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Difference in the effectiveness of subthalamic nucleus and globus pallidus deep brain stimulation in Parkinson’s disease
* Corresponding author: Hushyar Azari, MD.
Mailing address: Faculty of Medicine, School of Medicine, Urmia University of Medical Sciences, Urmia 571478334, Iran.
Email: hushyarazari@hotmail.com
Received: 20 April 2022 / Revised: 17 May 2022 / Accepted: 23 May 2022 / Published: 30 June 2022
DOI: 10.31491/APT.2022.06.082
Abstract
Deep brain stimulation (DBS) is regarded as a feasible Parkinson’s disease (PD) treatment option. The subthalamic nucleus (STN) and globus pallidus (GPi) are the two most common sites for DBS. The following criteria were used to select studies that examined the Unified PD Rating Scale (UPDRS) III: (1) had at least three months of follow-up; (2) compared both GPi and STN-DBS; (3) each group included at least five individuals; (4) were conducted after 2010. The majority of studies found no statistically significant difference in UPDRS score improvements between groups. Although there were some encouraging findings in terms of action tremor, rigidity, and urinary symptoms, indicating that STN-DBS would be a better alternative, GPi appeared to be better in terms of side effects; nonetheless, it cannot be said that it is superior. Other larger randomized clinical trials with longer follow-up periods and control groups are required to determine which target is more effective for stimulation and has fewer negative side effects on patients.
Keywords
Deep brain stimulation, globus pallidus, Parkinson’s disease, subthalamic nucleus, UPDRS
Parkinson’s disease (PD) is the most common mobility
condition, as well as the second most common progressive, debilitating, and neurodegenerative disease, with
12.9 million cases projected by 2040 [1-4]. Slow motions,
rigidity, and low amplitude movements without antecedent automaticity characterize PD. In 1911, the dopamine
precursor levodopa was developed for the first time [5]. It
has been used as an effective PD treatment for more than
50 years, although its efficacy has been demonstrated to
decrease as the disease advances [6, 7]. The deep brain
stimulation (DBS) technique was first used in 1987 to treat
movement disorders by targeting the ventral intermediate
nucleus of the thalamus [8, 9]. DBS is a frequent and effective surgical treatment for motor symptom relief. It was
first used roughly three decades ago and is now used on
a variety of new brain targets, including the subthalamic
nucleus (STN) and globus pallidus (GPi) [10-12]. According to studies, the efficacy of these two targets is varied.
It has been suggested that in PD, there is chronic betaband oscillation coordination, and short-term bursts of these oscillations demonstrate normal sensory and motor
processing. In PD, DBS can shorten bursts and enhance
movement [13].
Embase, Cochrane Library, and PubMed databases were
searched for potentially relevant English-language papers
published between 2010 and 2021. We looked for studies
that included both the targets (GPi and STN) as well as
their associated characteristics. DBS [MeSH term] or a
combination of the following keywords: controlled clinical trial [Publication Category], randomized controlled trial [Publication Category], globus pallidus internus [MeSH
term], globus pallidus [MeSH term], GPi [MeSH term],
STN [MeSH term], and PD [MeSH term].
We included clinical studies that (1) evaluated the unified
PD rating scale (UPDRS) III before and after DBS; (2)
compared GPi-DBS and STN-DBS for PD; (3) recruited
more than five subjects in the GPi and STN groups; (4)
had a description of adverse events; (5) had a follow-up
period of more than three months; (6) were available in
English full text. The main characteristics of the studies
are shown in Table 1.
Table 1
Main characteristics of studies.
