Surgery for Parkinson’s Disease Will Eliminate Tremor and Stiffness

When should we consider that a patient with Parkinson’s disease needs neurosurgical treatment?

The answer is one – only when the possibilities of drug treatment are exhausted.
When we have used all possible options for adjusting the medication regimen.
When further dose increase is impossible due to the occurrence of undesirable side effects.
When the use of new medications is limited due to contraindications.
When the patient is tired and can no longer go through endless medication regimens and live with unsatisfactory results

Then we begin discussing the option of neurosurgical treatment.

Important nuances:

💙 of different treatment methods DBS and MRgFUS) – its advantages and disadvantages, limitations for use, indications and contraindications

The choice of the best method is determined INDIVIDUALLY and only with the attending physician.

💙 No surgery cures PD (it only provides control and reduction of certain symptoms)

💙 No surgery slows the progression of PD – therefore, there is no point in performing surgery “for the future.” Surgery should be done to eliminate/reduce symptoms here and now

💙 Improves quality of life – it becomes easier, more convenient, and more comfortable for the patient to live

💙 Reducing the number of medications taken is a huge advantage for those whose physical condition depends on frequent daily intake of antiparkinsonian drugs.

Indications for Conducting DBS (deep brain stimulation)

Diagnosis “Parkinson’s Disease” necessarily in combination with

– BILATERAL motor complications of long-term levodopa therapy (motor fluctuations in the form of dose wearing off or on/off phenomena), drug-induced dyskinesias in the form of involuntary, dance-like movements in the arms/legs or torso

– Severe, bilateral, disabling pharmacoresistant tremor (trembling of the limbs that does not sufficiently decrease in response to medication)

For simplicity in assessing the patient’s readiness for DBS you can use the criteria developed by the so-called Delphi consensus. According to these criteria, a patient with Parkinson’s disease may be considered a candidate for surgical treatment using the deep stimulation method if the following conditions are met:

✅ at least 5 times/day intake of levodopa medications
✅ at least 2 hours of pronounced “off” periods during the day
✅ at least 1 hour of disabling dyskinesias per day
✅ high level of daily activity during the inclusion period

To the main limitations DBS can include:

– Older age group of patients (often up to 70 years), as this increases the risk of complications due to the higher frequency of chronic somatic diseases among them

– Duration of PD less than 5 years – in this case, there is no certainty in the accuracy of the diagnosis, and in the case of atypical parkinsonism (any other neurodegenerative disease, such as multiple system atrophy, progressive supranuclear palsy, etc.), such an operation simply will not be effective

– Stage according to Hoehn and Yahr not lower than 3 (often the start of levodopa therapy is associated with the beginning of the third stage according to Hoehn and Yahr due to the development of instability, and the effectiveness of levodopa medications is one of the main conditions for a good effect on DBS)

Indications for MRgFUS (MRI-guided focused ultrasound) in Parkinson’s disease:

Indications for focused ultrasound surgery in Parkinson’s disease

1. Age over 30 years
2. Confirmed diagnosis of tremor-dominant (tremor-rigid) form of Parkinson’s disease.
3. Tremor persists despite medication therapy.
4. Tremor is the main factor of disability
5. No contraindications for performing a CT scan of the skull before therapy to determine bone density
6. Absence of contraindications for MRI.
7. Absence of pathological changes in the projection of the thalamus and subthalamic nucleus on brain MRI
8. The patient’s ability to undergo a therapy session without sedation or with minimal sedation.
9. The patient’s ability to understand and perform motor tests during the procedure and activate the button to stop sonication ( Stop Sonication).

Indications for Focused Ultrasound Therapy  published  in the “BULLETIN of the National Society for the Study of Parkinson’s Disease and Movement Disorders”
№ 1 — 2020.