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If the probe is too deep the patient will experience his/her very own fireworks display and the probe will be slightly withdrawn.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.