To the Listmembers:
 
There has been a debate here regarding the indications
and benefits of stereotactic neurosurgery (pallidotomy,
thalamotomy, etc.) in the treatment of PD.  People
have expressed some "glowing reports" about the revival
of this surgery (which was originally started in the
sixties and which was essentially given up with the advent
of the L-DOPA family of drugs), this apparently
because of the observations that the beneficial effects of
the drugs were temporary (and there were significant
side-effects).  As one who had participated in the
use of surgery in the sixties, and who had remembered
the limitations of these procedures, I have posted several
messages urging extreme caution before having such
surgery done now, even though some of the techniques
for performing stereotactic surgery (gamma knife, etc.)
have improved from the "old days".  Because of the wide
swings of opinion here, and in the interests of education,
I decided to access MEDLINE, the National Database
for medical articles, and challenge the system for recent
information on this subject.
 
What follows below are abstracts from a series of
medical articles describing some of the recent work which
has gone on in this field; and there are several
additional citations (not listed) which did not have
sufficient information in their listings, so that I have requested
our Medical Librarian to obtain (the full articles) for me.
I will post that information when I have obtained such.  I
was quite surprised that, despite the enthusiasm of some
on this List as to the volume of the "new work" in this
field, I could only find approximately 15 articles (this
encompassing the period of 1985 to the present in this
search); and several of those articles were of "basic"
physiological interest, and not related to the treatment of
patients.  I will post below, each abstract; and, following
a "dotted line", will post my comments.
 
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 1/L/3
DIALOG(R)File 154:MEDLINE(R)
(c) format only 1994 Dialog Info.Svcs. All rts. reserv.
 
08845021   94160021
  Gamma  Knife  thalamotomy  and  pallidotomy  in  patients  with  movement
disorders: preliminary results.
  Rand RW; Jacques DB; Melbye RW; Copcutt BG; Fisher MR; Levenick MN
  Neurosciences  Institute,  Hospital  of  the Good Samaritan, Los Angeles,
Calif.
  Stereotact Funct Neurosurg (SWITZERLAND)   1993,  61 Suppl 1 p65-92,
ISSN 1011-6125   Journal Code: SFN
  Languages: ENGLISH
  Document type: JOURNAL ARTICLE
  JOURNAL ANNOUNCEMENT: 9406
  Subfile:   INDEX MEDICUS
  The  Leksell  Gamma  Knife  is  a  useful  and  safe  method  to  perform
thalamotomy  and  pallidotomy  in  selected older patients with Parkinson's
disease  and related movement disorders. In this preliminary report, 2 of 3
patients  with  severe  intention tremor were relieved of their symptoms by
thalamotomy,  as  were  4  of 7 patients with Parkinson's tremor. Four of 8
patients  had  significant  improvement of contralateral rigidity following
pallidotomy.
  Tags: Case Report; Female; Human; Male
  Descriptors:  *Globus  Pallidus--Surgery--SU; *Parkinson Disease--Surgery
--SU;  *Parkinson Disease, Symptomatic--Surgery--SU; *Radiosurgery--Methods
--MT;  *Thalamus--Surgery--SU;  Aged;  Aged,  80  and over; Globus Pallidus
--Pathology--PA;  Magnetic  Resonance  Imaging; Middle Age; Muscle Rigidity
--Pathology--PA;   Muscle  Rigidity--Surgery--SU;  Neurologic  Examination;
Parkinson Disease--Pathology--PA; Parkinson Disease, Symptomatic--Pathology
--PA;     Postoperative     Complications--Diagnosis--DI;     Postoperative
Complications--Pathology--PA;  Thalamus--Pathology--PA;  Treatment Outcome;
Tremor--Pathology--PA;  Tremor--Surgery--SU
 
 
--------------------------------------------------------------------------------
 ----------
 
This article, published in 1993, reports the use of the gamma knife in the
treatment of patients with both Parkinsonian tremor and "intention tremor"
which is usually due to *other* conditions.  In the case of the
Parkinsonian patients, only approximately 60% were relieved of their
tremor, and 50% were relieved of their rigidity.  The *total* number of
patients with Parkinson's disease treated was only 8 patients.  There is
no follow-up as to how long the benefits lasted.
 
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 1/L/6
DIALOG(R)File 154:MEDLINE(R)
(c) format only 1994 Dialog Info.Svcs. All rts. reserv.
 
