Surgery for Parkinson’s disease should be performed in a hospital with certain conditions, including the availability of MRI, a precise stereotactic system and radiofrequency therapy system, intraoperative electrophysiological monitoring system, intraoperative X-ray (C-arm machine), etc. The surgical team includes experienced neurologists/specialists in movement disorders, clinical psychologists and specially trained neurosurgeons and stereotactic neurosurgeons.
Surgical treatment of Parkinson’s disease is only indicated for those patients who have been treated by experienced neurologists/specialists in movement disorders and whose motor dysfunction continues to interfere with daily life or work despite adequate and effective medication.
The specific principles are.
1. primary Parkinson’s disease.
2, levodopa preparations are or were effective.
3. More than 5 years of disease
4. H&Y classification of 2.5 or above during the on period
If the drug “off” period exceeds 2 hours per day cumulatively, or the duration of the anomaly exceeds 2 hours per day cumulatively, and the patient is taking the combination of levodopa, receptor agonist, COMT inhibitor or other three drugs per day, the patient should still have one or more of the following conditions to be considered for surgical treatment.
(1) The symptom control effect of the drug does not last for a complete day.
(2) Development of drug-induced allodynia, end-of-dose phenomenon and impairment of motor function.
(3) Predictable or unpredictable motor fluctuations.
5. The following two conditions allow for earlier surgery
(1) Tremor that is not fully controlled by medication.
(2) Patients with Parkinson’s disease cannot tolerate the side effects of anti-Parkinson’s disease drugs
On the basis of meeting the above conditions, the patient has no contraindications to conventional neurosurgery (bleeding tendency, infection, etc.); has no significant intellectual impairment or psychiatric disorders, and is willing and able to cooperate during the procedure.
Preoperative evaluation is particularly important in the surgical treatment of Parkinson’s disease, not only to determine the surgical outcome in advance, but also to enable the family to have reasonable expectations of the surgical outcome. The preoperative evaluation should be done by neurologists and psychologists who have specialized training in movement disorders. Whether the patient is treated with disruptive surgery or deep brain electrical stimulation, the patient should receive a thorough and complete preoperative evaluation to determine the patient’s suitability for surgery and to predict the outcome of the procedure and to document the data for long-term follow-up. Patients are evaluated 3-7 days prior to surgery for motor and other functional status during the “on” and “off” phases of the drug. Commonly used assessment scales include the UPDRS, Hoehn-Yahr Scale, Schwab-England Daily Living Scale, and the Brief Psychiatric Symptom Inventory and Hamilton Depression Inventory. For patients with suspected cognitive impairment, the patient’s intelligence, memory, comprehension, judgment, and operative functions should be assessed preoperatively. All anticoagulant agents should be discontinued two weeks before surgery to reduce intraoperative bleeding and to control the patient’s hypertension and diabetes mellitus.
It is currently a very sensitive topic as to whether Parkinson’s disease can be treated surgically at an early stage. First of all, we should define the meaning of early stage: it usually means the early stage of the disease when the history of the disease is less than 5 years, or when the history of the disease is even more than 5 years, but the medication is effective and there are no drug side effects, or when the horn & Yahr classification is before grade 3. However, in patients with primary Parkinson’s disease, early levodopa preparations are very effective in controlling symptoms, and a small amount of medication can significantly improve Parkinson’s disease symptoms, and surgery is not necessary at this time. The exceptions are: patients who have severe adverse reactions to all anti-Parkinsonian drugs and are unable to receive drug therapy; those who have severe tremor symptoms and whose symptoms cannot be controlled by drug therapy, early intervention may be considered in order to improve their quality of life and ability to work. For young Parkinson’s disease patients who are PARK gene-positive, early surgery may be considered in order to delay the time when long-term medication causes side effects.
Another early concept refers to Parkinson’s disease patients within three years of developing drug complications such as switching phenomena and allodynia, when an article published in the New England Journal in 2013 confirmed that surgical treatment with a brain pacemaker is superior to drug therapy alone.
In addition to the duration of the disease, the age of the patient at the time of the procedure has a significant impact on the outcome. Generally speaking, younger patients with heavy eccentric symptoms, good response to levodopa, and better general health have better surgical results; patients should not be too old for surgery, should be in good physical condition, and should have no other serious brain lesions or brain atrophy on head CT or MRI. Although age is not an absolute limitation, physical fitness is still important. Although the surgery itself will not cause the death of the patient, but over 70 years old, the drowsiness and indifference that patients with poor physical fitness are prone to after surgery, some patients will be accompanied by lung infection, high fever, and even life-threatening, such tragedies have happened. In particular, patients with hypertension, diabetes, atherosclerosis, heart disease and poor general health are more likely to have postoperative complications.
It should be emphasized that since transplantation is still in the experimental stage, the surgical method currently applied in clinical practice is only symptomatic treatment and does not really cure Parkinson’s disease, which still requires post-operative medication, but the dose can be reduced.