Abstract
One of the main indications for stereotactic surgery in Parkinson’s disease (PD) is the control of levodopa-induced dyskinesia. This can be achieved by pallidotomy and globus pallidus internus (GPi) deep brain stimulation (DBS) or by subthalamotomy and subthalamic nucleus (STN) DBS, which usually allow for a cut down in the dosage of levodopa. DBS has assumed a pivotal role in stereotactic surgical treatment of PD and, in fact, ablative procedures are currently considered surrogates, particularly when bilateral procedures are required, as DBS does not produce a brain lesion and the stimulator can be programed to induce better therapeutic effects while minimizing adverse effects. Interventions in either the STN and the GPi seem to be similar in controlling most of the other motor aspects of PD, nonetheless, GPi surgery seems to induce a more particular and direct effect on dyskinesia, while the anti-dyskinetic effect of STN interventions is mostly dependent on a reduction of dopaminergic drug dosages. Hence, the si ne qua non-condition for a reduction of dyskinesia when STN interventions are intended is their ability to allow for a reduction of levodopa dosage. Pallidal surgery is indicated when dyskinesia is a dose-limiting factor for maintaining or introducing higher adequate levels of dopaminergic therapy. Also medications used for the treatment of PD may be useful for the improvement of several non-motor aspects of the disease, including sleep, psychiatric, and cognitive domains, therefore, dose reduction of medication withdrawal are not always a fruitful objective.
Highlights
Treatment of levodopa-induced dyskinesia (LID) is one of the most common indications for stereotactic surgery in Parkinson’s disease (PD)
One of the main indications for stereotactic surgery in Parkinson’s disease (PD) is the control of levodopa-induced dyskinesia. This can be achieved by pallidotomy and globus pallidus internus (GPi) deep brain stimulation (DBS) or by subthalamotomy and subthalamic nucleus (STN) DBS, which usually allow for a cut down in the dosage of levodopa
Interventions in either the STN and the GPi seem to be similar in controlling most of the other motor aspects of PD, GPi surgery seems to induce a more particular and direct effect on dyskinesia, while the anti-dyskinetic effect of STN interventions is mostly dependent on a reduction of dopaminergic drug dosages
Summary
Treatment of levodopa-induced dyskinesia (LID) is one of the most common indications for stereotactic surgery in Parkinson’s disease (PD). As early as the 50s, the inner segment of the GPi and the ansa lenticularis has been the common choice for functional neurosurgeons [2] This approach was advocated and further reinforced following the observation that ligation of the anterior choroidal artery, performed for the treatment of accidental bleeding in a PD patient, resulted in relief of tremor [3, 4]. As this technique (ansa – pallidotomy) became more widely utilized, the results for tremor control were mixed, despite the good outcome for rigidity. Thalamotomy was revived, and, in addition to improvements in the motor aspects of PD, several authors reported drastic suppression of LID [9]
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