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Parkinson's disease: neurosurgery at an earlier stage?
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  1. V Mesnage1,
  2. J–L Houeto1,
  3. M–L Welter1,
  4. Y Agid1,
  5. B Pidoux2,
  6. D Dormont3,
  7. P Cornu4
  1. 1Centre d’Investigation Clinique, Fédération de Neurologie and INSERM U 289, Hôpital de la Salpêtriére, Paris, France
  2. 2Fédération de Neurophysiologie Clinique, Hôpital de la Salpêtriére
  3. 3Service de Neuroradiologie, Hôpital de la Salpêtriére
  4. 4Service de Neurochirurgie, Hôpital de la Salpêtriére
  1. Correspondence to:
 Dr Y Agid, Centre d'Investigation Clinique, Hôpital de la Salpêtriére, 47 boulevard de l'Hôpital, 75013 Paris, France;
 agid{at}ccr.jussieu.fr

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Bilateral high frequency stimulation of the subthalamic nucleus (STN) is an alternative treatment for advanced forms of levodopa-responsive Parkinson's disease (PD) with severe motor complications.1 Most patients so far treated in this way had their disease for an average of 15 years,2 no longer worked, were socially isolated and dependent on their families. As this neurosurgical treatment remarkably improves parkinsonian motor disability and levodopa induced dyskinaesias, we wondered whether operating earlier during the course of the disease would enable patients to maintain their previous social and professional status. A retrospective analysis of 41 successive severely disabled PD patients operated in our department3 showed that four of them, who had disease duration of less than 10 years, were allowed to still maintain their professional activity after neurosurgery.

CASE 1

A 47 year old man, restaurateur with two dependent children, had had PD for five years. Levodopa induced dyskinaesias were so severe that he was no longer able to cope with his managerial functions and feared bankruptcy. Six months after neurosurgery, parkinsonian motor disability, daily doses of levodopa, and severity of levodopa induced motor complications decreased by 97%, 87%, and 100%, respectively. The patient has sold his business but has resumed his professional activity in another establishment.

CASE 2

A 48 year old woman, single without children, had had PD for five years. The response to levodopa treatment was excellent apart from disabling levodopa related motor complications.

She was the assistant director of a jewellry shop and had increasing difficulties performing her job. She was frequently on sick leave, and for this reason, was about to be made redundant. Bilateral stimulation of the STN reduced her motor handicap, daily doses of levodopa, and levodopa induced motor complications by 95%, 93%, and 90%, respectively. Nine months after the operation, she was again working full time.

CASE 3

A 46 year old woman, divorcee with two dependent children, had had severe PD for nine years. She was an emergency room nurse, but had been on sick leave for two years and expected to be let go for reasons of invalidity. The operation reduced her motor handicap, daily doses of levodopa, and levodopa induced motor complications by 87%, 76%, and 84%, respectively. Four months after the operation, she went back to work half time in the outpatient clinic of the department of medicine.

CASE 4

A 50 year old woman, married with one child, had had severe PD for five years. She was a lawyer and feared being unable to continue to exercise her profession. Nine months after neurosurgery, her motor handicap, daily doses of levodopa, and levodopa induced motor complications were reduced by 84%, 80%, and 75%, respectively. She is successfully pursuing her career.

These findings suggest that bilateral high frequency stimulation of the STN, when performed sufficiently early in the evolution of PD, can prevent the motor handicap and adverse reactions of levodopa from interfering with socio-professional integration and family life. Although this is an open label observation of select PD patients reported in the absence of long term follow up, we wonder whether one should not give PD patients a chance for a normal life, when otherwise they are certain to lose their job and their autonomy, even with optimised antiparkinsonian medications. We propose that a controlled study should be performed to demonstrate the validity and the economical consequences of this proposition. Such a decision needs to be balanced by taking into consideration the long waiting lists in the centres performing such surgery and the risks associated with neurosurgery.

References

Footnotes

  • Competing interests: none declared.

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