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Functional Neurosurgery: Movement Disorder Surgery

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Functional Neurosurgery: Movement Disorder Surgery FunctionalFunctional Neurosurgery:Neurosurgery: MovementMovement DisorderDisorder SurgerySurgery KimKim J.J. Burchiel,Burchiel, M.D.,M.D., F.A.C.S.F.A.C.S. DepartmentDepartment ofof NeurologicalNeurological SurgerySurgery OregonOregon HealthHealth andand ScienceScience UniversityUniversity MovementMovement DisorderDisorder SurgerySurgery •• New New resultsresults ofof anan OHSUOHSU StudyStudy –– Thalamotomy Thalamotomy v. v. DBSDBS forfor TremorTremor •• Latest Latest resultsresults ofof thethe VA/NIHVA/NIH trialtrial forfor DBSDBS Parkinson’sParkinson’s DiseaseDisease •• New New datadata onon thethe physiologyphysiology ofof DBSDBS •• The The futurefuture –– DBS DBS –– Movement Movement disorderdisorder surgerysurgery MovementMovement DisorderDisorder SurgerySurgery 1950’s1950’s :: PallidotomyPallidotomy 1960’s:1960’s: PallidotomyPallidotomy replaced replaced byby ThalamotomyThalamotomy 1970’s:1970’s: TheThe LevodopaLevodopa era era 1980’s:1980’s: ThalamicThalamic stimulationstimulation forfor tremortremor 1990’s:1990’s: Pallidotomy/thalamotomyPallidotomy/thalamotomy rediscovered rediscovered 2000’s:2000’s: STNSTN andand GPiGPi stimulation stimulation 2010’s2010’s andand beyond:beyond: 99 DiffusionDiffusion catheterscatheters forfor trophictrophic factors? factors? 99 TransplantationTransplantation ofof engineeredengineered cells?cells? 99 GeneGene therapy?therapy? TreatmentTreatment ofof Parkinson’sParkinson’s DiseaseDisease •• Symptomatic Symptomatic –– Therapies Therapies toto helphelp thethe symptomssymptoms ofof PDPD •Medicine•Medicine •Surgery•Surgery •• Neuroprotective Neuroprotective –– Therapies Therapies toto slowslow progressionprogression –– Therapies Therapies toto delaydelay onsetonset •• Neurorestorative Neurorestorative –– Therapies Therapies toto restorerestore lostlost dopaminedopamine cellscells TreatmentTreatment ofof Parkinson’sParkinson’s DiseaseDisease •• Symptomatic Symptomatic –– Therapies Therapies toto helphelp thethe symptomssymptoms ofof PDPD •Medicine•Medicine •Surgery•Surgery •• Neuroprotective Neuroprotective –– Therapies Therapies toto slowslow progressionprogression –– Therapies Therapies toto delaydelay onsetonset •• Neurorestorative Neurorestorative –– Therapies Therapies toto restorerestore lostlost dopaminedopamine cellscells MovementMovement DisorderDisorder SurgerySurgery VimVim GPiGPiGPi STNSTNSTN AblativeAblative NeuromodulationNeuromodulation MovementMovement DisorderDisorder SurgerySurgery VimVim ThalamotomyThalamotomy AblativeAblative PVPV PallidotomyPallidotomy (GPi) (GPi) VimVim StimulationStimulation NeuromodulationNeuromodulation GPiGPi Stimulation Stimulation STNSTN StimulationStimulation MovementMovement DisorderDisorder SurgerySurgery •DBS•DBS –– Less Less adverseadverse effectseffects (?)(?) –– Reversible Reversible // adjustableadjustable –– Equipment Equipment maintenancemaintenance –– Expensive Expensive •• Lesion Lesion –Easier–Easier –– Not Not bilateralbilateral (?)