Kumar R, Lozano A M, Montgomery E, Lang A E
Division of Neurology, The Toronto Hospital, Ontario, Canada.
Mov Disord. 1998;13 Suppl 1:73-82.
There has been a resurgence in the use of neurosurgical procedures for the treatment of Parkinson's disease (PD). Pallidotomy has become a widely performed procedure on the basis of reports which describe marked reduction of levodopa-induced dyskinesias and variable improvement in parkinsonism. Preliminary reports of the effects of globus pallidus internus (GPi) and subthalamic nucleus (STN) deep brain stimulation (DBS) have also been promising. At 6-month follow up, a cohort of our first 40 patients undergoing pallidotomy demonstrated the following mean improvements when examined after drug withdrawal (off) and under optimal medication (on): total motor off scores-31%; total off activities of daily living scores-30%; and total on dyskinesias-63% (contralateral and ipsilateral dyskinesias improved 82% and 50%, respectively). Although improvements in contralateral dyskinesias and total off parkinsonism were sustained at 2-year follow up (N = 11), benefit for ipsilateral dyskinesias was lost after 1-year follow up (N = 24). and postural stability and gait improvements lasted only 3-6 months. On-period, levodopa-resistant symptoms did not benefit from pallidotomy. Mean improvements in 8 patients undergoing GPi DBS (4 unilateral and 4 bilateral) at 3 months were as follows: total motor off scores-27%; total off activities of daily living scores-26%; and total on dyskinesias-60%. At most recent follow up, 6 patients with STN DBS (5 bilateral and 1 unilateral) showed the following mean improvements: total motor off scores-41%; total motor on scores-27%; total off activities of daily living scores-40%; and total on dyskinesias 41%. Pallidotomy reduces dyskinesias and off disability. GPi DBS may have effects similar to pallidotomy, but might be safer when bilateral procedures are required. Bilateral STN DBS may improve off parkinsonism more than other procedures and might also improve on-period motor function. A randomized trial will be required to determine which procedure is most effective for patients with different clinical features.
神经外科手术治疗帕金森病（PD）的应用再度兴起。基于描述左旋多巴诱发的异动症明显减轻以及帕金森症状有不同程度改善的报告，苍白球切开术已成为一种广泛开展的手术。内侧苍白球（GPi）和丘脑底核（STN）深部脑刺激（DBS）效果的初步报告也很有前景。在6个月的随访中，我们最初接受苍白球切开术的40例患者组成的队列在撤药（停药）后及最佳药物治疗（服药）状态下接受检查时显示出以下平均改善情况：运动总停药评分改善31%；日常生活活动总停药评分改善30%；异动症总服药评分改善63%（对侧和同侧异动症分别改善82%和50%）。尽管对侧异动症和帕金森症状总停药改善情况在2年随访时（N = 11）仍持续存在，但同侧异动症在1年随访后（N = 24）益处消失，姿势稳定性和步态改善仅持续3 - 6个月。在服药期，左旋多巴抵抗性症状并未从苍白球切开术中获益。8例接受GPi DBS（4例单侧和4例双侧）的患者在3个月时的平均改善情况如下：运动总停药评分改善27%；日常生活活动总停药评分改善26%；异动症总服药评分改善60%。在最近的随访中，6例接受STN DBS（5例双侧和1例单侧）的患者显示出以下平均改善情况：运动总停药评分改善41%；运动总服药评分改善27%；日常生活活动总停药评分改善40%；异动症总服药评分改善41%。苍白球切开术可减轻异动症和停药时的残疾状况。GPi DBS可能具有与苍白球切开术相似的效果，但在需要双侧手术时可能更安全。双侧STN DBS可能比其他手术更能改善帕金森症状停药时的状况，也可能改善服药期的运动功能。需要进行一项随机试验来确定哪种手术对具有不同临床特征的患者最有效。
