الفهرس 
Historical BackgroundOnly 14 pages are availabe for public view
 |  | from | 258 |  |  |
| | | from | 258 | | |
Abstract
Patients with idiopathic PD who have exhausted medical therapy to control disabling symptoms should be considered as possible candidates for pallidotomy. The criteria for the diagnosis of PD requires the presence of at least 2 of the cardinal features of PD; clear response to levodopa (patients should be examined in both the ”on” and ”off” states); no evidence of other causes (encephalitis, exposure to toxins, recent exposure to neuroleptics, head trauma, or relevant vascular disease); lack of cerebellar ataxia, vertical gaze palsy, and pronounced autonomic features; and MR images without lacunar infarcts that are thought to be causative of the parkinsonism, normal-pressure hydrocephalus, and marked cerebellar and/or brainstem atrophy.
Ventroposterior pallidotomy significantly improves motor performance and daily level of function in Parkinson disease. Cognition and behavior are not adversely affected in patients without dementia, and a cognitive screening battery is proposed.
No maximum or minimum age or stage of the disease should preclude consideration for pallidotomy but younger patients have the chance for better results. That’s why management of advanced PD can be difficult, the panel that’s why patient evaluations and treatment should be performed by a neurologist with expertise in movement disorders.
A standardized assessment system should be applied to all patients preoperatively and postoperatively based on appropriate rating scales. Electrophysiological monitoring is very important and needs a long time of training especially the microelectrode recording techniques.
Stereotactic pallidotomy should be performed at well equipped centers with a team of physicians and nursing staff. Adequate facilities should provide high-resolution MR imaging (with appropriate software) and full stereotactic capabilities. All patients should be examined and medically treated by a neurologist with expertise in diagnosing and caring for patients with PD.
Several issues should be discussed with all patients before surgery. It should be made clear that pallidotomy treats some symptoms better than others and patients should have realistic expectations.
Symptoms that respond best to pallidotomy include medication-induced dyskinesias, rigidity, and tremor, while balance, gait disorders, and hypophonia are generally less responsive to surgery.
Benefits of pallidotomy appear to be long lasting. The beneficial effects of unilateral pallidotomy persist for at least 12 months and, dyskinesias are most responsive to this procedure.
unilateral and simultaneous bilateral pallidotomy can reduce all the key symptoms of Parkinson’s disease (i.e., akinesia, tremor, and rigidity) and the side effects of L-dopa treatment (i.e., dyskinesias. Although simultaneous bilateral pallidotomy was more effective than unilateral pallidotomy regarding tremor, rigidity, and dyskinesias, it should be considered only as a staged procedure with at least a 6-month interval between surgeries. Indications for a second pallidotomy include severe drug-induced symptoms on the side not operated on and a good response to the previous surgery. Since bilateral pallidotomy carries a higher risk of postoperative speech deterioration Patients with speech or swallowing difficulties (by history and examination) or cognitive decline after the first procedure should be excluded from a second operation.
The stereotactic pallidotomies are effective and safe options in the treatment of the intractable cases of primary dystonia. It resulted predominantly in contralateral improvement of motor functions.
The pallidum should be considered the target of choice for secondary dystonia except in two conditions: the presence of signal change in the pallidum and in action dystonia or dystonic tremors. However longer follow up periods and larger number of cases will be needed to prove this conclusion.
Pallidal stimulation is nowadays the mainstay surgical treatment for patients with dystonia, particularly generalized dystonia. Various well designed recent clinical trials support the efficacy of the procedure. Improvements of 40-80% have been reported in primary generalized, segmental and cervical dystonia. For secondary dystonia, a similar outcome has been described in patients with tardive dystonia and pantothenate kinase-associated neurodegeneration.
DBS is currently preferred to ablation in stereotactic surgical treatment of different movement disorders, given the adjustability of stimulation parameters and potential reversibility of adverse effects, lack of interference with benefit from possible future drug therapies, and putatively lesser morbidity, especially in cases of bilateral surgery. It must be noted, however, that the cost of DBS and lack of readily available expertise in implanting, programming, and adjusting devices hinder the adoption of DBS in many geographic regions, especially in rural areas in developed countries and in developing regions
If all these aspects are taken into consideration, the results of these surgeries could be very promising, and the recover of patients might be complete.