Surgical
Management
of Movement
Disorders
NDT_half-series-title 6/24/05 12:31 PM Page A
NEUROLOGICAL DISEASE AND THERAPY
Advisory Board
Louis R. Caplan, M.D.
Professor of Neurology
Harvard University School of Medicine
Beth Israel Deaconess Medical Center
Boston, Massachusetts
William C. Koller, M.D.
Mount Sinai School of Medicine
New York, New York
John C. Morris, M.D.
Friedman Professor of Neurology
Co-Director, Alzheimer’s Disease Research Center
Washington University School of Medicine
St. Louis, Missouri
Bruce Ransom, M.D., Ph.D.
Warren Magnuson Professor
Chair, Department of Neurology
University of Washington School of Medicine
Seattle, Washington
Kapil Sethi, M.D.
Professor of Neurology
Director, Movement Disorders Program
Medical College of Georgia
Augusta, Georgia

9. Memory Disorders: Research and Clinical Practice,
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10. The Medical Treatment of Epilepsy,
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12. Handbook of Amyotrophic Lateral Sclerosis,
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13. Handbook of Parkinson’s Disease: Second Edition, Revised
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14. Handbook of Pediatric Epilepsy,
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32. Handbook of Olfaction and Gustation,
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33. Handbook of Neurological Speech and Language
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34. Therapy of Parkinson’s Disease: Second Edition,
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35. Evaluation and Management of Gait Disorders,
edited by Barney S. Spivack
36. Handbook of Neurotoxicology,
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37. Neurological Complications of Cancer,
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38. Handbook of Autonomic Nervous System Dysfunction,
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39. Handbook of Dystonia,
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Antonio Culebras
50. Handbook of Ataxia Disorders,
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53. Handbook of Multiple Sclerosis: Third Edition,
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58. Handbook of Stereotactic and Functional Neurosurgery,
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73. Gait Disorders: Evaluation and Management,
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74. Surgical Management of Movement Disorders,
edited by
Gordon H. Baltuch and Matthew B. Stern
NDT_half-series-title 6/24/05 12:31 PM Page F
Surgical
Management
of Movement
Disorders
edited by
Gordon H. Baltuch
University of Pennsylvania
Philadelphia, Pennsylvania, U.S.A.
Matthew B. Stern
University of Pennsylvania
Philadelphia, Pennsylvania, U.S.A.
Boca Raton London New York Singapore
NDT_half-series-title 6/24/05 12:31 PM Page i

DK3798_Discl.fm Page 1 Monday, July 11, 2005 4:15 PM
To our families, for their support

Preface
Movement disorders represent major causes of neurological disability and
eventual mortality affecting millions of people across the globe. From
Parkinson’s disease to spasticity, these neurological disorders dev astate
young and old worldwide. While progress continues to be made toward
effective treatment, many limitations remain.
The combination of the limitation of medical therapy and surgical
technological advances have, however, led to an exponential growth in func-
tional neurosurgery in the last 5 years. Surgery represents an alternative
where there existed only finite treatment options before. This field is devel-
oping rapidly with emerging novel therapies as well as evolving indications
for existing procedures.
We intended this book to be a thorough review of the surgical treat-
ments currently available for various movement disorders, with an emphasis
on surgical indications and results of surgery. It should be of utmost interest
to practitioners and trainees in the clinical neuro sciences (neurology/neuro-
surgery) who want a better understanding of candidates for movemen t dis-
order surgery, the current surgical procedures, the effected results of surgery,
and the complication rate of these procedures. Our goal was to summarize
the current status of the field as well as make projections for the next few
years.
Gordon H. Baltuch
Matthew B. Stern
v

Contents
Preface . . . . v

7. Securing the Electrode . . . . 55
8. Adverse Events . . . . 57
9. Postoperative Care . . . . 58
10. IPG Implantation . . . . 59
References . . . . 61
4. Surgical Results . . . 63
Jean-Guy Villemure, Joseph Ghika, and Franc¸ois Vingerhoets
1. Introduction . . . . 63
2. Thalamus . . . . 64
3. Pallidum . . . . 65
4. Subthalamic Nucleus . . . . 67
5. Preoperative Physiological Definition of the
Target . . . . 70
6. Conclusions . . . . 72
References . . . . 73
5. Novel Surgical Strategies: Motor Cortex Stimulation,
Transplantation, Gene Therapy, Stem Cells, and
CNS Drug Delivery . 83
Jason M. Schwalb and Andres M. Lozano
1. Introduction . . . . 83
2. Limitations of Current Therapy . . . . 83
3. Motor Cortex Stimulation . . . . 84
4. History of Transplantation . . . . 85
5. Ethics of Sham Surgery . . . . 89
6. Future Directions in Implanting Dopaminergic
Neurons . . . . 90
7. Induction of Endogenous Stem Cells . . . . 92
8. Trophic Factors Rather than Dopaminergic Neurons—
GDNF Therapy . . . . 92
9. Gene Therapy for Parkinson’s Disease . . . . 93

