Surgery

Surgical procedures are now available for specific patients who no longer respond to drug treatments. Advances in knowledge of the brain and new technologies, including brain "pacemakers" are making surgery a reasonable option for many patients. Patients who begin to experience dyskinesia and on-off fluctuations in spite of the optimal drug therapy might discuss surgery with their doctor. They should have good support at home and be prepared for postoperative issues. In general, deep brain stimulation is currently the option of choice.

Although surgery has produced significant improvements in symptoms, the benefits do not last. Also, not all patients are good candidates. For example, patients who did not experience any improvement to levodopa would not benefit from any of these procedures. Furthermore, the risks probably do not outweigh the benefits in patients with advanced disease.

Deep Brain Stimulation

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Deep brain stimulation (also called neurostimulation) uses electric pulse generators to control symptoms. They are proving to be safe and effective alternatives to surgery. Appropriate candidates are similar to those for surgery. (Patients being given neurostimulation, however, should not have pacemakers.) Like pallidotomy and thalamotomy, neurostimulation is not a cure. On the other hand, it does not remove brain tissue and is reversible. In general, the procedure works as follows:

• The surgeon implants a tiny pulse generator near the collarbone, which is connected to four electrodes that have been implanted in the target area in the brain.
• The generator delivers programmed pulses to this area, which the patient can turn on and off using a magnet held over the skin.
• When the pulses are turned on, the symptoms are suppressed.