Parkinson's disease is a chronic neurological disease which is secondary to decreased level of a substance, namely dopamine, in brain. Resulting from decrease or injury of dopamine-releasing cells of brain secondary to aging, the disease leads to movement disorders and involuntary movements. The disease is usually manifested by tremor in hands and feet, slowness of movement, rigidity and gait instability.
Who are particularly under risk?
Parkinson's disease is a disorder of old age. When 60 to 80% of dopamine-releasing cells (neurons) of brain are lost, symptoms occur and the onset age of Parkinson's disease is around 62 to 65 years; the incidence is around 2-3/1.000 subjects. Over the age of 70 years, the risk increases 10 folds and the frequency is around 0.5-2% in this age group. Depending on the onset age of the disease, the longer patient is symptomatic, the sharper dopamine decrease is. The prognosis of the disease is somewhat poorer in relatively young patients.
What is the incidence of this disease in Turkey?
Unfortunately, there is no scientific study which indicates actual number of people with Parkinson's disease in Turkey. However, it is estimated there are 100 thousand people with Parkinson's disease in our country.
Is Parkinson's disease a preventable condition?
Unfortunately, there is no diet, life style change or exercise program that may prevent onset of classical Parkinson's disease, also known as "Idiopathic Parkinsonism", which accounts for almost all patients. Excluding Parkinson's disease with genetic origin, which is a very rare clinical condition, the risk of this clinical picture is 0.3% for all of us at age above 65 years.
How is Parkinson's disease diagnosed?
Diagnosis of Parkinson's disease is based on clinical findings. The pill-rolling tremor in hands, which typically appears in single arm or leg, slowness of movements (bradykinesia), movements of arms not coordinated with body movements and walking with arms attached to body, glassy eyes and decreased facial mimics associated with a facial expression, also referred as "mask face" and walking with small steps at flexed posture are all indicative of early stage of the disease and such patients should immediately seek medical attention from a neurologist.
PATIENT NEEDS SUPPORT OF FAMILY AND FRIENDS
Parkinson's disease, in fact, is not a fearsome condition. One should think that it is somewhat similar to diabetes mellitus. Patients with this condition may have almost normal daily activities with medications, if they are started at early age, or with surgical approaches, if the patient is refractory to medications, such that diabetic patients live almost totally normal life after dietary approaches, medication and insulin therapy (if required) are started. Therefore, patient should support the patient in order to avoid social isolation and becoming introverted, and family members and friends should ensure that patient has exercises and takes medicines regularly. At advanced stage, patient should be supported when best therapeutic approach is selected, rather than conceding quality life due to despair.
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DEEP IMPACT ON SOCIAL LIFE
Parkinson's disease is associated with slowness of movements (bradykinesia), resulting with inability to do jobs independently followed by dependence to others in routine daily activities. Therefore, patients isolates themselves from business and social life at baseline and intermediate phases of the disease, while they should have support of others to survive at advanced stage. Those problems lead to adverse effects on emotional health, introversion or depression in patients who are already suffering from slowness of movements and tremor.
NEUROSTIMULATION OPENS A DOOR TO AN INDEPENDENT LIFE
Among most effective treatments of Parkinson's disease, neurostimulation offers a substantial improvement and patients may return to normal daily life. Neurostimulation creates a link to normal life for patients. Neurostimulation is associated with successful outcomes for patients who have poor response to medical treatment, experiences severe tremor or have poor benefit from drugs due to severe side effects. However, it is utmost important to select patients who are eligible for surgery and will benefit from outcomes of the surgery.
TALKING WITH PATIENT DURING SURGERY WHEN THERE IS POOR OR NO RESPONSE TO MEDICAL TREATMENT
For the treatment of Parkinson's disease, option of surgery can be considered when there is poor or no response to medical treatment. The option of surgery is divided into two sub-options: unilateral lesion surgery or implantation of neurostimulator. Patient is not fully anesthetized, or in other words, patient may intraoperatively talk with surgery team, in both surgeries.
Neurosurgeon Ali Zırh, M.D., from Medical Park Bahçelievler Hospital, informed us about Parkinson's disease, the nightmare of elderly subjects:
Is medical treatment the first option in treatment of Parkinson's disease?
