Outcomes from stimulation of the caudal zona incerta and pedunculopontine nucleus in patients with Parkinson's disease

Abstract

Introduction. Axial symptoms including postural instability, falls and failure of gait initiation are some of the most disabling motor symptoms of Parkinson's disease (PD). We performed bilateral deep brain stimulation (DBS) of the pedunculopontine nucleus (PPN) in combination with the caudal zona incerta (cZi) in order to determine their efficacy in alleviating these symptoms.

Methods. Seven patients with predominant axial symptoms in both the ‘on’ and ‘off’ medication states underwent bilateral cZi and PPN DBS. Motor outcomes were assessed using the motor component of the Unified Parkinson's Disease Rating Scale (UPDRS 3) and a composite axial subscore was derived from items 27, 28, 29 and 30 (arising from chair, posture, gait and postural stability). Quality of life was measured using the PDQ39. Comparisons were made between scores obtained at baseline and those at a mean follow-up of 12 months.

Results. In both the off and on medication states, a statistically significant improvement in the UPDRS part 3 score was achieved by stimulation of the PPN, cZi and both in combination. In the off medication state, our composite axial subscore of the UPDRS part 3 improved with stimulation of the PPN, cZi and both in combination. The composite axial subscore, in the ‘on’ medication state, however, only showed a statistically significant improvement when a combination of cZi and PPN stimulation was used.

Conclusions. This study provides evidence that a combination of PPN and cZi stimulation can achieve a significant improvement in the hitherto untreatable ‘on’ medication axial symptoms of PD.

Key words:

• Parkinson's disease
• deep brain stimulation
• functional neurosurgery
• stereotaxy

Acknowledgements

We wish to thank Dr. Peter Heywood for his assistance in the management of our patients and our movement disorder nurse specialist Mrs Karen O' Sullivan, for assisting in the clinical assessments. We also wish to thank Ms Becky Durham for the illustrations.

Competing interests

Steven Gill and Shazia Javed are consultants to Renishaw PLC. None of the other authors have conflicts of interest to declare.