five, and sleep disorders in three over four patients. There was 89% pain reduction. Mean L-Dopa intake was reduced from 690 ± 250 to 110 ± 190.Conclusions: Our results suggest an efficiency of bilateral PTT in controlling tremor, distal rigidity, distal hypobradykinesia, dyskinesias, dystonia, and pain when compared to best medical treatment at baseline. Larger series are of course needed.
Highlights
Bilateral stereotactic neurosurgery for Parkinson’s disease (PD) has a long history, beginning in the late 1940s
Case series of bilateral pallidotomies followed between the 1990s and early 2000s [8,9,10,11,12,13,14,15,16] until the deep brain stimulation (DBS) technique came to dominate the field
No additional ethical approval was sought because MR-guided focused ultrasound (MRgFUS) pallidothalamic tractotomy (PTT) has been approved by the Federal Once of Public Health of Switzerland and monitored since 2015 in the context of a registry controlled by this office
Summary
Bilateral stereotactic neurosurgery for Parkinson’s disease (PD) has a long history, beginning in the late 1940s. Lacking modern criteria for reporting, were impressive in the context of limited imaging modalities for guidance to reach deeply located brain targets. These results were probably favored by a patient collective who certainly did not match our current, older, and therapy-resistant one. Case series of bilateral pallidotomies followed between the 1990s and early 2000s [8,9,10,11,12,13,14,15,16] until the deep brain stimulation (DBS) technique came to dominate the field
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