Evaluation of surgery for Parkinson's disease: a report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. The Task Force on Surgery for Parkinson's Disease.

Abstract

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 Case1 and Klemme2 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.8,9 Microelectrode recording allowed Narabayashi10,11 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 …