Advances In Functional Neurosurgery
November/December 2006
Clinical studies suggest deep brain stimulation may be more effective than medical therapy for Parkinson’s patients.
Neurosurgical intervention is becoming increasingly important in the treatment of neurological movement disorders, including Parkinson’s disease. Recent European clinical findings suggest that deep brain stimulation (DBS) may actually be more effective than medical therapy in a selected group of patients with advanced Parkinson’s disease: “In a six-month study of patients under 75 years of age with severe motor complications of Parkinson’s disease, neurostimulation of the subthalamic nucleus was more effective than medical management alone.” (NEJM 2006; 355(12):1289.)
“This study is highly significant,” says Gordon Baltuch, MD, director of the Center for Functional and Restorative Neurosurgery at the University of Pennsylvania Health System. “For the first time, a well-designed randomized study has been published which indicates that if you have a patient suffering from severe Parkinson’s disease with poorly controlled motor fluctuations, they should be considered for evaluation for subthalamic deep brain stimulation. Even when you take into consideration the inherent risks of brain surgery, patients are likely to do better with surgery than medical therapy.
“Using quality of life as an outcome measure was an important element of the European study and, in part, why it received so much attention in the field," continues Dr. Baltuch. “For the first time, the outcome of the study was measured in terms of quality of life for the patient, not if he could move his arm an extra millimeter.”
Dr. Baltuch collaborates closely with the Parkinson’s Disease and Movement Disorder Center, recognized by the National Parkinson Foundation as a worldwide Center of Excellence. Directed by Matthew Stern, MD, the Center is one of the largest of its kind in the country and the most prominent in the Philadelphia area. Together, physicians from both Centers are currently participating in a similar U.S.-based clinical trial sponsored by the Veterans Administration and the National Institutes of Health.
DBS involves stimulating the brain’s networks using electrodes implanted deep within the brain. It has demonstrated effectiveness for Parkinson’s, dystonia and epilepsy and was FDA-approved for Parkinson’s disease in 2002. Since then, increased understanding of the neuroanatomical and pathophysiological substrates of Parkinson’s and advances in brain imaging and neurosurgical techniques have contributed to the effectiveness of DBS. “We’ve seen tremendous technological improvements,” says Dr. Baltuch. “Surgical mapping is more exact and we can integrate that information with our microelectrode recordings, which makes the surgery more precise.”
Typically, patients with advanced Parkinson’s who still respond to pharmacologic treatment are the best candidates for DBS. “We aren’t sure why yet, but once the medication no longer works for the patient, DBS is not effective,” says Dr. Baltuch.
Neurologists and neurosurgeons at Penn are leaders in the surgical management of movement disorders and have performed more than 400 DBS cases, one of the largest case volumes in the country. “Our goal is to develop the treatment approach that is right for the patient,” says Dr. Baltuch. “Not every patient is a candidate for DBS but it’s important that physicians are aware of it for those patients it would benefit.”
In addition to their work on Parkinson’s, several of Penn’s neurosurgeons are partnering with Penn psychiatrists to determine the efficacy of electrical neuromodulation including vagal nerve stimulation and DBS for treatment resistant depression. “The medical field has traditionally thought of depression as a chemical imbalance but now we’re moving to a different paradigm—considering stimulating the brain’s networking as treatment. If we can demonstrate DBS effectiveness, this will be the most exciting news in functional neurosurgery,” says Dr. Baltuch. “There are a series of pilot cases currently in Canada and the results have been very favorable. Our hope is to move forward with a pivotal trial here in the U.S.”
Penn researchers are also considering DBS for treatment of obsessive compulsive disorder.
For more information about the Center for Functional and Restorative Neurosurgery or to refer a patient, call Penn’s physician line,
PENNHealth, at 1-800-789-PENN.
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