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Surgical treatment of Parkinson disease

Author
Daniel Tarsy, MD
Section Editor
Howard I Hurtig, MD
Deputy Editor
John F Dashe, MD, PhD

INTRODUCTION

As many as 50 percent of patients on levodopa for five years experience motor fluctuations and dyskinesia [1]. These symptoms are especially common in patients with young-onset (eg, under the age of 50) Parkinson disease (PD); they are unique to levodopa and are not produced by the other antiparkinson drugs. (See "Pharmacologic treatment of Parkinson disease".)

The surgical management of patients with advanced PD who are experiencing motor fluctuations will be reviewed here. The medical management of motor fluctuations associated with PD and levodopa therapy and the general approach to therapy of this disorder are discussed separately. (See "Motor fluctuations and dyskinesia in Parkinson disease" and "Pharmacologic treatment of Parkinson disease".)

BACKGROUND

Motor fluctuations and dyskinesia — Patients typically experience a smooth and even response to the early stages of levodopa treatment. As the disease advances, however, the effect of levodopa begins to wear off approximately four hours after each dose, leaving patients anticipating the need for their next dose. This phenomenon has been explained by the observation that dopamine nerve terminals are able to store and release dopamine early in the course of disease but, with more advanced disease and increasing degeneration of dopamine terminals, the concentration of dopamine in the basal ganglia is much more dependent upon plasma levodopa levels. Plasma levels may fluctuate erratically because of the 90 minute half-life of levodopa and the frequently unpredictable intestinal absorption of this medication.

Motor fluctuations are alterations between periods of being "on," during which the patient enjoys a good response to medication, and being "off" during which the patient experiences symptoms of the underlying parkinsonism. Dyskinesia consists of abnormal involuntary movements that are usually choreic or dystonic but, when more severe, may be ballistic or myoclonic. Dyskinesia usually appears when the patient is "on." They may occasionally occur in the form of painful dystonias when the patient is "off," especially in the morning on awakening, when dystonic intorsion of a foot or curling of the toes (usually on the side of greater parkinsonian involvement) occurs as a withdrawal reaction because of the long interval without medication overnight.

Rationale for surgery — Two downstream effects of nigral degeneration and dopamine deficiency in PD are excessive subthalamic nucleus (STN) excitation of the internal globus pallidus (GPi) and excessive globus pallidus inhibition of the thalamus. These, in turn, cause reduced thalamocortical activity, which is believed to mediate the symptoms of akinesia and rigidity.

                       

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Literature review current through: Nov 2016. | This topic last updated: Tue May 19 00:00:00 GMT+00:00 2015.
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