Directed surgery for Parkinson's disease with Lewy bodies

Spiegel et al. (1947) first used stereotactic surgery to destroy globus pallidus for the treatment of Parkinson's disease (PD). Later, it was found that the destruction of the ventrolateral nucleus (VL) of the thalamus produced better effects on symptoms such as tremor, which is still used today. In 1992, Laitinen and other modern stereotactic techniques used the globus pallidus (PVP nucleus) as the target for surgery, and satisfactory results were obtained. The main symptoms of patients (tremor, muscle rigidity, bradykinesia, etc.) can be improved. To get promotion. Progress in pathophysiology has shown that in the pathogenesis of PD, globus pallidus and subthalamic nucleus are two important links, blocking the pallidal pathway of the subthalamic nucleus or the striatum globus pallidus pathway, which can block the pathogenesis of PD. Abnormal nerve impulses. Therefore, it is considered that the damaged lesion is more reasonable in the posterior and medullary nucleus of the globus pallidus, especially for the improvement of stiffness and dyskinesia. Treating diseases: Parkinson's disease Indication Directional surgery for Lewy body Parkinson's disease applies to: 1. Symptoms such as tremor, muscle rigidity, and retardation are obvious, and have affected unilateral or bilateral lesions of life and work ability. 2. The course of the disease is more than 1 year, the drug is invalid or can not continue to receive medication. 3.65 years old or younger. However, age is not a deciding factor. As long as the general condition is good, elderly people can also have surgery. Contraindications 1. Severe mental and intellectual disabilities, severe autonomic dysfunction and those with pseudo-ball paralysis. 2. There are severe arteriosclerosis, heart and kidney disease, high blood pressure, diabetes and poor general condition. 3. The symptoms are mild, and there is no significant impact on life and work. Preoperative preparation 1. Before the operation, pay attention to the physical examination of the whole body, pay special attention to the presence or absence of cardiovascular disease, and do blood and urine routine tests and EEG, electrocardiogram, liver function tests, chest radiographs, etc. 2. Patients who have been in bed for a long time and have difficulty in exercising should help to get out of bed or exercise as much as they can to enhance their heart function. 3. Patients with high blood pressure should take antihypertensive drugs to reduce blood pressure to the normal range. 4. If the patient is nervous, apply appropriate amount of sedative drugs on the day before surgery or on the night before surgery. 5. Shaving, procaine and iodine allergy tests. Surgical procedure 1. Install the orientation meter There are a variety of orientation meters, and the installation should be strictly in accordance with the requirements of various types of orientation instruments, and strive to standard. For example, Bintian Orientation, the patient's head position must be adjusted so that the earplugs on both sides of the frame are aligned with the external auditory canal, and the midline of the skull is aligned with the center hole before and after the frame (ie, the instrument centerline). The Leksell directional instrument must be installed with the sagittal midline of the frame coincident with the midline of the skull. The Y axis of the frame is parallel to the GI line. The head in the anteroposterior direction is located at the center of the frame, avoiding the frame reclining, leaning forward or rotating, and eliminating positioning errors as much as possible. 2. Scalp incision and skull drilling Before the coronal suture, a 2.5 cm long longitudinal incision was made 2.5 cm beside the midline of the surgical side. The skull is drilled in the center of the incision, and the dura mater is cut in a "T" shape, and then electrocoagulated on the surface of the cortex for preparation of cerebral puncturing and target puncture. 3. Ventricular angiography Transcranial drilling of the anterior horn of the lateral ventricle, pressure inflated ventriculography or injection of positive contrast agent 8 ~ 10ml, then the head of the skull is displayed, showing the third ventricle, interventricular space, aqueduct, pineal crypt and Positioning mark structure such as front and back commissure. 