Judy Annesley
 
I hope you will find the following information helpful.  Dr. Iacono's telephone
is 909-796-4822.
I trIed to send you this info to INTERNET:[log in to unmask], but I got a message
saying that was an undeliverable address so I will post this on the Parkinsons
Digest even though it has been posted before others may find it helpful.
 
A Parkinson Pallidotomy Primer
compiled & summarized
by Don Berns
 January 11, 1995
 
 
BRIEF HISTORY
Globus Pallidus
Years ago observant doctors noted that Parkinson patients who had a stroke in a
particular area of the brain experienced some relief from their symptoms.
Animal Model
With the serendipitous discovery  and identification of MPTP (Dr Langston, San
Jose, CA early 1980's) as a parkinsonian inducing chemical, research scientists
had the means for creating a parkinsonian animal model.
Research
Through pursuant studies researchers noted that one of the critical
abnormalities in animal models of Parkinson's disease is an increased amount of
electrical activity in the globus pallidus of the brain.  By cutting the
pallidofugal fibers as they travel from the globus pallidus to the thalamus the
abnormal signal causing the signs and symptoms of Parkinson's disease is
short-circuited.
Explanation
To understand how a pallidotomy works think of the brain as containing a series
of interconnected electrical circuits.  In the parkinsonian one of these
circuits is overly active because there is not enough of the neurotransmitter
dopamine to regulate the electrical activity.  A lesion (small hole)is created
on the electrical pathway between the globus pallidus and the subthalamic
nucleus.  Thus, using this metaphor, the overly active circuit is cut.
 
THE PROCEDURE
Technique
Through a procedure technically known as a Postero-Ventral Pallidotomy, a probe
will be inserted into a very precise location of the globus pallidus
approximately four inches beneath the top of the head.  The patient remains
conscious under a local  anesthetic.  When the probe is in the correct position,
immediately adjacent to the optic nerve a small electrical charge will be
transmitted to the tip of the probe.
If the probe is too deep the patient will experience his/her very own fireworks
display and the probe will be slightly withdrawn.  When it is properly located
there will be a slight twitch in the cheek or tongue.  At that moment heat will
be generated to the probe tip and a small lesion will be created.
Explanation
A simplistic explanation is this procedure creates lesions of pallidofugal
fibers leaving the globus pallidus on the way to the thalamus.   Rough
Translation  - An overly active neuronal pathway which results in abnormal and
extra-kinetic movements, is severed.  Although the Pallidotomy is not a cure it
can eliminate many of the manifestations.  The results  are instantaneous and
appear to be long lasting.
History
Similar surgical procedures have been available since the early 1940's, however
refinement in surgical technique, increased knowledge, the development of a
parkinson induced animal model, and monumental advances in technology (CAT scans
and MRI's), now enable very precise identification and hitting of the target in
the globus pallidus.
        Dr Robert Iacono (Loma Linda University Medical Center) states, "The
beneficial effects of Postero-Ventral Pallidotomy on akinesia, postural
instability, stooped posture, freezing, on-off phenomenon as well as tremor,
rigidity, dystonia and dyskinesia are superior to the results reported for fetal
graft implantation, best pharmacologic results, or conventional stereotactic
procedures." 1
        Dr. Lauri Laitinen in Stockholm, Sweden, uses CAT scans for locating
target area. CAT scans are not as precise as MRI used by doctors in U.S.
        In 1952, Dr. Lars Leksell in Lund, Sweden began to perform anterodorsal
Pallidotomies, but the results were not satisfactory and he gradually moved his
target area to the Postero-Ventral part of the Pallidum.  In so doing Dr. Lars
Leksell moved the Pallidotomy outside the classic anterodorsal target area.
        Dr. Lars Leksell in addition to this pioneering work also is credited
with developing the first Gamma Knife.  The Gamma Knife creates the Pallidotomy
lesion by using high-powered focused radiation beams.
        Between 1985 and 1990 Dr. Lauri Laitinen & Associates tested Dr. Lars
Leksell's Pallidotomy procedure on 38 Parkinsonian patients, using stereotactic
Postero-Ventral procedures as opposed to Gamma Knife or anterodorsal classic
procedures.
        "Upon re-examination 2 to 71 months after surgery (mean 28 months)
complete or almost complete relief of rigidity and hypokinesia (slowness of
movement) 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 dyskinesia and muscle pain had greatly
improved or disappeared in most patients, and gait and speech difficulties also
showed remarkable improvement."
"The positive effect of Postero-Ventral 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." 2
 
