Murata Jun-ichi, Kitagawa Mayumi, Uesugi Haruo, Saito Hisatoshi, Iwasaki Yoshinobu, Kikuchi Seiji, Tashiro Kunio, Sawamura Yutaka
Sapporo Azabu Neurosurgical Hospital, Sapporo, Japan.
J Neurosurg. 2003 Oct;99(4):708-15. doi: 10.3171/jns.2003.99.4.0708.
Tremors, including its proximal component, are often refractory to standard thalamic surgery. In the 1960s the posterior part of the subthalamic white matter was reported to be a promising target in treating various forms of tremor, but was also found to be associated with adverse effects. Advances involving a less invasive method, that is, deep brain stimulation (DBS), has led to a reappraisal of this target.
Eight patients with severe essential tremor involving the proximal arm were treated using unilateral stimulation of the posterior part of the subthalamic white matter. The tentative target was situated in the area lateral to the red nucleus and posteromedial to the subthalamic nucleus. Macrostimulation was used to find the optimal site to suppress tremor. Through a quadripolar DBS lead, somatosensory evoked potentials (SSEPs) were recorded. Improvement of tremor was evaluated based on a modified clinical tremor rating scale. Anatomical locations of all contacts were assessed using stereotactic guidance and represented on the Schaltenbrand-Wahren atlas.
A characteristic diphasic pattern of SSEPs reaffirmed the electrophysiological endorsement of this target. Tremors, both proximal and distal, were remarkably improved in all patients. The rate of improvement, as indicated by the total tremor score, was a mean of 81%. Axial tremors in the legs and head were also improved. Most of the contacts associated with remarkable improvement were located in the posterior part of the subthalamic white matter (the zona incerta and prelemniscal radiation). Neither major complications nor neurological deterioration was observed. The authors concluded that DBS of the posterior part of the subthalamic white matter together with SSEP recording is a safe and effective method to ameliorate severe intractable tremors.
震颤，包括其近端成分，通常对标准丘脑手术难治。在20世纪60年代，据报道丘脑底白质后部是治疗各种形式震颤的一个有前景的靶点，但也发现与不良反应相关。涉及侵入性较小方法即深部脑刺激（DBS）的进展，导致对该靶点的重新评估。
8例患有累及近端手臂的严重特发性震颤患者接受了丘脑底白质后部的单侧刺激治疗。暂定靶点位于红核外侧和丘脑底核后内侧区域。使用宏观刺激来找到抑制震颤的最佳部位。通过四极DBS电极记录体感诱发电位（SSEP）。基于改良的临床震颤评分量表评估震颤的改善情况。使用立体定向引导评估所有触点的解剖位置，并在Schaltenbrand-Wahren图谱上表示。
SSEP的特征性双相模式再次证实了该靶点的电生理支持。所有患者的近端和远端震颤均有显著改善。总震颤评分显示的改善率平均为81%。腿部和头部的轴向震颤也有所改善。与显著改善相关的大多数触点位于丘脑底白质后部（未定带和丘脑前辐射）。未观察到重大并发症或神经功能恶化。作者得出结论，丘脑底白质后部的DBS联合SSEP记录是改善严重难治性震颤的一种安全有效的方法。
