Here is the text of the Wall Street Journal article, which I
scanned in so please forgive the errors.  I hope this doesn't
violate any copyright laws.
 
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The Wall Street Journal
Wednesday, February 22, 1995
Page 1
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Hope From a Knife
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Surgery for Parkinson's Brings Success
Stories In Face of Skepticism
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Patients Tell of Great Relief Operation to
Cut A Spot Deep in the Brain
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Rediscovering an Old Idea
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By DAVID STIPP
Staff Reporter of THE WALL STREET JOURNAL
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Edward Weinberger has had Parkinson's disease
for 13 years. His symptoms grew steadily more
frequent and agonizing: painful periods of
near paralysis and, at times, uncontrollable
tremors. He tried drug after drug, with
dwindling benefits.
 
By last year, "I couldn't go out for more
than a half hour without freezing up," says
the 52-year-old New York investment banker.
"I couldn t get out of bed by myself or turn
over. I hadn't driven a car for 10 years.
Sometimes I couldn't talk, and choked" on
food.
 
Then he saw an electrifying report by a
Swedish neurosurgeon named Lauri Laitinen,
who had threaded a probe deep into the brains
of 38 Parkinson's patients and burned out a
sliver of hyperactive neurons in an area
called the pallidum. Some 92% had "complete
or almost complete relief of rigidity" after
this "pallidotomy" operation, while 81% had
"excellent or good long-lasting tremor
relief," said the 1992 report in the Journal
of Neurosurgery. "A good test of the
procedure," Dr. Laitinen wrote separately,
"is to have the patient dance after surgery."
 
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A Changed Man
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Last fall, Mr. Weinberger flew to Stockholm
for a pallidotomy by Dr. Laitinen. While in
surgery - done under local anesthetic - "I
went from a state of total rigidity to
feeling all of a sudden released," Mr.
Weinberger says. "Two days after. I was
walking through the streets of Stockholm as a
tourist. I could drive. I could go out for a
drink and read at night. It was so
miraculous, I didn't quite believe it."
 
With little notice, hundreds of Parkinson 's
patients have grasped at this surgical straw
over the past two years - most, it appears,
with startlingly good results. The procedure
isn t a cure. It sometimes doesn't help, and
when it does, symptoms are usually lessened
rather than eradicated. It poses a risk of
bleeding in the brain, which can paralyze or
kill. But some doctors say pallidotomy is the
most promising Parkinson's treatment since
the 1960s advent of L-dopa, the drug that
inspired the book and subsequent movie
"Awakenings."
 
"I was very, very skeptical when I first
heard Laitinen's claims," says Patrick Kelly,
a New York University neurosurgeon. "Even
when r saw the results the first couple of
times, I thought it was a fluke. But I've
become a believer." Dr. Kelly has now
performed about 30 pallidotomies himself.
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Waiting List
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Another neurosurgeon, Robert Iacono of Loma
Linda University in California, has done
almost 500 of the operations since hearing
Dr. Laitinen s results:   It s a real
revolution,"  he contends.  "I've seen dozens
of wheelchair-bound patients become almost
completely functional."
 
Demand is exploding for the operation as
stories about its benefits filter out through
patients  support groups. Some of  the 20 or
so U.S. medical centers that offer the
surgery have yearlong waiting lists. Dozens
of Americans have flown to Sweden for it,
although Dr. Laitinen also has a backlog.
 
Parkinson's disease afflicts roughly a
million Americans. Some doctors say perhaps
100,000 of them currently would be good
candidates for the surgery, generally the
ones whose drugs are failing them but who
don't yet have major brain damage  from the
disease. Many more patients, perhaps most
people who get Parkinson's, may need the
surgery as they lose benefit from drugs,
proponents add.
 
L-dopa generally becomes less effective over
time and often itself causes uncontrollable
limb spasms, facial tics and other problems.
"AII [patients] fail eventually" to respond
well to L-dopa, Dr. Kelly says. "Many of them
could become candidates for pallidotomy.
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Plenty of Doubters
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Such thinking has ignited a momentous debate:
On one side are neurosurgeons and hopeful
patients who are convinced the surgery can
help many; on the other are doctors and
health-maintenance organizations saying it is
a hyped, experimental treatment that doesn't
warrant insurance coverage. (Many non-HMO
insurers, including major Medicare
contractors, do cover the $20,000-to-$40,000
operation.)
 