COMMENTS BY THOSE WHO HAVE HAD PALLIDOTOMIES
 
Bill Dickinson: Fullerton, CA
        Date of surgery: Aug. 8, 1993
        Hospital: Loma Linda Medical Center
        Doctor: Dr. Iacono
        Procedure: Pallidotomy (right side)
        Life with Parkinsons: 6-7 yrs.
Before surgery: Freezing episodes, 1/2 hr. periods of mobility,homebound to
chair, lost 30-40 pounds, excessive sweating,    sleep perhaps 1-2 hr at night,
bothered by dyskinesia.  L-dopa intake 1800 mg/day.
After surgery: "It has given me a whole new life." Able to return to work in
mornings, go out to lunch, and play golf in afternoon.  First two weeks in
October left on a trip for Europe with his wife.  Reduced L-dopa intake to
1200mg. so far.
        Brian Keane  from New Zealand:
        Date of surgery: Oct. 27, 1993
        Hospital: Loma Linda Medical Center
        Doctor: Dr. Iacono
        Procedure: Pallidotomy (one side)
        Life with Parkinsons: 5 yrs., freezing bouts
Before surgery:"Before surgery I was unable to care for myself independently-
bathe, shave, shower, eat etc.  Now I am able to do all these."
After surgery: "Overjoyed!! The surgery has been a wonderful experience.  There
is really nothing to be afraid of."  (Four days after surgery)
Jack Pickens- Niceville, FL
        Date of surgery: Nov. 17, 1993
        Hospital: Loma Linda Medical Center
        Doctor: Dr. Iacono
        Procedure: Pallidotomy and Thalamotomy (same side)
Before surgery: Had Parkinsons for 5-6 years.  Now 68 years old. Tremor,
stiffness, and dyskinesia.
After surgery: Thrilled, delighted. "I can't believe it. I can't believe it."
Tremor gone.  No dyskinesia.  Side no longer stiff and unflexible.  Taking great
delight in being able to move his body as he chooses.
Don Berns- La Canada, CA.
        Date of surgery: Dec.  1, 1993
        Hospital: Loma Linda Medical Center
        Doctor: Dr. Iacono
        Procedure: Bilateral Pallidotomy (both sides)
        Life with Parkinsons: 12 1/2 yrs.
Before surgery: Bothered by dyskinesia, bradykinesia, akinesia, sweating, and
tremors.
After surgery: Ecstatic, Feels like I'm almost in a fantasy land, but with each
passing hour the fantasy becomes more a reality and what was the Parkinsonian
reality becomes a fantasy.
 
        The bilateral Pallidotomy seems to be a complete success.  I no longer am
plagued with stiffness, immobility, tremor, excessive sweating, akinesia,
bradykinesia,  dyskinesia, walking difficulties, stooped posture, swallowing
difficulties, or speech hindrances.  My eyes and mouth remain shut at night
while I sleep rather than both remaining partially open.  There is no longer an
"on-off" phenomena.
        My voice is strong again.  My face is expressive and noticeably
different.  I no longer have a sense of urgency when I need to urinate.  I do
not need to lie down for 3 hours in the afternoon because my body is so slowed
down.   I now sleep through the night and no longer take a sleeping pill before
I go to bed to help me  try to get a good night's sleep.  My appetite has
returned and eating is a joy rather than a chore.  Both my arms swing freely
when I walk.  My gait is loose and normal.  Karen says my hand feels soft and
pliable, rather than stiff and tense.  I move about easily, freely and
naturally.