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Background and purpose Methods Results Conclusion Several surgical techniques have been used to treat cervical dystonia (CD), however, to date, the optimal surgical technique for CD remains controversial. We therefore conducted the first network meta‐analysis to compare different surgical strategies for CD to inform clinical practice.Electronic databases were searched for surgical strategies for treating CD. The primary outcome was improvement in total Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) score. Subgroup analysis was performed to compare short‐term (< 1 year) and long‐term (≥ 1 year) outcomes. Safety outcomes included surgery‐related adverse events (AEs).A total of 55 trials with 2032 patients employing five surgical strategies were identified, including globus pallidus internus (GPi)/subthalamic nucleus (STN)‐deep brain stimulation (DBS), selective peripheral denervation (SPD), microvascular decompression (MVD) and pallidotomy. All strategies led to significant improvement in total TWSTRS score (mean improvement range 18.65–28.22). GPi‐DBS showed significantly greater enhancement than SPD for the whole dataset (mean difference [MD] 7.03, 95% credible interval [Crl] 1.53–12.56), while both GPi‐DBS (MD 8.05, 95% Crl 2.35–13.80) and STN‐DBS (MD 10.71, 95% Crl 2.22–19.20) exhibited more long‐term improvement than SPD. Regarding safety outcomes, GPi/STN‐DBS and MVD were associated with fewer surgery‐related AEs than SPD (ln odds ratio range −1.68 to −1.41).We conclude that DBS should be the preferred surgical option for CD, and the STN is a promising alternative target choice due to its comparable efficacy with the GPi. However, more direct evidence is still required. [ABSTRACT FROM AUTHOR]

To systematically review and conduct a meta-analysis to evaluate the safety and efficacy of the unilateral focused ultrasound (FUS) pallidotomy on motor complications in Parkinson's disease (PD) patients. A comprehensive search strategy was implemented through August 15, 2023, and updated on February 13, 2024, across six databases, identifying studies relevant to unilateral focused ultrasound pallidotomy and PD. Eligibility criteria included observational studies, clinical trials, and case series reporting on the impact of the intervention on motor complications in PD patients. The screening and data extraction were done by two independent reviewers. Risk of bias assessment utilized appropriate tools for different study designs. Statistical analysis involved narrative synthesis and meta-analysis. Subgroup analyses and leave-one-out analyses were performed. Five studies were included in our study, involving 112 PD patients undergoing FUS pallidotomy. UPDRS-II analysis revealed a significant improvement from baseline (mean difference (MD): -3.205, 95% CI: -4.501, -1.909, P < 0.001). UPDRS-III overall change was significant (MD: -10.177, 95% CI: [-12.748, -7.606], P < 0.001). UPDRS-IV showed a significant change from baseline (MD: -5.069, 95% CI: [-5.915, -4.224], P < 0.001). UDysRS demonstrated a significant overall improvement (MD: -18.895, 95% CI: [-26.973, -10.818], P < 0.001). The effect of FUS pallidotomy on motor complications in PD patients was effective, with a significant decrease in the UPDRS and UDysRS, reflecting improvement. The incidence of adverse events (headaches, pin-site pain, difficulty walking, and sonication-related head pain) of the FUS pallidotomy was not statistically significant, indicating its safety. [ABSTRACT FROM AUTHOR]

Background: Invasive treatments like radiofrequency stereotactic lesioning or deep brain stimulation of the globus pallidus internus can resolve drug‐resistant status dystonicus (SD). However, these open procedures are not always feasible in patients with SD. Objective: The aim was to report the safety and efficacy of simultaneous asleep bilateral transcranial magnetic resonance–guided focused ultrasound (MRgFUS) pallidotomy for life‐threatening SD. Methods: We performed bilateral simultaneous MRgFUS pallidotomy under general anesthesia in 2 young patients with pantothenate kinase–associated neurodegeneration and GNAO1 encephalopathy. Both patients had medically refractory SD and severe comorbidities contraindicating open surgery. Results: SD resolved at 4 and 12 days after MRgFUS, respectively. Adverse events (intraoperative hypothermia and postoperative facial paralysis) were mild and transient. Conclusion: Bilateral simultaneous MRgFUS pallidotomy under general anesthesia is safe and may be a valid alternative therapeutic option for fragile patients. Further studies are needed to assess long‐term efficacy of the procedure. [ABSTRACT FROM AUTHOR]

Introduction and purpose Pallidotomy is a neurosurgical procedure involving the ablation of the globus pallidus, resulting in reduced activity in this area of the brain. Pallidotomy is an irreversible stereotactic procedure performed only under local anesthesia. It was first used in the treatment of dyskinesias associated with Huntington's chorea, but its widespread application has been in Parkinson's disease. This method is increasingly less common in developed countries due to its replacement by deep brain stimulation (DBS); however, it remains an effective treatment, particularly in drug-resistant, idiopathic Parkinson's disease. Unilateral pallidotomy is considered safer than bilateral pallidotomy due to the risk of severe complications, and thus, the bilateral approach is not recommended. Materials and methods A comprehensive literature review was conducted through an extensive bibliographic search, with a primary focus on original research articles obtained from reputable databases such as PubMed, BioMed Central, Polish Medical Platform, and Google Scholar. The search was specifically targeted towards articles pertaining to Pallidotomy. Conclusions The study shows that pallidotomy is a well-established neurosurgical treatment primarily used in drug-resistant Parkinson's disease. It should only be performed in centers specializing in stereotactic procedures. Symptoms that respond best to pallidotomy are those that previously responded to treatment, such as rigidity and tremors. The replacement of pallidotomy by deep brain stimulation (DBS) is due to the increased safety, effectiveness, and the availability of bilateral and continuous stimulation. Bilateral pallidotomy leads to severe complications and is currently not recommended. Pallidotomy has become a procedure used in specific situations and may be an alternative surgical treatment when there are contraindications to deep brain stimulation.

