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Acoustic Neuroma
Adult Tethered Cord
Acromegaly
Acute Subdural Hematomas
Anaplastic Astrocytoma (AA)
Ankylosing Spondylitis
Aqueductal Stenosis
Arachnoid Cysts
Arnold Chiari Malformation
Arteriovenous Malformation (AVM)
Astrocytoma
Ballism
Basilar Invagination
Brachial Plexus Injury
Brain Aneurysm
Brain Attack (Stroke)
Brain AVM
Brain Conditions
Brain Metastases
Brainstem Glioma
Carotid Dissection
Carotid Stenosis
Carpal Tunnel Syndrome
Causalgia
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Cerebral Contusion and Intracerebral Hematoma
Chordomas
Chorea
Chronic Subdural Hematomas
Colloid Cyst
Coma
Concussion
Congenital Dermal Sinus
Cranial GunShot Wounds
Craniopharyngioma
Craniosynostosis
Cushing's Disease
Cyst Epidermoid Tumor
Dandy Walker Syndrome
Degenerative Disc Disease
Dermoid Tumor
Disc Herniation
Dural Arteriovenous Malformations
Dystonia
Ependymoma
Epidermoid Tumor (Cyst)
Epidural Hematomas
Epilepsy
Essential Tremor
Extratemporal Lobe Epilepsies
Facet Joint Syndrome
Fibromyalgia
Frontal Lobe Epilepsy
Ganglioglioma
Glioblastoma
Germinoma
Glioma
Glomus Jugulare Tumor
Glossopharyngeal Neuralgia
Hemangioblastomas
Hemi-Facial Spasm
Hydrocephalus
Hyperhidrosis
Intracerebral Hemorrhage
Intracranial Hypotension
JPA
Low-Grade Astrocytoma
Lymphocytic Hypophysitis
Lymphoma
Malignant Nerve Sheath Tumors
Medulloblastoma
Meningioma Brain Tumor
Meralgia Paresthetica
Metastatic Brain Tumors
Moyamoya Disease
Myelomeningocele
Myelopathy
Nelson's Syndrome
Neurocysticercosis
Neurofibromatosis Type 2 and Schwannomatosis
Normal Pressure Hydrocephalus
Oligodendroglioma
Optic Nerve Glioma
Osteoarthritis of the Peripheral Joint
Osteoarthritis of the Spine
Osteomyelitis
Osteoporotic Vertebral Fractures
Parkinsons Syndrome
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Pediatric Hydrocephalus
Peripheral Nerve Injury
Phantom Limb Pain
Pineal Tumor
Pineoblastoma
Pineocytoma
Platybasia
Postherpetic Neuralgia
Post-Traumatic Seizures
Primary CNS Lymphoma
Pseudotumor Cerebri
Radiculopathy—Cervical & Lumbar (Pinched Nerve)
Recurrent Adenomas
Rheumatoid Arthritis
Schwannomas
Scoliosis
Seizure
Skull Fracture
Slit Ventricle Syndrome
Spasticity
Spinal Arteriovenous Malformation (AVM)
Spinal Compression Fractures
Spine Conditions
Spinal Cord Injury
Spinal Cord Lipomas & Lipomyelomeningoceles
Spinal Cord Tumors
Stenosis
Subarachnoid Hemorrhage
Syringomyelia
Tethered Cord Syndrome
Thoracic Outlet Syndrome
Thyrotroph (TSH) Secreting Adenomas
Torticollis
Traumatic Hematomas
Trigeminal Neuralgia
Trochanteric Bursitis
Ulnar Nerve Entrapment
Conditions Treated
Acoustic Neuroma
Adult Tethered Cord
Acromegaly
Acute Subdural Hematomas
Anaplastic Astrocytoma (AA)
Ankylosing Spondylitis
Aqueductal Stenosis
Arachnoid Cysts
Arnold Chiari Malformation
Arteriovenous Malformation (AVM)
Astrocytoma
Ballism
Basilar Invagination
Brachial Plexus Injury
Brain Aneurysm
Brain Attack (Stroke)
Brain AVM
Brain Conditions
Brain Metastases
Brainstem Glioma
Carotid Dissection
Carotid Stenosis
Carpal Tunnel Syndrome
Causalgia
Cavernous Angioma
Cerebral Aneurysms
Cerebral Contusion and Intracerebral Hematoma
Chordomas
Chorea
Chronic Subdural Hematomas
Colloid Cyst
Coma
Concussion
Congenital Dermal Sinus
Cranial GunShot Wounds
Craniopharyngioma
Craniosynostosis
Cushing's Disease
Cyst Epidermoid Tumor
Dandy Walker Syndrome
Degenerative Disc Disease
Dermoid Tumor
Disc Herniation
Dural Arteriovenous Malformations
Dystonia
Ependymoma
Epidermoid Tumor (Cyst)
Epidural Hematomas
Epilepsy
Essential Tremor
Extratemporal Lobe Epilepsies
Facet Joint Syndrome
Fibromyalgia
Frontal Lobe Epilepsy
Ganglioglioma
