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Mortality and Morbidity in Cryothalamectomy for Parkinsonism* a Statistical Study of 2868 Consecutive Operations

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Mortality and Morbidity in Cryothalamectomy for Parkinsonism* a Statistical Study of 2868 Consecutive Operations Mortality and Morbidity in Cryothalamectomy for Parkinsonism* A Statistical Study of 2868 Consecutive Operations STANLEY STELLAR, M.D., AND IRVING S. COOPER, M.D., PH.D. Department of Neurologic Surgery, St. Barnabas Hospital, New York, New York T Is the purpose of this report to present a helpful in providing an appropriate perspec- statistical analysis of morbidity and mor- tive. I tality in 2868 consecutive cryothalamec- Mundinger and Riechert l~ cited a mor- tomies for tremor and rigidity of parkinson- tality rate of 1.64 to 2.69%. In contrast, ism. Previous statistical evaluations have Spiegel and Wycis14 had two deaths in 30 pa- demonstrated that 85 to 90 70 of parkinsonian tients operated upon, thus yielding a 6 70 mor- patients obtained significant relief from tre- tality in this much smaller and therefore con- mor, rigidity, and impaired movements by trasting series; these same authors and their cryothalamectomy on our service? ,4 Although colleagues15 also reported one death in 33 the disease often continues with respect to cases of campotomy. its other protean manifestations, postopera- Bertrand and Martinez 1 reported a 1.2% tive patients generally manifest functional im- mortality in 250 cases, while a higher per- provement concomitant with relief of tremor centage occurred in the 170-patient series of and rigidity. Osacar, et al., ~2 in which 15 patients died, Significant problems related to bradyki- yielding a 9 % mortality. In our own study of nesia, balance, gait, speech, and mental func- 1001 consecutive cases of cryothalamectomy tioning form an integral part of the parkin- recently published, 16 the over-all mortality was sonian syndrome in many instances. Preopera- 1.3 %. In our earlier experience with 1000 cases tive evaluation of these functions, as well as of chemopallidectomy and chemothalamec- careful assessment of tremor, rigidity, and tomy, the mortality rate was 2.3 %.2.3 In a con- impairment of alternating movements is nec- secutive series of 154 patients, who were 70 essary in order to appraise adequately the years of age or older, operated upon at St. benefits of surgery and, particularly, the mor- Barnabas Hospital, 17 the mortality rate was bidity that can properly be attributed to the 370. surgical procedure itself. One must also take The morbidity rates cited in the literature into account the usual progression of parkin- vary from 5 to 20 70 for temporary abnormal- sonism when evaluating the long-term post- ities and from 2 to 6 70 for permanent abnor- operative status especially in those areas of malities?. 1~ Figures of 15 to 2070 have been symptomatology not amenable to surgical reported for dysarthria and dysphonia, es- procedures. pecially in bilateral cases where the difficulty It is difficult to relate our own results to the was temporary in some instances and per- findings of other workers, not only because of manent in others. Spiegel, et al., 15 reported the problems associated with the proper one contralateral analgesia lasting 1 week and equating of patient samples, but also because two transient hemiplegias in 33 cases of camp- of the varied and continuously changing otomy. However, there were also three with operative techniques. In addition, the small ocular paresis and 17 with considerable de- size of many of the series reported makes pression of consciousness or psychic changes. statistical evaluation particularly hazardous. These latter symptoms were more common in Nevertheless, cognizance of operative com- older patients and lasted from 1 day to plications encountered by others may be several months. Markham and Rand 9 performed 149 tha- Received for publication September 11, 1967. lamic operations in 114 patients, with 1 death. * Supported in part by the John A. Hartford Foun- dation, Inc. Presented in part at the meeting of the They used alcohol to create the lesion in 142 ScandinavianNeurosurgical Society, Uppsala, Sweden, and radioactive 9~ in seven, observing September 1, 1967. a 20.8 70 incidence of hemiparesis with 14.1% 459 460 Stanley Stellar and Irving S. Cooper showing abnormal movements. An "organic" patients was three times that of matched mental syndrome was observed in 27.5 % and controls and deaths occurred frequently from dysarthria in 8% with an additional 2.7% bronchopneumonia and urinary infections; showing dysphagia. Convulsions occurred in medical treatment produced no change what- 2 % and sensory loss in 2.7 %. Incoordination ever. was reported in 4.7 %. In 224 operations for 206 patients per- Material and Methods formed largely by electrocautery, with a few The present report covers all cases of par- being done by means of a 6 X 5 mm surgical kinsonism undergoing cryothalamectomy in loop, Laitinen8 reported one death, whereas the Neurosurgical Department of St. Barnabas psychiatric deterioration occurred in 20. Three Hospital, New York, from the beginning of had prolonged unconsciousness while two had 1963 through 1966. During this period, 2868 hemiparesis; the duration and extent were not patients were so treated. The study was de- given. Eight patients had choreiform move- signed to assess those sequelae of surgery ments, one lasting as long as 2 years. Balance properly designated as complications. In- was impaired in nine and speech was impaired cluded were all patients in whom death or in seven, while one had convulsions. complication occurred during hospitaliza- In the second symposium on Parkinson's tion, no matter how long the interval follow- disease held in 1963, Gillingham, et al.p ,6 ing operation. Thus, the mortality group in- discussed bilateral surgery in 60 cases. There cludes patients who died anywhere from 1 to was no early mortality, but four died after 3 263 days postoperatively, and the morbidity months. There was no paralysis. Three cases group includes all patients who suffered any of postoperative hemiballismus were noted. complication whatsoever while still in the Voice volume was decreased in 24, tempo- hospital, the longest interval from operation rarily only in one, whereas dysarthria occurred to discharge being 194 days. in 29 patients and eight of these were tem- There were, in addition, two patients who porary. Psychiatric complications occurred in had complications after recovering from the 15 patients. In reviewing the immediate post- cryothalamectomy but who died as a result of operative sequelae for I001 cryothalamec- surgical procedures for other conditions not tomies, t6 we found that the two most common related directly to Parkinson's disease. One complications were 1) balance and 2) speech patient died from pulmonary embolization or language difficulties, with approximately a and coronary occlusion following transure- 13% incidence in each. Mental changes oc- thral prostatectomy done 17 days after cryo- curred in 8.5%, with unusual lethargy in thalameetomy. The diagnosis was verified at another 1.4 %; hemiparesis was noted in 2.4 %. autopsy, and an uncomplicated cryogenic In the report from our own department pre- lesion was found in the brain. Another died viously referred to t7 concerning 154 patients from probable fat embolization following sur- 70 years of age or older, the incidence of gical insertion of a femoral prosthesis for postoperative confusion was 24.6%, balance fracture. The orthopedic operation had been problems 34.5%, speech and language diffi- performed 9 days after cryothalamectomy. An culties 11.2 %, and hemiplegia or hemiparesis autopsy was not permitted. The figures in the 4.8%. accompanying tables are supplemented by It is of interest to interpret these surgical data taken from our 1001 case reports t6 on data in light of the report by Hoehn and morbidity related to language and speech, gait Yahr, 7 who studied the natural course of the and balance, and mental functioning since disease in 802 parkinsonian patients who did exact figures were not available for the larger not undergo surgery. Of these nonsurgical series here presented. patients, 25 % died within 5 years of the initial examination, 67% had died or become Results severely disabled between the 5th and 9th General. Of the 2868 patients followed up to years, and 80 % died or were severely disabled 9 months after cryothalamectomy, 44 (1.5 %) during the 10th to 14th years. They found died and 133 (4.6%) suffered from major evidence that Parkinson's disease shortens life morbidity. Table 1 gives the details for both substantially. The mortality in parkinsonian mortality and morbidity for the years 1963 .
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