08789104   94104104
  [Surgical treatment of Parkinson's disease]
  Komai N
  Department of Neurological Surgery, Wakayama Medical College.
  Nippon Rinsho (JAPAN)   Nov 1993,  51 (11) p2940-6,  ISSN 0047-1852
Journal Code: KIM
  Languages: JAPANESE   Summary Languages: ENGLISH
  Document  type:  JOURNAL  ARTICLE;  REVIEW;  REVIEW,  TUTORIAL    English
Abstract
  JOURNAL ANNOUNCEMENT: 9404
  Subfile:   INDEX MEDICUS
  Surgical  treatment  for  Parkinson's  disease  began  by blocking of the
pyramidal  system  in  early  part  of  this era. In 1942, Meyers performed
Ansotomy  for  the  treatment  of  Parkinsonism without leaving hemiplegia,
leading  subsequent  operating  target  to  blocking of pallidofugal fiber.
Then, the development of stereotaxy in 1947 caused an operative progress to
Pallidotomy  and  further  to  Thalamotomy. Although the spread of levodopa
therapy  gradually brought about decline of surgical treatment, Thalamotomy
became  to  be  reexamined  in view of not a little problems about and side
effects  of levodopa therapy. With the development of CT, MRI and the like,
Thalamotomy  via  MRI-stereotaxy was developed, making operations safer and
surer.  Besides,  transplantation of dopamine neurons into the striatum was
tried  as  an essential treatment and is in clinical application via animal
experiments.  Fetal  ventral  mesencephalic  tissue  and  adrenal medullary
tissue are available therefore, but demerits are such that the former poses
some  ethical  problem and the latter is poor and short-lived response. The
transplantation  of  stellate  ganglion  into  the  striatum, which we have
recently  developed  is  safe and more effective than the adrenal medullary
tissue.  The  respective  one  thirds  of  the  cases  did without levodopa
following transplantation, needed half as much as the preoperative levodopa
dose  and  needed  the  same  as the latter. Although Horner's syndrome was
noted  in all cases following transplantation, no Parkinson syndrome became
aggravated in any one of the cases.  (15 Refs.)
  Tags: Human
  Descriptors:  *Parkinson  Disease--Surgery--SU;  *Stereotaxic Techniques;
Adrenal  Medulla--Transplantation--TR;  Brain Tissue Transplantation; Fetal
Tissue Transplantation; Levodopa--Administration and Dosage--AD; Substantia
Nigra--Transplantation--TR; Thalamus--Surgery--SU
  CAS Registry No.: 0   (Levodopa)
 
 
--------------------------------------------------------------------------------
 --------------
This article, from Japan, does not make any mention of the *results*
of the surgery.  It discusses the newer techniques of
stereotactic surgery (use of the MRI and CT scanners to
better localize the lesions); but it goes on to discuss the
potential of the use of transplantation of fetal brain
tissue (with the ethical considerations of such) and the
use of adrenal gland tissue (which works poorly and
for a very short time).  One of the small benefits in
this series was that the dosage of L-DOPA was able
to be reduced in many patients; but again, there is no
mention of time of follow-up.
 
======================================================
 
 1/L/7
DIALOG(R)File 154:MEDLINE(R)
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08573757   93283757
  Transplantation and surgical treatment of parkinsonian syndromes.
  Widner H; Rehncrona S
  Department of Neurology, University Hospital, Lund, Sweden.
  Curr Opin Neurol Neurosurg (UNITED STATES)   Jun 1993,  6 (3) p344-9,
ISSN 0951-7383   Journal Code: BDI
  Languages: ENGLISH
  Document type: JOURNAL ARTICLE; REVIEW; REVIEW, TUTORIAL
  JOURNAL ANNOUNCEMENT: 9309
  Subfile:   INDEX MEDICUS
  Neurosurgical  attempts  to  correct  parkinsonism  use  strategies aimed
either  at  alleviating the underlying dopamine deficiency or at correcting
abnormal  compensatory effects in neural circuits within the basal ganglia.
During  the  review period, clinical trials of four different neurosurgical
approaches    were    reported.    These   approaches   are   intracerebral
transplantation of fetal dopamine neurons, intracerebral transplantation of
adrenal   medullary   tissue,   tremor-reducing  surgical  lesions  in  the
ventrolateral  thalamus,  and ventroposterior pallidotomy aimed at reducing
akinesia and rigidity. Experimental studies in rats and monkeys designed to
explore mechanisms of graft actions were also reported.  (33 Refs.)
  Tags: Animal; Human
  Descriptors:   *Adrenal  Medulla--Transplantation--TR;  *Globus  Pallidus
--Surgery--SU;   *Parkinson   Disease--Surgery--SU;   *Parkinson   Disease,
Symptomatic--Surgery--SU;     *Thalamus--Surgery--SU;    Adrenal    Medulla
--Physiopathology--PP;     Dopamine--Physiology--PH;     Globus    Pallidus
--Physiopathology--PP;  Parkinson  Disease--Physiopathology--PP;  Parkinson
Disease,  Symptomatic--Physiopathology--PP; Receptors, Dopamine--Physiology
--PH; Thalamus--Physiopathology--PP
  CAS Registry No.: 0   (Receptors, Dopamine); 51-61-6   (Dopamine)
 
