Stereotactic and Functional Neurosurgery: Movement Disorders and Pain: Medical Management and Functional Neurosurgery (Stereotactic and Functional Neurosurgery)

Deep brain stimulation (DBS) in the subthalamic nucleus (STN) and the internal segment of the globus pallidus (GPi) is increasingly being used for the treatment of advanced Parkinson’s disease (PD). Although both targets have demonstrated clinical efficacy in the treatment of the cardinal motor signs of PD, the STN has gained greater popularity and is now considered the site of choice by most centers performing these procedures. This preference stems predominately from the belief that STN DBS provides greater improvement in reducing the motor manifestations of PD and allows a reduction in dopaminergic medication not permitted with GPi DBS. There are, however, a number of issues that must be considered before abandoning GPi in favor of STN as the surgical target of choice for DBS. The maximal benefit reported for GPi stimulation is not significantly different than that reported for the STN, 67 versus 71%, and while reductions in medication are required with STN stimulation to avoid inducing dyskinesia, GPi stimulation may directly suppress dyskinesia obviating any need to reduce medication. As such, many centers may not attempt to reduce antiparkinsonian medication with GPi DBS. In addition, there are significantly more reports of changes in mood, behavior and a higher incidence of adverse events reported for STN stimulation. Most studies of DBS are nonrandomized, assessment protocols are not standardized, and lead locations are not reported. Thus, before drawing conclusions regarding the optimal site for DBS for advanced PD we must take a critical eye to the present data and address the outstanding questions that remain with well-designed clinical trials that evaluate motor, nonmotor and adverse events and address the above clinical variables by randomizing patients, using standardized methods of assessment and defining the lead location. Annotation Recent research and advances in the medical management of movement disorders and pain and in functional neurosurgery are collected in this issue arising from a conference held in April 2002 in Oxford. Excellent papers covering the spectrum of movement disorders and pain syndromes and the stereotactic neurosurgical interventions that have been used in their treatment are presented. Other outstanding articles deal with surgical techniques, overviews and developments in deep brain stimulation for dystonia and Parkinson disease. Further important topics such as safety and risk of microelectrode recording in surgery for movement disorders are also discussed. Presenting the state-of-the-art of the most recent surgical advances and current thinking about the management of these challenging conditions this publication is essential reading for stereotactic and functional neurosurgeons, movement disorder neurologists, pain specialists, and health care providers involved in the care of patients suffering from movement disorders and pain syndromes