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Revue Rezai.Pdf MOVEMENT DISORDERS SURGERY FOR MOVEMENT DISORDERS Ali R. Rezai, M.D. Center for Neurological Restoration, and MOVEMENT DISORDERS, SUCH as Parkinson’s disease, tremor, and dystonia, are Department of Neurosurgery, among the most common neurological conditions and affect millions of patients. Cleveland Clinic, Cleveland, Ohio Although medications are the mainstay of therapy for movement disorders, neurosurgery has played an important role in their management for the past 50 years. Surgery is now Andre G. Machado, M.D., Ph.D. a viable and safe option for patients with medically intractable Parkinson’s disease, Center for Neurological Restoration, and essential tremor, and dystonia. In this article, we provide a review of the history, neuro- Department of Neurosurgery, Cleveland Clinic, circuitry, indication, technical aspects, outcomes, complications, and emerging neuro- Cleveland, Ohio surgical approaches for the treatment of movement disorders. KEY WORDS: Deep brain stimulation, Dystonia, Essential tremor, Globus pallidus pars interna, Movement Milind Deogaonkar, M.D. disorders, Parkinson’s disease, Stereotaxis, Subthalamic nucleus, Ventralis intermedius nucleus Center for Neurological Restoration, and Department of Neurosurgery, Neurosurgery 62[SHC Suppl 2]:SHC809–SHC839, 2008 DOI: 10.1227/01.NEU.0000297003.12598.B9 Cleveland Clinic, Cleveland, Ohio Hooman Azmi, M.D. Historical Perspective predominantly limited to thalamotomy (8, Center for Neurological Restoration, and arious surgical approaches, such as 115–117, 149, 167, 254, 275, 343) for the treat- Department of Neurosurgery, resection, lesioning, stimulation, and ment of tremor and pallidotomy and thalamo- Cleveland Clinic, tomy for dystonia (224, 341, 371, 383). PD sur- Cleveland, Ohio others, have been used to treat patients V gery was rarely performed during this time. It with movement disorders. Craniotomies were Cynthia Kubu, Ph.D. performed for the resection of the motor cortex was not until the late 1980s that there was a Center for Neurological Restoration, and (68), cerebral peduncles (381, 382), and a vari- reemergence of interest in the neurosurgical Department of Psychiatry, ety of subcortical lesioning procedures (326). treatment for PD due to the increasing realiza- Cleveland Clinic, Irving Cooper (72a) first reported the effects of tion of the limitations of PD medications and Cleveland, Ohio ligation of the choroidal artery for Parkinson’s the side effects of L-dopa. This led to a resur- gence of lesioning surgeries such as pallido- Nicholas M. Boulis, M.D. disease (PD) in 1953. Six patients were treated tomies for PD. The initial Leksell (336) target of Center for Neurological Restoration, and with eight ligations, which resulted in signifi- Department of Neurosurgery, cant alleviation of rest tremor, rigidity, and pallidal lesions for treatment of PD was modi- Cleveland Clinic, contralateral cogwheeling. It was not until the fied and repopularized by Laitinen et al. (196, Cleveland, Ohio introduction of stereotaxis by Spiegel et al. 197). Original analytical descriptions of thala- (328) in 1947, and later by Leksell (206) in 1949, mic nuclei and circuitry by Hassler (142), Reprint requests: Hassler et al. (143), and Macchi and Jones (230) Ali R. Rezai, M.D., that a more accurate, less invasive, and more Center for Neurological Restoration, consistent placement of lesions in various sub- and basal ganglia circuitry by Delong et al. (81, 9500 Euclid Avenue, Desk S31, cortical locations became feasible. 82) also served as a foundational substrate for Cleveland OH 44122. The development of stereotaxy led to a vari- newer targets for therapeutic interventions Email: [email protected] ety of lesioning procedures of the basal ganglia using stereotactic techniques. The ability of electrical impulses to modify Received, May 30, 2007. and the thalamus for the treatment of rigidity functional outcome in certain brain regions Accepted, November 1, 2007. and tremor in the 1950s and 1960s. Various sur- gical techniques, lesion locations, lesion sizes, was identified almost 200 years ago, in 1809, and outcomes were reported (77, 256, 327, 392). by Rolando (98). Aldini had previously ONLINE The motor thalamus and the pallidal targets attempted to stimulate the brains of executed DIGITAL criminals immediately after death by applying VIDEO lying in the ventral and posterior portions of the globus pallidus internus (GPi) as well as current from voltaic piles (98). The use of elec- the pallidal projections were considered to be trical stimulation to understand and map the the most effective targets. However, it was the function of the human brain and its circuitry advent of L-dopa in the mid-1960s and its sig- became commonplace in the 20th century (4, nificant