Alvarez L, Macias R, Lopez G, Alvarez E, Pavon N, Rodriguez-Oroz M C, Juncos J L, Maragoto C, Guridi J, Litvan I, Tolosa E S, Koller W, Vitek J, DeLong M R, Obeso J A
Movement Disorders and Neurophysiology Units, Centro Internacional de Restauracion Neurologica (CIREN), La Habana, Cuba.
Brain. 2005 Mar;128(Pt 3):570-83. doi: 10.1093/brain/awh397. Epub 2005 Feb 2.
We conducted an open label pilot study of the effect of bilateral subthalamotomy in 18 patients with advanced Parkinson's disease. In seven patients, the first subthalamotomy pre-dated the second by 12-24 months ('staged surgery'). Subsequently, a second group of 11 patients received bilateral subthalamotomy on the same day ('simultaneous surgery'). Patients were assessed according to the CAPIT (Core Assessment Program for Intracerebral Transplantation) protocol, a battery of timed motor tests and neuropsychological tests. Evaluations were performed in the 'off' and 'on' drug states before surgery and at 1 and 6 months and every year thereafter for a minimum of 3 years after bilateral subthalamotomy. Compared with baseline, bilateral subthalamotomy induced a significant (P < 0.001) reduction in the 'off' (49.5%) and 'on' (35.5%) Unified Parkinson's Disease Rating Scale (UPDRS) motor scores at the last assessment. A blind rating of videotape motor exams in the 'off' and 'on' medication states preoperatively and at 2 years postoperatively also revealed a significant improvement. All of the cardinal features of Parkinson's disease as well as activities of daily living (ADL) scores significantly improved (P < 0.01). Levodopa-induced dyskinesias were reduced by 50% (P < 0.01), and the mean daily levodopa dose was reduced by 47% at the time of the last evaluation compared with baseline (P < 0.0001). Dyskinesias occurred intraoperatively or in the immediate postoperative hours in 13 patients, but were generally mild and short lasting. Three patients developed severe generalized chorea that gradually resolved within the next 3-6 months. Three patients experienced severe and persistent postoperative dysarthria. In two, this coincided with the patients exhibiting large bilateral lesions also suffering from severe dyskinesias. No patient exhibited permanent cognitive impairment. The motor benefit has persisted for a follow-up of 3-6 years. This study indicates that bilateral subthalamotomy may induce a significant and long-lasting improvement of advanced Parkinson's disease, but the clinical outcome was variable. This variability may depend in large part on the precise location and volume of the lesions. Further refinement of the surgical procedure is mandatory.
我们对18例晚期帕金森病患者进行了一项关于双侧丘脑底核切开术效果的开放标签试验性研究。其中7例患者，第一次丘脑底核切开术比第二次早12 - 24个月（“分期手术”）。随后，另一组11例患者在同一天接受了双侧丘脑底核切开术（“同期手术”）。根据CAPIT（脑内移植核心评估方案）协议、一系列定时运动测试和神经心理学测试对患者进行评估。在手术前、术后1个月和6个月以及此后每年，在“关”和“开”药状态下进行评估，双侧丘脑底核切开术后至少持续3年。与基线相比，在最后一次评估时，双侧丘脑底核切开术使“关”期（49.5%）和“开”期（35.5%）的统一帕金森病评定量表（UPDRS）运动评分显著降低（P < 0.001）。对术前以及术后2年“关”和“开”药状态下的录像运动检查进行盲法评分，也显示出显著改善。帕金森病的所有主要特征以及日常生活活动（ADL）评分均显著改善（P < 0.01）。左旋多巴诱发的异动症减少了50%（P < 0.01），与基线相比，最后一次评估时左旋多巴的日均剂量减少了47%（P < 0.0001）。13例患者在术中或术后即刻出现异动症，但通常较轻且持续时间短。3例患者出现严重的全身性舞蹈症，在接下来的3 - 6个月内逐渐缓解。3例患者出现严重且持续的术后构音障碍。其中2例患者出现双侧大病灶并伴有严重异动症。没有患者出现永久性认知障碍。运动益处持续了3 - 6年的随访期。这项研究表明，双侧丘脑底核切开术可能会使晚期帕金森病得到显著且持久的改善，但临床结果存在差异。这种差异可能在很大程度上取决于病灶的精确位置和体积。手术操作的进一步优化是必要的。
