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The Past, Present and Future of Surgical Procedures in Parkinson's Disease
Author(s) -
Bleasel Kevin
Publication year - 1971
Publication title -
australian and new zealand journal of medicine
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.596
H-Index - 70
eISSN - 1445-5994
pISSN - 0004-8291
DOI - 10.1111/j.1445-5994.1971.tb02565.x
Subject(s) - internal capsule , globus pallidus , medicine , pallidotomy , basal ganglia , lesion , dysarthria , thalamotomy , stereotactic surgery , surgery , anterior choroidal artery , thalamus , stereotaxy , parkinson's disease , disease , deep brain stimulation , magnetic resonance imaging , radiology , pathology , central nervous system , internal carotid artery , haptic technology , computer science , white matter , operating system , endocrinology
Summary: Effective surgery for the symptoms and signs of Parkinson's Disease began about 1940 when surgery was for the first time directed at the basal ganglia and internal capsule. The initial operations were by open craniotomy and it was not until 1947 that stereotaxic methods originally used by Horsley were applied by Spiegel and Wycis. Their first lesions were made in the ansa lenticu‐laris. From 1953 onwards stereotaxic techniques created lesions in the globus pallidus with success. Irving Cooper working from a different approach started in 1952 to cause lesions by deliberate occlusion of the anterior choroidal artery, the effectiveness of this depended upon the creation of a lesion in the globus pallidus, internal capsule and thalamic region. Cooper perfected a technique for making chemical lesions in the globus pallidus and later in the lateral ventral nucleus of the thalamus and refined this technique by developing a cryoprobe, which had the advantage of making an initially reversible lesion so that with the patient conscious possible complications could be anticipated and avoided. At the present time stereotaxic surgery for Parkinson's Disease is a predictable procedure, having a low mortality provided proper case selection is carried out pre‐operatively. Surgery is effective in abolishing rigidity in 90% of cases and tremor in 75% of cases. It has no effect on the brady‐kinesia and no effect on the bulbar disturbances such as softness of speech or dysarthria. In fact, these may be worsened, particularly in operations on the dominant hemisphere. Disturbances of gait such as locking of gait, slow stumbling gait and disturbances of balance in the form of forward or backward running are not influenced by surgery. The contra‐indications to surgery are dementia, severe bulbar disturbances, particularly diminished voice volume, and poor health. Hypertension is not necessarily an absolute contra‐indication. The ideal candidate for surgery is a patient who is still active and employable, who has rigidity predominantly affecting the intrinsic muscles of the hand and who has predominantly unilateral symptoms and signs. Age is better assessed on the physiological age of the patient rather than on an absolute value and patients in early 70's have been successfully operated upon. Surgery must be directed towards relieving the actual disability of the patient and not merely to the attempted cure of an unsightly tremor. It is likely that there will always be a place for surgery for unilateral disability followed by L‐dopa medication, to control the more generalised features when they arise.