Baseline approach is medical treatment in Parkinson's disease and a substantial part of patients with Parkinson's disease has good response to medical treatment. In Parkinson's disease, 80-85 percent of patients may be in remission for long time, if there is good response to drugs at baseline. However, after years elapse, recommended drugs and doses are no more beneficial since patient progresses and drug-intolerance occurs. This process varies from one patient to another. Usually, first 4-5 years of the disease is associated with good response to medical treatment. Even, everything in the garden is rosy within a mean period of 2-3 years, which is also referred as "honeymoon". Of course, this condition is based on good response to baseline medical treatment!
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When is surgery required?
The option of surgery can be considered only if patient cannot achieve complete remission although dose and dosing frequency are increased and if side effects are more frequently experienced, including but not limited to involuntary body movements (such as restlessness, convulsions, agitation and dance-like movements). In short, 10-15 percent of all patients become candidate of surgery. In addition, patients with somewhat more remarkable tremor have poor response to medical treatment even at baseline. For patients with poor response to baseline medical treatment, surgery can be an option at early stage if they are eligible for surgery. Moreover, considering side effects of dopamine therapy, neurostimulation is the more commonly preferred treatment modality at early stage rather than starting dopamine at earlier stages for patients with younger age of onset.
SAFEST METHOD
What are options of surgery and what is the secret underlying the success?
There are two options of surgery for cases with Parkinson's disease. If symptoms are unilateral (limited to single arm or leg), unilateral lesion surgery is carried out with laser, a method similar to "burning the lesion". If lesions are bilateral and if patient may not stand up or in general terms, if improvement is bilaterally required, then, bilateral surgery is carried out and usually, a neurostimulator is implanted. Among all surgical modalities, the safest and most successful method is "Micro-electrode Recording and Stimulation Technique", which ensures extremely satisfactory outcomes, minimizes risks or in other words "ensures correct intervention at correct site".
TALKING AND CONVERSING WITH PATIENT DURING SURGERY
The aim of "Micro-electrode Recording and Stimulation Technique", which enables us "listening to" electrical activity of single neuron (brain cell), is to identify cells involved in the process and anatomic structures surrounding the involved cell. For this purpose, patient should be awake during surgery and we talk with the patient intraoperatively. We advance an electrode, with a two-micron thick tip, into brain under guidance of computer and the electrode is connected to complex circuits; thus, we can listen to electrical activity of a single neuron or we can observe response of patient to low-current stimulations. Accordingly, we measure response of patient and it is easier to reach or identify the region involved.
Patient is awake within first 3-4 hours of surgery and we cooperate with the patient and vice versa. This technology, namely "Micro-electrode Recording and Stimulation Technique", makes us achieve our aim. Thanks to this system which is associated with an error rate of 80 microns, we can identify neurons involved and anatomic structures surrounding those neurons. Next, we apply laser method, which is somewhat like burning the lesion, and the neurostimulator is implanted.
A TOTALLY FREE LIFE OFFERED BY NEUROSTIMULATION
Considering implantation of neurostimulator, we place two electrodes to regions involved in bilateral surgery. A battery, similar to pace maker, is placed into subcutaneous layer on chest wall and extension wires are advanced through subcutaneous layer and thus, electrodes are connected to the battery. The system is not visible. You may see or feel a bulging (or swelling) on chest wall. Next, we adjust frequencies and stimulation parameters, which are beneficial for patient, using a computer system.
Patient should return to clinic frequently within postoperative 2-3 weeks. Normal daily life activities can be resumed after optimum adjustments are made. Patients will have impressive improvement and they may return to normal daily life in postoperative period.
A LINK TO LIFE OFFERED BY NEUROSTIMULATION TO PATIENTS WITH PARKINSON'S DISEASE
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NEUROSTIMULATION OFFERS FREEDOM TO PATIENTS WITH PARKINSON'S DISEASE, WHO MAY NOT EVEN HOLD SPOON,
Suffering from inability to shoe lace or buttoning up shirt, patients with Parkinson's disease attains healthy days, thanks to the neurostimulation surgery. For patients with Parkinson disease, who are totally dependent to care of others, neurostimulation means "back to the life". Surgery offers a totally independent life to patients who may not even hold a spoon in preoperative period.
