微电极记录技术在帕金森病手术治疗价值

目的　总结微电极导向立体定向手术治疗帕金森病的临床经验及治疗效果。方法　自 1 999年 4月至 2 0 0 1年 2月采用微电极导向立体定向手术治疗帕金森病 350例 ,其中苍白球腹后部毁损术 (PVP) 2 78例 ,丘脑腹中间核 (Vim)毁损术 35例 ,同期同侧PVP和Vim毁损术 1 5例 ,行同期双侧PVP 1 1例 ,分期双侧PVP 8例 ,分期一侧PVP或另一侧Vim毁损术 3例。对手术前后的“关”状态和“开”状态进行生活能力评分、UPDRS评分 ,并进行门诊随访。结果　术后日常生活能力评分“关”状态提高 2 9.8% ,“开”状态提高 2 5 .9%。UPDRS :在“关”状态下 ,总的改善率为 57.3 % ,其中精神行为情绪改善率为 50 .8% ,日常活动改善率 59.1 % ,运动功能改善率 58.2 %。结论　PVP对震颤效果不如Vim毁损术 ,对震颤明显 ,无明显僵直的患者可选择Vim毁损术 ,对震颤僵直型患者可分期双侧PVP毁损术。     

帕金森病毁损术治疗的手术方式选择与疗效关系

目的：总结帕金森病（PD）苍白球和丘脑毁损术的手术方式选择与手术效果关系。方法：对213例PD患者进行了221次微电极导向立体定向手术治疗。临床分型;震颤型17例,僵直型38例,震颤僵直型158例,其中苍白球腹后部毁损术（PVP）171例;丘脑腹中间核（Vim)毁损术21例;同期同侧PVP和Vim毁损术8例;同期双侧PVP5例,分期双侧PVP8例。结果：术后UPDRS评分发现上述各种术式在“关”状态下和“开”状态下症状均有明显改善。改善率分别为50.8%-60.8%和28.7-36.6%,但以多靶点毁损术为佳。同期双侧PVP发生明显构音障碍,吞咽困难1例,结论：应根据不同症状选择不同术式,PVP对僵直、“开-关”现象、异动症,肢体无力及肌肉酸痛效果较好,震颤效果略微差一些,对运动迟缓、连带动作、语言发音也有一定改善率,但对平衡,步态及姿势等轴性症状效果较差。甚至个别症人术后步态障碍加重。Vim毁损术对震颤效果最为理想,同期双侧PVP手术易产生并发症,应慎重采用。     

分期双侧丘脑及苍白球毁损治疗帕金森病的手术策略及疗效分析

目的 总结分期双侧丘脑及苍白球核团毁损治疗原发性帕金森病(PD)的疗效,探讨其有效性及安全性. 方法 安徽医科大学附属省立医院神经外科自1998年2月至2008年5月对已行一侧核团毁损术的19例患者施行微电极导向立体定向对侧丘脑及苍白球核团毁损治疗,其中16例患者一期行丘脑腹中间核(Vim核)毁损,二期行对侧苍白球内侧部(Gpi核)毁损,同时加做Vim核小灶毁损.3例患者一期行Gpi核毁损,二期行对侧Gpi核毁损及Vim核小灶毁损.采用PD国际统一评分量表(UPDRS)对患者术前、术后1周“开”、“关”两种状态进行评分,分析术后症状改善情况及并发症的发生. 结果 所有患者的整体病情和典型症状(震颤、僵直、行动迟缓)均得到明显改善,二期Gpi核毁损术对缓解僵直明显,加做Vim核小灶毁损,震颤缓解满意.2例患者术后出现构音困难,其中1例伴吞咽困难.3个月后症状缓解. 结论 对双侧症状均较严重的PD患者,只要严格掌握适应征,选择合适的靶点,严格控制毁损灶大小,分期双侧丘脑及苍白球核团毁损治疗是一种安全有效的方法.     

