17 Lesioning versus Deep Brain Stimulation for Movement Disorders
Abstract
Deep brain stimulation and the creation of stereotactic lesions are both effective means of treating essential tremor (ET) and Parkinson’s disease (PD). DBS has largely supplanted lesion generation as the treatment of choice in movement disorders, since it is reversible, adjustable and can be used to safely treat bilateral disease. This chapter highlights differences in efficacy and safety along with the advantages and disadvantages for lesion generation and DBS in the treatment of movement disorders.
17.1 Historical Considerations
Although lesion generation and deep brain stimulation (DBS) are often viewed as competing procedures, they were at first complementary. In 1947 Spiegel and Wycis designed the first apparatus for accurate human lesion generation in deep brain targets. The device was used for medial thalamotomy for neuropsychiatric disorders as a surgical alternative treatment to lobotomy. 1 Subsequent work in the 1950s, relied on high frequency operative stimulation to identify subcortical targets for lesioning. 2 In the late 1980s, implanted high frequency stimulating electrodes were combined with battery-powered pulse generators as the first DBS devices. 3 DBS has since revolutionized the treatment of movement disorders. This chapter will focus on the use of lesion generation and DBS for treatment of ET and PD.
17.2 Effectiveness
In PD, subthalamic nucleus (STN) DBS may improve Unified Parkinson’s Disease Rating Scale, Part III (UPDRSIII) scores 25–89%. Average improvement is 45%. Quality of life measures improve as much as 35%, with an average improvement of 18%. 2 Globus pallidus interna (GPi) DBS leads to comparable improvements in UPDRSIII scores and quality of life measures with average improvements of 35% and 10%, respectively. 4 A recent meta-analysis of ten randomized controlled trials comparing STN-DBS to GPi-DBS for PD showed that STN and GPi were equally effective. STN-DBS, however led to greater decrease in levodopa equivalent daily dose (LEDD). 5 Ventral intermedius nucleus (Vim) DBS and RF Vim thalamotomy for PD improve tremor scores by up to 90%. 4 Both techniques may not address other symptoms of parkinsonism and are generally reserved for tremor dominant PD. STN-DBS, however will treat the other PD symptoms that are known to worsen over time.
For ET, Vim-DBS and RF lesioning have comparable reductions in tremor scores, ranging from 55–90% improvement. 6 A recent prospective trial for Gamma Knife thalamotomy demonstrated average tremor score improvement of 54% at one year blinded evaluation. 7 MRI-guided focused ultrasound (FUS) has recently been FDA-approved. With this technique, tremor scores improve an average of 40% at 12 months. 8 Long-term clinical data is not yet available. Several studies have compared RF lesioning to DBS at various subcortical targets for PD and ET (▶ Table 17.1). 9 , 10 , 11 , 12 , 13 , 14 , 15 Most of these studies showed no difference in tremors or functional outcome. The majority of the studies compared unilateral lesioning to unilateral or to bilateral DBS.
Vim DBS and RF Vim thalamotomy are generally reserved for tremor dominant PD.
STN DBS treats other PD symptoms that will likely emerge later.
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