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Surgical Considerations

Certainty of Dx Identify Most Disability Motor Sx Unilateral VS Bilateral

Parkinson's Disease
Age Dopaminergic Response Pharm Status Cognitive Status Surgical Brain Target

Previous PD Surgery

Run thru DDx: dementia with lewy bodies (DLB), vascular parkinsonism , Parkinson's + syndrome, or progressive supra nuclear palsy (PSP)

Be sure that Sx can be tx'd with DBS

generally do bilateral for bilateral sx

does NOT preclude pt from DBS

degree of response to dopamine (levodopa) usually correlates to responsiveness of motor sx with DBS

DEMENTIA (poor candidate), DEPRESSION, PSYCHOSIS ensure pt is on the RIGHT meds before the are said to be "poorly" controlled

usually do not exclude based on age alone

Subthalmic nucleus (STN)

Globus Pallidus (GPi)

Tremor, bradykinesia, rigidity, motor flucutations

Ex: if positives of pallidotomy have waned --> bilateral STN DBS has good benefits

Presence of at least 2 of the 3 cardinal features of parkinsonism (rest tremor, rigidity, bradykinesia) Asymmetrical onset of signs/symptoms Substantial response to levodopa or dopamine agonist Absence of features suggesting alternative diagnoses: Prominent freezing phenomena early in the first three years Hallucinations unrelated to medication in the first three years of disease Dementia preceding motor symptoms or in the first year Supranuclear gaze palsy Upper motor neuron signs on examination Severe, symptomatic dysautonomia unrelated to medications Documentation of a condition known to produce parkinsonism and plausibly connected to the patient’s symptoms

PROS: 1. larger study base 2. more neurosurgeons are familiar with it 3. post-op meds are less with STN

PROS: antidyskinetic effect on levodopainduced dyskinesia 2. this allows for meds to be maintained for a more synergistic therapy