Long-term benefit of bilateral subthalamic deep brain stimulation on camptocormia in parkinson’s disease

Abstract

We report the case of a 63-year-old female with a long history of severe Parkinson's disease (PD) and subsequent onset of debilitating camptocormia who underwent successful bilateral subthalamic nucleus deep brain stimulation surgery (STN DBS). The literature and previous reports are reviewed. The patient history and details of the surgical procedure are reported including the implantable pulse generator (IPG) settings and response to stimulation. The results of her PD symptom and camptocormia improvements are discussed. Five year postoperatively, the patient has enjoyed good results for both her PD symptoms as well as significant and sustained improvement in her thoracolumbar flexion deformity. She remains on minimal medications and no longer requires any assistive devices for ambulation. Comparison and contrast of the current world literature on DBS for camptocormia is reviewed. We discuss the current targets used for DBS in the setting of camptocormia in the cases reported, both PD associated and not associated. The optimal target has yet to be defined and further work on appropriate patient selection is needed. ÖZUzun süredir şiddetli Parkinson hastalığı (PH) ve yakın zamanda maluliyete neden olan kamptokormisi olan ve bilateral subtalamik nükleus derin beyin stimülasyon cerrahisinin (STN DBS) başarıyla yapıldığı 63 yaşında bir kadın hastayı sunuyoruz. Literatür ve önceki raporlar gözden geçirilmektedir. Hasta öyküsü ve implante edilen puls jeneratörü (IPG) ayarları ve stimülasyona cevap dahil olmak üzere cerrahi işlem ayrıntıları bildirilmiştir. PD belirtilerinin sonuçları ve kamptokormideki gelişmeler anlatılmaktadır. Ameliyattan beş yıl sonra hasta halen PD belirtileri açısından iyi sonuçlar ve torakolumbar fleksiyon deformitesinde önemli ve uzun süreli iyileşme mevcuttu. Hasta çok az sayıda ilaç kullanmakta ve artık ambulasyon için yardımcı cihazlara gereksinim duymamaktadır. Kamptokormi için DBS konusunda mevcut dünya literatürü bilgileri karşılaştırılmış ve değerlendirilmektedir. Bildirilen vakalarda PD ile ilişkili olsun veya olmasın kamptokormi durumunda DBS için kullanılan mevcut hedefleri gözden geçiriyoruz. Optimum hedefin halen tanımlanması gerekmektedir ve uygun hasta seçimi açısından hâlâ yapılması gerekenler vardır.

Effects of Deep Brain Stimulation on Postural Trunk Deformities: A Systematic Review

“…These three studies report comparisons of pre‐ and postsurgical means, but individual patient data are not available . Of the remaining 35 articles, there were three additional retrospective cohort studies, 12 case series with sample sizes of up to 25 patients, and 20 case reports …”

“…Outcome measures were also variable. Most articles reported postural abnormalities as qualitative clinical observations . Some of them provided figure(s) and/or video(s) allowing for a semiquantitative estimation of the corresponding postural angles .…”

Subthalamic nucleus stimulation improves Parkinson's disease-associated camptocormia in parallel to its preoperative levodopa responsiveness

“…Although no such cases were included in our study, we cannot deny that this exceptional type of camptocormia contradicts our hypothesis that postoperative camptocormia improvement parallels its levodopa responsiveness. Lyons et al 30 reported a patient with PD with levodopa-unresponsive camptocormia that showed prolonged improvement after STN stimulation. Their patient's preoperative daily antiparkinsonian medication (500/125 mg levodopa/carbidopa, 4 mg pergolide and 200 mg amantadine) was reduced to only 100/25 mg of levodopa/carbidopa 5 years after surgery.…”

Camptocormia in Parkinson's disease: definition, epidemiology, pathogenesis and treatment modalities

“…857 Third, there have been a few cases showing that camptocormic symptoms could be reversed following levodopa. 6369 Fourth, camptocormic symptoms were also improved by high-frequency subthalamic nucleus 1970–75 or globus pallidus interna deep brain stimulation 7677 (STN or GPi-DBS) together with improved motor symptoms in patients with PD. The argument against this idea is that most cases of camptocormia in PD did not respond to either levodopa 858 or DBS.…”

“…The time of last follow-up ranged from 6 to 60 months after surgery. In PD with camptocormia, STN-DBS 10195870–7578102 and GPi-DBS 1976–78 have both been used. The details of studies of DBS in PD with camptocormia are summarised in table 3.…”