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Other Surgical Options

What is a Thalamotomy?

  • A type of brain surgery in which the thalamus A brain structure consisting of two egg-shaped masses of nerve tissue, each about the size of a walnut, deep within the brain. The thalamus is a key relay station for sensory information flowing into the brain and filters out information of particular importance from the mass of signals entering the brain. The ventralis intermediate nucleus (Vim) of the thalamus is one of three potential targets for deep brain stimulation (DBS). DBS to this site can reduce tremor but not the other symptoms of PD., a tiny area of the brain, is lesioned.
  • Before surgery, detailed brain scans using a CT scanA medical test that uses a computer linked to an x-ray machine to take pictures of the inside of the body. or  MRI (magnetic resonance imaging) A medical imaging technique that uses magnetic forces to obtain detailed images of the body. MRI is non-invasive and does not use radiation. identify the precise location for treatment.
  • Surgery on one side of the brain affects the opposite side of the body. If you have tremor Involuntary shaking of the hands, arms, legs, jaw or tongue. The typical Parkinson’s tremor is “pill-rolling” – it looks like holding a pill between thumb and forefinger and continuously rolling it around. Some people report an internal tremor, a shaking sensation inside the chest, abdomen or limbs that cannot be seen. Most Parkinson’s tremor is “resting tremor,” which lessens during sleep and when the body part is actively in use. in your right hand, for instance, the left side of your brain will be treated.
  • The procedure can be repeated on the other side of the brain if needed, but it greatly increases the risk of speech and cognitive problems after surgery if both sides are done.

How is the surgery performed?

  • During the surgery, the patient is awake, but the scalp area where instruments are inserted is numbed with a local anesthetic.
  • The surgeon inserts a hollow probe through a small hole drilled in the skull to the target location.
  • An extremely cold substance, liquid nitrogen, is circulated inside the probe. The cold probe lesions the targeted brain tissue.
  • The probe is then removed and the wound is closed.

What to expect after surgery?

The surgery usually requires a two-day hospital stay. Most people recover completely within about six weeks.  Because there are many risk factors, including underlying medical conditions, discuss the risks with your neurologist.

How common is this surgery?

  • Thalamotomy is rarely done today.
  • May be used to treat severe tremor on one side of the body (most often in an arm or leg) that does not respond to medications.
  • Does not assist with slow movement (bradykinesia Slowness of movement.), speech problems or walking difficulties.

Pallidotomy

What is a pallidotomy?

  • In PD a part of the brain called the globus pallidus A structure in the brain involved in the regulation of voluntary movement. It is a major part of the basal ganglia system, and the global pallidus internus (GPi) is one of three potential targets for some deep brain stimulation (DBS). DBS of the globus pallidus internus can reduce tremor, rigidity, bradykinesia, gait problems and dyskinesia. is overactive. This causes a decrease in the activity of a different part of the brain that controls movement. In a pallidotomy, the surgeon lesions a tiny part of the globus pallidus by creating a scar.
  • This reduces the brain activity in that area, which may help relieve movement symptoms such as tremor and stiffness (rigidity In Parkinson’s, stiffness of the arms or legs beyond what would result from normal aging or arthritis. Some people call it “tightness” in their limbs.).
  • Before surgery, detailed brain scans using MRI identify the precise location for treatment.
  • Most likely not a good option for treatment when a person has not responded to levodopaThe medication most commonly given to control the movement symptoms of Parkinson’s, usually with carbidopa. It is converted in the brain into dopamine..
  • Surgery on one side of the brain affects the opposite side of the body. If you have tremor in your right hand, for instance, the left side of your brain will be treated

The procedure can be repeated on the other side of the brain if needed. Pallidotomy may be considered when a person with advanced PD disease has:

  1. Severe motor fluctuations Changes in the ability to move, often related to medication timing; also called “on-off” fluctuations., such as dyskinesiaAbnormal, involuntary body movements that can appear as jerking, fidgeting, twisting and turning movements; frequently caused by dopaminergic medications to treat Parkinson’s. and on-off responses, due to long-term levodopa treatment.
  2. Severe or disabling tremor, stiffness (rigidity) or slow movement (bradykinesia) medication can no longer control.

How is the surgery performed?

  • The person is awake during the surgery, but the scalp area where instruments are inserted is numbed with a local anesthetic.
  • The surgeon inserts a hollow probe through a small hole drilled in the skull to the target location.
  • An extremely cold substance, liquid nitrogen, is circulated inside the probe.
  • The cold probe lesions the targeted brain tissue. The probe is then removed, and the wound is closed.

What to expect after surgery?

The surgery usually requires a two-day hospital stay. Most people recover completely within about six weeks.  Because there are many risk factors, including underlying medical conditions, discuss the risks with your neurologist.

How common is this surgery?

  • Doctors rarely perform pallidotomy anymore.
  • Instead, doctors use deep brain stimulation, a procedure that does not destroy brain tissue and has fewer risks than pallidotomy.

What Is a subthalamotomy?

  • Subthalamotomy is a type of brain surgery in which the subthalamus A region of the brain that sits below the thalamus and receives input connections from the substantia nigra and striatum., a tiny area of the brain, is destroyed.
  • Before surgery, detailed brain scans using a CT scan or MRI identify the precise location for treatment.
  • Surgery on one side of the brain affects the opposite side of the body. If you have tremor in your right hand, for instance, the left side of your brain will be treated.
  • The procedure can be repeated on the other side of the brain if needed, but it greatly increases the risk of speech and cognitive problems after surgery.

How is the surgery performed?

  • During the surgery, the patient is awake, but the scalp area where instruments are inserted is numbed with a local anesthetic.
  • The surgeon inserts a hollow probe through a small hole drilled in the skull to the target location.
  • An extremely cold substance, liquid nitrogen, is circulated inside the probe. The cold probe destroys the targeted brain tissue.
  • The probe is then removed, and the wound is closed.

What to expect after surgery?

The surgery usually requires a two-day hospital stay. Most people recover completely within about six weeks.  Because there are many risk factors, including underlying medical conditions, discuss the risks with your neurologist.

How often are they performed?

Subthalamotomy is rarely done today.

Page reviewed by Dr. Chauncey Spears, Movement Disorders Fellow at the University of Florida, a Parkinson’s Foundation Center of Excellence.

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