两种(核团)毁损术治疗帕金森病的疗效比较

目的 研究丘脑腹中间核（Vim核）毁损术与苍白球腹后内侧核（PVP）毁损术在治疗帕金森病（PD）的临床效果、术后反应及并发症。方法 回顾性分析我院从2000～2005年完成立体定向毁损术220例，行单侧Vim核毁损术125例（一组），PVP毁损术（二组）95例，对其两组临床效果、术后反应、并发症及头颅MRI扫描进行比较研究。结果两组术式手术有效率：Vim核124例（99．2％），PVP93例（97．9％）；术后反应：Vim核19例（15．2％），PVP7例（7．4％）；手术并发症：Vim核22例（17．6％），PVP2例（2．1％）。结论 帕金森病（PD）定向毁损术应根据震颤型、僵直型和运动不能型选择丘脑或／和苍白球毁损术，苍白球毁损术术后反应及并发症较丘脑毁损术明显减少，有显著差异。     

老龄帕金森病手术治疗的体会

目的：介绍微电极引导立体定向手术治疗老龄帕金森病的方法和结果。方法：采用CT/MRI双重影像学定位,术中行微电极记录技术靶点监测,对28例70岁以上老龄帕金森病患者行丘脑腹外侧核、苍白球腹后内侧部射频毁损,其中1例行单侧丘脑腹外侧核毁损术,1例行双侧丘脑腹外侧核毁损术;26例行苍白球腹后内侧部毁损术,其中1例行同期单侧苍白球腹后内侧部及丘脑腹外侧核毁损术,术前及术后12月应用motorUPDRS量表进行评价。结果：2例丘脑腹外侧核毁损术后12月,肢体静止性震颤完全或基本消除,其中1例下颌静止性震颤有明显缓解;26例行苍白球腹后内侧部毁损术,术后静止性震颤、僵直、运动迟缓均有较大改善。结论：微电极引导立体定向手术是治疗老龄帕金森病的有效手段之一。但是仍有可能出现严重的并发症。     

刺激术和毁损术在双侧立体定向手术治疗帕金森病中的比较

目的比较脑深部刺激术和毁损术在双侧立体定向手术治疗帕金森病中的优缺点。方法69例帕金森病病人进行了双侧手术治疗,其中同期双侧丘脑底核(STN)脑深部刺激术(DBS)11例,同期一侧苍白球腹后部毁损术(PVP),另一侧STNDBS3例,分期一侧PVP或腹中间核(Vim)毁损术、另一侧STN或VimDBS9例;分期双侧PVP或Vim毁损术41例,同期双侧PVP5例。平均随访9.3个月。结果UPDRS评分显示刺激术和毁损术均能显著改善对侧肢体震颤、僵硬和运动迟缓症状,双侧刺激术还能改善步态和姿势症状,但双侧毁损术可加重语言、吞咽及流涎等症状,并发症较高。结论双侧DBS是具有双侧症状的帕金森病病人手术治疗的最佳术式,双侧毁损术并发症较高,应严格慎重采用。     

立体定向选择性Vim核和(或)PVP核毁损术治疗帕金森病疗效观察

目的观察应用立体定向脑内核团毁损术治疗帕金森病的临床疗效。方法 2012年7至2013年12月采用立体定向丘脑腹中间核(Vim核)和或苍白球腹后外侧部(PVP核)毁损术治疗帕金森病45例。术前、术后1个月进行UPDRS评分,比较手术前后评分的变化和症状改善情况。结果 45例帕金森病患者的肢体震颤、僵硬及运动迟缓均得到明显改善,术后1个月的UPDRS评分较术前明显减少(P0.01),术后无明显并发症。结论立体定向脑内核团毁损术治疗帕金森病疗效显著,靶点定位、毁损范围及程度与手术疗效及并发症密切相关。     

微电极记录技术在治疗帕金森病手术中应用价值

目的总结微电极导向立体定向手术治疗帕金森病的治疗效果.方法采用微电极向立体定向手术治疗帕金森病380例,采用坐标和图像直接定位相结合.行苍白球腹后部毁损术(PVP)305例,丘脑腹中间核(Vim)毁损术34例,行同期同侧PVP和Vim毁损术16例,行同期双侧PVP11例,分期双侧PVP11例,分期单侧PVP或Vim毁损术3例,术前、术后的关状态和开状态进行生活能力评分、UPDRS评分.结果术后日常生活能力评分“关”状态提高29.8%,“开”状态提高25.9%.UPDRS总的改善率为57.3%,其中精神行为情绪改善率为50.8%,日常活动改善率59.1%,运动功能改善率58.2%;并发症颅内出血5例,全组无死亡.本组有220例术后随访4～18个月,其中显效130例(59%),改善75例(34%),无效15例(7%).结论用微电极记录可准确定位,了解周围结构,以提高疗效,减少并发症.在临床应用中观察到毁损灶偏向苍白球内侧对僵硬和运动障碍改善明显,而偏向苍白球外侧对震颤改善明显.PVP毁损对异动症、“开一关”症状及肌张力增高效果最好;对肌肉酸痛、震颤、步态、姿势、语言其次;对植物神经功能障碍无明显疗效.PVP对药物治疗反应较好的患者手术效果也较理想,Vim毁损术对药物治疗无效的震颤也有明显效果.     