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Parkinson's disease is a neurodegenerative pathology of the central nervous system that affects thousands of individuals worldwide. There are several treatment methods, from drugs to emerging surgical methods. Many studies in this field are carried out annually, in view of this, this study aims to bibliometrically analyze the 50 most cited articles regarding this topic. In February 2022, a search was performed in the PubMed, SCOPUS and Embase databases using the search terms “parkinson's disease”, “deep brain stimulation” and “pallidotomy”. A total of 960 articles were found and, after their selection, the analysis of the 50 most cited was performed and then the metrics analyzed were the H index of the first author, year of publication, institution, country of origin, journal and its impact factor, total number of citations and the article methodology. This analysis brought the characteristics of the articles with the greatest impact in the scientific community on the use of pallidotomy and deep brain stimulation (DBS), and some insights on studies in this area.

This article discusses the global availability of advanced therapies for Parkinson's disease (PD) and highlights the potential of radiofrequency ablation (RFA) as an alternative to deep brain stimulation (DBS) for patients who cannot undergo DBS. The article argues that RFA should not be overlooked and emphasizes the need for expertise in targeting and proper reporting of risks and complications. It also calls for further research and advocacy to maintain awareness and training in RFA as a viable treatment option for movement disorders. The article acknowledges the importance of shared decision-making and patient preferences in choosing the appropriate treatment. [Extracted from the article]

Background: The role of deep brain stimulation in the treatment of dystonia has been widely documented. However, there is limited literature on the outcome of lesioning surgery in unilateral dystonia. Objective: We restrospectively reviewed our cases of focal and hemidystonia undergoing unilateral Pallidotomy at our institute to evaluate the short‐term and long‐term outcome. Methods: Patients who underwent radiofrequency lesioning of GPi for unilateral dystonia between 1999 and 2019 were retrospectively reviewed. All patients were evaluated using the Burke–Fahn–Marsden Dystonia Rating Scale (BFMDRS) and Dystonia Disability Scale (DDS) preoperatively at the short term follow‐up (<1 year) and at long‐term follow‐up (2–7.5 years). Video recordings performed at these time points were independently reviewed by a blinded movement disorders specialist. Results: Eleven patients were included for analysis. The preoperative, short‐term, and long‐term follow‐up motor BFMDRS and DDS scores were 15.5 (IQR [interquartile range]: 10.5, 23.75) and 10.5 (IQR: 6.0, 14.5); 3.0 (IQR: 1.0, 6.0, P = 0.02) and 3.0 (IQR: 3.0, 8.0, P = 0.016); and 14.25 (IQR: 4.0, 20.0, P = 0.20) and 10.5 (IQR: 2.0, 15.0, P = 0.71) respectively. For observers B, the BFMDRS scores at the same time points were 19 (IQR: 12.5, 27.0), 7.5 (IQR: 6.0, 15.0, P = 0.002), and 21 (IQR: 7.0, 22.0, P = 0.65) respectively. The improvement was statistically significant for all observations at short‐term follow‐up but not at long‐term follow‐up. Conclusion: Pallidotomy is effective for hemidystonia or focal dystonia in the short term. Continued benefit was seen in the longer term in some patients, whereas others worsened. Larger studies may be able to explain this in future. [ABSTRACT FROM AUTHOR]

BACKGROUND: Lesioning surgeries in Parkinson's disease (PD) include target obliteration of a certain area in brain tissue to disrupt maladaptive neuronal arrangements. There was an advancement in treatment of movement disorders when stereotactic procedures were applied in lesioning. Target selections were modulated various times until in 1960s when thalamotomy was used for tremors and pallidotomy was used for bradykinesia and rigidity. OBJECTIVE: To report the efficacy of unilateral combined stereotactic radiofrequency pallidotomy and thalamotomy for idiopathic Parkinson's disease. PATIENTS AND METHODS: This is a prospective observational study including 62 patients with idiopathic Parkinson's disease who underwent stereotactic radiofrequency pallidotomy and thalamotomy between June 2017 and December 2019. Pre-operative clinical assessment was based on the Unified Parkinson's Disease Rating Scale (UPDRS) and Hoehn and Yahr scale for PD. Postoperative clinical assessment was based on the UPDRS and Hoehn and Yahr scale for PD in addition to complications at 1, 6, 12 and 24 months. RESULTS: Sixty patients who completed the two-year follow-up and fulfilled our criteria were recruited. The mean age was 57.47±9.90 years. The average UPDRS off state motor assessment results showed reduction after 1 month from 60.16 to 30.88, and at 24-months follow-up it was 41.6. The average Hoehn and Yahr scale was reduced from 3.63 to 1.19 after 1-month, and at 24 months it was 1.87. The average UPDRS constancy of tremors improved after 1-month from 3.53 to 0.75. Improvement in constancy of tremors reached 75% of cases after 24-months with average 1.62. The average UPDRS rigidity score improved at 1-month follow-up from 3.31 to 1.21. Total improvement of rigidity reached 63% after 24-months. Two patients had postoperative thalamic hematoma presenting with hemiplegia, which was conservatively managed, and improved after 1-month with little deficit. Around 51.6% of the patients had gait imbalance at 6-months follow-up while 22.5% showed dysarthria immediately postoperatively which totally resolved after 1-month in 12.9%. There were no recorded cases of infection, cerebrospinal fluid (CSF) leaks or cognitive dysfunction. CONCLUSION: Our data suggest that unilateral combined stereotactic radiofrequency Pallidotomy and Thalamotomy for idiopathic PD is an effective procedure. [ABSTRACT FROM AUTHOR]

BACKGROUND: The pallidum is a target for stereotactic surgery either by lesioning or deep brain stimulation (DBS) and it plays an important role in the functional stereotactic neurosurgery. DBS is a high cost method for treatment of parkinsonism especially for low income countries like Egypt, but it is reversible. On the contrary, ablation is a low cost method but it is irreversible. OBJECTIVE: The aim of this study was to introduce a novel application for mechanical pallidotomy by air concussion and intermittent inflation and deflation for treatment of parkinsonism and as a pre-DBS maneuver. PATIENTS AND METHODS: We operated on 6 patients with parkinsonism. We injected 2ml of hypertonic saline through 5ml syringe at the pericapsular area using Leksell stereotactic frame. RESULTS: Five cases (83.3%) showed good response to the maneuver with disappearance of the tremors for 1-6 months, while only one patient 16.7% showed no response. CONCLUSION: Non-destructive pallidal disruption for management of parkinsonism is a safe and effective transient maneuver. We are planning to apply microballoning and air concussion techniques to make it permanent and our future directions is to include more cases. We can use this maneuver as a pre-DBS stage to ensure the patient is a good candidate for DBS. [ABSTRACT FROM AUTHOR]

