A randomized double-blind crossover trial comparing subthalamic and pallidal deep brain stimulation for dystonia

Clinical article

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  • 1 Department of Neurosurgery, Rigshospitalet, Copenhagen University Hospital;
  • 2 Department of Emergency, Hilleroed Hospital, Copenhagen University Hospital;
  • 3 Section of Neurogenetics, Memory Disorders Research Group, Department of Neurology, Rigshospitalet, Copenhagen University Hospital;
  • 5 Department of Neurology, Bispebjerg, Copenhagen University Hospital, Copenhagen, Denmark; and
  • 4 Department of Cellular and Molecular Medicine, Section of Neurogenetics, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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Object

The authors' aim was to compare the subthalamic nucleus (STN) with the globus pallidus internus (GPi) as a stimulation target for deep brain stimulation (DBS) for medically refractory dystonia.

Methods

In a prospective double-blind crossover study, electrodes were bilaterally implanted in the STN and GPi of 12 patients with focal, multifocal, or generalized dystonia. Each patient was randomly selected to undergo initial bilateral stimulation of either the STN or the GPi for 6 months, followed by bilateral stimulation of the other nucleus for another 6 months. Preoperative and postoperative ratings were assessed by using the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) and video recordings. Quality of life was evaluated by using questionnaires (36-item Short Form Health Survey). Supplemental Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) scores were assessed for patients with focal dystonia (torticollis) by examining the video recordings.

Results

On average for all patients, DBS improved the BFMDRS movement scores (p < 0.05) and quality of life physical scores (p < 0.01). After stimulation of the STN, the mean 6-month improvement in BFMDRS movement score was 13.8 points; after stimulation of the GPi, this improvement was 9.1 points (p = 0.08). Quality of life did not differ significantly regardless of which nucleus was stimulated. All 12 patients accepted 6 months of stimulation of the STN, but only 7 accepted 6 months of stimulation of the GPi. Among those who rejected stimulation of the GPi, 3 accepted concomitant stimulation of both the STN and GPi for 6 months, resulting in improved quality of life physical and mental scores and BFMDRS movement scores. Among the 4 patients who were rated according to TWSTRS, after 6 months of stimulation of both the STN and GPi, TWSTRS scores improved by 4.7% after stimulation of the GPi and 50.8% after stimulation of the STN (p = 0.08).

Conclusions

The STN seems to be a well-accepted, safe, and promising stimulation target in the treatment of dystonia, but further studies are necessary before the optimal target can be concluded. Simultaneous stimulation of the STN and GPi should be further investigated. Clinical trial registration no.: KF 01-110/01 (Committees on Biomedical Research Ethics of the Capital Region of Denmark).

Abbreviations used in this paper:BFMDRS = Burke-Fahn-Marsden Dystonia Rating Scale; DBS = deep brain stimulation; GPi = globus pallidus internus; PD = Parkinson's disease; SF-36 = 36-item Short Form Health Survey; STN = subthalamic nucleus; TWSTRS = Toronto Western Spasmodic Torticollis Rating Scale.

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Contributor Notes

Address correspondence to: Lisbeth Schjerling, M.D., Department of Emergency, Hilleroed University Hospital, Dyrehavej 29, 3400 Hilleroed, Denmark. email: lisbeth.schjerling@regionh.dk.

Please include this information when citing this paper: published online October 11, 2013; DOI: 10.3171/2013.8.JNS13844.

  • 1

    Alexander GE, , DeLong MR, & Strick PL: Parallel organization of functionally segregated circuits linking basal ganglia and cortex. Annu Rev Neurosci 9:357381, 1986

    • Search Google Scholar
    • Export Citation
  • 2

    Anderson VC, , Burchiel KJ, , Hogarth P, , Favre J, & Hammerstad JP: Pallidal vs subthalamic nucleus deep brain stimulation in Parkinson disease. Arch Neurol 62:554560, 2005

    • Search Google Scholar
    • Export Citation
  • 3

    Andrews C, , Aviles-Olmos I, , Hariz M, & Foltynie T: Which patients with dystonia benefit from deep brain stimulation? A metaregression of individual patient outcomes. J Neurol Neurosurg Psychiatry 81:13831389, 2010

    • Search Google Scholar
    • Export Citation
  • 4

    Baizabal-Carvallo JF, , Roze E, , Aya-Kombo M, , Romito L, , Navarro S, & Flamand-Rouvière C, : Combined pallidal and subthalamic nucleus deep brain stimulation in secondary dystonia-parkinsonism. Parkinsonism Relat Disord 19:566568, 2013. (Letter)

    • Search Google Scholar
    • Export Citation
  • 5

    Breakefield XO, , Blood AJ, , Li Y, , Hallett M, , Hanson PI, & Standaert DG: The pathophysiological basis of dystonias. Nat Rev Neurosci 9:222234, 2008

