今天为大家分享的是“景昱—神经科学专栏”第九十期，由海军军医大学附属长海医院吴曦副教授带来的：“帕金森病DBS治疗的疗效分析(下）”，内容精彩，欢迎阅读。
承接上篇【景昱-神经科学专栏】| 帕金森病DBS治疗的疗效分析(上）
三、DBS治疗PD疗效分析
长期随访结果显示，随着手术方式和步骤的逐步改良，DBS术安全性逐步提高，目前手术死亡率约0.1%。如果患者适应证好、电极植入准确以及刺激参数设置适当，无论是STN刺激还是GPi刺激，都可以长期显著改善中晚期 PD患者的震颤、僵直、少动等核心运动症状。STN-DBS可以显著减少PD患者的药物用量，并减少药物引起的多种不良反应。国内手术安全性及治疗效果的长期随访研究结果与国外同期研究结果相仿。
姿态障碍是指在站立或行走时不能保持平稳。步行困难包括起步困难、冻结、慌张步态。PIGD虽然在UPDRS III运动症状评分占很小部分，但却是导致PD患者生活不能自理的重要原因。PD长期随访发现，虽然DBS对震颤，僵硬和肢体动作缓慢的疗效持续，但PIGD在术后数年后逐渐加重。由此，PIGD成为治疗后期PD的一个重要课题。
如果术前的轴性和步态症状对左旋多巴类药物有改善反应，这些症状可能对DBS同样有反应，虽然效果可能只维持数年。反之，若症状对左旋多巴类药物无反应，则预测DBS无效。如果步行困难是左旋多巴类药物的副作用导致，STN-DBS可通过术后减药而得以间接改善。
关于STN-DBS是否可以改善步态、吞咽、语言和平衡等轴性症状目前存在争议。近期1篇 META分析显示，STN-DBS确实可以在患者电极植入48个月内改善药物关期状态下的步态（步长、步速等）和冻结步态，但是上述症状仍会随着时间延长而逐渐恶化，不如核心症状改善持久。其原因可能是靶点核团参与情感、感觉与运动，而 ＤＢＳ的电刺激对不同神经网络的调控效果有差异。不同神经网络的神经递质、下游重要神经节点的数量、距电极触点的距离等差异导致其对电刺激的反应不同。如高频STN-DBS对吞咽能力的改善作用有限，甚至有负面作用。因此，通过调整DBS的激活触点、激活域、刺激参数来改善轴性运动症状，进而提高患者生活质量。
目前认为非运动症状较运动症状更影响患者的生活质量。术后1-3年，DBS可以部分改善某些非运动症状，如睡眠质量、便秘、肌张力障碍性疼痛、胃胀感、膀胱激惹症状。研究显示，STN-DBS可以改善多种类型的非运动症状，但该研究病例数较少，且随访时间较短。
另外由于STN参与边缘系统的神经通路，PD患者在STN-DBS术后减少药量过程中会出现撤药反应，导致心理或精神改变。临床中需要鉴别STN-DBS术后精神症状是病程进展结果、撤药反应或是电刺激引起的不良反应。大部分精神心理症状可通过调整刺激参数或辅助药物治疗改善。
DBS对绝大部分PD患者的认知能力影响较小。但是，DBS术后电刺激对额叶有抑制作用，可能导致患者认知功能轻微下降，主要表现在视觉空间感觉、语言流畅性、对他人语言理解力、注意力、冲突协调力、执行力下降。上述症状与术前认知功能下降有关尚无定论。
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【景昱-神经科学专栏】往期回顾