帕金森病外科治疗的适应证及毁损部位的选择

目的介绍微电极导向立体定向毁损手术治疗帕金森病的适应证及毁损部位选择的经验.方法回顾607例帕金森病患者采用微电极导向立体定向毁损手术治疗经验,根据临床症状分型确定,单纯震颤型,选择丘脑腹外侧核(Vim,Vop)为靶点;僵直少动型选择苍白球腹后内侧部为靶点;混合型首先选择苍白球腹后内侧部为靶点,术中如肢体震颤改善不理想时,再加丘脑腹外侧核(Vim)毁损.结果手术有效率97.3%,术后患者Hoehn和Yah分级及UPDRS评分及药物所致运动障碍均有显著改善.术后1周开状态改善率62.3%±11.3%,关状态改善率76.1%±8.7%.总并发症的发生率为5.5%,永久性并发症为1.3%.结论微电极记录技术能显著提高手术定位准确率及成功率.合适的病例选择对于良好的手术疗效是第一位的,手术适应证的选择应该遵循一个基本原则,即诊断明确,手术操作有助于改善患者目前的生活质量.毁损靶点的选择,取决于患者的临床症状分型,根据病人的临床症状,灵活地选择毁损靶点.     

帕金森病外科治疗的适应症及毁损部位的选择

目的介绍微电极导向立体定向毁损手术治疗帕金森病的适应证及毁损部位选择的经验.方法 607例帕金森病患者采用微电极导向立体定向毁损手术治疗,病例选择至少满足三个原则①确诊为原发性帕金森病;②左旋多巴类药物治疗有效;③认知功能良好,术中能良好合作.毁损靶点选择主要按临床症状分型确定.以苍白球腹后内侧部作为常规基础性治疗靶点,术中如震颤症状改善不明显时,加行丘脑腹外侧核毁损.单纯震颤型患者可首先选择丘脑腹外侧核为靶点.结果手术有效率97.3%,术后患者Hoehn和Yahr分级及UPDRS评分及“药物所致运动障碍”均有显著改善.术后1周“开”状态改善率62.3%±10.6%,“关”状态改善率76.1%±8.7%,总并发症的发生率为5.6%,永久性并发症为1.3%.结论微电极技术能显著提高手术定位准确率及成功率.合适的病例选择对于良好的手术疗效是首要的.毁损靶点主要根据临床症状分型确定,以苍白球腹后内侧部作为常规基础性治疗靶点.     

Bilateral pallidotomy in Parkinson's disease: a retrospective study.

We evaluated the effects of bilateral pallidotomy in patients with advanced Parkinson's disease. Thirteen patients with Parkinson's disease had a staged bilateral pallidotomy if they had severe response fluctuations, dyskinesias, painful dystonia, or bradykinesia despite optimum pharmacological treatment. Assessment scales were the Unified Parkinson's Disease Rating scale (UPDRS), the Schwab and England scale, and a questionnaire on the effects of disability in activities of daily living and adverse effects. Postoperative magnetic resonance imaging was evaluated for lesion location and extension. The median off-phase UPDRS motor score was reduced from 43.5 to 29 after the first pallidotomy, and it was further reduced to 23.5 after the second pallidotomy (n = 8). The UPDRS activities of daily living off-phase score improved from 28.5 to 20.5 after the first pallidotomy and to 19 after the second pallidotomy (n = 6). The Schwab and England scale off-phase score showed an improvement after both procedures, first from 40 to 60, and thereafter to 90 (n = 8). On-phase dyskinesias were reduced substantially. Eight patients had adverse effects, of whom five had problems with speech. One patient became hemiplegic due to a delayed infarction. Ten patients experienced further benefit from the second procedure. Bilateral pallidotomy reduces dyskinesias. A second contralateral pallidotomy may reduce parkinsonism, although to a lesser degree compared with the first pallidotomy and with an increased risk for adverse effects.     

