Surgical Procedures

When medications and non-pharmacological treatments and therapies are no longer working well to control motor symptoms, a surgical intervention is usually the next step.

Before making any decisions, a thorough evaluation by a multidisciplinary team, including a neurologist, neurosurgeon, and other specialists, is essential. They will assess the potential benefits and risks of surgery for your specific situation.

MR-guided Focus Ultrasound (MRgFUS)

MRgFUS is a common procedure for Essential Tremor, but less so for Parkinson’s Tremor.

There are two types, thallidomity and pallidomity, and they treat different areas of the brain. A laser causes a permanent lesion in the brain in the target area that e.g. fixes tremor and does not affect speech.

Pros

Incision-less for those with co-morbidities that make them not good surgical candidates (e.g. for DBS).
As the condition progresses you will still be able to take levodopa and adjunct therapies.
Post-MRgFUS, you can see immediate results.

Cons

Permanent, hard to retreat the same area if lesion is not large enough (but can have re-treatment).
Scarring around original lesion.
Second side may be harder to treat.

Also being a fairly new procedure for Parkinson’s, there are only a few places that do the procedure in Australia and long term data is lacking but showing about 70% improvement in tremor over 5 years.

Deep Brain Stimulation (DBS)

DBS is a surgical procedure used to treat the often debilitating movement symptoms of Parkinson’s. These include tremor, stiffness, slowed movement, and slowed walking as well as dyskinesia. It is important to note that DBS does not cure Parkinson’s or stop its progression.

Currently DBS is for people that have Parkinson’s whose motor symptoms cannot be adequately controlled with medications any longer but had responded well earlier.

Tiny electrodes are surgically implanted into the brain and connected by a wire under the skin to a battery. The pulse generator and electrodes painlessly stimulate the brain in a way that helps to improve many of the symptoms.

DBS is not right for everyone, as many symptoms, such as those impacting speech, swallowing, thinking, or gait (balance and freezing), do not consistently respond well to DBS.

Pros

While there may be some scarring, DBS is not felt to damage healthy brain tissue or destroy nerve cells. Instead, the procedure is believed to interrupt problematic electrical signals from targeted areas in the brain.
DBS is adjustable to adapt to progression of symptoms to some extent.

Cons

Like any surgery, the procedure does carry risks including infection, stroke, bleeding, or seizure.
DBS also has its own side-effects, for example, it may also lead to reduced clarity of speech, worsening of balance, or mood changes.

Levodopa-carbidopa intestinal gels

Instead of taking your carbidopa-levodopa (c/l) in pill form, levodopa-carbidopa intestinal gels (LCIGs) are delivered directly into the intestine. It is designed to improve absorption and reduce “off” times by delivering c/l directly to the small intestine.

After a surgery to insert a tube, the pump delivers gel directly to your intestine through a stoma. This pump is specifically programmed for your individual needs.

Who its for…

People with Parkinson’s who used to respond well to levodopa but failed to control motor fluctuations with other dopamine agonists or MAO-B inhibitors.
If having motor fluctuations with three or more hours of “off” time each day, and have already optimised your medication regime.

Risks

Any surgery carries risks, as does use of the device that delivers the drug. These include movement or dislocation of the tube, infection, redness at the insertion point, bleeding, air or infection in the abdominal cavity and pump failure.
Tubing of the device needs to be maintained to prevent blockages. It should also be flushed with a syringe before and after every pump use. Routine care will vary depending on the type of PEG-J tubing used.
Gel l/c has the same potential side effects as the pill form. These may include nausea, lower blood pressures, dyskinesia, confusion, and hallucinations.
Good hand hygiene and site preparation is crucial for staving off potential infections.

Surgical considerations

What may work best for you is a decision made by you and your multidisciplinary care team. For example, while DBS is a good treatment for tremor the elderly and people with medical co-morbidities have higher risks when undergoing surgeries with incisions and general anaesthesia.

For younger patients with severe tremor that may progress, perhaps DBS has better efficacy or longevity. Remember that these are not necessarily good at helping freezing of gait, balance issues and any non-motor symptoms.

Your care team

It is important to get a care team together to advise. Look to GPs, physiotherapists, occupational therapists, speech pathologists, dietitians, psychologists, social workers, and specialist nurses.

Remember most symptoms can be reduced only with a combination of optimising your medication (i.e. avoiding protein, taking with a full glass of water and taking it on time every time), good hydration and nutrition, physiotherapies, good sleep habits and exercise.