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Comparison Between Unilateral and Bilateral Placement

William Ondo, MD; Michael Almaguer, RN; Joseph Jankovic, MD; Richard K. Simpson, MD, PhD

Arch Neurol. 2001;58:218-222.

Background  Unilateral thalamic deep brain stimulation (DBS) is accepted as an effective treatment for essential tremor (ET) and the tremor of Parkinson disease (PD). There are, however, relatively little data concerning bilateral thalamic DBS and no thorough comparisons between the 2 methods.

Methods  To assess the relative benefit of a staged second contralateral DBS placement in patients with PD and ET, we compared preoperative baseline assessments with those at 3 months after the initial implantation, and again at 3 months after the second contralateral implantation. The assessments included the Unified Parkinson's Disease Rating Scale for patients with PD (n = 8) and a modified Unified Tremor Rating Assessment for patients with ET (n = 13). The design included open and blinded (unknown activation status) assessments.

Results  Overall, after the second implantation, all specific measures assessing tremor contralateral to that side improved in patients with PD and ET, generally without sacrificing those contralateral to the first side implantation. Midline tremors (face and head) improved only after the second side implantation. In patients with ET, functional and subjective scores tended to further improve after the second placement; however, patients with PD had less subjective improvement. Hand tremor scores in patients with ET randomized to "on" stimulation improved from 6.7 ± 0.9 to 1.3 ± 1.2 (P<.005). The scores of patients with PD randomized to on stimulation improved from 9.3 ± 1.0 to 1.0 ± 0.5. (Data are given as mean ± SD.) Tremor scores did not change from baseline in those patients randomized to "off" stimulation in either group. Adverse events related to stimulation increased after the second implantation in both groups.

Conclusions  Bilateral thalamic DBS is more effective than unilateral DBS at controlling bilateral appendicular and midline tremors of ET and PD. Despite this, overall functional disability only improved in patients with ET, possibly secondary to more problematic adverse events in patients with PD, especially balance problems. Bilateral DBS should be considered when unilateral DBS does not offer satisfactory benefit, especially in patients with ET.

From the Departments of Neurology (Drs Ondo and Jankovic and Mr Almaguer) and Neurosurgery (Dr Simpson), Baylor College of Medicine, Houston, Tex.

Corresponding author and reprints: William Ondo, MD, Department of Neurology, Baylor College of Medicine, 6550 Fannin Dr, Suite 1801, Houston, TX 77030 (e-mail: wondo{at}bcm.tmc.edu).

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