Stereotactic pallidotomy and thalamotomy using individual variations of anatomic landmarks for localization.

Abstract

The optimal choice of imaging and localization for stereotactic surgery for movement disorders remains uncertain, with controversy surrounding the use of microelectrode recording and the role of distortion of magnetic resonance imaging (MRI) scans in reducing the accuracy of lesion placement. We review our experience with 67 pallidotomies and 35 thalamotomies performed without microelectrode recording, using instead individual variations in anatomic landmarks. Computed tomography is used as the primary modality, with comparison with carefully angled MRI scans and the use of neural structures, such as the mamillary bodies and the vascular anatomy. Pallidal target sites are chosen immediately lateral and superior to the optic tract on a line bisecting the axis of the peduncle, with macrostimulation guiding the final adjustment of target position. Forty-seven patients undergoing unilateral pallidotomies were studied in the "off" state and the "on" state using a modified Unified Rating Scale for Parkinson's disease (URSP) score and a dyskinesia scale, preoperatively and postoperatively at 2 weeks, 2 months, 6 months, and 12 months. In the 31 patients undergoing thalamotomy, tremor was rated preoperatively and postoperatively as near-complete resolution, partial resolution, and failure. The "off" state Unified Rating Scale for Parkinson's disease motor score declined from 42.0 to 32.2 at 2 weeks after surgery (P < 0.0001, n = 42). The Unified Rating Scale for Parkinson's disease motor score was 34.2 at 2 months (P < 0.0001, n = 35), 29.4 at 6 months (P < 0.0001, n = 27), and 24.9 at 12 months (P = 0.005, n = 12), representing an overall improvement in "off" state motor function of approximately 25 to 40%. The "on" state dyskinesia score fell from 5.5 to 2.0 at 2 weeks (P < 0.0001) and persisted in the later visits. The dyskinesia score for the contralateral side fell from 2.5 preoperatively to 0.26 at 2 weeks, 0.28 at 2 months, 0.22 at 6 months, and 0.0 at 12 months. Of the patients undergoing thalamotomies, 65% experienced near-complete or complete tremor resolution, 23% experienced partial tremor relief, and 13% were considered treatment failures. Stereotactic procedures for movement disorders requiring high precision can be safely and successfully performed without the use of microelectrode recording techniques. Meticulous alignment of MRI and computed tomographic scans based on visualized anatomy allows precise lesion placement and avoids the distortion inherent in MRI scans.