    • Search Google Scholar
    • Export Citation
  • 6

    Chou KL, , Hurtig HI, , Jaggi JL, & Baltuch GH: Bilateral subthalamic nucleus deep brain stimulation in a patient with cervical dystonia and essential tremor. Mov Disord 20:377380, 2005

    • Search Google Scholar
    • Export Citation
  • 7

    Comella CL, , Stebbins GT, , Goetz CG, , Chmura TA, , Bressman SB, & Lang AE: Teaching tape for the motor section of the Toronto Western Spasmodic Torticollis Scale. Mov Disord 12:570575, 1997

    • Search Google Scholar
    • Export Citation
  • 8

    Coubes P, , Cif L, , El Fertit H, , Hemm S, , Vayssiere N, & Serrat S, : Electrical stimulation of the globus pallidus internus in patients with primary generalized dystonia: long-term results. J Neurosurg 101:189194, 2004

    • Search Google Scholar
    • Export Citation
  • 9

    Fahn S, , Bressman SB, & Marsden CD: Classification of dystonia. Adv Neurol 78:110, 1998

  • 10

    Follett KA, , Weaver FM, , Stern M, , Hur K, , Harris CL, & Luo P, : Pallidal versus subthalamic deep-brain stimulation for Parkinson's disease. N Engl J Med 362:20772091, 2010

    • Search Google Scholar
    • Export Citation
  • 11

    Funkiewiez A, , Ardouin C, , Krack P, , Fraix V, , Van Blercom N, & Xie J, : Acute psychotropic effects of bilateral subthalamic nucleus stimulation and levodopa in Parkinson's disease. Mov Disord 18:524530, 2003

    • Search Google Scholar
    • Export Citation
  • 12

    Grabli D, , Ewenczyk C, , Coelho-Braga MC, , Lagrange C, , Fraix V, & Cornu P, : Interruption of deep brain stimulation of the globus pallidus in primary generalized dystonia. Mov Disord 24:23632369, 2009

    • Search Google Scholar
    • Export Citation
  • 13

    Hammond C, , Ammari R, , Bioulac B, & Garcia L: Latest view on the mechanism of action of deep brain stimulation. Mov Disord 23:21112121, 2008

    • Search Google Scholar
    • Export Citation
  • 14

    Isaias IU, , Alterman RL, & Tagliati M: Deep brain stimulation for primary generalized dystonia: long-term outcomes. Arch Neurol 66:465470, 2009

    • Search Google Scholar
    • Export Citation
  • 15

    Jahanshahi M, , Czernecki V, & Zurowski AM: Neuropsychological, neuropsychiatric, and quality of life issues in DBS for dystonia. Mov Disord 26:Suppl 1 S63S78, 2011

    • Search Google Scholar
    • Export Citation
  • 16

    Kiss ZH, , Doig-Beyaert K, , Eliasziw M, , Tsui J, , Haffenden A, & Suchowersky O: The Canadian multicentre study of deep brain stimulation for cervical dystonia. Brain 130:28792886, 2007

    • Search Google Scholar
    • Export Citation
  • 17

    Kleiner-Fisman G, , Herzog J, , Fisman DN, , Tamma F, , Lyons KE, & Pahwa R, : Subthalamic nucleus deep brain stimulation: summary and meta-analysis of outcomes. Mov Disord 21:Suppl 14 S290S304, 2006

    • Search Google Scholar
    • Export Citation
  • 18

    Kleiner-Fisman G, , Liang GS, , Moberg PJ, , Ruocco AC, , Hurtig HI, & Baltuch GH, : Subthalamic nucleus deep brain stimulation for severe idiopathic dystonia: impact on severity, neuropsychological status, and quality of life. J Neurosurg 107:2936, 2007

    • Search Google Scholar
    • Export Citation
  • 19

    Krause M, , Fogel W, , Kloss M, , Rasche D, , Volkmann J, & Tronnier V: Pallidal stimulation for dystonia. Neurosurgery 55:13611370, 2004

  • 20

    Kupsch A, , Benecke R, , Müller J, , Trottenberg T, , Schneider GH, & Poewe W, : Pallidal deep-brain stimulation in primary generalized or segmental dystonia. N Engl J Med 355:19781990, 2006

    • Search Google Scholar
    • Export Citation
  • 21

    Lyons KE, & Pahwa R: Effects of bilateral subthalamic nucleus stimulation on sleep, daytime sleepiness, and early morning dystonia in patients with Parkinson disease. J Neurosurg 104:502505, 2006

    • Search Google Scholar
    • Export Citation
  • 22

    Nambu A, , Tokuno H, & Takada M: Functional significance of the cortico-subthalamo-pallidal ‘hyperdirect’ pathway. Neurosci Res 43:111117, 2002

