SECTION I: PARKINSON’S DISEASE
6. CONCLUSIONS
The main surgical targets have historically been, and remain, the VIM nucleus of the thalamus, the postero-infero-lateral portion of the globus pallidus internus (GPi), and subthalamic nucleus. While the thalamic target has been successful in controlling parkinsonian tremor, it has had little, if any, impact on bradykinesia, rigidity, and dyskinesia. This had been the tar-get of choice over a 40-year period, until Laitinen re-emphasized the benefits obtained with the GPi target in improving the motor fluctuations encoun-tered in akineto-rigid patients suffering from drug-induced dyskinesias.
The pallidal target has not, however, allowed patients to benefit from a lower medication dosage, and many series have confirmed its non-lasting efficacy in controlling symptoms. The definition of the role of the STN in the pathophysiology of PD and the surgical results obtained with surgery at this target have led most teams to consider at this time, the STN as the ideal target for the surgical treatment of PD.
While similar benefits on motor functions are obtained with lesion or sti-mulation at these targets, results obtained with these methodologies have con-firmed the superiority of the stimulation technique in terms of overall benefits and reduction of complications or side effects. In that respect, comparative data concerning lesion and stimulation of the STN are too scarce to allow a statement, but STN-DBS provides excellent results with low morbidity.
At this point in time, it is obvious that, on the one hand, the stimulation technique has replaced the lesional approach, and on the other hand, the STN has turned out to be the best target for the treatment of PD. There remain considerations for targeting the thalamus in long-standing, stable dominant parkinsonian tremor, but there are really no reasons not to target the STN. Additionally, one could also find a reason to perform a thalamic lesion in a unilateral long-standing non–dominant parkinsonian tremor, in order to avoid the cost of the stimulation equipment. In our opinion, there are no more indications for pallidal surgery in PD.
The microrecordings during STN-DBS surgery, combined with clinical observations resulting from stimulation, are excellent tools for determining the final electrode position. It does not seem that an effective stimulation requires refined positioning of the electrode within the STN. There are indi-cations that some structures in the neighborhood of the STN may also be responsible for clinical improvement with DBS. However, stimulating within the STN has been demonstrated to be effective. While it is assumed that the greater number of brain penetrations with electrodes should be asso-ciated with a greater risk of hemorrhage, there are conflicting reports related to the issue. There is emerging evidence that further refinement in MRI-based targeting provides an accuracy comparable to the preoperative physiological localization techniques. More clinical studies are necessary before MRI-based
targeting and surgery under anesthesia can be recommended as standard practice.
In our opinion, STN-DBS represents, at present, the surgical treat-ment of choice for advanced PD.
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