Mann J M, Foote K D, Garvan C W, Fernandez H H, Jacobson C E, Rodriguez R L, Haq I U, Siddiqui M S, Malaty I A, Morishita T, Hass C J, Okun M S
Department of Neurology, University of Florida College of Medicine/Shands Hospital, Movement Disorders Center, McKnight Brain Institute, Gainesville, Florida 32610, USA.
J Neurol Neurosurg Psychiatry. 2009 Jul;80(7):794-7. doi: 10.1136/jnnp.2008.159558. Epub 2009 Feb 22.
To determine how intraoperative microelectrode recordings (MER) and intraoperative lead placement acutely influence tremor, rigidity, and bradykinesia. Secondarily, to evaluate whether the longevity of the MER and lead placement effects were influenced by target location (subthalamic nucleus (STN) or globus pallidus interna (GPi)).
Currently most groups who perform deep brain stimulation (DBS) for Parkinson disease (PD) use MER, as well as macrostimulation (test stimulation), to refine DBS lead position. Following MER and/or test stimulation, however, there may be a resultant "collision/implantation" or "microlesion" effect, thought to result from disruption of cells and/or fibres within the penetrated region. These effects have not been carefully quantified.
47 consecutive patients with PD undergoing unilateral DBS for PD (STN or GPi DBS) were evaluated. Motor function was measured at six time points with a modified motor Unified Parkinson Disease Rating Scale (UPDRS): (1) preoperatively, (2) immediately after MER, (3) immediately after lead implantation/collision, (4) 4 months following surgery-off medications, on DBS (12 h medication washout), (5) 6 months postoperatively-off medication and off DBS (12 h washout) and (6) 6 months-on medication and off DBS (12 h washout).
Significant improvements in motor scores (p<0.05) (tremor, rigidity, bradykinesia) were observed as a result of MER and lead placement. The improvements were similar in magnitude to what was observed at 4 and 6 months post-DBS following programming and medication optimisation. When washed out (medications and DBS) for 12 h, UPDRS motor scores were still improved compared with preoperative testing. There was a larger improvement in STN compared with GPi following MER (p<0.05) and a trend for significance following lead placement (p<0.08) but long term outcome was similar.
This study demonstrated significant acute intraoperative penetration effects resulting from MER and lead placement/collision in PD. Clinicians rating patients in the operating suite should be aware of these effects, and should consider pre- and post-lead placement rating scales prior to activating DBS. The collision/implantation effects were greater intraoperatively with STN compared with GPi, and with greater disease duration there was a larger effect.
确定术中微电极记录（MER）和术中电极植入如何急性影响震颤、僵直和运动迟缓。其次，评估MER和电极植入效果的持续时间是否受靶点位置（丘脑底核（STN）或内侧苍白球（GPi））的影响。
目前，大多数为帕金森病（PD）患者进行深部脑刺激（DBS）的团队使用MER以及宏观刺激（测试刺激）来优化DBS电极位置。然而，在MER和/或测试刺激之后，可能会产生一种“碰撞/植入”或“微损伤”效应，被认为是由穿透区域内的细胞和/或纤维破坏所致。这些效应尚未得到仔细量化。
对47例连续接受单侧DBS治疗PD（STN或GPi DBS）的患者进行评估。使用改良的运动统一帕金森病评定量表（UPDRS）在六个时间点测量运动功能：（1）术前，（2）MER后即刻，（3）电极植入/碰撞后即刻，（4）术后4个月停药、开启DBS时（药物洗脱12小时），（5）术后6个月停药且关闭DBS时（洗脱12小时），以及（6）术后6个月服药且关闭DBS时（洗脱12小时）。
观察到MER和电极植入后运动评分（p<0.05）（震颤、僵直、运动迟缓）有显著改善。改善程度与DBS编程和药物优化后4个月及6个月时观察到的相似。当停药（药物和DBS）12小时后，与术前测试相比，UPDRS运动评分仍有改善。MER后STN组的改善比GPi组更大（p<0.05），电极植入后有显著趋势（p<0.08），但长期结果相似。
本研究表明，PD患者术中MER和电极植入/碰撞会产生显著的急性穿透效应。在手术室对患者进行评分的临床医生应了解这些效应，并应在开启DBS之前考虑电极植入前后的评分量表。与GPi相比，STN术中的碰撞/植入效应更大，且病程越长，效应越大。