Reference | Target | Age | Sample size | UPDRS on-periodbaseline | UPDRS off-periodbaseline | Follow up period | Location |
---|---|---|---|---|---|---|---|
Odekerken [14] | GPi STN |
59.10 ± 7.80 60.90 ± 7.60 |
62 63 |
16.00 ± 8.00 17.00 ± 9.90 |
43.80 ± 13.50 44.40±15.50 |
12 | Europe |
Troche [15] | GPi STN |
64.26 ± 8.79 66.50 ± 7.02 |
19 14 |
23.13 ± 6.73 23.43 ± 10.64 |
39.89 ± 11.06 35.93 ± 8.98 |
6 | Asia |
Odekerken [16] | GPi STN |
59.10 ± 7.80 60.90 ± 7.60 |
43 47 |
N/A | 43.00 41.00 |
36 | Europe |
Gong [17] | GPi STN |
63.20 ± 9.10 62.30 ± 10.40 |
28 36 |
26.20 ± 7.50 29.00 ± 10.00 |
N/A | 4 | Asia |
Fan [18] | GPi STN |
60.43 ± 8.44 59.65 ± 9.11 |
23 20 |
N/A | 50.68 ± 15.36 47.85 ± 14.95 |
12 | Asia |
Celiker [20] | GPi STN |
54.00 ± 4.51 56.16 ± 9.60 |
6 6 |
22.50 ± 6.65 22.16 ± 6.55 |
49.00 ± 13.57 47.00 ± 14.01 |
24 | Asia |
Okun [21] | GPi STN |
60.10 ± 5.50 58.00 ± 10.70 |
14 16 |
20.80 ± 8.68 21.30 ± 7.56 |
40.50 ± 11.20 41.20 ± 9.32 |
12 | USA |
Wong [19] | GPi STN |
63.00 ± 8.12 61.00 ± 10.33 |
31 57 |
N/A | 47.32 ± 11.79 44.12 ± 10.45 |
12 | USA |
Note: Data presented as mean ± SD.
Odekerken et al. found that the GPi group had a lower
change in UPDRS score during the off-drug phase than
the STN group, and the GPi group had less dyskinesia
during the on-drug period than the STN group. The reduction in time was similar in both phases, however, it was
only significant in the off-phase (P = 0.02) [14]. Troche
et al. found that both groups’ UPDRS scores improved significantly in the off-medication state before and after
surgery (P < 0.001) [15]. Odekerken et al. found that the
STN group showed larger improvements in the off-drug
phase UPDRS-ME score after three years (P = 0.04),
whereas there were no between-group differences in the
on-drug phase [16]. Gong et al. found that four months
after DBS, all patients experienced improvement (≥ 30%
) in UPDRS score in off-period, and pain symptoms improvement rate was 79% ± 27% and 75% ± 27% in STN
and GPi groups, respectively [17]. In the drug off-phase,
Fan et al. found that the mean improvement of UPDRS in
the STN and GPi groups was 41.50% and 43.56%, respectively, with no significant difference between the groups
(P = 0.609). GPi-DBS also demonstrated anti-dyskinesia
effects directly [18]. When compared to GPi-DBS, Wong
et al. found that STN-DBS was associated with a statistically significant decrease in bradykinesia and rigidity at
six months (P < 0.001 and P = 0.025, respectively). In
terms of tremor results, however, there was no significant
difference between groups [19]. Celiker et al. found that
on-phase UPDRS motor scores decreased considerably in
both the STN and GPi groups (P < 0.05) and that STNDBS improved bladder symptoms better. Furthermore,
both groups experienced reduced sleep issues following
surgery [20]. Okun and colleagues looked at the effects of
unilateral and staged bilateral STN and GPi-DBS. They
discovered that off-phase UPDRS motor scores improved
considerably after four and twelve months of follow-up in
both unilateral and staged bilateral modes [20].
In terms of adverse events, Odekerken et al. found no
statistically significant difference between groups (P >
0.05) [14]. According to Troche et al., mean penetrationaspiration (PA) scores did not change substantially for
participants who got GPi surgery (P = 0.857) but significantly worsened for those who received STN-DBS (P = 0.007), indicating that STN-DBS has a negative influence
on swallowing performance. In contrast, unilateral GPiDBS does not have this negative effect [15]. In the study
by Fan et al., 50% of patients in the STN group showed
dyskinesia caused by stimulation. In ten of these patients,
the direct anti-dyskinesia effect of STN-DBS was also
noticed [18]. Okun et al. found relatively minor effects
on mood and apathy that were not significant [21]. Odekerken et al. revealed no significant differences in adverse
events between the two groups in another trial, only mild
incidents were noted [16]. The most prevalent adverse
events, according to Wong et al., were difficulties with
DBS lead hardware and bleeding, both of which were
small and controlled easily [22]. The results of this study
should be viewed with caution. Both STN-DBS and GPiDBS are potential stimulation sites, but this has not been
confirmed. STN, on the other hand, had better results in
terms of urinary symptoms, discomfort, dyskinesia, and
action tremor.
Declarations
Acknowledgments
The author would like to express his gratitude to Urmia University of Medical Sciences, for English editing, especially Dr. Nazila Farrokh Eslamloo.
Authors’ contributions
The author contributed solely to the article.
Availability of data and materials
Not applicable.
Financial support and sponsorship
None.
Conflicts of interest
The author declared that there are no conflicts of interest.
Ethical approval and consent to participate
Not applicable.
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