Cryopallidotomy in Parkinson disease. Effect on somatosensory potentials

The paper reports 4-years results of a pilot study concerning the influence of a stereotactic pallidotomy on somatosensory evoked potentials in idiopathic Parkinson's disease. Potentials were recorded through the scalp surface from sensorimotor cortex of both hemispheres. Amplitudes and latencies of early and late waves were compared before and after the surgery. The surgery was recommended after 4 years of L-dopa therapy when bradykinesia and rigidity of right leg led to gait difficulty and postural instability. The dominant features of the syndrome were accompanied by tremor, micrography, chorea and lower responsiveness to L-dopa. Following the surgery a clear improvement of motor activity was observed. Increase of 20-90 ms waves amplitudes and P45 latency prolongation of 6-11 ms appeared due to the attenuation of pallidal inhibition exerted upon the thalamo-cortical transmission and a new arrangement of a cortical motor program. These electrophysiological changes, correlated with a clinical amelioration, may indicate as a favourable prognosis for a patient. Five months after pallidotomy a slight decrease of amplitudes occurred in relation to the previous examinations. Four years after surgery increase of most amplitudes and latencies and reconfiguration of later waves were related to deterioration of clinical course and worsening of left-side signs. We believe that somatosensory evoked potentials change may be a sensible indicator of motor state in Parkinson's disease. As far as we know the present study is one of the first presentation of somatosensory evoked potentials after pallidotomy.     

Randomized trial of pallidotomy versus medical therapy for Parkinson's disease

Thirty-six patients with Parkinson's disease (PD) were randomized to either medical therapy (N = 18) or unilateral GPi pallidotomy (N = 18). The primary outcome variable was the change in total Unified Parkinson's Disease Rating Scale (UPDRS) score at 6 months. Secondary outcome variables included subscores and individual parkinsonian symptoms as determined from the UPDRS. At the six month follow-up, patients receiving pallidotomy had a statistically significant reduction (32% decrease) in the total UPDRS score compared to those randomized to medical therapy (5% increase). Following surgery, patients' showed improvement in all the cardinal motor signs of PD including tremor, rigidity, bradykinesia, gait and balance. Drug-induced dyskinesias were also markedly improved. Although the greatest improvement occurred on the side contralateral to the lesion, significant ipsilateral improvement was also observed for bradykinesia, rigidity and drug-induced dyskinesias. A total of twenty patients have been followed for 2 years to assess the effect of time on clinical outcome. These patients have shown sustained improvement in the total UPDRS (p < 0.0001), "off" motor (p < 0.0001) and complications of therapy subscores (p < 0.0001). Sustained improvement was also seen for tremor, rigidity, bradykinesia, percent on time and drug-induced dyskinesias.     

分期立体定向双侧多靶点毁损术治疗帕金森病

目的:探讨分期双侧多靶点毁损术的疗效、适应证、靶点的选择及并发症。方法:对比第一次手术350例与第二次手术387例患者的UPDRS评分、评分改善率、并发症及主要症状改善率，进行统计学分析。结果两次手术均有显著近期疗效，二次手术单项症状改善率为震颤95．3％、僵直94．6％、运动迟缓82．9％、步态62．4％、平衡65．3％、异动症和痛性痉挛96．4％，总有效率97．2％。第二次手术总体改善率较第一次低，一过性特异性并发症增多，能于短期内恢复，永久性并发症发生率为5．43％。美多巴用量较术前减少。结论:分期双侧多靶点毁损术治疗帕金森病是一种有效、安全的方法，术前选好手术适应证、手术方式至关重要，两次手术间隔时间以半年以上为宜。     

