Surgery for Parkinson's Disease
The limitations of medical therapy are the driving force behind the development of surgical procedures for the treatment of Parkinson's disease. Surgical procedures were relatively common in the 1950s as adequate medical therapy was not available. With the introduction of levodopa, the perceived need for surgical therapies was greatly reduced and few procedures were performed in the late 1960s and through the 1970s. By the 1980s, the long term inadequacies of levodopa therapy were apparent. In addition, increased understanding of Parkinson's disease allowed rational targets for surgical procedures to be identified. Advances in brain imaging and electrophysiologic recording provided hope that these targets could be accessed with greater precision and consistency. Improved surgical techniques lowered morbidity and mortality. The convergence of these advances rekindled interest in surgical procedures.
The three basic types of surgery for Parkinson's disease are:
Lesioning involves the destruction of a target site to modify function. Most lesions today are created by the application of efectrotherrnal energy.
Stimulation procedures involve the implantation of an electrode with an exposed tip into a target site. The electrode is connected to a wire run beneath the skin to a stimulator placed in the chest wall. When electrical current is activated it modifies the function of the target site. The principal advantage of stimulation is that it provides a degree of control. The stimulator can be adjusted externally using a programmer with an electromagnetic head. If a side effect occurs due to electrical stimulation, the stimulation can be reduced and the side effect will resolve.
Implantation involves the delivery of tissue or other material into a target site. It is hoped that implanted cells can replace lost neurons to restore function. Neurologists and neurosurgeons have explored various ways of grafting dopamine-producing cells in the brain rather than trying to correct the neurotransmitter imbalance with drugs. One promising approach uses fetal-tissue implants. Some improvements have been observed, but because of the source of the cells, the technique is highly controversial. Alternative dopamine-producing cell lines are being developed.
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