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Previous Volume 342:461-468 February 17, 2000 Number 7 Next

	Full Text PDF Editorial by Deuschl, G. Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited PubMed Citation

ABSTRACT

Background Deep-brain stimulation through an electrode implanted in the thalamus was developed as an alternative to thalamotomy for the treatment of drug-resistant tremor. Stimulation is thought to be as effective as thalamotomy but to have fewer complications. We examined the effects of these two procedures on the functional abilities of patients with drug-resistant tremor due to Parkinson's disease, essential tremor, or multiple sclerosis.

Methods Sixty-eight patients (45 with Parkinson's disease, 13 with essential tremor, and 10 with multiple sclerosis) were randomly assigned to undergo thalamotomy or thalamic stimulation. The primary outcome measure was the change in functional abilities six months after surgery, as measured by the Frenchay Activities Index. Scores for this index can range from 0 to 60, with higher scores indicating better function. Secondary outcome measures were the severity of tremor, the number of adverse effects, and patients' assessment of the outcome.

Results Functional status improved more in the thalamic-stimulation group than in the thalamotomy group, as indicated by increases in the score for the Frenchay Activities Index (from 31.4 to 36.3 and from 32.0 to 32.5, respectively; difference between groups, 4.4 points; 95 percent confidence interval, 2.0 to 6.9). After adjustment for base-line characteristics, multivariate analysis also showed that the thalamic-stimulation group had greater improvement (difference between groups, 5.1 points; 95 percent confidence interval, 2.3 to 7.9). Tremor was suppressed completely or almost completely in 27 of 34 patients in the thalamotomy group and in 30 of 33 patients in the thalamic-stimulation group. One patient in the thalamic-stimulation group died perioperatively after an intracerebral hemorrhage. With the exception of this incident, thalamic stimulation was associated with significantly fewer adverse effects than thalamotomy. Functional status was reported as improved by 8 patients in the thalamotomy group, as compared with 18 patients in the thalamic-stimulation group (P=0.01).

Conclusions Thalamic stimulation and thalamotomy are equally effective for the suppression of drug-resistant tremor, but thalamic stimulation has fewer adverse effects and results in a greater improvement in function.

Source Information

From the Departments of Neurology (P.R.S., R.M.A.B., J.D.S.), Neurosurgery (P.R.S., D.A.B.), and Clinical Epidemiology and Biostatistics (P.M.M.B., G.J.B., M.P.M.), Academic Medical Center; and the Netherlands Institute for Brain Research (E.J.W.S.) — both in Amsterdam.

Address reprint requests to Dr. Speelman at the Department of Neurology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands, or at j.d.speelman{at}amc.uva.nl.

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• Chen, H., Hua, S. E., Smith, M. A., Lenz, F. A., Shadmehr, R. (2006). Effects of Human Cerebellar Thalamus Disruption on Adaptive Control of Reaching. Cereb Cortex 16: 1462-1473 [Abstract] [Full Text]  
• Iremonger, K. J., Anderson, T. R., Hu, B., Kiss, Z. H. T. (2006). Cellular Mechanisms Preventing Sustained Activation of Cortex During Subcortical High-Frequency Stimulation. J. Neurophysiol. 96: 613-621 [Abstract] [Full Text]  
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• Pahwa, R., Factor, S. A., Lyons, K. E., Ondo, W. G., Gronseth, G., Bronte-Stewart, H., Hallett, M., Miyasaki, J., Stevens, J., Weiner, W. J. (2006). Practice Parameter: treatment of Parkinson disease with motor fluctuations and dyskinesia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology.. Neurology 66: 983-995 [Abstract] [Full Text]  
• Klostermann, F., Wahl, M., Marzinzik, F., Schneider, G.-H., Kupsch, A., Curio, G. (2006). Mental chronometry of target detection: human thalamus leads cortex. Brain 129: 923-931 [Abstract] [Full Text]  
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• Molnar, G. F., Sailer, A., Gunraj, C. A., Cunic, D. I., Lang, A. E., Lozano, A. M., Moro, E., Chen, R. (2005). Changes in cortical excitability with thalamic deep brain stimulation. Neurology 64: 1913-1919 [Abstract] [Full Text]  
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• Hariz, G-M, Lindberg, M, Bergenheim, A T (2002). Impact of thalamic deep brain stimulation on disability and health-related quality of life in patients with essential tremor. J. Neurol. Neurosurg. Psychiatry 72: 47-52 [Abstract] [Full Text]  
• Eskandar, E. N., Cosgrove, G. R., Shinobu, L. A. (2001). Surgical Treatment of Parkinson Disease. JAMA 286: 3056-3059 [Full Text]  
• Jankovic, J. (2001). Surgery for Parkinson Disease and Other Movement Disorders: Benefits and Limitations of Ablation, Stimulation, Restoration, and Radiation. Arch Neurol 58: 1970-1972 [Full Text]  
• Thompson, A. J (2001). SYMPTOMATIC MANAGEMENT AND REHABILITATION IN MULTIPLE SCLEROSIS. J. Neurol. Neurosurg. Psychiatry 71: ii22-ii27 [Full Text]  
• Matsumoto, J., Morrow, D., Kaufman, K., Davis, D., Ahlskog, J.E., Walker, A., Sneve, D., Noseworthy, J., Rodriguez, M. (2001). Surgical therapy for tremor in multiple sclerosis: An evaluation of outcome measures. Neurology 57: 1876-1882 [Abstract] [Full Text]  
• The Deep-Brain Stimulation for Parkinson's Disease, (2001). Deep-Brain Stimulation of the Subthalamic Nucleus or the Pars Interna of the Globus Pallidus in Parkinson's Disease. NEJM 345: 956-963 [Abstract] [Full Text]  
• Louis, E. D. (2001). Essential Tremor. NEJM 345: 887-891 [Full Text]  
• Alusi, S. H., Aziz, T. Z., Glickman, S., Jahanshahi, M., Stein, J. F., Bain, P. G. (2001). Stereotactic lesional surgery for the treatment of tremor in multiple sclerosis: A prospective case-controlled study. Brain 124: 1576-1589 [Abstract] [Full Text]  
• Olanow, C. W., Watts, R. L., Koller, W. C. (2001). An algorithm (decision tree) for the management of Parkinson's disease (2001):: Treatment. Neurology 56: S1-S88 [Full Text]  
• Habib-ur-Rehman, (2000). Diagnosis and Management of Tremor. Arch Intern Med 160: 2438-2444 [Abstract] [Full Text]  
• Lang, A. E. (2000). Surgery for Parkinson Disease: A Critical Evaluation of the State of the Art. Arch Neurol 57: 1118-1125 [Full Text]  
• (2000). Thalamic Stimulation or Thalamotomy for Suppression of Refractory Tremor?. JWatch Neurology 2000: 13-13 [Full Text]  
• (2000). Deep-Brain Stimulation vs. Thalamotomy for Tremor. JWatch General 2000: 5-5 [Full Text]  
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