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Pallidotomy: Effective and Safe in Relieving Parkinson's Disease Rigidity

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Pallidotomy: Effective and Safe in Relieving Parkinson's Disease Rigidity View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Pakistan Journal Of Neurological Surgery ORIGINAL ARTICLE Pallidotomy: Effective and Safe in Relieving Parkinson’s Disease Rigidity NABEEL CHOUDHARY, TALHA ABBASS, OMAIR AFZAL Khalid Mahmood Department of Neurosurgery, Lahore General Hospital, Lahore ABSTRACT Introduction: Parkinson's Disease (PD) is a progressive neurological disorder caused by a loss of pigmented dopaminergic neurons of the substantia nigra pars compacta. The major manifestations of the disease consist of resting tremor, rigidity, bradykinesia and gait disturbances. Before the advent of Levodopa surgery was main stay of treatment of PD. Medical therapy is still the mainstay of treatment for Parkinson's diseasebut its prolonged use results in side effects like drug induced dyskinesia. In 1952 Dr. Lars Leksell introduced Pallidotomy that was successful in relieving many Parkinsonian symptoms in patients. Later on thalamotomy became widely accepted, replacing pallidotomy as the surgical treatment of choice for Parkinson's Disease. Thalamotomy had an excellent effect on the tremor, was not quite as effective at reducing rigidity rather bradykinesia was often aggravated by the procedure. Objective: Effectiveness of Pallidotomy in rigidity in medically refractory Parkinson’s disease and its complications. Study Design: Descriptive prospective case series. Setting of study: Department of Neurosurgery, Lahore General Hospital, Lahore. Duration: June 2013 to April 2016. Materials and Methods: Patients of Parkinson’s disease with predominant component of muscular rigidity despite maximum medical therapy admitted through outdoor department. Detailed history and physical exami- nation was done. Grading of muscular rigidity was done by applying UPDRS score Rigidity part 22. Secondary Parkinsonism was ruled out with the help of CT scan and MRI brain. Surgery was performed after informed consent. Results: Twenty patients were included in the study with no lost to follow up. There were 14 (70%) male and 6 (30%) female patients. Mean age of the patients was 47.58 ± 8.69 years. There were 11 (55%) left sided procedures and 9 (45%) right sided Pallidotomy procedures performed. Mean pre-operative rigidity using UPRDS was 24.9 ± 1.47, while post-operative score was 11.87 ± 1.53. Pallidotomy procedure in our study had no mortality but 4 (20%) patients suffered from procedure related complications one patient (5%) had transient hemiparesis, 1 (5%) suffered from wound infection, 1 (5%) having dysarthria and 1 (5%) transient diplopia. Conclusion: Pallidotomy is effective as well as safe surgical treatment option in reducing rigidity for medically refractory Parkinsonism’s Disease. Key words: Parkinson’s disease, dyskinesia, rigidity, medically refractory. Abbreviations: PD: Parkinson’s Disease. INTRODUCTION individuals older than 60 years. It causes progressive Parkinson disease (PD) is one of the most common disability that can be slowed, but not halted, by treat- neurologic disorders, affecting approximately 1% of ment. The classic motor features of Parkinson disease Pak. J. of Neurol. Surg. – Vol. 20, No. 3, Jul. – Sep., 2016 -136- Nabeel Choudhary, et al typically start insidiously and emerge slowly over dose of carbidopa (200 mg/day and levodopa 800 weeks or months. The 3 cardinal signs of Parkinson mg/day) for 6 months and have rigidity grade ≥ 2. disease are resting tremor, rigidity, and bradykinesia. Postural instability is sometimes considered as the fourth cardinal feature. MATERIAL AND METHODS The basal ganglia motor system modulates the Study Design cortical output necessary for normal body movements. Prospective Descriptive case series study. Signals from the cerebral cortex are processed through the basal ganglia – thalamocortical motor pathway and return to cerebral cortex via a feedback pathway.The Setting direct and indirect pathways exist within the basal Department of Neurosurgery, Postgraduate Medical ganglia circuit. In Parkinson disease, decreased striatal Institute / Lahore General Hospital, Lahore. dopamine causes increased inhibitory output from the Globus Pallidus internus/substantianigra pars reticulate (GPi/SNr) via both the direct and indirect pathways. Duration of Study The increased inhibition of the thalamocortical path- June 2013 to April 2016. way suppresses movement.1 In the early 1900s, surgical treatment of Parkin- son's Disease was common. A variety of operations Sample Size targeted at destroying certain areas of the brain were 20 patients were included in this study. tried in an attempt to relieve severe tremor and rigi- dity. In 1952 Dr. Lars Leksell