--------------------------------------------------------------------------------
 ----------
 
This article appears to be a "review article", but no "results" are
expressed.  I have requested the full article from my Library.
 
========================================================
 
 1/L/8
DIALOG(R)File 154:MEDLINE(R)
(c) format only 1994 Dialog Info.Svcs. All rts. reserv.
 
08430974   93140974
  Neurosurgical horizons in Parkinson's disease.
  Goetz CG; De Long MR; Penn RD; Bakay RA
  Department of Neurological Sciences, Rush-Presbyterian-St. Luke's Medical
Center, Chicago, IL 60612.
  Neurology (UNITED STATES)   Jan 1993,  43 (1) p1-7,  ISSN 0028-3878
Journal Code: NZ0
  Languages: ENGLISH
  Document type: JOURNAL ARTICLE; REVIEW; REVIEW, ACADEMIC
  JOURNAL ANNOUNCEMENT: 9304
  Subfile:   AIM; INDEX MEDICUS
  Based  on recent neuroanatomic and physiologic discoveries, neurosurgical
therapies  may  increasingly complement and extend pharmacologic management
of  Parkinson's  disease. Procedures showing promise include subthalamotomy
and pallidotomy; thalamic electrical stimulation may also offer application
for  tremor  control.  Transplantation  of adrenal chromaffin cells has not
been associated with consistent long-term improvement in most patients, and
fetal  mesencephalic transplantation remains controversial. Trophic factors
that  may be pivotal to cellular repair and survival of transplanted tissue
have  potential  therapeutic  roles when purified and perfused centrally or
when the cells that produce the factors are transplanted.  (92 Refs.)
  Tags: Animal; Human
  Descriptors:     *Parkinson    Disease--Surgery--SU;    Adrenal    Glands
--Transplantation--TR;  Brain  Tissue  Transplantation;  Combined  Modality
Therapy; Electric Stimulation Therapy; Fetal Tissue Transplantation; Globus
Pallidus--Surgery--SU;     Mesencephalon--Transplantation--TR;     Thalamus
--Surgery--SU
 
 
--------------------------------------------------------------------------------
 ---------------
 
This article, by the group (previously mentioned on this List) at
Rush-Presbyterian-St. Luke's in Chicago), suggests that,
in some cases, surgery may "extend" drug therapy; but
again, it is mainly *tremor* that is being discussed.   The
authors also confirm the prior impression that adrenal
gland transplantation is short-lived in its effect.
 
====================================================
 
 1/L/9
DIALOG(R)File 154:MEDLINE(R)
(c) format only 1994 Dialog Info.Svcs. All rts. reserv.
 
08357680   93067680
  Ventroposterolateral pallidotomy can abolish all parkinsonian symptoms.
  Laitinen LV; Bergenheim AT; Hariz MI
  Department of Neurosurgery, Sophiahemmet Hospital, Stockholm, Sweden.
  Stereotact  Funct Neurosurg (SWITZERLAND)   1992,  58 (1-4) p14-21,  ISSN
1011-6125   Journal Code: SFN
  Languages: ENGLISH
  Document type: JOURNAL ARTICLE
  JOURNAL ANNOUNCEMENT: 9302
  Subfile:   INDEX MEDICUS
  Stereotactic ventroposterolateral pallidotomy in 46 parkinsonian patients
resulted  in  a  complete  or  almost  complete  and long-lasting relief of
rigidity  and  hypokinesia  in  91% of the patients. Good tremor effect was
obtained  in  80%  of them. The L-dopa-induced dyskinesias, gait and speech
improved  in most patients. Complications were observed in 7 cases after 51
pallidotomies,  i.e.  14% (partial homonymous hemianopia in 6 and transient
dysphasia  and  facial  weakness  in 1). We believe that the good effect of
surgery    is    based   on   interruption   of   some   striopallidal   or
subthalamopallidal pathways.
  Tags: Human
  Descriptors:  *Globus  Pallidus--Surgery--SU; *Parkinson Disease--Surgery
--SU;  Dystonia--Physiopathology--PP;  Electric  Stimulation;  Gait; Globus
Pallidus--Physiopathology--PP;   Middle   Age;   Pain--Physiopathology--PP;
Parkinson   Disease--Physiopathology--PP;  Retrospective  Studies;  Speech;
Stereotaxic Techniques
 