Introduction: Parkinson's disease (PD) is one of the most common neurodegenerative progressive disorders. Despite the dominance of neurostimulation technology, stereotactic lesioning operations play a significant role in the treatment of PD. The aim of the study was to evaluate the effectiveness and safety of staged bilateral asymmetric radiofrequency (RF) stereotactic lesioning in a highly selected group of PD patients. Material and Methods: A retrospective review of 418 consecutive patients undergoing stereotactic ablation for advanced PD at our institution revealed 28 patients who underwent staged asymmetric bilateral ablation. In this subset, after initial RF thalamotomy, contralateral pallidotomy was performed in 16 (57.1%) patients (group Vim-GPi), and contralateral lesion of the subthalamic nucleus (STN) was performed in 12 (32.9%) patients (group Vim-STN). The mean duration of disease before the first surgery was 9.9 ± 0.8 years. The mean interval between the two operations was 3.5 ± 0.4 years (range, 1–10 years); in the Vim-GPi group, it was 3.1 ± 0.4 years; and in the Vim-STN group, it was 4.3 ± 0.1 years. After the second operation, the long-term follow-up lasted from 1 to 8 years (mean 4.8 ± 0.5 years). All patients were evaluated 1 year after the second operation. Results: One year after staged bilateral lesioning, the mean tremor score improved from baseline, prior to the first operation, from 19.8 to 3.8 (improvement of 81%), the overall mean rigidity score improved from 11.0 to 3.7 (improvement of 66%), and hypokinesia improved from 14.8 to 8.9 (improvement of 40%). One year after staged bilateral lesioning, the total UPDRS score improved in the Vim-GPi group by 47% in the OFF and 45.9% in the ON states. In the Vim-STN group, the total UPDRS score improved from baseline, prior to the first operation, by 44.8% in the OFF and 51.6% in the ON states. Overall, levodopa dose was reduced by 43.4%. Neurological complications were observed in 4 (14.3%) cases; among them, 1 (3.6%) patient had permanent events related to local ischemia after pallidotomy. Conclusion: Staged asymmetric bilateral stereotactic RF lesioning can be a safe and effective method in highly selected patients with advanced PD, particularly where deep brain stimulation is not available or desirable. Careful identification and selection of patients for ablative surgery allow achieving optimal results in the treatment of PD with bilateral symptoms. [ABSTRACT FROM AUTHOR]

Background: Non-spastic movement disorders in children are common, although true epidemiologic data is difficult to ascertain. Children are more likely than adults to have hyperkinetic movement disorders defined as tics, dystonia, chorea/athetosis, or tremor. These conditions manifest from acquired or heredodegenerative etiologies and often severely limit function despite medical and surgical management paradigms. Neurosurgical management for these conditions is highlighted. Methods: We performed a focused review of the literature by searching PubMed on 16 May 2023 using key terms related to our review. No temporal filter was applied, but only English articles were considered. We searched for the terms (("Pallidotomy"[Mesh]) OR "Rhizotomy"[Mesh]) OR "Deep Brain Stimulation"[Mesh], dystonia, children, adolescent, pediatric, globus pallidus, in combination. All articles were reviewed for inclusion in the final reference list. Results: Our search terms returned 37 articles from 2004 to 2023. Articles covering deep brain stimulation were the most common (n = 34) followed by pallidotomy (n = 3); there were no articles on rhizotomy. Discussion: Non-spastic movement disorders are common in children and difficult to treat. Most of these patients are referred to neurosurgery for the management of dystonia, with modern neurosurgical management including pallidotomy, rhizotomy, and deep brain stimulation. Historically, pallidotomy has been effective and may still be preferred in subpopulations presenting either in status dystonicus or with high risk for hardware complications. Superiority of DBS over pallidotomy for secondary dystonia has not been determined. Rhizotomy is an underutilized surgical tool and more study characterizing efficacy and risk profile is indicated. [ABSTRACT FROM AUTHOR]

Refractory movement disorders are a common feature of inborn errors of metabolism (IEMs), significantly impacting quality of life and potentially leading to life-threatening complications such as status dystonicus. Surgical techniques, including deep brain stimulation (DBS) and lesioning techniques, represent an additional treatment option. However, the application and benefits of these procedures in neurometabolic conditions is not well understood. This results in challenges selecting surgical candidates and counseling patients preoperatively. In this review, we explore the literature of surgical techniques for the treatment of movement disorders in IEMs. Globus pallidus internus DBS has emerged as a beneficial treatment option for dystonia in Panthotate-Kinase-associated Neurodegeneration. Additionally, several patients with Lesch--Nyhan Disease have shown improvement following pallidal stimulation, with more robust effects on self-injurious behavior than dystonia. Although there are numerous reports describing benefits of DBS for movement disorders in other IEMs, the sample sizes have generally been small, limiting meaningful conclusions. Currently, DBS is preferred to lesioning techniques. However, successful use of pallidotomy and thalamotomy in neurometabolic conditions has been reported and may have a role in selected patients. Surgical techniques have also been used successfully in patients with IEMs to treat status dystonicus. Advancing our knowledge of these treatment options could significantly improve the care for patients with neurometabolic conditions. [ABSTRACT FROM AUTHOR]

Background. Pallidothalamic tractotomy" can be effective in Parkinson's disease by exhibiting anti-parkinsonian effects. Case presentation. The patient was a 53 years old gentleman, having Parkinson's disease for the last 14 years. The disease onset was on the left side and slowly moved to the right side. He had tremors, slowness of body movements and stiffness of the movements. The first right Pallidotomy was done in January 2019. There was a noticeable improvement in a few weeks. He continued to have symptoms on the right side. The preoperative Unified Parkinson Disease Rating Scale (UPDRS) part 3 score in 2019 was 53 while the postoperative score was only 26 showing drastic improvement after right Pallidotomy. After 2 years of the first surgery, a new technique called Pallido Thalamic Tractotomy (PTT), an MRI-guided stereotactic surgery was done on the left side. Tremors reduced gradually by 99% in 3 weeks after surgery. This is the first case of PTT performed on a patient with Parkinson's disease in India. Conclusion. PTT is an effective procedure in PD that acts by disconnecting the pallidothalamic tract. Unilateral pallidothalamic tractotomy done on the left side improved contralateral side rigidity, tremors and bradykinesia. [ABSTRACT FROM AUTHOR]

