SECTION I: PARKINSON’S DISEASE
8. FUTURE OF PARKINSON’S DISEASE SURGERY AND PATIENT SELECTION
The value of currently available surgical treatments for Parkinson’s disease—
particularly deep brain stimulation—is their ability to often dramatically sup-press motor symptoms and provide patients with more consistent, high quality motor function. Patient selection for these procedures therefore heavily emphasizes patients with significant motor disability and focuses on those patients with relatively advanced disease in whom the risks of surgery can be justified by the benefits typically achieved. There is vital need to provide patients with therapies that do more than merely provide symptomatic benefit, however. Disease-modifying treatments that decelerate or halt disease progres-sion, repair and restore degenerated neural circuits, and protect against the symptomatic declaration of disease in the first place are desperately needed.
As these restorative and protective therapies, likely delivered using neuro-surgical approaches, become available, selection criteria for their use will undoubtedly evolve. In the future, our therapies will be directed at those patients with new-onset or newly diagnosed Parkinson’s disease and a mild level of symptomatology.
Patient Selection and Indications for Surgery 39
Thus, it seems likely that the field of surgical movement disorders will arrive at the point of being able to provide patients a spectrum of interven-tional therapies along the continuum of Parkinson’s disease progression, with patient candidacy algorithms designed according to the efficacy and risk/benefit calculus at each stage of the disease.
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Patient Selection and Indications for Surgery 43
3
Surgical Technique and Complication Avoidance
Joshua M. Rosenow
Department of Neurosurgery, Feinberg School of Medicine of Northwestern University, Chicago, Illinois, U.S.A.
Ali R. Rezai
Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, U.S.A.
1. INTRODUCTION
The rapid rise in the number of patients undergoing subthalamic nucleus (STN) stimulation for Parkinson’s disease is remarkable, given the tradi-tional view that STN lesions cause disabling hemiballismus and the hypo-thesis that deep brain stimulation (DBS) produces a ‘‘functional lesion.’’
However, human trials followed the demonstration that STN lesions could alleviate many of the symptoms observed in primate models of Parkinson’s disease (1–3). The clinical benefits of chronic electrical stimulation of the STN were first reported by the Grenoble group in 1994 (4) and a lengthier paper in 1995 (5) describing the first three patients to have electrodes imp-lanted chronically in the STN for the treatment of Parkinson’s disease.
In this chapter, we present a practical methodology for implanting deep brain stimulating electrodes in the STN. While the techniques and pre-ferences described here are ones our group has found work best (6,7), alter-native successful styles do exist (8–11). Moreover, the advent of frameless techniques has added an extra dimension to the procedure. In general, the
45
anatomic and physiologic considerations for the frame-based and frameless techniques are essentially the same. However, each frameless system has its own nuances regarding setup and alignment. This chapter will focus on the traditional frame-based procedure and will not delve into the multiple frameless systems available.