Some people with Parkinson's say they quit
their primary doctors in a huff after the
surgery, adding that the physicians opposed
it and sometimes later refused to acknowledge
its benefits. "My neurologist was totally
against it," says Lenore Rabjohns, a San
Diego resident whose former HMO doesn't pay
for the surgery. Paying out of pocket, she
had Dr. Laitinen do the procedure on both
sides of her brain - each side has a pallidum
- giving "immense relief  from Parkinson s
symptoms, she says.   When I went back to my
neurologist, he said it was just a placebo
effect."
 
 
Neurologists, the main specialists for
Parkinson s, tend to be the most skeptical.
Their main tools are drugs, and they often
regard surgeons as willing to cut first and
ask questions later, "There's benefit to be
derived from pallidotomy for very carefully
selected patients," says Robert Feld-
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Please Turn to Page A8, Column 1
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Hope From a Knife:  Parkinson s Patients
Claim Relief After Operation to Cur a Spot
Deep in Brain
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Continued From First Page
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man, a neurologist at Boston University. But
 I wouldn t refer patients to Iacono. I don t
think he s thinking critically. He s thinking
surgically.
 
Dr. Iacono, the operation's leading U.S.
proponent, has become a lightning rod for
skeptics. Some of his patients recently
posted "testimonials" about benefits of the
surgery on the Internet that "almost sound
like snake oil," says Robert Fink, a
neurosurgeon in Berkeley, Calif. , who
doesn't do pallidotomies.
 
Replies Dr. Iacono: The benefits of the
surgery "are very dramatic, and neurologists
just can't stand it. Their mildly positive
statements about it are a form of apathy
that s malignant.
 
There are some good reasons for caution,
though. What causes Parkinson s disease,
first identified in 1817, remains a mystery,
as does the precise mechanism of relief
afforded by pallidotomies. The progressive
disease often causes a confusing array of
symptoms that can dramatically worsen or
improve several times a day - providing
fertile ground for oversold remedies and
outright quackery.
 
The average age of onset is 57, but some 30%
of cases are diagnosed before age 50.
Parkinson's typically starts with weakness in
a limb or a slight hand. tremor, then worsens
over five, 10 or 20 years, potentially ending
in paralysis, dementia and early death.
 
Parkinson's sufferers often have impassive
faces, speak in soft monotones and walk with
small, shuffling steps, hunched forward. They
suffer insomnia, excruciating pain from rigid
muscles, depression, nightmares and
hallucinations from Parkinson's drugs, one of
which is chemically similar to LSD. The
disease inflicts both the inability to move
and uncontrollable movement, from slight
tremors to wild flopping that can dislocate
joints.
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Other Initiatives
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Skeptics about pallidotomy often cite the
false hopes raised in 1987 by a Mexico City
surgeon named Ignacio Madrazo. He reported
helping patients by transplanting into their
brains cells from adult adrenal glands, which
were thought to spew chemicals offsetting a
neuronal deficiency. Patients rushed to get
the transplants, but U.S. researchers in 1989
quashed the fad by reporting that careful
evaluations of such patients showed minimal,
short-lived benefits and a high rate of
complications.  (The effectiveness of another
kind of brain transplant for Parkinson's
disease - of brain tissue from aborted
fetuses - isn't yet established. A study of
the technique is expected to begin within
weeks.)
 
Surgery can cause a placebo effect. In a
1950s study, heart patients given sham artery
bypass operations - incisions without
bypasses - reported as much relief from the
pain of angina as those who got bypasses.
With Parkinson's, the risk of overestimating
an operation's benefits is heightened by the
subjective nature of many of the disease's
symptoms, says Chicago neurologist Harold
Klawans. "A patient's mood can affect how
much he can do" in overcoming the disease's
lack of muscle control, he says.
 
While acknowledging that pallidotomies can
help some people, the doubters say desperate
patients may rush to get the operation from
surgeons who don't have much experience doing
it, with potentially disastrous results.
Indeed, Dr. Laitinen reported that six of his
first 38 pallidotomy patients had permanent
blind spots in their visual fields after the
surgery. The problem no longer occurs, he
says, because he has figured out how to avoid
damaging neurons that carry visual signals.
 