Background: The principal type of Parkinsonism that occurs most often is Parkinson's disease [PD]. Pallidotomies decrease stiffness, tremor, and dyskinesias, however bilateral pallidotomies have a higher risk of consequences, including cognitive decline and dysarthrias. Aim of the Work: The clinical motor results of stereotactic pallidotomy procedures for Parkinson's disease and possible complications.Patients and Methods: This research, which included 20 patients who received stereotactic unilateral pallidotomies for Parkinson's disease, was carried out in both a retrospective and prospective manner at the Department of Neurosurgery Al-Azhar University Hospitals. Results: This study demonstrated a comparison of Unified Parkinson's Disease Rating Scale [UPDRS] 3 [motor symptoms]. There was very statistical substantial [p-value < 0.001] decreased UPDRS 3 post-operative [33.0 ± 8.5] and 6 months post-operative [33.3 ± 9.02] when compared with pre-operative UPDRS 3 [45.8 ± 10.4]. As regards Post-Hoc test for multiple comparisons and UPDRS 3, there was very statistical substantial variation [p-value < 0.001] between pre-operative and post-operative UPDRS 3 and 6 months post-operative UPDRS. As regards comparison of activity daily life [ADL] [UPDRS 2], there was statistically substantial [p-value = 0.009], decreased ADL [UPDRS 2] post-operative [25.6 ± 6.02] and 6 months post-operative [24.7 ± 5.5] when compared with pre-operative ADL [UPDRS 2] [31.8 ± 7.7]. As regards Post-Hoc test for multiple comparisons and ADL [UPDRS 2], there was statistically substantial variation [p-value = 0.004] between pre-operative and post-operative ADL [UPDRS 2]. Considering comparison of dyskinesia, there was highly statistical substantial variation [p-value < 0.001] of dyskinesia.Conclusion: Stereotactic Unilateral pallidotomy for Parkinson’s Disease had good effect on improving motor functions assessed by Unified Parkinson's disease rating scale especially the motor functions in follow up after operation with little prevalence of complications.

Background. Pallidothalamic tractotomy” can be effective in Parkinson’s disease by exhibiting anti-parkinsonian effects. Case presentation. The patient was a 53 years old gentleman, having Parkinson’s disease for the last 14 years. The disease onset was on the left side and slowly moved to the right side. He had tremors, slowness of body movements and stiffness of the movements. The first right Pallidotomy was done in January 2019. There was a noticeable improvement in a few weeks. He continued to have symptoms on the right side. The preoperative Unified Parkinson Disease Rating Scale (UPDRS) part 3 score in 2019 was 53 while the postoperative score was only 26 showing drastic improvement after right Pallidotomy. After 2 years of the first surgery, a new technique called Pallido Thalamic Tractotomy (PTT), an MRI-guided stereotactic surgery was done on the left side. Tremors reduced gradually by 99% in 3 weeks after surgery. This is the first case of PTT performed on a patient with Parkinson’s disease in India. Conclusion. PTT is an effective procedure in PD that acts by disconnecting the pallidothalamic tract. Unilateral pallidothalamic tractotomy done on the left side improved contralateral side rigidity, tremors and bradykinesia.

Refractory movement disorders are a common feature of inborn errors of metabolism (IEMs), significantly impacting quality of life and potentially leading to life-threatening complications such as status dystonicus. Surgical techniques, including deep brain stimulation (DBS) and lesioning techniques, represent an additional treatment option. However, the application and benefits of these procedures in neurometabolic conditions is not well understood. This results in challenges selecting surgical candidates and counseling patients preoperatively. In this review, we explore the literature of surgical techniques for the treatment of movement disorders in IEMs. Globus pallidus internus DBS has emerged as a beneficial treatment option for dystonia in Panthotate-Kinase-associated Neurodegeneration. Additionally, several patients with Lesch–Nyhan Disease have shown improvement following pallidal stimulation, with more robust effects on self-injurious behavior than dystonia. Although there are numerous reports describing benefits of DBS for movement disorders in other IEMs, the sample sizes have generally been small, limiting meaningful conclusions. Currently, DBS is preferred to lesioning techniques. However, successful use of pallidotomy and thalamotomy in neurometabolic conditions has been reported and may have a role in selected patients. Surgical techniques have also been used successfully in patients with IEMs to treat status dystonicus. Advancing our knowledge of these treatment options could significantly improve the care for patients with neurometabolic conditions.

Chorea‐acanthocytosis (ChAc) is a progressive degenerative disease, which manifests movement disorders including chorea and dystonia. Deep brain stimulation has been reported to successfully improve chorea and dystonia in ChAc. However, there are no reports of lesioning surgery for ChAc. The patient was a 47‐year‐old female with a mutation in VPS13A, which led to the diagnosis of ChAc, presenting with chorea in bilateral hands. The Unified Huntington's Disease Rating Scale‐Motor Score (UHDRS‐MS) was 51. The patient underwent staged bilateral pallidothalamic tractotomy and pallidotomy, which resulted in 60.8% improvement of UHDRS‐MS (20 at 3‐month postoperative evaluation). There was no perioperative complication. No chorea recurrence was observed during the 2‐year postoperative follow‐up period. [ABSTRACT FROM AUTHOR]

