Parkinson’s disease is one of the most common neurological degenerative disorder of the central nervous system causing serious disability due to the loss of dopaminergic neurons in the substantia nigra region of brain. Surgery may be contemplated in a Parkinson’s disease patient either to control symptoms of the disease or for some cause unrelated to Parkinson’s disease, such as a hip replacement, a broken shoulder or prostate gland removal.
The risks associated with surgery need to be analyzed so as to decide whether the benefits outweigh the risks and if surgery is justifiable in such patients. Considerations such as age of the patient, type of surgery, and the stage of Parkinson’s disease should be kept in mind before arriving at a decision.
Deep brain stimulation is the most common surgical procedure adopted for Parkinson’s Disease. Other surgical options include thalamotomy, pallidotomy and sub-thalamotomy. However, surgery can be a very effective treatment option, but it is beneficial only to the symptoms which were previously improved after the levodopa treatment. It can also be said that surgical treatment is exclusively reserved for those Parkinson’s patients, who have an exhaustive history of medical treatment and who suffered through profound tremors and motor fluctuations.
Surgery for Treatment of Parkinson’s Disease
Specific surgery to control the symptoms of Parkinson’s disease may be considered when medication becomes less effective or the side effects become intolerable.
Any of the following available surgical procedures may be undertaken.
- Ablative surgery. A clearly-defined area of the brain affected by PD is isolated and destroyed by a heated probe (electrode) or a super-cooled probe (cryosurgery). Either a pallidotomy or a thalamotomy is done by this procedure.
- In Thalamotomy, A small area of the brain, called as thalamus is removed after taking detailed brain scans using the CT scan or MRI to identify the precise location of treatment. If the patient has tremors of the right hand, the left side of the brain is treated. In other words, Surgery on one side of the brain will affect the other side of the body. This surgery is usually reserved for people younger than 65 years of age.
- In Pallidotomy, the tiny part of the brain called as Globus pallidus is destroyed, as this region is quite overactive in Parkinson’s disease which indirectly causes a decrease in the activity of the part of the brain which controls movement. Thus, this procedure relieves the movement symptoms such as tremor and stiffness. Pallidotomy treatment on one side of the brain will improve the motor symptoms on other side of the body.
- Deep brain stimulation (DBS). This procedure is used to treat a myriad of disabling neurological symptoms like tremors, rigidity, stiffness, slowed movements, walking problems, and freezing of gait. It does not damage the healthy brain tissue or the nerve cells, but it blocks the electrical signals from the targeted areas in the brain. At present it is used with caution in the patients whose symptoms are uncontrollable through medications. The subthalamic nucleus is inactivated by an implanted electrode.
- Transplantation or restorative surgery – stem cell therapy.
Common Risks of any Surgery
Any surgery carries certain risk with it. This includes :
- Anesthetic complications such as reaction to anesthesia drugs, though rare, may be life-threatening.
- Problems may arise while intubating a patient (inserting the breathing tube).
- Aspiration of food or liquids into the lungs.
- Increased heart rate, blood pressure, or rapid increase in body temperature (malignant hyperthermia).
- Hemorrhage or excessive bleeding during surgery or in the post-operative period.
- Accidental injury to other organs during surgery.
- Deep vein thrombosis (DVT) is a serious risk of surgery which may occur due to prolonged immobilization after surgery. Blood clots may travel to the lungs and cause pulmonary embolism or to the brain, causing a stroke.
- Urinary tract infection.
- Breathing problems after surgery.
- Post-operative infection.
- Poor post-operative healing of wounds, especially in case of diabetic patients.
- Paralysis caused by surgery is a possibility, especially in case of brain or spinal surgery.
- Less than satisfactory outcome after surgery is a possibility if the problem was worse than anticipated or due to development of complications during surgery which necessitated cutting short the procedure. Inexperience of the surgeon may be the reason for poor results of surgery.
- The risk of death is there even in minor surgeries, although compounded in more complicated surgeries.
- Parkinson’s patients, because of their frailty, advanced age, lowered immunity, medication, complications, and/or other diseases, are more likely to be at risk while undergoing surgery.
Risk of Surgery For Parkinson’s Patients
In addition to the risks associated with any surgery, these procedures carry some additional risks such as :
- Speech problems, visual defects, and other complications if the electrodes are placed too near to other brain regions.
- Allergic response to implanted material.
- Mechanical or electrical problem with the implant.
- Secondary surgery may become necessary for removal of the implant in case of breakage or malfunction.
- Complications due to Blood Pressure: Some Parkinson’s disease patients have postural hypertension (which is a drop in blood pressure while sitting or standing up) whereas, some of the patients have supine hypertension (which is a characteristic increase in the blood pressure while lying down). These patients are more prone to rises and falls of blood pressure and its associated complications during the surgery
- Drug complications: The post surgical patients of Parkinson’s disease are prescribed Compazine and phenergan for nausea, and reglan to stimulate bowel function. These drugs further block the dopamine and worsen the pre-existing symptomatology. The patients are now at increased risk of falls, fracture, and aspiration pneumonia
- Anaesthesia problems: The anaesthetic problems include old age and adverse interaction of the anesthetic agent with other anti parkinsonian drugs. As in the case of interaction between Levodopa and anaesthetic agent might lead to severe nausea and vomiting and such patients are prone to get dehydrated and hypovolemic.
- Intracranial hemorrhage (bleeding inside the brain).
- Neurological complications.
- Delirium. The patient might develop delirium and rotate between Rehab centres and hospitals.
- There may be no improvement or there may be worsening of symptoms after surgery.
- Abnormal involuntary movements (chorea, dystonia, dyskinesia).
- Tingling and numbness.
Educating the hospital staff about this fatal disease and changing the way of their functioning, might bring about a slow, yet an effective change in the Healthcare system and in the meantime, will save a lot of people from getting hurt.