Posteroventral Medial Pallidotomy in Advanced Parkinson's Disease

Lang, Anthony E.; Lozano, Andrés M.; Montgomery, Erwin B.; Duff, J.; Tasker, Ronald R.; Hutchinson, W. B.

doi:10.1056/nejm199710093371503

Cited by 422 publications

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“…Side effects were rather mild in our sample, although only the Mini-Mental Status Examination and the confrontation method of testing visual fields were performed to detect the abnormalities reported with pallidotomies 4,[30][31][32][33][34] . The only patient with dysarthric speech was already with that deficit before the procedure (Case 2).…”

Section: Discussionmentioning

confidence: 99%

“…The growing experience with pallidal lesions for Parkinson's disease shows frequent improvement of all kind of dyskinesias/dystonias, including the ones not related to L-Dopa therapy [3][4][5][6][7][8][9][10][11] . These findings, along with some recent reports of marked improvement in medically refractory dystonias prompted us to evaluate the effectiveness of this procedure in a group of selected patients [12][13][14][15][16] .…”

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confidence: 99%

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Bilateral pallidotomy for generalized dystonia

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et al. 2001

Arq. Neuro-Psiquiatr.

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-Objective: To evaluate the efficacy and safety of bilateral pallidotomies in five patients with generalized dystonia. Background: Generalized dystonias are frequently a therapeutic challenge, with poor responses to pharmacological treatment. GPi (globus pallidus internus) pallidotomies for Parkinson's disease ameliorate all kinds of dyskinesias/dystonia, and recent studies reported a marked improvement of refractory dystonias with this procedure. Methods: Five patients with generalized dystonias refractory to medical treatment were selected; one posttraumatic and four idiopathic. The decision to perform bilateral procedures was based on the predominant axial involvement in these patients. Dystonia severity was assessed with the Burke-FahnMarsden Dystonia Scale (BFM). Simultaneous procedures were performed in all but one patient, who had a staged procedure. They were reevaluated with the same scale (BFM) by an unblinded rater at 1, 2, 3, 30, 60, 90, 120 and 180 days post-operatively. Results: The four patients with idiopathic dystonia showed a progressive improvement up to three months; the patient with posttraumatic dystonia relapsed at three months. One patient had a marked improvement, being able to discontinue all the medications. A mean decrease in the BFM scores of 52,58% was noted. One patient had a trans-operative motor seizure followed by a transient hemiparesis secondary to rack hemorrhage; other was lethargic up to three days after the procedure. Conclusions: Our results show that bilateral GPi pallidotomies may be a safe and effective approach to medically refractory generalized dystonias; it can also be speculated that the posttraumatic subgroup may not benefit with this procedure.KEY WORDS: dystonia, pallidotomy, stereotactic surgery. Palidotomia bilateral para distonias generalizadasRESUMO -As distonias generalizadas são freqüentemente um desafio terapêutico, com pobres respostas aos tratamentos farmacológicos. As cirurgias estereotáxicas, como a palidotomia, têm sido utilizadas com êxito no tratamento da doença de Parkinson e estudos recentes relatam importante melhora das distonias generalizadas, refratárias ao tratamento farmacológico, com a palidotomia bilateral. O objetivo dos autores foi avaliar a eficácia e segurança da palidotomia bilateral em cinco pacientes com distonia generalizada. Foram selecionados cinco pacientes com distonia generalizada, predominante axial, refratários ao tratamento farmacológico (quatro idiopáticas e uma pós-traumática). A severidade da distonia foi avaliada através da escala de Burke-Fahn-Marsden (BFM), no 1º, 2º, e 3º dia após a cirurgia e nos dias 30, 60, 90, 120 e 180 do pós-operatório. Quatro pacientes com distonia idiopática tiveram uma progressiva melhora dentro de 3 meses após a cirurgia e o paciente com distonia pós-traumática teve uma piora da distonia após 3 meses da cirurgia. Um dos pacientes teve uma melhora acentuada do quadro de distonia, ficando livre das medicações. Em média ocorreu redução de 52,58 % dos escores da escala de BFM. Um dos...

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Bilateral pallidotomy for generalized dystonia

Teive

Sá

Grande

et al. 2001

Arq. Neuro-Psiquiatr.

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“…The reports of the pre-levodopa era [2][3][4] used nonvalidated methods of assessment, and those patients presented a different clinical profile when compared to the patients of the levodopa era. More recent studies [5][6][7][8][9][10][11][12][13][14][15][16] present different methods of assessment, leading to different conclusions.…”

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confidence: 99%

Motor performance after posteroventral pallidotomy and VIM-thalamotomy in Parkinson's disease: a 1-year follow-up study

Aguiar

Ferraz

et al. 2000

Arq. Neuro-Psiquiatr.