Background:Parkinson's Disease (PD), Essential Tremors (ET), and Dystonia are movement disorder diseases managed surgically. Deep brain nuclei include the globus pallidus internus (GPI), ventral intermediate nucleus (VIM), and subthalamic nucleus (STN). Proper choice of the target is based on the appropriate diagnosis, patient's symptoms, and possible adverse effects following the ablative surgery. Methods:We had 40 patients diagnosed with movement disorders. A complete neurological assessment was done on the patients. 3D MRI was done on the patients for diagnosis and preoperative target planning. Results:We had 30 males and ten females. Twenty-four had PD, 14 had ET, and two had dystonia. We did pallidotomy in four cases, thalamotomy in 22 cases, subthalamotomy on eight patients, and combined pallidotomy and VIM thalamotomy on six patients. The thalamotomy group had a remarkable improvement in tremors. The subthalamotomy or combined pallidotomy and thalamotomy groups improved all three cardinal PD symptoms, the ON/OFF fluctuations, and a reduction in L-Dopa Induced dyskinesia. Patients who had a pallidotomy had an improvement in bradykinesia, and rigidity, improvement in the ON/OFF fluctuations, and a reduction in L-Dopa-induced dyskinesia. Two patients suffered from hematoma, four ataxia, one contralateral hypothesia, and one hypophonia. One hemiballismus, two contralateral weaknesses, and one urine incontinence. Conclusions:Proper planning and choice of target is an essential cornerstone to reaching the best results. When choosing the target for stereotactic ablation, all functional neurosurgeons dealing with movement disorders must know all anticipated outcomes and possible complications. [ABSTRACT FROM AUTHOR]

Abstract Background Cervical dystonia is the most common form of focal dystonia and is managed by multiple modalities including repeated botulinum toxin injections, in addition to medical treatment with anticholinergics, muscle relaxants, and physiotherapy. However, surgical interventions could be beneficial in otherwise refractory patients. This study aims to report our experience in the neurosurgical management of cervical dystonia and evaluate patient outcomes using reliable outcome scores for the assessment of patients with cervical dystonia and possible complications. This case series study was conducted on 19 patients with cervical dystonia of different etiologies who underwent surgical management [ten patients underwent selective peripheral denervation, five patients underwent pallidotomy, and four patients underwent bilateral globus pallidus internus (GPi) deep brain stimulation (DBS)] in the period between July 2018 and June 2021 at Ain Shams University Hospitals, Cairo, Egypt. With the assessment of surgical outcomes using the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) and the Tsui scale 6 months postoperatively. Results Surgical management of patients with cervical dystonia of either primary or secondary etiology was associated with significant improvement in head and neck postures after 6 months without major complications associated with the different surgical procedures. The mean improvement in total TWSTRS and Tsui scores were 51.2% and 64.8%, respectively, compared with preoperative scores, while the mean improvement in the TWSTRS subscales (severity, disability, and pain) were 40.2%, 66.9%, and 58.3%, respectively. Conclusion Cervical dystonia patients in whom non-surgical options have failed to alleviate their symptoms can be managed surgically leading to significant improvements with minimal adverse effects. However, surgical treatment should be tailored according to several factors including but not limited to the etiology, pattern of dystonic activity, and comorbidities. Therefore, management should be tailored to achieve long-term improvement with minimal risk of complications.

Parkinson's disease (PD) is a progressive neurodegenerative illness with both motor and nonmotor symptoms. Deep brain stimulation (DBS) is an established safe neurosurgical symptomatic therapy for eligible patients with advanced disease in whom medical treatment fails to provide adequate symptom control and good quality of life, or in whom dopaminergic medications induce severe side effects such as dyskinesias. DBS can be tailored to the patient's symptoms and targeted to various nodes along the basal ganglia–thalamus circuitry, which mediates the various symptoms of the illness; DBS in the thalamus is most efficient for tremors, and DBS in the pallidum most efficient for rigidity and dyskinesias, whereas DBS in the subthalamic nucleus (STN) can treat both tremors, akinesia, rigidity and dyskinesias, and allows for decrease in doses of medications even in patients with advanced stages of the disease, which makes it the preferred target for DBS. However, DBS in the STN assumes that the patient is not too old, with no cognitive decline or relevant depression, and does not exhibit severe and medically resistant axial symptoms such as balance and gait disturbances, and falls. Dysarthria is the most common side effect of DBS, regardless of the brain target. DBS has a long‐lasting effect on appendicular symptoms, but with progression of disease, nondopaminergic axial features become less responsive to DBS. DBS for PD is highly specialised; to enable adequate selection and follow‐up of patients, DBS requires dedicated multidisciplinary teams of movement disorder neurologists, functional neurosurgeons, specialised DBS nurses and neuropsychologists. [ABSTRACT FROM AUTHOR]

Magnetic resonance-guided focused ultrasound (MRgFUS) is an emerging treatment for tremor and other movement disorders. An incisionless therapy, it is becoming increasingly common worldwide. However, given MRgFUS' relative novelty, there remain limited data on its benefits and adverse effects. We review the current state of evidence of MRgFUS for tremor, highlight its challenges, and discuss future perspectives. Essential tremor (ET) has been the major indication for MRgFUS since a milestone randomized controlled trial (RCT) in 2016, with substantial evidence attesting to the efficacy and acceptable safety profile of this treatment. Patients with other tremor etiologies are also being treated with MRgFUS, with studies – including an RCT – suggesting parkinsonian tremor in particular responds well to this intervention. Additionally, targets other than the ventral intermediate nucleus, such as the subthalamic nucleus and internal segment of the globus pallidus, have been reported to improve parkinsonian symptoms beyond tremor, including rigidity and bradykinesia. Although MRgFUS is encumbered by certain unique technical challenges, it nevertheless offers significant advantages compared to alternative neurosurgical interventions for tremor. The fast-growing interest in this treatment modality will likely lead to further scientific and technological advancements that could optimize and expand its therapeutic potential. [ABSTRACT FROM AUTHOR]