4. Target positioning The target coordinate value is obtained by the selected target point. Select the target according to the symptoms: the inner part of the globus pallidus is effective for stiffness and slowness of movement, followed by tremor; the ventrolateral nucleus of the thalamus is effective for tremor and stiffness, and the effect on exercise retardation is not certain. Target position: the inner part of the globus pallidus, X=1820mm, Y=2mm, Z=46mm. The middle nucleus of the thalamus (Vim), X = 14 mm, Y = 4 ~ 5 mm, Z = 0. Use the anatomically located data to find the target point, and then measure the distance between the target point to the front and back (Y axis), up and down (Z axis) and inside and outside (X axis) of the instrument origin or central ray point to obtain the target coordinate value. In addition to traditional methods, MRI positioning guided surgery can also be used in recent years. Due to the application of high-resolution MRI and thin-layer scanning, the images of deep brain structures in AC, PC and basal ganglia can be clearly displayed, which provides conditions for direct and accurate target location. This method has no contrast pain, and is also higher than CT resolution. If there is special software, it can save time and accuracy by directly positioning the target and calculating the target coordinates on the display. 5. Guided puncture Adjust the three coordinate axes of the orienter according to the target coordinate data, that is, move the instrument coordinate origin to the side, front and back, and up and down. After adjustment, the origin of the coordinates coincides with the target. In this way, the surgical instrument carrier (or the needle holder) provided on the spherical surface of the bow can be guided and puncture, and the needle can be accurately reached at any point. 6. Check and identify the location of the target After the needle or electrode is punctured to the target point, a neurological, mental function test, an electrical stimulation test, or a positive lateral slice of the skull is performed to observe whether the position of the electrode or the operator is correct. 7. Damage target structure Prove that the puncture is correct, and the brain damage can be made. At present, RF temperature control quantitative destruction method is widely used in China. Choose to solidify at 75 ° C for 80 s, if necessary, extend the setting time or adjust the needle tip position. For example, when the VL nucleus is destroyed, the target of the tremor-based patient may be slightly posterior, and the muscle rigidity is mainly in front of the person, the upper limb is effective when the inner side is destroyed, and the lower limb is effective when the outer side is the outer side. The contralateral limb tremor disappeared and the flexibility of the movement was significantly improved. The size of the damaged stove is 6 to 9 mm. 8. Suture scalp incision After the destruction of the lesion was completed, the wound was washed with saline, and the cap membrane and scalp were sutured intermittently with a thread to remove the orientation instrument. complication Due to the emergence and application of high-tech and advanced equipment such as stereotactic and neuroimaging, modern stereotactic surgery has developed rapidly and entered a new era of more accurate positioning, less trauma and better effects. Surgery complications have been greatly reduced compared with the past, mainly in the following categories. 1. Dyskinesia: Occasionally, hemiplegia, balance disorder, ADHD, etc., due to positioning error, vascular injury, thrombosis and edema, etc. involving the internal capsule, cerebellum-cortical pathway, subthalamic nucleus. Most of the movement disorders are temporary, but a few can exist for a long time. 2. Speech disorders: including volume reduction, dysarthria and aphasia. Generally seen in bilateral surgery and superior hemisphere surgery, mostly temporary. The part related to the speech function is located in the outer upper part of the dominant hemisphere thalamus. During the operation, the patient can perform electrical stimulation when the patient continuously counts or continually naming. If there is a count or a naming interruption, the part is related to the speech function, and the damage area must be Move before the front. 3. Mental disorders: mostly temporary. The operation of the dominant hemisphere has more influence on the oral function such as counting and sentence making, and the memory disorder in recent events is more common. The operation of non-dominant hemisphere has more influence on the spatial image function such as composition and modeling. Insomnia can occur after the inner part of the bilateral VL is destroyed. It is reported that the core of the thalamus is related to the memory of recent events, and the lesion is placed in a low position, which can reduce the occurrence of recent memory impairment. 4. Intracerebral hemorrhage: may directly damage the blood vessels or localized hemorrhage due to puncture (after secondary damage such as electrocoagulation, freezing or mechanical cutting). Systemic factors such as arteriosclerosis and hypertension are the predisposing factors for bleeding. Most of the bleeding is acute, sometimes subacute or chronic. The patient gradually developed hemiplegia after operation, the consciousness was unclear and the intracranial pressure was increased, and the condition was progressively deteriorated. Hemorrhage may be considered. CT examination can be quickly diagnosed. The only treatment is timely craniotomy.

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