The skeptics also note that before L-dopa,
neurosurgeons often tried, with only limited
success, to help by destroying parts of the
pallidum. The idea arose from the observation
that Parkinson s patients who had minor
strokes sometimes lost their tremor. The
strokes apparently had disabled misfiring
neurons that were responsible for the
quivering.
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First Efforts
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Beginning in the 1930s, surgeons tried to
nick the same brain area hit by the
beneficial strokes. The results were
promising - and appalling. One pioneer,
Russell Meyers, reported that after he cut
nerve tracts near the pallidum in 38
patients, 25 had lessened Parkinson s
symptoms but six died soon afterward.
 
Later, surgeons improved the precision of
probes, and did better.  By destroying part
of the pallidum, an area that helps control
movement, they alleviated some of the muscle
rigidity. But the surgery reportedly did
little for tremor and the inability to make
voluntary movements.
 
Then researchers learned that the brains of
Parkinson s patients  were deficient in
dopamine, a  neurotransmitter  that carries
signals between neurons. In the late 1960s,
they found that oral doses of a dopamine
precursor, L-dopa, could ease the deficiency,
mitigating symptoms. That killed off most
surgery for the disease.
 
Unknown to most doctors, however, a noted
Swedish surgeon named Lars Leksell had found
that by knocking out part of the pallidum not
usually targeted, he could dramatically
improve all Parkinson s symptoms.  The late
Dr. Leksell didn't publish his finding
"because he believed that a neurosurgeon was
biased in reporting his own results,  says
Dr. Laitinen, one of his proteges. Less old-
fashioned, Dr. Laitinen issued his startling
1992 report on the procedure after trying it
on 38 patients who were failing on L-dopa.
 
"Neurologists were extremely surprised  by
the results, says Dr. Laitenen. He says he
has now performed about 350 pallidotomies
with similar results. Younger patients do
particularly well.   We recently checked the
first 10 patients" who got pallidotomies in
1985 and 1986, he says, "and nine of them are
doing well."
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How It Might Work
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Medical textbooks say brain surgery can help
the tremor of Parkinson s but not the
freezing. Rethinking that in light of the new
pallidotomy results, scientists theorize that
lack of dopamine incites furious firing by
certain neurons that normally help suppress
undesired movement. That causes Parkinson's
patients to freeze up. Pallidotomy appears to
cut these overactive "inhibitory" brain
pathways, as well as ones that induce
tremors.
 
But the jury is still out on crucial issues:
how effective the surgery is, how much risk
it poses, precisely what part of the pallidum
to destroy for maximum benefit and how long
the benefit lasts. An Emory University team
in Atlanta has begun a federally funded study
to answer these questions, but its results
aren't expected for years. A report on 126
patients given pallidotomies by Dr. Iacono is
expected to be published soon.
 
Meanwhile, patients are getting some answers
via the Internet and support groups. After
flying to Stockholm for a pallidotomy, Alan
Bonander, of San Ramon, Calif., recently
produced a videotape on the surgery that is
now circulating in the Parkinson's-disease
network. In a moving segment, Mr. Bonander is
shown with immobile limbs just before the
surgery. then flexing his limbs with fluid
speed just after - calling to mind the
"Wizard of Oz" scene in which Dorothy oils
the rusted tin man. Mr. Bonander say he still
has some problems with tremor and rigidity,
but "my quality of life has improved.
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Outcomes Research
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David Devor, a Jerusalem resident whose wife
has Parkinson's, recently posted on the
Internet what may be the most comprehensive
report so far on pallidotomy outcomes. After
being advised against the surgery by his
wife's doctor, he asked Dr. Iacono for
evidence that it works. "I heard a lot of
neurologists call him a charlatan," Mr. Devor
says.
 
Dr. Iacono responded by sending him the names
of all his pallidotomy patients from late
1993 to late 1994. Running up a $1,000 phone
bill, Mr. Devor interviewed 113 of the
patients or their spouses. Nine said they
hadn't been helped, including five who said
they got worse, Mr. Devor reported; but about
80% said the surgery gave them "marked
improvement," with symptoms lessened by 20%
to 100%.
 
Many described the surgery with words like
"miraculous," he added in the report.  Most
typical were the expressions of relief to be
again able to turn over in bed, shower and
dress alone, eat normally . . ., to walk,
write and work normally or almost normally,
and even drive a car." Mr. Devor concluded by
asking, "Would I fly in a shuttle that had a
92% reliability of getting me some distance
away from hell on earth, 8% of doing me some
harm and well under 1% of killing me?"
 
His wife, Aviva, is scheduled to have a
pallidotomy next week.