Background: Device‐assisted and neuromodulatory therapies are the standard of care for Parkinson's disease (PD) with disabling motor complications. We aimed to compare and rank the currently available advanced therapies for PD on patient relevant outcomes. Methods: We searched various databases for randomized controlled trials that studied subthalamic nucleus deep brain stimulation (STN‐DBS), globus pallidus interna (GPi) DBS, pallidotomy, subthalamotomy, continuous subcutaneous apomorphine infusion (CSAI), or intrajejunal levodopa infusion (IJLI), in patients with PD and motor complications. Primary outcome was the quality of life (QOL) at 6 months. Secondary outcomes included Unified Parkinson's Disease Rating Scale III and II, ON time, OFF time, levodopa equivalent daily doses, and adverse events (AE). Data were pooled using a Bayesian network meta‐analysis, summarized as mean difference (MD) with 95% credibility intervals (CrI) and visualized in forest plots/league tables. Surface under the cumulative ranking curve plots determined the ranking probability. Results: We identified 6745 citations and included 26 trials. STN‐DBS (MD, −8.0; 95% CrI, −11, −5.8), GPi‐DBS (MD, −7.1; 95% CrI, −11, −2.9), and IJLI (MD, −7.0; 95% CrI, −12, −1.8) led to better QOL than medical therapy alone, without significant differences among them. STN‐DBS had the highest probability of being ranked the best treatment for QOL (79.6%), followed by IJLI (63.5%) and GPi‐DBS (62.8%). Conclusions: In advanced PD, STN‐DBS alleviates more patient and clinician relevant outcomes, followed by GPi‐DBS and IJLI. In resource limited settings, unilateral pallidotomy may improve motor symptoms and activities of daily living, although overall QOL may not be improved. © 2022 International Parkinson and Movement Disorder Society. [ABSTRACT FROM AUTHOR]

Focused ultrasound ablation achieves selective thermal lesioning of the thalamic and basal ganglia targets using real-time MR imaging guidance. It is US Food and Drug Administration-approved to treat essential tremor and Parkinson's disease tremor, fluctuations, and dyskinesias. Patients often seek focused ultrasound treatment because symptom relief is immediate, and hardware implantation is not required. This review summarizes the current and potential future application of focused ultrasound ablation to treat movement disorders. We also discuss the ongoing research optimizing the technique of focused ultrasound ablation to improve long-term efficacy and minimize the risk of side effects., Competing Interests: Disclosures Dr V. Krishna is funded by NIH, United States. All other authors do not have commercial or financial conflicts of interest, and there are no funding sources for all authors., (Copyright © 2024 Elsevier Inc. All rights reserved.)

The history of focused ultrasound is a parallel history of neuroradiology, functional neurosurgery, and physics and engineering. Multiple pioneers collaborated as ultrasound transitioned from a wartime technology to a therapeutic one, particularly in using it to ablate the brain to treat movement disorders. Several competing technologies ensured that this "ultrasonic neurosurgery" remained in a lull. An algorithm and other advancements that obviated a craniectomy for ultrasonic neurosurgery allowed magnetic resonance-guided focused ultrasound to flourish to its modern phase., Competing Interests: Disclosure D. Gandhi reports grants from Microvention, the Focused Ultrasound Foundation, United States, the NIH, United States and University of Calgary, United States/NoNo Therapeutics. All other authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Globus pallidus internus (GPi) deep brain stimulation (DBS) is widely used in patients with dystonia. However, 10-20% of patients receive insufficient benefits. The objectives of this study are to evaluate the effectiveness of bilateral subthalamic nucleus (STN) DBS along with unilateral posteroventral pallidotomy (PVP) in patients with dystonia who experienced unsatisfactory GPi-DBS and to address the reported rescue procedures after suboptimal DBS or lesion surgery in dystonia patients. Methods: Six patients with isolated dystonia who had previously undergone bilateral GPi-DBS with suboptimal improvement were included. Standardized assessments of dystonia using the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) and quality of life using SF-36 were evaluated before surgery and 1, 6 months, and last follow-up (LFU) after surgery. STN bilateral OFF (bi-OFF), unilateral ON (uni-ON), and bilateral ON (bi-ON) states were recorded at LFU. Specific items were used to find publications published before 10 April 2022 regarding rescue procedures after suboptimal DBS or lesion surgery in patients with dystonia for reference. Eleven original studies including case reports/series were identified for discussion. Results: Substantial clinical benefits were achieved in all six patients. Significant amelioration was achieved during the 1-month (6.5 ± 7.45; p = 0.0049), 6-month (5.67 ± 6.3; p = 0.0056) follow-ups, and at LFU (4.67 ± 4.72; p = 0.0094) when compared with the baseline (LFU of GPi DBS with on status) (17.33 ± 11.79) assessed by BFMDRS. The percentage of improvement reached 70.6, 74.67, and 77.05%, respectively. At LFU, significant differences were found between the stimulation bi-OFF and uni-ON (11.08 ± 8.38 vs. 9 ± 8.52, p = 0.0191), and between the stimulation bi-OFF and bi-ON (11.08 ± 8.38 vs. 4.67 ± 4.72, p = 0.0164). Trends depicting a better improvement in stimulation bi-ON compared with uni-ON (4.67 ± 4.72 vs. 9 ± 8.52, p = 0.0538) were observed. Conclusion: Our results suggest that bilateral STN-DBS plus unilateral PVP may be an effective rescue procedure for patients with isolated dystonia who experienced suboptimal movement improvement following GPi-DBS. However, given the heterogeneity of patients and the small sample size, these findings should be interpreted with caution. [ABSTRACT FROM AUTHOR]

Background: For safety reasons, both magnetic resonance‐guided high‐intensity focused ultrasound (MRgHiFUS) thalamotomy and pallidotomy are currently approved exclusively for unilateral treatment, but axial symptoms like levodopa‐induced orofacial dyskinesia require a bilateral approach. Objectives: We report the first case of successful bilateral MRgHiFUS pallidotomy for peak‐dose dyskinesia in a patient with Parkinson's disease (PD). Methods: The treatment decision was based on the patient's reluctance toward brain implants and pump therapies and the fact that he had limited access to a deep brain stimulation center in his home country. The treatment was planned as staged procedure with an interval of 18 months because of travel restrictions because of the coronavirus disease (COVID)‐19 pandemic. Results: After the second treatment, levodopa‐induced orofacial dyskinesia remitted and improved bradykinesia and rigidity with stable gait and good postural reflexes. Conclusions: This promising result suggests that in selected PD patients with dyskinesia, staged bilateral MRgHiFUS pallidotomy might be considered. [ABSTRACT FROM AUTHOR]