--------------------------------------------------------------------------------
 ---------
 
This is one of the original articles by Dr. Laitinen (Sweden), having
been published in Europe in 1992.  Some of the results appear
favorable, but there is no real mention of follow-up.  The rate of
complications seem to be 14-15%, with some visual loss and
muscle weakness/speech deficit being the risks.  I have also sent
for the full article from my Library.
 
====================================================
 
 1/L/11
DIALOG(R)File 154:MEDLINE(R)
(c) format only 1994 Dialog Info.Svcs. All rts. reserv.
 
07941042   92079042
  Leksell's  posteroventral  pallidotomy  in  the  treatment of Parkinson's
disease [see comments]
  Laitinen LV; Bergenheim AT; Hariz MI
  Department of Neurosurgery, Sophiahemmet Hospital, Stockholm, Sweden.
  J Neurosurg (UNITED STATES)   Jan 1992,  76 (1) p53-61,  ISSN 0022-3085
Journal Code: JD3
  Comment in  J Neurosurg 1992 Sep;77(3):487-8
  Languages: ENGLISH
  Document type: JOURNAL ARTICLE
  JOURNAL ANNOUNCEMENT: 9203
  Subfile:   AIM; INDEX MEDICUS
  Between  1985 and 1990, the authors performed stereotactic posteroventral
pallidotomies  on 38 patients with Parkinson's disease whose main complaint
was  hypokinesia. Upon re-examination 2 to 71 months after surgery (mean 28
months), complete or almost complete relief of rigidity and hypokinesia was
observed in 92% of the patients. Of the 32 patients who before surgery also
suffered  from  tremor,  26 (81%) had complete or almost complete relief of
tremor. The L-dopa-induced dyskinesias and muscle pain had greatly improved
or  disappeared  in  most  patients, and gait and speech volume also showed
remarkable  improvement. Complications were observed in seven patients: six
had  a  permanent  partial  homonymous  hemianopsia (one also had transient
dysphasia  and  facial weakness) and one developed transitory hemiparesis 1
week  after  pallidotomy.  The  results  presented  here  confirm  the 1960
findings  of  Svennilson,  et  al., that parkinsonian tremor, rigidity, and
hypokinesia  can be effectively abolished by posteroventral pallidotomy, an
approach developed in 1956 and 1957 by Lars Leksell. The positive effect of
posteroventral  pallidotomy  is believed to be based on the interruption of
some   striopallidal  or  subthalamopallidal  pathways,  which  results  in
disinhibition of medial pallidal activity necessary for movement control.
  Tags: Female; Human; Male
  Descriptors:  *Globus  Pallidus--Surgery--SU; *Parkinson Disease--Surgery
--SU;  Adult;  Aged;  Aged,  80  and  over;  Follow-Up Studies; Middle Age;
Movement;  Parkinson Disease--Physiopathology--PP; Psychomotor Performance;
Retrospective Studies; Stereotaxic Techniques
 
--------------------------------------------------------------------------------
 ----
Another article by Dr. Laitinen, this quite optimistic as far as
results are concerned; but the work only involved 38
patients with PD, and the follow-up time averaged only
slightly more than 2 years.  The operation seemed to reduce
some of the side-effects of L-DOPA, but the medication had
to be continued despite the surgery.  It was mentioned by
one contributor to this List that the "target" of the
pallidotomy in the "new procedures" was "different" from
where we used to create the lesions in the "old days", but
this article reports that the location of the lesions are
quite the same; only there are now slightly better ways to
make them.
 
