Objective: Evaluate the effects of bilateral Deep Brain Stimulation (DBS) in Subthalamic Nucleus (STN) versus Globus Pallidus Internus (GPi) for patients with refractory dystonia.

Background: Dystonia is a disorder involving sustained muscle contractions that induces twisting, repetitive movements, or abnormal postures. When refractory to medications, the recommended treatment option is DBS in the STN or GPi. Although both are known to be effective, it is still not clear which option can be most beneficial.

Method: We conducted a systematic review, searching in the PubMed and Scopus databases using the terms ‘refractory dystonia’ AND ‘deep brain stimulation’ AND ‘subthalamic nucleus’ AND ‘globus pallidus’. Two reviewers independently evaluated the titles and abstracts of studies published before January 2024. Studies that were not in English, reviews, pilot studies, and case reports were excluded.

Results: 51 articles were identified and 12 met inclusion criteria. Sample sizes varied from 5 to 108 participants (n= 276). Two retrospective studies with 30 and 108 patients comparing both targets indicated that STN-DBS produced a superior clinical response in the Burke‐Fahn‐Marsden Dystonia Rating Scale (BFMDRS) movement score in the first month compared to baseline (64% vs 48% and 67% vs 41%, respectively, p<0.05) [1,2]. At 36 months, STN-DBS was superior to GPi-DBS in the areas of the eye (81% vs. 56%; p = 0.01), mouth (92% vs. 66%; p = 0.002), and arms (77% vs. 43%; p = 0.03), and GPi-DBS showed superiority especially on trunk symptoms (82% vs. 94%; p = 0.015) [2]. One randomized double-blind crossover trial with 12 patients and one prospective study with 8 participants showed no differences between both targets using the BFMDRS score [3,4]. STN-DBS presented an economic advantage in lower battery consumption [1-6]. Concerning the adverse effects profile in both treatment groups, GPI-DBS presented more bradykinetic-like manifestations [1,4], whereas STN-DBS presented a substantial number of transient depression episodes [1,6,7].

Conclusion: The STN-DBS may be an alternative to GPi-DBS due to its rapid action, advantages for ocular, mouth and arm symptoms, and lower battery consumption. GPi-DBS might be preferable especially for symptoms of trunk involvement. Both targets appear to be equally effective with different adverse effect profiles.

References: [1] Lin S, Wu Y, Li H, Zhang C, Wang T, Pan Y, et al. Deep brain stimulation of the globus pallidus internus versus the subthalamic nucleus in isolated dystonia. Journal of Neurosurgery JNS. 2020;132(3):721–32.

[2] Lin S, Shu Y, Zhang C, Wang L, Huang P, Pan Y, et al. Globus pallidus internus versus subthalamic nucleus deep brain stimulation for isolated dystonia: A 3-year follow-up. European Journal of Neurology. 2023;30(9):2629–40.

[3] Schjerling L, Hjermind LE, Jespersen B, Madsen F, Jannick Brennum, Steen Solvang Jensen, et al. A randomized double-blind crossover trial comparing subthalamic and pallidal deep brain stimulation for dystonia. 2013 Dec 1;119(6):1537–45.

[4] Liu Y, Zhu G, Jiang Y, Wang X, Chen Y, Meng F, et al. Comparison of short-term stimulation of the globus pallidus interna and subthalamic nucleus for treatment of primary dystonia. World Neurosurg [Internet]. 2019 [cited 2024 Jan 26];123:e211–7. Available from: https://pubmed.ncbi.nlm.nih.gov/30481618/

[5] Sun B, Chen S, Zhan S, Le W, Krahl SE. Subthalamic nucleus stimulation for primary dystonia and tardive dystonia. PubMed. 2007 Dec 1;207–14.

[6] Cao C, Pan Y, Li D, Zhan S, Zhang J, Sun B. Subthalamus deep brain stimulation for primary dystonia patients: A long-term follow-up study. Movement Disorders. 2013 Jul 16;28(13):1877–82.

[7] Ostrem JL, Racine CA, Glass GA, Grace JK, Volz MM, Heath SL, et al. Subthalamic nucleus deep brain stimulation in primary cervical dystonia. 2011 Mar 7;76(10):870–8.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/bilateral-deep-brain-stimulation-in-subthalamic-nucleus-versus-globus-pallidus-internus-for-refractory-dystonia/