(?) –– Less Less expensiveexpensive MovementMovement DisorderDisorder SurgerySurgery VimVim GPiGPiGPi STNSTNSTN AblativeAblative NeuromodulationNeuromodulation ThalamotomyThalamotomy TargetTarget Location Location VIMVIM ThalamotomyThalamotomy ThalamotomyThalamotomy ThalamotomyThalamotomy MovementMovement DisorderDisorder SurgerySurgery VimVim GPiGPiGPi STNSTNSTN AblativeAblative NeuromodulationNeuromodulation PallidotomyPallidotomy MovementMovement DisorderDisorder SurgerySurgery VimVim GPiGPiGPi STNSTNSTN AblativeAblative NeuromodulationNeuromodulation MovementMovement DisorderDisorder SurgerySurgery VimVim GPiGPiGPi STNSTNSTN AblativeAblative NeuromodulationNeuromodulation MovementMovement DisorderDisorder SurgerySurgery VimVim GPiGPiGPi STNSTNSTN AblativeAblative NeuromodulationNeuromodulation DBSDBS SystemsSystems DBSDBS ImplantationImplantation ActivaActiva®® Parkinson’sParkinson’s ControlControl SystemSystem VimVim DBSDBS FirstFirst DBS*DBS* *Outside France ThalamicThalamic DBSDBS OHSUOHSU Study:Study: ThalamotomyThalamotomy v. v. DBSDBS •• 20 20 patientspatients withwith EssentialEssential TremorTremor (ET)(ET) •• Matched Matched demographicsdemographics •• Rigorous Rigorous testingtesting •• Randomly Randomly assignedassigned toto –– Deep Deep brainbrain stimulationstimulation (Vim)(Vim) –– Thalamotomy Thalamotomy (Vim) (Vim) •• Follow-up Follow-up withwith repeatrepeat testingtesting AdverseAdverse EventsEvents Event Thalamotomy (N= 10) DBS (n= 10) Surgical: Repeat thalamotomy (poor 1 tremor control post fall) Replace burr hole cover screw 1 Transient: 2 weakness balance disturbance 2 speech difficulties 1 numbness, peri-oral 1 incisional pain 1 hematoma 1 metallic taste in mouth 1 ClinicalClinical scalesscales showshow nono differencedifference inin functionfunction afterafter 66 monthsmonths ofof THTH oror DBSDBS TH DBS 40 40 WHIGET Tremor Rating CADET Tremor Disability Ques 30 30 score ContralateralContralateral tremortremor powerpower isis reducedreduced byby DBSDBS andand TH;TH; PeakPeak frequencyfrequency isis notnot OnOn thethe ipsilateralipsilateral hand,hand, neitherneither tremortremor powerpower nornor peakpeak frequencyfrequency areare affectedaffected byby DBSDBS oror THTH CVCV determineddetermined fromfrom analysisanalysis ofof thethe middlemiddle thirdthird keystrikeskeystrikes ContralateralContralateral simplesimple repetitiverepetitive (SS)(SS) fingerfinger movementsmovements areare improvedimproved byby bothboth DBSDBS andand THTH SS 0.14 P0-6 (DBS v TH) = 0.03 0.12 0.10 TimingTiming variabilityvariability ofof contralateralcontralateral alternate alternate fingerfinger tappingtapping tendstends toto improveimprove moremore withwith DBSDBS Trill P0-6 (DBS v TH) = 0.12 0.3 0.2 V AccuracyAccuracy ofof contralateralcontralateral finger finger movementsmovements improvesimproves withwith DBSDBS Scale 12 r o r 8 TimingTiming variabilityvariability ofof ipsilateralipsilateral tappingtapping isis improvedimproved byby DBSDBS SS Control 0.3 TH * DBS Trill 0.2 0.5 CV 0.1 0.4 0.0 0136 Time, months 0.3 IpsilateralIpsilateral accuracy accuracy errorserrors areare unchangedunchanged byby DBSDBS andand THTH Scale 16 12 ror r ThalamotomyThalamotomy v. v. DBSDBS •• TH TH andand DBSDBS bothboth reducereduce contralateralcontralateral tremortremor equallyequally –– Neither Neither THTH oror DBSDBS changeschanges