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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. =========================================== 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. =========================================================== 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) (c) format only 1994 Dialog Info.Svcs. All rts. reserv. 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. ==================================================== 1/L/12 DIALOG(R)File 154:MEDLINE(R) (c) format only 1994 Dialog Info.Svcs. All rts. reserv. 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" ********************************************************