Pallidal stimulation as treatment for camptocormia in Parkinson’s disease

Abstract

Camptocormia is a common and often debilitating postural deformity in Parkinson’s disease (PD). Few treatments are currently effective. Deep brain stimulation (DBS) of the globus pallidus internus (GPi) shows potential in treating camptocormia, but evidence remains limited to case reports. We herein investigate the effect of GPi-DBS for treating camptocormia in a retrospective PD cohort. Thirty-six consecutive PD patients who underwent GPi-DBS were reviewed. The total and upper camptocormia angles (TCC and UCC angles) derived from video recordings of patients who received GPi-DBS were used to compare camptocormia alterations. Correlation analysis was performed to identify factors associated with the postoperative improvements. DBS lead placement and the impact of stimulation were analyzed using Lead-DBS software. Eleven patients manifested pre-surgical camptocormia: seven had lower camptocormia (TCC angles ≥ 30°; TCC-camptocormia), three had upper camptocormia (UCC angles ≥ 45°; UCC-camptocormia), and one had both. Mean follow-up time was 7.3 ± 3.3 months. GPi-DBS improved TCC-camptocormia by 40.4% (angles from 39.1° ± 10.1° to 23.3° ± 8.1°, p = 0.017) and UCC-camptocormia by 22.8% (angles from 50.5° ± 2.6° to 39.0° ± 6.7°, p = 0.012). Improvement in TCC angle was positively associated with pre-surgical TCC angles, levodopa responsiveness of the TCC angle, and structural connectivity from volume of tissue activated to somatosensory cortex. Greater improvement in UCC angles was seen in patients with larger pre-surgical UCC angles. Our study demonstrates potential effectiveness of GPi-DBS for treating camptocormia in PD patients. Future controlled studies with larger numbers of patients with PD-related camptocormia should extend our findings.

Deep brain stimulation in the subthalamic nuclei alters postural alignment and adaptation in Parkinson’s disease

“…There is also an argument over the effectiveness of DBS in the STN vs. Globus Pallidus internus (GPi). In a case study of two patients with near crippling camptocormia (a trunk flexion exceeding 30° [ 39 ]), GPi DBS completely reversed the camptocormia and restored posture to normal [ 40 ]. Furthermore, in a small study of three patients with PD, two with bilateral DBS in the STN and one with bilateral GPi DBS, no or mild improvement of trunk flexion was seen in the two patients with DBS in the STN but a moderate improvement was seen in the patient with GPi DBS [ 41 ].…”

Deep brain stimulation for Parkinson’s disease–related postural abnormalities: a systematic review and meta-analysis

“…The included studies have been conducted between 2003 and 2021. Regarding study designs, nine case reports [ 5 , 13 , 17 – 20 , 23 , 25 , 28 ] (i.e., 50%), four case series [ 14 , 16 , 22 , 26 ] (i.e., 22.2%), three retrospective observational cohort studies [ 21 , 24 , 30 ] (i.e., 16.6%), one review article including two reported cases [ 27 ] (i.e., 5.6%), and one prospective trial [ 29 ] (i.e., 5.6%) were assessed. Fifteen studies [ 13 , 14 , 16 – 21 , 25 , 27 – 30 , 32 ] reported follow-up data with a mean follow-up time of 21.5 months (range 5–67 months).…”

“…(1) Five studies reported clinical outcomes by standardized scores (i.e., Visual Analogue Scale [VAS] [ 16 , 24 ], Burke-Fahn-Mardsen Dystonia Rating Scale |BFM-RS] [ 16 , 17 ], S-LANNS Score [ 17 ], Schwab-England activity of daily living scale [S-E] [ 29 ], and special consideration of Unified Disease Parkinson Rating Scale [UPDRS]-III item 28 score [ 26 ]), four studies anecdotally reported the clinical outcome without standardizes scores [ 13 , 18 , 19 , 27 ], and nine studies did not take the clinical course into account. (2) Changes of the sagittal thoraco-lumbar angle (TLA) (or shoulder-hip knee and head-shoulder-hip angle) assessed by photographs were assessed in 13 (i.e., 72,2%) studies [ 5 , 14 , 17 , 19 – 25 , 28 – 30 ], with outcome parameter either defined as improvement in case of > 50% relative reduction of the TLA or as absolute value < 30° of the TLA at last follow-up (Table 1 ). Two studies further distinguished improvement as effective and partially effective: in Sakai et al, partially effective was defined when the TLA became < 30° after DBS but did not last for > 6 months [ 21 ].…”

“…However, the results of spinal surgery for degenerative spinal conditions in patients with PD are disappointing with failure rates of 25.8-100% [8][9][10][11][12]. As an alternative treatment strategy for the underlying pathomechanism, some authors have described the influence of deep brain stimulation on PD-related postural abnormalities [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30]. We aim to present a systematical review of the current literature.…”

“…Summary of preliminary data resultsFig.1PRISM flowchart of the study selection process were assessed in 13 (i.e., 72,2%) studies[5,14,17,[19][20][21][22][23][24][25][28][29][30], with outcome parameter either defined as improvement in case of > 50% relative reduction of the TLA or as absolute value < 30° of the TLA at last follow-up (Table1). Two studies further distinguished improvement as effective and partially effective: in Sakai et al, partially effective was defined when the TLA became < 30° after DBS but did not last for > 6 months[21].…”