Functional neurosurgery for movement disorders: a historical perspective
Introduction
Parkinson's disease (PD) is due to the nigral degenerescence of dopaminergic neurons, leading to a disorganization of functional circuits in the basal ganglia (BG). This involves primarily the substantia nigra pars compacta (SNc) sending both inhibitory and excitatory dopaminergic projections to the caudate putamen or striatum. From the striatum, two descending parallel pathways project either directly (GABAergic output) to the globus pallidus internus (GPi)/substantia nigra pars reticulata (SNr) complex, or indirectly through (gamma-aminobutyric acid) GABAergic projections to the external pallidum (GPe) and then to the subthalamic nucleus (STN). The STN projects through a glutamatergic pathway to the GPi–SNr complex. This complex is considered to be the final output structure of the BG and projects through a GABAergic projection to the motor thalamus, which itself projects to the cortex. In turn, the cortex sends a strong glutamatergic projection to the STN, which receives also a glutamatergic projection from the centrum medianum–parafascicularis (CM–Pf) complex, and from the pedunculopontine nucleus (PPN).
The decrease of the dopaminergic output of the SNc induces an imbalance between the two output pathways from the striatum to the pallidum. GPi is disinhibited and hyperexcited and, as a consequence, increases its inhibitory output to the thalamus and then to the cortex, which is therefore inhibited. This is the putative pathogenicity of akinesia and rigidity, which are two main symptoms of the parkinsonian triad. The third component, tremor, can be explained as the symptomatic expression of the disorganization of the BG, leading to a periodic or oscillatory behavior.
Section snippets
Therapy for movement disorders: a random walk around a logical thread
The underlying logic or rationale is that a lesion of the motor system would weaken the motor function, and thereby the motor disturbance and disorders. These lesions can be produced by pyramidotomies or corticectomies, but essentially by lesions in the motor control system (Hassler et al., 1960; Meyers, 1942).
Serendipity has played a role in the discovery of surgical solutions to treat movement disorders. Cooper (1953), during a surgical procedure to perform pyramidotomy, had an accidental
The thalamic ventral intermedius nucleus (VIM)
Stimulation of the thalamic VIM works essentially on tremor with a long-lasting effect that does not change along time (Benabid et al. (1991), Benabid et al. (1996)), even not over a period of 20 years (Fig. 2).
As tremor in PD is equally improved by STN HFS (Benabid et al., 2009), the indications of VIM stimulation have strongly decreased. They are currently restricted to essential tremor where VIM is still the consensual target, although data are being reported on the efficiency of STN
Deep brain stimulation: a preferred tool in functional neurosurgery?
DBS has advantages, particularly flexibility, in addition to reversibility and adjustability of the intensity of stimulation (Table 1). The best demonstration is given in PD patients suffering from freezing of gait, where bilateral STN stimulation at 130 Hz is able to control akinesia and rigidity and simultaneous bilateral simulation of the PPN at 25 Hz improves the freezing of gait (Mazzone et al., 2005; Plaha and Gill, 2005; Stefani et al., 2007). This combination of targets at different
The pharmacology of STN high frequency stimulation
From depression to normal mood and then hypomania, there is a continuum that can be traveled along the intensity of any treatment, whether pharmacological or electrical. There is a narrow band called “normality,” corresponding to an optimal value of DBS treatment or drug dosage. Below these levels, one may see bradykinesia, doubt, obsessions, depression, sadness (Bejjani et al., 1999), and apathy (Krack et al., 2003; Funkiewiez et al., 2004). For higher values than needed, one may see
Conclusions
The saga of functional neurosurgery for movement disorders runs over almost a century. It has been driven by the combined and intertwined forces of therapeutic needs from the pathology, available tools from technology and pharmacology, scientific knowledge from clinical and basic research, anatomy, and neurophysiology. Its course has been shaped by creativity of investigators, positive thinking, luck, and serendipity. The increasing amount of technologies, the improved efficiency of
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