Long-term follow-up results of selective VIM-thalamotomy

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✓ The authors report the results of a long-term follow-up study of the effects of the physiologically defined selective VIM (nucleus ventralis intermedius)-thalamotomy on tremor of Parkinson's disease in 27 patients and essential tremor in 16 patients. The follow-up period ranged from 3.25 to 10 years (mean 6.58 years). In 43 patients a total of 50 operations (including four bilateral operations and three reoperations) were carried out. The early (2 to 4 weeks after surgery) and late effects on the tremors were determined clinically and electromyographically. Fourteen parkinsonian cases were treated with minimal lesions (about 40 cu mm). Their late results were very similar to the early results: in 10, the tremors were completely abolished, three had a slight residual tremor, and one underwent reoperation 3 months after the first surgery. Eleven essential tremor cases were treated with minimal lesions. Six of these tremors were completely abolished, four patients had slight residual tremors, and one patient with a recurrence underwent reoperation 2 years after the initial surgery. In these 23 successful operations with minimal lesions (excluding two cases with reoperation), the tremor was abolished without discernible long-lasting side effects. The other 23 operations on 16 patients with Parkinson's disease (including one reoperation) and on seven with essential tremor (one of whom also had a minimal lesion on the other side) involved relatively large lesions. In this group, the surgery was successful in almost every case. It was concluded that radiographically and physiologically monitored selective VIM-thalamotomy for parkinsonian and essential tremor is effective even when lesioning is minimal. Moreover, the beneficial effect is maintained over a long period of time.

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Address reprint requests to: Yoshishige Nagaseki, M.D., Department of Neurosurgery, Yamanashi Medical College, 1110, Shimokato, Tamaho-machi, Nakakoma-gun, Yamanashi, Japan.

© AANS, except where prohibited by US copyright law."

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    Example of physiological identification of the ventralis intermedius (VIM) nucleus in a 64-year-old woman with Parkinson's disease who underwent minimal coagulative lesioning. Upper Left: Two semimicroelectrode trajectories (A and B) are shown directed toward the proposed target area on a three-dimensional display of the thalamus reproduced with a personal computer from the atlas of the thalamus by Schaltenbrand and Bailey.31 The right thalamus cut is coronal, passing through the posterior commissure (PC) as viewed from the right posterolateral side. The tentative target is a point 15 mm lateral and 5.8 mm anterior to the PC, as determined on intraoperative ventriculography. Right: Two intraoperative recordings reproduced from two different points (see Upper Left). Multiple spike discharges recorded from the presumed right VIM nucleus at two points — 1 mm above (A-1.0) and just at the target point (A-0) — as well as from the electromyographic findings (lower traces) of the left upper arm flexor muscle (L-Biceps, point A-1.0) and of the left gastrocnemius muscle (L-Gastro, point A-0) are shown. At point A-1.0, the rhythmic discharge from the right VIM nucleus is almost time-locked with the peripheral spontaneous tremor. At point A-0, the rhythmic discharges are discernible, although peripheral spontaneous tremor is not detectable. However, the unitary spike discharges increased on stretch (arrows with SR). Lower Left: Schematic illustration of the coagulative lesions. A unit of thermocoagulation is performed for 10 seconds at 65°C between a pair of coagulation needles (1.5 mm in diameter) of 4 mm effective length and 3 mm separation (extreme left, hatched area). In this case, two lesions were produced within one quadrant of an imaginary cylindrical zone with a 3-mm radius, with the second lesion 1 mm above the first lesion. The tremor was completely abolished. Th = thalamus.

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    Results in patients with Parkinson's disease receiving Group I lesions. The duration from onset to operation, the extent of the lesion (vertical view), and its early and late results are shown. Double circle = complete abolition; single circle = residual tremor; cross = recurrence.† = death. GR: preoperative grading of tremor; SD = operated side (opposite side from the affected limbs); M: moderate tremor; S: severe tremor; R: right side; L: left side. VIM-TOMY: nucleus ventralis intermedius-thalamotomy.

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    Results in patients with essential tremor receiving Group I lesions. The length of preoperative course, the extent of the lesion (vertical view), and its early and late results are shown. For symbols and abbreviations see Fig. 2.

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    Sequential evaluation of the operative results showing those from the minimal lesion group (left) and those of the entire series (right). Severe: coarse oscillation involving proximal muscles. Moderate: tremor of low amplitude, moderate frequency (4 to 10 Hz), and distal in distribution. Mild: transient episode of fine tremor (although not a clinical problem) or slight partial tremor. Numbers in parentheses indicate number of cases.

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