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 1/L/12
DIALOG(R)File 154:MEDLINE(R)
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07661491   91180491
  Correlation  between  clinical outcome and size and site of the lesion in
computed tomography guided thalamotomy and pallidotomy.
  Hariz MI
  Department of Neurosurgery, University Hospital, Ume.ANG.a, Sweden.
  Stereotact  Funct  Neurosurg (SWITZERLAND)   1990,  54-55  p172-85,  ISSN
1011-6125   Journal Code: SFN
  Languages: ENGLISH
  Document type: JOURNAL ARTICLE
  JOURNAL ANNOUNCEMENT: 9107
  Subfile:   INDEX MEDICUS
  Fourteen  thalamotomies  and  five  pallidotomies  were  performed  in 19
patients  with  hereditary  intention  tremor  or  Parkinson's disease. The
target  coordinates  were  determined by a stereotactic computed tomography
study  using  the  Laitinen  noninvasive  stereoadapter.  Surgery  was done
without  ventriculography. The patients were assessed 3-12 months later. In
a  postoperative  stereotactic  computed tomography study, the positions of
the  thalamic  and pallidal targets were marked, and the coordinates of the
center of the lesion were measured in relation to these targets. The volume
of  the  lesion  was  calculated.  In 3 thalamic lesion patients, no lesion
could be visualized. The size of the eleven visible thalamic lesions ranged
from  4  to 75 mm3 (mean 26), and the size of the 5 pallidal lesions ranged
from  28 to 150 mm3 (mean 67). On the average, the center of the lesion was
1.4 mm medial to the position of the anatomical target (p less than 0.002).
Neither size nor site of the lesion correlated with the clinical outcome.
  Tags: Female; Human; Male
  Descriptors:  *Globus  Pallidus--Surgery--SU; *Parkinson Disease--Surgery
--SU;  *Stereotaxic Techniques; *Thalamic Nuclei--Surgery--SU; *Tomography,
X-Ray  Computed--Methods--MT;  *Tremor--Surgery--SU; Adult; Aged; Follow-Up
Studies;  Globus  Pallidus--Radiography--RA;  Middle Age; Parkinson Disease
--Radiography--RA; Postoperative Complications--Radiography--RA; Stereotaxi
c    Techniques--Instrumentation--IS;   Thalamic   Nuclei--Radiography--RA;
Tomography, X-Ray Computed--Instrumentation--IS; Tremor--Radiography--RA
 
--------------------------------------------------------------------------------
 -------
 
This work, done in Sweden, attempts to correlate the size of
the lesion created, with the results, and was unable to do so.
It involved only 19 patients, some of whom (it is not clear how
many) had conditions *other* than PD.  I have requested a copy
of the full article from my Library, as well.
 
========================================================
 
COMMENTS:  I am not trying to "throw a wet blanket" on the
concept of pallidotomy or any other treatment which may be
effective in the treatment of PD.  What I am trying to do,
however, is to caution the lay public, especially sufferers from PD
and their families (and I have a family member with this
condition, as well), that something as invasive as *surgery* needs
to be carefully scrutinized before submitting to same, this
especially since we have "been through" an era of surgery for
PD (30 years ago), this with equivocal results; and, in my
opinion, the "newer techniques" are not *that much* "newer".  I
am also concerned that this work is not being done in more
university medical centers in the U. S. (as this method
of "highly controlled research" is the best way to evaluate a
treatment program); and I wonder if the reason for this lack
of research in more than just a few places in this country is
not due to many academic physicians feeling that this approach
(pallidotomy and other destructive operations) is not
productive.  The future may lie in nerve tissue transplantation
or in other techniques; and if so, the surgical methods used for
pallidotomy and such will be useful in trials of new therapy;
but, for me, I am afraid that I have a very hesitant opinion
about pallidotomy and other lesion-making procedures in the
treatment of Parkinson's disease.
 
This has been LONG, and I apologize for taking up so much
bandwidth and disk space; but I wanted to give this matter
the attention that it deserves.  I will make follow-up
postings as the additional information which I have
requested comes in.  Best wishes to all on this List.
 
Sincerely,
 
Bob
--
********************************************************
 
Robert A. Fink, M. D., F.A.C.S.   Phone: 510-849-2555
Neurological Surgery              FAX:  510-849-2557
2500 Milvia Street  Suite 222
Berkeley, California 94704-2636
USA
 
E-Mail:  [log in to unmask]
CompuServe:  72303,3442
America Online:  BobFink          "Ex Tristitia Virtus"
 
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