Parkinson’s and trembling

Relief of extrapyramidal symptoms by sympathetic block

ESB has been used successfully to treat Parkinson’s. A case is presented below.

Published 2003-07-15, updated 2010-12-17, Timo Telaranta1 and Markku Partinen2,3


We present a 44 years old male patient, whose extrapyramidal symptoms were relieved by an endoscopic sympathetic block at high thoracic level. Following surgery his symptoms related to anxiety and social phobia were also relieved, and his capacity in daily living improved markedly. This finding opens new questions about pathophysiology of Parkinsonian symptoms and may give new possibilities to treat patients with Parkinson’s disease who are anxious or who suffer from social phobia.


Extrapyramidal symptoms are found in patients with Parkinson’s disease and also as a consequence of neuroleptic (antidopaminergic) treatment. The golden standard of treatment is based on dopaminergic drugs (dopamin agonists and L-dopa-preparations). The effect of surgical procedures is considered limited (1).

Disabling dysfunction of sympathetic nervous system may be present, and sympathetic ganglion transplantation from upper thoracal sympathetic ganglia into the caudate and putamen unilaterally has been proposed (2).

Also depression and most recently anxiety has been the focus of Parkinson’s comorbidity representing up to 40 % of Parkinson’s patients (3).

On the other hand, endoscopic sympathetic block has been proposed as a possible treatment for patients with social anxiety relieving also trembling (4).

The case

A Finnish 44 years old male had his first extrapyramidal symptoms at the age of 36. Earlier he had been operated on for hyperthyreosis at the age of 25, and had as a complication hypoparathyreosis, which is balanced with medication. The neurological disease progressed quite rapidly causing significant incapacity in daily activities and forced him into early retirement. The main motor symptoms were rigidity, bradykinesia, hypomimia and resting parkinsonian-type tremor of both upper extremities. Estimated UPDRS-motor examination gave 38-42/56 points.

The diagnosis of Parkinson’s disease was confirmed with b-CIT mapping of the brain. He was subsequently treated with L-dopa and carbidopa combibed with entacapone. During the last few years the effectiveness of the drugs gradually decreased, both in terms of the efficacy and duration of relief. As a young man under the age of 30, the patient had suffered considerably from stage fright. With time he learned to withstand it due to his work as a director of financing in a major bank.

After the onset of the Parkinsonian symptoms, however, the signs of social phobia recurred together with anxiety. The patient has had a long-lasting therapy contact with ambulatory mental care unit and with a private psychiatrist. He had been treated with several SSRI drugs and mirtazapine without significant effect. The sympathetic function of the patient was investigated, and a slight dysfunction without any increase in sympathetic tone was found. A stellate ganglion block was performed in April. The patient experienced some, but not significant, relief. He notwithstanding wanted to continue to an experimental endoscopic sympathetic block (ESB), which was performed later on the same day according to Lin-Telaranta (5).

After surgery

Immediately after the surgery he felt that his tremor had decreased and his walking and coordination had improved. During the following 10 months post-surgery, the situation has further improved. We decreased his medication. The patient himself estimated at that point that the muscular rigidity and tremor were still present during some hours a day (20 %), compared to 50-70 % one year ago.

After the surgery the UPDRS-motor examination gave 17-21/46 points. A year ago he was able to only occasionally drive a car, whereas now he was able to drive distances of over hundred miles. The patient intended to return to work from the already approved pension. Three years after the surgery he tells having been steadily getting better and he sends a home made video to us. He had turned to lead a family business instead of getting back to his former work. ESB has been demonstrated to be effective in the treatment of social phobia (6).

In an extended Medline search we have not been able to find a single mention of its use in the treatment of extrapyramidal symptoms or in the treatment of Parkinson’s disease. The Parkinsonian type symptoms in our case were aggravated by anxiety, and the patient had also been diagnosed with social phobia. We can only speculate about possible pathophysiologic mechanisms. The results of motor improvement may be due to changes in the noradrenergic-dopaminergic feed-back systems. It is also possible that the autonomic nervous system plays a role in the Parkinson’s disease which is still poorly understood. Anyhow, so it seems to be in several cases of our Parkinson patients. Further studies are needed on this topic.

Further studies

1 Dysautonomia Research Institute, Tampere, 2 Haaga Neurological Research Centre, and 3 Department of Clinical Neurosciences, University of Helsinki, Finland (1)

Schapira AH. Science, medicine, and the future: Parkinson’s disease. BMJ 1999;318:311-4 (2)

Nakao N, Kakishita K, Uematsu Y, Yoshimasu T, Bessho T, Nakai K, Naito Y, Itakura T. Enhancement of the response to levodopa therapy after intrastriatal transplantation of autologous sympathetic neurons in patients with Parkinson disease. Neurosurg 2001;95:275-84 (3)

Walsh K, Bennett G. Parkinson’s disease and anxiety. Postgrad Med J 2001;77:89-93 (4)

Telaranta T. Past, present and future of the surgery of the sympathetics. Ann Chir Gyn 2001;90:153-6 (5)

Lin CC, Telaranta T. Lin-Telaranta classification: The importance of different procedures for different indications in sympathetic surgery. Ann Chir Gyn 2001;90:161-6 (6) Pohjavaara P, Telaranta T, Väisänen E. The role of sympathetic nervous system in anxiety: Is it possible to relieve anxiety with endoscopic sympathetic block. Nord J Psychiatry 2003;57:55-60