Surgical Management of Movement Disorders

DBS does not improve symptoms that are resistant to levodopa and, consequently, careful documentation of an adequate response to levodopa is important in surgical candidates. A positive symptomatic benefit from levodopa exposure predicts a better surgical outcome than otherwise. There is no clear age cut-off for the procedure. Octogenarians undergoing the procedure have done well. In general, surgery is reserved for those with a confirmed clinical diagnosis of idiopathic Parkinson disease who have developed motor fluctuations and drug-induced dyskinesias despite optimal medical therapy. Patients should have no general medical contraindications to surgery and should be without dementia or psychiatric comorbidities. In patients with atypical symptoms or a Parkinson-plus syndrome, a poor response to levodopa, dementia, or marked psychiatric disease, DBS is associated with an increased risk for poor outcome and is generally contraindicated. All parkinsonian symptoms improve with surgery, particularly tremor and medication-related abnormal involuntary movements on the side contralateral to the procedure. Rigidity and bradykinesia respond well but to a lesser degree. Postural instability and gait disturbances are less likely to respond.

It is not clear how DBS works. What is evident is that DBS provides a nondestructive and reversible means by which to disrupt neuronal function. DBS continues to evolve as an important and established treatment for neurologic diseases, with new indications being added continuously. A multidisciplinary approach to management provides the best chances for a good outcome in those who are candidates for surgery.

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