introduced Pallidotomy for treating Parkinsonian symptoms.At the same time, Sampling Technique thalamotomy became widely accepted, replacing It was Non probability consecutive sampling. pallidotomy as the surgical treatment of choice for PD. Thalamotomy had good control of tremor but was not Inclusion Criteria effective at reducing rigidity; bradykinesia was often 1. Adult population of both sexes having muscles aggravated.In 1985, Dr. Lauri Laitinenre – introduced rigidity grade 2 to grade 4due to medical refrac- the pallidotomy, as a treatment for patients who had tory Parkinson’s disease. previously undergone thalamotomy but remained symptomatic.After 1992 encouraging experience of Lauri prompted other specialists to re-examine the role Exclusion Criteria of pallidotomy in PD.Stereotactic pallidotomy being 1. Muscle rigidity due to stroke/ infarction, demyeli- ablative procedure is not without certain surgical risks. nation, trauma seen as hypodense area on CT or hyper intense on MRI. OBJECTIVES 2. Lesion in Basal ganglia on MRI Effectiveness of Pallidotomy in rigidity of medically refractory Parkinson’s disease and its complications. Data Analysis All the collected data was entered and analyzed using Operational Definitions IBM SPSS Statistics version 22. The qualitative data like demographics (Gender) was presented as per- Effectiveness: Reduction in rigidity, grade 1 or more centage and frequency distribution tables. The Quan- from base line, after pallidotomy measured by Unified titative data like age was presented in Mean ± S.D. Parkinson Disease Rating Score part 22 after 3 months. After fulfilling the parametric test assumptions, Paired sample t-test was used to determine the sig- Muscle Rigidity: resistance to passive movements of nificance differences before and after treatment in muscles measured with UPDRS part 22, grade 0 to 4. UPDRS score. The complications were noted and pre- sented as percentages. The p value of ≤ 0.05 was taken Medical Refractory: PD patients getting maximum as significant. -137- Pak. J. of Neurol. Surg. – Vol. 20, No. 3, Jul. – Sep., 2016 Pallidotomy: Effective and Safe in Relieving Parkinson’s Disease Rigidity Operative Technique then after 3 months to assess improvement in reduct- Antiparkinsonian medicine/s stopped 12 hours before ion in muscular rigidity. procedure and kept patients nil by mouth for 6 hours. Under local anesthesia Leksell G stereotactic frame was applied followed by MRI brain plain and contrast. RESULTS MRI brain images were transferred to Elekta Surgi- In this study mean age of the patients was 47.58 ± 8.69 planto calculate anterior and posterior commissure, x, years. In this study 14 (70%) were male and 6 (30%) y, z coordinates and trajectory.After getting measure- were female. ments of coordinates all frame attachments were adjusted on operation table. Surgical site was painted 0 with povidine iodide solution and draping done. Drap- ing is done in such a way that intraoperative assess- ment of the patients could be made i.e. patients eyes 4 and face were not covered. Incision made at marked site under local anesthetic infiltration and 12mm burr hole made. The dura is coagulated and opened in Male cruciate fashion. Stereotactic frame adjusted and Female brought in positioned and the macroelectrode of 2.1 mm diameter with un-insulated tip was passed through burr hole. The electrode was placed at a point 4 mm above the target and macrostimulation was started by Cosman G Radiofrequency Lesion Generator. Macro- 16 stimualation was used to get optimal target location. On macrostimulation adverse effects like contractions Fig. 1: Gender. of fingers, facial deviation, visual hallucination, and slurred speech were cautiously examined by Neurolo- gist along with therapeutic effects like decreased in In this study 5 (25%) patients were below 40 years rigidity by pronation and supination, flexion and of age, 6 (30%) were between 40 to 50 years of age extension at elbow joint, bradykinesia by tapping of and 9 (45%) were aged more than 50 years of age. index finger and thumb. Problems in speech were also assessed during stimulation by asking the patient to repeat words or answer the simple question and 12 observing any difficulties. Gradual increase in voltage 10 9 from low to high stimulation was used to check pro- ximity to optic nerve, internal capsule and any speech 8 dysfunction. Same steps are repeated to go down each 6 millimeter to find optimal target. Lesion madeon target 6 5 Age at 1.5 volt, temperature 60 to 90 degree °F for 60 4 …… Linear (Age) seconds. After lesioning electrode withdrawn slowly and wound closed in layers. For bilateral Pallidotomy 2 …… Linear (Age) same procedure is repeated on other side. Patients 0 were advised to continue with their preoperative anti- < 40 41 - 50 > 51 parkinsonian medications and analgesics and antibio-
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