Intraoperative neurophysiological assessment of disabling symptoms in DBS surgery

Abstract

Introduction: Neurophysiological assessment can provide quantitative measures for the selected motor signs that have been targeted for surgery and may be helpful in predicting the therapeutic effects of deep brain stimulation (DBS) on pathological tremor, motor performance, and rigidity.

Objective: To present a survey and demonstrate the contribution of neurophysiological assessment of side effects and effects on disabling motor symptoms at various steps of DBS surgery, and to confirm its role for optimal target localization, as an adjuvant to anatomic imaging.

Material and methods: The data result from 192 nuclei in 118 procedures on patients with Parkinson's disease (84), essential tremor (24), Hallenvorder Spatz dystonia (4), multiple sclerosis (4), and Holmes tremor (2). The intraoperative neurophysiological monitoring (IOM) protocol consists of semimicroelectrode recording (for subthalamic nuclei), whereas accelerotransducers and spectral analysis allow assessment of tremor, finger tapping (FT), diadochokinesis (DDK), and determination of the distance between DBS electrodes and internal capsule (IC). Rigidity is assessed by surface EMG recordings in combination with a goniometer.

Results: The determination of the functional distance between the DBS electrode and the IC is based on the activation functions of axons in the IC. We show the high sensitivity of accelerometers for tremor over a large part of the body, the relationship between clinical scores and spectral frequencies of FT and DDK. Parkinsonian rigidity can be assessed from surface EMG (sEMG) by means of a balance coefficient, which can detect negative rigidity, for low unified Parkinson's disease rating scale (UPDRS) scores (0-2) and quantified EMG when negative rigidity is excluded.

Conclusion: Accelerometer and sEMG recording have shown their value for intraoperative assessment of disabling motor symptoms and side effects during surgery, to optimize the target position electrodes for DBS. The combination with contemporary signal analyzing techniques permit intraoperative monitoring without a significant delay. IONM improves sensitivity and adds objective neurophysiological data.