Bilateral subthalamic nucleus stimulation after bilateral pallidotomies in a patient with advanced Parkinson's disease

A 54-year-old man with advanced Parkinson's disease (PD) presented to our institution in early 2000. He had undergone a right pallidotomy in 1994, a left pallidotomy in 1996, and bilateral subthalamic nucleus (STN) electrode implants in 1999. The patient had cervical myelopathy for which he had undergone neck surgery in 1998. We used the Unified Parkinson's Disease Rating Scale (UPDRS) to evaluate motor performance in four states: combinations of stimulation OFF or ON and medication OFF or ON. There was no significant change in motor UPDRS scores with STN stimulation or with medications. Multiple attempts to optimize stimulation parameters and medication dosages did not result in significant and sustained improvement in activities of daily living or motor performance. To our knowledge, this is the first reported case of bilateral STN stimulation after bilateral pallidotomies. The presence of cervical myelopathy and the limited response to anti-Parkinson medications in this patient underscores the importance of patient selection for functional neurosurgery in PD.