February 25, 1995
 
 
TO:  Kuo-Yung Chyan   <[log in to unmask]>
 
RE:  Pallidotomy
 
 
Barbara Patterson of the Parkinson's disease List has forwarded your
message concerning pallidotomy along to me.  I have been one of the
"caution-sayers" as regards this operation, especially as related to the
glowing reports which some have made concerning the procedure,
especially as related to the work going on at Loma Linda University of
Southern California.  I was also quoted (very briefly) in the Wall
Street Journal article of February 22.
 
Below, I am "pasting" the text of the e-mail that I had sent to David
Stipp, the author of the WSJ article, and this, I think, provides an
overview of my opinions regarding Parkinson surgery these days:
 
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TO:  David Stipp  <[log in to unmask]>
 
RE:  Pallidotomy
 
 
Dear David:
 
I am a neurosurgeon who has been active on the Parkinson's Disease List,
and I have become involved in the ongoing debate on pallidotomy.  I did
pallidotomies back in the sixties while I was a resident at the
University of Chicago, this during the era when this kind of surgery
(including thalamotomy, which was done more specifically for tremor) was
quite popular.  In the late sixties, two things happened which markedly
decreased the usage of this type of surgery; one was the failure, after
much hoopla, of Margaret Bourke-White's operation; and later, the
discovery of L-DOPA by Cotzias, which revolutionized the treatment of
Parkinson's at that time.  Bourke-White, a LIFE magazine photographer
(and Pulitzer winner, I think), had a dramatic result for her tremor
when operated by Irving Cooper in New York; but several years later, the
disease advanced, and she died after becoming an invalid.
 
The problems with the Parkinson's surgery back in the sixties were that
those earlier operations seemed to reduce, sometimes dramatically, the
tremor, but had less effect on the rigidity that is associated with PD,
and almost no effect on the "slowness" that is characteristic of the
disease in the later stages.  The beneficial effects of the surgery,
also diminished with time.  By the mid-seventies, almost nobody was
doing PD surgery anymore.
 
A few years ago, a Swedish surgeon (Lauri Laitinen, M. D.) resurrected
the operation (as done by a now-deceased Swedish colleague, Lars
Leksell, M. D.), and added some newer technology to same.  Laitinen has
published a few articles reporting some improvement in the rigidity and
slowness problems (he went back to the globus pallidus as the site for
the lesion), and a number of other neurosurgeons, some in the USA, have
started to do the operation again (I, personally do not).  The results
of this new work, as published in the scientific literature (and I have
searched such), are still somewhat equivocal, especially as to the
*length of time* that the beneficial effects last; and, in my opinion,
it is too soon to call the present-day work with pallidotomy more than
"experimental".  For certain patients, there may be a role for this
approach, especially since the drug therapy of PD also seems to lose its
beneficial effects with time.
 
The way that I got involved with this debate was when, on the Parkinson
List, a man named Don Berns, from Southern California, began making
posts there extolling the pallidotomy operation (he has had one).  His
posts were almost "testimonial" and full of what was almost "religious
zeal", this as it pertained to a program going on at Loma Linda
University in Southern California, this program being directed by Robert
Iacono, M. D., a neurosurgeon there.  I did not object to the program in
any way; but I was highly disturbed at Mr. Berns' posts (because of
their, IMHO, unrealistic optimism) to a group made up of people with a
chronic and disabling disease; and this debate, including some personal
and direct correspondence between myself and Mr. Berns, has become
somewhat heated.  I have written directly to Dr. Iacono (as a colleague)
to ask whether he is aware of the "testimonializing" of one of his
patients, and I have not yet received a response.  There are exchanges
going on in the Parkinson's List from as far away as Israel (from family
members of severely disabled people with PD), and it almost sounds like
"snake oil", especially in view of what I think is a premature
endorsement based on what actually does appear in the medical
literature.
 
Recently, I have taken up this problem with several other neurosurgical
colleagues, many of whom share my views (that the research being done by
Dr. Iacono at Loma Linda and elsewhere is worthwhile but not "proven"
yet); and I refer you to Patrick J. Kelly, M. D., Professor of
Neurological Surgery and Chairman of the Department at NYU Medical
School in New York City.  Dr. Kelly does pallidotomies and believes that
the surgery may be useful in selected cases, but he shares my skepticism
and concern over the "testimonializing" that has recently been going on.
 I would suggest that you may wish to contact Dr. Kelly and discuss the
situation with him, this to get a reasoned approach to a complex
problem.  Dr. Kelly's e-mail address is:  <[log in to unmask]>,
and you can use my name when you write to him.  If you wish, you can
feel free to correspond further with me (see my "sig" at the end of this
message); but I think that you will get more information about the
current "state of the art" in Parkinson's surgery from Dr. Kelly.  I
would very much appreciate receiving a copy of your article when it is
completed.
 
Thank you for your interest.
 
 
Best wishes,
 
Robert A. Fink, M. D.
 
------------------------------------------------------------------------
-------------
 
In essence, I think that the "first line" of treatment in PD is
medication.  L-DOPA (usually Sinemet), along with Selegiline (Eldepryl)
appears to be quite effective in PD, and, in the beginning, is often
dramatic in its restoration of good function in patients.  This occurred
with my father-in-law, a retired physician, who was in his eighties when
he was found to suffer from PD.  As you probably know, however, the
effects of the medication "wear off" in time, and the side-effects of
increased dosage can be difficult.
 
The "new pallidotomy" as done by Laitinen in Stockholm *may* offer some
relief in patients who no longer obtain good relief with medications,
and it appears that this new operation (a variant of a very old
procedure) *may* help such things as rigidity and "slowness", these
symptoms that were not helped much by the older procedures (the surgery
used in the sixties seemed to mainly help tremor); but I do not think
that *anyone* (except perhaps some of Dr. Iacono's patients) feel that
surgery is a "cure", since what the surgery appears to do is to restore
a balance between the inhibitory and excitatory pathways which have been
"imbalanced" by the disease.  Furthermore, patients who have had a
pallidotomy *may* be excluded from trials using some newer (and still
unproven) techniques using, for example, implantation of fetal cells.
From what I have read in the literature, it would seem that candidates
for pallidotomy would include elderly patients who have totally
"escaped" the beneficial effects of the medication (despite good medical
management), very young patients with the same problem; and (perhaps),
patients with severe rigidity and/or bradykinesia (slowness) who have
not responded to medication in a satisfactory way.
 
Dr. Laitinen can probably be reached at the Karolinska Institute in
Stockholm (the main neurological hospital there is the Serafimer
Lazarettet); but there is an institution here in Northern California
(since you are at UC Davis, we are "neighbors") where some work is being
done with Parkinson surgery.  Contact Dr. Nicholas Barbaro, neurosurgeon
at UC San Francisco, as I think that Dr. Barbaro is doing pallidotomies.
 I would also strongly recommend consultation with Dr. Patrick Kelly,
Professor of Neurosurgery at NYU in New York City; who has, I believe,
done more of such surgery than has Dr. Barbaro.  Dr. Kelly's address is:
 
Patrick Kelly, M. D.
Department of Neurosurgery, New York University
Phone:  212-263-8002
E-Mail:  <[log in to unmask]>
 
I wish you good luck in your quest for information.  Please keep in
touch.
 
 
Best wishes,
 
Bob
 
 
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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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