Brain Surgery for PD Symptoms: Thalamotomy, Pallidotomy, and Deep Brain Stimulation

Mrs. Quixley: "I've never responded to Sinemet. Right now I'm taking 1500 mg daily and it doesn't seem to be doing anything. Should I undergo one of these new brain surgeries?"
Unfortunately Mrs. Quixley is unlikely to benefit from any of the surgeries for PD. If you don't respond to carbidopa/levodopa, you will not respond favorably to surgery. The only exception is tremor. If tremor is her primary problem, then thalamic deep brain stimulation or thalamotomy might be considered. Parenthetically, stimulation of the pallidum or subthalamic nucleus will also reduce tremor, although perhaps not as effectively as thalamic stimulation.

 Deep brain stimulation (DBS) electrode inside the brain. The high-frequency stimulation turns off the neurons in the vicinity.

Mrs. Ruben: "I would be doing great if it weren't for these wild dyskinesias. When I lower my levodopa dose they go away, but then I can't move. Would surgery help?"
 If dyskinesias are prominent and disabling, and can't be controlled adequately with medication adjustments, this alone is adequate reason to consider surgery. Subthalamic nucleus or pallidal deep brain stimulation are appropriate considerations. If the dyskinesias are one-sided, a unilateral pallidotomy could also be considered.

 The initial step in any of these surgeries is attachment of the stereotactic head frame, which allows the surgeon to identify the brain target in a three-dimensional coordinate system. The surgical head frame is fastened to the skull with small bolts.

Mr. Stewart: "My levodopa makes me almost normal, but the effect only lasts about 90 minutes. Not only do I need to take medicine all the time, but sometimes it doesn't work and I can't walk. My mother-in-law suggested brain surgery. What do you think?"
 Most mother-in-laws who advise brain surgery are kidding; this is one case where that advice was right on target. Mr. Stewart's levodopa responses suggest that he is a good candidate for subthalamic nucleus deep brain stimulation. With that surgery, you can capture the levodopa response and sustain it throughout the day. However, you need to balance these potential benefits against the risks of surgery and the hassle factor inherent in deep brain stimulation.

 Deep brain stimulation. The programmable neurostimulating unit is implanted in the upper chest under the skin (like a heart pacemaker). Current from the unit passes via the insulated wire (under the skin) to the stimulating electrode within the brain.