1. Introduction . . . . 135
2. Classification . . . . 136
3. Etiology and Pathophysiology . . . . 139
4. Best Medical Therapy . . . . 142
5. Surgical Therapy . . . . 148
6. Anatomical Targets in DBS Surgery . . . . 149
Contents ix
7. Surgical Technique . . . . 153
8. Results of Surgery in Dystonia . . . . 154
9. Conclusions . . . . 157
References . . . . 157
SECTION V: CERVICAL DYSTONIA
9. Chemodenervation: Botulinum Toxin . . . 169
Tanya Simuni
1. Introduction . . . . 169
2. Clinical Efficacy of BTX-A for CD . . . . 172
3. BTX-B . . . . 175
4. Other BTX Strains . . . . 176
5. Conclusions . . . . 176
References . . . . 177
10. Ablative Denervation 183
Jeff D. Golan and Line Jacques
1. Introduction . . . . 183
2. Clinical Presentation . . . . 184
3. Etiology . . . . 185
4. Clinical Forms of Torticollis . . . . 186
5. Clinical Evaluation . . . . 186
6. Treatment . . . . 188
7. Selective Peripheral Denervation . . . . 190
8. Results . . . . 195

2. Epidemiology . . . . 228
3. Symptoms and Clinical Signs . . . . 229
4. Diagnosis, Staging, Classification . . . . 229
5. Physiopathology . . . . 230
6. Surgical Anatomy . . . . 232
7. Treatment . . . . 234
8. Contraindications to Surgery . . . . 238
9. Results . . . . 238
10. Complications . . . . 239
11. Conclusions . . . . 240
References . . . . 241
SECTION VII: SPASTICITY
14. Cerebral Palsy . . . . . . 245
Jean-Pierre Farmer and Sandeep Mittal
1. Introduction . . . . 245
2. Epidemiology and Demographics . . . . 246
3. Pathophysiology . . . . 246
4. Diagnosis and Clinical Presentation . . . . 249
5. Classification . . . . 250
6. Therapeutic Avenues . . . . 252
References . . . . 255
15. Baclofen . . . . 257
Jean-Pierre Farmer and Sandeep Mittal
1. Introduction . . . . 257
Contents xi
2. Baclofen . . . . 257
3. Pump Technology . . . . 259
4. Selection of Patients for Intrathecal Baclofen
Infusion . . . . 260
5. Preoperative Evaluation . . . . 260

Royal London Hospital, London, U.K.
Jean-Pierre Farmer Division of Pediatric Neurosurgery, McGill
University Health Centre, Montreal, Quebec, Canada
Santiago Figuereo Department of Neurosurgery, Philadelphia Veterans
Administration Hospital, University of Pennsylvania, Philadelphia,
Pennsylvania, U.S.A.
Joseph Ghika Neurology Service, Centre Hospitalier Universitaire
Vaudois, Lausanne, Switzerland
Jeff D. Golan Divi sion of Neurosurgery, McGill University, Montreal,
Quebec, Canada
Line Jacques Division of Neurosurgery, McGill University, Montreal,
Quebec, Canada
xiii
Galit Kleiner-Fisman Parkinson’s Disease Research Education and
Clinical Center (PADRECC), Philadelphia Veterans Administration
Hospital, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.
Andres M. Lozano Division of Neurosurgery, Toronto Western
Hospital, University of Toronto and University Health Network,
Toronto, Ontario, Canada
Michel R. Magistris Department of Neurology, University of Geneva,
Geneva, Switzerland
William J. Marks, Jr. Department of Neurology, University of
California, San Francisco and San Francisco Veterans Affairs Medical
Center, San Francisco, California, U.S.A.
Sandeep Mittal Division of Pediatric Neurosurgery, McGill University
Health Centre, Montreal, Quebec, Canada
Jill L. Ostrem Department of Neurology, University of California,
San Francisco and San Francisco Veterans Affairs Medical Center,
San Francisco, California, U.S.A.
Ali R. Rezai Department of Neurosurgery, Cleveland Clinic Lerner

Minnesota, Minneapo lis, Minnesota, U.S.A.
Contributors xv

1
Overview
Kelvin L. Chou
Department of Clinical Neurosciences, Brown University Medical School,
Providence, Rhode Island, U.S.A.
Gordon H. Baltuch
Department of Neurosurgery, Penn Neurological Institute, University of
Pennsylvania School of Medicine, Philadelphia, Pennsylvania, U.S.A.
Matthew B. Stern
Parkinson’s Disease and Movement Disorders Center, Pennsylvania Hospital,
University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, U.S.A.
1. INTRODUCTION
From Parkinson’s disease (PD) to dystonia, movement disorders are major
neurologic causes of disabi lity, causing not only physical handicap, but
often social embarrassment as well. Although a plethora of pharmacologic
options exists to treat these disorders, many limitations unfortunately
remain. Functional neurosurgery now has the ability to r educe the sev erity of
symptoms and improve the quality of life for patients with these devastating
neurological disorders.
Surgery for the field of movement disorde rs has evolved significantly
since Spiegel et al. first described stereotaxis in 1947 (1). Much of this progress
has been made within the last decade with the development of techniques
for precise targeting of brain structures and the discovery of new targets
and indications for existing procedures such as deep brain stimulation
(DBS). This chapter provides a general overview of the field of movement
1
disorders surgery, including a brief summary of basal ganglia structure and

motor activation and the facilitation of voluntary movement. In contrast,
stimulation of the indirect pathway causes inhibition of the GPe, disinhibition
of STN excitatory fibers, and an increase in the inhibitory outflow from the
GPi onto the thalamus, resulting in decreased output to the motor cortex
and suppression of voluntary movement.
The exact mechanism by which the basal ganglia interpret the
information flowing through these two opposing motor circuit pathways
to control normal movement is unclear. Two theories have been proposed:
scaling and focusing (2–4). In the scaling hypothesis, movement is controlled
2 Chou et al.