Glioblastoma
Germinoma
Glioma
Glomus Jugulare Tumor
Glossopharyngeal Neuralgia
Hemangioblastomas
Hemi-Facial Spasm
Hydrocephalus
Hyperhidrosis
Intracerebral Hemorrhage
Intracranial Hypotension
JPA
Low-Grade Astrocytoma
Lymphocytic Hypophysitis
Lymphoma
Malignant Nerve Sheath Tumors
Medulloblastoma
Meningioma Brain Tumor
Meralgia Paresthetica
Metastatic Brain Tumors
Moyamoya Disease
Myelomeningocele
Myelopathy
Nelson's Syndrome
Neurocysticercosis
Neurofibromatosis Type 2 and Schwannomatosis
Normal Pressure Hydrocephalus
Oligodendroglioma
Optic Nerve Glioma
Osteoarthritis of the Peripheral Joint
Osteoarthritis of the Spine
Osteomyelitis
Osteoporotic Vertebral Fractures
Parkinsons Syndrome
Pediatric Conditions
Pediatric Hydrocephalus
Peripheral Nerve Injury
Phantom Limb Pain
Pineal Tumor
Pineoblastoma
Pineocytoma
Platybasia
Postherpetic Neuralgia
Post-Traumatic Seizures
Primary CNS Lymphoma
Pseudotumor Cerebri
Radiculopathy—Cervical & Lumbar (Pinched Nerve)
Recurrent Adenomas
Rheumatoid Arthritis
Schwannomas
Scoliosis
Seizure
Skull Fracture
Slit Ventricle Syndrome
Spasticity
Spinal Arteriovenous Malformation (AVM)
Spinal Compression Fractures
Spine Conditions
Spinal Cord Injury
Spinal Cord Lipomas & Lipomyelomeningoceles
Spinal Cord Tumors
Stenosis
Subarachnoid Hemorrhage
Syringomyelia
Tethered Cord Syndrome
Thoracic Outlet Syndrome
Thyrotroph (TSH) Secreting Adenomas
Torticollis
Traumatic Hematomas
Trigeminal Neuralgia
Trochanteric Bursitis
Ulnar Nerve Entrapment
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Conditions Treated
Parkinsons Syndrome
Parkinson's Syndrome
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About Parkinson's Syndrome
General Information
Parkinson's disease involves an imbalance between dopamine and acetylcholine, two chemicals involved in transmitting signals from the brain. The imbalance can cause involuntary movement, decreased movement, rigidity, and abnormal walking and posture.
Most cases occur without a known cause, but others are induced by drugs or environmental toxins.
Drugs such as phenothiazines, butyrophenones, metoclopramide, reserpine, and tetrabenazine may cause a reversible Parkinson's syndrome.
Toxins such as manganese dust or carbon disulfide may also lead to disease symptoms.
The recreational drug MPTP can cause Parkinson’s by selectively destroying dopamine neurons in the midbrain.
In the first half of the 20th century Parkinsonism often developed in patients with a history of von Economo's encephalitis. This type of infection, called encephalitis lethargica, is not now encountered; therefore this type of Parkinson's is rare.
The
UCLA Neurosurgical Movement Disorders Program
is one of the leading centers for the surgical treatment of Parkinson's disease.
Symptoms
Tremor
Involuntary movement called tremor is most conspicuous at rest, increases at times of emotional stress, and often improves during voluntary activity.
It commonly begins as a rhythmic flexing of the fingers or toes, and frequently involves the face and mouth as well.
It often starts asymmetrically, affecting one side of the body more than the other.
Rigidity
Rigidity typically is uniform throughout the range of movement.
In some instances the symptom is described as “cogwheel” rigidity because of the ratchet-like interruptions of passive movement.
Hypokinesia
The most disabling feature of this disorder, hypokinesia is a slowness of voluntary movement and a reduction in automatic movement, such as arm swinging while walking.
Facial symptoms include infrequent blinking, fixed expression, and a smile that develops and fades slowly.
The voice typically is low in volume and poorly modulated.
