Blomstedt P, Fytagoridis A, Tisch S
Department of Neurosurgery, University Hospital of Northern Sweden, Umeå, Sweden.
Acta Neurochir (Wien). 2009 Jan;151(1):31-6. doi: 10.1007/s00701-008-0163-7. Epub 2008 Dec 18.
Several studies have described lesional therapy in the posterior subthalamic area (PSA) in the treatment of various movement disorders. Recently, some publications have illustrated the effect of deep brain stimulation (DBS) in this area in patients with Parkinson's disease, essential tremor, MS-tremor, and other forms of tremor. Even though the clinical series is small, the reported benefits prompted us to explore DBS in this area in the treatment of tremor.
Five patients with tremor were operated using unilateral DBS of the PSA. Two patients had dystonic tremor, one primary writing tremor, one cerebellar tremor and the other neuropathic tremor. All patients were assessed before and 1 year after surgery using items 5 and 6 (tremor of the upper extremity), 11-14 (hand function), and when appropriate item 10 (handwriting) from the essential tremor rating scale.
The mean improvement on stimulation after 1 year was 87%. A pronounced and sustained microlesional effect was seen in several of the patients, and while the mean improvement off stimulation was 56% the reduction in the three patients with the most pronounced effect was 89%. The two patients with dystonic tremor did also become free of the dystonic symptoms and pain in the treated arm. No severe complication occurred.
DBS of the PSA in this small group of patients had an excellent effect on the different forms of tremor, except for the neuropathic tremor where the effect was moderate. These preliminary results suggest PSA to be an effective target for the treatment of various forms of tremor. Further studies concerning indications, safety and efficacy of DBS in the posterior subthalamic area are required.
多项研究描述了丘脑底后区（PSA）损伤治疗各种运动障碍的情况。最近，一些出版物阐述了帕金森病、特发性震颤、多发性硬化症震颤及其他震颤形式患者在该区域进行脑深部电刺激（DBS）的效果。尽管临床病例数较少，但所报道的益处促使我们探索在该区域进行DBS治疗震颤。
对5例震颤患者进行了PSA单侧DBS手术。2例为张力障碍性震颤，1例为原发性书写震颤，1例为小脑性震颤，另1例为神经性震颤。所有患者在手术前及术后1年使用特发性震颤评定量表的第5项和第6项（上肢震颤）、第11 - 14项（手部功能），并在适当时使用第10项（书写）进行评估。
1年后刺激时的平均改善率为87%。在数名患者中观察到明显且持续的微损伤效应，在刺激关闭时平均改善率为56%，而3例效果最显著的患者改善率降低了89%。2例张力障碍性震颤患者治疗侧手臂的张力障碍症状和疼痛也消失了。未发生严重并发症。
在这一小群患者中，PSA的DBS对不同形式的震颤有极佳效果，但对神经性震颤效果中等。这些初步结果表明PSA是治疗各种形式震颤的有效靶点。需要进一步研究DBS在丘脑底后区的适应证、安全性和有效性。
