Other Surgical Options

surgery

Focused Ultrasound

What is a Focused Ultrasound?

  • Guided by magnetic resonance imaging (MRI), high-intensity, inaudible sound waves are emitted into the brain. Where these waves cross, they create high energy. This high energy creates heat, destroying a very specific area in the brain connected to tremor.
  • Focused ultrasound uses computer software through an MRI. It is considered non-invasive because it does not involve incisions or holes in the skull.
  • The U.S. Food and Drug Administration (FDA) has approved the procedure for those with Parkinson’s disease (PD) tremor.

How is the surgery performed?

  • The patient wears a special helmet called a transducer that allows focusing of ultrasound energy targeting certain areas in the brain.
  • The care team uses an MRI to guide the waves and target areas, destroying the area in the brain responsible for tremor.
  • Focusing the waves on a specific target and monitoring with MRI helps prevent damage in surrounding brain tissue.

What to expect after surgery?

  • Many patients are fully awake after surgery and can eat and drink right away.
  • They can usually go home as soon as an hour later.
  • The most common side effects include face numbness, arm numbness, weakness, poor balance and difficulty with speech and swallowing. Side effects are usually temporary.

How common is this surgery?

  • Focused ultrasound is not very common.
  • This procedure is not recommended for those with very thick skulls or who cannot undergo an MRI.
  • Additional research is needed to establish the long-term procedure benefits and risks and to determine the best candidates.

Thalamotomy

What is a Thalamotomy?

  • A type of brain surgery in which the thalamus, a tiny area of the brain, is lesioned.
  • Before surgery, detailed brain scans using a CT scan or MRI (magnetic resonance imaging) identify the precise location for treatment.
  • Surgery on one side of the brain affects the opposite side of the body. If you have tremor in your right hand, for instance, the left side of your brain will be treated.
  • The procedure can be repeated on the other side of the brain if needed, but it greatly increases the risk of speech and cognitive problems after surgery if both sides are done.

How is the surgery performed?

  • During the surgery, the patient is awake, but the scalp area where instruments are inserted is numbed with a local anesthetic.
  • The surgeon inserts a hollow probe through a small hole drilled in the skull to the target location.
  • An extremely cold substance, liquid nitrogen, is circulated inside the probe. The cold probe lesions the targeted brain tissue.
  • The probe is then removed and the wound is closed.

What to expect after surgery?

The surgery usually requires a two-day hospital stay. Most people recover completely within about six weeks.  Because there are many risk factors, including underlying medical conditions, discuss the risks with your neurologist.

How common is this surgery?

  • Thalamotomy is rarely done today.
  • May be used to treat severe tremor on one side of the body (most often in an arm or leg) that does not respond to medications.
  • Does not assist with slow movement (bradykinesia), speech problems or walking difficulties.

Pallidotomy

What is a pallidotomy?

  • In PD a part of the brain called the globus pallidus is overactive. This causes a decrease in the activity of a different part of the brain that controls movement. In a pallidotomy, the surgeon lesions a tiny part of the globus pallidus by creating a scar.
  • This reduces the brain activity in that area, which may help relieve movement symptoms such as tremor and stiffness (rigidity).
  • Before surgery, detailed brain scans using MRI identify the precise location for treatment.
  • Most likely not a good option for treatment when a person has not responded to levodopa.
  • Surgery on one side of the brain affects the opposite side of the body. If you have tremor in your right hand, for instance, the left side of your brain will be treated

The procedure can be repeated on the other side of the brain if needed. Pallidotomy may be considered when a person with advanced PD disease has:

  1. Severe motor fluctuations, such as dyskinesia and on-off responses, due to long-term levodopa treatment.
  2. Severe or disabling tremor, stiffness (rigidity) or slow movement (bradykinesia) medication can no longer control.

How is the surgery performed?

  • The person is awake during the surgery, but the scalp area where instruments are inserted is numbed with a local anesthetic.
  • The surgeon inserts a hollow probe through a small hole drilled in the skull to the target location.
  • An extremely cold substance, liquid nitrogen, is circulated inside the probe.
  • The cold probe lesions the targeted brain tissue. The probe is then removed, and the wound is closed.

What to expect after surgery?

The surgery usually requires a two-day hospital stay. Most people recover completely within about six weeks.  Because there are many risk factors, including underlying medical conditions, discuss the risks with your neurologist.

How common is this surgery?

  • Doctors rarely perform pallidotomy anymore.
  • Instead, doctors use deep brain stimulation, a procedure that does not destroy brain tissue and has fewer risks than pallidotomy.

What Is a subthalamotomy?

  • Subthalamotomy is a type of brain surgery in which the subthalamus, a tiny area of the brain, is destroyed.
  • Before surgery, detailed brain scans using a CT scan or MRI identify the precise location for treatment.
  • Surgery on one side of the brain affects the opposite side of the body. If you have tremor in your right hand, for instance, the left side of your brain will be treated.
  • The procedure can be repeated on the other side of the brain if needed, but it greatly increases the risk of speech and cognitive problems after surgery.

How is the surgery performed?

  • During the surgery, the patient is awake, but the scalp area where instruments are inserted is numbed with a local anesthetic.
  • The surgeon inserts a hollow probe through a small hole drilled in the skull to the target location.
  • An extremely cold substance, liquid nitrogen, is circulated inside the probe. The cold probe destroys the targeted brain tissue.
  • The probe is then removed, and the wound is closed.

What to expect after surgery?

The surgery usually requires a two-day hospital stay. Most people recover completely within about six weeks.  Because there are many risk factors, including underlying medical conditions, discuss the risks with your neurologist.

How often are they performed?

Subthalamotomy is rarely done today.

Page reviewed by Dr. Chauncey Spears, Movement Disorders Fellow at the University of Florida, a Parkinson’s Foundation Center of Excellence and Kathryn Moore, MD, Senior Movement Disorders Fellow at the University of Florida.

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