Background: Cervical dystonia is the most common form of focal dystonia and is managed by multiple modalities including repeated botulinum toxin injections, in addition to medical treatment with anticholinergics, muscle relaxants, and physiotherapy. However, surgical interventions could be beneficial in otherwise refractory patients. This study aims to report our experience in the neurosurgical management of cervical dystonia and evaluate patient outcomes using reliable outcome scores for the assessment of patients with cervical dystonia and possible complications. This case series study was conducted on 19 patients with cervical dystonia of different etiologies who underwent surgical management [ten patients underwent selective peripheral denervation, five patients underwent pallidotomy, and four patients underwent bilateral globus pallidus internus (GPi) deep brain stimulation (DBS)] in the period between July 2018 and June 2021 at Ain Shams University Hospitals, Cairo, Egypt. With the assessment of surgical outcomes using the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) and the Tsui scale 6 months postoperatively. Results: Surgical management of patients with cervical dystonia of either primary or secondary etiology was associated with significant improvement in head and neck postures after 6 months without major complications associated with the different surgical procedures. The mean improvement in total TWSTRS and Tsui scores were 51.2% and 64.8%, respectively, compared with preoperative scores, while the mean improvement in the TWSTRS subscales (severity, disability, and pain) were 40.2%, 66.9%, and 58.3%, respectively. Conclusion: Cervical dystonia patients in whom non-surgical options have failed to alleviate their symptoms can be managed surgically leading to significant improvements with minimal adverse effects. However, surgical treatment should be tailored according to several factors including but not limited to the etiology, pattern of dystonic activity, and comorbidities. Therefore, management should be tailored to achieve long-term improvement with minimal risk of complications. [ABSTRACT FROM AUTHOR]

Introduction: The globus pallidus nucleus is a structure part of the basal ganglia and is involved in carrying out movements. Objective: To substantiate the reasons why the globus pallidus nucleus is selected as a surgical target for some diseases that present with movement disorders. Evidence acquisition: A bibliographic review (UptoDate, NCBI, Pubmed, Scielo and EBSCO) of more than 35 articles in Spanish and English related to globus pallidus nucleus was carried out, including anatomical nomenclatures, texts and atlases describing it, its structural organization, normal and pathological functioning and implications in the practice of Functional Neurosurgery. Most were published from 2016 to date. Results: Anatomically, globus pallidus is considered as a structure that belongs to the so-called basal ganglia together with the caudate, putamen, substantia nigra (reticulate and compact parts) and the subthalamic nucleus. An internal medullary lamina divides it into the external globus pallidus and the internal globus pallidus. By taking these two portions into account, the designed functional models of the basal ganglia give it a dual role in the control of movement. The internal portion (internal globus pallidus) is justified as a surgical target for both hypokinetic and hyperkinetic movement disorders. Conclusions: The anatomical and functional connections of both portions of the globus pallidus and their role in the direct and indirect pathways of movement control, as well as in the pathophysiology characterized by an environment with altered dopaminergic neurotransmission, justify its use as a surgical target in some diseases with movement disorders, by modifying the influence of these pathways on the activity of the motor thalamus. [ABSTRACT FROM AUTHOR]

The study design was prospective and patients were followed up for at least 1 year after surgery with the earliest patients of the series having follow-up for 5 years. Presently, we already see a re-emergence of lesioning surgery in the form of MR-guided focal ultrasound and other techniques.35 Certainly, there is a need for functional neurosurgeons worldwide to preserve knowledge and skills about therapeutic lesions in movement disorders surgery. The operation had little effect on dysarthria, but transient "dysphasia" was noted in 24% of patients with wide ventricles, and in 7.5% of those with normal ventricles when surgery was performed on the dominant hemisphere. Keywords: globus pallidus internus; history; neurosurgery; pallidotomy; Parkinson's; stereotactic surgery; thalamotomy EN globus pallidus internus history neurosurgery pallidotomy Parkinson's stereotactic surgery thalamotomy 173 177 5 02/07/22 20220201 NES 220201 Svennilson E, Torvik A, Lowe R, Leksell L. Treatment of parkinsonism by stereotactic thermolesions in the pallidal region. [Extracted from the article]

Background: Rare movement disorders (RMDs) throw remarkable challenges to their appropriate management particularly when they are medically refractory. We studied the outcome of functional neurosurgery among patients with RMDs. Methods: Retrospective chart-review from 2006 to 2021 of patients with RMDs who underwent either Deep brain Stimulation (DBS) or lesional surgeries in the department of Neurology and Neurosurgery at a tertiary care centre. Results: Seventeen patients were included. Generalized dystonia (11 patients, 64.7%) and tremor (5 patients, 29.4%) were the most common indication for surgery whereas, Wilson's disease (8 patients, 47.1%) and Neurodegeneration with brain iron accumulation (5 patients, 29.4%) were the most common aetiology. Sixteen patients (94.1%) had objective clinical improvement. Significant improvement was noted in the dystonia motor scores both at 6-months and 12-months follow-up (n = 11, p-value of <0.01 and 0.01 respectively). Comparison between DBS and lesional surgery showed no significant difference in the outcomes (p = 0.95 at 6-months and p = 0.53 at 12-months), with slight worsening of scores in the DBS arm at 12-months. Among five patients of refractory tremor with Wilson's disease, there was remarkable improvement in the tremor scores by 85.0 ± 7.8% at the last follow-up. Speech impairment was the main complication observed with most of the other adverse events either transient or reversible. Discussion: Surgical options should be contemplated among patients with disabling medically refractory RMDs irrespective of the aetiology. Key to success lies in appropriate patient selection. In situations when DBS is not feasible, lesional surgeries can offer an excellent alternative with comparable efficacy and safety. [ABSTRACT FROM AUTHOR]

Background: Reports on the long-term effects of pallidotomy for cervical dystonia remain scarce. Case Description: We report a case of cervical dystonia successfully treated by unilateral pallidotomy. The patient was a 29-year-old man without past medical and family history of cervical dystonia. At the age of 28 years, neck rotation to the right with right shoulder elevation developed and gradually became worse. After symptoms failed to respond to repetitive botulinum toxin injections and oral medications, he underwent left pallidotomy, which resulted in significant improvement of cervical dystonia and shoulder elevation without surgical complications. At the 3-month evaluation, the symptoms completely improved. The Toronto Western Spasmodic Torticollis Rating Scale score dramatically improved from 39 points before surgery to 0 points at 7-year postoperative evaluation. Conclusion: This case suggests that unilateral pallidotomy can be an alternative treatment option for cervical dystonia. [ABSTRACT FROM AUTHOR]

