Deep-Brain Stimulation in Parkinson's Disease
Deep-Brain Stimulation in Parkinson's Disease
Follett KA, Weaver FM, Stern M, et al; CSP 468 Study Group
N Engl J Med. 2010;362:2077-2091
For patients with advanced Parkinson's disease, the preferred option for surgical intervention is deep-brain stimulation of the globus pallidus interna or subthalamic nucleus. The goal of this randomized trial was to compare 24-month outcomes for patients treated with bilateral pallidal or subthalamic stimulation.
Of 299 patients with idiopathic Parkinson's disease enrolled at 7 Veterans Affairs and 6 university hospitals, 152 were randomized to undergo pallidal stimulation and 147 to subthalamic stimulation. Change in motor function, which was evaluated in a blinded manner using the Unified Parkinson's Disease Rating Scale, part III (UPDRS-III) while patients were receiving stimulation but not antiparkinsonian medication, was the main study endpoint. Self-reported function, quality of life, neurocognitive function, and adverse events were the secondary endpoints.
The study groups did not differ significantly in mean changes in UPDRS-III or in self-reported function. Compared with patients undergoing pallidal stimulation, those undergoing subthalamic stimulation required a lower dose of dopaminergic drugs (P = .02) and had a greater decrease in a visuomotor component of processing speed (P = .03). Depression severity worsened after subthalamic stimulation but improved after pallidal stimulation (P = .02). At 24 months, the groups did not differ significantly in serious adverse events, which occurred in 51% of patients undergoing pallidal stimulation and in 56% of those undergoing subthalamic stimulation.
Given concerns about the long-term durability of pallidal stimulation for Parkinson's disease, it would be important to continue follow-up beyond the 2-year duration of this study. Other study limitations include lack of adjustment for repeated significance tests, and possibly limited clinical significance of the differences seen in secondary outcomes.
Despite these limitations, the findings suggest that pallidal and subthalamic stimulation were associated with similar improvements in motor function in patients with Parkinson's disease. In choosing between these 2 procedures, clinicians may reasonably consider patient-specific nonmotor factors, as well as operator experience and technical considerations regarding preoperative radiographic and intraoperative electrophysiologic target localization and postoperative programming and management.
Pallidal Versus Subthalamic Deep-Brain Stimulation for Parkinson's Disease
Follett KA, Weaver FM, Stern M, et al; CSP 468 Study Group
N Engl J Med. 2010;362:2077-2091
Summary
For patients with advanced Parkinson's disease, the preferred option for surgical intervention is deep-brain stimulation of the globus pallidus interna or subthalamic nucleus. The goal of this randomized trial was to compare 24-month outcomes for patients treated with bilateral pallidal or subthalamic stimulation.
Of 299 patients with idiopathic Parkinson's disease enrolled at 7 Veterans Affairs and 6 university hospitals, 152 were randomized to undergo pallidal stimulation and 147 to subthalamic stimulation. Change in motor function, which was evaluated in a blinded manner using the Unified Parkinson's Disease Rating Scale, part III (UPDRS-III) while patients were receiving stimulation but not antiparkinsonian medication, was the main study endpoint. Self-reported function, quality of life, neurocognitive function, and adverse events were the secondary endpoints.
The study groups did not differ significantly in mean changes in UPDRS-III or in self-reported function. Compared with patients undergoing pallidal stimulation, those undergoing subthalamic stimulation required a lower dose of dopaminergic drugs (P = .02) and had a greater decrease in a visuomotor component of processing speed (P = .03). Depression severity worsened after subthalamic stimulation but improved after pallidal stimulation (P = .02). At 24 months, the groups did not differ significantly in serious adverse events, which occurred in 51% of patients undergoing pallidal stimulation and in 56% of those undergoing subthalamic stimulation.
Viewpoint
Given concerns about the long-term durability of pallidal stimulation for Parkinson's disease, it would be important to continue follow-up beyond the 2-year duration of this study. Other study limitations include lack of adjustment for repeated significance tests, and possibly limited clinical significance of the differences seen in secondary outcomes.
Despite these limitations, the findings suggest that pallidal and subthalamic stimulation were associated with similar improvements in motor function in patients with Parkinson's disease. In choosing between these 2 procedures, clinicians may reasonably consider patient-specific nonmotor factors, as well as operator experience and technical considerations regarding preoperative radiographic and intraoperative electrophysiologic target localization and postoperative programming and management.
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