分期双侧多靶点毁损术治疗帕金森病疗效的相关因素分析

目的　探讨分期双侧多靶点毁损术治疗帕金森病 (PD)疗效的相关因素。方法　将 387例需手术治疗的PD患者按年龄、手术方式、两次手术的间隔时间、毁损电极粗细 4项进行分组 ,探讨上述因素与疗效、并发症的关系。结果　二次手术近期疗效显著 ,分期双侧苍白球腹后内侧部 (PVP)毁损术是应用最多的术式 ;双侧丘脑腹中间 (Vim)核毁损术并发症的发生率高 (10 0 % ) ;5 5岁以上的患者并发症发生率 (2 9 70 % )明显高于 5 5岁以下的患者 (12 6 6 % ) (P <0 0 5 ) ;二次手术间隔时间在半年以内者并发症的发生率 (41 6 7% )高于间隔半年以上者 (P <0 0 5 ) ;1 8mm电极的治疗效果 (98 0 1% )好于 1 1mm电极 (96 6 1% ) ,但并发症的发生率却高于 1 1mm的电极 ,达 2 8 4 8% (P <0 0 5 )。结论　分期双侧PVP毁损术相对安全 ;分期一侧PVP加对侧Vim核毁损可减少并发症 ;术前选好手术适应证、术中控制毁损灶大小可减少并发症的发生 ;二次手术应以单靶点毁损为宜 ,时间间隔宜在半年以上。     

微电极导向VL核和PVP核联合毁损治疗帕金森病

目的：对震颤、僵硬及运动迟缓帕金森病（ＰＤ）患者的立体定向手术方法学进行探讨。方法：应用微电极导向技术,对４３例ＰＤ患者,同侧丘脑腹外侧核（Ｖｉｍ／Ｖｏｐ）及苍白球腹后部（ＰＶＰ）进行联合毁损术。结果：４３例ＰＤ患者的肢体震颤、僵硬及运动迟缓均得到明显改善,术前术后ＭｏｔｏｒＵＰＤＲＳ积分,开状态及关状态均显著改善（Ｐ＜０．０１）,无永久并发症。结论：应用微电极导向立体定向技术对伴有肢体震颤、强直及运动迟缓的ＰＤ患者,行同侧Ｖｉｍ核和ＰＶＰ核联合毁损手术,能全面改善ＰＤ患者的症状,是一种安全有效的手术方法。     

立体定向手术治疗帕金森病--附669例临床分析

目的 观察立体定向手术治疗帕金森病的疗效,探讨手术靶点与适应证的选择原则。方法对669例帕金森病患者实施微电极导向立体定向毁损与脑深部电刺激术,单靶点分别选择苍白球腹后部(314例)、丘脑腹外侧核(48例)及丘脑底核(48例);多靶点则为单靶点的结合(259例)。手术后采用UPDRS评分进行疗效评估和随访。结果 与手术前UPDRS评分相比:(1)丘脑底核切开术对“关”时相疗效最佳(P<0.05);(2)丘脑腹外侧核对震颤有效,改善率达97％,丘脑底核对僵直和运动迟缓有效,改善率分别为85％和57％;(3)多靶点手术对难治性帕金森病患者有显著疗效(P<0.01);(4)手术后丘脑底核切开组左旋多巴用量减少45％(P<0.05);(5)手术后总复发率为1.79％(12/669),永久性并发症发生率为2.39％(l6/669)。结论 外科手术对帕金森病有肯定而持久的疗效,手术前明确诊断及适应证、靶点选择是手术成功的重要前提。手术后仍须继续药物治疗。丘脑底核可能是最具潜力的治疗性核团。     

Usefulness of pallidotomy in advanced Parkinson's disease.

OBJECTIVE: The combined effect of posteroventral pallidotomy and optimal medical treatment was assessed in 22 patients with levodopa sensitive Parkinson's disease. METHODS: Timed motor tests, video recordings, and computer assisted optoelectronic movement analysis were used for serial hourly assessments performed preoperatively and four and 12 months after operation. Tests were made while patients were on optimal medical therapy. RESULTS: There were no serious adverse events of surgery. Two of the 22 patients could not complete all the tests after operation. The proportion of dyskinesia periods decreased in the 20 patients and there was a proportional increase in normal or fairly normal occasions. "Off" periods were not significantly affected. In 12 of 13 patients with limb dyskinesia this symptom was completely abolished in the contralateral limbs. There was also some degree of improvement axially and ipsilaterally. Tremor was moderately improved contralaterally. Bradykinesia remained unchanged. Results at 12 months follow up were similar to those at four months. CONCLUSION: Pallidotomy produced a pronounced positive effect on dyskinesia and a moderate effect on tremor. Bradykinesia was not affected. Posteroventral pallidotomy may be useful in patients with Parkinson's disease who have severe motor fluctuations and may allow an increase in levodopa dose to alleviate bradykinesia in "off" states.