Abnormal gait and posture
Rising from a bed or easy chair is difficult and standing posture is bent.
Patients walk with small, shuffling steps and lack the arm swing that normally accompanies walking. Patients may also have trouble stopping.
Medical Treatment
Medical management is first-line therapy in the treatment of patients with Parkinson's disease.
Medication can be used to treat the chemical imbalance in the brain by enhancing effects of dopamine and/or blocking the effects of acetylcholine.
Levodopa can ease most major symptoms of Parkinson’s, including hypokinesia. The most common side effects are nausea, vomiting, low blood pressure, abnormal movements, restlessness, confusion and occasional cardiac arrhythmias.
Anticholinergic drugs that block the effects of acetylcholine are more helpful in alleviating tremor and rigidity than hypokinesia, but overall are generally less effective than dopamine-enhancing medications. Among the most commonly prescribed drugs are trihexyphenidyl (Artane), benztropine (Cogentin), procyclidine (Kemadrin), and orphenadrine (Disipal). Common side effects include dryness of the mouth, constipation, urinary retention, confusion and blurred vision.
Amantadine is used to enhance the release of dopamine and can quickly improve all symptoms. Unfortunately, many patients fail to respond and the benefits can be short-lived. Side effects are relatively uncommon but can include restlessness, confusion, skin rashes, edema and cardiac effects.
Other options include dopamine agonists, such as bromocriptine, which directly stimulate dopamine receptors.
Surgical Treatment
For patients who are intolerant of medications or who experience significant motor fluctuations, surgery can be considered.
Deep brain stimulation (DBS)
surgery is used more often in Parkinson's disease than any other movement disorder.
Depending on age, symptoms, and comorbidities, DBS can either target the subthalamic nucleus or the globus pallidus internus.
Stereotactic RF ablation can also be considered but is rarely used since the advent of DBS. Lesions can be considered in the globus pallidus or in the thalamus.
DBS Selection Criteria
Diagnosis of idiopathic Parkinson's disease
DBS therapy is only efficacious for patients with idiopathic parkinsonism and not atypical parkinsonism. Signs of idiopathic or typical Parkinson's disease include asymmetric presentation, sinemet responsiveness, slow progression, intact cognition, and lack of autonomic (i.e., incontinence) or cerebellar symptoms (i.e., postural instability). Patients with signs, symptoms, or neuroimaging consistent with ayptical parkinsonism are not surgical candidates for DBS therapy.
Sinemet responsiveness
When successful, DBS therapy reduces motor fluctuations and enables patients to spend more of their day in their best "on" state and to reduce time in the "off" state. Patients should therefore have good motor function and independence during their best "on" state with Sinemet. Patients who have poor function even during their best "on" state are not good surgical candidates.
Intact cognitive function
While DBS therapy can help motor function, in patients with cognitive decline, the greatest source of disability often is not motor dysfunction but cognitive dysfunction. Moreover, because DBS surgery is brain surgery, it can exacerbate cognitive dysfunction. Significant cognitive decline is therefore a contraindication.
Age-appropriate brain MRI
MRI of the brain should be consistent with idiopathic Parkinson's disease and not have evidence of atypical parkinsonism (e.g.,. cerebellar or pyramidal atrophy), significant cerebrovascular disease, or other neurodegenerative disease.
Medically suitable for surgery
Major medical comorbidities, especially hypertension, increase the risk of DBS surgery. Patients should be medically suitable for surgery and have controlled blood pressure to be considered for surgery. Moreover, patients must be able to tolerate a 3-6 hours of awake surgery.
Realistic expectations and interest
Patients must realize that DBS therapy is not a "cure" but symptomatic therapy and that it can take up to 6 months of programming to achieve optimal therapy.
Patient age
Increasing age is associated with greater risk of surgery and decreased benefit of therapy. DBS therapy can still benefit those over 75 years of age, but expectations should be modest and patients should be in excellent general health, have intact cognition, and have good function in the "on" state.
Outcome
Over 70% of patients experience meaningful improvements in their motor function after
Deep Brain Stimulation
. Moreover, on average, they gain about 4 ½ hours of good "on time" without troublsing dyskinesias, allowing them to be more comfortable and enjoy life more.
Eight-five percent to 93 percent of pallidotomy patients find relief from tremor, and 50 percent or more find relief from rigidity and hypokinesia. Neurological complications are usually mild and temporary, but significant complications occur in 4 percent to 6 percent of patients. They include changes in equilibrium, speech or mental acuity. Mortality is 1 percent or less.