We thank Hariz and colleagues for their comments 1 regarding the origin and use of the term subthalamotomy. Based on its historical use and meaning, they suggest that therapeutic ablation of the subthalamic nucleus (STN) should be referred to as subthalamic nucleotomy.
The main argument raised against using the term subthalamotomy is that, in the classic literature, the procedure was variably referred to as ablation of “pallido‐thalamic projections, the prelemniscal radiations, the zona incerta and the cerebello‐thalamic pathways, but never the subthalamic nucleus”. We understand this historical point. However, there are several valid reasons for retaining the term subthalamotomy, which has been used since the re‐introduction of ablative basal ganglia surgery for Parkinson's disease (PD) in the 1990s. Thus, when monkey studies in the MPTP monkey model showed that cytochemical lesioning of the STN was associated with marked motor improvement, 2 the notion that a lesion of the STN could be beneficial in PD patients was put forward, and the term subthalamotomy was applied. 3 This occurred somewhat in parallel with the revitalization of pallidotomy, led and spurred on by Laitinen et al.'s relevant observations. 4 Thereafter, a considerable number of articles from several research teams used the term subthalamotomy. 5 Admittedly, modern subthalamic lesions do indeed target and impinge upon the STN proper, but a dorsal extension to interrupt pallido‐thalamic fibers is also systematically performed in order to reduce/avoid the possibility of hemichorea‐ballism. 6 Thus, the term “nucleotomy” would inaccurately neglect part of the current standard approach. It is noteworthy that pallidotomy and thalamotomy, which are perfectly accepted for all, also interrupt connecting fibers. Moreover, the authors themselves refer to the use of STN deep brain stimulation (STN‐DBS) and not subthalamic stimulation as an argument and, to be completely accurate, the volume of tissue stimulated by STN‐DBS is well known to extend well beyond the STN itself. 7 Finally, but importantly, the term nucleotomy may imply that the entire STN is lesioned, which is not the case purposefully. Thus, the limbic and associative regions and their connections are deliberately omitted to avoid behavioral–emotional manifestations, and it is the STN motor region predominantly and the adjacent medio‐dorsal fibers which are targeted and lesioned. 6
Overall, the term subthalamotomy therefore describes the actual lesioning procedure more comprehensively than nucleotomy of the STN. Medical terms can be imperfect. However, language serves the purpose of facilitating understanding and, currently, the term “subthalamotomy” is widely understood in the field. Moreover, magnetic resonance imaging (MRI)‐guided lesioning is approved for the lesioning of thalamic, subthalamic, and pallidal regions; the term subthalamic nucleotomy could be interpreted in contrast to the existing CE certification.
Accordingly, “subthalamotomy” is appropriate and accurately reflects both the anatomical location of the lesions and the current MRI‐guided focused ultrasound nomenclature used for other targets until better nomenclature becomes available.
Author Roles
(1) Manuscript Preparation: A. Writing of the First Draft, B. Review and Critique.
1A: S.P., E.N.‐V., G.D., R.M.‐F., J.A.O.
1B: S.P., E.N.‐V., R.R.‐R., M.d.A., J.A.P.‐P., A.‐K.H., J.H., G.D., R.M.‐F., J.A.O.
Steffen Paschen and Elena Natera‐Villalba share first co‐authorship.
Relevant conflicts of interest/financial disclosures: S.P. reports speaker honoraria from Insightec, AbbVie, Medtronic GmbH, and Boston Scientific outside the submitted work and grant/research funding from Deutsche Forschungsgemeinschaft (DFG), Parkinson Fonds Deuschland gGmbH, and UCB Pharma GmbH. E.N.‐V. has received financial support from Zambon, Bial, Esteve, and Insightec to attend scientific meetings and received grants from Sociedad Española de Neurología and Asociación Madrileña de Neurología. R.R.‐R. has received speaker honoraria from Zambon and Insightec outside the submitted work. M.d.A. has received speaker honoraria from Insightec, Palex, and Boston Scientific and reimbursement of travel expenses to attend scientific conferences from Boston Scientific and Medtronic outside the submitted work. J.A.P.‐P. has received speaker honoraria from Insightec, Palex, and Zambon outside the submitted work. A.‐K.H. has received lecture fees from Boston Scientific and Insightec outside the submitted work. J.H. has served as a consultant for Stryker Neurovascular and Balt. He has received reimbursement of travel expenses to attend scientific meetings by Rapid Medical outside the submitted work. G.D. has served as a consultant for Boston Scientific, Insightec, and Functional Neuromodulation. He has received royalties from Thieme Publishers, funding from the German Research Council (SFB 1261, T1), and private foundations. R.M.‐F. reports speaker honoraria from Insightec, Palex, Esteve, Zambon, and Bial outside the submitted work and grant/research funding from Instituto de Salud Carlos III, Madrid, Spain for health research projects (PI21 Proyectos de investigacion en salud, AES 2021). J.A.O. has received honoraria for lecturing and reimbursement of travel expenses to attend scientific meetings by Insightec outside the submitted work.
Funding agency: None.
Contributor Information
Steffen Paschen, Email: s.paschen@neurologie.uni-kiel.de.
Jose A. Obeso, Email: jobeso.hmcinac@hmhospitales.com.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.