Background: Pallidotomy is the oldest stereotactically performed neurosurgical procedure for movement disorders. Consequently, there is a wealth of literature available on the topic. Objectives: The aim of this analysis was to identify the top-cited articles on pallidotomy in order to discern the origins, spread, the current trends, and the future directions of this surgical procedure. Methods: We performed a search of the Web of Science database on 19 October 2020 using the keyword "pallidotomy." The top-100 cited articles found were arranged in descending order on the basis of citation count (CC) and citation per year (CY). Relevant conclusions were derived. Results: The 100 top-cited articles were published between 1961 and 2017, in 24 journals. The average CC and CY were 118.1 (range – 856–46) and 5.326 (range – 29.52–2.09), respectively. The 3 most prolific authors were Lang AE (Neurologist – Toronto), Lozano AM (Neurosurgeon – Toronto), and Vitek JL (Neurologist – Atlanta). The Journal of Neurosurgery published the highest number of top-cited articles [Neurology. 1960;10:61–9]. The maximum articles were from the USA. University of Toronto and Emory University were the most productive institutions. Conclusions: Pallidotomy has gone through several ebbs and flows. Unilateral pallidotomy is currently recommended for the treatment of motor symptoms of Parkinson's disease and dystonia. The need for further research and improved technology to make the technique safer and prove its efficacy is highlighted, especially keeping in mind a large number of populations to which the prohibitively expensive deep brain stimulation is unavailable. [ABSTRACT FROM AUTHOR]

BackgroundRadiofrequency lesioning (RFL) though used since the 1950s, had been replaced by DBS in the 1990s. The availability of magnetic resonance-guided focused ultrasound for lesioning has renewed the interest in RFL.ObjectiveThis paper analysis RFL in contemporary Functional Neurosurgery for various indications and its outcome. Complication rates of RFL are compared with the same author’s experience of DBS.MethodsOne hundred and seven patients underwent RFL between 1998 and 2019. Indications included Parkinson’s Disease (PD), tremors, dystonia, and obsessive-compulsive disorders (OCD). The surgeries performed include thalamotomy (29), pallidotomy (49), subthalamotomy (23), and anterior capsulotomy/nucleus accumbens lesioning (6). Appropriate rating scales were used for preoperative and postoperative evaluations.ResultsThere was a 25% recurrence rate of tremors for PD after thalamotomy. Writer’s cramp rating scale improved from a mean of 10.54–1.6 in task specific dystonia (TSD) patients, after thalamotomy. In PD patients, after pallidotomy, contralateral motor Unified Parkinson’s Disease Rating Scale (UPDRS) and dyskinesia scores, improved by 41 and 57%, respectively, at 1-year. Burke-Fahn-Marsden Dystonia Rating Scale in hemidystonia patients improved from 18.04 to 6.91, at 1-year. There was 32 and 31% improvement in total and motor UPDRS, respectively, in the subthalamotomy patients, at 2-year. All patients of OCD were in remission. There were three deaths in the pallidotomy group. Postoperative, dysarthria, confusion, hemiparesis, dyskinesia, and paraesthesia occurred in 12 patients, of which, 7 were transient.ConclusionRFL is a useful option in a select group of patients with tremors and dystonia. It is our preferred treatment option for TSD and OCD.

Background: Radiofrequency lesioning (RFL) though used since the 1950s, had been replaced by DBS in the 1990s. The availability of magnetic resonance-guided focused ultrasound for lesioning has renewed the interest in RFL. Objective: This paper analysis RFL in contemporary Functional Neurosurgery for various indications and its outcome. Complication rates of RFL are compared with the same author's experience of DBS. Methods: One hundred and seven patients underwent RFL between 1998 and 2019. Indications included Parkinson's Disease (PD), tremors, dystonia, and obsessive-compulsive disorders (OCD). The surgeries performed include thalamotomy (29), pallidotomy (49), subthalamotomy (23), and anterior capsulotomy/nucleus accumbens lesioning (6). Appropriate rating scales were used for preoperative and postoperative evaluations. Results: There was a 25% recurrence rate of tremors for PD after thalamotomy. Writer's cramp rating scale improved from a mean of 10.54–1.6 in task specific dystonia (TSD) patients, after thalamotomy. In PD patients, after pallidotomy, contralateral motor Unified Parkinson's Disease Rating Scale (UPDRS) and dyskinesia scores, improved by 41 and 57%, respectively, at 1-year. Burke-Fahn-Marsden Dystonia Rating Scale in hemidystonia patients improved from 18.04 to 6.91, at 1-year. There was 32 and 31% improvement in total and motor UPDRS, respectively, in the subthalamotomy patients, at 2-year. All patients of OCD were in remission. There were three deaths in the pallidotomy group. Postoperative, dysarthria, confusion, hemiparesis, dyskinesia, and paraesthesia occurred in 12 patients, of which, 7 were transient. Conclusion: RFL is a useful option in a select group of patients with tremors and dystonia. It is our preferred treatment option for TSD and OCD. [ABSTRACT FROM AUTHOR]

ABSTRACT: BACKGROUND & OBJECTIVE: To assess the results of pallidotomy in Parkinson’s disease, and its effect on improving the lifestyle of the patients and cost-effectiveness. METHODOLOGY: A descriptive study was conducted at Neuro-Spinal & Cancer Care Institute, Karachi from June 2014 to January 2020. Patients who were known case of Parkinson’s disease refractory to medication and developed side effects to medication were included in the study and patients with previous brain surgery, associated brain disorders like Alzheimer’s disease, basal ganglia lesion, brain trauma were excluded. All patients were treated by pallidotomy on the contralateral side. The significance of the difference between groups to compare between the pre-op or post-op treatments was calculated through non-parametric assessment Kruskal-Wallis tests. RESULTS: The mean age of the patients was around 57 years. There were 34(81%) male and 8(19%) female patients’ Maximum number of patients who were more than 45 years, were having a left-sided proportion. More male patients were having a left-sided proportion as compared to female patients. The majority of patients (57.5%) were having dyskinesia as q primary symptom. A significant difference (p-value