A 52-year-old man with Parkinson disease (PD) of 9 years’ duration was referred to the DBS clinic for medication-refractory severe unilateral rest and re-emergent tremor and frequent motor fluctuations. He was approved for DBS, with debate over the optimal target to treat severe tremor and fluctuations (subthalamic nucleus [STN] plus/minus the ventral intermediate [Vim] thalamus) and unilateral versus bilateral implantation. The committee decided to perform unilateral STN lead placement first, to provide benefit for both motor fluctuation and tremor, with the option of adding Vim concurrently if required. Intraoperatively, there was incomplete tremor capture, so a second lead was placed in Vim with success. Subsequent DBS programming achieved marked improvement of tremor and fluctuations at low stimulation, although side effects necessitated bipolar configurations in both leads. The patient reported excellent sustained tremor suppression at 2-year follow-up, although motor fluctuations recurred. This case illustrates that for intraoperative stimulation-refractory PD tremor, consideration can be given to adding a second Vim DBS target (dual DBS targets).
Dual-lead SCS combined with low-dose ketamine drip infusion therapy for the treatment of neuropathic pain