Neurosurgeon Ali Zırh, M.D., from Medical Park Bahçelievler Hospital, answered questions about Parkinson's disease, which is known as disorder of elderly subjects and colloquially referred as "shaky stroke":
What is neurostimulator and who are candidates of the implantation?
Neurostimulator is a complicated electronic device, which is, recently, more commonly used for surgical treatment of many movement disorders, including Parkinson's disease. Neurostimulator is used particularly for treatment of Parkinson's disease. Neurostimulation is associated with satisfactory outcomes in patients who have no response to drugs and suffer from severe tremor. Considering the fact that patient cannot even hold fork or thread a needle, tremor disappears at early postoperative period, immediately after patient is transferred from operating theater. In addition, neurostimulation is successfully used for tremors, which are aggravated by movement and referred as "Essential tremor", and for severe muscle contractions, also referred as "dystonia". Studies are ongoing for depression, obsessive-compulsive disorders, memory disorders such as Alzheimer, epilepsy and obesity.
What are advantages of neurostimulator?
The fact that it is a programmable and adjustable treatment method is the underlying advantage of neurostimulation. In other words, when a side effect occurs, parameters can be adjusted. We can adjust best parameter values for a particular patient in the postoperative period. Although we had never experienced, we can close or explants the device if patient is not satisfied or if a problem is encountered; in other words, it is possible to restore preoperative conditions without leading to any permanent effect/injury.
INDEPENDENCE IS ELIMINATED
Patients with Parkinson's disease will have impressive improvement and they may return to normal daily life in postoperative period. Neurostimulation creates a link to normal daily life for patients. After necessary battery parameters are adjusted in the postoperative period, patients, who may not event hold fork, thread a needle or write, may enjoy old healthy days. Suffering from inability to tie shoe lace, button up shirt and live without support of a caregiver, resulting with social isolation, patients will have the chance to live an independent life and return to ordinary work life after neurostimulator is implanted.
When do you consider neurostimulation surgery for patients with Parkinson's disease?
The option of surgery is considered when medical treatment is no longer of actual benefit. Moreover, patients with remarkable tremor usually have poor response to baseline medical treatment. Such patients are candidate of surgery at early period. In addition, considering side effects of dopamine therapy, neurostimulation is the more commonly preferred treatment modality at early stage rather than starting dopamine at earlier stages for patients with younger age of onset.
Neurostimulator is recognized as an important alternative approach in treatment of Parkinson's disease and it is implanted similar to that of pacemaker. We place two electrodes at cerebral zones involved. A battery, similar to pace maker, is implanted to subcutaneous layer of chest wall and electrodes are connected to the battery using extension wires, which are advanced through subcutaneous layer. Next, best possible frequencies and stimulation parameters are adjusted under guidance of a computer system.
We achieved complete cure in 850 patients who had movement disorders refractory to medical treatment. Lesion surgery is carried out in most patients and neurostimulator is implanted in more than 280 cases. Patient is awake and talks with us in a substantial part of surgery. They chat with doctor, talk about grandson or even, they have football match conversations. Think about a patient telling jokes during surgery.
RESPONSES OF THE PATIENT LEAD THE WAY
We can listen to electrical activity of a single neuron using "Micro-electrode Recording and Stimulation Technique" in neurostimulation surgery. The aim of this method is to identify cells involved in the process and anatomic structures surrounding the involved cell. Therefore, patient should be awake and we talk with the patient in intra-operative period. Thus, we measure response of patient and it is easier to reach or identify the region involved.
Patient is awake within first 3-4 hours of surgery and we cooperate with the patient and vice versa. This advanced technology makes us achieve our aim. Thanks to this system, we can draw physiological map of brain and accurately identify localization of cells, which are responsible for onset of the disease. Next, the neurostimulator is implanted
The neurostimulation sets biological clock of brain backwards in order to treat Parkinson's disease! A successful neurostimulation surgery turns the patient, who is suffering from the condition for 10 years, to the first year of onset. Hand tremors can be completely eliminated at rate of 85-90 percent.