ipsilateralipsilateral tremortremor frequencyfrequency •• Early Early adverseadverse eventsevents moremore commoncommon withwith THTH ThalamotomyThalamotomy v.v. DBSDBS ••B Bothoth THTH andand DBSDBS affectaffect neuralneural systemssystems involvedinvolved inin temporaltemporal processingprocessing andand sequencingsequencing ofof contralateralcontralateral fingerfinger movementsmovements inin ET:ET: ––RRegularityegularity ofof simple,simple, repetitiverepetitive movementsmovements isis improvedimproved byby bothboth THTH andand DBS,DBS, withwith greatergreater improvementimprovement afterafter DBSDBS ––RRegularityegularity andand accuracyaccuracy ofof moremore complexcomplex sequencessequences thatthat involveinvolve non-motornon-motor corticalcortical areasareas areare improvedimproved byby DBSDBS andand maymay bebe worsenedworsened byby THTH ThalamotomyThalamotomy v. v. DBSDBS ••DBSDBS improvesimproves regularityregularity ofof fingerfinger movementsmovements ipsilateralipsilateral toto thethe stimulatedstimulated thalamusthalamus ThalamotomyThalamotomy v. v. DBSDBS •Taken•Taken together,together, thesethese resultsresults provideprovide evidenceevidence that:that: –DBS–DBS affectsaffects aa moremore widespreadwidespread neuralneural networknetwork thanthan THTH –That–That networknetwork mostmost reasonablyreasonably includesincludes ipsi-lesional:ipsi-lesional: •• motor motor cortexcortex •• basal basal gangliaganglia •• cerebellar cerebellar structures. structures. MovementMovement DisorderDisorder SurgerySurgery VimVim GPiGPiGPi STNSTNSTN AblativeAblative NeuromodulationNeuromodulation PhysiologyPhysiology ofof Parkinson’sParkinson’s DiseaseDisease Cortex Normal Putamen Normal D2 D1 SNc facilitationfacilitation GPe inhibitioninhibition VL STN GPi/SNr Brainstem/spinal cord PhysiologyPhysiology ofof Parkinson’sParkinson’s DiseaseDisease Cortex Putamen ParkinsonismParkinsonism D2 D1 SNc facilitationfacilitation GPe inhibitioninhibition VL STN GPi/SNr Brainstem/spinal cord TheThe brainbrain systemsystem thatthat producesproduces movementmovement isis normallynormally inin balancebalance GPe VLVL GPi/SNr Putamen D2 D1 SNc STNSTN InhibitionInhibition (-)(-) FacillitationFacillitation (+)(+) Parkinson’sParkinson’s DiseaseDisease putsputs itit outout ofof balancebalance -- movementmovement becomesbecomes difficultdifficult GPe GPi/SNr Putamen VL D2 D1 SNc STN InhibitionInhibition (-)(-) FacillitationFacillitation (+)(+) TheThe systemsystem cancan bebe rebalancedrebalanced byby shuttingshutting downdown thethe rightright partsparts -movement-movement isis improvedimproved GPe GPi/SNr STN Putamen D2 D1 SNc VLVL InhibitionInhibition (-)(-) FacillitationFacillitation (+)(+) STNSTN DBSDBS STNSTN DBSDBS MicroelectrodeMicroelectrode andand DBSDBS ElectrodeElectrode MicroelectrodeMicroelectrode MappingMapping MicroelectrodeMicroelectrode MappingMapping STNSTN MicrorecordingMicrorecording GPiGPi MicrorecordingMicrorecording GPiGPi DBSDBS STNSTN DBSDBS STNSTN DBSDBS VA/NINDSVA/NINDS DBSDBS StudyStudy StudyStudy DesignDesign ••E Entryntry criteriacriteria ––I Idiopathicdiopathic Parkinson’sParkinson’s DiseaseDisease ––H Hoehnoehn & & YahrYahr> > 22 (off(off meds)meds) •• RRandomizedandomized
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