帕金森病脑深部电刺激术后基于微电极记录结果远程程控的临床疗效分析

Clinical efficacy of remote programming after deep brain stimulation for Parkinson's disease based on microelectrode recording results

目的比较帕金森病(PD)脑深部电刺激(DBS)术后远程程控与传统门诊程控的疗效,并探讨微电极记录(MER)在术后程控刺激触点选择中的指导作用。方法本研究为回顾性队列研究。纳入2019年2月至2021年12月在中国科学技术大学附属第一医院(安徽省立医院)神经外科行双侧丘脑底核(STN)-DBS治疗的122例PD患者,术后1个月开机,开机后1年进行随访。根据术后程控方式和首次程控刺激触点的选择策略分为门诊常规程控组(39例)、远程常规程控组(41例)和MER指导远程程控组(42例),比较3组患者的术前基线资料、开机用时,以及开机时出现不适感的次数、开机后1年药物关期统一PD评定量表第三部分(UPDRS-Ⅲ)震颤与运动迟缓评分之和的改善率、左旋多巴每日等效剂量(LEDD)减少率、开机后1年的程控次数、随访期间的程控需求比例。结果3组患者的年龄、性别、病程、Hoehn-Yahr分期(H-Y分期)、术前LEDD、术前药物关期UPDRS-Ⅲ评分、术前药物关期UPDRS-Ⅲ震颤与运动迟缓评分之和、术前左旋多巴冲击试验改善率的差异均无统计学意义(均P>0.05)。开机后1年,3组患者药物关期UPDRS-Ⅲ震颤与运动迟缓评分之和改善率的差异无统计学意义(F=0.60,P>0.05),而在LEDD减少率[M(Q_(1),Q_(3))]方面,远程常规程控组和MER指导远程程控组均显著高于门诊程控组[分别为46.7%(30%,50%)、46.6%(30%,60%)、33.3%(0%,50%),H=6.05,P=0.049];程控次数[M(Q_(1),Q_(3))]方面,远程常规程控组和MER指导远程程控组均高于门诊常规程控组[分别为6(57)次、6(5,8)次、5(4,7)次,H=8.35,P=0.015],而随访期间程控需求比例均低于门诊常规程控组[分别为31.7%(13/41)、31.0%(13/42)56.4%(22/39),χ^(2)=7.00,P=0.030]。MER指导远程程控组的开机用时[M(Q_(1),Q_(3))]显著短于门诊常规程控组和远程常规程控组[分别为43.5(36.0,54.0)min、125.0(106.0,134.0)min、124.0(104.5,150.0)min,H=79.72,P<0.001],开机时出现不适感的次数[M(Q_(1),Q_(3))]显著少于门诊常规程控组和远程常规程控组[分别为1(0,1)次、3(3,3)次,3(3,3)次,H=86.17,P<0.001]。结论PD患者DBS术后远程程控可获得与门诊程控相当的疗效,而应用MER能够提高远程程控的效率,减少不良反应,值得临床推广应用。

Objective To compare the efficacy of postoperative remote programming and conventional outpatient programming of deep brain stimulation(DBS)for Parkinson's disease(PD),and to explore the guiding role of microelectrode recording(MER)in selecting contacts for postoperative programming.MethodsThis study was a retrospective cohort study.A total of 122 PD patients who underwent bilateral subthalamic nucleus(STN)-DBS treatment at the Neurosurgery Department of the First Affiliated Hospital of University of Science and Technology of China(Anhui Provincial Hospital)from February 2019 to December 2021 were enrolled.The DBS devices was turned on at 1 month after surgery and follow-up was performed at 1 year after the start-up of device.According to the postoperative programming method and the selection strategy of stimulation contact in initial programming,the patients were divided into outpatient conventional programming group(39 cases),remote conventional programming group(41 cases)and MER-guided remote programming group(42 cases).The surgical outcomes of the three groups of patients were compared.Pre-baseline data,improvement rate of the sum of tremor and bradykinesia scores in the Unified PD Rating Scale Part Ⅲ(UPDRS-Ⅲ)during the 1-year med-off period after surgery,daily levodopa equivalent dose(LEDD)reduction rate,times of programming adjustments during the 1 year after start-up,the percentage of patients requiring programming adjustment at follow-up,the time taken in initial programming after device start-up,and the number of discomforts experienced during the start-up period.Results There were no significant differences in age,gender,course of disease,Hoehn-Yahr stage,preoperative LEDD,preoperative"med-off"UPDRS-Ⅲ score,sum scores of preoperative"med-off"UPDRS-Ⅲ tremor and bradykinesia,or improvement rates of preoperative levodopa challenge test(LCT)among the three groups(all P>0.05).At the follow-up of 1 year after stimulation,there was no significant difference in the improvement rate of the sum scores of"med-off"UPDRS-II tremor and bradykinesia in the three groups,while the reduction rates of LEDD[median(Q_(1),Q_(3))]in the remote conventional programming group[46.7%(30%,50%)]and MER-guided remote programming group[46.6%(30%,60%)] were both significantly higher than that in the outpatient conventional programming group[33.3%(0%,50%),H=6.05,P=0.049].The times of programming adjustments in the remote conventional programming group and MER-guided remote programming group was more than that in the outpatient conventional programming group[M(Q1,Q3):5(4,7),6(5,7)and 6(5,8)respectively,H=8.35,P=0.015],while the patients'programming requirements during follow-up were significantly less than those in the outpatient conventional programming group[percentage:31.7%(13/41),31.0%(13/42)and 56.4%(22/39)respectively,χ^(2)=7.00,P=0.030].The initial programming time of MER-guided remote programming group was significantly shorter than that of the outpatient conventional programming group and remote conventional programming group[M(Q_(1),Q_(3)):43.5(36.0,54.0)min,125.0(106.0,134.0)min and 124.0(104.5,150.0)min respectively,H=79.72,P<0.001].The number of discomforts was significantly less than that of the outpatient conventional programming group and remote conventional programming group[M(Q_(1),Q_(3)):1(0,1),3(3,3)and3(3,3)respectively,H=86.17,P<0.001].Conclusions Postoperative remote programming for PD patients can achieve therapeutic efficacy comparable to that of outpatient programming.The MER results can be used to guide the selection of programming contacts and improve the efficiency of remote programming with fewer adverse events,which is worthy of clinical promotion and application.