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    1. Merrits Neurology, 9th ed., Ed. Lewis P. Rowland, 2000 . 687



    The surgical approaches are not considered in the early stages of PD but are reserved for patients who have failed to respond satisfactorily to drugs. Thalamothomy and thalamic stimulation (target for both is the ventral intermediate nucleus) are best for contralateral tremor. Tremor can be relieved in at least 70% of cases. Although a unilateral lesion carries a small risk, bilateral operations result in dysarthria in 15% to 20% of patients. Thalamic stimulation seems to be safer and can be equally effective against tremor, but it runs the risk associated with foreign bodies and thin electronic wires that can break. Pallidotomy (target is the posterolateral part of the globus pallidus interna) is most effective for treating contralateral dopa-induced dystonia and chorea but also has some benefit for bradykinesia and tremor. The target in the globus pallidus interna is believed to be the site of afferent excitatory glutamatergic fibers coming from the subthalamic nucleus, which is overactive in PD. Lesions of the subthalamic nucleus, although effective in relieving parkinsonism in annual models, are haz-ardous in humans because or hemichorea or hemiballism may result. Instead, stimulation of he subthalamic nucleus is used and appears to be the most promising in reducing contralateral bradykinesia and tremor. Subthalamic nucleus stimulation in a patient appeals to reduce symptoms of PD that respond levodopa in that patient. It is not effective against symptoms that do not respond to levodopa. This type of surgery often allows a marked reduction of levodopa dosage, thereby reducing dopa-in-duced dyskinesias and treting parkinsonian symptoms. Fetal dopaminergic tissue implant are being investigated. This surgical procedure may reduce bradykinesia and rigidity in younger patients but is less effective in those over age 60; it is not effective against tremor. Its lone-term effect is not established, but in some patients it has replaced bradykinesia with persistent dyskinesia in the absence of levodopa. Until this problem can be solved, transplantation surgery is not a useful option.

    Levodopa is uniformly accepted as the most effective drug available for symptomatic relief of PD. If it were uniformly and persistently successful and also free or complications new statistics for other treatment would not be needed. ( ; ). Unfortunately, 75% of patients have serious complications after 5 years of levodopa therapy (Table 114.7).



    TABLE 114.7. FIVE MAJOR OUTCOMES AFTER MORE THAN 5 YB OF LEVODOPA THERAPY (N = 330 PATICNT5) (a)



    Smooth good response, n = 83 (25%)

    Troublesome fluctuation, n =142 (43%)

    Troublesome dyskinesias n = 67 (19%}

    Toxicity at therapeutic or subtherapeutic dosages, n = 1414%]

    Total or substantial loss of efficacy, n = 27 (8%)



    (a) Thirty-six patients had both troublesome fluctuations and troublesome dyskinesias

    From Fahn, S. Adverse effects of levodopa. In Olanow CW, Lieberman AN, eds. The scientific basis for the treatment of Parkinsons disease. Carnforth, England: Parthenon Publishing Group, 1992



    2. Neurology in clinical Practice. Principles of Diagnosis and Management 3rd ed. Ed. By Walter Bradley, 2000 . 955



    The neurosurgeon continues to play an important role in the treatment of some disabling movement disorders such as hemiballism, myoclonus, and some of the dystonias includ-ing spasmodic torticollis. The latter condition can be treated relatively satisfactorily with a variety of rhizotomies or peripheral neurotomies, which can be relatively selective and ordinarily should be guided by the results of electrophysiological testing. The other more generalized disorders are variably responsive to selective stereotactic lesions that should be performed only by neurosurgeons with special interest in these relatively rare conditions (Gildenberg 1996). A revival of interest in the surgical treatment in Parkinson's disease has occurred. Before adequate pharmacological treatment was available, neurosurgery was the mainstay of treatment of Parkinson's disease. Surgery for this condition was almost completely abandoned several decades ago, except in cases of unilateral tremor in which the tremor was the overwhelming symptom. More recently, with a gradual realization chat there are limitations to the pharmacological treatment of Parkinson's disease, both in terms of effective-ness as well as side effects, the interest in surgery has resurged. Both thalamotomies and pallidotomies have become more refined surgical techniques and the indications for each have been better clarified. There is also great excitement about the potential of transplantation. It is clear that transplantation of adult adrenal tissue will not be the answer and even transplantation of fetal cells capable of producing dopamine may not find a practical application. However, there is great excitement about experimental techniques of transplanting cells that have been cultured and are geneti-cally modified to produce dopamine (as well as other neurotransmitters in other neurotransmitter-deficiency diseases). In addition, there is considerable interest in chronic stimulation of specific subcortical areas with stereotactically inserted electrodes. Several centers are now participating in a variety of protocols to evaluate this modality of treatment.



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