Tasker R R
Department of Surgery, University of Toronto, Ontario, Canada.
Neurosurg Clin N Am. 1990 Oct;1(4):841-64.
Despite astounding progress in the biochemical management of Parkinson's disease in particular and of other movement disorders, there are still patients disabled by severe tremor and not by bradykinesia in whom thalamotomy remains the treatment of choice. Though the irreducible complications of surgery must be taken into account, the problems of prolonged multiple drug therapy should not be ignored. The same rationale applies to selected patients with essential or familial tremor. For some patients with ataxic tremor caused by multiple sclerosis and other brain lesions, or with dystonia or, rarely, other movement disorders, thalamotomy may offer limited though significant relief from an otherwise intractable disability. Indications for the use of stereotactic destructive lesions in the treatment of nociceptive pain in those cases where cordotomy and intraspinal morphine infusion are unsuitable have contracted with the introduction of lower-risk alternatives such as intraventricular morphine instillation. When destructive lesions are indicated, the choice will lie between mesencephalic tractotomy, with its higher success rate but irreducible mortality and morbidity, and medial thalamotomy, which, though less risky, is also less effective. For central and deafferentation pain, the same two procedures may be considered. However, destructive lesions are seldom effective for the treatment of the most common element of these pain syndromes: steady burning or dysesthetic pain. They may be more promising, though, for the intermittent, often shooting pain and the evoked elements (hyperpathia and allodynia) of central and deafferentation pain. Even so, it is advisable first to carry out a trial of VC and PVG stimulation before considering a destructive lesion, which should be a last resort.
尽管在帕金森病及其他运动障碍的生化治疗方面取得了惊人进展，但仍有一些患者因严重震颤而非运动迟缓而致残，丘脑切开术仍是他们的首选治疗方法。虽然必须考虑到手术不可避免的并发症，但长期多种药物治疗的问题也不应被忽视。同样的道理也适用于某些特发性或家族性震颤患者。对于一些由多发性硬化症和其他脑部病变引起的共济失调性震颤患者，或患有肌张力障碍或极少情况下患有其他运动障碍的患者，丘脑切开术可能会从原本难以治疗的残疾中提供有限但显著的缓解。在脊髓切开术和脊髓内吗啡输注不合适的情况下，立体定向毁损性病变用于治疗伤害性疼痛的适应证随着脑室内吗啡滴注等低风险替代方法的引入而有所收缩。当需要进行毁损性病变时，选择将介于中脑束切断术（成功率较高但死亡率和发病率不可降低）和内侧丘脑切开术（虽然风险较小，但效果也较差）之间。对于中枢性和去传入性疼痛，也可考虑这两种手术。然而，毁损性病变很少能有效治疗这些疼痛综合征最常见的症状：持续的灼痛或感觉异常性疼痛。不过，对于间歇性、常呈刺痛的疼痛以及中枢性和去传入性疼痛的诱发因素（痛觉过敏和感觉异常），它们可能更有前景。即便如此，在考虑进行毁损性病变之前，最好先进行Vim和PVG刺激试验，毁损性病变应作为最后的手段。