clinical benefits that led to a dramatic 64, 65, 291). Early explorations by Hassler et al. decrease in surgery for PD. For the next 20 revealed that acute low-frequency stimulation years, surgery for movement disorders was during stereotactic exploration for ablation of NEUROSURGERY VOLUME 62 | NUMBER 2 | FEBRUARY 2008 SUPPLEMENT | SHC809 REZAI ET AL. the pallidum could augment tremor, whereas high-frequency neurocircuitry of PD and other movement disorders (2, 29, 39, stimulation at 25 to 100 Hz had the opposite effect (143). These 41, 53, 56, 62, 83, 99, 120, 133, 135, 144, 152, 204, 205, 209, 223, observations paved the way for the future development of 234, 239, 241, 246, 248, 249, 262, 273, 283, 292, 320, 325, 332, 340, chronic electrical stimulation therapies for the management of 343, 385, 391). These data provided support for the concept of movement disorders. the cortico-striatal-pallidal-thalamic-cortical (CSPTC) circuits. The first systematic use of chronic deep brain stimulation Alexander et al. (7) hypothesized that a network of five parallel, (DBS) for the treatment of movement disorders is attributed to segregated circuits exists that underlies a variety of functions. Bechtereva et al. (22) in Russia. Beginning in 1967, they These circuits originate in various regions of the frontal lobes reported benefits with chronic DBS of the thalamus, striatum, and then traverse through different nodes in the striatum, pal- and pallidum. But it was not until the 1980s that Brice and lidum, and thalamus before returning to their cortical points of McLellan (54), Blond and Siegfried (52), Siegfried and Shulman origin. One of these circuits underlies complex motor function (319), and Benabid et al. (34, 36) published reports of the use of and is implicated in the pathophysiology of PD. chronic electrical stimulation or DBS for the treatment of move- The concept of a CSPTC motor circuit or loop implies that a ment disorders, thus ushering in a new era of functional neu- number of the nodes involved in the circuit are potential targets rosurgery for movement disorders. for neuromodulation including neurosurgical procedures such DBS has similar efficacy as that reported with various lesion- as lesioning and DBS, somatic or stem cells, or gene therapy. ing procedures (e.g., pallidotomy, thalamotomy). However, the In the CSPTC circuitry model, the striatal structures, such as superior safety profile of DBS relative to lesioning procedures, the caudate and putamen, serve as the input structures, particularly bilateral thalamotomy and pallidotomy, has made whereas the GPi and substantia nigra pars reticulata (SNr) are it the procedure of choice in countries where access to this tech- the primary output structures. The motor circuit originates in nology is available the precentral motor regions (especially Brodmann areas 4 and DBS, with its inherent features of reversibility and adjustabil- 6). Information passing through the basal ganglia is organized ity, has gained popularity and emerged as the neurosurgical anatomically though “direct” and “indirect” pathways within standard of care for movement disorders such as PD, dystonia, the CSPTC circuit (Fig. 1). Information in the direct pathway and essential tremor over the past 20 years (6, 9, 25, 32, 33, 37, passes monosynaptically from the putamen to the output struc- 70, 101, 187, 193, 201, 202, 227, 252, 268, 274, 280, 293, 294, 343, tures of the basal ganglia, the GPi, and the SNr. Information 351, 357, 394). Since its inception, more than 40,000 DBS from the indirect pathway passes multisynaptically through implants have been performed in more than 500 centers world- the globus pallidus externa (GPe) and the subthalamic nucleus wide (28). In addition to the widespread use of DBS for move- (STN) before terminating on the GPi/SNr. The information ment disorders, a number of clinical investigations using DBS from both the direct and indirect pathways then projects to are under way to explore its safety and efficacy for conditions various thalamic relay nuclei, including the ventral oralis ante- such as Tourette’s syndrome (14, 88, 111, 155, 243, 266, 322, rior (Voa) and ventral oralis posterior (Vop) nuclei (in Hassler’s 366), chronic pain (48, 69, 119, 188, 210, 295), and psychiatric nomenclature) (230). This information is then projected back to disorders such as depression (60, 109, 238, 310, 314) and the frontal region of origin, thereby closing the circuit. The obsessive-compulsive disorder (OCD) (73, 121, 122, 190, 242, direct and indirect pathways appear to balance one another. 386). Because DBS is the most commonly used neurosurgical The direct pathway is presumed to be responsible for the initi- procedure for the treatment of movement disorders, it is the ation of action
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