    • Search Google Scholar
    • Export Citation
  • 23

    Novak KE, , Nenonene EK, , Bernstein LP, , Vergenz S, , Cozzens JW, & Rezak M: Successful bilateral subthalamic nucleus stimulation for segmental dystonia after unilateral pallidotomy. Stereotact Funct Neurosurg 86:8086, 2008

    • Search Google Scholar
    • Export Citation
  • 24

    Ostrem JL, , Racine CA, , Glass GA, , Grace JK, , Volz MM, & Heath SL, : Subthalamic nucleus deep brain stimulation in primary cervical dystonia. Neurology 76:870878, 2011

    • Search Google Scholar
    • Export Citation
  • 25

    Paluzzi A, , Belli A, , Bain P, , Liu X, & Aziz TM: Operative and hardware complications of deep brain stimulation for movement disorders. Br J Neurosurg 20:290295, 2006

    • Search Google Scholar
    • Export Citation
  • 26

    Skogseid IM, , Ramm-Pettersen J, , Volkmann J, , Kerty E, , Dietrichs E, & Røste GK: Good long-term efficacy of pallidal stimulation in cervical dystonia: a prospective, observer-blinded study. Eur J Neurol 19:610615, 2012

    • Search Google Scholar
    • Export Citation
  • 27

    Soeder A, , Kluger BM, , Okun MS, , Garvan CW, , Soeder T, & Jacobson CE, : Mood and energy determinants of quality of life in dystonia. J Neurol 256:9961001, 2009

    • Search Google Scholar
    • Export Citation
  • 28

    Sun B, , Chen S, , Zhan S, , Le W, & Krahl SE: Subthalamic nucleus stimulation for primary dystonia and tardive dystonia. Acta Neurochir Suppl 97:207214, 2007

    • Search Google Scholar
    • Export Citation
  • 29

    Tisch S, , Zrinzo L, , Limousin P, , Bhatia KP, , Quinn N, & Ashkan K, : Effect of electrode contact location on clinical efficacy of pallidal deep brain stimulation in primary generalised dystonia. J Neurol Neurosurg Psychiatry 78:13141319, 2007

    • Search Google Scholar
    • Export Citation
  • 30

    Valldeoriola F, , Regidor I, , Mínguez-Castellanos A, , Lezcano E, , García-Ruiz P, & Rojo A, : Efficacy and safety of pallidal stimulation in primary dystonia: results of the Spanish multicentric study. J Neurol Neurosurg Psychiatry 81:6569, 2010

    • Search Google Scholar
    • Export Citation
  • 31

    Vidailhet M, , Vercueil L, , Houeto JL, , Krystkowiak P, , Benabid AL, & Cornu P, : Bilateral deep-brain stimulation of the globus pallidus in primary generalized dystonia. N Engl J Med 352:459467, 2005

    • Search Google Scholar
    • Export Citation
  • 32

    Vitek JL: Deep brain stimulation for Parkinso's disease. A critical re-evaluation of the STN versus the GPi DBS. Stereotact Funct Neurosurg 78:119131, 2002

    • Search Google Scholar
    • Export Citation
  • 33

    Voges J, , Hilker R, , Bötzel K, , Kiening KL, , Kloss M, & Kupsch A, : Thirty days complication rate following surgery performed for deep-brain-stimulation. Mov Disord 22:14861489, 2007

    • Search Google Scholar
    • Export Citation
  • 34

    Ware JE Jr, & Sherbourne CD: The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 30:473483, 1992

    • Search Google Scholar
    • Export Citation
  • 35

    Wichmann T, , DeLong MR, , Guridi J, & Obeso JA: Milestones in research on the pathophysiology of Parkinson's disease. Mov Disord 26:10321041, 2011

    • Search Google Scholar
    • Export Citation
  • 36

    Wöhrle JC, , Blahak C, , Capelle HH, , Fogel W, , Bäzner H, & Krauss JK: Combined pallidal and subthalamic nucleus stimulation in sporadic dystonia-parkinsonism. Case report. J Neurosurg 116:9598, 2012

    • Search Google Scholar
    • Export Citation
  • 37

    Woehrle JC, , Blahak C, , Kekelia K, , Capelle HH, , Baezner H, & Grips E, : Chronic deep brain stimulation for segmental dystonia. Stereotact Funct Neurosurg 87:379384, 2009

    • Search Google Scholar
    • Export Citation
  • 38

    Yianni J, , Bain PG, , Gregory RP, , Nandi D, , Joint C, & Scott RB, : Post-operative progress of dystonia patients following globus pallidus internus deep brain stimulation. Eur J Neurol 10:239247, 2003

    • Search Google Scholar
    • Export Citation

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