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-Twenty-three patients with Parkinson's disease underwent stereotactic surgery. To study the long-term motor performance, the patients were evaluated at the pre-operative period and at the 1 st , 3 rd , 6 th , and 12 th post-operative months, with the following scales: Unified Parkinson's Disease Rating Scale (UPDRS) motor score and Larsen's Scale for Dyskinesias. The patients under levodopa therapy were assessed both in "on" and "off" periods. Fourteen unilateral ventrolateral thalamotomies (VLT), 4 unilateral posteroventral pallidotomies (PVP), 2 bilateral PVP, and 3 VLT with contralateral PVP were performed. The motor improvement was significant and long-lasting in the "off" period, except for 2 patients. The "on" period quality improved, mainly due to the control of dyskinesias. The improvement of dyskinesias was long-lasting for the majority of the patients. There was no significant decrease in the levodopa dose. Three patients showed permanent complications, but none was severe.KEY WORDS: Parkinson's disease, thalamotomy, pallidotomy.Desempenho motor após palidotomia póstero-ventral e talamotomia ventro-lateral na doença de Parkinson: acompanhamento de um ano RESUMO -Vinte e três pacientes portadores de doença de Parkinson foram submetidos a cirurgia estereotáxica para tratamento da doença. Com o objetivo de estudar o desempenho motor a longo prazo, os pacientes foram avaliados clinicamente no período pré-operatório, no 1°, 3°, 6°, e 12° mês pós-operatório, com as seguintes escalas: Escala Unificada para Doença de Parkinson (Unified Parkinson's Disease Rating Scale-UPDRS), item III, escore motor e com a Escala de Larsen para Discinesias. Os pacientes que utilizavam levodopa foram avaliados nos estados "off" e "on". Foram realizadas 14 talamotomias ventro-laterais (TVL) unilaterais, 4 palidotomias póstero-ventrais (PPV) unilaterais, 2 PPV bilaterais; 3 TVL associadas à PPV contralateral. O benefício motor foi observado de forma significante no estado "off", e manteve-se a longo prazo na maioria dos pacientes, exceto em 2. Houve melhora da qualidade do período "on", devido ao controle das discinesias. A melhora das discinesias se manteve a longo prazo na maioria dos pacientes. As cirurgias não promoveram um decréscimo significante na dose de levodopa.Três pacientes tiveram complicações permanentes, mas nenhuma delas foi considerada grave e nem houve prejuízo funcional importante em decorrência das mesmas. PALAVRAS-CHAVE: doença de Parkinson, talamotomia, palidotomia.Levodopa remains the goldstandard treatment for patients with Parkinson's disease (PD). However, after some years, part of these patients develop complications related to the prolonged use of the drug, such as fluctuations and disabling dyskinesias 1 . In the absence of satisfactory pharmacological therapy, there has been a resurgence of interest for stereotactic surgery in the last

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“…Firing pattern changes in the subthalamic nucleus (STN) and the basal ganglia output nuclei, the internal segment of the globus pallidus (GPi) and substantia nigra pars reticulata (SNpr), appear especially relevant to PD symptomatology. This is evidenced by the efficacy of STN and GPi lesion and deep brain stimulation treatments in advanced PD, procedures that eliminate or modify STN and GPi output (Baron et al, 1996;Gill and Heywood, 1997;Lang et al, 1997;Limousin et al, 1998;Krack et al, 2000;Lozano, 2001;Obeso et al, 2001;Benabid, 2003).The symptomatological relief associated with these therapies supports the idea that dopamine cell death triggers alterations in STN and GPi/SNpr activity that exert dysfunctional effects on downstream nuclei and contribute to the disabilities of PD.Animal models of PD provide an opportunity to explore the effect of dopamine cell loss on firing patterns in individual basal ganglia nuclei. In addition, they provide an opportunity to examine relationships between interconnected nuclei to gain insight into the extent to which firing pattern changes in individual nuclei are linked to broader changes engaging the entire basal ganglia network.…”

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Phase relationships support a role for coordinated activity in the indirect pathway in organizing slow oscillations in basal ganglia output after loss of dopamine

et al. 2007

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The goal of the present study was to determine the phase relationships of the slow oscillatory activity that emerges in basal ganglia nuclei in anesthetized rats after dopamine cell lesion in order to gain insight into the passage of this oscillatory activity through the basal ganglia network. Spike train recordings from striatum, subthalamic nucleus (STN), globus pallidus (GP), and substantia nigra pars reticulata (SNpr) were paired with simultaneous local field potential (LFP) recordings from SNpr or motor cortex ipsilateral to a unilateral lesion of substantia nigra dopamine neurons in urethane anesthetized rats. Dopamine cell lesion induced a striking increase in incidence of slow oscillations (0.3-2.5 Hz) in firing rate in all nuclei. Phase relationships assessed through paired recordings using SNpr LFP as a temporal reference showed that slow oscillatory activity in GP spike trains is predominantly antiphase with oscillations in striatum, and slow oscillatory activity in STN spike trains is in-phase with oscillatory activity in cortex but predominantly antiphase with GP oscillatory activity. Taken together, these results imply that after dopamine cell lesion in urethane anesthetized rats, increased oscillatory activity in GP spike trains is shaped more by increased phasic inhibitory input from the striatum than by phasic excitatory input from STN. In addition, results show that oscillatory activity in SNpr spike trains is typically antiphase with GP oscillatory activity and in-phase with STN oscillatory activity. While these observations do not rule out additional mechanisms contributing to the emergence of slow oscillations in the basal ganglia after dopamine cell lesion in the anesthetized preparation, they are compatible with 1) increased oscillatory activity in the GP facilitated by an effect of dopamine loss on striatal 'filtering' of slow components of oscillatory cortical input, 2) increased oscillatory activity in STN spike trains supported by convergent antiphase inhibitory and excitatory oscillatory input from GP and cortex, respectively, and 3) increased oscillatory activity in SNpr spike trains organized by convergent antiphase inhibitory and excitatory oscillatory input from GP and STN, respectively. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errorsmaybe discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. NIH Public Access Author ManuscriptNeuroscience. Author manuscript; available in PMC 2012 May 17. NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript KeywordsParkinson's disease; subthalamic nucleus; substantia nigra; globus pallidus; striatum; bursting; local field potentials Dopa...

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Posteroventral Medial Pallidotomy in Advanced Parkinson's Disease

Cited by 422 publications

References 20 publications

Bilateral pallidotomy for generalized dystonia

Bilateral pallidotomy for generalized dystonia

Motor performance after posteroventral pallidotomy and VIM-thalamotomy in Parkinson's disease: a 1-year follow-up study

Phase relationships support a role for coordinated activity in the indirect pathway in organizing slow oscillations in basal ganglia output after loss of dopamine

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