REOPERATION FOR SUBOPTIMAL OUTCOMES AFTER DEEP BRAIN STIMULATION SURGERY
REOPERATION FOR SUBOPTIMAL OUTCOMES AFTER DEEP BRAIN STIMULATION SURGERY
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DOI：
10.1227/01.neu.0000325492.58799.35
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发表时间：
2008-10-01
期刊：
影响因子：
4.8
通讯作者：
Okun, Michael S.
中科院分区：
文献类型：
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作者：
Ellis, Tina-Marie;Foote, Kelly D.;Okun, Michael S.
目的：研究一系列深部脑刺激(DBS)导联再次手术的病例，在这些病例中，临床场景显示前一次手术的结果不太理想。放置不合理的DBS导联是帕金森病(PD)、特发性震颤(ET)或肌张力障碍术后效果不佳的一个潜在原因。在之前的一项对经历了次优结果的患者的研究中，41名患者中有19名患者导线错位。同样，另一份报告评论说，导联放置超过2-3 mm的窗口会导致临床益处不足，在I患者中，翻修可以改善结果。本研究的目标是对再次手术的DBS患者进行非盲法回顾。方法：通过对机构评审委员会批准的运动障碍数据库的回顾，对再次手术后行DBS导联替换的患者进行评估。纳入因临床效益不佳而再次手术的病例，排除因感染或硬件故障而更换DBS导联的病例。研究的数据点包括年龄、病程、诊断、运动结果(帕金森病统一评定量表III，震颤评定量表，肌张力障碍统一肌张力评定量表)，生活质量(帕金森病问卷-39，帕金森病患者)，以及临床医生总体印象量表。结果：11例PD患者，7例ET患者，4例肌张力障碍患者。PD组平均年龄52岁，病程10年，DBS活动性接触部位平均向量距离调整5.5 mm。6名帕金森病患者(54%)在DBS统一帕金森病评定量表上有术前停药的评分，这可以与术后停药的DBS评分相比较。这组患者的平均改善为24.4%。帕金森病问卷-39在活动能力(28.18)、日常生活能力(14.77)、情感(14.72)、耻辱(17.61)和不适(17.42)方面有所改善。ET组平均年龄66岁，病程29年，平均调整距离6.1 mm。队列中有5例ET患者(83.3%)在DBS颤抖评定量表上有预先放置，在DBS Tremor量表上有放置后放置，平均改善60.4%。肌张力障碍组平均年龄39岁，平均病程7年，平均调整导联距离6.7 mm。3例(75%)肌张力障碍患者在DBS统一肌张力障碍评定量表上进行了预放置，在放置后进行了DBS统一肌张力障碍评定量表的评分。在这3名肌张力障碍患者中，改善了12.8%。临床医生总体印象量表评分(1，非常改善；2，显著改善；3，轻微改善；4，无变化；5，轻微恶化；6，非常糟糕；7，非常糟糕；7，非常糟糕；PD患者：1，7例；2，3例；3，1例)；ET(1，4例；2，3例)；以及肌张力障碍(1，1例，2，2例；3，1例)。从最初的导联到再次手术(重新定位/翻修)的总潜伏期为28.9个月(2~104mo)，而从外部机构转诊的导联(n=11例)的潜伏期为48个月(12~104mo)，而来自佛罗里达大学的外科医生(n=11例)植入导联的潜伏期为9.7个月(2~19mo)。最常见的临床病史是未能达到预期的结果；然而，22名患者中有4名(18.2%)存在不对称受益史，22名患者中有3名(13.6%)存在铅迁移。结论：DBS术后受益不佳的潜在原因有很多。及时确定次佳的导联位置，然后对部分患者进行再次手术和重新定位/置换，可能会改善预后。
OBJECTIVE: To examine a case series of reoperations for deep brain stimulation (DBS) leads in which clinical scenarios revealed suboptimal outcome from a previous operation. Suboptimally placed DBS leads are one potential reason for unsatisfactory results after surgery for Parkinson's disease (PD), essential tremor (ET), or dystonia. In a previous study of patients who experienced suboptimal results, 19 of 41 patients had misplaced leads. Similarly, another report commented that lead placement beyond a 2- to 3-mm window resulted in inadequate clinical benefit, and, in I patient, revision improved outcome. The goal of the current study was to perform an unblinded retrospective chart review of DBS patients with unsatisfactory outcomes who presented for reoperation.METHODS: Patients who had DBS lead replacements after reoperation were assessed with the use of a retrospective review of an institutional review board-approved movement disorders database. Cases of reoperation for suboptimal clinical benefit were included, and cases of replacement of DBS leads caused by infection or hardware malfunction were excluded. Data points studied included age, disease duration, diagnosis, motor outcomes (the Unified Parkinson Disease Rating Scale III in PD, the Tremor Rating Scale in ET, and the Unified Dystonia Rating Scale in dystonia), quality of life (Parkinson's Disease Questionnaire-3 9 in PD), and the Clinician Global Impression scale. The data from before and after reoperation were examined to determine the estimated impact of repeat surgery.RESULTS:There were 11 patients with PD, 7 with ET, and 4 with dystonia. The average age of the PD group was 52 years, the disease duration was 10 years, and the average vector distance of the location of the active DBS contact was adjusted 5.5 mm. Six patients (54%) with PD had preoperative off medication on DBS Unified Parkinson Disease Rating Scale scores that could be compared with postoperative off medication on DBS scores. The average improvement across this group of patients was 24.4%. The Parkinson's Disease Questionnaire-39 improved in the areas of mobility (28.18), activities of daily living (14.77), emotion (14.72), stigma (17.61), and discomfort (17.42). The average age of the ET group was 66 years, the disease duration was 29 years, and the average adjusted distance was 6.1 mm. Five ET patients (83.3%) in the cohort had a prereplacement on DBS Tremor Rating Scale and a postreplacement on DBS Tremor Rating Scale with the average improvement of 60.4%. The average age of the dystonia group was 39 years, the average disease duration was 7 years, and the average adjusted lead distance was 6.7 mm. Three patients (75%) with dystonia had prereplacement on DBS Unified Dystonia Rating Scale and postreplacement on DBS Unified Dystonia Rating Scale scores. Across these 3 dystonia patients, the improvement was 12.8%. Clinician Global Impression scale scores (1, very much improved; 2, much improved; 3, minimally improved; 4, no change; 5, minimally worse; 6, much worse; 7, very much worse) after replacement revealed the following results in patients with PD: 1, 7 patients; 2, 3 patients; 3, 1 patient); with ET (1, 4 patients; 2, 3 patients); and with dystonia (1, 1 patient, 2, 2 patients; 3, 1 patient). The latency from original lead placement to reoperation (repositioning/revision) overall was 28.9 months (range, 2-104 mo); however, in leads referred from outside institutions (n = 11 patients), this latency was 48 months (range, 12-104 mo) compared with leads implanted by surgeons from the University of Florida (n = 11 patients), which was 9.7 months (range, 2-19 mo). The most common clinical history was failure to achieve a perceived outcome; however, history of an asymmetric benefit was present in 4 (18.2%) of 22 patients, and lead migration was present in 3 (13.6%) of 22 patients.CONCLUSION: There are many potential causes of suboptimal benefit after DBS. Timely identification of suboptimal lead placements followed by reoperation and repositioning/replacement in a subset of patients may improve outcomes.