Brain, Vol 121, Issue 1 59-75, Copyright © 1998 by Oxford University Press
M Samuel, E Caputo, DJ Brooks, A Schrag, T Scaravilli, NM Branston, JC Rothwell, CD Marsden, DG Thomas, AJ Lees and NP Quinn
We have studied the effects of unilateral ventral medial pallidotomy in 26
patients with medically intractable Parkinson's disease with marked
drug-induced dyskinesias. Preoperatively, all patients were assessed during
one 5-day admission according to the Core Assessment Programme for
Intracerebral Transplantation (CAPIT) protocol, including rating in the
'practically defined off' and 'best on' states before and during a
single-dose levodopa challenge. Motor performance was assessed with subset
categories of the Unified Parkinson's Disease Rating Scale (UPDRS), timed
motor tests and a standard dyskinesia rating scale. Pallidotomy was
performed under stereotaxic CT guidance with intra- operative extracellular
microelectrode recording made from the basal ganglia. All patients were
re-assessed 3 months postoperatively and a subgroup (n = 9) have so far
also been re-assessed after 1 year. Pre- and postoperative performance
scores were compared in order to determine which categories of performance
improved postoperatively. Significance was accepted at P < 0.005 in
order to take into account the multiple number of comparisons performed.
Patient medication was compared pre- and postoperatively and the morbidity
associated with surgery was also recorded. The most significant improvement
postoperatively was the diminution of 'on' dyskinesias contralaterally
(67%, P = 0.0001); however, ipsilateral (45%, P = 0.0006) and axial (50%, P
= 0.0008) dyskinesias also improved. Contralateral to pallidotomy, the
median 'off' motor UPDRS score improved by 27% (P = 0.001) and a
significant improvement was also observed in contralateral rigidity by 25%
(P = 0.001). There were trends towards improvement in contralateral tremor
(33%, P = 0.016) and bradykinesia (24%, P = 0.013) scores. Ipsilateral
rigidity improved by 22% (P = 0.005), but other ipsilateral motor scores
did not alter significantly. The 'off' gait/postural instability score and
'off' walking time showed marginally significant improvements by 7% (P =
0.007) and 29% (P = 0.014), respectively. On medication, no significant
postoperative improvements in parkinsonism were detected. Anti-parkinsonian
medication increased by 11% postoperatively. In the subgroup who were
available for assessment 1 year postoperatively, responses were generally
maintained. Two (7.7%) of the 26 patients had fatal complications (one
cerebral haemorrhage and one haemorrhagic infarct) directly related to
surgery. Among the remaining 24 patients, four (15.4% of the total 26) had
major complications (two persisting and two transient). Ten patients
(38.5%) had minor complications. The majority of the complications (major
and minor) occurred in the earlier operated patients and the complication
rate subsequently declined with increasing operative experience. The
remaining 10 patients (38.5%) had no significant side-effects. One of these
10 patients died from an incidental malignant glioma 6 months
postoperatively. These findings confirm that levodopa-induced dyskinesias
are dramatically reduced following ventral medial pallidotomy and
constitute the principal indication for pallidotomy. Improvements in
underlying parkinsonism were of smaller magnitude. Pallidotomy may also
offer some patients an opportunity to increase antiparkinsonian medication.
Patient selection for medial pallidotomy should, therefore, be based
largely on anticipated improvements in levodopa-induced dyskinesias, but
this must be balanced against the associated morbidity and mortality.
ARTICLES
A study of medial pallidotomy for Parkinson's disease: clinical outcome, MRI location and complications
MRC Cyclotron Unit, Hammersmith Hospital, London, UK.
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