Considering Lesion Surgery over Deep Brain Stimulation

It is generally accepted that subthalamic nucleus (STN) DBS is effective, allows lower overall drug requirements, and may involve less permanent risk compared to lesion surgery since the target is not electrocoagulated. The consequences of inaccurate targeting are more reversible with DBS, but irreversible with lesion surgery. This has most importance when considering bilateral procedures since the risks of dyspha-sia, dysarthria, dysphagia, and cognitive deficits are increased in bilateral procedures (28-31). There are no clear blinded, evidence-based trial data to indicate which type of surgery to offer. However, if a patient requires a bilateral procedure, then bilateral DBS is usually preferred over bilateral lesion surgery. This is the case for most patients with advanced PD. If a patient has already had a unilateral surgical procedure and requires a second procedure in the other hemisphere, or a bilateral procedure in a different location, then DBS should be considered in preference to a lesion since any new side effects from the second procedure are more likely to be reversible. If a patient is considered for a unilateral procedure, then lesion surgery and DBS should be considered according to the local preference of the patient and surgical center. The likelihood of needing a second contralateral procedure in the future should also be weighed in this decision.

Long-term results include 10 years of follow-up for pallidotomy (37) and 13 years for thalamotomy (16). There are some general advantages of lesions compared with DBS. First, when health resources of either an individual or a healthcare provider are limited, it is usual to adopt the more economical option. Lesion surgery avoids the cost of the hardware, the potential cost of replacing the implantable pulse generators due to battery failure or depletion over the remaining lifetime of the patient, as well as the manpower expenses for programming the stimulators. Secondly, for patients who live in areas that have no local expertise in maintenance of deep brain stimulators, the placement of a lesion may avoid frequent journeys to a neurosurgical center for stimulator programming. Thirdly, it is possible that with time we shall discover more unique but deleterious complications of stimulators interacting with other electrical systems, such as diathermy for dental treatment (38). Finally, DBS electrodes can fracture, become infected, cause skin erosion, or the battery lifetime may become impractically short. In these instances, a lesion may be the only alternative for patients for whom DBS is no longer suitable for technical reasons. Oh et al. (39) described two patients in whom therapy was changed from DBS to a lesion because one patient needed four battery replacements in five years, whereas the others developed skin erosions over the electrode leads.

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